The case against ‘reviews’ in therapy

There are the obviously contentious and highly debated practices in therapy and there are those that are less questioned – perhaps because they are presumed to be benign or assumed to always be good practice. These practices get less scrutiny and one that has been on my mind lately is the topic of ‘reviews’ in therapy.

In brief, a review is the practice in therapy where the therapist ‘reviews’ with the client how the therapy is going, often in a structured way by having a review session. These are often at set intervals (6 sessions is often mentioned, or 6 months in long-term therapy) and involve specific questions about the client’s goals, progress, whether they are being achieved, etc. There are many valid reasons for doing this - to make sure the therapy is working, that the client is progressing, to get feedback from the client about this and so on. However, we don’t often hear about the potential negative impacts or why some people may not use reviews at all.

I work from the person-centred model and some of the criticisms I have are specific to that modality, but others are relational and trauma-based reasons that are not necessarily about modality so will be more broadly useful. I also work long term and have a lot of long-term experience as a client which also informs my perspective.

Reviews are often referred to in training and in the wider therapy discourse as something that everyone should be doing, without considering whether this, like many other interventions is something that could be navigated on an individual bases. They are suggested as a way to check on “progress”, at times of ‘stuckness’ or as a standard part of long-term therapy. There is a belief that not doing reviews could mean a client is stays in therapy that is not working and that this is unethical. However, approaching a review as one would an ethical issue can bring in more thoughtfulness e.g. by exploring the pros and cons, and really engaging with the underlying ethics of why one chooses the practices one does.

Reviews were included in my person-centred training and expected of me during placement and once qualified, as I moved out into the world of private practice and started making my own decisions, I dutifully tried to bring these into my work. However they often felt clunky, or sometimes worse in a way that I couldn’t’t quite put a finger on. They didn’t fit smoothly into the work. I could feel the potential for confusion and rejection in them. When I came into sessions with the intention of doing a review I was showing up with an agenda in a way that did not fit with how I worked at other times. I find it hard and also incongruent to my way of working to do something I don’t understand the value of just because somebody else says I should, so I gradually just dropped them altogether. (Interesting side note, there is research that links client outcomes to the therapists relationship with their own rationale of working, so offering an unconvincing review probably wasn’t doing my clients much good anyway).

Now with a lot more experience and reflection I can express cognitively what was formerly a felt sense of discomfort and these broadly break into two categories. Firstly, having structured review sessions that are initiated and led by the therapist is a distinct step away from the core person centred stance of non-directivity so of course they can feel clunky and incongruent from the rest of the therapy process. This may not be an issue for other modalities or integrative or pluralistic person-centred therapists but for a very non-directive practitioner - and the client who is used to it - of course this could feel incongruent. In addition, a review is often explicitly or implicitly asking about things like goals and ‘progress’ which in person-centred work may not be easily identified and this can place more focus on the therapist’s frame of reference rather than the individual clients needs.

I did in some of my attempts at reviews get into some kind of compromise - for example asking how clients felt about the work, what they were getting out of it etc. then immediately caveating that with ‘but it is ok if you are not sure, or don’t have any goals’. In hindsight I think this probably just came across as confusing for clients. I know that therapists cannot know what is ultimately going on for clients and we should not assume that things are going well just because we have not been told it is not, but I ended up letting go of the review as a specific intervention and instead trying to incorporate the things a review is supposed to inform into the relationship. I developed trust in my own ability to attune to the relational dynamics and got more comfortable and fluent at reflecting back in real time if I saw progress, or stuckness or naming if I felt there was a change in the dynamic that might mean the work was changing course or coming to an end. This felt much more aligned with my way of working.

The second and I feel more important reason I have ended up not using reviews is about the relational vulnerability that many people bring to therapy, and the power the therapist has because of this. These are valid whatever your modality, but especially in long-term and relational work. People who do not necessarily present as particularly vulnerable can still have this insecurity. How often have you heard clients say that they worry their problems are not ‘bad enough’, or question if they deserve the space in therapy (even as they are paying for it). I wonder this too about my own therapy sometimes, even as I know on another level how much I do need it. How might the perception that the therapist wants to end due to a lack of “progress” land on such feelings, which may be too vulnerable to have been directly expressed in therapy so far?

We often may never know the full extent of a client’s vulnerabilities around being able to even access the therapy space, even if we have worked with them long term. People who are sensitive, with interpersonal trauma, cPTSD and/or innate neurodivergence or otherwise ‘fragile’ areas of process (which one could argue is potentially a large population of clients, since these are the very things that often bring people to therapy in the first place) can experience even a subtle hint that they may not be making progress or doing therapy ‘right’ as very painful. They may also be used to masking or fawning as a way to stay safe in relationships so they may well not show noticeable signs of distress. Carolyn Spring has shared very well from a client’s perspective around this and other seemingly innocuous (at least to the therapist) ways that clients can feel excluded or rejected in therapy. For those with interpersonal trauma and deep attachment wounds, the suggestion however well meant that their access to the therapeutic relationship is conditional upon them displaying progress in a way that is meaningful the therapist can feel deeply destabilising and potentially re-traumatising, and understandably so. I have similar criticisms of the concept of ‘always working towards an ending’ because it introduces a relational insecurity from the get-go that can prevent a person from feeling feel safe enough to do deep relational work. How is it possible to lean into a relationship in the ways that people often need to in long-term therapy if the other person has one foot out the door the whole time?

I do think being a long-term client myself does significantly inform this kind of work. It could be hard to imagine the client’s side of this if you do not experience it yourself. I think that therapists without experience of long-term work as a client need to be aware that they may lack the client’s perspective on this and be mindful not to overlook that the client can experience this quite differently.

For those who do work long- term, the generally accepted review periods (6 sessions, 6 monthly, annually) will roll round quicker than you think and to be repetitively putting a client through a review process every six months when they're in long term therapy to me again feels like it layers up that potential for making a client feel like the work they're doing, whatever they're using the space for is not being experienced as valid or useful. It makes me wonder who the review is actually for, ultimately, and if we offered clients the choice, how many would decline them. I personally do not want reviews in my long-term therapy and I'm happy to say that my therapist and indeed my supervisor (the latter at my request) don't ask me to participate in structured reviews because for me they would be unhelpful.

As is usually the case when I have launched some criticism of some of the accepted norms of therapy, I like to explore then what do I do instead because it's not that in the absence of doing reviews I'm doing nothing to evaluate or check in with my clients or even with myself about how the therapy is going.

One could develop an approach to reviews that was sensitive to those issues. I think this would look more collaborative, with consent and the option to change or adapt it. I am wary about frontloading the initial therapy sessions with too much paperwork or questions but finding a place to ask about these things and get consent would be useful (and fits with a pluralistic and personalising approach to therapy – Mick Cooper).

I have ended making the things that a review seeks to achieve part of the ongoing relationship - by noticing and reflecting back progress where I see it, stuckness, when that comes up, and explicitly seeking clients consent and feedback as ongoing qualities in the work. This is very congruent with a person-centred approach and can feel a more organic and gentle way to get the clients input around those issues.

One example of this is - which I am sure many therapists will recognise - is a shift in the feel of the therapy, this is often described as it ‘feeling more like a chat’ in a relationship that has previously felt more therapeutic. This change can be named very naturally and doing so often opens up the knowledge that the client may be moving towards an ending.

Finally, I want to address the hypothetical concern that without reviews, clients would stay long-term in therapy that is not working. I question this (although I am interested if anyone has evidence of this happening). Certainly, in the UK, long-term therapy on the NHS is as rare as hens’ teeth, third sector/free provision is very time limited, the only place where open ended and years long therapy happens regularly is in private practice. Those with the capacity to arrange and pay for their own private therapy I would argue will mostly have capacity and a have a strong financial incentive not to keep paying for a premium service if they are not getting something from it. It would be unethical and against most membership bodies codes of practice to coerce clients in any way to stay in therapy or act in other ways to diminish their autonomy around this (e.g. by telling them they must be in therapy for a certain amount of time, or that they should continue even if the therapy doesn’t feel right) but reviews are by no means the only way to handle this potential risk.

As always, I am not saying everyone should work how I do but I hope that by having thoughtful discussions that consider more perspectives, particularly the lesser heard ones that individually we can all work more intentionally and collectively that can have the effect of making therapy more accessible to a wider range of people.