Some clients come to psychotherapy because they are entirely non-functional and need help establishing the basics--routine eating and sleeping, and a reasonable degree of physical comfort, financial stability, and social support. Other psychotherapy clients are already highly functional and fairly content, but want help tweaking their life to achieve better relationships, a more meaningful career, or less stress.
Which type of client is more rewarding to work with? Is it better to slightly improve the already-good quality of life of high-functioning clients or to work with low-functioning clients who improve more slowly but whose progress, even if minimal, constitutes a huge improvement in quality of life?
I've always been partial to the idea of tweaking--of helping high-functioning clients meet their potential and achieve their stretch goals. But last week I had a therapy gold (term I made up in my post about friendship versus therapy) moment that changed my thinking somewhat:
I had a session with an extremely depressed client with a serious chronic medical condition. He was going through a flare-up in his condition and I expected him to report that his mood had plummeted correspondingly; however, when I asked him about mood, he replied that it was stable, good even. He reported that he had been using some of the strategies we had discussed in therapy and then said (and this is the therapy gold part), "I have more control over my situation than I thought I did."
After he left, I practically jumped up and clicked my heels! My singular therapy goal with this client been to improve his mood by instilling a modicum of hope and personal control; the serious joy I experienced at seeing this happen diminished my conviction that working with high-functioning clients is more rewarding.
NB: My cup of therapy joy ran over when, before the client left, I assigned him the What Went Well exercise.