“Who am I?” Erica asked, sounding weary. “When will I ever feel good about myself. Why does it seem so easy for everyone else?” Erica had been coming to therapy for about a year, reporting depressed mood, anxiety and relationship difficulties. In our early sessions, her narrative remained superficial. She talked about the tribulations of her daily life. But even when describing stressful situations, her telling lacked any emotional depth. We’ve all been met with resistance. We all know that we must honor the patient’s need to remain safely where they are—that we must build ego strength and create curiosity. So, this was how we worked in the beginning. I listened. She talked. And we didn’t go too deep. But eventually, I realized that her need to remain on the surface and the lack of emotional vitality went deeper than anxiety about what she’d uncover. Erica was alienated from her real self as a result of the cultural climate. As clinicians, we know we must remain vigilant of the impact of the social environment. Symptoms of individual psychology don’t happen in a vacuum. They emerge within a context. Today’s societal atmosphere is filled with filtered photos and personal branding, where everyone is trying to be seen, where significance is slowly being equated with the amount of “likes” and the reaches of social media posts, where there’s a decline in meaningful interactions, where people are increasingly vulnerable to becoming someone they are not in order to receive validation. Pride and self-worth are slowly dissolving. What’s missing is being searched for in the very place it got lost. That is, validation is being sought from the outside, from “likes” on social media posts, something to give a brief dose of emotional validation. But that sense of validation doesn’t last. Karen Horney talked about the tyranny of the shoulds. For her, these were unrealistic demands placed – I should be this, I should do that – on our self to become what she called the idealized self, an image of perfection that could never be attained, a paragon that squelched the ability for the real self, the spontaneous self, the vital self, to pursue natural personal growth. The idealized self disables the real self and stops it from flourishing. It also blocks the individual’s ability to realize and use what Karen Horney called constructive forces, (our unique strengths and endowments) to go towards what would offer a sense of meaning and pride, a sense of aliveness. In a world filled with personal branding and contrived social profiles, in a world where how we look can be altered—people are shrinking their bodies, contouring curves, brushing out normal expression lines on their faces. We’re slowly losing the ability to know who anyone really is. How are we as clinicians to help our patients, particularly our younger ones, to remain connected to their real selves? Karen Horney’s theories, I believe, give us a window of hope. Patients most likely won’t come into the office saying, “I’ve completely lost who I am in order to be who I thought I should be. I’ve become who I present to the world. I’ve been faking it for so long, I don’t know what’s real anymore.” Like Erica, many times the symptoms are much more general, but there will be indications in the narrative that there’s an absence of true connection and vitality, of integrated personal significance. Real pride will be lost and instead we may hear of many frustrated and unrealistic aspirations. Sometimes we may hear inflated ideas about the self that are vacant of any real accomplishment or emotional connection. We can’t take pride in something we aren’t. And authentic pride is revealed not through self-aggrandizement, but through reverence and humility, by remaining awed by life and by others, and by having the emotional strength to doubt oneself. The real self is the thriving self, the spontaneous self, the part that exists within all of us that’s real. This is where true self-worth, efficacy, a sense of competency, pride, and meaning come from. Sometimes we have to help patients “unbecome” who they’ve been conditioned to believe they needed to be. One of Horney’s main ideas about therapy was to unblock the constructive forces. She believed that psychological distress occurred when our natural strengths became blocked, rendering us unable to use them. So, this is where I began with Erica. I looked for her innate strengths and dynamic forces and then worked with her to uncover them and nurture them. It took a while, but I was able to help Erica recognize her strengths. We can’t coddle patients by saying nice things to make them feel better, either. If we want them to find what’s real inside, then we need to listen closely and help them discover it. What makes this person unique? What are their personal endowments? Who is buried, alive, deep inside? Erica was artistic. She played piano, sang, wrote music and painted. She also was very good with numbers. She did all of her own accounting and even did some for her friends. Piecing together meticulous details was something she was not only good at, but also enjoyed. She loved organizing. She hadn’t even considered these as endowments. She also was quite athletic but felt that she was not as toned as many other women, especially the ones she looked at on the internet. We talked a lot about the psychological aspects of exercise and feeling strong and healthy and finding a true sense of pride in completing difficult workouts. We spent months discussing her feelings about her strengths, about who she was underneath all of the “shoulds.” It became clear that she didn’t recognize her endowments, because she kept aspiring to reach an idealized self, an unattainable image that matched the imagined lives of people she saw on social media. But as we continued to explore avenues for her to feel her talents and endowments, where she could gain true confidence, she showed more spontaneity in her choices. She decided to go back for a graduate degree in public health. She wanted to do research, a pursuit where she could combine her creativity with her love of meticulous details. She wanted to contribute to the world. This process was two steps forward one step back. It’s challenging to help patients maintain strengths while still immersed in and affected by the world. But with every step forward, she was one more inch toward who she was and one more step away from who she thought she “should” be. Perhaps, it’s time for all of us to revisit the brilliant contributions of Karen Horney. For those not familiar with her work, I highly recommend Neurosis and Human Growth where you will find the aforementioned ideas elaborated. *Erica’s information was changed to protect her anonymity.  

There are many helpful lenses and methods that psychotherapists employ in the course of their work, typically reflective of a chosen therapeutic modality. Ultimately faith, hope, relationship and an unfathomable number of factors impossible to “procedurize” may catalyze therapeutic transformation. Yet with many competing priorities in our age of innovation and managed care, we must narrow our focus. Master psychotherapists use these three techniques in every session—

#1 – Approach problems with warmth, empathy, and curiosity.

Years ago, at a middle school, a student—my client—ran from class yelling obscenities at his teacher who was chasing him and demanding obedience. I was asked to quickly make my way outside to assist. For ten minutes I watched the teacher run in circles after him, demanding compliance. She gave up and retreated only after reciting her demands one last and futile time.

I stood quietly by as the boy ran wildly to the football field. He found a long PVC pipe and began using it as a martial arts bo staff. Once within a few yards of him and as he began to prepare his weapon for defense, I grabbed another pipe and awkwardly swung it around. He scoffed, “Haaa! You’re an idiot! You don’t know what the [bleep] you’re doing!” I laughed at myself, then offered, “Nice moves. Where’d you learn how to do all that.”

He immediately began to brag about his belt rank in karate, and I listened, uttering “Ah’s” and “Oh’s” and “Um-hm’s,” along with genuinely curious questions—it was, after all, quite interesting—as he explained forms and sparring. By the time he took his first pause, nearly out of breath—from not only all the angst and exercise but also in the excitement of having someone listen to him—I shared, “Well, thanks, this was fun, but I’d better get back to my office. I have a lot of paperwork to do. Do you want to walk back with me?" I noticed a glint of suspicion in his eyes, and he declined. "Don’t stay too long," I responded. You and I both have work we should be doing.”

As I walked away, my anxiety rose. I couldn’t leave him. Yet I couldn’t force him, and I saw no good coming from a power struggle. Still, I couldn’t return inside the building without him, or I would be reprimanded. What if he got hurt? What if he ran away?

I was thirty yards from the building by the time he caught up with me. He had run to my side and began walking with me. We walked all the way to the door of his class’s portable building, which I opened and said, “Have a great afternoon.” He retorted, “Have fun with all that paperwork.” We both laughed, and he took his seat. The teacher silently mouthed to me gratefully, “Thank you.”

We've all taken medication whose label cautioned to "use only the minimum effective dosage." Person-centered therapy is minimalist. Jay Efran and Rob Fauber (2015) wrote, "When the therapeutic canvas is cluttered, therapists are likely to become embroiled in the client's story and distracted by their own concerns about how to intervene, often failing to see the broader perspective that might enhance therapy's impact."

Carl Rogers (1961) taught, “The paradoxical aspect of my experience is that the more I am simply willing to be myself, in all this complexity of life and the more I am willing to understand and accept the realities in myself and in the other person, the more change seems to be stirred up.”

Most clients don't wish for more sophisticated interventions; they wish for a more genuine relationship—in their real lives and in the ill-defined relationship with a therapist. Viktor Frankl (1988) wrote, “A purely technological approach to psychotherapy may block its therapeutic effect.” If therapists are too lifeless or their technique too technical, participation in therapy may be worthless. Therapy, in this case, does not engage the healing power of the encounter, and what remains is, perhaps, little more than a kind of scientific experimentation.

#2 – Lean into constructive change talk and meaning-making.

Back in the '80’s, Wallace Gingerich, Steve de Shazer, and Michele Weiner-Davis (1988) conducted research which indicated a strong correspondence between a therapist’s use of what was referred to as “change talk” and positive treatment outcomes. For instance, when therapists stated in terms of “when” and “will” rather than “if” and “would” as they engaged their clients in “change talk,” clients themselves became focused on their own personal successes and, in many cases, went on to actualize those successes.

Therapists who wish to stir clients' own latent energies and motivations engage in conjecture that has the tone of curiosity, not clairvoyance. Therapists must come to believe in their clients if they expect their clients to gain in self-responsibility. If we train ourselves to talk about constructive changes, constructive changes begin to follow in some form or another, more often than not. As we talk about change, we engage language and co-create a narrative in an ongoing dialogue, and we cautiously aid in bringing the language to life.

#3 – Elicit feedback about progress toward established goals.

Zig Ziglar said, “When you aim at nothing, you will hit it every time.” When therapists and clients in therapy do not take the time to assess with therapeutic goals in mind, then they may enjoy therapeutic experience and even constructive therapeutic progress, so called, yet it is difficult to say whether meaningful successes will occur in a therapeutic relationship with no consolidated agenda.

Watzlawick, Weakland, and Fisch (1974) offered, “Change can be implemented effectively by focusing on minimal, concrete goals, going slowly and proceeding step by step, rather than strongly promoting vast and vague targets with whose desirability nobody would take issue, but whose attainability is a different question altogether.”

The Short of It

Carl Rogers (1942) set the tone for a psychotherapy undergirded by such values. In Counseling and Psychotherapy, he cautioned, "Much well-intentioned counseling is unsuccessful… Frequently therapists have no clear-cut notion of the relationship which should exist, and as a consequence their therapeutic efforts are vague and uncertain in direction and outcome."

Advice and the sometimes rigid interventioning of models often pressure a client to see through our eyes. Empathy promotes confidence and self-awareness as we see more clearly a client’s situation as only they can. Whatever lenses may aid therapeutic focus and drive in-session activity, the most effective artisans of change embody a reverence for human dignity through warmth, empathy and curiosity. And they engage in an intentional therapeutic optimism that redirects clients from cynicism toward hope and expectancy, and establish a clear and consolidated set of meaningful goals.

References

Efran, J., & Fauber, R. (2015, March/April). Spitting in the Client's Soup: Don't Overthink Your Interventions. Psychotherapy Networker, 31-48.

Frankl, V. (1988). The Will to Meaning: Foundations and Applications of Logotherapy. New York: Penguin Books.

Gingerich, W., de Shazer, S., & Weiner-Davis, M. (1988). Constructing Change: A Research View of Interviewing. In E. Lipchik (Ed.), Interviewing (pp. 21-31). Rockville, MD: Aspen.

Rogers, C. (1942). Counseling and Psychotherapy. Cambridge, MA: The Riverside Press.

Rogers, C. (1961). On Becoming a Person: A Therapist’s View of Psychotherapy. Boston: Houghton Mifflin Company.

Watzlawick, P., Weakland, J, & Fisch, R. (1974). Change: Principles of Problem Formation and Problem Resolution. New York: W.W. Norton & Company, Inc.
 

An intern said to me, “You always stress the importance of getting examples. I’m seeing a young woman who complains of anxiety, but she won’t or can’t give examples. She will say only that it happens often, and when I ask what happens, she’ll only say anxiety.”

There are three ways that patients communicate with therapists: journalism, poetry and theater. Journalism involves reporting information. Journalism is often used to block relational bonds by filling the space with speech that is not designed for or responsive to the particular relationship. Journalism often strengthens the professional aspect of the relationship (like reporting symptoms to a doctor) at the expense of the therapeutic aspects of the relationship (which involves revealing oneself without too much cognitive packaging). A certain amount of journalism is needed in the initial professional frame to decide if the dyad will venture into the therapeutic frame.

Poetry, often the result of free association, or telling a story or stray thought without really knowing why, has metaphorical elements. The therapist wonders why, of all the millions of things the patient could have said at that moment, they picked this one, and the answer usually involves some aspect of the immediate environment reminding the patient of some aspect of the story. For example, the intern’s patient might have said, “Well, one time I felt anxious was when I was going to the dentist for a checkup. I wasn’t afraid of physical pain or anything. I was afraid I was going to get berated for not flossing often enough.” The therapist could now consider this story as a metaphor for the patient’s experience of the therapist. Was he asking her to open her mouth to find out what she has been doing wrong so he could blame her for her own troubles? Had he already done something like that? If so, he will need to process that exchange with her before she could be expected to treat his inquiries as welcoming and curious.

Theater refers to communication that is shown rather than told to the therapist. It’s often a form of projective identification, where the patient shows the therapist what they’re feeling by getting the therapist to feel it instead. That’s not intentional, of course; it’s a function of the way feelings are often expressed in behavioral patterns , such as bullying and intimidation. If a patient wants to avoid feeling intimidated, it may be that the only counterpoint they know to intimidation is bullying, so they bully the therapist, who then feels intimidated. Theatrical communication also stems from the general principle that the variables that control behavior in one situation are often the same ones that control it in another. Communication within therapy is often ambiguous, which can encourage this phenomenon. My view is that good therapy depends on the observation that patients mess up therapy relationships in the same ways they mess up other relationships.

In the intern’s case, the patient is enacting something about her anxiety by refusing to explore it. The therapist might say something along the lines of, “Walking through life feeling uneasy with no recollections, no images of what dangers lurk and no reminiscences about what happened in similar situations in the past—walking through life with earplugs and a blindfold and distracting sounds—that sounds nerve-wracking.” The therapist might suggest working first on what’s so dangerous about letting the imagination wander.

Another patient sought therapy because he realized that he doesn’t have any real friends, only what he called acquaintances. The therapist invited him to consider which person among his acquaintances would be most likely to become a friend, so they could explore what keeps him from making friendly moves in a specific context. The patient insisted that none of his current acquaintances could become friends, so the dyad discussed abstract situations and hypothetical friends. The therapist might have said something like, “I wonder if what’s keeping you from playing along with me keeps you from playing along with others?” This would have been based on the idea that the refusal to name a specific acquaintance as a potential friend was not journalism about the people in his life, but a theatrical communication about what gets in his way.

A narcissistic man started therapy only after reading a great deal about therapy in technical books typically written for therapists. Everything his new therapist said or did was subjected to scrutiny and critique. For instance, the therapist asked him for examples of his presenting problem—repeated disappointment by his friends and family. He cited the extensive literature on the disadvantages of asking questions compared to making observations and I-statements. The therapist treated this at first as journalism, information about his extensive knowledge of therapy, but when he said that the therapist’s looking flustered made him angry, she interpreted it as an effort to intimidate her. He might not have been a good therapeutic fit for this particular therapist, but it might have helped to view his performance as a form of theater. “It seems like you’re showing me what it’s like to be constantly appraised and constantly criticized.” The idea would be to make him feel understood and, just as importantly, to show him that there may be a way for them to relate to each other as teammates rather than as judge and contestant. It might turn out that he is used to relating to others only as an object of scorn or as an object of admiration, and they might have developed a therapeutic contract around relating to each other differently.

Family therapists developed the technique of enactment. Instead of just talking about marital fights or efforts to discipline a child, the therapist asks the couple to fight about something or asks the child to misbehave so the parents can discipline her right there in the therapy office. This allows for real-time intervention in the problematic ways of relating. It also shows the couple or the family that fighting and misbehaving are more under their control and more tolerable than they might think. The essential idea behind relational therapy is that the patient is already performing enactments. The therapist has to be open to construing annoying patient behaviors as a kind of communication to capitalize on this idea.

As professional clinicians, we are often well-prepared to engage in journalistic communication with patients about their symptoms and situations. As therapists, we are often well-prepared to listen for metaphors that express patients’ psychological patterns or their experiences of us. Some communications from patients are disruptive of our agendas, but instead of treating them as resistant or non-compliant, the working alliance can be bolstered by treating them as theatrical efforts to show us rather than tell us what’s going on with them. 

In any other domain of performance (e.g., sports, music) it would be unheard of for the performer not to analyze her performance. Yet, in the field of psychotherapy, we do less of examining the moment-by- moment dynamics of the therapy hour and more theorizing (see Three Types of Knowledge Clinical Supervisors Need to Know).

Much like other professional fields, it’s important to record sessions to receive feedback about actual performance rather than feedback about a perceived or reported performance. Feedback is useful when it’s based on well-defined objectives that are observable and specific.

After a workshop where I related this idea of making it a routine practice to record sessions as part of deliberate practice and service improvement for our clients, an experienced therapist said to me, “Yes, it is a brilliant idea. I used to do that as a post-grad student. It’s helpful for students…Not so much for me now.” Another therapist said to me, “I cannot stand hearing my own voice in the recordings.”

Now imagine this: You are a coach of a tennis player. He comes to you and says that he doesn’t want to analyze his videos of the games because he gets uncomfortable looking at himself on-screen. Would you accept that?

Who has a problem with recording the sessions? Mostly, it isn’t our clients. It’s us. A recent study by a team of researchers found that a majority of clients have no objections to audio/video recording of the sessions, and close to three-quarters of them are willing to consider it. Less than a third of them express discomfort about it¹.

It is critical that you do not no use recordings in isolation. Make sure your supervisees couple the recordings with client outcome and engagement measures (see Marrying Data With Intuition).

Marrying Macro and Micro with ROM Session Recordings

When ROM (routine outcome monitoring) is employed without the use of recordings, you will lack the specificity of what to work on in your learning endeavor. When recordings are used without the context of ROM, you risk walking blind. You wouldn’t know if what you’ve identified as issues are indeed concerns from your client’s perspective (i.e., working alliance measures), and you wouldn’t know if what you chose to work on has any impact on benefiting clients.

Real Feedback

Some years ago, Bill Gates gave an important TED talk called “Teachers Need Real Feedback.” Many teachers got only one word of feedback once a year and that was "satisfactory." With no feedback or coaching, there was just no way to improve. Gates suggested that every great teacher can get better with smart feedback, and he laid out a program for his foundation to bring it to every classroom, based on a project called “Measures of Effective Teaching (MET).” The tool that was used was simply a video recording device.

Listen to what Sarah Brown Wessling, a high school English teacher at Johnston High School in Iowa, has to say about the use of video recording in her teaching:

"There is a difference for teachers between the abstract of how we see our practice and then the concrete reality of it…I think what video offers for us is a certain degree of reality. You can't really dispute what you see on the video. And there is a lot to be learned from that and there are a lot of ways that we can grow as a profession when we actually get to see this. I just have a flip camera and a little tripod and invested in a tiny little wide-angle lens. At the beginning of class I just put it in the back of the classroom. It's not a perfect shot. It doesn't catch every little thing that's going on, but I can hear the sound and I can see a lot and I'm able to learn a lot from it…it really has been a simple but powerful tool in my own reflection. Having the notes is part of my thinking process and I discover I'm seeing as I'm writing. I really have used it for my own personal growth and my own personal reflection on teaching strategy and methodology and classroom management, and just all of those different facets of the classroom.”

As therapists, when we talk about a session instead of listening to how it actually went, we try to recreate the experience in our heads. In the absence of the subject at hand, especially when we're talking about that in clinical supervision, it’s possible that we fill in some parts of reality with our imagination. We create interpretations. We become “explainaholics.”

Once you have the client’s formal consent to record for the sake of improving the service delivery, I would suggest recording all of your therapy sessions as a default. Instead of trying to predetermine who you should record your sessions with, make it part of your practice to record the majority of your clinical work. Make recording your sessions a default practice rather than an exception. This in turn reduces the cognitive load on your mind, given that it’s on most of the time, thus fading into the background. The value of recording your sessions is priceless.

By doing this front work in the sessions, you've taken the cognitive load off your mind for future sessions. I would suggest you provide a clear rationale to your clients of why you are doing this. So, for example, provide a social norm of your practice (e.g., “I do this with 90% of my sessions”), and provide a sound rationale for the purpose of recording (e.g., “I record my sessions so that I get to ensure the highest service delivery and experience in therapy…I would review them, when needed, and if we are off-track, I might get the help of a supervisor to offer a different perspective”). Clients are more likely to agree when you provide sound reasons.

The rate of compliance to be audio/video recorded is dependent more on the therapist than the client. Clearly, when your client is not comfortable with this idea, do not proceed with the recording. Let them know that their preferences are the priority. Must the recordings be videotaped or would audio suffice? I much prefer video as this allows me to look at the nonverbals. But interestingly, a recent study demonstrates that we are no more accurate reading emotions with audio with video, as compared to just audio alone. When we listen to the voice only, though handicapped by the lack of visual input, we seem to be able to pick up the emotional cues from the vocal quality alone². Note: If you're using audio-visual recording, the audio quality is more important than the visual.

Final Notes to Supervisors:

What to Watch

I recommend supervisors watch a handful of your supervisees at work, to get a sense of their presence, style and voicing within the context of facilitating therapy.

Pair Video and Client Feedback

Make sure that you pair video feedback with client feedback i.e., session by session outcomes and engagement levels (see Marrying Data With Intuition).

Figure Out the Growth Edge

After getting a (real) sense of how a therapist conducts therapy through the sessions recordings paired with client feedback, help your supervisees figure out their growth edge (see: Circle of Development). Thereafter, watch only thin slices of their recordings that are in relation to their identified growth edge. For instance, if you are working on helping a therapist deliberately practicing improving the way they solicit feedback, zoom in and watch only the last 10-15mins segment.

Focus less on content knowledge, and more on process and conditional knowledge (see Three Types of Clinical Knowledge). When we figure out the what to work on, therapists are more likely to be ignited with their own why.

Finally, go one step further. Once your supervisee’s growth edge is identified, help the therapist design a deliberate practice plan around this area (Watch this keynote to get ideas). Put both of your efforts on this sweet spot. This zone of proximal development is likely to evolve through time. (More about this in a future post on helping supervisees identify learning objectives that are predictive of improving client outcomes).

References

[1] Briggie, A. M., Hilsenroth, M. J., Conway, F., Muran, J. C., & M., J. J. (2016). Patient comfort with audio or video recording of their psychotherapy sessions: Relation to symptomatology, treatment refusal, duration, and outcome. Professional Psychology: Research and Practice, 47(1), 66-76. doi: http://dx.doi.org/10.1037/a0040063

[2] Kraus, M. W. (2017). Voice-only communication enhances empathic accuracy. American Psychologist, 72(7), 644-654. doi: http://dx.doi.org/10.1037/amp0000147 

“If your compassion does not include yourself, it is incomplete.”
— Jack Kornfield

My therapist was attuned to me. She was speaking, I thought, "eloquently like poetry,” as I sat across from her, feeling held, listening to her, reflecting her own authentic experience of being with me.

I was in a good place in my life with a stable, happy family—my husband and I filled with pride and happiness at seeing the joy in our toddler's life. I was saying how much I treasured what I had built with my husband; a close and loving family, and celebrating and creating family traditions, especially as I had not known that warmth and security as a child. Receiving a gift one has never had makes it so much more precious.

As I continued talking, I noticed my therapist's face fill with sadness and tears forming around her eyes. I thought to myself "Oh, she must have had a very hard time as a child" and I blurted out to her, "I hope this doesn't remind you of your own pain and what you did not have as a child.” Then I quickly added, "Anyway, I don't want to hear about that!” This was my therapy, after all! As someone who is well attuned to the other’s emotional state, I didn’t want to be burdened with the responsibility of having to take care of my therapist and her feelings in these sessions.

My therapist's face softened as she explained that she was merely reflecting what she was feeling, listening to MY story, and that although I was in a happy place in my life now, my story was tinged with sadness and loss for what I had missed as a child, and that was the reason for her tears. I allowed what she had just said to sink in and inhaled long and deep.

I have always been critical of that unhappy child (the younger me), holding her responsible for the unhappiness of those around her, and fervently refusing to feel compassion for her own suffering. Connecting with the genuine compassion that my therapist felt for the younger me, I began to feel compassion for the little girl (or rather me in my tweens, with the unhappy, angry face, the dark and clouded me) and I allowed myself to feel the grief and sadness that came along with it.

This was a pivotal experience for me, both in my personal growth and in my growth as a psychotherapist, for this is when I learned experientially that it is only by cultivating self-compassion that one can find true healing—and it was my therapist's own authentic and compassionate stance towards me that helped me find my way back to it.

In my role as a psychotherapist, I am now better able to help my clients, especially those who carry the burdens of childhood emotional neglect, by seeing beyond their fierce independence, their overly self-reliant front, to their core empathic selves that deeply cares about others—helping them to experience that their feelings matter, and more importantly that they matter. 

17-year-old Ellie and her mother sat on my office couch ready to discuss how Ellie’s mood had been since starting on an antidepressant medication. Before getting started, Ellie’s mom handed me her credit card to pay for the visit. Again, my phone’s app wouldn’t respond but after some fiddling, finally accepted the payment. Forgetting to mute my phone for this first appointment of the day, I set my phone on the table next to my chair. As soon as Ellie began sharing about her first few days of school, my phone beeped alerting me to a call waiting on my office line. I apologized to Ellie and her mother, muting my phone and moving it behind my chair. After briefly discussing how Ellie was feeling, I asked her mom to leave so that Ellie and I could talk privately. Before I could begin to explore Ellie’s mood in more depth, she excitedly pulled out her phone and showed me Instagram posts of several cheesecakes she had created from her own recipes. Beaming, she told me that she hoped to one day become a chef. I praised Ellie for her creativity and work. I was pleased to see such excitement from a girl who, a couple of months ago, couldn’t name anything that she did for fun.

One of the earliest lessons I learned in residency was the importance of tuning into the emotional and physical cues of everyone in my office. Lectures described personality types, relational dynamics and defense mechanisms such as transference and countertransference, all issues important in understanding patients’ complex lives. Now years out of training, I have become comfortable integrating all these concepts into my patient interactions. However, recently I have become aware of a surreptitious invader into the safe space that I have created in my office: technology.

Technology has become ubiquitous in our personal and professional lives. Before I have arrived in my office in the morning, I have used my phone and often my computer. Both have become integral in my work used to communicate with patients, track visits, collect payment and carry through a variety of medically necessary tasks. It is the third entity in the room during every patient visit. However, I have always felt uneasy about the presence of my devices in my space, especially when they creep into my patient encounters. Experimenting with my laptop placement, I tried resting it on my lap as I attempted to simultaneously type and listen to patients as they discussed their concerns. Uncomfortable with my computer’s interference, I returned to handwritten notes, dismissing my laptop to my desk. Not long after, my smart phone eased its way to my side table, an arm’s length away to collect payments and research medication questions. I wondered if my patients felt its intrusiveness as it sat waiting to alert me to some call, text or other notification. I quickly learned to not only turn off my phone off during patient visits, but to move it out of our direct line of sight when a patient is in the room.

All of this has left me wondering how we as mental health providers can invite technology into our practices with intention. While devices can be invasive and disruptive to my connection with my patients, I also realize that these digital instruments can be helpful, even mandatory, in our work. As professionals whose work depends on engaging in and modeling healthy relationships, understanding the presence of technology in our practices is critical.

The very physical presence of technology can have both a behavioral and emotional impact. A 2019 study by Glas and Kang showed that college students who were allowed to have their phones and computers during class scored lower on final exams than their peers. The proximity and intrusiveness of our devices can impact our work with patients. Turning devices off or placing them on mute, putting devices out of site or, at the very least, removing them from between us and our patients, can help reduce the disruption of the person-to-person interaction. Not only are we modeling prosocial behaviors for the people who we work with, we can use our own behaviors to highlight the impact of devices in our lives. I have placed a basket in my office for devices that prove too tempting and distracting for the youth and families that I see. It is kept near the door so that, physically and visually, it is removed from our interaction.

On the other hand, technology can be an important tool in our work. For my children and adolescent patients, using apps to track mood and sleep have yielded more cooperation than tracking those metrics on paper. Apps that track mood and anxiety symptoms can help individuals share their symptoms with their doctor or therapist. As professionals, we can guide our patients in choosing apps that best meet their needs. Apps are not regulated and there is little oversight into their creation or claims. We can help our patients become better equipped to choose apps that are helpful rather than harmful. The American Psychiatric Association has created guidelines to assist professionals in helping individuals choose the best mental health related apps. The APA has developed the App Evaluation Model that can help providers evaluate the appropriateness of an app with their patients. (see figure)

Technology can also help us learn more about our patient’s interests and can assist us in forming a better treatment alliance. Asking a teenager about his or her Instagram or Snapchat accounts can lead to discussions about personal interests, friendships and conflicts with peers.

Technology is not leaving anytime soon and is likely to gain a greater presence in our personal and professional lives. When we are proactive about recognizing where technology can enhance or interfere with our work and connection to the people we care for, we can become better equipped to optimize its presence and function in our professional lives.

References:

Arnold L. Glass & Mengxue Kang (2019) Dividing attention in the classroom reduces exam performance, Educational Psychology, 39:3, 395-408

The American Psychiatric Association, https://www.psychiatry.org 

My patient, Karen, emailed me saying she had come to my office for our appointment and I was not there. Oh my God! I had it written down in my scheduling book, but decided it was a mistake and crossed it out. I didn’t call or email her before the session to confirm that it was cancelled. I didn’t go to my office at the time of the session to make sure I didn’t make a scheduling mistake. It was obvious to me that this was countertransference. I responded to her email saying I was very sorry for my mistake and that I would see her at the next appointment. Then I started to think about what this “mistake” meant.

I thought about what had been going on in recent sessions. She had been changing appointments frequently, so maybe I was angry at her for treating her therapy (and me) so casually. Then I thought about our last session—it had been particularly difficult. At one point in the session Karen said she thought therapy was about learning lessons.

“What kind of lessons?” I asked.

“You know, you’re the therapist, you tell me what I’m doing wrong.”

“Therapy isn’t about lessons or showing you what you’re doing wrong. It’s about understanding how you feel,” I said.

“I know it isn’t about lessons. I’m not stupid,” she responded tersely.

I knew this was going in a bad direction. How was I going to get the two of us on the same side again?

“Let’s take a time out, okay? Let’s look at what’s going on between us,” I said.

She nodded, but in a stilted way.

“You said you thought therapy was about lessons about what you do wrong,” I said. I thought I was just going back to the beginning of the interchange so we could trace the steps.

“No,” she protested, “I never said the word ‘lessons’, you used that word, not me.”

She was defending herself from what she experienced as my criticism and she also didn’t believe me.

“You sound angry,” I said.

“Not angry. I’m frustrated. You don’t get it.”

“What is it that I don’t get?” I asked.

“You want to go in a direction and you’re just focused on that,” she said.

I understood that this was her mother transference. She felt her mother had constantly criticized her and didn’t tell the truth. She had told me, in earlier sessions, that her mother had her own agenda. Discussions were never about Karen and her needs.

“You seem to feel therapy is not for you. I have my own agenda and it’s telling you what’s wrong with you.”

She was quiet for a few moments. Then she said, “It’s strange. I don’t feel therapy is for me.”

The session was over and I sat in my chair for a while after she left the office. I felt beat up. The next session was the one I missed. I decided it must have been cancelled! I acted out my unconscious wish.

When Karen arrived for the next appointment, I apologized again. She said it was okay, shrugging it off. I asked how she felt about arriving at my office for her session and finding I was not there.

“I thought I made a mistake,” she said.

“That’s curious, isn’t it, that you thought it was your mistake?”

“Well, I figured you would say I got the time confused,” she said.

“You mean, you thought I would blame you?”

“Yes, I guess I’m used to being blamed when things go wrong. My mother never admitted being wrong about anything,” she said tearfully. “I don’t think anything is for me,” she continued. “It’s always for someone else and I get blamed for everything that goes wrong. I think I’ve been living like that for a long time.”

Admitting that I made a mistake was a breakthrough in the treatment. It made Karen aware that she didn’t trust me. She expected me to blame her for my mistake as her mother would have done. The fact that I took responsibility for my mistake helped her begin to understand that she often feels criticized unjustly and when she defends herself, she expects the other person to respond like her mother.

Missing the session was also a breakthrough for me because it made me realize the depth of my reaction to her mother transference toward me. I know that her constant defensiveness and distrust of me will not end because of her new insight, but this episode was the beginning of a working alliance, and I think my ability to withstand her defensiveness will be enhanced. While I was at first mortified that I had missed a session, now I was hopeful that her insight that she was treating me as if I was her mother, would help to grow and deepen our work. 

Whether it’s the anger-fueled drive that results in the winning goal or the disgust over a ref’s call that ends in a turnover, emotion is almost always present in sports.

The field of sports psychology is relatively young and is comprised of various disciplines such as mental performance, mental health, coaching education and leadership development. As universities are hiring in-house sports psychology practitioners to improve the performance, wellbeing, and leadership of athletes and coaches, high schools across the country are beginning to follow suit. While I continue my journey in the field of counseling psychology as a 4th year doctoral student at UW-Milwaukee, I also help area teams and individuals improve their mental performance through my performance consulting practice.

One of my major clients is a high school in Southeastern Wisconsin, where my role is to work on an integrated team that oversees the 22 sports programs at the school. This team is comprised of an athletic trainer, school counselors, strength and conditioning coaches, head coaches, and administrators. Each part of the team comes in contact with student-athletes to help them improve, and my role as the mental skills coach is to help athletes enhance mental and emotional aspects of training and competition that are sub-clinical in nature. Should elevated risk become apparent, student-athletes are referred to the school counselor.

Following an early season mental skills session with the girls track and field program, an assistant coach approached me with an athlete I had not yet met. Anna, a shotput and discus thrower on the team, asked if I would be willing to work with her to improve her confidence and the mindset she carries into competition.

After we chatted for a bit, it became clear that Anna was looking for two things. First, she directly discussed her lack of self-confidence and asked for help improving it, and secondly, she alluded to an inability to manage her emotions when she was in the throwing ring at competitions.

Throughout the season, Anna and I met during practice to discuss progress made toward becoming more confident when competing. Things seemed to be trending in a positive direction as she was able to improve her self-talk, visualization, and acceptance of things she cannot control, all elements to improving confidence in sports. She was achieving high grades in her advanced-placement courses and was throwing better and better at each meet. While the championship season approached, Anna, like so many other high school athletes, started to doubt her ability to complete a successful season, yet was excited to throw at the upcoming Regional Championships coming.

After throwing a personal best in both shotput and discus at the regional championship, Anna qualified for the sectional championships—a goal she’d had since beginning her athletic career.

Despite having achieved her goal, at the sectional meet Anna seemed to lack the confidence and poise that had become a staple in her competition game plan. She scratched her first throw in discus and under-performed in her next two. With three throws remaining, Anna was feeling the heat. Her coaches continued to give feedback on technique, and finally she came up to the coach’s box where I was watching her throw.

“You look really angry, and your body language is showing it,” I said. This was a tone not typical in my repertoire, yet the situation called for a direct approach as time was an imminent factor.

“Yeah, my first three throws were horrible and I’m not going to make it to state,” she responded.

“Has being angry been helping?”

“No.”

“Has telling yourself you’re not going to make it to state been helping?”

“No.”

“Am I way out of line to think that maybe we need to try something new?”

“No.”

“How can we manage our anger right now?”

“Let it go?”

“Yes! We’ve been working on a lot of breathing and that may help but find a way to bring your anger down a little during these next few throws and let’s go from there.”

“Alright, yeah, that sounds good.”

Anna closed her eyes, focused on her breath, and looked visibly more relaxed heading into the next few throws. She qualified for the state meet on her fifth throw, delivering a new personal record in discus. Carrying her relief into shotput, Anna set another personal record to qualify in her second event.

Two weeks later, after setting a new discus school record at the state championship and the largest stage of her career, Anna sat in the stands discussing her progression throughout the season.

“I just got in the ring and relaxed,” she said. “I don’t know, I just let it go.”

As the mental skills coach, I could not have been prouder.

My joy for Anna didn’t come from some sort of vicarious experience through her state championship run and school record toss, but rather in her ability to acknowledge her areas for growth, seek out someone to help, and engage in the journey to improve. The end result was the product of intrinsic motivation and facing up to vulnerability week in and week out.

Not once did Anna need to “calm down” nor was she ever told that her emotions were “getting in the way” It wasn’t implied by anyone who she trusted to work with. Instead, she was empowered by her coaching staff to find ways to manage what she was experiencing and go after her goals with all she had. She was tough, and her fighting spirit shone through in the good times and the bad.

No matter how you identify or what you do, emotions are not inherently bad. They’re just a piece of the puzzle that can be analyzed, managed, and at times, utilized. Anna was encouraged to strive for more, but not at the cost of her self-identity or personal values. She showed up on the biggest athletic stage in her career and found success by sticking to her values and game plan; and having a little fun along the way.