Psychotherapy.net Team, Author at Psychotherapy.net

Sam came to our session with two wooden cars he had made in occupational therapy. When I asked hi how things were going, he made a few comments about not wanting to return to his father and stepmother’s home. He seemed pensive and sober, but had little more to say. Instead, he seemed to be increasingly absorbed in playing with the wooden cars—one a larger Model T, and the other a smaller “Buggy.”

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Like many 12-year-olds, Sam was not especially fond of talking, particularly about the problems that had led to his hospitalization. I made some additional attempts to engage with him verbally, but eventually I, too, became more absorbed in what Sam and the cars were doing. Sam was steering them wildly around the top of my desk. Sometimes one or the other, or both, would come screeching to a halt, right at the edge of the desk, which seemed to be a cliff. At other times, they interacted with each other, and, on a couple of occasions, the little one pushed the big one off the cliff.

As I was drawn more deeply into the drama that Sam was playing out, I began to think about our session somewhat differently. At a minimum, Sam’s involvement with the cars seemed to reflect, among other things, the discomfort he had just displayed about discussing his problems. Maybe the best thing to do was to drop the questions and engage with Sam around the play. I started narrating what the cars were doing: “Hmm! The big one is towing the little one. . . Now they’re spinning around each other. . . Wow! They hit each other that time!”

It felt like Sam and I were more engaged now. But what, exactly, was going on here? The interplay of the cars seemed to be more than a mere resistance or fantasy about driving. What was being played out between the cars was intense—a dynamic and developing relationship of some kind. It appeared that Sam was using the cars to express something emotionally significant in the medium of play. An interpretation seemed to be called for.

Psychotherapists have had mixed feelings about interpretation throughout the history of the field. In the early days of psychoanalysis, Freud and others believed that insight gained through interpretation was the primary curative factor in psychotherapy. It was generally held that in order to be effective, an interpretation had to be accurate in all its details. However, Edward Glover later pointed out that while many of the interpretations reported by earlier authors had probably not been entirely accurate, those same interpretations had often, apparently, been quite effective. Furthermore, evidence was starting to accumulate that a good therapeutic relationship was more helpful to patients than intellectual insight gleaned through interpretation.

Nevertheless, some sessions—like the one with Sam—do seem to involve an alternate form of meaning-making in which interpretation may play a useful role. And so, in this situation I found myself pondering just what Sam might be trying to communicate to me.

Perhaps the little car was Sam and the big car was me, trying to get him to talk. But the intensity of Sam’s play suggested that the dynamics within his family were more likely to be relevant. One possibility was that the big car was Sam’s father—but most of Sam’s conflicts were with his stepmother, whom he resented for taking the place of his biological mother. Indeed, Sam and his stepmother had been colliding into each other and spinning around in circles for years. I ventured an interpretation:

“The little one and the big one are pushing against each other, kind of like you and your stepmom fighting with each other.”

“Mm-hm.”

Not very enthusiastic. Maybe I had jumped in too quickly. Or maybe the interpretation that I had ventured was off the mark. The big car might be Sam’s biological mother. She had been described as physically and verbally abusive, abandoning Sam with his father on several occasions. After custody was given to Sam’s father, Sam’s biological mother had been involved with Sam only sporadically, staying away for long periods of time and intermittently making promises to visit Sam but not following through.

More play. Now, the big car drove headlong off the cliff and crashed into the canyon below. Then, slowly, it returned up a mountain road, back to the top of the cliff.

“Gee, it drove off the cliff and then it came back!”
“No. This is another car.”
“Ahh!” I said. I had the information I needed.

“You know what I think?” I said. “I think what’s happening in your family is like what’s happening with the cars. When the big one went off the cliff, the little one was left alone, like you were left alone when your biological mom went away. Then another big one came, like your stepmom; and now you and your stepmom have to try to get along with each other and help each other, like the two cars towing each other. But it’s really hard because you still miss your biological mom. You don’t know when you’ll see her again.”

“I don’t think I’ll ever see her again.”
“Really?”
“Yeah.”
“It’s hard for a kid to lose a parent.”
“I think the more I don’t see my mom, the more mad I get.”

We talked about this. He expressed anger that when he had recently said he wanted to get in touch with his biological mother, his father and stepmother had replied that this was not a good idea. I suggested we discuss it with them in our next family meeting.

That night, Sam had his first good evening in the hospital, and over the next few days he shared, first, his anger, and then his hurt, about his biological mother’s many failures to visit him.

In the next session with his parents he called his stepmother “Mom” for the first time. At the end of that meeting he gave her the big car and said, “You can take this home.”

Origins of Empathy

As a child, I remember the frustration of not being able to tie my shoes, ride a bike or grip a pencil. The fact that I needed extended time on tests and note takers throughout high school and college was no less discouraging. However, one of my greatest challenges was adapting to adult employment and social demands; a process during which few people seemed to care about my specific struggles. I still remember fearing the supervisor who would criticize my handwriting and the sting of rejection after a first date. Although my therapists were empathetic, I was often curious about whether they had similar personal experiences, and whether disclosing them would have strengthened the alliance between us. Now, as a therapist who specializes in working with young adults with learning differences, I have made self-disclosure not only a basic component of treatment, but also part of how I present myself to the outside world, as my personal story is published on my website as well. This dynamic has led to a transference and countertransference between my clients and myself that starts from our first session and strengthens our relationship in many ways, while also providing an opportunity for us to reflect on our differences.

Part of my initial interest in becoming a psychotherapist and coach stems from my personal experiences struggling with learning differences. I am interested in using some aspects of my life to help other young adults with similar diagnoses navigate their challenges. It is reported that 75 to 85 percent of young adults on the spectrum are unemployed, and although the exact statistics on unemployment among adults with other learning differences are not known, it is widely thought that they also face a variety of barriers.1 The clients that come to my practice often say that they are struggling to manage their workload, navigate interpersonal situations with colleagues and bosses, and establish friendships and romantic relationships. “Preserving the uniqueness of their challenges while drawing on my own experiences is a tricky balance as a psychotherapist”, but I have developed a few strategies for doing so.

Fellow Travelers

My clients frequently find me through my writings for the NVLD (Nonverbal Learning Disorder) project, a non-profit that disseminates research and builds awareness regarding this unique visual-spatial disorder. One of the first things I tell them is that everyone’s experience is unique, and that my job is to help them to navigate their lives while also drawing on some of my own personal experiences related to common issues such as self-disclosure in the workplace, creating organizational systems and finding mentorship. The key is to listen fully to their stories and experiences, helping them to brainstorm and find their own solutions, while also offering, when appropriate, some personal anecdotes that might be helpful for their specific situations. An example could be a client who states that he or she is not sure how to best self-disclose their learning difference to their employer. We may explore ideas about different times and places to self-disclose, and I can talk about what I have learned from my own experience. I have found that many clients often appreciate this approach, stating that when I speak from a personal viewpoint it helps them to trust me more and feel as if I can relate better to their experiences.

If transference in psychotherapy normally consists of unresolved feelings and expectations that are placed onto the therapist–oftentimes in an unconscious attempt to recreate or approximate a past relationship, and countertransference is the therapist’s resulting conscious and/or unconscious feelings that are projected onto the client, “the therapeutic relationship between two young people with learning differences is ripe for the enactment of these feelings/experiences”. I often find that the clients I work with report a feeling of safety and security, perhaps seeing me as an older sibling or parental figure, especially when they describe feeling understood or supported by my being in a unique position to empathize with their learning differences.

Transference & Countertransference

One client, whom we will call Joyce, frequently contacted me after our therapy had ended in order to ask questions that usually began with “since you have and know about NVLD…” Because our work together had ended, I redirected her to another therapist who practiced in my office, but she did state that she had felt a sense of security and safety with me that she may have felt earlier with her mother, whom she used to call to help guide her with difficult situations. In some ways, she may have unconsciously seen me as a parental figure helping her to navigate difficult questions related to her job and personal life.

While working with male clients, I have often found that the transference/countertransference relationship may take on a different form. This is due to the fact that there is an element of both bonding and competition; many of the young men I have worked with may have a complicated history with women, especially regarding rejection and feelings of emasculation, a topic about which they may look to me for understanding. While I do not usually disclose my romantic status or experiences, by validating the unique challenges of dating with a learning difference and providing some practical steps for managing these feelings, I establish a bond with these clients, who describe previous male friendships in which they discussed these issues. A dynamic of male companionship can often form between my clients and me. However, some of my male clients have also seen me as a source of competition, and have reacted strongly, stating “you don’t know anything” or “how can you understand me?” Admittedly, it may be uncomfortable for some of my clients who see me as a “success story,” especially when they are struggling to find work or build interpersonal relationships. This is also a dynamic that I try to work through with them, making space for it to be discussed in the therapy room.

I attempt to use my countertransference as an indicator of not only how I should respond to the client in the room, but also of when, if and how I should self-disclose. A dynamic of male connection may lead me to respond to a client’s disclosure regarding rejection in the dating world with a few suggestions for improving one’s strategies, perhaps with the caveat that I have learned from my personal experiences. Depending on my relationship with the client, I may also use my countertransference as an indicator of my familiarity with certain aspects of the client’s professional experiences. For example, I remember identifying with a client I will call Michael, when he described challenges figuring out certain aspects of his job, as I have had similar experiences. However, if a client expresses competition or hostility towards me, I may also notice a feeling of defensiveness that arises in me, which will cause me to be more cautious regarding self-disclosure. Again, “countertransference can be an indicator of when and how to self-disclose”.

In my clinical work, transference and countertransference are often sparked by the patient’s vulnerability in the therapeutic relationship, something that individuals with learning differences will sometimes go to great lengths to conceal. Sometimes, they will hide behind a veneer of competence, lest anyone discover their sometimes painfully embarrassing challenges. The transference and countertransference dynamics in a therapeutic relationship often emanate from these struggles becoming visible, causing relief, vulnerability and perhaps shame at the same time. An articulate and thoughtful client, whom we will call Jenny, recounted how she had transferred to a reputable private school to receive more academic support and was subsequently abandoned by her previous friends, who stated, “So you think that you are better than us?” Despite distancing herself from her new school’s perceived “preppy” culture, she was reticent to explain that she had enrolled there because the workload and lack of individual attention at her local public school had become too onerous to handle. Quite the opposite of feeling “better,” her true reasons for transferring were a source of embarrassment. Hence, she described feeling “invisible” to her former friends, as they had falsely assumed she must have chosen the school for its supposed prestige. Jenny’s story prompted me to reflect on how many of my peers had also judgmentally questioned my parents’ decision to send me to small private schools, with statements such as, “Wait! How many people go to your school!? That’s weird.” Not to mention, “Are your parents rich or something?” I stated to her, “It is so frustrating and somewhat ironic when people assume you attend a private school because your rich parents want to help you escape the chaotic real world of public education, instead of the reality that you would do anything to be able to thrive while attending a school with over thirty students per class, loud and confusing hallways, and overwhelmed teachers.” Jenny thanked me, and although I never disclosed my experience, the fact that I had made hers visible created a positive transference between us. In that moment, I may have seen her in a way she would have wanted to be seen by an empathetic friend.

“Group therapy sessions necessitate a different kind of self-disclosure” and create a different stage for the expression and integration of transference and countertransference into the therapeutic work. I led a small group on developing dating skills for young men on the spectrum. The participants asked me, “Do you have a girlfriend,” and “What dating experience do you have?” I did not answer the first question but did confirm that I had faced some the challenges in this area. I added that I had developed some strategies and techniques of my own for finding success. My self-disclosure sparked an ongoing discussion of the struggles of dating between the group members, a discussion in which I was a participant in but not the expert leader. In other words, my self-disclosure leveled the playing field, so to speak, which facilitated a deeper and more meaningful conversation in the gruop. Because the participants acknowledged that they did not feel comfortable speaking about these issues with anyone else, the transference that may have developed was that of a relationship between intimate friends. Regarding my countertransference, I also felt a sense of kinship with the other participants.

Self-disclosure regarding around my learning differences and a careful monitoring of the related transference and countertransference relationships with certain clients has enriched my clinical work. My clients have had both positive and negative reactions to my self-disclosure, which has provided an important opportunity for deepening the clinical relationship. While not all my clients react positively to knowing that I also have a learning difference, the majority have developed a trust and willingness to explore how my self-disclosure may help them in treatment. Although I will continue to make sure that sessions focus on clients and not on myself, I believe that, overall, my decision to self-disclose has been a positive experience for clients.

Resources

Carley, J. M. (2017, April 13). The Employment Shift: Rethinking Autism Employment Initiatives. Fallbrook, California , USA.

In doing psychotherapy, I sometimes feel like I am wandering with my client through a dense forest of brush and brambles, trying to find a pathway out. Often there is no clear direction or clue, and the way ahead may be difficult. However, there are also times when I have found it particularly helpful to ask my client to return with me to a salient event in his or her life and look at it once again in considerably more detail. This might involve, for example, reexamining a triggering experience or an incident that brought the client into therapy. I call this process of reexamining an earlier event—exactly as the client remembers it happening, moment by moment—the “instant replay.”

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You might do this when the client first brings up such an experience, but often it is best not to do so right away. The event may be too raw and painful when it first comes up in therapy; and additionally, you may not yet know enough about the client to grasp the full significance of this landmark in the larger terrain of his or her life. Consider the following case.

Beth, a fifteen-year-old, had been admitted to the hospital due to explosive outbursts, depression and suicidal ideation. Her anger toward her family seemed inexplicably intense, and her worst outbursts were directed toward her mother. For example, on the day she was admitted to the hospital, she had planned to run away, and when her mother found out and tried to stop her, Beth had threatened to “deck” her mother, had refused to return home and had threatened to jump out of the car when her mother tried to bring her back. When asked about her anger in family sessions with her mother—and sometimes in individual sessions as well—Beth would withdraw into a seemingly impervious and almost catatonic silence. When she did talk about her anger, Beth expressed feeling criticized, and stated a belief that everyone in her family blamed her for all the family’s problems, including the breakup of her mother’s marriage to her stepfather, and the fact that her biological father had stopped all contact with her. She was not convinced by attempts at reassurance that her mother and stepfather had had their own marital problems and that her biological father had stopped contact not only with her, but with other family members as well.

As time went on, another side of Beth began to emerge. Her mother revealed that at times, Beth had written letters expressing unbearable remorse about her behavior and a desperate wish to change. One letter, which was four-pages long, was entitled “The Unconditional You.” It described a story from a book Beth had read about a girl who was ungrateful and cruel toward her mother until she realized with shock that her mother still loved her unconditionally. The letter went on to express Beth’s belief that she and her mother were like the girl and mother in the story. Beth’s mother voiced exhausted confusion about letters like this and the fact that her daughter could still explode into rage toward her, even after writing them. Beth’s mother seemed to have difficulty accepting that her daughter could have such seemingly contradictory feelings.

At about this time, Beth opened up, first in group and then in individual therapy, about her history with her biological father. He and her mother had separated when Beth was very young, but he had continued to visit Beth, and had remained close with her until he moved to another state when she was 11. They had promised to write each other every week. They did so for a while, but a few months later he remarried and without explanation stopped responding to her letters. Beth’s behavior worsened after this.

The day after she told me about this, I found Beth crying in her room when I came to meet with her. She had spoken to her mother on the phone and was feeling hopeless about ever returning to her family. We talked about the phone call, and then I told her that her mother had showed me the letter about the story she had read. I said that I knew how badly she wanted unconditional love but that I believed that her mother couldn’t always give her this kind of love because her mother was dealing with her own problems.

At this point, the time seemed right to do an “instant replay” of the events that had brought Beth into the hospital. I reminded her of what had happened the day of her admission—how her mother had tried to stop her from leaving, how they had argued, and how she had exploded and eventually been taken to the hospital. I asked her to tell me what they had actually said to each other and we reviewed their argument, step-by-step and word-for-word. She described how her mother had attempted to talk her into returning home. Beth had refused, and after more attempts to persuade her, her mother had finally grown exasperated and said “You can just stay [away]! I’ve tried for seven years, and I give up!” That was the moment when Beth exploded and threatened her mother.

“It sounds like it really upset you when you mother said that. It really hurt you and made you angry.”

“Yes,” she said.

“It scares you when your mother says things like that.”

“Yeah.”

“Can you say why?”

“Because I’m afraid my mother is going to leave me like my dad did.”

This was the first time Beth had ever explicitly made a connection between her behavior toward her mother and her hurt about her father.

In the next few sessions, we clarified and extended this insight. Working individually with Beth, I pointed out that when she had felt hurt by some of her mother’s actions, the hurt had been supercharged by the past pain related to her biological father’s rejection. In parent work with Beth’s mother, I explained that Beth’s battle for distance was accompanied by a fear that she would lose her mother completely, leading her to do things that forced her mother to take greater parental control, while simultaneously pushing her mother away. And in family sessions, we explored together how Beth’s feelings about both of her parents had come to be focused on her mother. As Beth said to her mother in one of these sessions, “It’s easier to get mad at the parent who is there for you.”

Somewhere within us, painful memories are frozen in time. Unexpectedly, they may leap to life, opening old wounds. But under the right conditions, we can gain the upper hand over time—revisiting and re-running those painful experiences, freeze-framing the exact moments when we gave them power, and clearing a path to healing.

Mr. C doesn’t say he is sad. He isn’t crying. But his face is like stone, draped in a small disconnected smile, and my own insides have turned to lead. Hopelessness clamps down like a vise. I am sitting at the foot of his hospital bed in the nursing facility where I provide psychiatric consultation. Mr. C rarely leaves his bed, around which he insists the thin pink privacy curtains remain closed to wall off the three other men who share his room. The social worker had asked me to see Mr. C because he’s due to be discharged, and she’s been worried about him. Even the air in the room feels heavy. It’s hard to move or even breathe without hope.

Mr. C is only in his early 40’s, but diabetes has taken a part of each foot, and he can no longer work as a chef or care for his mother, who has dementia. “Now I’ve got nobody. Even when I was taking care of my mother and had a job, I could barely leave the house because of my anxiety, and I let my feet rot,” he says. “I’m afraid I’m not going to do the basic things to take care of myself. There really isn’t any hope for me.”

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My thoughts start to churn. There is no way I can help this man. His problems are not solvable. What I have to offer is too puny, and my own background too sheltered. I even notice a small spark of anger at him rising inside me. I want to leave, to retreat to the comfort of my office and sit with thoughts unmarred by unbeautiful things.

I’ve had the luck of meeting a master of empathy, a meditation teacher I met last spring on a day of silent retreat. Attempting to focus on my breath as I sat on my cushion, my mind had erupted with grief over a recent personal loss. The pain was disorienting, concentration all but impossible. My teacher’s advice was simple: let the feelings come, notice them. Her words were ordinary, but her compassion was not. She received my sadness without flinching, letting it vibrate within her as she held my gaze and smiled with warmth and calmness. I felt my connection with her creating another dimension that allowed my sadness to find the space to take its own shape; I did not have to carry the pain alone. It opened like a quilt held between us, and I could see it for what it was and only for what it was. My pain was no longer the sign of inevitable and unending suffering; it was just a feeling I was having in that moment.

Now, as I sit with Mr. C, I gently shake myself from the trance of hopelessness and the trap of my own ego that sustains it. I can’t solve this man’s problems, but that is not shameful. His problems are severe and overcoming them will require a lot of hard work from him. He may or may not be willing to do that work. I can offer him empathy, compassion, and guidance. Those things might not be enough, but then again, they just might be. As I bring myself back to this moment at the foot of his hospital bed, I recognize that within an experience that feels like a burden is a remarkable privilege: that of being close to another human being.

“You can’t see things getting any better. You don’t have your mother to take care of anymore. You won’t have your job, and you are worried that you’ll give up fighting the anxiety. You remember how hard it used to be, and it’s going to be even harder now. That must feel utterly overwhelming, and you are probably terrified and feeling intensely hopeless. Is that right?”

He nods somberly, holding my gaze, and tells me about the spells that come down on him in the afternoons when things quiet down here at the nursing home. The feeling of tunnel vision, of unreality, of feeling almost outside of his own body.

“I have such a sense of sadness as I hear you speak about this,” I tell him. “And at the same time, I am grateful that you are sharing this with me. I admire the strength it takes to be honest about what you are facing. And I can see how believing that things are hopeless might almost feel like a kind of relief. You can stop fighting so hard.”

He almost interrupts me, showing more life than I’ve seen him show to this point, “Yes! It’s so, so hard. I hate it here, but all I want to do is curl up in this bed and hide from everything!” And for the first time, he starts to cry. As his tears fall, he asks me earnestly, “What can I do? Can you help me?”

At this moment, something shifts. He isn’t falling back into hopelessness and helplessness. He is asking me for help. In fact, I have plenty to offer him. “There are powerful tools to address your anxiety,” I tell him. And gently, keeping tabs on his level of interest, I explain how avoidance locks anxiety in place, and how exposure therapy can retrain the mind to experience anxiety differently. “If you want,” I offer, “I could show you how to systematically challenge your fears. It’s very hard work, but it could open a lot of possibilities for you. Would you want to work in that direction?”

“Yes, I’d like that,” he replies.

Hopelessness is a horrible feeling; it is no wonder we flinch from it. When we welcome it between us, it becomes all of what it is, and only what it is, and there is room for something else that looks a lot like hope.

Despite prevailing evidence that exposures are an effective (if not, the most effective) component of treatment for child anxiety disorders¹, therapists might reasonably feel reluctant to implement this therapeutic strategy in their practice. “By design, and simply stated, exposures make children with anxiety feel more anxious”. How, then, can they be used to treat anxiety? This seems counterintuitive. I certainly thought so when I first started my training as a doctoral student in clinical psychology, and as a child-anxiety therapist. However, through my training, I learned more about the rationale that underlies the efficacy of exposures, and continuously witnessed the benefits of exposures firsthand through my own clinical work. Through this process, I transitioned from an exposure-skeptic to a strong believer.

Exposures, Anxiety & Children

“Exposures” are clinically created and controlled scenarios that involve introducing an anxiety-evoking image or experience in a graded fashion so that individuals can learn how to regulate and manage their anxiety response to a feared stimulus or situation. For example, if a child has a fear of the dark, then an “exposure” would involve having the child sit in a dark room. Exposures are effective because they allow anxious children the opportunity to learn through their own experience that what they fear will happen (e.g., a monster will pop out from a dark corner) does not actually happen. After repeated practice experiencing the feared event or image while building coping responses, the child learns that the feared situation (e.g., dark room) is no longer associated with danger (e.g., because a monster never popped out of the corner). Some children learn this after only one or two exposures, other children require more practice. Additionally, exposures allow children the opportunity to “sit in” their anxious feelings and learn how to tolerate them by letting uncomfortable, anxious feelings come and go. Many children initially think that if they confront a feared situation, their anxiety levels will skyrocket and never come back down. Exposures allow children the opportunity to learn that although their fear levels will likely increase when confronting a feared situation, over time (i.e., as they learn that nothing “bad” or “dangerous” is happening), their fear levels will eventually come back down—and usually within a few minutes.

In my clinical experience, exposures work best when they are implemented gradually. I wouldn’t have the child sit in a pitch-black room by himself for 20 minutes at the second or third treatment session. This is called “flooding” and may have detrimental effects. Instead, I might start with having the child sit in a room with dim lighting for 30 seconds, and then gradually move up in time and darkness level week-by-week until the child reaches his treatment goal (which in this case, might be to fall asleep alone at night with the lights off).

Exposures should also be planned in advance and agreed upon by all parties. The child (and parent) should know what’s coming and should play a collaborative role in planning the exposures. This is often done by creating a “fear ladder” wherein the child, parent, and clinician determine a treatment goal (e.g., to be able to fall asleep alone with the lights off) which is at the top of the ladder, and then plan “steps” to reach that goal (in the form of gradual exposures).

Example fear ladder that I created:

In addition to being gradual and planned, exposures should be frequently practiced. The more practice the child has with exposures, the easier (i.e., less scary) the exposures will get. More practice with the exposures allows for more opportunities to realize that the feared situation is not truly dangerous. Therefore, exposures should ideally be conducted both in-session and at-home as “therapy homework.”

Furthermore, given that one of the main purposes of anxiety treatment is to improve the child’s use of coping skills when facing feared events, exposures should be taught and delivered alongside active coping skills. Other coping skills include relaxation strategies (e.g., slow, controlled breathing; progressive muscle relaxation) and thought switching (i.e., identifying negative, anxious thoughts and switching them to neutral or positive thoughts). These skills should be practiced before and during the exposures, and are meant to facilitate the regulation of the child’s fears as s/he sits through the exposure. Coping skills teach the child that “I have some control of my scary feelings” and exposures teach the child that “Nothing bad happened, even though I thought it would.” Together, these practices work to reduce anxiety in children.

Common (and Reasonable) Myths

The prospect of conducting exposures in treatment sessions can be daunting for therapists, particularly beginning clinicians. At first, I, too, had reservations. What if these exposures make my patients’ anxiety worse? What if my patients despise me for putting them through distress and they never return again? How am I supposed to convince children that confronting the things they’re extremely afraid of will actually help them?

To my relief, I am not alone in having experienced these concerns, as other therapists, according to Stephen Whiteside and his colleagues², have reported feeling reluctant about exposures for similar reasons. Over time, however, I have come to learn that although these concerns are shared and understandable, they are actually myths, or perhaps in the lingo of practice, irrational thoughts.

Myth #1: Exposures Make Anxiety Worse

The proper delivery of exposures involves the following three steps:

The child confronts a feared situation (increase in anxiety)
Nothing “bad” or “dangerous” happens (decrease in anxiety)
The child realizes that what s/he was afraid was going to happen did not end up happening (return to zero anxiety)

Given that proper exposure delivery involves steps 2 and 3, exposures do not make anxiety worse. Rather, exposures help children learn that the feared situation is not associated with real danger, which leads to reductions in anxiety, and often a sense of pride and accomplishment for successfully facing their fears. A potential concern might then be, “Well, what if something bad does happen during the exposure?” This is an understandable concern (one I admittedly had), but perhaps not a reasonable one. For example, let’s say the child with the dark phobia hears a noise while he is in the dark room. At first, he may interpret this as something “scary” happening, which one might reason would lead to an increase in anxiety during the exposure and subsequent maintenance of the dark phobia. However, upon examining the situation more closely, the therapist can guide the child into realizing that even though the child perceived the noise as something “scary” or “bad” happening, nothing bad actually happened. Did the noise itself cause the child any danger? What other (non-scary) thing could the noise have been?

Another important lesson here is that even though something dangerous happening during an exposure is possible, that does not mean that it is probable (this is also a lesson that we teach our patients!). Just like it is possible for us to get into a car accident any time we get into a car, it is not highly probable; therefore, we should not let the possibility of a car accident prevent us from ever getting into a car. This is because the benefits of car transportation (i.e., the ability to get around to wherever we want, whenever we want) outweigh the slight risk involved. Similarly, we should not let the possibility of something bad happening during an exposure prevent us from delivering exposures to our patients. There is a much stronger likelihood that the exposure will be successful, which will lead to major anxiety reductions in our patients. The benefits here outweigh the risk.

Another potential counterargument may then be, “Well, why can’t I just continue to do what I do (e.g., teach relaxation skills and/or teach children to focus on “positive” thoughts), given that these strategies are less risky and are also beneficial to my patients?” This is a great point. Relaxation and other strategies (e.g., changing anxious thoughts to positive thoughts) are important coping tools for anxious children. However, to maximize the effectiveness of our therapeutic work, these strategies should be taught alongside exposures. This allows children to practice such coping tools in real-time while they are doing an exposure during the treatment session. Therefore, instead of telling our patient to “practice slow breathing the next time you are anxious,” we get to witness the patient practicing slow breathing in real time while s/he is anxious. This allows us to provide live feedback on the child’s use of the skills (e.g., “try breathing even slower”) while they are in an anxiety-provoking situation. By receiving such feedback while they are in an anxiety-provoking situation, the skill is more likely to generalize to when they confront anxiety-provoking situations outside of the session (compared to practicing the skills in-session while they are calm/not anxious).

Myth #2: Exposures Damage the Therapeutic Relationship

This one was a big concern for me. I feared that if I pushed children into confronting distressing situations, they would resent me, hate coming to therapy sessions, and then convince their parents to take them out of therapy. However, after conducting hundreds of exposures with my patients, this has never happened. Not even once. In fact, by the end of treatment, many of my patients have reported that they are happy that they completed exposures as part of treatment. They say that they are proud of themselves for completing the exposures, and have reported “feeling brave” after the sessions. I’ve even heard patients say, “I didn’t think I could do it, but I did, and it wasn’t so bad!”

This is not to say that I have never been met with resistance when planning or bringing up the idea of exposures. Usually that is addressed by patiently re-explaining the purpose of why we’re doing the exposures, in a way the child understands. But overall, based on my experience, I believe that as long as the therapist conveys empathy/understanding towards the patient’s fears (e.g., “I understand how scary this might feel for you”), remains consistent in encouraging the patient to face his/her fears (e.g., “It’s okay if that was too hard this time, let’s talk about it and then see if we can try again”) and demonstrates a sense of pride when the patient attempts or successfully completes an exposure (e.g., “Nice job facing your fear! That was so brave!”), the therapeutic relationship tends to stay intact.

But don’t just take my word for it. Research also shows that “introducing exposures into treatment does not damage the therapeutic relationship”³.

Myth #3: Children Are Unable to Foresee the Benefits of Exposures

A third major concern that I had was whether younger children (i.e., as young as 6 or 7 years old) would be able to understand the purpose and rationale for doing exposures. I worried that children would consider therapy a “scary” place and wouldn’t understand why I was asking them to confront their fears.

Contrary to my initial belief, most children can grasp the concept if explained in a developmentally appropriate manner. For example, for younger children, I give an example of a girl named Andrea who is very scared of puppies (first I make sure the child is not scared of dogs or puppies). I ask the kids,
“If Andrea is really, really scared of puppies, will she want to play with puppies, or stay away from them?”

Most will say “Stay away from them.”

“But are puppies actually scary?”

“No!”

“What will probably happen if Andrea goes up to a puppy?”

“I don’t know, maybe it will lick her and want to play.”

“Yes, that’s right, the puppy probably just wants to play. But if Andrea is scared of puppies, what does Andrea think will happen if she goes up to one?”

“She probably thinks it will bark at her or bite her, maybe.”

“Yes that’s probably exactly what she’s thinking! But will it?”

“Probably not.”

“Okay, so let’s say Andrea practices being brave one day, and goes up to a puppy. Like we just talked about, the puppy just licks her on the hand a couple times and maybe brings her a toy. Makes sense, right?”

“Right.”

“So, once Andrea realizes that the puppy didn’t bite her or bark at her, will this make her feel more scared of puppies next time or less scared?”

“Less scared.”

“Yes, less scared! Now Andrea is less scared of puppies. So, the way Andrea became less scared of puppies was by facing her fears, going up to the puppy, and seeing that nothing bad happened (even though she thought the puppy would bark or bite). Does that make sense?”

“Yeah.”

“So in the same way, the work we will be doing together will involve being brave, facing our fears, and learning (like Andrea did) that even though we think something bad will happen, it actually won’t. But we’re going to do this in a slow, step-by-step way to make sure it’s not too scary.”

After this, I present a rationale for why we do it step-by-step, and let the child know that s/he plays a role in deciding which exposures to do. Most of the time, this rationale and an explanation of the up-and-down nature of fearful feelings are enough to help children understand the purpose of exposures.

Tips on Delivering Exposures

There is a right and wrong way to deliver exposures, so here are some (research-supported) techniques on how to reduce the chances of exposures going wrong:

Prior to beginning exposures:

Ensure that the child and parent understand the rationale behind exposures

Just like therapists need to know how and why exposures work in order to feel comfortable delivering them, children need to know how and why exposures work so they can feel more comfortable practicing them. See the example above on how to explain the rationale for exposures. Keep in mind that the type of explanation should match the child’s developmental level.

Seek child and/or parent input during the construction of the fear ladder

The child and parent should be a part of the treatment planning process. Allowing child and parent input can make exposures seem less intimidating, and allow children a sense of control over their treatment. Work together to determine a treatment goal and ensure that the exposures gradually move toward and reach that goal. “Remind children and parents that the exposures should ideally elicit a moderate amount of fear” (not too little, and not too much).

During exposures:

Track the child’s fear ratings immediately before, during, and immediately after the exposures

Tracking the child’s fears can be done by obtaining a number from a scale of 0-10 of how scared the child is feeling. There are multiple benefits to tracking the child’s fear ratings throughout the exposures. From the therapist’s perspective, tracking the child’s fear ratings can provide helpful insight into whether the exposures are “too easy” or “too difficult.” Fear monitoring can also provide insight into whether the fear is moving in the anticipated direction (with fear ratings highest before the exposure and lowest after the exposure). From the child’s perspective, fear monitoring can provide “evidence” that the anticipation of the exposure tends to make him/her feel more scared than the exposure itself.

Try to minimize distractions

In order to maximize the effectiveness of exposures, the child should enter the exposure with some level of fear and anticipation that something negative/dangerous will happen. While in the exposure, the child should still experience some fear and think about what it is s/he is afraid will happen. After the exposure, the child should realize that the feared outcome did not happen.

If the child is distracted during the exposure (i.e., doing anything that would prevent him/her from realizing and s/he is scared and fearful of some outcome), then the effectiveness of the exposure goes down. It is better for the child to confront the anxious feelings and realize that “I was scared and thought something bad would happen, but everything still turned out okay” versus “I wasn’t scared because I was distracted, but yes, nothing bad happened”.

After exposures:

Praise the child’s efforts

Given that exposures can be temporarily distressing to children, it is important to “acknowledge the child’s bravery for attempting to face his/her fears”. Praise should be given when the child successfully completes an assigned exposure, or when the child makes any effort to complete the exposure (even if completion of the exposure is unsuccessful). Praising the child allows the child to feel a sense of accomplishment, reinforces continued practice of exposures, and can also aid in maintaining the therapeutic relationship.

Help the child articulate what s/he learned from doing the exposure (i.e., that what s/he feared was going to happen, did not happen)

For exposures to be successful, the child should be able to articulate that the feared outcome did not occur. Therapists can facilitate this conclusion by explicitly asking, “What did you learn from this practice?” For younger children, the question can be framed as, “What did you think was going to happen before you went into the dark room?” “Did that end up happening?” “What actually happened?”

Stephanie’s Messy Hair

Stephanie (name and identifying details changed) was a 10-year old girl who had previously been diagnosed with social anxiety disorder. At the start of treatment, Stephanie and her mother reported that Stephanie avoided asking or answering questions in class, initiating or joining in peer conversations, and speaking to adults (e.g., waiters) because of excessive fear of appearing “stupid” or “weird”. Stephanie’s mother also reported that she took 30 minutes to fix her hair in the morning, which often resulted in arriving late to school and her mother arriving late to work. Stephanie reported that the reason she spent 30 minutes on her hair was because she was afraid other people would make fun of her if her hair was messy.

Stephanie’s main treatment goal was to be able to initiate and join conversations with other kids in school and extracurricular activities. Stephanie and her mother reported that a secondary treatment goal was to decrease the amount of time it took Stephanie to get ready in the morning, so that she and her mother were no longer late to school and work. Stephanie was on board with doing exposures to achieve her treatment goals (although she would initially try to avoid doing them), and demonstrated a good understanding of why we were doing exposures. I devised a “fear ladder” jointly with Stephanie and her mother. The first few weeks of exposure practice involved situations such as Stephanie saying “hello” and introducing herself to another adult and child in the clinic, asking questions to the front desk staff (e.g., “Can I borrow a pen?” and “What time is it?”), ordering for herself at restaurants, and saying “hi” to peers at school. Stephanie also practiced doing presentations in front of an audience of 3-4 people and engaging in back-and-forth conversations with other people for at least 5 minutes. By the ninth session, after completing several steps on the ladder, it was time for her to practice going out in public with messy hair. Here’s how the exposure went:

Therapist (Me): “Alright Stephanie, do you remember what was next up on the ladder for this week?”

Stephanie: “Yes, going outside with messy hair”.

Therapist: “That’s right. And how are you feeling about practicing that today?”

Stephanie: “Do we have to?”

Therapist: Smiles. “What do you think?”

Stephanie: Smiles and looks down. “Ok, I’ll try…”

Therapist: “Ok, wonderful! That’s all I care about, remember? That you try. So, going outside with your hair kind of messy: what makes that scary for you? What do you think will happen?”

Stephanie: “Wait. How messy is my hair going to be?”

Therapist: “We can decide that together. I was thinking of putting your hair in braids and having some hair falling out and sticking out in different places, because your mom told me about how you don’t like that. What do you think?”

Stephanie takes a deep breath and I notice her start to blush.

Stephanie: “Okay…”

Therapist: “I like how you just took a deep breath when you started to notice your fear go up. So now, back to my previous question: what makes this scary for you? What do you think will happen when we go outside?”

Stephanie: “Everyone will stare at me and come up to me and say, ‘Why is your hair so messed up?’”

Therapist: “Has that ever happened before, when your hair has been messed up?”

Stephanie: “No.”

Therapist: “Okay, so what do you think the chances are of that happening today?”

Stephanie: “I don’t know. I’m still scared it will happen.”

Therapist: “Okay, so as always, this will be our experiment. It’s never happened before, but let’s see if it happens this time.”

Stephanie nods.

Therapist: “So what’s your fear rating right now?”

Stephanie: “Seven.”

Therapist: “Ok, and what are some coping skills we can do to prepare us for this practice?”

Stephanie: “Deep breaths and positive thoughts.”

Therapist: “Exactly. What’s a positive thought you can tell yourself to feel more brave?”

Stephanie: “I’ve done this before and nothing’s happened.”

Therapist: “Great! And what if someone does stare at you? What did we talk about last time that you can tell yourself?”

Stephanie: “That I should say to myself, ‘So what?’”

Therapist: “Yes! You can ask yourself, ‘So what if they stare? Will it matter tomorrow that a random person stared?’ And will it?”

Stephanie: “No.”

Therapist: “Alright, let’s go.”

While we walked outside, Stephanie initially walked close behind me, hiding her face. After the first person walked by, I asked Stephanie, “Did that person stare at you?”

Stephanie: “No.”

Therapist: “Okay. Let’s keep experimenting and see what happens.”

As we walked around outside the therapy building, I asked a couple more times if she caught anyone staring. Stephanie reported that her fear rating decreased to a 4 in about 45 seconds. After another minute passed by, Stephanie reported that her fear rating was 2. Once we returned to the therapy room:

Therapist: “You did it! You walked around for 5 whole minutes with your hair messy, even though there were other people around. You stayed in the situation the whole time (even though you didn’t want to do it at first), and I even noticed that you moved from behind me to next to me! How did that feel for you?”

Stephanie: “Good. I was scared at first, but that wasn’t as bad as I thought it’d be.”

Therapist: “Great. So, what are the results from our experiment? Did anyone stare at you or ask you why your hair looked like that?”

Stephanie: “No, nothing bad happened.”

Therapist: “Yes, nothing bad happened. And what did you learn from today’s practice?”

Stephanie: “If I go outside with messy hair, people might not stare at me or come up to me.”

Therapist: “Great. And how do you feel knowing that you just faced your fear on something that was really scary, and stayed with it the whole time? You were at a 7!”

Stephanie: “I feel good, proud.”

Therapist: “Glad to hear it. I feel good and proud, too.”

Closing Comment

At first, I was intimidated by conducting exposures. I worried that exposures might make my patients’ anxiety worse, rupture the therapeutic relationship, and that I would not be able to effectively explain the purpose of exposures to children. Despite these fears, my training experiences have led me to become a strong believer in their effectiveness in treating child anxiety.

Once I “exposed” myself to the delivery of exposures with children and adolescents, I quickly learned that what I was afraid was going to happen (e.g., their anxiety will get worse, the therapeutic relationship will be damaged) did not actually happen. After continuously conducting exposures in treatment sessions with my patients, I learned that exposures do not tend to have negative or dangerous consequences. (It also helps that decades of strong research evidence show exposures do not have negative consequences). So, for any therapists out there who treat children (or adults) with anxiety disorders, especially those new to the field, I encourage you to confront any fears, myths or preconceptions you might have about exposures (gradually, if you must) and join me in this beneficial and therapeutic practice.

Resources

1. Chorpita, B. F., Daleiden, E. L., Ebesutani, C., Young, J., Becker, K. D., Nakamura, B. J., … & Smith, R. L. (2011). Evidence?based treatments for children and adolescents: An updated review of indicators of efficacy and effectiveness. Clinical Psychology: Science and Practice, 18(2), 154-172.

2. Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety disorders, 40, 29-36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868775/

3. Kendall, P. C., Comer, J. S., Marker, C. D., Creed, T. A., Puliafico, A. C., Hughes, A. A., . . . Hudson, J. (2009). In-session exposure tasks and therapeutic alliance across the treatment of childhood anxiety disorders. Journal of Consulting and Clinical Psychology, 77(3), 517-525. doi:10.1037/a0013686.

In my previous article, Seven Mistakes in Clinical Supervision, I highlighted common pitfalls we make in our pedagogy of choice in professional development.

In this blog post, I will provide a pathway out of the first of the seven issues, Too Much Theory-Talk, by suggesting the regular use of recording and reviewing of the supervisee’s clinical work.

Clinical supervision typically entails case discussion, case conceptualization, theoretical formulation, treatment planning/implementation and a myriad of therapist/client-related variables. Most clinical supervision sessions are constrained by a prescribed theoretical construction, dictated by both the supervisor’s and therapist’s theoretical biases. When a “stuck” case, one in which clinical progress is not forthcoming, is being reviewed, it is important that the supervision have a sound base of content knowledge of a client’s presenting concerns (e.g., depression, obsessive-compulsive disorder, complex trauma, borderline personality), a critical form of guidance related to process knowledge (i.e., the moment-by-moment engagement between client and therapist), and finally, conditional knowledge (i.e., how the supervisee/clinician may work with a client who is depressed in the context of grief, compared to someone else whose depression results from domestic violence)¹. Even in our individual pursuits as therapists, those moments spent outside of our immediate supervisory role, much of our time spent learning to become more effective clinicians is anchored in the “content knowledge” domain. While it may be necessary, this isn’t sufficient.

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When there is a gap in the supervisee’s clinical knowledge, the supervisor can impart specific content knowledge by adopting a didactic stance and providing “just-in-time” relevant corrective information. In addition, especially for beginning practitioners, supervisors can provide relevant reading materials and resources.

However, in order for supervisors to provide relevant and useful feedback and guidance regarding process and content knowledge, those more complex and dynamic elements of the therapeutic encounter, it is not enough to simply talk about the content of the case from the removed position of clinical information-sharing. Much like other fields (music, sports), it’s important for the supervisee to record their therapy sessions so the supervisor may provide feedback about actual in-the-moment performance with particular clients, rather than feedback about a perceived performance by the supervisee. Feedback is useful when it’s based on well-defined objectives, observables, and specifics.

Take the renowned basketball coach, John Wooden. In an analysis of Wooden’s teaching practices, researchers found that 75% of his active coaching time consisted of “discrete acts of teaching . . . pure information: what to do, how to do it, [and] when to intensify an activity.” Slightly less than 7% of his time was spent dispensing compliments or disapproval².

As an aside, it is important to note that most theories are developed after the fact. As Gregory Bateson once said, “The theorist can only build his theories about what the practitioner was doing yesterday. Tomorrow the practitioner will be doing something different because of these theories.”

The field of psychotherapy is less about “specialized” technical knowledge, than it is about deep relational mastery to resolve the client’s (and occasionally, the clinician’s) emotional wounds. We need to move beyond content knowledge and design our learning to improve our process and conditional knowledge. Recall when Carl Rogers (1939) said “…A full knowledge of psychiatric and psychological information, with a brilliant intellect capable of applying this knowledge, is of itself no guarantee of therapeutic skill.”

In the next blog post, I will tackle the second issue raised in the article Seven Mistakes in Clinical Supervision, the “pat-on-the-back” phenomena in clinical supervision.

This blog post was adapted from the original titled: Three Types of Knowledge and Why This Matters in Psychotherapy.

References:

(1) Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. In D. S. Prescott, C. L. Maeschalck, & S. D. Miller (Eds.), Feedback-informed treatment in clinical practice: Reaching for excellence (pp. 323-355). Washington, DC, USA: American Psychological Association.

(2) Gallimore, R., & Tharp, R. (2004). What a coach can teach a teacher, 1975-2004: Reflections and reanalysis of John Wooden’s teaching practices. The Sport Psychologist, 18(2), 119-137. doi:10.1123/tsp.18.2.119

On those two nights after leaving school following back-to-back, eye-opening and unsettling experiences in my graduate counseling classes, I had a strange feeling that I had arrived at the intersection of possible culture blindness, social discomfort and the questioning of my own clinical supervisory competence.

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I reflected back on two absolutely unrelated but clearly convergent events in two separate graduate counseling classes on back-to-back nights—ethics and psychopathology. As it was to turn out, challenging, unanticipated and enriching lessons in diversity were in the making.

Scenario one: My back was to the class as I was about to write down their responses to a question I had posed. One of my students, located in the far back right corner of the classroom had offered a verbal response, and as I turned to make eye contact I wasn’t quite sure where the voice had originated. My eyes landed on one particular African-American woman who I thought had made the comment, but quickly the student sitting next to her, also African-American, quipped “it was me, but there is a lot of chocolate in the room.”

Instantly embarrassed, I did my best to conceal the painful feeling of embarrassment and the deeper thought that, in that moment of failed echo-location, I had conveyed the message that the voices of all black people sound alike. Or, had I?

Scenario two: Occasionally, I joke with students about the snacks they bring to class. A Latina student in the back of the room offered up a bag of potato chips, across the front of which was a green elliptical design that on quick glance I thought was meant to be a jalapeño. I thanked her and said, “I don’t eat jalapeños.” Just as quickly as in the first scenario, this student shot back, partly in humor but also likely in defense, “did you assume these are jalapeño-flavored chips because you know I’m Mexican?”

Still reeling from the chocolate event of the previous night, I was once again embarrassed, thinking that I had somehow awkwardly fumbled insensitively across a cultural divide, falling flat on my face in the process.

I knew that these were learning opportunities in the making, both for myself and my counseling students, who had each taken our program’s multicultural course with Judi Bachay, an international scholar and diversity expert here at St. Thomas. But, there is nothing quite like a live-action, and as Irvin Yalom puts it¹, “here-and-now experience,” for conveying an important concept. And while I made a nominal attempt to address my concerns in class each time, I could tell that the two students were equally uncomfortable.
Was it my cultural insensitivity that provoked their humor-cloaked defensive comments, or over-sensitivity to their own racial/cultural positioning in my class…in society? In either event, I believed that as their (white) teacher, I needed to do my best to find out, for them, for myself and for the class.

I was indeed able to speak in private with each of these two students on separate occasions and discovered the following. The formative educational years of the student in the first scenario was spent alongside white peers, where a sense of racial discomfort led to concern that she would be judged primarily by her skin color, rather than the qualities of her character. Racial invisibility as Darrick Tovar-Murray suggests², was in a sense, a psychological survival strategy. During her transition to college, the student in the second scenario attended classes in a less-Latinx environment compared to earlier years. She became less comfortable with her Mexican roots, often trying to conceal her accent—a different, but no less poignant form of invisibility. She lived with the fear of being called a chola.

I felt sadness for each of these students who grew up believing they had to trade elements of their racial and cultural origin for the security, or perhaps false security, that invisibility falsely promises. I have never felt that pressure—part of my privilege, I guess. I shared with each of them the guilt I felt, perhaps white guilt, and my concern that I had contributed unknowingly to their experience of invisibility. But in retrospect, perhaps their respective protestations were statements of visibility, and refusals to remain hidden. Lessons were learned on both sides of the divide those nights.

References

(1) Yalom, I. (2017). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: Harper Perennial.

(2) Tovar-Murray, D., & Tovar-Murray, M. (2012). A phenomenological analysis of the invisibility syndrome. Journal of Multicultural Counseling and Development, 40(1), 24-36.

Money is often an emotion-laden topic that triggers many associations and meanings for both the therapist and the client. As a therapist starting out in private practice, I had to stumble and fumble my way around decisions regarding setting session fees, enforcing or waiving my cancellation fees and other money matters. I am sharing with you my lessons learned—and what better way to learn than from the mistakes I made.

Mistake #1: Adhering to theory or rules, even when it feels "wrong" (i.e., not aligned with my own personal values).

Something that is ingrained in us as therapists, especially for those of us who are trained psychoanalytically, is to "keep the frame" and "set boundaries." Stating and holding clear boundaries within the therapeutic relationship creates safety for the client. This could be translated rigidly into not negotiating around our fee, or enforcing cancellation policies by the rule. However, depending on the client’s situation and their personal history, this can actually backfire. It can negatively affect the client and the therapeutic relationship, especially if it is experienced by the client as punitive, shaming, unfair/exploitative or controlling. There must be some flexibility in all matters to accommodate therapists’ own values and clients’ needs, which translates into a willingness to reconsider session frequency, waiving cancellation fees, or negotiating around the fee on a case-by-case basis.

Mistake #2: Not examining and having clarity around my own issues with money/fees.

It is important to examine and have clarity on our own internal conflicts and issues around money matters, as well as to know the limits on our flexibility (e.g., what is the lowest fee that we will be comfortable with for a particular client and their situation?), especially when trying to establish boundaries and set a framework with a client.

I had to consider several conflicting needs and values when establishing my regular rate for therapy sessions. I do value my experience, training and what I have to offer as a psychotherapist, and a therapist with a higher fee is often perceived as offering “higher quality” services. At the same time, I think therapy is quite expensive, especially since weekly (or more frequent) sessions are usually recommended. People belonging to lower socio-economic classes face more stressors, therefore making it even more necessary to offer affordable mental health services. Despite my desire to make my services affordable and accessible, I have a strong aversion to being paneled with insurance companies. With so many competing values, initially I was often riddled with guilt, resentment or doubt as I tried to establish a fee that was “just right.” I have finally found a formula (using a combination of a regular rate, sliding scale fees and offering low fee and pro-bono slots via openpathcollective.org that works well for me, embodying the maxim “No size fits all.”

Scenario

What follows is a description of a scenario from when I was just starting out in private practice that highlights both Mistake #1 and Mistake #2 mentioned above:

The client and I agreed on a fee of $120 during the initial free consultation. At the end of the next session, the client told me she’d just found out that her insurance did not cover her sessions (she had a very high deductible) and asked for a reduced fee. Since we were already at the end of session (and keeping in mind that I had already provided her with a free initial consultation), I said that she had to pay $120 for this session, and that we could work out a lower fee moving forward. She asked for a fee of $80, and I said, “That is too low.” (yes, I have to admit that I actually said that). The client wrote a check for $120 for the first session and perhaps not unsurprisingly, did not return to therapy.

What played out in the above scenario were my own unresolved issues around money, and unfortunately these negatively impacted the client.

I was not completely okay with having provided her with an initial free consultation—I was holding some resentment, and thinking that the client now owed me or should feel obliged to me.
I was unsure about how low I could or should slide my fees. I was conflicted between what I had learned about enforcing boundaries, and my own instinct to be flexible in accepting lower fees. This resulted in me responding “That is too low” to the fee suggested by the client. This was shaming to my client, especially given her history of having grown up very poor.

Mistake #3: Not taking into account a client’s culture, history/background and relationship with money.

What I have seen replayed again and again, is that a client's relationship with money and how they approach the issue of the fee is often an extension of their psychology, and therefore, a clinical issue to be examined in therapy in order to help the client navigate more skillfully around such matters. Sometimes their relationship with money is shaped by culture—I have some clients who are bent on trying to negotiate a lower fee, although they have very high incomes—they cannot imagine paying so much “just” for therapy. Sometimes it is shaped by their personal history. I had another client who requested a lower fee due to her many medical expenses and I agreed, only to learn through the course of therapy that this client is a multimillionaire with an inherited fortune. Having grown up with financial scarcity and hardship, the client found it hard to spend or truly enjoy her newfound financial abundance, and she was always looking for a “good deal” or discount. If I, as the therapist, merely see such clients as “manipulative” or if I am offended by their requests and fail to consider the client's context and subjective experience, it is a signal for me to look into what is being triggered for me. I have learned that I must be mindful and navigate such issues around money with skill and sensitivity to the client's experience. In other words, letting the client know that I am open to discussing or negotiating the fee, but that it is important for me to first understand more of their history and their subjective experiences and relationship regarding having or not having things.

Guidelines

Below are my own personal guidelines around money matters in therapy:

Rules (such as charging for missed sessions) are set and enforced based on clinical implications and the client's best interest, and not merely based on business considerations.
Own my own issues (including privilege or scarcity) around money, examine my own relationship and views around money, and gain clarity on my limits in flexibility regarding session fees, cancellation policies and other money-related issues.
A client’s relationship with money (their meanings and associations around money, rather than simply their income or wealth) is an important factor to take into consideration when discussing and setting fees.
What works well for one therapist may not work for another. Differences may be due to business goals, theoretical orientation, populations served, and personal style/values.
Above all, be authentic.

I would like to end this article with a scenario that was posted on an online group for therapists that I participate in, that started me thinking more on this topic and prompted me to write this article. The scenario went as follows: If a person you were working with needed time off from therapy for a couple of months due to a short-term schedule conflict, but didn't want to lose their appointment space, and they offer to pay for that space until they were able to return (you have no other available appointments), is it ethical to accept that offer? The question elicited some emotionally charged but widely differing responses from the therapist group members. How would you handle this situation?

We’d love to hear your responses. Feel free to post to our facebook page here.

After my husband and I moved to our new home state, I found myself coping poorly, to put it mildly. Hundreds of miles from our friends and family, unable to find work and struggling to start a family, I found myself spending entire afternoons lying on the floor of our would-be nursery. I had no appetite, snapped at my husband over every minor annoyance, and was consumed by utter hopelessness.

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But when my husband gently suggested that I seek professional help, my defensive glare could have sliced him in half. Me go to counseling? Had he forgotten that I was the therapist here? I knew what to do; I didn’t need anyone’s help.

But after another month of being impossible to live with, I conceded. I found a clinician who shared my therapeutic approach, swallowed my pride, and stepped into her office feeling completely powerless.

I quickly discovered that my therapist had no idea what to do with me. She also believed that I already knew everything I needed to know to cure my own symptoms, and spent most sessions starting psychoeducational sentences, then cutting herself off.

“Here is a sheet with some common types of cognitive distortions—although I’m sure you already know them…Let’s try keeping a thought record. In the first column—well, you don’t need me to explain that.”

To make matters worse, I was a horrible client. I had intentionally chosen a clinician with more education and experience than me, but the result was that every session felt like supervision with one of my old bosses. I felt the need to impress her, and struggled to discuss my symptoms honestly. When I didn’t offer her anything to work with, my therapist ended up talking shop with me, making me feel more than ever that I was in a work setting where my symptoms would be unacceptable signs of weakness.

After a few months, I stopped booking appointments. The feeling of discomfort must have been mutual, because my therapist never reached out to ask why I had stopped coming. I wondered to myself if this was a common experience, if those of us who are the most steadfast proponents of therapy and bear the emotional burdens of 20 to 30 people at a time, end up having the most difficulty accessing (or contributing to) quality treatment.

A Washington, D.C. area clinician I asked about this noted that she had long avoided counseling for the same reasons I had. “I am certain that working in this field has prevented me from seeking out treatment in times where I could have greatly used it,” she said. “I believe I didn’t seek treatment because of my own belief that I could ‘treat’ myself because ‘I know what I should do and not do.’” Another clinician, based in Massachusetts, confided that when she did seek out mental health treatment, differences in therapeutic approach between her and her therapist made her experience unsatisfying.

“[My therapist] was very approachable, patient and validating,” she recalled. “[But] what I found disappointing was that, in my work with my clients, I generally had items prepared as tools we could use to address challenges or present new perspectives and techniques, and that was not my experience in my own sessions. It had more of your stereotypical air about it where you sit on a couch and talk about your feelings, no preparation, just whatever the client brings. And my work being different, I had a harder time appreciating that and eventually discontinued my work with her.”

I only found one person who felt that being a clinician had improved her experience as a client. Mia DeCristofaro, a Florida-based LMHC, recalled seeking counseling early in her career, when concern for her clients escalated into unmanageable anxiety. “My fear of not doing a good enough job or someone getting hurt on my watch was really hard for me to manage at first,” she recounted. “But being in the field also made it easier to be a client, I think, because I knew what I expected for my own treatment, what I believed about treatment, and I knew how motivated I had to be for it to be effective.”

Perhaps if more therapists who have received mental health treatment were open about their experiences, other clinicians would not feel like professional failures for seeking counseling. Although it may be awkward to discuss, who knows how many clinicians—and their clients—could benefit from this transparency. “We take on a lot of pain in this field and, diagnosable or not, I think we need somewhere to safely manage our own feelings,” DeCristofaro said. “Even if a problem we’re going through isn’t related to our work, we should manage it so that it doesn’t impact our work.”

Maybe this shift in focus from reducing our own symptoms to better serving our clients is the cognitive key to getting more mental health professionals through a therapist’s door. But whatever your reason for going, be the brave one at work and start the conversation about your experiences; you may be surprised to find you’re in good company.

I used to work with a guy named Tom Sullivan. Tom was an accomplished author, singer and inspirational speaker. Tom was blind and traveled the country with his various service dogs. They were seeing-eye dogs specially trained for more than a year to assist Tom in tasks like crossing the street, standing in a line and getting him through airports. These dogs were truly amazing in their devotion and their ability to keep Tom safe, and enabled him to have as independent a life as everyone else. The dogs performed very specific services and allowed Tom to travel on his own. I have also been introduced to hearing-ear animals that can detect an oncoming heart murmur or epileptic attack. These pets are amazing and crucial and are also highly trained. It is easy to state why they are necessary companions.

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Sometimes it is too easy. At Register My Service Animal LLC, one need only confirm that the “dog or miniature horse,” or whatever, can perform a task for you. The pet does not have to be taken anywhere for a test but must be “stable, well-behaved, unobtrusive, and not pose a public hazard.” These are thin qualifications.

Now we come to the age of emotional support dogs. The airlines refer to these as comfort animals. As a psychotherapist, I believe that there are animals that bring a great sense of calm and comfort to their owners. They can quell anxiety or stress when it comes to flying. They can be the fur-ball antidote to depression. Severe extremes of these emotional issues are indeed disabilities, but let’s be real. How many of us in this profession are asked by our clients or friends to sign airline forms stating that one has a necessary service dog, when all they really want to do is get their dog across country either in the cabin avoiding the hull or just not pay the $75 or more extra to transport their pet?

Have I signed some of these forms? Yes, but only because I believed there was an honest need for that kind of assistance. Have I refused others? Yes, not because I felt they were scamming the airlines, but because there are many who just who just do not need their dogs, cats, monkeys, pigs, ducks—yes, all are permitted on the airlines—in order to get through a flight. Getting an Emotional Support Animal (ESA) letter is very easy. It states that there is a “special bond” between the owner and the snake or gerbil or whatever, and that the animal is very important in helping ease symptoms such as depression, anxiety, sleeplessness, PTSD, and more. If these animals can do all this, why do we need professional therapists or psychiatrists?

Psychiatrists can sign documents entitling one to a Psychiatric Service Dog (PSD). For some reason, no other animals are mentioned. The Americans with Disabilities Act distinguishes ESAs from PSDDs by the following: A PSD must not only respond to the owner’s request for needed for help but must be trained to recognize the need in the first place. An ESA need not be trained to perform a certain act—just have genuine therapeutic effect. A PSD is also allowed in public places most ESAs are not. Bring your PSD to a movie theater and that means there is no need to just desire popcorn. Your dog will have it ready for you as the movie begins. Clearly, I am exaggerating but there is a very thin line between emotional support and psychiatric support.

According the Department of Transportation (DOT), US passenger airlines transported an estimated 784,00 pets, 751,000 comfort animals and 281,000 service animals last year. American Airlines said it carried 48% more service/comfort animals this year from last. Has emotional need really risen that dramatically in one year?

Various “watch-dog” industries for the airlines have recommended that the DOT prohibit comfort animals and recognize only trained service dogs. The disabilities-rights groups put up a fight stating there is no distinguishing criteria. Is there really a difference between a hearing-ear cat that can alert their owner to someone trying to get their attention, and a comfort monkey who can wipe away tears of distress? I plead the 5th because the hate mail will surely come in.

What about the rights of other passengers? The Asthma and Allergy Foundation of America stated that airlines need to start enforcing new regulations that also protect these people. (According to the Centers for Disease Control, about 25 million Americans have asthma and more than 20 Million have allergies).

And what about those who are just petrified of anything with four-feet? My mother was scheduled to fly with me across the country from Philadelphia to Los Angeles. Once boarding the plane, she took one look at a German Shepherd, the size of a horse, who apparently could fit under a seat and stated she just would not get on the plane. She wasn’t kidding. There is no airline in the US that currently bans in-cabin support or service animals.

Are service animals needed? Absolutely, unless the person in need is traveling with a companion. Are emotional support animals needed? Sometimes, if the psychological issues are extreme. Must these animals be on the plane all the time? Absolutely not.

So, I figure my Mom and I are about halfway through Kansas in our drive now, thanks to the emotional support German shepherd that scared the life out of her. So, therapists, social workers, MDs and more, before you sign those emotional support letters, please really think about what your responsibilities are not just to your clients and doing a nice thing for them, but to the rest of the travelers who deserve your remote care as well.

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Author: Psychotherapy.net Team

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Origins of Empathy

Fellow Travelers

Transference & Countertransference

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The Shape of Hopelessness

Addressing Common (and Reasonable) Myths About Exposure-Based Therapy for Child Anxiety

Exposures, Anxiety & Children

Common (and Reasonable) Myths

Tips on Delivering Exposures

Stephanie’s Messy Hair

Closing Comment

Three Types of Knowledge Clinical Supervisors Need to Know

Chocolate, Jalape

Money Matters in Therapy

When the Clinician Becomes a Client

Is That a Monkey on my Back? No, It