Category: Blog

The Importance of Being Heard: When Clients Need Us to Listen

Posted on by Psychotherapy.net Team

“I feel completely useless to him. I feel like I could fall into a coma mid-session, and he wouldn’t even notice. He’d just keep jabbering away.”

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Navigating Challenging Therapeutic Waters

I spoke these words to my clinical supervisor, Ari. I had been a therapist for just a few months and had no idea how to help one of my clients. Tony, I told Ari, had arrived early to our first session, and before I could even ask, he began telling me his goal for therapy. “I need to learn how to cope with things, especially my girlfriend. When we get into a fight, all I can do is obsess over her. I can’t function at work; I can’t even get myself to do the laundry. I just sit there, looking at my phone, waiting for her to text me.”

I had initially found Tony’s volubility refreshing. Unlike those one-word-answer clients with whom I was struggling to connect, he would answer each question with enough detail to obviate my follow-up questions. Everything about him seemed expressive, even his thick, shape-shifting mop of black hair seeming to change each session as though reflecting his current mood.

Week after week, month after month, he shared his story, telling me about the father who had always seemed intent to one-up him and the mother who would drunkenly come into his room at night and, through tears, complain about her marriage. I started to see how he replicated these childhood conditions in his romantic pursuits, choosing self-involved and emotionally unavailable partners.

Some weeks, his hair spikier than normal, he would describe the wonderful weekend he’d had with his girlfriend—going rock-climbing, going to fancy restaurants—and wonder if she might be the one. Other weeks, his hair noticeably droopier, he would recount with tears in his eyes how she hadn’t once over the past week shown any interest in him. “It might seem like I’m playing a game, but I’m just trying to gather information. Every night last week, I asked about her day, and I’d listen and ask more questions as she went on and on about her horrible coworkers. All the while I’m waiting for something, for anything, for just one question, one piece of evidence that she’s interested in me.”   

When Tony would say that he was going to start looking at engagement rings, I would feel my muscles tense and tell myself to keep my opinion to myself. When he would describe yet another way she had mistreated him—“She gets jealous if I’m on the phone with my sister too long, but like every day she’s texting her old boyfriend”—I would ask what he wanted in this relationship and what he believed he deserved. I would sometimes try to explore the similarities between his girlfriend and his parents, but he never seemed interested in that inquiry.

I initially felt such a strong connection with him, I was now telling Ari, but then something seemed to change. It now felt like it didn’t matter if I was even there, like it wouldn’t make any difference if he spent the hour talking to my plant. He would just go on and on without even pausing. If I wanted to ask a question or share an observation, I would have to interrupt him.

Ari asked some questions and then fell silent. Ari does not have expressive hair, but I’ve noticed that sometimes his brow will reveal his emotional state, and just then his forehead lines deepened. “It sounds like you’re doing good work with him,” he finally said. But I wasn’t doing any work with him, I countered; that was the problem. “When I was starting out as a therapist,” he said, “I felt a lot of pressure to say the right thing and make the right interpretation, but that’s not always what our clients need.”

Ari said that there was probably a reason Tony kept coming to see me. I thought about this and realized that he never came to sessions late, and if he ever needed to cancel a session, he would always make sure to reschedule that same week.   

“You’re listening to him,” Ari continued, “you’re paying attention. It doesn’t sound like his parents ever really listened to him. It doesn’t sound like his girlfriend really listens to him.”

When Tony entered my office later that week, I felt, for the first time in several weeks, excited about our session. Moreover, my changed mindset caused me to see him differently. I still saw the energetic 30-something with ever-evolving hair — today’s style making him resemble Rob Lowe from The Outsiders—but as I looked into his eyes, I also saw the little boy he’d once been. I saw his excitement and fear, his longing to be heard and loved.   

The session itself felt different. I had wanted to help Tony all along, but it took Ari to help me see what type of help he really needed. I had wanted to make life-transforming interpretations, but I could now see that he was not yet at a place where he could receive such interpretations.

Tony first needed the corrective experience of being heard. He needed to know that I cared enough to give him my complete attention and move at his pace without forcing my own agenda upon him. There might be time later for interpretations, but that’s not what he needed now, and understanding that made all the difference, for him and for me.   

Questions for Thought and Discussion

In what ways are the author's experiences like those of your own?

What are some of the methods you found effective for working with Clients like Tony?

What have you found to be some of the more effective uses of supervision?  

The Transformative Power of Empathy in Therapy

Posted on by Psychotherapy.net Team

Therapy as a Place of Safety and Respite

Each person’s therapeutic process will be unique, as will their stories, experiences, and needs. With that in mind, the approach I take with each of my clients varies. I offer a bespoke approach, tailored to the individual needs of each client, built around their personality and presentation. But regardless of their differences and needs, I will always use, and deeply value softness.

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I have come to realise the immense importance of being gentle with my clients. Life, with all its challenges and hardships, can often leave individuals feeling battered, tired, and worn. Many of them seek therapy in a state of heightened vulnerability. It is during these moments that therapy becomes a sanctuary, one that offers them a soft place to land.

As a therapist, I believe deeply that it is my duty to create an environment of warmth, understanding, and compassion. I recognise that my clients may be carrying heavy burdens, and that it is my role to offer them temporary solace and respite from the outside world. I strive to be a gentle presence, providing a safe space where they can lower their defences and be truly seen and heard.

In this gentle space, I encourage my clients to explore their emotions at their own pace. I do not rush or push them to confront their pain before they are ready. Instead, I hold space for their vulnerability, allowing them to express themselves without judgment or criticism. I offer a listening ear, a compassionate heart, and a genuine desire to understand their experiences.

In moments of distress, I remind my clients that it is okay, and perhaps even necessary, to be gentle with themselves. I encourage self-compassion and self-care as essential tools for navigating life’s challenges. Together, we explore gentle practices such as mindfulness, relaxation techniques, and self-soothing strategies that can provide comfort and support during difficult times.

Being gentle in therapy also means recognising and respecting each client’s unique journey. I understand that what works for one person may not work for another. I adapt my therapeutic approach to meet the needs and preferences of my clients, honouring their autonomy and empowering them in their healing process.

Through gentle guidance and unconditional support, I aim to instil hope in my clients. Life may be hard, but therapy can be a refuge amidst the storm. It is a place where they can find solace, gain clarity, and develop the strength to face their challenges with resilience and grace.

In the gentle space of therapy, I strive to be a source of comfort and empowerment for my clients. I believe in their inherent worth and their capacity for growth and healing. By offering them a soft place to land, I hope to help them navigate life’s complexities with kindness, understanding, and a renewed sense of hope.

As a therapist, I am privileged to witness the incredible resilience and strength of the human spirit. Every day, I can guide individuals on their unique journey towards healing and self-discovery. One such client who stands out in my mind is a past client, Emily.

The Use of Compassion and Kindness in Therapy

When Emily first entered my office, I could sense the weight she carried on her shoulders. Her eyes held a mixture of pain, fear, longing for relief, and a need to understand and be understood. It was clear that she had been through significant hardships and was in desperate need of support.

With empathy as my compass, I created a safe and nonjudgmental space for Emily to explore her emotions and share her story. I listened intently, acknowledging the depth of her pain and validated her experiences. I understood that healing begins with feeling seen and heard, and I made it my priority to provide those for Emily. Emily’s hardships had clearly and profoundly taken their tolls—she was tired, mentally, emotionally, physically, and spiritually.

Through our sessions, I encouraged Emily to delve into her emotions and confront the underlying traumas that had shaped her life. It was not an easy process, as she had built walls of self-protection to shield herself from further pain. However, with gentle guidance, she was gradually willing and increasingly able to navigate through the layers of her past and unravel the patterns that held her back.

As our therapeutic relationship grew, Emily began to trust me and felt safe enough to peel back the layers of her vulnerability. She shared her deepest fears, insecurities, and darkest moments with me. In those moments, I realized the immense responsibility I held as her therapist, and I vowed to hold space for her pain and support her in her journey towards healing. There were moments when Emily faced overwhelming emotions that threatened to consume her. She felt lost, as if she would never find her way out of the darkness. In those moments, I provided a steady presence, a beacon of hope, reminding her that healing takes time and that she was not alone in her struggles.

Together, we explored various therapeutic techniques and coping strategies that would help Emily regain control over her life. We worked on building her resilience, nurturing self-compassion, and cultivating healthier ways of relating to herself and others. It was a collaborative process, and I marvelled at Emily’s courage and determination to confront her pain and grow from it. Over time, her wounds began to heal, and I witnessed her transformation into a resilient and empowered individual. She reclaimed her sense of self-worth and discovered her true potential.

***

Emily’s story serves as a reminder to me of the transformative power of therapy. It reaffirms my belief that every individual has the capacity to heal and grow, given the right support and guidance. As a therapist, I am honoured to walk alongside my clients, witnessing their strength and resilience as they navigate their path towards self-discovery and emotional well-being.

Questions for Thought and Discussion

In what ways is the author's orientation to therapy similar to your own?

How do you assure that therapy will be a place of safety for your clients?

How do you address situations where clients enter therapy feeling very unsafe?  

Balancing Between Creative and the Clinician: Reflections on Self-Integration

Posted on by Psychotherapy.net Team

I was only 100 hours away from finishing my registrar program to be endorsed as a clinical psychologist when I confessed to my clinical supervisor:

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“I don’t think I can do this anymore. I want to quit being a psychologist.” The pressure of clinical work was all too much. But let’s start at the beginning, a few years before that confession. Now, burnout is an experience all too familiar to psychologists, particularly early career psychologists. The insurmountable weight of emotional involvement, the pressure to provide “effective” therapy, and the complexity of cases can lead to a sense of fatigue and sometimes even disillusionment. I was no stranger to this experience. Just a few months into my clinical registrar program, working in a group private practice, I found myself teetering on the crispy edge of burnout. With what felt like the weight of the profession on my shoulders, I began to question my career choice. The disconnection from the passion that once drove me was almost too much to bear. In a bid to relieve some of the pressure, I went into solo private practice. At least then, I could practice in a way that worked for me.

Exploring a Non-Clinical Business

Unfortunately, the relief from burnout was fleeting. In another desperate bid, I explored a non-clinical creative venture. This creative detour in writing allowed me to show up as my full self, not having to hold back aspects of my personality and mask as a “professional.” The creative work also rekindled my love for helping others in a different capacity. As I helped businesses find their writing voice, I started to find mine again. Just as I thought I had found the answer in creative work, a new challenge emerged.

How could I work as both a psychologist and a creative? At the heart of my issue was a paralysing fear of stepping out of my traditional clinical role as a psychologist. I feared potential repercussions, repercussions from my peers for doing work that was wildly different from what my university degrees were in. I also feared repercussions from the psychology institution. This internal conflict made me feel like a tug-of-war rope being pulled in too many directions. I was trying to balance both worlds without breaking apart.

The Importance of Supervision and Therapy

Thankfully, clinical supervision and my own psychotherapy were stabilising forces throughout this inner turmoil. Supervision provided an open space to explore my fears, rage, and uncertainties without being shut down. My supervisor’s questioning led me to realise it was possible to have the two roles without compromising my professional integrity.

Psychodynamic psychotherapy played an equally supportive role. It helped me explore the underlying causes of my anguish, and the deeper, unconscious conflicts that were contributing to my struggles. I discovered that my fear of being a regulated professional was actually a manifestation of an unconscious fear of authority.

Supervision and therapy helped me to see this internal conflict had latched onto my professional identity as a psychologist because it felt safer than confronting the real, underlying fear. As I faced that underlying fear, my inability to see a future in the profession lifted. With space to think outside of myself, I then wondered how many other professionals were in similar situations. Turns out, there are many health professionals with non-clinical or creative businesses. Many were also silent about their non-clinical ventures for similar reasons to me.

With grief in my heart, I wished I had known how many other professionals were doing non-clinical or creative stuff at the start of my journey. It would have made holding the two jobs and two professional identities that much easier.

***

Returning to psychotherapy, I felt like I had come home. But this time, home felt like a space where I could be open, confident, and creative. For the past few months, I’ve had my biggest caseload with the most complex patients, and I am nowhere near that crispy shell of a therapist I once was. I can now channel my angst into my creative work, and as a result, I have a newfound flexibility and creativity in my therapeutic practice.

Sitting back on my supervisor’s couch with only a few hours left in my program, I reflect on my initial confession of wanting to quit psychology. I now see that it wasn’t about the profession, but about finding a way to integrate all aspects of myself.   

Honesty, Not Empathy, is the Greatest Gift a Clinician Can Offer

Posted on by Psychotherapy.net Team

Despite spending years in my own therapy, attending graduate school, receiving excellent supervision, and working as a therapist for the past couple of years, I am still in the process of discovering what exactly people find so healing about therapy. Is it the experience of empathy and unconditional positive regard? Perhaps it’s the space to express repressed thoughts and emotions? Then again, some people say it’s the reparative attachment relationship. Others feel that it’s the wisdom and insight of the therapist that’s paramount.

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In my previous post, I shared my belief that clients heal most when they can express themselves fully without fear of judgment and retaliation. So, when a friend expressed that her most pivotal moment in therapy occurred when her therapist expressed helplessness and despair, I was intrigued. Didn’t she want her therapist to be strong and confident? How could my friend feel safe to be herself if her therapist was so reactive? To me, this sounded like an unethical experience of countertransference. I needed to understand more.

Countertransference or Therapeutic Transparency

Ella (not her real name) had been questioning her therapist’s care and commitment relentlessly. Despite many conversations and ongoing reassurance, Ella continued to doubt that her therapist had her best interest in mind. While she repeatedly challenged and tested her therapist, they would continue to show up unconditionally without judgment.

Her therapist helped Ella to check the facts, reflected on the possibility of transference, and continued to offer a reparative attachment relationship. Ella knew that her emotions were irrational. She would lash out and her therapist would not retaliate. What more proof did she need that her therapist was not going anywhere?

About a year and a half into their course of therapy, Ella’s therapist informed her that she would be taking two weeks off for a vacation. Ella expressed fear and worry and accused her therapist of abandoning her. Her therapist listened to her nondefensively, validated her experience, and helped her cope forward.

Ella worked through object constancy and knew intellectually that her intense emotions were a reenactment from her childhood. While her therapist was away, she used every strategy from self-compassion and acceptance skills to reframing her thoughts. She engaged in distress tolerance skills and tried to keep herself busy. She reminded herself repeatedly that a temporary break does not mean the relationship is over. But her emotions got the better of her and she texted her therapist with a suicide threat. Luckily, despite being on vacation, her therapist noticed the text. She contacted Ella’s emergency contact who was thankfully able to deescalate the situation.

Upon her therapist’s return, Ella and her therapist met for a session. As soon as Ella walked into the room, her therapist burst into sobs. Through her tears, she shared that she was overwhelmed and unsure if she could help Ella, who was expecting therapy to save her from herself. Although she had wished to help Ella, the burden was too much for the therapist to bear.   

After hearing this story, I was perplexed. How could Ella have found this experience to be so therapeutic? I thought the therapist had been way too honest about her feelings. She sounded judgmental, hurtful, and perhaps even a bit self-centered. What right did she have to hijack the session with her own fears? I would’ve been devastated if my therapist were to react this way.

Ella, however, was relieved. She had experienced the tears as a piercing jolt of reality that cut straight through her debilitating insecurities. She had been unable to synthesize her rational thoughts with her internal emotional experience. While she “knew” rationally that her therapist cared about her wellbeing, she had never been able to “feel” it. She could not get herself out of the insidious loop of doubting and testing. She had been heading towards a self-fulfilling prophecy and the reaction of her therapist stopped her in her tracks.  

After this incident, Ella’s behavior shifted dramatically. She and her therapist had a meaningful repair and they continued to work together for another couple of years. She shares that although she continued to struggle with doubts, both in and out of therapy, she learned to accept her intense emotions while also choosing more effective ways to navigate them.

***

I’ve learned a lot from Ella’s story. Sometimes the most powerful tool that we have as therapists is simply our own feelings. We can be the first person to be brave and honest enough to reflect on their impact. Others may have responded with anger and accusations towards them but that’s not the same as honesty. That’s defensive and retaliatory. I’m suggesting that sometimes, what a client needs is a chance to see themselves in a mirror. And when we are certain that we have built enough safety in our relationship with them, I think being vulnerable and honest enough to share our feelings may be the biggest gift we can give them.

Questions for Reflection and Discussion

Do you agree or disagree with the notion that honesty is more important in therapy than empathy?

What are your limits of expressing your feelings with a client?

How did you address a challenging situation in therapy around expressing your feelings?  

Standing With Clients in the Twilight of Life

Posted on by Psychotherapy.net Team

Chris had advanced cancer, and only a short time left to live.

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Connecting at the End of Life

Chris was in his 70s, and he felt full of regret as he approached the end of his life; he felt afraid of dying, and disappointed in himself. He believed he’d damaged and lost all the key relationships in his life — who would want to be near to him now, he wondered?

In the course of our weekly therapy conversations, Chris came to realize ways his selfishness had hurt his personal relationships, and he came to recognize that his supposed preference for a solitary lifestyle had become an excuse or rationalization for his estrangement. He thought, though, that he was now paying too dear a price for his errors: dying alone in a nursing home.

Chris lacked a formal religious faith, yet he had spoken of his vague sense of a life beyond this one, and he expected to again see the loved ones who had already passed away. One morning when I came to his room, Chris was sitting on the edge of his bed crying.

He looked up and said, “Talk to me, Tom, I’m scared.”

I pulled a chair up close and looked at him and spoke quietly.

“Chris, when you first came here, you told me you thought you had wasted your life and burned all your bridges. You thought that you’d made all the wrong choices, and had neglected relationships, and that you would die alone.

“But you have been surprised by so many things that have happened during the past few months. Your son came from the west coast to see you and decided to stay here with you till the end; and you thought you had lost him. You hadn’t spoken with your sister for years, yet she and her husband have become regular visitors to you here.

“Many friends you had long lost touch with have reappeared, and you didn’t know how they found you or learned you were ill. Look around the room, Chris, and see all the gifts and cards and flowers you have received from people you thought would not know or care that you were ill. So many unexpected hands have reached out to you, Chris, to help comfort you as you prepare to move on from this world; you never expected such tenderness and reassurance.

“You have spoken lovingly of your parents and grandparents and aunts and uncles, and how you look forward to seeing them again on the other side. So, here you are Chris, poised between this world and the next. You have been loved by many over the past few months, even when you had believed yourself to be unloved. Many hands have been extended to you in this world to help you on your journey, and you anticipate many hands to greet you when you arrive in the next world.”

His quiet sobbing subsided, and he gave a big sigh and said, “Okay, okay, thanks, I feel better.”

A few days later Chris quietly passed.

Nursing homes, typically less formal than outpatient settings, have been special places for me as a psychotherapist, especially when I encounter people with major or terminal illnesses. I commonly engage in exquisitely poignant therapy conversations about life and coping, and about dying and grieving. Clients facing the end of their lives often feel a need to speak openly about their fears, hopes, doubts, and beliefs. Meeting their needs often involves bold entry into topics sometimes avoided or not considered as part of treatment. But it can be profoundly touching and rewarding to meet clients directly in the midst of their most vulnerable moments.

Questions for Reflection and Discussion

What are your reflections on the type of clinical work this author describes?

In what ways do you embrace or avoid working with the elderly or dying client?

What are some clinical challenges that might accompany working with this population?  

The Secret to Forming Powerful Relationships that Spark Change

Posted on by Psychotherapy.net Team

The very best paper on how psychotherapy works was also one of the earliest (written in 1936) – Saul Rosenzweig’s “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” It made the bold prediction that the psychotherapy relationship is much more powerful than specific psychotherapy techniques in promoting change. Hundreds of studies comparing different forms of psychotherapy (mostly done during the last forty years) confirm Rosenzweig’s brilliant intuition. Although a given specific technique may occasionally score a small win over another specific technique, the overwhelming number of randomized clinical comparisons result in tie scores. It’s remarkable how little this robust finding from psychotherapy research has impacted on psychotherapy training and practice. Most training programs focus on teaching just one narrow- gauge technique and their graduate practitioners tend to identify themselves for life by the school of therapy in which they trained. Paradoxically, then, most psychotherapy training pays least attention to what matters most in clinic practice — forming a powerful healing relationship with the patient. And psychotherapy training also often ignores the most important practical issues that help determine the nature of that relationship. If and when should a therapist give advice? What if any is the place of humor in therapy? Is it OK ever to self-disclose? What kind of contact makes sense outside of sessions and after treatment ends? We will briefly touch on these issues.

Forming A Relationship

The first session with any new patient is by far the most important — if it doesn’t get off to a good start toward a strong relationship, there may not even be a second session. And first impressions do have a very strong impact on the later ones. The patient will always regard the first meeting with a therapist as an important life event and it is important that the therapist never treat it as routine. I loved first meetings — the chance to be helpful; getting to see the world through another person’s eyes; the excitement of a new relationship; the challenge to my empathic and relating skills. Getting information is, of course, an important goal of every first visit, but getting the patient’s attention and confidence is even more important. The patient must leave the session feeling understood, that you care, and that you know what you are doing; Diagnosis and psychoeducation are part of establishing an empathic relationship. It is a great relief for patients to learn that their previously puzzling symptoms fall into a well-recognized pattern, with a fairly predictable course and well recognized, effective treatments. They are not uniquely damned; not hopeless, not alone. Treatment plans are negotiated between patient and therapist — never delivered from on high. Options are offered with an explanation of the pros and cons of each- and the patients get to choose what best fits their goals, needs, and resources. Decisions made early can always be revised as more is learned and the relationship deepens. The patient should leave the first session much more hopeful than before they arrived. This must be based on realistic hope encouraged by the developing new relationship and a sense that presenting problems have been understood and are manageable. But note; there is no room at all for phony reassurance or underestimating the work that must be done. I would often end a first session saying something like: “if you really put your heart into this, and I put my experience, I think that together we can accomplish a lot.”

Is It Ever OK Ever to Give Advice?

Many training programs, and their graduates, teach and preach against ever giving patients advice. This is based on the theory that advice always reduces patients’ autonomy and ability to figure things out on their own. In support of this view is the ancient Chinese proverb, “If you give a man a fish, you feed him for a day. If you teach a man how to fish, you feed him for a lifetime.” This is sometimes good advice, especially for very healthy patients — but never say never. For contrast, my commonsense rule of thumb is to titrate advice — the more advice the patient needs, the more advice you should give. This applies especially to patients with more severe psychological problems who sometimes lack the judgment to make good decisions on their own and often don’t have other people to turn to for help. Trainers and therapists who preach most vociferously against offering advice must treat only the healthiest of patients.

When Is Self-Disclosure OK?

Many training programs also preach against therapists ever telling patients anything about their feelings, lives, or experiences. This is partly based on the notion that therapists should be a “blank screen”, partly on the fear that therapist self-disclosure may be self-servingly exploitive and impede patient progress. I agree up to a point, but less dogmatically and categorically. Therapist self-disclosure is indeed rarely necessary, carries risks, and should be reserved for special situations and specific purposes. But again, this is another case of “never say never.” With grieving patients, I’ve often revealed what my own feelings were on the loss of a loved one — as an expression of empathy and indication that exquisitely painful loss is an inevitable and normal part of our shared human condition. I have also on occasion shared work, child rearing, and marital experiences as a way of role modeling methods of dealing with life situations that have worked for me and might work for the.patient. Self-disclosure must be rare and to the point lest it lose impact and risk being done more for the therapist’s benefit than for the patient’s. I have occasional seen self-disclosure become a boundary violation in itself and on three occasions it evolved into therapists committing even worse Boundary violations. So, handle with care!

Can Therapists and Patients Share a Laugh?

Some, apparently humorless therapists claim that humor has no role in therapy — that, in one way or another, the joke is always at the patient’s expense or a distraction from real therapy. This attitude strikes me as being sad for the therapists who hold it and harmful to the patients who are subjected to their prim austerity. Charlie Chaplin said it best: “Life is a tragedy when seen in close-up, but a comedy in long-shot.” Seeing life in a longer shot is an essential part of any good therapy — and shared humor is an essential part of gradually gaining greater perspective. Rarely will shared humor take the form of telling a predigested joke; almost always the wisdom of humor comes from seeing the comedic in everyday situations. This is not to ignore that the patient is also suffering, but rather to achieve respite, distraction, and distance. A piece of advice I give to almost every patient is to find more good minutes into every day — and recapturing the ability to smile or laugh is a great step toward more good minutes and better days. Psychotherapy, like life, is a very serious thing, but both can be much brighter if leavened with a tincture of humor and the benefit of comic distance. Evolution surely built in the universal human capacity for fun because it has tremendous survival value. All work and no play makes therapy very dull for both patient and therapist.

What’s Appropriate on Social Media?

Here I am very strict; perhaps hypocritically so. I don’t think therapists should display their personal lives on any form of social media. Unlike occasional and specific self-disclosure during sessions that is directed to the patient’s specific needs at that moment, social media self-disclosure is generic; self-not-patient centered; and has many risks with no benefit. My hypocrisy: I do often express my fear and loathing of Trump on Twitter and even wrote a book about it. Here I felt my responsibility as a citizen trumped my role as a therapist. Others may disagree with this choice — I don’t apologize for it but can’t argue against their view.

When Is It OK to Have Contact Outside Sessions?

Some severely ill and/or suicidal patients definitely need out of session contact — either by phone or (I think preferably) by text. Behavior therapists routinely do sessions out of sessions- accompanying phobic patients when they are beginning to enter previously forbidden territory or situations. And I had a psychoanalyst friend who combined his usual quite traditional practice with doing runs with more seriously ill and demoralized patients who needed behavioral activation. All in all, though, I strongly discourage out of session contact except in special circumstances like these or to help patients experiencing emergencies.

Is Contact OK After Treatment Ends?

I think any close nonprofessional contact after therapy ends is a bad idea and should always be off the table no matter how much therapist and patient like each other. It is just too subject to exploitation and the possibility it could ever happen is too likely to influence the therapy before it ends. In contrast, I do recommend having occasional email or text follow up exchanges with patients after therapy ends. My longest such contact has extended for 56 years since the end of our treatment — it consists of brief but mutually satisfying emails exchanged every few months. Follow-ups help me learn what works, and what doesn’t in therapy and are encouraging because most people do much better than I expected.

***

As in all useful human relationships, therapy is a two-way street. We usually help our patients. They almost always help us become better people and expand our knowledge of human nature; ourselves; and how the world works. I loved the wonderful opportunity to do psychotherapy and am forever grateful to the patients who shared their lives with me. Questions for Thought and Discussion Which of the author’s points resonate most with you? Which of the author’s points are very different from your own, and why? What would be the top of your list of key elements of therapy?

Gift Giver: The Impact of Giving Clients Gifts

Posted on by Psychotherapy.net Team

I don’t remember the first time I gave a client a gift. I don’t remember who it was or what I chose, but years ago, I established a tradition of giving gifts at particular milestones. If gift-giving was mentioned at all during my training as a psychologist, it was solely in the context of how to manage receiving gifts from clients. Therapists might lend something from their office as a transitional object during a long separation or a particularly difficult time, but to give a gift was viewed as a breach of boundaries. Forty years later, I take a different perspective.

The Value and Challenges of Therapist Gift Giving

Giving a gift is an opportunity to acknowledge the special relationship between therapist and client. It has the power to reinforce the depth of closeness, of being known, that often only happens in the setting of a therapeutic alliance. Transference and countertransference are part of the connection between therapist and client, but not the sum total of the relationship. Showing our humanity can be a true gift to a client.

Over the years, I have settled on a few select items to give at times of major transition. I give a copy of Gift from the Sea, by Anne Morrow Lindbergh, to clients getting married; Make Way for Ducklings when a baby is born; and a stone coffee coaster with the town seal of Brookline, where my office was located, when clients move or end therapy.

Additionally, I mail condolence cards when someone experiences a significant loss. Recently, one client who received a card from me on the occasion of his father’s death remarked that it felt so formal to get a card in the mail. In a sense, it seemed out of character to him for me to be that traditional. As generational and cultural norms shift, I may need to rethink my choices.

I don’t have a rule about who gets a gift or a card, and I don’t give them to everyone. I decide based on a gut feeling that this act will be well received, and that acknowledging our relationship as something that exists beyond the allotted sessions will be beneficial. There is a basic humanness that exists inside the professional alliance that I value expressing. It touches my sense of gratitude for the trust the client has placed in me. For certain clients, there also can be worth in modeling an act of kindness for them.

In preparing to write about this topic, I reached out to a dozen colleagues to inquire about their philosophy regarding gift-giving. I realized I had never talked with another clinician about my tradition, nor had I heard anyone else mention this subject. Although I was a bit nervous that I might be judged negatively for my behavior, I approached the conversations without bias about other clinicians’ practices. I am more curious about their thinking than the position they take.

I learned from these exploratory conversations that only one other colleague gives gifts regularly. She reported that the more trauma the client suffered, the greater the chance she would give them a gift to help with the healing. Others talked about calling clients or sending texts to acknowledge life events, which mirrors their behavior in their personal lives. Interestingly, one therapist talked about the significance of the gifts she had received from her therapist many years ago, mementos she still treasures, but she herself never adopted this practice because she struggled to find gifts that she deemed suitably meaningful.

Unanswered questions for me include whether the age of the patient population might impact giving gifts, whether the gender of the therapist and/or client influences the choice, and whether the type of training and years of experience are reflected in how one thinks about gift giving in therapy.

And finally, I am curious if doing remote versus in-person sessions will have any impact on this practice. With more therapists only doing remote therapy, I wonder if gift giving on either side of the equation might diminish. I know for myself that now having a fully remote practice, I receive fewer holiday gifts than when I was seeing clients in person. But, to date I have maintained my gift-giving practice even though it now requires more trips to the post office, and I miss the connection from handing the gift personally to a client.

Giving gifts has enriched my practice. Although I largely rely on my words to communicate in therapy, gift-giving is a tangible way to communicate that I value clients and care about them. It is a concrete representation of the very real relationship that is carved out of years of hard work together.

Questions for Thought and Discussion

  • What is your position on this practice of giving gifts to clients?
  • To what kinds of clients have you given gifts?
  • If you do give gifts, how do you choose them for specific clients?

Looking Beyond Trauma: A Neurodivergent Therapist Shifts Her Clinical Focus

Posted on by Psychotherapy.net Team

As a therapist, I often find myself navigating the complex layers of my clients’ lives, working to untangle the web of trauma and its aftermath. In my years of practice, I have had the privilege of helping many individuals heal from deep traumatic wounds. I never planned on this, but my first job laid it in my lap, and I’ve loved every minute of it since. The hardships that I’ve seen people go through and be able to heal themselves are nothing short of impeccable. It’s almost indescribable. However, one particular case has profoundly impacted my perspective and approach: the story of an 18-year-old biracial male recently diagnosed with Autism, whom I initially treated for PTSD and trauma-related attachment symptoms. I referred him for an ADOS evaluation and looked at the report. I was glad that this assessment lent clarity but frustrated at myself that I didn’t see it sooner.

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Missing the Autism Tree for the Forest of Trauma

Alex came to me with a history marked by significant trauma; he witnessed domestic violence most of his childhood, was abused by a daycare worker, and did not have any relationship with his biological father. His experiences had left him struggling with severe PTSD, anger outbursts, and disengagement from school. He had relational problems with his mother and would not often communicate.

My initial sessions were focused on addressing these urgent, debilitating symptoms — the depression and the outbursts. My training and instincts as a trauma-focused therapist kicked in, and I dedicated myself to creating a safe space for him to process and heal. We did a lot of experiential work, along with play and gaming therapy. We worked on externalizing all that had been internalized — bringing it out and releasing the frustration of not having a relationship with his father, anger towards his mother, anger towards the men who abused her, and fear. We also spent some time deepening the relationships between the sibling and mother.

However, as weeks turned into months, something nagged at the back of my mind. There were aspects of Alex’s behavior that didn’t entirely fit within the framework of PTSD. After moving through the trauma work and no longer meeting criteria for PTSD, he still did not engage in effective two-way communication with me — his answers were often short, and he remained hyper focused on his hobbies.

My focus on his trauma had been so all-encompassing because of my own hyper focusing, that I missed the autism, which in retrospect, had been masked beneath the trauma only to surface afterwards. I saw this a lot in my practice and experienced it myself. And it’s not as if I could have “treated” the autism, but perhaps I could have been more helpful had I helped Alex to better understand himself, and not pathologize himself.

It wasn't until I embarked on my own journey of self-discovery, guided by insights from other autistic providers, that the pieces began to fall into place. I realized that my training and the field’s emphasis on trauma had not adequately prepared me to see neurodivergence, especially in individuals whose trauma symptoms were so pronounced. This is a common question I get from students, “why are we not prepared for neurodivergence?” I have a few theories, but this is just where we are. We need to listen to the autistic and other neurodivergent communities, their narratives, their stories, because our research and clinical training can’t keep up. This realization was both humbling and enlightening.

My work with Alex prompted me to seek further education and collaboration with autistic and neurodivergent colleagues. Their perspectives and experiences have been invaluable in reshaping my approach to therapy. I now understand that trauma can sometimes overshadow neurodivergent traits, making them harder to recognize. This has reinforced the importance of a nuanced, multifaceted approach to therapy. I have read that some do not agree with this concept, but I have seen this over and over in my practice. I’ve also witnessed narratives of where once their ADHD is managed the autism pops its head out, surprise!

In sharing Alex’s story and my journey, I hope to encourage other therapists to broaden their perspectives, as I have mine. I have come to value the necessity of being vigilant and open to the possibility that neurodivergence might be present even in the most trauma-affected clients. By doing so, I believe that I have been able to provide more comprehensive and compassionate care. I have also come to value the importance of ongoing learning and self-reflection — not just for me but for the entire field. Alex’s story is a testament to the importance of this mindset. As a neurodivergent therapist, I hope to continue in my commitment to being informed and adaptive, ensuring that I do not miss the vital aspects of my clients’ identities and experiences. Through this commitment, I can better help my clients to heal and thrive.

Postscript

Once Alex received the autism diagnosis, the mother and I met to review what this all means for her and her almost adult child. We’ve spent a lot of time talking about transitioning into adulthood and the challenges and strengths that Alex has. This diagnosis hopefully opened the door for more supportive services, and it opened up the pathway for the mother to start examining herself in a new light. As she and I talked, she started to look at herself through a neurodivergent lens and her experiences made more sense to her. We also talked about how not knowing has impacted her and Alex’s relationship negatively in the past but now they have a new perspective on things they can connect in a different manner. They have internalized ableism within her parental expectations, which often led to highly intense conflict. But now, they see themselves as a nervous system responding within the context of each other rather than blaming one another. This opened up space for compassion, understanding, and empathy.   

Questions for Reflection and Discussion

How might you have worked with this client?

What are some of the gifts a neurodivergent therapist might bring to therapy?

In what ways might a neurodivergent therapist struggle with particular clients?  

The Healing Power of Therapeutic Presence

Posted on by Psychotherapy.net Team

I was driving to my therapist’s office and listening to an audiobook when I started to cry. I wasn’t even sure why I was crying. Once in my twenties, I went several years without shedding a tear, but now, in middle age, two years since becoming a therapist, one year since starting psychoanalysis, I was doing this weekly.

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“What were you listening to?” Laura asked once I sat down in her office.

“It’s actually a children’s book. It’s this scene where nobody believes this girl, and she feels all alone. But then her brother,”—and now I felt the tears again welling up—“her brother tells her that he believes her. And she’s not alone anymore. It’s not even a sad scene,” I sniffled. “I don’t know why it gets to me.”

The Power of a Therapist’s Self Awareness

Earlier that week, I had been in my own office, sitting across from my own client. Rachel, a 10-year-old girl, who had started meeting with me to process her father’s alcoholism. She had been vivacious and funny during our first several sessions, causing me to wonder whether she even needed therapy. I kept listening, asking about her father’s drinking but not pushing too hard for her to talk. And then the previous day, seemingly out of the blue, she started recounting some painful memories of her father, one in which he called her mother some horrible names and blamed her for ruining his life.

Rachel had always had a manufactured exterior, a smile usually on her face, but as she shared these memories, I could see tears filling her big blue eyes. “When he blamed your mom for ruining his life,” I said, “I wonder if you thought he was maybe talking about you.” She slowly nodded and then bit her lower lip as though hoping this would stanch her tears.

I felt at that moment inadequate as her therapist. I didn’t know what to say. I wanted to tell her that everything would be okay, but I didn’t know if that was true and didn’t want to lie to her. I tried recalling some clinical vignettes I’d read in different psychotherapy textbooks, trying to remember the life-altering words that those master clinicians had spoken in similar situations. Nothing came to me.   

I realized that I was matching Rachel’s pained expression with one of my own. “It’s good that you’re talking about these things,” I finally said. “I wish that talking would make them better.” She kept looking at me. “But that’s not how it works.” I again tried to imagine what a master clinician would say. My mind again drew a blank.

I suddenly flashed to a time in my early thirties when my paternal grandmother had unexpectedly died. I immediately called my mother, and as soon as I began telling her what had happened, I started to cry. She drove over to my apartment and sat with me for several hours. I don’t remember her saying anything especially profound, but she made me feel less alone, and that was what I most needed.

Now sitting in Laura’s office, having told her about the audiobook, I started to talk about my session with Rachel and my flashback to that day with my mother. “Part of me felt I was giving Rachel what she needed, but another part kept thinking there was something I should be saying to her. I felt like such a failure.”   

I then told Laura that when I’d been listening to the audiobook, she herself had come to mind. “This probably doesn’t make sense, but as I think about it now, it’s like I suddenly realized that you’ve been here all along. It’s like I’ve in some sense, not recognized your full humanness and presence in these sessions. I’ve always respected your skills as a clinician, but I think I’ve seen you as this impersonal instrument or tool that I could use to learn how to gain personal insight.”

The tears were again coming. “But you’re not a tool. You’re a person who listens to me and cares about me. When I’m sad, you feel sad with me. When I’m happy, you’re excited for me. You’ve been here all along, and I think I’ve been afraid to truly acknowledge that.”

Laura and I talked some more, and I eventually thought back to Rachel. There would be times when the words I spoke to her would matter, when I would need to ask the right question or make the right interpretation, but I now saw that I had not failed her during that last session. I had been there with her, allowing her to share her pain and feeling her pain with her. I had given her what my mom had given me that day years earlier and what Laura was now giving me every week. I had given Rachel my full humanness and presence, and that had been what she most needed.   

How to Be Successful in Child Therapy: Lessons From 5 Decades of Practice

Posted on by Psychotherapy.net Team

The insights I value the most came from direct work with children, adolescents, and families who taught me what is most important and helpful in the work that we do. I learned from children that what is most essential is that we do not give up on them. Embracing unwavering faith in children as they go through the worst times of their lives may prove to be far more important than any technique or intervention we employ.

The Importance of Therapeutic Presence with Children

Repeatedly, my former child clients tell me this when they come back to visit 10, 20, or even 30 years later as they establish themselves in their adult lives. Surprising to me is the fact that at the time I was seeing these former child or adolescent clients, I did not feel that I was particularly helpful. The crises that brought them to therapy were so intense that I was unable to appreciate the power of therapeutic presence and commitment.

One of the most important insights that emerged from my private supervision with the late Walter Bonime, MD, senior training psychoanalyst, has helped sustain me during the most challenging moments of my 55-year career as a clinical psychologist working with children and families. Dr. Bonime taught me that no matter how frustrated, discouraged, angry, hopeless, or impotent the therapist may feel, it cannot begin to match the depth of the same feelings in the child.

Children taught me that sometimes “more is less.” In certain moments what is most important is that we be a caring presence, a trusted witness. The temptation is for therapists to shower intense moments with words that can diminish the transformative potential of a deep encounter with a child.

I’ve met many a “fawn in gorilla suit” during my career. The analogy suggests that the “fawn” as the core self is highly vulnerable — has been hurt too many times! The aggression (putting on the gorilla suit) is intended to protect that vulnerable fawn by keeping people at a safe distance. Yet, the longing for connection burns deeply within.

Another important understanding gained from the decades of work with children is that whenever a youth says, “I don’t care!” we should assume they once cared a lot, but it simply hurts too much, it is too great a risk to care anymore.

I’ve always told my interns and young clinicians, “when you don’t know what else to do, just treat children and families with profound respect and dignity.” They are surprised how far that goes.

Children carry within them powerful narratives that all too often no one takes the time to elicit or hear. The youth, as much as they might avoid it, long to unburden.

The therapist’s willingness to risk themselves in the therapy encounter, and sometimes be wrong, is a “gift” to children by creating a safer context for the child to express what is difficult to put into words.

An 8-year-old boy asked me to explain the initials after my name. This led the boy to say, “Well, you don’t look that smart!” I told him my family tells me the same thing. It reminded me of how important a sense of humility is in working with children. To connect with children, we must be willing to look like fools sometimes. Otherwise, we are no fun at all. Children will only feel free to talk when they feel free to not talk.

Our goal is to honor strengths without trivializing suffering. This is a delicate operation. The work we do is rewarding. We get paid in the currency of the heart. Some of the moments we share with children and families are precious and priceless. But our work is hard. There is an undeniable emotional toll exacted from caring for children with deeply wounded spirits.

Can we hear the hard stories without the hardening of our heart? To do so requires diligent and disciplined efforts to take adequate care of the instrument of healing — our self. As much attention in our field has been paid to the importance of self-care, each child therapist will need to reflect and honestly assess to what degree it is a priority. If we short-change ourselves, it is likely that we are also stiffing our families, and perhaps the children and families we treat as well.

[Editor’s Note: David and I are colleagues and friends, and we are honored to offer his reflection here, which is not about “what to do” with children and teens in therapy, but, “how to be.”]

Questions for Thought and Discussion 

  • In what ways is the author’s orientation to child therapy Similar to your own?
  • What have you found to be the most effective ways to intervene with children and teens?
  • What have you found to be some of the greatest challenges in working with young clients?