Category: Beginning Therapists

Avoiding Burnout Traps: Managing the Conflict between Empathy and Exhaustion

Posted on by Psychotherapy.net Team

“The best people possess a feeling for beauty, the courage to take risks, the discipline to tell the truth, the capacity for sacrifice. Ironically, their virtues make them vulnerable; they are often wounded, sometimes destroyed.” – Ernest Hemmingway

As a beginning therapist, my first five years were spent in uncomfortable places. Maximum security facilities, county crisis centers, and emergency rooms. In these environments, I could feel stress in the air like it was coastal humidity, and chaos was the rule rather than the exception. I seemed to meet two types of therapists in these places. There were those at the beginning of their careers and those who were nearing their end. The clinicians in their middle chapters of their work had often left for administrative roles and private practices.

I found the new and veteran therapists to be different in some noticeable ways. The new therapists were often energetic and inspired. They were personally invested, and despite their lack of experience, they seemed to help clients make significant improvements. They didn’t make much money, but they didn’t mind having roommates or driving economical cars. They had a cause and that was more than enough.

The veteran therapists were less excitable. They were wise and calm, and they had witnessed how idealism can lead to painful lessons in therapy. Sometimes they were rough around the edges, but because they had the benefit of making a therapist’s salary for many decades, they drove slightly newer economical cars. Their vehicles had fewer miles, powertrain, and bumper to bumper warranties. The big leagues.

I had only been a therapist for a few years, but I quickly found myself losing my passion. I wasn’t sure I would grow into a seasoned therapist because I wasn’t sure I would remain a therapist for much longer. To manage my exhaustion and stress, my days became bookended between caffeine in the morning and alcohol at night. My sense of humor darkened, my wife worried, and my friends pulled me aside to express their concerns. I was changing, and those around me were whispering about it.

What I believed about therapy was changing, too. I started to believe that my clients who improved would have done so without my help. With my clients who didn’t make improvements, I started believing they simply couldn’t change. I was once a true believer, but I was becoming a skeptic. I was losing my faith in therapy.

I didn’t notice I was changing while it was happening. The process was gradual, and it didn’t have an obvious turning point. It felt like a current had pulled me down the shoreline and I lost track of my towel which was further up the beach. I had become someone different, and it wasn’t someone I wanted to be. I spent months asking myself how this transformation occurred, and eventually, I came back with my answers.

The Empathic Personality

In graduate school, I was taught that empathy was a vital part of therapy. I was told to pack my bags, leave myself behind, and join my clients behind their eyes. To be a therapist was to commute to the deepest feelings and perceptions of another. Empathy was interpersonal travel, and to be a therapist meant holding a passport that permitted me into deeply private conversations. It got me through customs.

At that time, I thought about empathy in the way I thought about kindness. I wanted to exhibit more empathy and kindness for the people in my life. Clients or not! These virtues seemed pure and uncomplicated, and it was hard to imagine an overabundance of either. But eventually, I started thinking about empathy as something more complicated than kindness. This tendency to be aware of others and to travel into their worlds wasn’t simply a virtue, but it was a temperamental characteristic. Unlike kindness, this personal characteristic came with risks.

It was this new understanding of empathy’s risks that unlocked the answers about what happened to me. It helped me understand why I transformed from an energetic therapist into a calloused one. It helped me understand why I hated my economical car.

I think that empathy can be separated into two different categories: there’s unmanaged empathy and managed empathy. Here’s how I think about the difference. When my empathy is unmanaged, I can join into the pain of others, but I can’t disconnect from it. This type of empathy has one step and so becoming glued to the suffering of others becomes inevitable. Alternatively, when my empathy is managed, I can join in the pain of others and then uncouple from it. Managing my empathy has been a two-step process.

My therapeutic training only focused on joining into suffering, but I was never taught how to uncouple from it. I never made the distinction between unmanaged and managed empathy. To be fair to my counseling educators, it’s not realistic to expect a seminar entitled, “Uncoupling from the Suffering of your Clients.” But because I didn’t learn to separate from suffering effectively, I relied on my unmanaged empathy. Joining into the pain of others had always come intuitively, and so I simply did with clients what I had always done in my personal life. This unmanaged empathy flowed by the gallon, but it eventually became a stream, and then it dripped and dried bare.

The Interpersonal Dynamics of Burnout

When my classmates and I studied to become counselors, we shared universal experiences. Nighttime classes, unrelated daytime jobs, and increased coffee consumption. At some point, my classmates and I purchased our first therapist uniforms. Horn-rimmed glasses for some and shawls for others. Some bought cardigans. It was Carl Rogers couture.

During this time, those in my personal life expressed an interest in what I was learning. I was asked for my perspective more often and I eventually became more comfortable giving it. People changed towards me, and I changed towards them. I gradually became a therapist in my own mind and in the minds of others. These changes in my social world weren’t always positive. I answered late-night phone calls when help was needed. I was cornered into awkward conversations at parties. During an argument with a friend, I was told, “You should know better — you’re a therapist.” I wasn’t yet, but fine. Checkmate.

After I finished my graduate program, I found my first clinical job. My empathic temperament had previously led me to help those in my personal life, but I was suddenly assisting clients, too. While it was once possible to have a private life filled with people I hoped to help, the new empathic demands of therapy led to working with suffering on all sides. There was no place to separate from suffering and I became a 360-degree giver. This was the first trap that led to unmanaged empathy and subsequent exhaustion. Mother Theresa could do it, but I couldn’t turn my life into Calcutta.

To practice managed empathy, I could no longer remain in the helper-role in my personal relationships. While my relationships with clients were characterized by one-way assistance, my personal relationships couldn’t remain this way. Most of the time, a simple conversation changed my one-sided relationships into two-sided ones, but occasionally more was required. Sometimes I had to use dials and levers. This was how I disconnected from the suffering of others, practiced managed empathy, and escaped this unmanaged empathy trap.

Restructuring the Interpersonal Dynamics of Burnout

I’ve never liked the word boundaries. The word has always seemed forceful and rigid, and to “set boundaries,” always sounded formal and severe. For me, this made the prospect of establishing limits less approachable. But the space between myself and others did need to be refereed, because it had become flooded with unrealistic and demanding people. It seemed that like nature, dysfunction abhorred a vacuum.

Rather than “setting boundaries,” I started thinking about using dials and levers. Here’s how this worked. When a relationship was one-sided, but the relationship was too important for me to end, I set the relationship on a dial. I reduced my involvement in the relationship by lengthening my distance in degrees. I took steps backward until I reached a comfortable interval. Putting a one-sided relationship at a greater distance made these relationships more sustainable. I could help when I was around, but I wasn’t around too much. But other relationships exhausted me regardless of the distance that I created. When I attempted to leave the helper role behind, some people didn’t go without a fight. Pro bono therapy was a hell of a drug. In these situations, I used levers to end the relationships entirely. I moved the lever from the “on” position to the “off” position. While the dials worked in degrees, the levers worked in absolutes.

I found distance by degrees to be preferable to absolutes, and eventually I was able to regain some measure of control in my relationships. When I changed my one-sided relationships into reciprocal ones, I could step back from being a 360-degree giver. Once I implemented dials and levers, this created newfound open space in my personal relationships, and in this space, I could practice the second step of managed empathy. I could uncouple from suffering there.

The Intrapersonal Dynamics of Burnout

My public roles and my private values have always been an important part of understanding myself. Part of my sense of self comes from being a spouse, father, brother, and the professional role that I play. The other part of my selfhood comes from the values that I’ve privately held dear. But problems emerged for me when there was a poor balance between the public roles I played and the private values I held, and this was a setup for the second unmanaged empathy trap.

In my earlier stages of counselor development, I viewed becoming a therapist as too central to who I was. I over-identified with my therapeutic role, and I lost part of myself. To understand how this occurred, I started noticing professionals who went through similar transformations. I also noticed the professionals who didn’t.

What I learned is when a public role elicits some amount of societal reinforcement, there’s a tendency to over-identify with it. Take the surgeon, for example. Most surgeons don’t think being a surgeon is something they simply do for work, but instead, being a surgeon is a central component of their identity. This is also true for professional athletes, executives, politicians, and lawyers. But it’s not true for those who stock vending machines or drive garbage trucks. These jobs don’t come with societal applause. When talking about their work, these folks often say things like, “It pays the bills.” The job serves a purpose, but it’s not the most important thing about them. They leave it off the dating profile.

While being a therapist doesn’t elicit the same societal reinforcement as being a surgeon, I think it comes with similar risks. It was often difficult to leave my therapeutic identity in the chair. I was a therapist when I drove into work, and I was a therapist when I left.

I think I underwent a charismatic therapeutic conversion. My identity had become consumed by my new public role, and my transformation into the therapeutic persona was too thorough. I became a therapist in every area. I read books about therapy and talked about therapy with my therapist friends. I attended therapy conferences and built my community around therapy. I even started talking in a therapeutic dialect: “reframe” this and “normalize” that. I became a born-again clinician. It wasn’t a good look for me.

When I allowed myself to be overtaken by my therapeutic role, I stepped into this second unmanaged empathy trap. I was always a therapist behind my eyes, and so I was never without clients. This meant there were fewer places in my life to separate from suffering. Luckily, there was a way out. I didn’t need to accept that my personal identity would be consumed by my public role, but instead I could learn to do something requiring just a bit less personal investment.

Restructuring the Intrapersonal Dynamics of Burnout

It was those who worked less emapthically-demanding jobs who taught me how to escape this trap. Like them, I learned to create space between my professional and personal identity by prioritizing my private life. The person who drove into work became different from the person who drove away.

This meant treating therapy more like functional work and less like a totalizing identity. To develop a sustainable therapeutic career, I needed to nurture and protect my non-therapeutic self. I needed to cultivate an identity that rested more upon my private values and not entirely upon my vocational role.

In order to do this, I adopted new endeavors that weren’t remotely connected to therapy. I also reconnected with old friends. These old relationships helped me remember who I was before I was a therapist. I didn’t use words like “schema” or “metacognition” back then. But in order to avoid the second unmanaged empathy trap, I had to avoid the charismatic therapeutic conversion. I had to cultivate a private life where my non-therapeutic self was expressed. It was when I allowed the part of myself that was disconnected from my therapy to engage the world around me that I could separate from suffering more easily. I could practice managed empathy there.

The Attachment Dynamics of Burnout

It seems that within human relationships there’s a spectrum of give and take. On one side of the spectrum, I’ve met the habitual givers. These folks are highly empathic and accommodating. As moons orbit planets, they orbit the lives of others. Orbiters rotate around the people in their lives and keenly discern and meet their needs. They’re natural satellites.

On the other side of the spectrum, I’ve met the habitual takers. It seems that these folks expect to be accommodated. They’re unaware or disinterested in the feelings of others. They often find it upsetting when others don’t adjust to them. They expect to be orbited. And of course, most of the people I’ve known fall somewhere in between these two extremes.

This spectrum became relevant to my eventual exhaustion because, like most therapists, I found myself closer to the cooperative patterns within the orbiters. The ability to assess and meet the needs of others had always come naturally, and so becoming a therapist was a perfect fit. Perhaps without knowing it, it was my cooperative predisposition that guided my professional direction.

Eventually, problems emerged because of this strong cooperative urge. When decisions were made, I often found myself deferring to the preferences of others. Instead of imagining what I might enjoy, I would comply to connect. When people asked about where to go for dinner, I might say, “Wherever, I’m easy.” When asked if I needed anything from the store, I would respond reassuringly, “No, I’m okay with whatever you pick up.” I was engaged in need-mirroring. I think of need-mirroring as the reflexive matching of the preferences of others, and while it increases cooperation in relationships, it also leads to a life that’s directed by others.

With my interactions often characterized by deference, I lost track of my own desires. My difficulties with a self-directed life became even more concerning when I tried to listen inward for my own preferences, but no inner voice responded. I could no longer locate what I sincerely wanted. It seemed that desire itself worked like a muscle, and because I hadn’t listened to myself for an extended period, this muscle eroded. I had undergone appetite atrophy.

Becoming locked into this orbiting orientation was the third unmanaged empathy trap that led to my exhaustion. It became difficult to separate from suffering when I was overly attuned to the perceptions and desires of others. While rotating around my clients was essential to my therapeutic work, when I orbited those in my personal life, it became difficult to know what I needed. But like the first two traps, there was a solution that helped me practice managed empathy. This strategy helped me restrengthen the muscle of desire, it separated me from the needs of others, and I became able to listen to myself once again.

Restructuring the Attachment Dynamics of Burnout

The path to overcome my orbiting style was to express my needs more regularly within my relationships. Prioritizing myself more allowed me to move closer towards the middle of the spectrum of give and take, and this restored the balance within my interactions.

There were problems at first. I had practiced need-mirroring for too long, and when I tried to track down my desires, I couldn’t find them. So, I tried something simple. Instead of searching for my needs, I invented them. I practiced having a preference. When I got it right, it sounded something like this:

Them: “Where do you want to go to dinner?”
Me: “Eh. I don’t care, – you know what, I feel like Mexican food.”  

When I was halfway through need-mirroring, I tried to express an invented preference, instead:

Them: “I’m headed to the store. Do you need something?”
Me: “I’m good, thanks. On second thought, can you pick up some gum?”  

My objective wasn’t to detect and convey my deepest desires, but to practice expressing any preference at all. This was effective because the strength of my cooperative impulse had anesthetized my desires, and to lift the anesthesia, I needed to increase my comfort with being less cooperative. When I practiced expressing an invented need, I was creating a moment where I stood apart from the desires of others. I was practicing a small act of non-cooperation. Slowly, as my comfort within this non-cooperative space grew, my desires eventually reawakened, and I was able to express these desires within my relationships.

It’s a strength to orbit clients in therapy because this can help me perceive unspoken needs and adjust on their behalf. Yet when this tendency ran free in my personal life, I lost the ability to direct myself, and my exhaustion knocked at the door. But when I practiced having a preference and become more comfortable standing apart from the needs of others, my desires could be once again detected. This created separation from the suffering of others and a return to managed empathy.

***

While I once thought that empathy was an uncomplicated force for good, my exhaustion led me to conclude otherwise. Empathy is something that’s effective when guided, but it’s harmful when it’s not. Empathy is like water. It’s beautiful in the river, but not in the flood. However, if the traps that lead to unmanaged empathy can be understood and managed, the wisdom of the seasoned therapist can be cultivated without losing the spirit of the new one. That has and will forever be my goal.

Psychotherapy Status Report: Past Achievements/Current Failures/Future Disruptions

Posted on by Psychotherapy.net Team

A Very Brief History of Psychotherapy

Depending upon how you look at it, psychotherapy is among the oldest of professions — or one of the newest. Lacking effective active treatments, doctors always got by with some combination of supportive psychotherapy, magic, and placebo effect.

The Shaman in prehistoric times was the first psychotherapist — diagnosing and treating the mental and physical ills of tribal members by negotiating with the spirits on their behalf. In settled agricultural societies, priests assumed the same role, though the negotiation was with gods, not spirits. Then came the philosophers.

All the basic principles of CBT were laid out by the Epicurean and Stoic philosophers in ancient Greece and Rome. The Arab world, one thousand years ago, was the first to have a separate profession of psychiatry, whose practitioners developed techniques of psychotherapy quite similar to how we practice today. And Pinel substituted psychotherapy for chains in caring for the mentally ill in Paris 225 years ago.

Modern psychotherapy began with the few practitioners of psychoanalysis in Vienna 140 years ago — but psychotherapy quickly became a growth industry, both in the number of practitioners and in the wide variety of techniques they used in their practice.

One hundred years ago, there were very few people who would label themselves psychotherapists; now there are almost 200,000 in the US. About 60% hold a master’s degree, 40% are PhD’s; 70% are female; and average age is 45. Seventy percent of therapists provide mostly individual therapy; 30% also work with couples and/or families. Therapists in private practice usually see 20-25 patients a week; charge anywhere between $75-$200 for sessions that last 50 minutes; and on average, see patients for anywhere between1 and 12 sessions. The average wait time for a first appointment is several weeks.   

CBT is the most popular form of treatment followed by psychodynamic approaches. Two thirds of therapists feel deep satisfaction in their work, but half report having felt burned out at times during their careers. The US Bureau of Labor Statistics estimates that the number of therapists will increase by about 20% by 2030. You can find many more interesting statistics characterizing therapists and therapies here: 

My purpose in writing this piece is to provide my personal, and admittedly biased, view of the major achievements and major failures of our psychotherapy enterprise — and to provide some guesses of what likely future directions will be.

Five Major Achievements in Psychotherapy

The Therapeutic Relationship

The greatest paper in the history of psychotherapy was among the first — Saul Rosenzweig’s 1936 “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” Rosenzweig correctly predicted that the most robust finding in all the later extensive psychotherapy research would be that “everybody has won, and all must have prizes.” His “Dodo Bird verdict” (borrowed from Carroll’s “Alice in Wonderland”) asserted that most comparisons of the efficacy of various forms of psychotherapy result in tie scores. Although therapies may differ greatly in theory and technique, the greatest contributors to good outcomes are the factors all have in common; the therapeutic relationship, patient and therapist positive expectations, healing rituals, catharsis, and regression to the mean with the passage of time. The success of any given form of therapy is not proof of its specific theories or practice, because so much of the variance comes from what is shared across therapies, not what is particular to each. This is not to deny that specific techniques have specific value for specific indications, but it does focus therapist attention on getting right the more general factors that cut across therapies. Rosenzweig guessed the Dodo Verdict without the benefit of any controlled studies, but many thousands of subsequent well-controlled, randomized comparison studies have proven him remarkably prescient.

Documenting The Efficacy of Psychotherapy

The most important thing I’ve ever done in my career was serving on the NIMH committee that funded the early studies of CBT and DBT during the 1980s. These were the early days in systematic psychotherapy research applying the model of clinical trials — the controlled, randomized comparison method that had already revolutionized medical research and efficacy studies of psychiatric medications. 

The few million dollars that supported research documenting the efficacy of CBT and DBT have since benefited millions of patients worldwide. In contrast, NIMH has since spent many tens of billions of dollars on brain and gene research that has provided little to no benefit to patients. The research success of CBT and DBT legitimized psychotherapy and led to their widespread acceptance as reimbursable treatments worldwide. Tens of thousands of therapists have subsequently received systematic training in CBT and DBT — and both have generated extensive professional literatures and also books aimed at patient education and self-help materials, virtual and written. Psychotherapy would not be nearly so widely accepted today if it lacked this demonstration of efficacy.

Expanding The Scope of Psychotherapy and Its Specificity

Modern psychotherapy began with Freudian psychoanalysis, usually conducted several times a week, with the patient lying on a couch and free associating. Within decades, innovative pioneers developed less regressive short and long-term psychodynamically-based therapies that eventually largely replaced the original model. Almost simultaneously, behavior therapy had its origin in Pavlov’s dog conditioning experiments and was brought into clinical practice through innovations introduced by John Watson, B. F. Skinner, and Joseph Wolpe.

Cognitive therapies developed independently by Albert Ellis and Aaron Beck became popular in the 1970s and dialectical behavior therapy was developed at about the same time. In subsequent decades, at least 50 different psychotherapies have been named and defined. This profusion of different therapies is not an unmixed blessing (as we shall soon see), but it has vastly augmented the toolkit of modern therapists and increased the specificity of psychotherapy techniques for depression, panic attacks, generalized anxiety, phobias, anorexia, bulimia, addictions, sexual, and many other disorders. 

Research Comparing Psychotherapy with Psychiatric Medications

The ultimate test of psychotherapies is not how they do against one another (because such comparisons routinely result in tie scores (actually, CBT is usually found to be more effective than others), but rather how they do against medications (when either might be indicated) and how they do against no specific treatment (when meds are not indicated). The evidence of hundreds of studies across different therapies, different medications, and different disorders is that psychotherapy and meds are about equally effective when both might be indicated and that the combination of both may be more effective than either alone. Meds work quicker (not entirely true); psychotherapy has more enduring effects. 
A useful rule of thumb is that psychotherapy alone may be indicated for most milder psychiatric problems; psychotherapy or meds, alone or in combination for moderately severe symptoms, and meds plus supportive therapy for more severe and enduring symptoms. Very mild and transient symptoms do well with watchful waiting (or, as prescribed in the UK, self-help materials or self-help groups).

Reducing Stigma

Mental illness had been more easily accepted before the urbanization that followed the industrial revolution. And in some cultures, the mentally ill had even been revered as a source of spiritual power and insight. But stigma increased dramatically when individuals with mental illness became inconvenient denizens of crowded cities. The typical expectation was that the mentally ill were all badly out of touch with reality; useless; in the way; untreatable; likely to deteriorate and become dangerous; and worthy only of warehousing in badly overcrowded, dingy, smelly, neglectful inpatient snake pits. This stigmatization of mental illness has been much dissipated with the expansion of disorder definitions according to the DSM; the inclusion in the DSM of much less severely impaired individuals; and the widespread experience of psychotherapy in the general population. Many people, especially in cities, have been in therapy or know someone who has.   

Five Major Failures

Lack Of Access

In the US, most people needing psychotherapy can’t get it or wait months on waiting lists. Some of this is due to a shortage of trained therapists. Some is due to lack of parity in insurance coverage and tricky ways insurance companies have of avoiding responsibility for reimbursement. Some is due to geographical distribution of therapists — people with psychiatric symptoms live everywhere, but almost all psychotherapists live in cities.

But economic inequality is by far the greatest culprit in depriving needed psychotherapy for the very people who are experiencing the greatest psychosocial stresses. Add to this that most therapists are white, come from middle class backgrounds, and have little experience with or empathy for (or deep understanding of) people of color, with diverse cultural experiences and values, and with the economically disadvantaged. It is a great failure of public funding in rich nations that the needs of the vulnerable, most in need, are so often neglected. 

Lack of access is exacerbated by the fact that most psychotherapists focus on doing the most possible for each individual patient, rather than having the public health ethos of striving to do the greatest good for the greatest number. Many psychotherapists exclusively conduct long term therapies with very ambitious goals, resulting in long waiting lists or no treatment at all for those frozen out of the system. Most patients want and need only brief treatments aimed at symptom relief. Long term therapy is valuable, but it should be the exception, not the usual first reflex.

Community mental health centers, often vastly understaffed and with therapists with less training, are expected to treat a crushing number of patients per week. And then there has been the emptying of psychiatric hospitals without needed therapeutic services, housing, and vocational support

Lack of Integration

There has been a tension during the past 50 years between the psychotherapy splitters (those who create an ever-expanding list of new psychotherapies) and the psychotherapy lumpers (those seeking to integrate psychotherapy into one coherent whole). Despite the best efforts of the lumpers (count me in here), the splitters are winning out. At last count, there are more than 50 named psychotherapies — a veritable alphabet soup. Most therapists are narrowly trained in one type of therapy and remain tribally loyal to it — applying the same techniques to all their patients rather than developing sound conceptualizations and treatment plans for each individual, integrating and flexibly applying the specific techniques most appropriate for that individual.

Most training programs are narrow in focus — locked into the techniques developed and taught by their founders, rather than teaching a wide array of the best techniques from across all models. Cognitive therapies are now by far the most prominent in the world because they have been by far the most flexible — over the past 40 years incorporating behavioral, psychodynamic, experiential, and recovery techniques and applying them flexibly to a widening range of symptoms within their theoretical framework

Losing The Battle with Drug Companies

Psych meds are essential for those with severe psych symptoms, and often necessary for those with moderate symptoms. Even though most people with milder symptoms would do better with psychotherapy or watchful waiting, a startling 20% of the general population are instead regularly taking a very often unnecessary psych medication.  

There are three causes of this overuse of psych meds and accompanying/underuse of psychotherapy; 1) drug companies spent billions of dollars promoting meds; virtually nothing has been spent promoting psychotherapy; 2) 80% of psych meds are prescribed by primary care doctors with little training and great eagerness to get a satisfied patient quickly out of the office; and 3) psychotherapists are so hard to access in most communities. This overuse of meds and underuse of therapy is bad for patients, bad for therapists, bad for society — it is good only for drug companies.

Underemphasizing Supportive Therapy

The flourishing of specific techniques of therapy has obscured the fact that supportive psychotherapy is valuable and should be part of every patient encounter, whether in a medical or a psych setting. With the exception of some psychiatric residency programs, there are few training programs teaching how to do supportive therapy, and few books and papers describing it. This, despite the facts that supportive therapy is the only helpful tool most doctors have had during most of the history of medicine, that psychotherapeutic support creates hope, reverses demoralization, and counters isolation, and that supportive psychotherapy requires more skill and empathy than the use of specific techniques.  

Failing To Include Evolutionary Perspectives

Darwin was the greatest psychologist who ever lived. He had three seminal insights that should vitally inform modern psychotherapy: 1) we have inherited many of our emotions and behaviors from our animal ancestors in the same way we inherited our bodily morphology; 2) we are unaware of the underlying motivations of our behaviors; and 3) many of our now maladaptive behaviors are relics of a time when they were much more adaptive.

An evolutionary perspective helps patients normalize their symptoms by better understanding where they come from and why they have them. It is normal to grieve as the price of love. It is normal to feel sad when we fail as a motivator to do better in the future. It is normal to have anxiety and phobias in response to dangers, to feel paranoid when confronted by potential enemies, to be dependent when in need of help, to overeat when delicious food is available, and so on.

Normal feelings and behaviors become problematic symptoms only when they are severe, prolonged, stereotyped, and not adapted to the current environmental contingencies. Understanding the normal roots of symptoms reduces the patient’s feeling of being uniquely damned and points the way to more adaptive responses. The valuable application of an evolutionary perspective toward psych symptoms has been described for 30 years — but most psychotherapists are woefully ignorant about it. Notably, one of Aaron Beck’s last papers did include an evolutionary perspective on depression. 

Five Future Trends

Teletherapy

Telemedicine has been around for 60 years, particularly for providing services in rural areas and particularly in psychiatry. But all this was on a small scale until Covid isolation protocols temporarily made telethetherapy the predominant way for psychotherapists and patients to communicate and for young psychotherapists to be trained. States temporarily relaxed licensing restrictions that had prevented therapists from extending their reach across state jurisdictions. The results were remarkable — many therapists (and patients) preferred zoom to in-person sessions because they afforded greater scheduling convenience, eliminated travel, allowed access to a greater range of therapists, reduced waiting time for first sessions, reduced therapist overhead, and achieved surprisingly high rates of patient and therapist satisfaction.

The lifting of Covid restrictions has made teletherapy something of a geographical jumble. Different states now have very different licensing requirements, some welcoming teletherapists from other states, some tightly restricting, and many in between. But the trend is clear — more and more, psychotherapy (like so many other aspects of life) will be done remotely via screens, rather than in person.

Text Therapy

Covid isolation also resulted in the explosive growth, increasing acceptance, and commercialization of text-based therapy. The convenience and advantages of easy and expanded access, flexible scheduling, efficiency, and low cost are clear. But texting as a psychotherapy modality also has some real advantages over in-person meetings. Patients are often more open in texts than face to face, and less likely to ignore or reject therapist’s comments. Writing gives them the opportunity to think through their problems, and texts can be read and reread and considered in a way not possible with fleeting verbal communication. One exception may be CBT, where clients are encouraged to take good notes of the most important points of the session.

The disadvantages of texting are also obvious — the lack of visual appraisal and non-verbal cues can lead to incomplete evaluations and miscommunication. We can’t really trust the few generally positive studies on texting as they may be biased, but my guess is that it will play an increasing role with the advent of a new generation of patients and therapists, who have grown up using texting as one of their major forms of relatedness.

Competition From Coaching

Life coaching is a fast-growing profession with over 70,000 coaches practicing worldwide. Theoretically, coaching and psychotherapy have different goals, practitioners, and consumers. Therapists receive more extensive training, require more formal licensure, and treat psychological symptoms that are diagnosed, coded, and compensated as “mental illness.” Coaches receive much less training, have much looser licensure requirements, and provide wellness training to improve business, interpersonal, organizational, or sports performance and to enhance life satisfaction. People with more severe problems need psychotherapists; those who are generally doing well but want to do better may seek coaching. Coaching has the advantage of less stigma (no DSM disorder required); but the disadvantage of not being reimbursed by medical insurance. As coaching becomes more available and well known, it will doubtless draw many people who would otherwise have seen therapists.

Corporatization

Psychotherapy began as mostly an individual endeavor — one practitioner contracting with one patient who paid out of pocket. Soon however, and particularly after World War II, psychotherapists increasingly began working in institutional settings — hospitals, outpatient departments, community mental health clinics, the military, and VA facilities. Especially beginning with managed care in the 1990s, psychotherapists have increasingly worked as employees of increasingly larger and larger private, for-profit groups.

Teletherapy has recently exponentially speeded up the concentration of psychotherapist — one company has accumulated a network including tens of thousands. This has the possible advantages of improving patient access and quality control but drains money from the system and risks creating inappropriate uniformity and decreased quality.  

Artificial Intelligence

I have previously written on the very real risk that computers will replace psychotherapists.  

Conclusion

It is the best of times and the worst of times for psychotherapy. Best because we have so many therapists and effective therapies. We can help most patients more than medication can and no profession is more interesting or fulfilling. I am a much better person than I otherwise would have been because my patients taught me so much. Worst because the field is so unnecessarily fragmented, so poorly compensated, and so at risk of being controlled by corporate interests and/or reduced by coaching or replaced by artificial intelligence.  

The best hope for the future, both for patients and practitioners, is to do our job well. We must integrate the hodgepodge alphabet soup of existing therapies by combining what works best from each within the context of a sound conceptualization. Therapists should no longer be trained in, and express fealty to, just one school of therapy. We should discuss, but rather feel comfortable applying techniques across all relevant schools, flexibly meeting the specific needs of each patient.

Psychotherapists have, since the dawn of time, provided comfort and solace to mankind. Labels change — shaman, priest, minister, doctor, psychiatrist, psychologist, social worker, counselor, nurse, occupational therapist, coach, and many more. But the essential function of explaining and healing human suffering has always, and likely always will be part of the human condition.  

The Wisdom of Therapist Uncertainty

Posted on by Psychotherapy.net Team

“Uncertainty is your space for growth.” – Angela, psychologist

Work hours for many are unpredictable. Political divisions, pandemics, and extreme weather add further unknowns to daily life. In an era that challenges mental health, it’s easy to assume that therapists should be pillars of all-knowing sureness.   

One Fear to Rule them All

But growing evidence suggests that practitioners can benefit from leaning into their uncertainty in times of flux. Skillfully accepting and even embracing not-knowing is linked to better mental well-being and improved decision-making in both clinicians and their patients. “We need to help psychologists view uncertainty not as a horrible thing you need to minimize, but as an opportunity to learn and grow,” says Elly Quinlan, a senior lecturer in psychology at the University of Tasmania and a leader in the study of uncertainty in clinical practice.

How humans contend with the unknown is a topic attracting attention in clinical psychology. This critical capacity is measured by gauging people’s “intolerance for uncertainty,” or the degree to which they view unknowns and the unsureness they spark as threatening or merely challenging. (Sample assessment component: “Unforeseen events upset me greatly.”) (1) Importantly, being intolerant of uncertainty is now recognized as a transdiagnostic vulnerability factor for a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. (2) As Canadian researcher Nicholas Carleton writes, this trait (and state) may be the “one fear to rule them all.” (3)

As a result, leading psychologists are targeting uncertainty intolerance as a promising new way to treat many mental disorders. By taking on more unknowns in daily life, patients gain skill at meeting life’s twists with a curious, open mind, rather than fearfully racing to eliminate uncertainty through denial or snap judgment. During one intervention, young adults tried answering their phones without caller ID. (4) An adult learning uncertainty tolerance in therapy challenged himself to delegate more at work. (5) Results are encouraging: in one recent study focused on bolstering uncertainty tolerance, worry and anxiety in people with generalized anxiety disorder fell after treatment to levels experienced by the general population. (6)

Now Quinlan and others increasingly see uncertainty tolerance as a needed skill for psychologists themselves to practice. Psychologists interviewed for a small quantitative study led by Quinlan reported primarily negative responses to situations filled with unknowns, such as an ethical dilemma or the challenge of selecting treatment for a high-risk patient. (7) The psychologists, who had diverse levels of experience, reported anxiety, feeling inadequate, frustration, and anger. Some avoided complex, ambiguous cases or left a client in order to escape uncertainty. “I actually could not resolve that uncertainty, so I shifted the client to another clinician,” said one.  

Such markers of an inability to manage uncertainty are associated with both anxiety and with burnout, conditions that undermine well-being and decision-making skill. In one study of 252 psychologists, their uncertainty intolerance in client care and in daily life predicted burnout (8), a form of exhaustion that up to 40 percent of mental health providers experience today. (9) Uncertainty intolerance is also linked to overtesting, according to studies in primary care medicine. (10)

The Importance of Uncertainty Tolerance

In contrast, psychologists who accept the intrinsic uncertainty of their work and see not-knowing as an opportunity for learning, as discomfiting as that may be, tend to have higher mental well-being. Angela, a psychologist who participated in another of Quinlan’s qualitative studies, advises younger peers to “treasure the darkness a bit. Uncertainty is your space for growth.” (11) Uncertainty-agile clinicians ask, “What is this ambiguity or my uncertainty telling me?” instead of rushing to bury or eradicate the unknown, says Quinlan, whose research has inspired her to assure her trainees that it's okay, and even helpful, to not know.

By recognizing uncertainty as a path to wisdom, providers gain time and space to consider nuance and alternative perspectives. In a speed-driven world where experts are expected to be all-knowing and ultra-decisive, psychologists often “long for the magic wand” of the quick, clear answers, observes educational psychologist Daniela Mercieca of the University of Dundee. But “it is only by allowing ourselves to be uncertain that we are open to shock and surprise … and complexity.” (12)

How can psychologists learn to recognize unsureness as an opportunity? Efforts to map uncertainty tolerance are so new that interventions to teach this skill set to practitioners are sparse in both psychology and in general medicine. One intervention found that training in non-judgmental mindfulness helped trainee psychologists become less stressed by uncertainty. (13) Other studies have shown that exposure to the visual arts or the humanities can boost uncertainty tolerance in medical students. (14) Quinlan plans to begin formally testing uncertainty-tolerance strategies for trainee psychologists in a few years. 

There may come a day when healthcare practitioners will be routinely taught to manage uncertainty as a way to improve their well-being and their efficacy. But until that time, perhaps clinicians can learn from the peers and patients around them who find wisdom in accepting life’s inherent unpredictability and in realizing that at any one moment they might not know.

Recently, two young practitioners found that openly admitting uncertainty in their practice felt unexpectedly liberating. The opportunity arose in 2020 as cognitive behavioral therapist Layla Mofrad and psychologist Ashley Tiplady worked with Mark Freeston of the University of Newcastle to develop a group intervention to teach uncertainty tolerance to patients just starting to receive care for a range of disorders. (15) To model the intervention’s content, they explicitly talked to one another and to patients about the program’s unknowns, ranging from outcomes of this novel treatment to how a tech outage might affect the day’s schedule.   

Most patients who completed the “Making Friends with Uncertainty” intervention showed significant improvements in their anxiety and depression and nearly half became more tolerant of uncertainty. Moreover, the facilitators themselves found that working with, not hiding from, uncertainty improved group solidarity and their own ability to be partners in care. “It’s easy as a therapist to jump into trying to make things feel more certain … we tried to hold back from that,” says Mofrad, adding that this approach returns therapy to its ideals. “The best therapy will always have an uncertain element, and the best therapists are those who will ask questions, be curious, and not stick to a rigid framework.”

Note: All quotes are from interviews with the author unless otherwise noted. Due to an editing error the references below have been updated as of 4/24/2024


Questions for Thought and Discussion

1. What were your impressions of the author’s premise about certainty and uncertainty?
2. How comfortable are you with uncertainty both professionally and personally?
3. In what ways might you carry forward the author’s research in your own clinical work?  


References

(1) Carleton, R. N.; Norton, P. J., & Asmundson, G. J. G. Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.

(2, 15) Mofrad, L., Tiplady, A., Payne, D., & Freeston, M. (2020). Making friends with uncertainty: Experiences of developing a transdiagnostic group intervention targeting intolerance of uncertainty in IAPT: Feasibility, acceptability, and implications. The Cognitive Behaviour Therapist, 13 (49), 1-14.

(3) Carleton, R. N. (2016). Fear of the unknown: One fear to rule them all. Journal of Anxiety Disorders, 41, 5-21.  

(4) Unpublished material shared with the author by Stephanie Gorka and Nicholas Allan of Ohio State University’s College of Medicine.

(5) Keith Bredemeier Assistant Professor at the University of Pennsylvania Perelman School of Medicine Center for the Treatment and Study of Anxiety, in discussion with the author, September, 2023.

(6) Michel Dugas et al. (2022). Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults with Generalized Anxiety Disorder. Behavior Therapy, 53 (6), 1147-1160.

(7) Quinlan, E., Schilder, S., & Deane, F. P. (2021). `This wasn’t in the manual’: A qualitative exploration of tolerance of uncertainty in the practicing psychology context. Australian Psychologist, 56 (2), 154-167.

(8) Malouf, P., Quinlan, P., & Mohi, S. Predicting burnout in Australian mental health professionals: Uncertainty tolerance, impostorism, and psychological inflexibility. Clinical Psychologist, 27 (2), 186-195.

(9) O’Connor, K., Muller Neff, D., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74-99.

(10) Korenstein, D., Scherer, L. D., Foy, A…Morgan, D. J. (2022). Clinician attitudes and beliefs associated with more aggressive diagnostic testing. American Journal of Medicine, 135 (7); also Lam, J. H., Pickles, K., Stanaway, F. F., & Bell, K. J. L. (2020). Why clinicians overtest: development of a thematic framework. BMC Health Services Research, 20 (1011),

(11) Fewings, E., & Quinlan, E. (2023). ‘It hasn’t gone away after 30 years.’: Late-career Australian psychologists’ experience of uncertainty throughout their career. Professional Psychology: Research and Practice, 54 (3), 221-230.

(12) Mercieca, D. (2009). Working with uncertainty: Reflections of an educational psychologist on working with children. Ethics and Social Welfare, 3 (2), 170-180.

(13) Pickard, J. A., Deane, F. P., & Gonsalvez, C. J. (2024). Effects of a brief mindfulness intervention program: Changes in mindfulness and self-compassion predict increased tolerance of uncertainty in trainee psychologists. Training and Education in Professional Psychology, 18 (1), 69-77.

(14) Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56 (12), 1163-1173.   

Sidestepping the Dependency Dance in Psychotherapy

Posted on by Psychotherapy.net Team

“Not I, nor anyone else can travel that road for you. You must travel it by yourself. It is not far. It is within reach.” – Walt Whitman

We’ve all had someone text us a single question mark after not responding to them within the timeframe they expect. You know the one. It looks like this:

“Can I come over — 12:00pm?”

“?”

I mean, did your question mark wander off and get lost somehow? Should we head to the front of the store to reunite it with its missing sentence? While I think the use of this orphaned punctuation should be considered a misdemeanor offense, it points to a natural phenomenon about human interaction, especially the disembodied kind most common in the digital universe — when we communicate with each other, there are rhythmic expectations. When we want the rhythm of a conversation to be slower, but someone else wants it to be faster, the single question mark makes its grand appearance.

“I’m waiting,” it complains.

When starting a new relationship, deciphering these rhythms can be a challenge because the response time between parties can suggest very different things. If one party responds to a text message quickly, it might mean they’re interested in the relationship, or it might indicate that their device was simply nearby. Yet if someone responds to a text message slowly, it might indicate they’re disinterested in the relationship, or it might simply mean they’re preoccupied. The signals are unclear and they require interpretation.

If we’re honest, it’s probably impossible to know what someone’s response time actually indicates, but this doesn’t stop us from reading between the lines. But the problem with reading between the lines is that we simply end up interpreting or projecting. When we feel alone, we might imagine that our text was read but ignored, and when we’re preoccupied, we might feel smothered by a quick response back to us. While much of our communication has moved into the digital space, it remains timelessly true: new relationships have a way of tempting our projections.

It’s only after the relationship leaves its early stages that the conversational rhythms fall into place, and the uncertainties become clear. Familiarity with someone’s rhythms comes with time. Similar dynamics also exist within therapy. When the therapist and client are in the process of creating a new relationship — learning, in a sense, to dance together — the rhythms of communication are uncertain before becoming apparent. And while rhythms in a non-therapeutic relationship require time before becoming understood, therapists don’t always have the luxury of time. Fortunately, the therapist can learn strategies to remove these rhythmic uncertainties, and the process of understanding our clients can be accelerated. I certainly have.

The Rhythmic Uncertainties of Therapy

One effective way I have found to remove the rhythmic uncertainties in therapy is to be forthcoming about my own rhythms. Most of my clients have not met with me beforehand, so they don’t know the therapy rules — at least not mine. They don’t know if I take phone calls after 5pm, if I correspond on weekends, or if emails should contain intimate session details. Whatever my own therapeutic rhythms might be, it is my responsibility to make them explicit.

Another area where I have made my rhythms explicit is in my response time to phone calls and emails. Most therapists I’ve encountered choose a 24-hour window, while others choose 48. While I don’t think the timeframe itself matters too much, it’s important to pick a response time and stick to it. This is because when we stick to a consistent rhythm of communication, it elicits important questions about our clients.

“Jessica called me twice in the past 24 hours, is something wrong?”

“James calls me every day. What’s going on here?”

When I create a consistent schedule of responding to my clients, I create a baseline, and by holding my own behavior constant, it helps me to notice any deviations in a client’s behavior. If someone attempts to reach me multiple times within a single communication cycle, sometimes this deviation signals that I need to intervene. A client might attempt to make contact several times because their personal safety can’t wait until the end of a 24- or 48-hour window. Multiple missed calls can be flares shot into the sky.

In other instances, consistent attempts to contact me within a single communication cycle can indicate something much different. This behavioral rhythm often elicits an important question that each new therapist has to learn — and certainly, I was no exception. That question is, “what should be done when a client makes persistent contact and has no intention of slowing down?”

The Dependency Dance

One of the challenges of being a beginning therapist is working with highly dependent clients. While these clients are different in innumerable ways, they also share striking similarities. The stories that bring them to therapy contain universal themes.

One such theme I’ve noticed is that these clients experience a strong sense of helplessness, and as a result, they depend on others for excessive amounts of support. They don’t mean to, but they rely on their relationships to balance and guide them; they turn human beings into handrails.

The difficulty associated with this excessive need for support is often manifested through a dependency dance: a symbiotic cycle marked by ever-increasing client support, and ever-decreasing client security.

Here’s how the cycle has functioned in my own clinical work. Feelings of panic surge within the client, and in response, they contact their loved ones to help them de-escalate. Yet after the panic eventually finds its resolution, the inner turmoil soon returns, as does their need for support. From within the client’s subjective experience of the cycle, each time they’re de-escalated, they feel more convinced that they can’t de-escalate themselves. Receiving help from others unintentionally reinforces their feelings of helplessness. This increases the client’s experience of fear, and then this fear ushers the panic back in with greater frequency. It’s a panic trap.

As the frequency of their panic accelerates, so do their requests for help, and this creates fatigue in their support system. Eventually, and usually with great reluctance, their loved ones exit the dependency dance by either distancing themselves or ending the relationship entirely. Once these supportive relationships end, the client’s feelings of shame become overwhelming. With no remaining handrails in reach, they reach out for a therapist.

In my early days of practicing therapy, it took a process of trial and error before learning how to step into this complicated cycle effectively. My learning curve was steep and uncomfortable. My hope is that by sharing my early mistakes, that I can offer some modicum of guidance to fellow clinicians, both nascent and experienced.

Early Mistakes in Psychotherapy

When I first started working with highly dependent clients, there were three mistakes that I tried to avoid. The first was allowing the cycle of crisis-and-relief to continue inside of the therapy. If I allowed the client to implement their dependent style into our relationship, then the heart of their problem would remain unaddressed. I’d be providing de-escalation services, but this would reinforce their feelings of helplessness, and then their surges of panic would return more frequently. I didn’t want to contribute to the dependency dance.

The second mistake I hoped to avoid was connected to the first. I worried that if the cycle continued, I would undergo the same exhaustion that their support system did. These clients had a long line of exhausted people behind them, and I didn’t want to find myself at the end of that line. If I joined the dependency dance, I worried their exhausted support system would only be replaced by their exhausted therapist.

But the mistake that concerned me the most, the third one, was creating distance in our relationship too quickly. These clients often had important relationships recently ended, and they were bracing for rejection. They had been deeply hurt, and I worried that if I created distance in our relationship too quickly, their feelings of shame would be quickly reactivated. I didn’t want the shame they experienced in their previous relationships to be reexperienced with me.

I spent time thinking about how to simultaneously avoid these three mistakes. How could I elude the dependency dance, protect myself from exhaustion, and avoid reactivating their feelings of shame at the same time? This was hard. I felt anxious and stuck.

Each answer I came up with seemed unsatisfactory, and despite my best efforts, I made all three mistakes multiple times. I took phone calls after hours and scheduled extra sessions, and just as I worried, my client’s surges of panic became more frequent. No matter how I pretzeled myself, their need for my help only increased.

In other cases, I was too reactive. I was exhausted from being overly available with dependent clients in previous treatment episodes, and so I expressed my limits too firmly. These clients ejected from my office as if launched from a catapult before disappearing into the clouds. Their feelings of shame had reactivated, and they quickly terminated the therapy. I couldn’t blame them.

Eventually my mistakes brought me to a solution. I discovered that I didn’t need to choose between my clients becoming dependent on me, or more independent from me. Instead, I could do one before the other. I could first join the dependency dance, and then show them how to end it.

A Therapeutic Strategy Applied

I’ve come to believe that to help clients become less dependent on those in their lives, they must first be allowed to temporarily become dependent on their therapist. With this logic, and joining the client on their terms, I could work to change the relationship from the inside. Instead of telling a client to become less dependent on me, I could show them how to do it, and then they could then learn how to replicate this process within their personal relationships.

But what does temporarily joining the dependency dance mean in practice? Highly dependent clients will request extra sessions and phone calls, and so how available to make myself was the challenge.

There’s no hard and fast rule on this, but I think it’s useful to make ourselves available two additional times outside of our scheduled sessions. There’s a reason to settle on two times instead of one or three. If I make myself available outside of scheduled sessions for one time only, once I start to create distance from the client, it becomes harder to protect them from feelings of shame. These feelings of shame simmer just beneath the surface, and if I create distance too readily, this feeling can be brought to a boil. When this happens, the client’s disengagement from therapy becomes more likely.

Yet being available three times or more creates a dynamic that’s too similar to their previous relationships. If I fall into their old pattern for too long, the client isn’t working on ending the dependency dance, they’ve simply found themselves a new person on whom to become dependent. Yet by making myself available twice outside of scheduled sessions, I have the best chance of avoiding both negative outcomes: the client can avoid shame and early termination, and I can avoid becoming trapped inside the dependency dance.

Making myself available twice outside of scheduled sessions also allows me to structure two different conversations. In the first conversation, I can introduce strategies to help the client work through their feelings of panic, but I refrain from discussing their dependency. There’s not enough trust yet, and the risk of the client reexperiencing their shame is too high.

Instead, I can introduce grounding skills, breathing exercises, and other emotional regulation techniques. It’s important to introduce these strategies in the first conversation, because when their dependency is eventually addressed, I want to remind the client that they already have the mood regulation techniques that they require. More on this a little later.

But the first conversation is just as much about earning trust as it is about introducing emotional regulation skills. What I’ve learned is that when trust is low in therapy, my words must be delivered with more precision. Low trust lowers the margin for error. When clients are skeptical of my intentions or competency, my interventions need to be effective. The dart must hit the bullseye.

The good news is that the reverse is also true. When trust is high in therapy, the margin for error widens. The presence of client trust permits the absence of clinical perfection. My words don’t have to hit the bullseye, or the dartboard for that matter. It’s for this reason that I consider trust-building to be the therapeutic master-skill. It allows me to maintain my effectiveness while remaining imperfect in my practice. When I earn a client’s trust, inevitable errors are less damaging, and the prospect of client improvement despite my imperfections remains intact.

When I introduce emotional regulation skills in the first conversation, I’m also practicing this master-skill; developing trust by making myself available to the client. This is important because for the second conversation, the degree of difficulty increases. My clinical imperfections are more likely to assert themselves, and so I’m going to need a wider margin of error for what’s to come. This next dart is a little harder to throw.

The Second Conversation

Once I’ve built some degree of trust and provided strategies to help the client manage their feelings of panic, I need to exit the dependency dance the next time we meet. If I don’t, I run the risk of exhausting myself and reinforcing their feelings of helplessness. So how do I exit this dance without activating the client’s shame? I can do so by implementing these four steps:

Taking the Blame

Externalizing the Helpless Feeling

Triangulating Against the Helpless Feeling

Affirming that New Rules are for Next Time

Let’s explore an example of how this conversation might sound in a telehealth setting, and then we can unpack the steps therein:

Client: “- -”

Therapist: “You’re on mute.”

Client: “Oh, sorry. Can you hear me now?”

Therapist: “Yes, but now your picture is frozen — wait, now you’re unstuck.”

Client: “ – -”

Therapist: “You’re on mute again somehow.”

Client: “Sorry, how about now?”

Therapist: “You’re good.”

Client: “Wow, okay. Thanks for making the time. I’m feeling really bad, and I just need to talk about things with you again.”

Therapist: “Thanks for reaching out. I’m sorry things continue to be difficult. It sounds like these strong feelings keep rushing over you.”

Client: “Yeah, what should I do about it?”

Therapist: “That sounds really awful. So, I hate to sidetrack us before getting started, but would you mind if I shared something that I’ve been worrying about?”

Client: “Yeah, of course.”

Therapist: “I don’t doubt that these feelings are really difficult to experience, they actually sound physically painful. But I’ve been thinking since the last time we talked, and I’m worried about eventually making things harder for you.”

Step 1: Taking the Blame. When I start the second conversation, I can lean on the phrase “I’m worried about eventually making things harder for you.” There’s a reason this phrase can be helpful. As I’ve discussed, these clients have felt rejected in previous relationships, and their feelings of shame are just beneath the surface. Yet if I express concerns about the dependency dance, not in terms of our own personal difficulty, but in terms of the potential difficulty for them, I can reduce the chances of reactivating these feelings. I can help keep the shame beneath its boiling point.

Now is it possible that I’ll feel inconvenienced by making myself available for this second conversation? Yes. But is it helpful to share these feelings with the client? In this case, I don’t think so.

Perhaps the person-centered therapist will object, “But this isn’t authentic. You’re not demonstrating congruence!” That’s a valid critique. Sometimes there’s a tension between my intention to be helpful and my ability to be congruent. My private reactions aren’t always useful to my clients, and when faced with the choice of demonstrating perfect transparency or perfect sincerity, I want to prioritize sincerity.

While these two concepts might seem identical at first glance, I am careful not to confuse them. The word transparency comes from the early 15th century, and from the Latin nominative transparens. It translates to something like, “to show light through.” Transparency is a pane of glass from which nothing is hidden on either side. But the notion of sincerity means something entirely different. Sincerity comes from the 16th century, and from the Latin word sincerus which translates to something like “whole, pure, and clean.”

While I may not be able to maintain perfect transparency in each moment, I can always work to cultivate intentions towards my clients that are “whole, pure, and clean.” In this case, the disclosure of my own fatigue risks eliciting a shame response from the client, and if I’m to be helpful, avoiding this reaction is paramount. While it’s ideal to practice both transparency and sincerity whenever possible, in moments like these it’s better to prioritize the sincerity of my intentions over the transparency of my reactions.

After expressing that I’m worried about eventually contributing to the client’s distress, I can implement:

Step 2: Externalizing the Helpless Feeling. When implementing this step successfully, it sounds something like this:

Client: “Making things harder for me? I don’t feel that way. What do you mean?”

Therapist: “This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering if there’s this voice that tells you that you can’t manage these moments of distress on your own. My concern is if I talk through these feelings with you each time they come up, I’m agreeing with this invalidating voice. It’s as if the voice is saying, ‘You can’t do this by yourself,’ and I’m saying, ‘You’re right, let me jump in to help.’ Then each time you work through these feelings with me, it reinforces the sense that you can’t do it alone. But tell me what I’m missing.”

This intervention is more directive in nature and so it’s placed between therapeutic airbags, but to help clients approach their feelings of helplessness with more emotional safety, I can also use language that helps them externalize their feelings of helplessness. If I use the phrase, “there’s this voice that tells you…” this invites the client to think about their feelings from a safer distance. Here’s an example to demonstrate how this works.

Imagine hearing the following two phrases and listen for any differences in how you experience each statement. If it’s difficult to notice the differences while reading privately, it might be helpful to have someone read them aloud. Here’s the first phrase:

“You feel like you can’t do this by yourself.”

and the second one:

“There’s this voice that tells you that you can’t do this by yourself.”

Did you notice anything? The first phrase moves us into an emotional space and the second moves us into an evaluative one. This occurs because describing a feeling as “a voice” pulls the feeling out from the internal world, and places it into the world that’s external. An emotion is something we feel internally, but a voice is something we hear externally.

When I invite the client to think of their feeling of helplessness like it’s coming from the outside, this helps them step back from their uncomfortable emotional state. It creates space and emotional safety. This can make it easier for them to think about what they’re experiencing.

After I’ve taken the blame and externalized the feeling of helplessness, I can move into:

Step 3: Triangulating Against the Helpless Feeling. Let’s reenter the transcript to hear how this might sound:

Client: “I guess that makes sense. But what do I do about it?”

Therapist: “Well I think we could team up against this voice that says you’re incapable. I think we could create a practice arena for you to prove it wrong. If we can build some victories where you move through these times independently, then you can grow in your confidence to manage these difficult feelings. But please, push my thinking around here.”

When I externalize the helpless feeling in Step 2, I’m not only creating distance for the client to think about their feelings with more safety, but I’m also laying the groundwork for Step 3. These two steps work well together because by using the “the voice” intervention, I’ve increased the number of participants in therapy by one. Therapy goes from two parties (the therapist and the client), to three parties (the therapist, the client, and “the voice”). And once I’ve created this third party, I’ve created the opportunity for triangulation.

Now, triangulation typically carries a negative connotation and for good reason. It’s used to describe the process whereby two people inappropriately collude to exclude a third party. Triangulation is the reason groups of three are often unsuccessful in adolescent friendships; two friends grow closer to one another by excluding the third.

Yet in this case, the third party (the voice of helplessness) needs to be sidelined, and I can grow closer with my client by excluding it. I can initiate this benevolent triangulation by using the phrase, “we could team up.” This phrase prevents me from challenging the client’s feelings of helplessness directly, and instead I’m able collaborate with them against “the voice.”

That was Step 4: Affirming that New Rules are for Next Time, and this brings my four-part strategy to its conclusion. Here is the therapeutic dialog:

Client: “I hear what you’re saying, but I still don’t know what to do.”

Therapist: “Maybe we can start by reviewing what worked last time. This way I can help you find some relief today, but we can also figure out what to practice next time. Then when you steady yourself without me, you can push back against the invalidating voice that tells you that you can’t manage these feelings independently. What do you make of that?”

The rationale behind Step 4 is when I challenge the dependency dance, I don’t want to increase distance from the client in the same conversation. Instead, I can review the emotional regulation skills from the first conversation, but the client won’t attempt to manage their panic independently until its next occasion. This helps me demonstrate to them that changes to the relationship are not an expression of rejection. I’m not expressing my own need for distance, but instead, I’m creating opportunities for them to disprove the voice of helplessness. I’m not taking space from the client, but together, I’m creating space for them.

Now that I’ve discussed each step on its own and explored the internal rationale, I’ll provide a fuller sense of how this four-part strategy sounds with all four parts together. Here’s the transcript in its entirety:

Therapist: “I don’t doubt that these feelings are really difficult to experience, they actually sound physically painful. But I’ve been thinking since the last time we talked, and I’m worried about eventually making things harder for you (step 1).”

Client: “Making things harder for me? I don’t feel that way. What do you mean?”

Therapist: “This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering if there’s this voice that tells you that you can’t manage these moments of distress on your own. My concern is if I talk through these feelings with you each time they come up, I’m agreeing with this invalidating voice. It’s as if the voice is saying, ‘You can’t do this by yourself,’ and I’m saying, ‘You’re right, let me jump in to help.’ Then each time you work through these feelings with me, it reinforces the sense that you can’t do it alone. But tell me what I’m missing (step 2).”

Client: “I guess that makes sense. But what do I do about it?”

Therapist: “Well I think we could team up against this voice that says you’re incapable. I think we could create a practice arena for you to prove it wrong. If we can build some victories where you move through these times independently, then you can grow in your confidence to manage these difficult feelings. But please, push my thinking around here (step 3).”

Client: “I hear what you’re saying, but I still don’t know what to do.”

Therapist: “Maybe we can start by reviewing what worked last time. This way I can help you find some relief today, but we can also figure out what to practice next time. Then when you steady yourself without me, you can push back against the invalidating voice that tells you that you can’t manage these feelings independently. What do you make of that (step 4)?”

***

I’ve learned that while it’s understandable for the therapist to feel overwhelmed when working with highly dependent clients, it’s important to remember that these clients are living incredibly uncomfortable lives. It becomes even more important, therapeutically, to try to imagine their surges of anxiety, their loss of important relationships, and the sense that life is a spinning room. By working to understand what these clients experience in their emotional and social worlds, it becomes easier to provide support they’ve yet to experience. The real work then focuses on earning their trust, teaching them strategies to reduce their distress, and watching with admiration as they learn to exit the dependency dance themselves.

[Editor’s note: In the next installment of this five-part series, the author will address the challenges of working in the shadows of client suicidality]    

Deploying Therapeutic Airbags to Enhance Clinical Outcome

Posted on by Psychotherapy.net Team

“Angels can fly because they take themselves lightly.” -C.K. Chesterton

Jessica

Jessica (an amalgam) was 30 years old when she came to our clinical team. Her health was complicated and so I attended a consultation to discuss the details. This meant another meeting sitting around a round blonde table that looked like it was donated by a local elementary school. If you’ve ever worked in an institution, you know the table I’m talking about. I was told that Jessica had a brain tumor that would periodically swell with blood, and it was hypothesized that this tumor was the reason she would become aggressive. The theory was that when the tumor would expand, it placed pressure on the parts of her brain that stimulated survival reactions, and this is what led to her violent outbursts. This caught my attention. I was astounded, really. These were the early years in my practice, and this case formulation was bringing all the pieces together. It made sense of what I learned in graduate school about the fight-or-flight response, and it demonstrated the mistake of thinking that aggressive behavior was simply a result of poor character. It opened the door for compassion, and it humanized Jessica. I left the meeting with a bit of a brain buzz. It’s that feeling you get when you come across a new idea that you can chew on for a couple of days. It’s like a runner’s high, but for therapists.

Eager to meet Jessica, I walked down the hallway enjoying my high. I eventually found the right room, stepped in, and we made small talk for a bit. The discussion was off to a smooth start, and with my compelling conceptualization in hand, I decided to jump in.

“If you’re comfortable, tell me about the brain tumor. I’ve heard it plays a role in the aggressive times.”

With the appearance of deep reflection, Jessica looked down, paused, and then looked back at me. Then she gave me something to think about.

“I’m 30 years old, and somehow, I’ve got a brain tumor. Has it occurred to you over-educated and stubbornly inept shrinks that this is the reason that I’m angry?”

I felt the capillaries in my cheeks begin to swell, and I knew my skin was glowing red. It seemed there was nothing left to do, and so I just sat there, draped in embarrassment’s ridiculous costume.

Clinical Creeds

When we’re in graduate school, we learn about the maxim, “First, do no harm.” The adage comes from the ancient Greek physician Hippocrates, but we talk about what this motto might mean for a therapist. No dual relationships. No receiving large gifts. Keep your clothes on.

We learn that therapy can be dangerous in its most negligent manifestations. What makes it powerful is also what makes it dangerous. Therapy is like a flame; it can warm you or it can burn you.

While the cardinal sins seem easy enough to avoid, once we move deeper into our work, we discover how difficult it really is to do no harm. No harm? Really? Zero? Well, what about the time I was caught checking the clock only five minutes after I started the session? Or the time I made theatrical eye contact and then confidently called my client the wrong name? Masterstroke! And what about the time I immediately damaged my rapport with Jessica because it was more important that I be entertained by an interesting idea than to discover who she really was? Some amount of harm was done in each of those instances, and for the record, I’ve made much bigger mistakes.

I understand the intent behind the axiom, but I think, “First, do no harm,” is a puritanical expression. I don’t like that third word. No mistakes allowed. Be perfect. You’re only one fumble away from doing serious damage. That’s a lot of pressure, and so I’m going to try to convince you to gently set this motto aside.

Like many creeds, “do no harm” is a noble abstraction, and when we try to pull abstractions down from the ethereal world of ideas and place them into the corporeal world in which we live, we discover their limitations. We find out that what makes sense in our head doesn’t always translate into our hands. It’s like when an inspirational speaker tells you to “Carpe Diem” or “Do what you love, and the money will come.” These diet Deepak Chopra-isms seem to know more about lofty slogans than implementable methods; more about the sky than the soil.

Why does this matter? It matters because something happens when our eventual mistakes collide with this puritanical mandate to do no harm. It creates fear, and it’s a fear that lives in the heart of every therapist I’ve ever met.

Mistakes are Mentors

Fear runs deep in the heart of this profession. We fear being sued, we fear being interrogated by the regulatory board like we’re testifying before congress, and ultimately, we fear losing our careers.

But maybe this climate of fear shouldn’t surprise us. While in school, we watch video clips of awe-inspiring clinical moments. We read transcriptions of perfectly executed interventions. How many of these moments are helped along by editors? We can’t be sure. My hunch is these videos clips are often highlight reels, and the perfect dialogue transcriptions are like glossy grocery store magazines — air brushed to remove blemishes. It’s tabloid therapy.

Tabloid therapy is any presentation of the therapeutic process that’s absent of imperfection, and unfortunately, it saturates the university and post graduate training environments. But where are the blooper reels, the blunders, the awkward moments, and the misunderstandings? Where is the throat clearing, the sneezing, the spilled coffee on the shirt? I never saw myself in any of those videos or books. The unpolished learning process wasn’t role modeled, and because we’re only introduced to perfect therapy, it makes sense why we treat our blemishes like pathologies.

Problems begin to emerge when we’re too afraid of our mistakes, because this makes it difficult to learn from the valuable information held within them. When making mistakes becomes forbidden, our mistakes create fear, and then the adjustment signals are more difficult to discern. But when we relate to mistakes effectively, they signal to us where to adjust. They mentor us. This means that to grow as a therapist, the great majority of our mistakes must be taken lightly. We must sit safely with our mentors and listen for their guidance.

While I wish that all harm could be entirely avoided, I don’t see a way around it. This isn’t an invitation into clinical recklessness, but the reality is that some of our clients will experience our growing pains, while others will benefit from what we’ve learned. So go ahead, stumble over your words, double-book an appointment, botch a reflection, catch yourself zoning out, violate HIPAA, and commit insurance fraud. Okay, don’t do the last two things, but because “do no harm” interferes with the learning process, we should sweep it into the dustpan with the other noble abstractions. Carpe Diem could use the company.

First, Reduce Harm

Instead of developing an adversarial relationship with our mistakes, what if we thought about learning therapy in the same way we think about learning to drive? I didn’t want to make mistakes when I first got in a car, but despite wanting to drive perfectly, it wasn’t meant to be. The speeding tickets and fender benders were part of the learning process.

As I learned to drive, the car had safety features to reduce the risks. I did my best to drive safely, but just in case, I could rely on the airbags. What if we approached therapy this way? We don’t want to make mistakes when we’re practicing therapy, but mistakes will invariably occur. Therapy carries inherent risk, and eventually we’ll get into accidents, but what if we built strategies into therapy for damage-reduction? “First, do no harm” is unrealistic, but “First, reduce harm” might work. We could create therapeutic airbags.

The types of mistakes that can occur within therapy are limitless, and so it’s natural to wonder where we should begin with trying to reduce the risk of harm. Which mistakes should we build these airbags around? Let’s start by exploring where the accidents are the most dangerous.

Over many decades, a slow consensus began to emerge about why therapy works. Instead of believing that the correct therapeutic method was necessary for the client’s improvement, researchers noticed that there were common factors across different types of therapies that ultimately made the difference.

There were many people involved in this emerging consensus, but it was Michael Lambert who suggested that the single variable that influenced client improvement more than any other had little to do with the therapist. Instead, the client improved because of their personal qualities and environmental resources. When the client improved, about 55% of the reason had nothing to do with the therapist (1).

Up until this point, therapists were taking credit for improvements they had no part in influencing. As the saying goes, we were roosters taking credit for the sunrise. This didn’t mean that therapy wasn’t effective, but it did mean that the single most influential part of what made a person feel better was not within the therapist’s control. In hindsight, it was hubris to think we could take most of the credit for a client’s improvement.

The area where the therapist had the most influence was the quality of the therapeutic relationship. Lambert concluded that the relationship between the therapist and the client accounted for 30% of why the client improved. It mattered if empathy and warmth were characteristic of the relationship. It mattered if there was a sense of personal closeness. So, there it is. If the relationship with the client is where we can make the biggest difference, then damage to the relationship with the client is where our accidents are the most dangerous. This is where we should install the therapeutic airbags.

What does damage to the therapeutic relationship really mean? It seems to depend on who you ask. If you talk with a client-centered therapist, they’ll warn you about directing the client too much. They’ll remind you about the problems with giving advice. Directive therapy can create an aura of expertise that makes it harder for our clients to disagree with us. If it’s difficult for the client to disagree with us, they will express agreement even when they privately disagree. Then the client can’t be themselves, even with their therapist. Giving advice can lead to client hiddenness. That’s one way we can do damage to the relationship.

If you talk to a therapist that’s directive in their style, they’ll tell you about how nondirective therapy becomes aimless, and for that reason, frustrating for the client. They’ll tell you about how cognitive behavioral therapy, dialectical behavioral therapy, and acceptance and commitment therapy are each directive treatments protocols, and they work just fine. They’ll tell you about how expecting people to come up with their own answers is a form of withholding help. Clients will think you’re too removed, they’ll say. That’s another way to damage the relationship. I think they both have a point.

I once had a well-meaning directive therapist say to me, “You know when you have to tell your client that it’s time to leave their marriage?”

Nope, I really don’t. Point for non-directive therapy.

I’ve also heard something like this said multiple times, “My problem with therapy is that eventually, I need someone to tell me what they think. Some therapists just want to listen. I start to wonder if they don’t know what to do with me.”

I get that, too. Point for directive therapy.

Both directive and non-directive therapies have important critiques about each other. They’re a divorced couple that has a refined sense of the other’s shortcomings. Fortunately, the truth is that our choice is not between directive or non-directive therapy. We don’t have to pick a parent. Instead, there’s a long green field between these two positions, and how much we engage with the client should be a matter of degree. When we decide to engage with our clients more directly, we can incorporate strategies that address the concerns of the non-directive therapists, but we can proceed with our work, nonetheless.

Using Therapeutic Airbags

If we decide that we’re going to be directive to some degree with a client, then we should use a strategy that helps reduce the risk of potential harm to the therapeutic relationship. As Lambert demonstrated, the relationship that we have with our client is the single greatest factor where we have influence, and so it’s where we should be the most careful. This is where we should use the therapeutic airbags. The nondirective therapists are correct that our clients might be uncomfortable disagreeing with us, and so the purpose of a therapeutic airbag is to incentivize client disagreement. This way we can be confident that our clients aren’t overtly agreeing with us even when they privately don’t. We can work to prevent hiding, and here’s how we can do it.

Step 1: “This simply crossed my mind…”

Before we’re directive to any degree, it’s important to signal to the client how seriously we’re taking our own thoughts. If we present our impressions as authoritative theories, then the client will feel more pressure to agree with us. For many clients, it will be difficult to disagree with the theory of a professional. But if we use the opening, “This simply crossed my mind,” then we can signal something quite different. This phrase seems uninteresting on its face, but when we look closer, the words “simply” and “crossed” are doing some heavy lifting.

The word “simply” suggests that we aren’t taking ourselves too seriously. It diminishes the authority of what we think. It’s casual. There’s no grand theory about the client’s life that’s about to be introduced, because the thought just simply came to mind.

The word “crossed” also communicates our own lack of commitment to what we’re about to share. The thought passed through our mind. It came, and it went. We haven’t spent excessive amounts of time thinking about what we’re about to say. We’re signaling that we’re not personally committed to the ideas that they’re about to hear. We’re keeping things relaxed.

Step 2: “…and so tell me if this doesn’t fit.”

This is an invitation for disagreement, but it’s also more than that. Notice what word isn’t being said. We aren’t saying, “…and so tell me if this is wrong.” If we were to use the word “wrong” it would make the disagreement overt. This would make it harder for the client to disagree with us. For some people it will be hard to explicitly say to a therapist, “No, that’s wrong.”

Instead, we can use language that invites more subtle disagreement. “Tell me if this doesn’t fit,” sounds more like we’re in the changing room of a department store. Yes, there would be ethical issues with that, but you know what I mean.

Step 3: “but I found myself wondering.”

This is where we share our impressions about the client or their situation. It’s where we’re the most directive. In this step we aren’t conveying conviction, but it’s opposite — we communicate wonder.

Wonder is an essential quality in a therapist. Wonder is the combination of imagination, openness, and awe. It helps us to travel into the experience of another, and for this reason, wonder is a relative of empathy. Expressing wonder might sound like this:

“This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering…”

Notice the difference between, “I found myself,” and “I find myself.” The first one is past tense and the second one is present tense. When we say, “I found myself” then we are sharing a memory. When we say, “I find myself,” then we’re talking about right now. The present tense creates immediacy, and immediacy can create intensity in the conversation. There’s a place for immediacy in therapy, but this isn’t one of them. Instead, if we express what we found ourselves wondering about in a previous moment, then we can continue to keep the pressure on the client low.

Step 4: “But tell me where this misses the mark.”

This is the closing phrase. It’s useful because, “tell me where” assumes that we made a mistake. If we were to finish the skill with, “Did I miss the mark?” then for many agreeable clients, this would elicit a reassurance reaction, “No, you got it right.”

Instead, the client must correct us if they want to express agreement. Here’s how this might look:

Therapist: “But tell me where this misses that mark.”

Client: “Well, I’m not sure it does miss the mark.”

If the client wants to agree with us, then they must be disagreeable. They must jump a hurdle to correct our assumption that we made a mistake. When we set things up this way, we can have more confidence that the client is being sincere in their agreement because we’ve made the agreement harder. We’ve also made disagreement easier, because conveying the assumption that we’ve made a mistake makes it easier for the client to follow our lead.

Here’s a fictional example of the skill in its entirety. This is how things often transpire when we successfully get our client to correct us:

Therapist: “This simply crossed my mind (step 1), and so tell me if it doesn’t fit (step 2), but I found myself wondering (step 3) if part of the difficulty is that you’ve thought that setting boundaries is selfish. Setting boundaries seems to chafe against your values. But tell me where this misses the mark (step 4).”

Client: “Well, I don’t really believe that having boundaries is selfish, so I’m not sure.”

Therapist: “Okay, I gotcha. You don’t take issue with boundaries. Can you help me understand what I’m missing?”

Client: “Well, I think it’s okay to have boundaries, but I just don’t do it for some reason.”

Therapist: “I think I’m getting it now. You don’t have anything against having boundaries, but putting them into action doesn’t happen, and you’re not sure why. Tell where this missed the mark.”

In the last exchange, the therapist can return to the assumption that a mistake was made by repeating step 4 (“tell me where this missed the mark”). This way the therapist can gain confirmation from the client, or elicit a second correction.

***

This strategy is built to constantly elicit feedback from the client. It’s a feedback machine. If we use the strategy effectively, then we’ll be corrected more often. When I first started using therapeutic airbags, I thought I was getting worse at my job. The truth is that I was previously unaware of how many mistakes I was making, and this strategy was bringing my mistakes forward.

Let’s learn to view our mistakes differently. Rather than be afraid of them, we should actively work to hear about them, and then we can protect our relationship with each client. Mistakes don’t have to be blemishes, and they don’t have to be threatening. A client who talks about our mistakes is a client who feels safe enough to share them. This is not a sign of damage to the therapeutic rapport, but a sign of investment in the relationship — the client has decided not to hide. When we use these therapeutic airbags, our mistakes will come forward, and when they do, so will our clients.

Editor’s Note: This is the first in a series of five articles by David Prucha. While initially intended for beginning therapist based on his own clinical evolution, you will see that there is certainly something in each of these essays for clinicians at all levels. In the next installment of this five-part series, the author will address the challenges and benefits of working effectively with client dependence.

Reference (1) Lambert, M.J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J.C. Norcross & M.R. Goldfried (eds.), Handbook of psychotherapy integration (pp.94-129). Basic Books.

An Early Career Lesson in Boundary Setting Helps the Client and Therapist Grow

Posted on by Psychotherapy.net Team

As is true in the lives of clinicians outside of the office, asserting and maintaining clear professional boundaries is essential clinically, ethically, and personally. I have found it not only helpful, but often critical to help my clients gain awareness of the limits in our professional relationship, not only for their safety but for my own. As to be expected, my clients have tested these boundaries, sometimes in minor and other times significant ways. Regardless of the size of these crossings, I have always found their navigation challenging. If their behavior inside of the therapy room is in some way a reflection of similar behavior outside of those walls, then I would like to think that by setting boundaries, I have been helpful in their personal relationships. I’d like to share an instructive experience I had several years ago.

An Early Career Therapeutic Experience with Boundaries

In my early therapeutic work, a client sought help for anxiety and self-esteem issues. Throughout her life, the client had felt misunderstood by parents and peers, leading to a powerful desire to be heard, coupled with a deep need to feel understood. In sessions with me, she often attempted to dominate and control the work, deflected from that work, and resisted my therapeutic efforts and techniques. Having attended for several months, she often interrupted me, changed the direction of counselling, challenged suggestions, resisted recommended coping strategies, and all the while — and quite ironically — pushed for more session time and dropped “doorknob disclosures” at the end of sessions. I often left those sessions feeling frustrated, powerless, and occasionally angry with her. I quickly recognised her need to address these boundary challenges for the sake of her growth, and my own therapeutic — and perhaps personal — peace of mind. The week after a particularly frustrating session in which the client was extremely resistant, I broached the subject of boundaries. I enquired what boundaries meant to her, but the subject was quickly and quite handily deflected and changed. Firm and focused, I resisted the redirection. “Let’s circle back to my question,” I encouraged, keeping my body language open, my expression warm and my eye contact fixed. The client did not respond. Maintaining eye contact, I held space for the silence in the room, allowing a few moments to pass. It was an uneasy silence, like a standoff of sorts. I carefully monitored her emotional response to the intervention. Smiling, I broke the silence. “It appears you couldn’t answer my question, and that’s ok. Perhaps you aren’t ready to answer right now. We can come back to that when you are ready. However, I would really like to share my thoughts on boundaries with you. Could we stay with that for a moment?” I invited. Due to the direct nature of my statement, the client looked at me curiously. “Yes, ok,” she replied, slightly irritated.

A Therapeutic Door Open Once Boundaries are Asserted

Following some psychoeducation around boundaries, I gently shared my thoughts and observations, applying curiosity and compassion to her behaviours that I noticed in our sessions, addressing the boundary violations which had presented over the past few months. I discussed the ethics of counselling and the importance of boundaries, expressing genuine empathy. This intervention opened the door of awareness for the client to explore her own boundaries, and after some discussion, she acknowledged their looseness in certain areas of her life and that pushing boundaries with others helped maintain a level of control at a time when she did not feel in control of her emotions and thoughts. Keeping focus, we talked through the rationale behind boundaries, highlighting how doing so created a safe space for exploration and growth. I offered, “fostering strong healthy boundaries within our therapeutic relationship will help you harness boundaries in your personal life and move you closer to your goals.” Concluding the pivotal discussion, we defined and discussed the therapeutic framework, ensuring the shared understanding that boundaries were necessary for a productive therapeutic relationship, and laid the foundation for a revised framework we would adhere to as we re-contracted with each other. My client seemed to appreciate my assertiveness, and the renewed structure of our work together. From that point, our sessions flowed with more focus and structure, and she demonstrated a will to apply the techniques both in and outside of the therapy room. Whenever she subsequently attempted to push boundaries in session, I quickly re-focused on that earlier breakthrough session. She was even able to discuss instances from outside of therapy where she was able to assert and maintain healthy boundaries. As boundaries became more consistent in her life, her self-esteem improved, and her self-confidence expanded. Growth, resilience and self-discovery followed. By holding firm to my boundaries, I demonstrated professionalism while modelling self-respect and honouring my client’s process. Doing so allowed her to gradually understand the significance of these boundaries and the transformative potential she held. In retrospect, I believe we identified the underlying motivations behind her actions, holding space for fear of vulnerability, and the emotional injury underneath the need for control. This exploration fostered healing, self-awareness, and empowered my client to take ownership of her behaviour, laying the foundation for personal transformation. Our work flourished, and in the process, I gained confidence in setting boundaries with future clients. I’m not saying that clients no longer test me, but I am thankful for that and similar early-career opportunities to assert and hold fast to boundaries.

The Truth About Professional Growing Pains from a Novice Psychotherapist

Posted on by Psychotherapy.net Team

A Novice Therapist

I remember my first session as a therapist. Walking into the waiting room and wondering if the blonde in the pink cashmere sweater was Susie. Meeting a patient for the first time felt — and sometimes still does — like a blind date.

I recall thinking to myself, she could be there for another therapist who shares the office suite. Do I awkwardly call out “Susie?” Or do I wait for the other therapist to retrieve her patient from the waiting room to prevent me from calling out Susie when in fact this may not be Susie but rather, the other therapists’ patient? I wouldn’t know — I’ve never met Susie before.

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Who I saw that day in the waiting room matched the description of the individual on the screening sheet, a 19-year-old female. In that moment, I reminded myself that I was trained and also clinically-oriented toward not making assumptions. But I wasn’t trained not to doubt myself. Fast forward to the present era of telehealth when meeting a patient for the first time feels less like a blind date and more like a fifth date — when you are already invited to the persons’ home — even if just through a screen. There is a certain level of “intimacy” joining someone via telehealth versus in an office setting.

Working in an office feels more like a meeting at a neutral place, like a coffee shop, rather than over a digital medium, which creates the sense that you are picking someone up at their apartment. I gain entry into their life and can observe their decor, see books they read, notice whether or not they are messy or neat and if there are any pictures of family and friends nearby.

Therapeutic Alliance

In my career thus far, I have had patients’ parents say to me after I finish treatment with one of their children, “I think you’d be a good fit for my other child. I’d like for them to be in therapy with you.” As my supervisor has told me, finding a therapist is like dating. Some people shop around for a therapist until they find their match.

What works for one patient may not work for another, which is why there is no “one size fits all” approach to therapy. I’ve had another patient say to me, “I didn’t want to come to therapy today. I was upset after our last session, but then I realized you hit something within me.” I have also had patients blame me and “break up” with me due to transference or feelings about something explored in the therapy space.

I have had patients doubt my expertise and skills due to my age. Their questions about my competency trigger my own insecurities as a clinician. Patients who are older than me, and some who are parents themselves, have still chosen to work with me. Some have exhibited ambivalence regarding my skills and capabilities. I have utilized psychoeducation and have experience, schooling, and training to allow patients to understand that I have the tools to support their needs.

I have one patient, whom I have been working with for many months, who was skeptical of my age when we first began together. Now she embraces my age because she feels I am able to inform her on “the current generation” and allow her to better understand her children and their habits, behaviors, and thought processes in relation to herself.

On the other hand, I had a patient who was close in age with me who no longer wanted to continue sessions together due to wanting someone “older with more life experience.” This patient identified as Black and also wanted a Black therapist, which made sense to me.

I value patients’ wishes of working with someone with shared experiences. I also reflected on my own about how therapeutic alliances are formed. My thought is that therapy is not always a “been there, done that” relationship. Rather, therapy is about accomplishing goals and finding deep meaning and exploration through shared vulnerability.

I have also had male patients verbalize finding me physically attractive, which has made me uncomfortable. I even had a female patient who was around my age comment on my appearance during almost every session. While these moments were flattering, my focus with these particular patients remained on helping them to better process and understand their thoughts and feelings toward me, and their relationship with thoughts and feelings towards other significant figures in their lives.

I too have found a patient attractive and often ponder whether I show up in the treatment room in a different manner than clients who present as less attractive. I also wonder whether patients who admit to finding me attractive are doing so to curry favor with me. Even with complimentary statements from patients, I sometimes doubt the support I offer, the guidance I provide, and my clinical perspective — all while trying to figure out my own life.

Progress Notes and Clinical Supervision

I have always considered myself to be a writer, so I never anticipated that clinical documentation as a therapist would be a “skill” that I would need to acquire, let alone hone. I am grateful for my first supervisor who allowed me to learn clinical-case note documentation language. In the past, I’ve felt that I was unable to develop my own clinical voice due to needing to follow strict guidelines on what a “proper progress note” looks like. Another form of self-doubt and self-scrutiny came to fruition when told that I was not documenting in the “correct way.” Progress notes being professional, concise, and readable is more than sufficient.

Just as we do not conduct our therapy sessions in one way, why should all progress notes rely on the same verbiage? What about diversity in patient care and treatment? I once had a supervisor who required clinicians to draft progress notes several times until she approved them. While I understand that I was working under my supervisor, I also felt that time spent with patients was taken away by tedious paperwork. I doubted my intuition because the supervisor was more experienced. However, I sometimes wondered if I had more experience than the supervisor because I was the one who was working directly with the patient. To this day, I’m still uncertain as to what a “correct” progress note is.

As I have gained clinical experience and confidence, my priority sometimes shifts from meeting patients’ needs and working to understand and achieve their stated goals, to over-fixating on writing treatment plans that may or may not reflect the work that is done in the therapy space. While supervisors have an obligation to the agency or practice, they also have, or should have an equal commitment to the therapists that they supervise.

It is my hope that any future supervisor or mentor I have recognizes my strengths while simultaneously challenging me. I believe that supervisors and their quality of supervision can contribute as much to a therapist's negative self-talk and self-doubt as the therapist bestows upon themselves.

My Imposter Syndrome

When in session, I sometimes experience imposter syndrome, negative self-talk, self-doubt, or all of the above. As a new clinician, feeling uncertain, ambivalent and/or in disbelief of the work I am doing with a client or patient is normal — or at least I truly hope it is. Which therapeutic modality do I use? Which intervention am I using without yet being aware? Am I speaking enough? Am I speaking too much? Am I too gentle? Not gentle enough? Am I truly understanding patients’ agency, or am I asking them to consider what I think is right? I have so many blanks in my intake paperwork.

Being a new therapist feels just as vulnerable to me as patients letting us into their lives may feel. The negative self-talk and self-doubt that I may experience mirrors that of patients who may bring their own insecurities and uncertainties into session. Perhaps, my own internal voice, sometimes filled with ambivalence, mirrors those of my patients.

The parallel process of therapists and patients work in tandem. I often support patients in challenging their negative thoughts when I may be experiencing my own negative self-talk relating to the work that I do with patients. Therapists who demonstrate negative self-talk regarding their work with patients may be impacting the therapeutic relationship in a negative way. How can I support a patient with less negative self-talk when I am doing exactly what I am helping them not do?

If a patient and I discuss their negative self-talk and doubts, perhaps I will become more aware of my own both in and out of the therapy room. I must address my own ambivalence, negative self-talk and self-doubt in order to best support patients and myself. Patients may be able to sense when I am exhibiting self-doubt and negative self-talk, even if I am not articulating this.

My patients feed off my energy, and vice versa. However, I have learned, sometimes painfully, that it is my job as a therapist to take note of when patients’ experiences, doubts, and negative self-talk affect me. I continually attempt to be self-aware when these areas come to the surface for me. Being a new therapist comes with much to balance. Placing time to be with family and friends, clean and do chores becomes a juggling act.

***

As both a young person and novice therapist, I am simultaneously learning to “adult” and find my professional identity. I am grateful for the growing experiences that I have had in my career, and I look forward to more reflection, learning and time to come spent with patients!  

Radical Listening: A Key to Therapeutic Success

Posted on by Psychotherapy.net Team

The space between musical notes is called an interval, I just learned. French composer Claude Debussy described music as “the space between the notes.” Without the space between, it would just be a cacophony of noise. The space allows for the notes to resonate and reverberate and mature into their fullness of expression. It gives room for relativity and reflection and response. This analogy could be applied to many things in life to improve their experience and outcome: dialogue, relationships, life, and psychotherapy.

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Being untrained in the art and technicalities of music, I listen to and appreciate music more intuitively. I hear the Gestalt of the composition or song rather than attempting to discern the nuance of their parts. Knowing this about music, and then extending it analogously to other areas of life, clarifies and shines a light on the “space between” in some illuminating ways.

Competing for Space in Relationships

Sometimes in relationship conflict, when two people are vying for space to be heard, there are times when there is little space for absorption, reflection, and appreciation of the other. Defensiveness and/or attack predominate. Or sometimes one person needs space and the other does not provide it, pursuing relentlessly, forcing the other into either complete retreat and shutdown, or drawing them reluctantly into defensive engagement. It is a simultaneous and continual banging of pots and pans and blasting of horns with no space in between.

In this particularly heated kind of context, creating “space between” facilitates relative quiet and calm. It allows for reflection time. It provides the opportunity to digest the other’s words, and for words of retort to be more considered and chosen. It gives feelings time to catch up. It allows each to be heard and seen. For the uninitiated or unaccustomed, to break through requires the practice of self-reflection and awareness raising. It also requires getting in touch with one’s bodily sensations to change the state of one’s nervous system. The space between — the intervals — needs to be conscientiously placed in between the notes, just as in the writing of a piece of music, like the unfolding of an experimental jazz set.

Sexual Abuse and the Need to be Heard

I was inspired to think about the space between in a relatively new job I am working in. It is in a community legal clinic providing counselling support to adult survivors of sexual abuse. For many of these clients, it is the first time they have spoken about their childhood abuse, particularly in any detail. They trust us, the intake team, counsellors and lawyers, especially considering most of our work is done on the telephone. In most cases, clients and staff never even meet face to face.

Being in this new role and working within a new modality for me (telephone-based counselling), I have been in observer mode, taking in the similarities and differences to my previous counselling roles and clientele. I noticed a tendency in some clients to talk ceaselessly and seemingly uninterruptedly for the full hour, quite easily and without allowing anything much in return from me. I can sometimes barely get a word in edgeways. How dare they! Are they not aware of the wisdom and insight they are missing out on? Did they not come here for my well-honed techniques of reflection and Socratic enquiry? My gifts are going to waste! I am not here to just listen! Besides, I have got a wealth of experiential Gestalt learnings to practice (I am currently a student of this art).

After composing myself, I realized that this was exactly what they needed right now. I had to adjust. They needed to be heard. Needed to be seen. To be believed. Some clients did not have any meaningful contact, let alone any contact at all, with another person in the space between our phone calls. Many have very deeply entrenched fears around trust and relational intimacy. It was their time. I had to adjust. I needed to be the one to provide the space between.

I am there to just listen. And this is a powerful ally for many for where they are right now. I continually receive feedback from clients about how grateful they are and how important it is for them just to be listened to. To be acknowledged. To be given space, just for them. It is sometimes difficult to accept and implement. Nevertheless, my greatest wisdom is to just be minimal. Not always, of course, but to know when and how.

The Power of Space in Group Therapy

I recently participated in an experiential group facilitation workshop. It was taught by an extensively experienced Gestalt and Psychodrama practitioner. It was a profound learning opportunity for me, the standout technique which I observed being “space”. I was like Ludwig van Beethoven, I imagine, witnessing…hmmm, I don’t know…help me out here Google…Herbert von Karajan conducting Bizet’s Carmen? Sure, why not? The space the facilitator provided to the group, to those doing a piece of work, was enlightening to observe. The empty space they allowed for the subject and other participants to sit with their feelings, their uncertainty, the potential void, without jumping in to fill the space or to offer insight or comfort, seemed so natural. But it was not natural. Well, not for me. They seemed to know exactly when to allow another group member to break the silence and when to pause them, when to slow things down. It impacted me deeply. It inspired me to be a better space maker in my work. For, while in this group, I was imagining what I might have said during moments of others work, how I would have broken the silences possibly out of anxiety or impatience or those egotistical impulses that often lurk just beneath the surface. I was moved by the experience, emotionally and practically, for a few reasons. It led group participants into new ways of experiencing ourselves, giving more room for us to feel into the phenomenological moment, and because it once again revealed to me a learning edge of mine, shining a light on another way of being with clients. With people. And with myself.

***

The space between is a fertile ground. I have noticed that when I do not allow for space in between life activities, my world becomes a cacophony of noise. It is less beautiful. And there is less space to understand myself, my feelings, my impulses, or for insights to emerge. I miss out on flowing with the natural rhythm of life, the hidden laws of being perhaps. Part of my development is to extend this ‘space between’ to more areas of my life — counselling to be specific. To increasingly get myself out of the way, and to tune in better to the needs of the moment, to the needs of my client.   

Radical Listening is the Secret Ingredient to Successful Psychotherapy

Posted on by Psychotherapy.net Team

I recently woke up feeling sick. I had a sore throat and could hardly utter any words beyond a whisper.

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“I need to immediately call and reschedule all of my private practice clients,” I instinctively thought. However, I began considering how frustrating it is when my clients cancel on me at the last minute. They were expecting to see me, so I decided to work. I work virtually so there was no risk of getting anyone sick. I also felt as though I had enough energy to actively engage with clients as I regularly do. The only problem was my raspy voice.

Despite my attempt at fortitude, my mind wouldn’t quite let me off the hook. I became flooded with a barrage of critical thoughts about whether my clients would view me as being “less than” if I communicated with them through a hoarse voice. At one point, I conjured up a fantasy of being fired by one of my more critical clients. Further, I even imagined that if my voice was only at 30% of its capacity, I should only charge 30% of my rate. This flurry of thoughts helped me to empathize with many of my clients who struggle with overthinking.

As I proceeded throughout my day, I quickly became aware that most clients interacted with me as usual. Either they didn’t notice or didn’t care. I did have one teen ask if I had been practicing ASMR (Autonomous Sensory Meridian Response) — a pleasurable sensory experience — and another client asked if I was sick. Two out of ten clients wasn’t too bad. In the days that followed, I noticed a similar trend of clients being more concerned about their own problems than they were about me sounding a little different.

However, the experience offered a great lesson in self-awareness. Though I pride myself on “active listening,” I tend to talk way too much in therapy. I guess that I enjoy hearing myself speak. After all, I worked so hard to get a Dual Master’s in Counseling Psychology and I deserve to be heard, right? Talking makes me feel brilliant, but it is not always effective when getting clients to tell their stories.

Having a sore throat forced me to shut up more often than I wanted to. At times, I felt enraged with myself for not being able to point out patterns in my client’s distress or offer carefully planned interventions. Fortunately, over time, I accepted my fate as a somewhat voiceless therapist and stopped trying. To my surprise, clients did well with more space. They even made connections on their own without the imposition of their self-aggrandizing psychotherapist. Perhaps Carl Rogers would be proud of me.

But, how about the client that I fantasized about firing me? Towards the end of our session, I shared this fantasy with her. She had been talking about struggling with intrusive thoughts and I thought that this disclosure might be appropriate. She found my concern humorous, and I used it to help her understand how she could accept negative thoughts without necessarily having to change or challenge them.

Now that my voice has mostly recovered, I still find myself utilizing the lesson I learned from when it was hoarse. I remind myself to have clients lead and be the main experts in the room. As a therapist, we can sometimes be speechless and still have a voice.

Questions for Thought and Discussion

Did the author’s plight resonate with you? If so, how?

Do you tend to talk more than you think you should with clients?

Are there particular clients with whom you tend to talk more? Less?

What could you do to improve your presence with clients?   

How to Learn from Painful Early Career Failures

Posted on by Psychotherapy.net Team

A friend's adult son recently returned home after a failed relationship. When his parents questioned him in hopes of understanding the relationship’s demise and to help him process the experience, they were quite discouraged to learn that from their son’s perspective, “she (his now ex-girlfriend) was always on me for not taking my clothes out of the washing machine when the cycle was done so it had to be rewashed or else it would become mildewed.” Had the son been unfaithful or did the infidelity lie with his girlfriend? Was it financial strain? Immaturity on one or both of their parts? Had the stress of childbearing done them in? Or was it, as the girlfriend claimed, relationship death by a thousand spin cycles? 
 

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Since hindsight is 20/20, metaphorically speaking, the story of my friend’s son gave me pause to reflect on a couple I worked with many years ago. In looking back, I regret not having had the confidence, skill, or comfort in using metaphors at the nascency of my clinical career when a couple was referred to me for counseling. And yes, perhaps I should have referred that ailing dyad to a more seasoned clinician, but I was, after all, receiving supervision. In retrospect, my supervisor was very task-oriented, not particularly emotionally focused, and to add just the right pinch of irony, I had recently graduated from a behaviorally- inspired clinical Ph.D. program. At the time, behaviorism seemed like very powerful magic to me, and my supervisor’s cock-suredness provided the necessary added ingredients I needed to help this couple. Ah, 20-20 hindsight! 

The husband had come to counseling with his wife under duress — more likely threat of who knows what. He didn’t perceive anything to be wrong in the relationship and couldn’t — truly couldn’t—understand why his wife was “so damn upset with me” over the chicken.” Ah, the chicken! According to the aggrieved wife — and I am paraphrasing from remote memory, “all he ever wants to eat is chicken, whether we eat at home or go out to a restaurant…I’m fed up!” She went on, “he doesn’t even want me to spice it up!” 

Although my graduate training and clinical supervision at the time blended to offer me what I thought was the right recipe for clinical success, I’m almost embarrassed to admit to what I did in those tense two or three sessions I had with this couple. I attempted (and you probably have already guessed where this is going) to build a behavioral contract which included small steps the husband would take to diversify his poultry paltry palate which would then be reinforced by the wife. God only knows what I cooked up for them in that ridiculous contract. But they were willing customers, and of course, the counseling predictably ended as quickly as it takes to flash-fry chicken wings. True to form and quite predictably, my supervisor lambasted me for failing to create a sufficiently detailed contract.  

What might I have done differently? Well, I might have used the husband’s singular food choice as a metaphor for his desire for certainty and predictability, maybe going as far as he would let me in exploring the basis for that need. I might have reframed his diet as the desire to make it easier for his wife to prepare meals. I might have shifted focus to his wife’s frustration and encouraged expression of what about her husband’s restricted food choice was particularly distressing for her. Or, I might have worked within the metaphor of spicing up the relationship. I certainly would have worked harder to create a therapeutic atmosphere in which emotions could flow freely to the top.  

I often wonder whatever happened to that couple who had the misfortune of falling under my care all those years ago. Did the marriage survive my ineptitude? Did the husband ever learn why his wife was so upset about his unrelenting choice for chicken? Did they find their way to a therapist who was able to salvage the meat from the decaying bones of their frayed bond? 

   ***


Questions for Reflection 

How did the author’s reflections impact you personally? Professionally? 

How have you framed/re-framed some of your early therapeutic mistakes?

What might you have done with the couple depicted in this narrative?

What are some of the resources you rely upon when confronted with a challenging case?