Category: Beginning Therapists

Powerful Ways to Improve Your Presence with Suicidal Clients

Posted on by Psychotherapy.net Team

Suggested Tips for Clinicians:

  • Explore your own preconceptions of suicidality and how they impact your interventions
  • Meet clients where they are rather than where you think they should be
  • Manage your own fears and anxiety around client suicidality
  • Develop a strategic therapeutic plan including supportive clinical resources


***
 

In our first session together, I asked Judy if she had had any thoughts of wanting to die or of suicide. She looked at me as if she wasn’t sure what to say, and then seemed to decide to be frank. “I’ve had serious thoughts about killing myself for a long time now.”

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Revealing her thoughts of suicide was a moment of extreme vulnerability for Judy as she let me know that her pain was so deep that not existing was actually an attractive option. There is a strong stigma attached to suicide, despite greater mental health awareness in recent years, and I’m sure Judy knew that thoughts of self-harm are still considered taboo. She probably knew as well that I had the power to take away her freedom if I thought it was necessary; my consent form let her know as much.

It was a vulnerable moment for me, too. I didn’t know exactly how great Judy’s risk was for imminent self-harm, and the potential costs were high in either direction if I misjudged the situation. Underestimating the risk could contribute to her death, while overreacting could result in a rupture in our relationship or an unnecessary involuntary stay in a psychiatric ward, which is not a benign experience.

These perils and apprehensions notwithstanding, a unique opportunity opened to me when Judy told me she was suicidal. This moment invited me to meet her as a full human being in a deeply human encounter.

Meeting Clients Where They Are

When one of my clients is suicidal, I know they’re in extreme pain, whether physical or emotional. But research and my clinical experience show that pain alone doesn’t invariably lead to suicidality — it needs to be paired with hopelessness. Believing that the pain will never end, however, is strongly linked to becoming suicidal. Having strong connections to other people buffers against the risk of suicide in the face of pain and hopelessness, while feeling disconnected from others predicts more severe thoughts of suicide. When someone I’m treating is in a suicidal crisis, the best I can hope to offer them is hope and connection.

However, I’ve often struggled to give my clients what they need in these moments which are fraught with anxiety. I felt my stomach drop when Judy told me that she had been suicidal. I had lost a patient to suicide about a decade earlier, and the reassurances from everyone around me that it wasn’t my fault didn’t make it any less heartbreaking or traumatic. Since that loss, I feel an even stronger sense of responsibility to help my clients and to do everything I can to keep them safe, while at the same time balancing safety with not wanting to overreact and encourage or require that the person go to the emergency room if the risk is not that severe. The threat of legal liability also looms large if I underestimate the risk and my client ends their own life.

As a result of these competing tensions and fears, there have probably been times when I unwittingly diminished hope, short circuited therapeutic connection, and left a client alone with their deepest pain. I was taught during my master’s program to be sure to “contract for safety,” which meant having the client sign a form that said they promised not to kill themselves. Even as a new trainee I could feel in my core that something was fundamentally wrong with this approach, which seemed like the ultimate gesture of pointless self-interest. It was clear to the client, too, that the agreement was meaningless, and that it was designed to protect me and the clinic where I was working as a practicum student.

Even though safety contracts are largely a thing of the past, I still need to be careful not to give more subtle indications that my focus is on mitigating risk, perhaps not mostly out of concern for my client. Without intending to, I could send the message that I care more about the possibility that my client might end their life than about the pain and hopelessness that are making their life unbearable.

Perhaps I might signal my nonverbal disapproval when a client describes being suicidal and react more positively when they reassure me that they’ll be OK. Or I might try to nudge a client toward agreeing that they “would never act on their urges,” or show with my body language that this conversation is making me extremely uncomfortable. In one way or another, I could discourage future openness.

It's easy to understand my fear in these situations. There is a widespread assumption that if a client ends their life, the therapist must somehow be to blame. I’ve witnessed organizations where there was a presumption that the therapist must have messed up unless they could prove otherwise. This toxic mentality burdens therapists with the illusion of an absolute ability to prevent suicide, but the truth is that a client may decide to end their life even when I’ve done everything possible to prevent it. Not surprisingly, I’ve found it hard at times not to focus on risk mitigation at the expense of the therapeutic alliance and the hurting human being in front of me.

Looking Back

Months later, Judy told me that my equanimous response to her confession in that first session was the main reason she continued in therapy with me. “I was afraid you might have me locked up,” she said, “or that you’d say you couldn’t treat me.” Instead, she felt she could trust me, and that I cared about her and not just about “covering your ass,” as she put it.

But there was a moment when I was less receptive to Judy’s suicidal thinking, which I didn’t understand (or share) at the time. In one of our later sessions a couple of years after that first meeting, she said with conviction that nobody in her family would care if she killed herself. I reacted with an intensity that surprised both of us.

There was no validation of Judy’s feelings, no gentle Socratic questioning to test the evidence. Instead, I replied, “I have to tell you, that is categorically untrue.” I was nearly shaking with emotion. She looked taken aback. I continued, “I can guarantee that your family would be devastated, and the effects would ripple through multiple generations.”

Judy told me later that she was startled by the fierceness of my words and tone of voice, which I attributed to my own family history of suicide. My dad’s dad, a veteran of World War II, died from a self-inflicted gunshot wound seven years before I was born. That loss colored not just my dad’s adulthood but my parents’ relationship and our family’s emotional life. But while I don’t doubt that the echoes of my grandfather’s suicide were in the room when I snapped at Judy, there were more recent and personal forces at play.

For the past few months, I had been in a moderate major depressive episode following a prolonged illness, which included a frequent desire to die. I was plagued by recurrent thoughts that I was letting down my wife and three young kids, and that they would be better off without me. I knew rationally that the last thing my family needed was my suicide, but the thoughts came with such conviction, as if they were established fact, that they were hard to dismiss. When I responded to Judy in that session, I wasn’t speaking just to her. I was addressing my own ambivalence about staying alive.

Based on my clinical experience with Judy and other clients who have shared their suicidality with me, I offer the following self-awareness exercises to enhance your therapeutic presence when you encounter these challenging moments with your own clients.

Foster Awareness

My lived experience inevitably affects my work as a therapist. The more aware I am of my thoughts and feelings around suicide, the more constructively I can put them to use in the therapy room. Just as I might encourage my clients to develop greater self-awareness, I can practice mindfully attending to my own reactions when a client has suicidal thoughts.

Try this: Notice what’s happening in your body when a client is suicidal — are you tensing? Is your breathing restricted? Are you moving away, or adopting a self-protective posture? You can mind your emotions, too. Are you anxious? Annoyed? Sad? Fearful? Take an easy breath in and out and see what it’s like to observe those reactions with a bit of distance, rather than letting them necessarily drive your words or actions.

Question the Story

What I feel often comes from the stories my mind is telling me. By noticing my thoughts, I can recognize that the stories may not be true.

Common thoughts I’ve had in reaction to a client’s suicidality include:

  • I don’t know how to handle this
  • This is going to end badly
  • I’m going to get sued

The thoughts may come as wordless impressions rather than actual statements, such as:

  • Images of the client’s death
  • Being questioned by investigators
  • Feeling inadequate to the task

Try this: Notice when the mind is creating stories. It’s often not necessary (or practical) to do formal cognitive restructuring to change unhelpful beliefs; just noticing that we’re having thoughts that may not be true helps us to hold them more lightly, and to realize there are other ways things could turn out.

Open Continually

My automatic impulse in the face of vulnerability is to shut down: to close my heart, resist discomfort, quickly resolve ambiguity, and fall back on well-worn habits. These default reactions may be effective at managing my anxiety, but they can shut down my flexibility, creativity, and ability to connect with the person in my care.

Try this: When you sense the urge to shut down, take a slow breath in and out, feeling the points of contact between your body and your chair. Then ask yourself, “Can I open to this?” Even if part of us is resisting the experience, another part wants to stay present and to seek connection. Gently nurture that willingness.

Embrace Uncertainty

My mind doesn’t sit easily with not knowing how something I care about is going to turn out—especially when the outcome could be catastrophic. My automatic reaction is to try to resolve the uncertainty as quickly as possible, and to make sure things turn out okay. But when my client is thinking of suicide, the only thing I can know for sure is that they’re in real pain and are looking to me for help.

Try this: Rather than trying to know the unknowable, lean into not knowing what will happen. Accept that you have imperfect knowledge, and that you can decide only with the information in front of you. Make as much space as possible for the outcomes you fear—not because you’re indifferent to what happens, but because uncertainty is the reality you’re faced with.

***

Self-awareness and greater openness are the foundation for all the effective risk-management techniques I’m trained in such as asking about desire, plans, preparatory steps, access to means, and documenting what my clients tells me. I still collaborate with clients to make safety plans, which reduce suicide attempts by over 40 percent — one suicide attempt is prevented for every 16 clients who receive a safety plan — and I aim to take these lifesaving steps in the context of nurturing lifegiving connection.

***
 

Questions for Thought:

In looking back on your clinical work with suicidal clients, what might you have done differently with a few in particular?

What is it about working with suicidal clients that you find most challenging both professionally and personally?

What about this blog touched you or challenged you in a way you hadn’t anticipated?

What might you do differently next time you take on work with a suicidal client?  

Surrounded by the Village Idiots

Posted on by Psychotherapy.net Team

My heart is not a home for cowards.

D. Antoinette Foy 
 

Surrounded by the Village Idiots

The day I opened my private practice as a psychologist, I sat smugly in my office, fortified with the knowledge I’d acquired, taking comfort in the rules I’d learned. I eagerly looked forward to having patients I could “cure.”

I was deluded.

Fortunately, I had no idea at the time what a messy business clinical psychology was, or I might have opted for pure research, an area where I’d have control over my subjects and variables. Instead, I had to learn how to be flexible as new information trickled in weekly. I had no idea on that first day that psychotherapy wasn’t the psychologist solving problems, but rather two people facing each other, week after week, endeavouring to reach some kind of psychological truth we could agree on.

No one brought this home to me more than Laura Wilkes, my first patient. She was referred to me through a general practitioner, who in his recorded message said, “She’ll fill you in on the details.” I don’t know who was more frightened, Laura or I. I was newly transformed from a student in jeans and a T-shirt to a professional, decked out in a silk blouse and a designer suit with linebacker shoulder pads, de rigueur in the early eighties. I sat behind my huge mahogany desk looking like a cross between Anna Freud and Joan Crawford. Luckily, I had prematurely white hair in my twenties, which added some much-needed gravitas to my demeanour.

Laura was barely five feet high, with an hourglass figure, huge almond eyes, and such full lips that had it been thirty years later, I would have suspected Botox injections. She had masses of shoulder length blond highlighted hair, and her porcelain skin contrasted sharply with her dark eyes. Perfect makeup, with bright red lipstick, set off her features. She was chic in spike heels, a tailored silk blouse, and a black pencil skirt.

She said she was twenty-six, single, and working in a large securities firm. She’d started out as a secretary but had been promoted to the human resources department.

When I asked how I could help her, Laura sat for a long time looking out the window. I waited for her to tell me the problem. I continued to wait in what’s called a therapeutic silence—an uncomfortable quiet that’s supposed to elicit truth from the patient. Finally, she said, “I have herpes.”

I asked, “Herpes zoster or herpes simplex?”

“The kind you get if you’re totally filthy.”

“Sexually transmitted,” I translated.

When I asked whether her sexual partner knew he had herpes, Laura replied that Ed, her boyfriend of two years, had said he didn’t. However, she’d found a pill vial in his cabinet that she recognized as the same medication she’d been prescribed. When I questioned her about this, she acted as though it was normal and that there wasn’t much she could do about it. She said, “That’s Ed. I’ve already ripped a strip off him. What more can I do?”

That blasé reaction suggested that Laura was used to selfish and duplicitous behaviour. She’d been referred to me, she said, because the strongest medication wasn’t limiting the constant outbreaks and her doctor thought she needed psychiatric help. But Laura was clear about having no desire to be in therapy. She just wanted to get over the herpes.

I explained that in some people stress is a major trigger for attacks of the latent virus. She said, “I know what the word stress means, but I don’t know exactly how it feels. I don’t think I have it. I just keep on keeping on, surrounded by the village idiots.” Not much had bothered her in her life, Laura told me, although she did acknowledge that the herpes had shaken her like nothing else.

First, I tried to reassure her by letting her know that one in six people aged fourteen to forty-nine has herpes. Her response was “So what? We’re all in the same filthy swamp.” Switching tacks, I told her I understood why she was upset. A man who purported to love her had betrayed her. Plus, she was in pain—in fact, she could barely sit. The worst part was the shame; forever after she’d have to tell anyone she ever slept with that she had herpes or was a carrier.

Laura agreed, but the worst aspect for her was that although she’d done everything possible to rise above her family circumstances, she was now wallowing in filth, just as they always had. “It’s like quicksand,” she said. “No matter how hard I try to crawl out of the ooze and slime, I keep getting sucked back in. I know; I’ve almost died trying.”

When I asked her to tell me about her family, she said she wasn’t going to go into “all that bilge.” Laura explained that she was a practical person and wanted to decrease her stress, whatever that was, so that she could get the painful herpes under control. She’d planned to attend this one session, where I’d either give her a pill or “cure” her of “stress.” I broke the news to her that stress, or anxiety, was occasionally easy to relieve but could sometimes be intransigent. I explained that we’d need to have a number of appointments so that she could learn what stress is and how she experienced it, uncover its source, and then find ways to alleviate it. It was possible, I told her, that so much of her immune system was fighting stress that there was nothing left to fight the herpes virus.

“I can’t believe I have to do this. I feel like I came to have a tooth pulled and by mistake my whole brain came with it.” Laura looked disgusted, but she finally capitulated. “Okay, just book me for one more appointment.”

It’s difficult to treat a patient who isn’t psychologically oriented. Laura just wanted her herpes cured and, in her mind, therapy was a means to that end. Nor did she want to give a family history, since she had no idea how it would be relevant.

There were two things I hadn’t anticipated on my first day of therapy. First, how could this woman not know what stress is? Second, I’d read hundreds of case studies, watched lots of therapy tapes, attended dozens of grand rounds, and in none of them did the patient refuse to give a family history. Even when I worked the night shift in psychiatric hospitals—where they warehoused the lost psychological souls in backwards—I’d never heard anyone object. Even if they said, as one did, that she was from Nazareth and her parents were Mary and Joseph, they gave a history. Now my very first patient had refused! I realized that I’d have to proceed in Laura’s weird way, and at her own pace, or she’d be gone. I remember writing on my clipboard, my first task is to engage Laura.

***

From Good Morning, Monster: A Therapist Shares Five Heroic Stories of Recovery by Catherine Gildiner. Copyright © 2020 by the author and reprinted by permission of St. Martin’s Publishing Group.  

The Rest of the Story: Digging Beneath the Diagnosis

Posted on by Psychotherapy.net Team

I remember sitting across from my client, wondering why we couldn’t make any progress with his depression. We had covered the terrain of cognitive distortions, the necessity of making behavioral changes, and even stepped outside the CBT stream in order to address insights he had experienced into the relationship between his childhood and current state of unmotivated listlessness. Nothing seemed to work.

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He didn’t have the kind of sad, angry, irritable depression that practitioners commonly see in clients. His was the kind of depression that stripped him entirely of his energy. For him, it was a daily struggle to get out of bed in the morning, to make his own meals, to take out the garbage, or even to take on the seemingly insurmountable task of doing the laundry. But, I thought, or hoped, that with enough time, support, and psychoeducation, he might begin to budge in the right direction—in any direction. So I put my nose to the grindstone and retreaded familiar ground, covering cognitive distortions once again, revisiting the treatment plan, formulating habit-building strategies, and enlisting social support.

Our clinical stagnation seemed to give way during one session when we began discussing the clients’ interests. He shared that he was a huge sports fan. He religiously checked game stats, participated in online discussion forums, watched basketball, football, and soccer games. He devoutly followed his favorite teams and knew everything about his favorite players and coaches. It was really fascinating to observe the life flood back into my client when talking about this. Following my curiosity, I asked him to estimate how many hours of sports media he was consuming on a daily basis. He guessed that he was consuming upwards of 14 to 15 hours of sports media a day, every day. My jaw hit the floor.

It became apparent to me that my client was not suffering from depression, although his presentation was consistent with MDD, but was in fact addicted to media. So addicted that he had no time, attention, or energy for anything else. And since sports media is so pervasive and readily available in every platform and media outlet imaginable, my client’s addiction was readily fed, monetized, and maximized to the fullest extent. The problem was only worsened by a very forgiving, if not too forgiving, roommate. My client wasn’t working, nor pulling his weight regarding household responsibilities around his apartment. He couldn’t even recall the last time he took out the garbage. I asked if his roommate ever got upset; he said sometimes, but mostly he just ignored it or covered for him (like doing his chores for him and not pressing him on missing rent). That is one forgiving roommate, right?! Sadly, it was also a very enabling roommate. The roommate’s lax standards and minimum expectations were like gasoline to my client’s media addiction fire.

After exploring and reflecting on this new data set, we had a candid conversation—my client was coming to counseling because he wanted something in his life to change. He knew he needed to change. He wasn’t satisfied with the way things were going. Yes, he loved sports and couldn’t get enough of the latest sports news, but at the end of the day, he wasn’t satisfied. He had bigger goals for his life and felt like he was letting himself down by not getting a job, not pursuing his ambitions, and not contributing to the apartment. I put it to him rather bluntly that there wasn’t space in his life for his goals and that his sports media was a form of addiction; one or the other would have to go. He acknowledged that I was right but expressed fear of going “cold turkey” on sports media. So we devised an experiment: if he titrated his consumption of sports-related media down to something more manageable, he would feel more energy and motivation throughout his day? The thought of having more energy to accomplish his goals without the total loss of sports seemed to intrigue him. He committed to running the experiment and would report back his findings next session.

In my career, I haven’t had many spontaneous recoveries, but this, I am pleased and proud to say, was one of them. Something about the experiment clicked for him, and he realized that there was more to life than his media consumption addiction. His dissatisfaction with not making progress on life goals paired with lessened consumption of sport media carved out enough energy and motivation for him to make progress on smaller, more manageable alternate goals, leading to increased self-efficacy. He ran with the motivation boost and parlayed his newfound enthusiasm to accomplish bigger and bigger goals. Even getting outside to retrieve the mail felt good to him. Within a matter of weeks, he was doing household chores, grocery shopping and preparing his own meals, submitting job applications, and reconnecting with friends. I knew our therapeutic relationship was near its end when he got a job and joined a gym. He was feeling good and didn’t see the need for him any longer, for which I was grateful.

***

This clinical experience was an eye-opener for me. It was helpful to step outside the confines of my favored, tried-and-true therapeutic modality and the client’s presumptive diagnosis in order to consider contextual factors that often get ignored. This was the “rest of the story,” as broadcaster and commentator Paul Harvey so famously said, when digging just a bit deeper into the context beneath the headline, or in my case, the context beneath my client’s ostensible depression.

I now make it a regular practice to broach the topics of diet and nutrition, media consumption, social connectedness, feelings about current events, and finances, to name a few. In my better moments, I take time to consider what isn’t manifestly evident in my client’s clinical presentation that may be critical to address in counseling. What have I not thought of or asked about may make the difference for my client. What is going on in their life that they haven’t thought to mention, but may hold the key to their motivation, growth and healing?

In Praise of Termination

Posted on by Psychotherapy.net Team

I don’t think I’m the only one, at least I hope not, who feels an immense pressure to produce a “win” with every client. I feel like I owe clients a positive outcome and if I’m not able to produce, then I’ve let the client down. This pressure leads me to put the blame, if that’s the right word to use, on myself. If the client is struggling in any way; if they aren’t seeing results; if they aren’t motivated; if they aren’t putting in the effort to complete their homework or follow the steps in their treatment plan, I am the one who failed, according to that lingering, irrational neural circuit. All that changed after one fateful conversation with a colleague.

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I remember unburdening my woes on a colleague regarding a couple I was working with. I told her that every week the couple would spend their time complaining about each other. We would discuss their relational problems ad nauseam, inevitably arriving at the same place when they would proclaim some version of “If only we could just do X, then everything would be better.” They would get so excited, and I could hear their thoughts as if broadcasted; this idea was their silver bullet. The excitement was palpable as they left the office with an action plan, only to return the next week to tell me they hadn’t done anything we’d discussed. This pattern repeated week after week. I found this baffling. But, as I told you, the reason had to be that somehow I dropped the ball. So each session I’d go into overdrive and dissect what didn’t work and strain every last neuron in that circuit to come up with yet another dazzling idea, which, as you guessed also wouldn’t work.

I finally finished telling my colleague about the couple and downloading all my feelings when she looked at me and said in a matter-of-fact tone, “You’re way more patient than me. I would have fired them long ago.” “Huh?” I replied. Fire my client?! I had never done this or even considered this as a possibility. As I asked her more questions, she explained that when you have a client like this, the problem may not be you, or even them. Maybe the timing isn’t right. Maybe they aren’t in a place to make change. Maybe it’s easier to dream about change than actually doing it. Maybe the fit isn’t right and they would be better served by another clinician. Or maybe I needed to draw a line somewhere, and tell them that I could no longer work with them if they were not willing to follow through.

My colleague was making this pretty clear, but I honestly needed her to spell it out for me. She told me to make continuation of the therapeutic relationship contingent upon their completing their homework. If they said they would commit to a date night once per week, then I needed to raise the stakes and make doing the date night actually matter. They clearly valued coming to therapy every week since they were willing to pay for something that wasn’t producing the results they allegedly desire. The fact of the matter is, she went on to explain, that there could be a hundred different reasons why they weren’t actually following through, but in the final analysis, I was not doing them any good by smoothing over their failure to complete the homework or follow through with other therapeutic suggestions.

Yeah, I had to sit back in silence and take a few minutes to digest this. My first thought was, “Well, isn’t this kinda mean? Or, at the very least, won’t my client think I’m being kinda mean?” My colleague disabused me of this idea rather quickly. Holding my client accountable does not have to be a mean thing to do, nor does it mean that I am being so. This can be done in a very professional and respectful manner, and even in a way that may at some later time lay the foundation for real therapeutic progress—you know, planting seeds! Besides, I would hold myself to no less of a standard. I would not let myself off the hook if I committed to something and then never followed through. So why the double standard? Why do I look the other way with clients, but not with myself? Further, my clients most likely hold themselves to this standard when outside the office. So, why the double standard? Why do they look the other way when it comes to their relationship?

This question was very challenging, but incredibly helpful. I went back to my couple, nervous but motivated to put these new ideas into practice. I let them know, respectfully, that I noticed a pattern of them not following through on homework. And that if they wanted to continue working with me, we needed to agree that doing so was dependent upon their completing homework. My heart was in my throat when I said this, but to my surprise, they had little to no pushback. Despite their agreeing to the terms, the next week they had not completed their homework. As I said I would, we decided to wrap up therapy.

Fast forward a few weeks.They called me asking if they could come back, but they said this time would be different. They would not only agree to the homework-related conditions for termination, but they committed to actually doing their homework. Suffice it to say, they did, and the change they so badly wanted started materializing.

***

In reflection, I learned a lot from this couple and from my colleague’s insight. This lesson has stayed with me and affected my work with virtually every client since. I no longer place immediate blame on myself for clinical failure (although I do reflect often on how I can do better). Rather, I am more broadminded when things aren’t working. I’m more open to the option of terminating the therapeutic relationship, and, in fact, I see it as a potentially important step in the healing journey of some clients. I share with my clients that termination can be an act of empowerment. If the client feels like they aren’t getting what they need from a therapist, they should not feel beholden to stay for the therapist’s benefit. Instead, I encourage clients to broach the topic of termination, to explore other options, and to find what works for them, as I am now in the habit of doing.
 

The Subtle Art of Therapeutic Rudeness

Posted on by Psychotherapy.net Team

Beginning therapists typically struggle with a particular issue that can be the cause of much consternation given that they tend to be “nice” people. You might already know where I’m going with this—therapists struggle with interrupting, cutting off, butting in, or engaging in any kind of behavior with clients that might be perceived as rude.

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Under what conditions would a therapist ever need to resort to anything that resembles rudeness? I could give you a number of reasons, but I’ll limit myself to just one. A client could consciously or unconsciously avoid a certain topic for fear that it will be overwhelming for them, or because they don’t want to own up to something or acknowledge the impact of X on their life. A “nice” therapist will not want to upset their client; they will indulge the client’s avoidance by following the client-led conversation along a subject-hopping surface-level path. But ultimately, this is not to the client’s benefit.

We are not in the business of being nice, we are in the business of healing. And healing can hurt. If I am truly committed to the healing of my clients, I have to be willing to be rude, or at least act in a manner that may strike the client as such—to interrupt their avoidance and redirect their attention, sometimes kicking and screaming, to the topic they are sidestepping. My motivation is not to be sadistic, for I know that those areas that clients avoid are usually those that contain the greatest potential for growth and healing. But by indulging in their avoidance, I potentially infantilize my client. I reinforce the implicit notion that they are weak and incapable of facing the issue. Therefore, I have to notice the niceness tendency within myself and purposely tell myself that what feels comfortable is not for the ultimate good of the client. I then have to step outside of my comfort zone and act out a behavior that in most circumstances would be considered rude. This might include talking over my client by raising my voice and refusing to stop until they relinquish the reins of the conversation.

Now, this is where the art comes into play. When interrupting, I am trying my best to be artfully rude, but never disrespectful. I never denigrate or judge my client. I never put them down or do anything that undermines their dignity. Rather, my rude interjection comes from a place of empathy and understanding. I get it! I avoid hard stuff, too! It’s painful to look in the metaphorical mirror and face yourself. But avoiding the mirror only elongates my problems; it only gives more time and space for my issues to grow. So, if I truly love myself, I must drag myself over to the mirror and force myself to look. I need to love my clients in the same way.

I remember working with a middle-aged mother who had recently suffered a number of setbacks in her life. I remember looking at her and thinking to myself that she seemed so sad. Despite my best efforts to focus on and build up the positives in her life, no footing could be found in anything resembling hope. I remember one session in particular, where she kept talking about her knitting group and one group member’s relationship problems. I asked why it was important to discuss this person and not what was going on in her life. She said she was worried about her friend and was really trying to help her. I kept pressing my client to get a better sense of what she was thinking and feeling.

Over the course of our conversation, it became clear to me that my client felt as if her life was over—she had no sense of a future, and she was just trying to help someone, anyone, before she took her own life. She didn’t say this outright, but I could read between the lines that my client was considering suicide. I felt an internal panic when I realized this. I really liked this client. She reminded me of my own mother in some ways. I also felt a tremendous urge to keep the conversation away from the topic of suicide, to indulge my client’s wish of focusing on her friend in the knitting group. I also knew I could not let her leave my office without assessing her risk level. I took a deep breath, and as kindly as I could, I interrupted her and asked if she had been or was currently thinking about hurting or killing herself. The tears started rolling down her cheeks. What followed was a very helpful conversation that involved a safety plan, engaging with a support network, providing contact information in case of an emergency, and pulling in additional services. The conversation shed light on her under-the-radar risk for suicide that had developed over the last few weeks and provided a space for planning and support. That conversation needed to happen.

And I thank the art of rudeness for giving me the insight and words to respectfully interrupt my client and ask a tough question.

Taking Care of My Own Mental Health

Posted on by Psychotherapy.net Team

In August 2021, history was made at the rarely visited intersection of the worlds of Olympic sport and mental health. Renowned gymnast Simone Biles intentionally chose to self-select out in an effort to protect her emotional well-being. Wow. Just wow. She respected that she was not strong enough emotionally to be able to perform at her best and decided to support her team from the sidelines.

I often ask myself, “When was the last time that I, as a clinician, ‘sat out’ because it was creating too much of an emotional struggle for me? And what does it mean to ‘sit out’ as a therapist? To not take on a new client? To limit the time I spend in my practice? To block out thoughts of clients when I am not with them? To do less? To be less?” While it may not always seem so, especially when clients are not in crisis, therapeutic stakes are typically high for them most, if not all, of the time. And I don’t want to do less at the cost of the therapeutic relationship, let down my guard or put either my client(s) or myself at risk or in a potentially libelous situation. Yet how this constant pressure to perform at the highest clinical and professional level does impact my physical and mental health.

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Being a caretaker to my patients, my practice, and my own personal and familial obligations requires an ongoing Olympian effort. No breaks, no holidays, no weekends, no sick days. Always on. Always watching. Always watched. I don’t often have the luxury of turning off my mind, letting the next steps or decisions play out on their own. I don’t easily turn off my mind as I am always thinking about the next step or, even worse, what could happen.

I can’t just turn off and not take care of my patients, my child(ren), my family, my job, my house. And I don’t typically ask myself to make big shifts, as they can be too scary and abrupt. Instead, I try to think about changing the way I can more seamlessly (when possible) build in mental and physical breaks. I’m not suggesting that I regularly schedule weekend yoga retreats or hours at the spa. That kind of thing doesn’t work for me, although it sounds lovely. And these activities aren’t realistic for me at this point in my life.

My concern is with burnout, which I have come to recognize in myself in the following ways. It’s not an all-or-none thing, as I may experience variations on these themes at different times:

  • Fatigue
  • Agitation
  • Feeling sad
  • Difficulty formulating thoughts or sentences
  • Struggling to make simple decisions
  • Feeling waves of anxiety without a known trigger
  • Overeating
  • Undereating
  • Waking up in the middle of the night and not being able to return to sleep
  • Not being able to turn thoughts off at night
  • Staying busy and distracted all day
  • Feeling overstimulated—it’s too loud, it’s too bright, feeling over-touched
  • Not being able to start and finish a task
  • Noticing daily routines, like showering, seem complicated and laborious

Shifting My Mindset

As a psychologist who has a strong sense of responsibility, I set unrealistically high standards for what I “should'' be doing on a daily basis. I am often anxious in my attempts to stay on top of it all. I attempt to anticipate and accommodate the needs of my children, family, friends, my employees, and my patients. You could call me an over-functioner. My natural tendency is to give, give, give, and I have a hard time receiving. This mind contributes at times to a feeling of being burned out, depleted, and resentful. These are some of the mental tactics I have tried:

Instead of thinking…“I have to get this done today.”
I try to think…“If I don’t get this done today, I will get it done tomorrow or the next day.”

Instead of thinking…“I didn’t get enough accomplished today.”
I try to think...“I got as many things as I could get done today, and that is good enough.”

Instead of thinking…“I didn’t anticipate that well.”
I try to think…“I’m not a fortune teller, and I will manage whatever situation arises as it arises.”

Instead of thinking…“I can do more.”
I try to think…“I need to stop when my body and mind tell me I’m done.”

Instead of thinking…“Everyone needs me.”
I try to think…“I need to satisfy my own needs first so that I can be there for others. I need to fill my cup first.”

Case Example

I have been working with a particular woman, a mother of two children with special needs whose anxiety mimics mine. Sometimes her anxiety triggers mine. She is often in tears during a session and feels like the demands of her world are many and overwhelming. She is burned out from her daily internal high demands that she believes she simply can’t meet. She feels that she has a “role” and “job” to complete each day, which is to tend to her children, husband, mother, siblings, friends, and her children’s school as a PTA member. Her self-care is forced and difficult for her to implement. During our sessions, I am very aware of how her experiences are very similar to mine, and how difficult it is to help her find good outlets for her anxiety and to help her set boundaries in her life. I often think, “I can dish it, but it’s so hard to take my very own advice.”

Find Boundaries and Set Them

Setting boundaries has always come hard for me when it comes to choosing myself over others. However, I have had some success with practice in saying (and sticking with) practicing some of the following:

  • “Thank you, but I’m going to pass.”
  •  “I appreciate you thinking of me, but not this time.”
  • “Thank you, but that’s not going to work for me.”
  • “That sounds good, but I’m going to take a raincheck.”
I have often learned the hard way that there is no reason for why I can’t do something for myself without apologizing or feeling the need to apologize. I’ve learned that it’s okay to decline joining the PTA committee or whichever school committee I know is going to take big chunks of my time and energy. It’s okay to not agree to host a family event at my home if I know I don’t have the time or energy for it. It’s even okay if I decide not to join the next professional meeting. It’s okay. It’s just okay.

Setting boundaries has also come for me with a ton of guilt. I have come to expect these feelings and so have learned to respect them, honor them, and let them pass. I have resisted the urge to return to the person I said “no” to and change my response. And the more boundaries I set, the more comfortable I have become. It has gotten easier. These have been important lessons that I have been able to impart to some of my clients who are willing to try to be different—for their own sakes. Sidestepping my own burnout has been the payoff. Helping my clients do the same is a bonus.

Reclaiming Our Artistry, One Session at a Time

Posted on by Psychotherapy.net Team

“Who, me, an artist? But I’m not going to drop an album, release a book, or be in a movie anytime soon.”

Yes, you, an artist! Hear me out before you wave this one away, as did Irvin Yalom when I initially posed the question to him at a Psychotherapy Networker conference. I had asked him if he realized how he had taught so many therapists to be artists like himself, when he quickly demurred that he wasn’t really an artist in the way we usually think of it and in the way he admired so many artists himself. In a subsequent communication, he acknowledged the connection I had attempted to make when I posed the question to him at the conference.

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Wait, master clinician Irvin Yalom doesn’t see himself as an artist, either, at least not in the traditional sense or strict definition of the word, or the way in which I am asking you to consider in this essay? That’s right, even the best therapists out there don’t always appreciate the “artistry” in what they do. Sound familiar?

So many of us fail to see ourselves as artists, and yet it’s also crucial so we remain solidly confident and regularly inspired in our day to day work. And don’t even get me started on how it cushions against the rampant burnout happening on both sides of the couch during this pandemic.

We conduct intakes for a reason. We are implicitly asked all the time to figure out the unique music our clients are playing without even having a score or knowing the key, tempo, or composer. Imagine yourself as a jazz player reading the chord changes, making something interesting and musical out of the sadness, anxiety, fear, pride, and desire all trying to express themselves in your client’s unique pain and possibility.

Isn’t this what we do?

Every day, we summon ourselves like actors into the role of deeply imagining and empathizing what our clients are experiencing and playing it back to them, so they can vary it and try on new roles, so they can have more freedom, fulfillment, and hope.

It’s easy for us to see ourselves as authors, helping clients tell their stories more fully, switching back from present drama to flashbacks and, of course, the future dreams they only wish someone could help them see more clearly. What is it that I really wish to happen, and why, like a dream, can’t I grasp it? We write and revise with and alongside our clients, and it’s about time that we see ourselves as the artists we truly are.

Starting to get convinced? Don’t feel bad, even the high-level musicians I work with at the Manhattan School of Music don’t see themselves as artists, either. In their personal lives, that is. As a culture, we lop off our personal creativity from our artistic creativity and only reserve the term “artist” for a small subsegment of the population: painters, actors, musicians, dancers. But this is a disservice, not only to the general public but even more so to we therapists who need to lead the way, showcasing mental health as the art of living life creatively.

Therapists, like artists, make new forms out of old, familiar ones and, better yet, they take liberties and become subversive with them. Think Bansky. His punny painting Show Me the Monet reimagines and refashions Monet’s iconic Waterlilies strewn with toppled grocery carts and a jarring orange construction-site cone. It’s a tour de force commentary of the ways in which humankind pollutes the environment it wishes to glorify and how we overconsume and lose contact with what is most essential. And yet it also echoes and builds on the work of the masters, paying homage to Monet’s capacity to see the beauty in his world and challenge it with his realism. As therapists, we, too, help our clients to both connect and complicate what is both possible and real in their family stories, relationships, and unfolding selves.

We are neurologically built to be artists, as Pablo Picasso once noted when he suggested that all children start out being artists but merely forget as adults. Our right brain’s capacity for imagination, empathy, metaphor, humor, and dreams is the true maestro, to paraphrase writer Iain McGilchrist, and our left brain, the home of our vaunted logic, language, and linear view of ourselves, is the emissary. Albert Einstein once said, “The intuitive mind is a sacred gift, and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift.” Nowhere is this more important and more lacking than in therapists.
We need to reclaim the notion of our work as art and take pride again in the unique music, narrative, and drama that our work produces, and how it changes us, them, and our world, one session at a time.
If not now, when?

Encouraging Clients to be Preventative

Posted on by Psychotherapy.net Team

Stephen Covey, author of The 7 Habits of Highly Effective People, said in his book, 

Look at the word responsibility—“response-ability”—the ability to choose your response. Highly proactive people recognize that responsibility. They do not blame circumstances, conditions, or conditioning for their behavior. Their behavior is a product of their own conscious choice, based on values, rather than a product of their conditions, based on feeling.

Covey is not a psychotherapist, but as a therapist I find it beneficial to take a page out of his playbook. I encourage clients to assume a proactive stance when it comes to the challenges they may face in life. I do this in a sober-minded manner, not sugarcoating the fact that they will indeed face hardships. In my own practice, I’ve found that upon hearing this uncomfortable message, clients find hearing the truth spoken ennobling, even if it hurts. Clients bring an abundance of untapped strength, fortitude, and resilience, which can be accessed and drawn forth in therapy, a fact that motivates me to candidly share with clients that problems only get worse when ignored. My goal is not to be obvious or annoying, but to lovingly embody the role Socrates played, to be the gadfly in the ointment; to assume the role no one wants to play, the bearer of bad, but truthful, news.

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Out of a sense of compassion, I ask my clients to directly face those ignorable “what-ifs.” In the absence of a plan, in the absence of daily health-promoting routines and rituals, what will happen if a client misses too many days of work? What will happen when a client’s spouse finds them drunk again? What will happen when a client forgets to pick their kid up at school once again? What will happen if a client consistently shrugs off opportunities to support their closest friends? Clients may rationalize and answer that yes, they are prepared to face certain contingencies. But when a problem is up close and personal, I’ve witnessed client after client ignore and avoid problems at all costs. Why do clients do this? Despite my best efforts, clients manage to play out the same pattern of avoidance, over and over again. Don’t get me wrong, I understand that clients are scared. To admit their marriage is struggling, to acknowledge their addiction is out of hand, to recognize their imperfect parenting, to confess their social shyness is causing isolation and loneliness, is truly terrifying. Facing a problem comes with the necessity of change, so, it’s easier to pretend like the problem isn’t there. I see this fear manifest in clients in one way or another, but I see it most clearly with couples.

In my experience based on the clients with whom I’ve worked, and in discussion with colleagues, couples tend to engage counseling services six years after the problem has been going on. Six years! That’s a long time to live with a problem. That kind of time allows resentment, bitterness, and hurt to accumulate to the point of no return. Neurologically speaking, allowing a problem to go on like that creates reinforced neural pathways that are hard to rewire. Relationally speaking, permitting a harmful relational pattern to persist unabated leads to irrevocable harm to intimacy, trust, and communication. So what’s the solution? How can I navigate this and motivate my clients to nip a problem in the bud? My way of approaching this issue is to encourage clients to be preventative, to seek a solution when the problem is in its infancy.

For example, couples who proactively work towards solutions before problems have reared their ugly heads make a commitment to attend maintenance sessions with a therapist once every few years or sooner. They do this habitually not because of a crisis, but because they want to make sure they are on the right track. That’s the ideal scenario, but not every client is at that stage. To get my clients thinking along these lines, I ask clients to take a moment and reflect on the fact that they see a dentist every six months for a cleaning. Why should they attend these appointments if they aren’t experiencing any dental problems? If you don’t have a toothache, why go? I usually get a range of answers, but the theme is usually prevention. It takes little effort to understand the benefit of preventing physical issues, but this logic fails to map onto mental health. So I gently nudge my clients to consider the logical contradiction, asking them to be consistent and apply the same logic to mental, emotional, and relational issues.

The alternative to being proactive is being reactive, I explain to clients. Reactivity, as I have observed over the past several years of doing clinical work, is defined as jumping to conclusions, being on the defense, only seeking solutions when problems are reeling out of control. In other words, it’s a bad strategy that doesn’t work, and it’s no way to live your life. I make the case to clients that if they are being reactive, they are only adding to the problem instead of working towards a solution; reactivity compounds problems. It is so much easier to fix a problem before it starts or in its infancy, instead of when it’s lingered, done damage, and been compounded by time and resentment.

I remember working with a mother and son who lived in a small apartment in the rough part of town. Their relationship could be defined as challenging. Mom fought the urge to not feel disappointed, but she felt like everything her son did made her mad. She was angry at him for getting poor grades, hanging out with the wrong crowd, playing too many video games, and getting into fights at school. She found that it was easier to be mad at him than to look at her own behavior and examine the reasons why their relationship had gotten so rocky. Keeping the focus on him kept the focus off her. Deep down, she was terrified to look in the mirror and acknowledge how her past and present actions had affected her son. I cautioned her that if things didn’t change between them, his behavior would likely worsen. I made the case that she had to come to the table and work on herself and the relationship before having any expectation of seeing him shape up. Despite my urging and pleading, I couldn’t convince her to let go of the blame and evaluate her behavior. Over time, the strain on their relationship grew too strong. He decided to move out of his mother’s apartment, drop out of high school and live with a friend whom she felt like was a bad influence. The day he left, they didn’t even say goodbye to each other.

***

So I urge you to encourage your clients to avoid living a life of reactivity and instead, to adopt a proactive, solution-seeking, adaptive, contingency-based, response-ability mindset towards current and future problems. You will find that when they do, they will be happy, and you will feel gratified.

Excerpt from: The 7 habits of highly effective people: Powerful lessons in personal change (25th Anniversary Edition). Rosetta Books.

A Behavior Treatment Plan as a Psychological MRI

Posted on by Psychotherapy.net Team

As a psychotherapist providing services in nursing facilities, I am accustomed to using a variety of forms, including initial assessment, progress notes, and treatment plans. I have come to appreciate that the behavioral treatment plan may be the most powerful, yet the most overlooked or avoided, clinical form.

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My clinical task is to provide direct assessment and treatment services to nursing facility residents. Yet I also have an obligation to offer insights that help the facility caregivers to better understand and more effectively manage the sometimes-troubling behaviors demonstrated by that resident. Direct care staff persons at the nursing facility might observe only the most obvious and observable element of the resident’s behavior—the unkempt appearance, the irritable defensiveness, the argumentative refusals of care, the unwelcome sexual remarks, the tearfulness, the yelling, the social avoidance, or the aggressive and abusive language aimed at them. In response, the caregiver may react in a personal manner, with expressions of indignation or criticism, or even patronizing efforts at persuasion. What I have often seen lacking is a keen awareness of the inner meanings and motives behind those behaviors; the ways they might reflect or represent symptoms of varied medical and psychological conditions and the ways that the caregivers’ responses might increase or decrease the intensity and duration of those symptomatic behaviors.

Nurses and clinical aides might occasionally notice the assessment and progress notes that I and fellow clinicians generate but at the same time never read those documents. However, the nurse or aide might not readily gain a new understanding of the resident even if they did read those forms. A behavior treatment plan, though, can provide a window into the psychological nuances that illuminate and explain the actions of the resident. The behavior treatment plan can be like a psychological MRI that provides an inside view of factors influencing a resident’s behavior.

A behavior treatment plan is effective because it does not simply get written and quietly entered in the chart. It requires review, explanation, and education so the facility staff persons can understand and implement the plan. Brief staff in-service training follows the writing of a plan so that it can be introduced and clarified. Those trainings allow for discussions that may be a first opportunity for the staff persons to readily understand the psychiatric diagnoses of the residents and how their psychiatric symptoms are behaviorally manifested.

Resident: Leslie (Identifying information has been altered from the example below.)

Diagnosis: 295.70 Schizoaffective Disorder, Bipolar Type; Epilepsy; Developmental Disability due to Fetal Alcohol Syndrome; and PTSD Associated with Childhood Sexual Abuse.

Presenting Problem/Target Behavior: Leslie demonstrates unstable affect with frequent bouts of crying or expressions of anger; fluctuating levels of alertness and mental clarity; and apparent passive-aggressive and/or attention-seeking behaviors such as self-admittedly putting herself on the floor and crawling towards the bathroom to express her anger over perceived delay in staff response to her need to use the toilet. In general, Leslie sometimes displays a child-like manner with inconsistent cooperation with care and treatment and a tendency to over-dramatize daily upsets in ways that elicit comforting and extra involvement of staff persons.

Description of Resident & History of Problem: Leslie is a 51-year-old single woman with epilepsy and major mental illness, developmental problems, and past trauma. Considering the above diagnoses, it is to be anticipated that she might demonstrate problems with her social behaviors and critical thinking skills. It is important to remember that her actions reflect serious problems with brain development and functioning and do not simply represent “bad behavior.” Behavior and cognition can be significantly affected for persons with epilepsy as well as by unwanted effects of antiepileptic drugs. Also, a person with the above diagnoses can be burdened by painful feelings of social stigma and by difficulties establishing and sustaining trusting relationships with others.

Clinical Assessment of Behavior & Resident: Leslie experienced developmental disability due to effects of Fetal Alcohol Syndrome. She later developed Schizoaffective Disorder, Bipolar Type. Her psychosocial development was further undermined by sexual abuse by her father, the forced termination of a resulting pregnancy, and associated traumatic consequences.

It is well known that consequent to long-term institutional care, some persons can develop dysfunctional patterns of behavior referred to as “learned helplessness.” These factors provide a background context in which to view and understand the behavior problems demonstrated by Leslie. The resident is not to be blamed or negatively judged for having acquired a child-like, passive-aggressive, and dependent style of coping and problem solving. At the same time, Leslie cannot be expected to simply snap out of it and immediately display a fully adaptive adult style of coping with daily stresses. Over time and with consistent encouragement and reinforcement, Leslie can be helped to learn and practice dealing with problems and expressing emotions in more reasonable and mature and independent ways. Presently, she is effective in soliciting emotional support and the close and helpful attentions of others by displaying emotional distress (tears or anger) or by taking risks, such as placing herself on the floor in defiance, that draw others closer to her.

Behavioral Interventions: The main purpose or intent of this behavior plan is to foster, encourage, and reward small progressive steps towards more self-reliant adult ways of meeting her needs. Leslie directly contributed to the development of this behavior plan. I shared with her the feedback and observations and stated concerns of staff persons and elicited from Leslie her own ideas for ways to address those concerns.

Leslie offered the following points: “I will not express anger by doing unsafe things like putting myself on the floor; I learned my lesson good.” “I will try to show good emotional self-control.” In the event that she was to again lower herself to the floor, Leslie suggested that staff persons should stand safely nearby and “let me try to pull myself up.” Leslie said, “Let me do more on my own.” “If I am crying or angry, let me alone for a while and I’ll calm myself down.”

Staff persons interacting with Leslie should keep in mind the general principle of promoting her growing maturity and improved ability to soothe her own upset emotions and to work constructively and cooperatively with staff to meet her needs. Avoid correcting her with scolding or display of annoyance, as that could trigger withdrawal or passive-aggression or tearful emotional collapse. Invite Leslie to brainstorm ideas for ways to correct problems, resolve dissatisfactions, compromise with others, or be more compliant with needed care and treatment. Encourage Leslie to take deep breaths and to collect herself emotionally before engaging in such brainstorming or came back later if she needs more time to soothe her emotions. Expect Leslie to adopt a more measured and sensible sets of problem-solving skills, but do not become frustrated or annoyed by the unavoidable delays and lapses she will continue to display along the way. Use your words and actions as ways to invite her into more mutually rewarding adult ways of coping. Guide her toward the acquisition of genuinely adult skills and viewpoints while remaining patiently aware of the deep and longstanding obstacles that interfere with her having already learned those methods.

***

I met with the unit nurses and aides to review and discuss this treatment plan. Some had not been aware of Leslie’s history of Fetal Alcohol Syndrome, of her hearing voices, or of her history of sexual assault. Some were surprised by the discussion of epilepsy and psychological and behavioral symptoms. Yet a renewed sense of compassion and of helpful mission were awakened by the conversation about ways they might aid her development—even during their ordinary and routine tasks. The workers now applied the new insights and asked thoughtful questions about her specific behaviors. They felt less reactive in a personalized sense, and better prepared to shape their actions so as to improve hers.

Thinking of You Too

Posted on by Psychotherapy.net Team

I don’t typically assign homework to patients, at least not in the traditional sense. But when patients ask for something to work on during the week, something that would help maintain the momentum they’ve gathered in resolving distress, I suggest they think about our work—to reflect on the themes we’re uncovering and how they apply to their current experiences. I emphasize that while growth starts in session, it is a process that continues after.

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The work of therapy is not limited to 50-minute sessions every week; it’s happening during all that time in between, too—for both patients and therapists. I think about my patients after sessions as well; it is only natural when we’re working persistently, week after week, to understand sources of distress and facilitate change. Some of my own insights about my relationships with patients occur when I’m off the clock. And in the same way I ask patients to make sense of their thoughts, it’s equally important that I do the same.

The Regulars

While picking up the living room the other night, it suddenly occurred to me: my patient earlier in the day had spent the entire session attempting to get my approval in the same indirect way he tried to engage with his mother in the past. Amaan* and I had been working together for almost two years, and a large theme in our work has been recognizing his mother’s limited capacity for offering emotional support and the impact this has had on his efforts in current relationships. Amaan has made great progress in integrating his experiences of his mother, coming to terms with what she may never be able to give him; I realized suddenly that he was trying to cast me in that now-vacant role. In session, he had listed the areas in which he felt he had grown, the insights he had fostered about himself, and the clarity with which he felt he could move forward. I actually agreed entirely with him, but there was something about the way he expected me to corroborate his own opinions, as though anything but clear agreement on my part would undermine all his progress.

I thought about why this did not occur to me during session; after all, this is someone I’ve come to know very well, and was part of a conversation related to the exact theme we’ve been identifying for quite some time. I’ve gathered that at times, my patients’ ways of relating directly complement my own—I enjoy validating their experiences and highlighting progress we’ve made together. Recognizing Amaan’s progress would also mean an opportunity in recognizing my own as his therapist, but I have to remind myself this is not about my own ego. With this discovery, I can return to future sessions with even more awareness of what Amaan is attempting to reconstruct in our relationship and identify his efforts in real time. More importantly, I can encourage him to take faith in his own progress as he recognizes it, not through me.

Realizing blind spots are not the only reasons I find myself thinking about patients, though. Sometimes I find myself thinking about them out of genuine care, concern, and curiosity for what they are going through. Did their husband take the news well? They were grappling with whether to call their mom—what did they decide? Did our session help provide any clarity? When I find myself wanting to know more, I think about what this says of the patient more than it says of me. Perhaps the patient’s general motivation is to keep others engaged by employing a “stay tuned” attitude—and it certainly works. Maybe it is unlike a patient to attract this much concern, which is even more telling of the gravity of their distress.

Other times, a patient stays with me in a gnawing way, long after the session is over. I wonder if they’re feeling it, too. This feeling lingers after sessions where it felt like a patient was not feeling something enough. These moments feel like a dramatic irony, in which I see the whole story but they’re not yet ready to. Depending on the patient, I may use these thoughts to motivate an intervention—point out distorted thinking or question their assumptions. But if it feels so strong, I may realize that this patient needs me to hold on to the feelings they cannot yet own until they are fully capable of doing so. And that guides our work—preparing them for a realization instead of directly handing them one.

The Absentees

What about the patients who regularly cancel or forget? The patients who are ambivalent about therapy, saying that they really want to be here, but their attendance say otherwise. How is it that the patients we see less often seem to take up the most space in our minds? I’ve gathered that they use their absence to communicate something to me—to shake things up, to make me feel more toward them, to get me more engaged, only for them to walk away. When patients cancel repeatedly, or even no-show, I’ve learned that rather than take feelings toward them at face value, it’s more beneficial to use these feelings as a cue to their ambivalence about treatment.

Melanie* is a newer patient of mine, unknown to therapy in the past. In session she would often say she wasn’t sure if therapy would be helpful and was confused as to why she was here in the first place. After her initial distress regarding her relationship with her father had subsided, she grappled with how to use the space, minimized other stressors, and looked to me for direction. Her anxiety about being in therapy but not knowing how to make use of the time likely explains her frequent cancellations without request to reschedule.

Initially, I offered to reschedule and was usually met with the impossibility of doing so. Over time, I began to feel resentful of the way in which she treated our relationship and disappointed in being more interested in her experience than she was. These feelings stayed with me, and I wondered for a while how to make sense of them. Why did I seem to care more than she did? I remembered how she had a “one foot in, one foot out” attitude at the start of most sessions but eventually warmed up after a few minutes. Her ambivalence made sense all of a sudden—she needed validation for the pain she felt so deeply before being able to commit to the space and herself.

The Graduates

And then there are the patients I’ve worked with in the past. I wonder so often how they are doing—if they ever married that guy we spent so many sessions talking about, if they ever found what they were looking for that we could not seem to find together, if they think about the relationship we shared at all. For some time in both our lives, we were constants for each other. For as much as I was a part of their lives, they were a part of mine. Therapeutic relationships coming to an end means coming to terms with possibly never hearing from our patients again. But I still let myself wonder how they’re doing. When I think of these patients, I am reminded of what seemed to be most helpful, what wasn’t, what they learned, and what I did. I think about how much I’ve grown and changed because of every relationship I have had with a patient and how to make meaning of this growth for myself and other patients.

From time to time, I have run into some previous patients. Pauline* stands out to me, since I ran into her at a time when I was going through some personal life transitions and was caught off guard in seeing her. But in the few minutes we spoke, she shared that she had made many steps forward in ways we hadn’t even spoken about but in ways she was very proud of. And I was so proud of her, too. I remember when our work ended, I wondered if I could have done more to foster more insight and self-compassion. She had not accomplished her goals in the ways she intended at the start and our work had to end abruptly. In running into her, I learned that even if our relationship ended, the work continued. She too was changed because of it, and it continued to impact her motivation to take steps toward herself.

***

Patients wonder if we think about them just as they are thinking about us. When I tell patients that I think of them or disclose that something they said has stayed with me since the last session, I can detect both surprise that they are remembered and relief for finally being seen. We want our patients to make meaning of therapy and take in the work. I think that when they realize we’ve internalized them, they’ll finally do the same.