Category: Beginning Therapists

The Gossamer Thread: My Life as a Psychotherapist

Posted on by rezendevknowfully.com

Below are three extracts from my book, The Gossamer Thread: My Life as a Psychotherapist (Karnac, 2010). The book describes my personal journey as a psychotherapist, how I started as a bumptious behaviour therapist, young, inexperienced and highly confident, and ended as a psychodynamic psychotherapist with a more reflective and intuitive way of working. Along the way I trained in Beck’s cognitive therapy although I found myself almost immediately doubting the rational simplicities of this approach.
The first extract describes my attempt to demonstrate the wonders of behaviour therapy to one of my students by treating an elderly lady, a chronic agoraphobic stuck in her flat on a run-down estate in south London.
In the second extract, Frances, a model cognitive therapy patient up to that point, becomes suddenly depressed and I behave in a not very therapeutic way.
In the third extract I take on my first psychodynamic psychotherapy patient, a charming, narcissistic young man, and discover how tricky it is to get through well-established defences.
 

Working as a behaviour therapist, London, 1970s

I park my car on the road that borders the estate, thinking that the safer option. Graham and I walk down the hill seeking to locate Arlington House where Mrs Hewittson lives. I’m aware that we stand out, dressed in our smart, professional clothes, each carrying a leather briefcase. But no one bothers us and we find No. 7, a ground floor flat fortunately, so we don’t have to negotiate what I imagine to be urine-smelling lifts or flights of bare concrete stairs. I ring the bell and wait.

I had briefed Graham beforehand. This is to be an assessment. Given that this is behaviour therapy, it would of course be a behavioural assessment. My plan was that flanked by the two of us, Mrs Hewittson would come out of her flat. Then we would send her off on her own as far as she could go until she couldn’t go any further. And I was going to be really scientific about this, for we would note down exactly how far she went, how long she took and how much anxiety she experienced on a scale of 0 to 100. This would be the baseline against which her recovery would be measured. In my mind, I fantasised Mrs Hewittson going further and further each week until we had her travelling all over London.

The door is opened cautiously by a young girl, no more than nine. I explain that we are psychologists and that we have come from the Maudsley hospital to see Mrs Hewittson.
“‘Nan,’ she yells back into the flat, ‘there’s two psychos from the hospital to see ya. Waddya want to do?’”
We hear the sound of talking from inside the flat, two voices, one female sounding very tremulous. Graham and I exchange looks. The door opens wider. ‘Nan says you can come in.’ The girl disappears into the gloom of the flat. When we get used to the darkness, for the curtains are drawn and the main lighting comes from a TV blaring away in the background, we see that the room is full of people. There are three girls, including the little girl who opened the door, playing around a Wendy house in one corner. A woman, barely in her teens, is seated at a table holding a baby who is guzzling milk from a bottle. A tiny, wizened man in an old grey suit sits on a huge settee, a cigarette dangling from his hand. And, in a rocking-chair in the centre of the room, there is a woman in her fifties, strands of mousy brown hair straggling down either side of a pale, thin face in which watery blue eyes stand out like on those odd goggle-eyed fish one sees in aquariums. She is staring at us unblinking. Mrs Hewittson I presume.

It is an unnerving situation, not what I’d expected. I’d imagined Mrs Hewittson stuck on her own, lonely perhaps, even pleased to have a bit of company. Not in the midst of a melee of people. But I’m the professional. So I take charge. ‘Mrs Hewittson?’ I say, addressing the lady in the rocking chair. ‘We’re psychologists from the Maudsley. We’ve come to help you get better.’
The woman says nothing. ” She rocks forward and back in the chair. I am uncomfortably reminded of the Bates motel in Psycho and the skeletal mother in the basement.”
‘Your daughter,’ I press on, ‘arranged for us to come and help you.’
‘Did she now?’ Mrs Hewittson says. It’s a rasping, throaty voice, the product no doubt of thousands of cigarettes smoked in the gloomy flat. ‘That was nifty of Jean.’
Somehow I feel that being ‘nifty’ is not something Mrs Hewittson approves of. The tiny man on the settee leans forward. ‘My Madge is not well, you know,’ he says confidentially as though she cannot hear him. ‘Trouble with her nerves. Had it a long time.’
‘That’s why we’re here,’ I say triumphantly. ‘To get her better.’
‘How are you going to do that then?’ puts in the woman with the baby.
‘First, we’ll go out for a short walk, say, to the post box.’ We’d passed the post box just twenty metres along the road. I turn to Mrs Hewittson. ‘You might have a letter you want to post and we could do it together.’
‘Sammy takes all my letters. He delivers them and takes whatever I’ve got. Don’t need to post anything, thanks all the same.’
‘Anyway, it’s an assessment, a sort of test, to see how far you can go. You don’t have to go far,’ I add hastily. ‘Just as far as you feel you can go.’
‘I can’t do that, doctor. Sorry, I can’t do that at all.’
‘Oh.’ This blanket refusal takes me back. ‘Well,’ I press on gamely, ‘what about going out of the front door and down the path to the gate? It’s only a couple of yards. I’m sure you could do that with our help.’
‘I would do it, sir. But it’s the fits, you see. Can’t risk it. I have these terrible fits.’
‘She does,’ interjects the man in the grey suit who I take to be her husband. ‘She has these fits. She’s a martyr to them.’

I sense I am losing the battle. What are these ‘fits’? Could they be epileptic fits? If they are, what do Graham and I do if she has one? I have never seen an epileptic fit. All I know is what everyone else knows from the films, how you have to grab the tongue, but then what? I curse myself. I should have read Mrs Hewittson’s case file before we came. Before I have time to say anything, the front door opens and in breezes another youngish woman with a two-year old in tow.
‘Madge, darlin’,’ she starts, then stops having spotted us. ‘Sorry, love, didn’t know you had visitors.’
‘They’re from the hospital. Psychiatrists,’ says Madge.
‘Psychologists.’
‘Sorry, didn’t mean to offend and all that.’
‘No offence.’
‘Thing is,’ says the new arrival, ‘I was hoping you’d look after Darren while I go to the Social.’
‘No problem, love. You leave him here with me.’ Mrs Hewittson turns to me. ‘Very sorry about the walk. But you see I’ve got my hands full. Another time, doctor.’
‘Yes. Right,’ I say decisively. ‘What about Friday morning? At 11?’
‘That would be ticky-tack. I’ll be more meself then, I expect.’
Unfortunately, that’s exactly what worries me.
 
Friday morning comes and Graham and I make our way back to the Dog Kennel Hill estate, to Arlington House, No. 7. I have found Mrs Hewittson’s case file. A bulging, tattered, beige-coloured, wallet with letters, documents, case notes, and other bits of paper loosely packed into it. I have waded through it all. There is no mention of epileptic fits. Just panic attacks, which I suspect is what Mrs Hewittson meant. As we approach the door, we see pinned on it a scrap of white paper, fluttering in the wind. I fold it down so we can read what is on it.
Too the Doctors. Very sorry, had too go to the dentists for me tootheyk really bad it is. Mrs Hewittson
We try to peer in through the windows but the curtains are closed. There is not a sound from inside. But I knock a couple of times anyway.
““It seems,” Graham says, “that a visit to the dentist is preferable to a visit from us.””
“Maybe it was an emergency.”
“Yes, of course that might be it.” He gives a half smile.
I take the paper off the door and, beneath Mrs Hewittson’s scribbled message, I write:
Sorry about your toothache. Hope you get it fixed. We’ll come again on Monday at 11.
I am not about to give in so easily.
 
On a bright, sunny Monday morning Graham and I are again standing outside No. 7 Arlington House. This time there is no scribbled note on the door. We knock but there is no response. The curtains are not completely drawn on one of the windows. Peering in, I see that the front room is empty and the TV is off. There is no sign of occupation. I step back and look at Graham. He shrugs. Just then a young girl, a similar age to the ones we had seen playing around the Wendy house, comes skipping down the street towards us. She skips right up to us and proceeds to skip round us as though we are part of some game she is playing.
“Are you,” she says as she skips, “the doctors?”
“I suppose so. Yes, I mean.”
“To see Mrs H?” Skip, skip.
“Mrs Hewittson, that’s right.”
Skip. “She left a message.” Skip, skip.
“And?”
Skip, skip. “She’s gone to the Isle of Wight.” Skip. “To visit her brother-in-law.” Skip, skip.  “For the whole week.” At that she skips off the way she came.
As we trudge back to the car, Graham says: “You could say we had a great success. After all, we got her out of the house.”
“Drove her out,” I say with a grin.
“And in one session.”
“We should write a paper. ‘One session treatment for agoraphobia: a breakthrough in behaviour therapy.’”
We did not write a paper, of course. Nor did we return to bother Mrs Hewittson again. It had taken me a while to get the message but I did get it in the end.
 

Training as a cognitive therapist, Oxford, 1980s

One week Frances fails to attend a session, something she has never done before. We are well into the therapy. We have moved on from changing negative thoughts to identifying the underlying beliefs, what Beck calls schemas. These are the major drivers of depression, ideas that are often formed in childhood and become reactivated in current crises. They can be encapsulated in key phrases or prescriptions like: To be happy I have to be accepted by everyone all the time, I must succeed in whatever I do, I have a fatal flaw in my personality, I am fundamentally a bad person. According to Beck, to produce lasting change it is essential to get to these core beliefs and deal with them.

In the session before Frances failed to attend, she had complained that her work as an administrator was boring. I asked why she didn’t try to get a more demanding and interesting job, something that drew more on her academic ability perhaps. She said vaguely that there was no point. Puzzled, I pursued this and we came to an example of a powerful underlying belief. Life is meaningless, she claimed. In the end we all die.
‘How do you know life is meaningless?’ I ask.
‘I just do.’
‘Come on. You know that won’t do. Let’s do some cognitive work on this. List ‘pros’ and ‘cons,’ for example.’
Frances says nothing. I try to read her face but I can’t. It’s expressionless.
‘Don’t you want to challenge this belief?’
‘I can’t see the point.’
‘To get better. To deal with your depression.’
‘Deal with it,’ she says sarcastically. ‘You don’t deal with the meaningless of our existence.’

I am startled by Frances’s tone. It’s the first time I’ve heard her talk in this angry way. I backtrack. ‘Okay. I’m sorry. A poor choice of words. But I do think we should examine this belief, don’t you? It seems central to your depression.’
Frances stares at me. For the first time in the therapy I feel unsure. More than that. I have a sense of unease.
‘Maybe,’ she says at last. ‘But not today. Can we leave it to next time?’
‘Okay.’
Later, I wonder if I should have agreed so readily. Was this avoidance on my part? Up to now the therapy had been going smoothly. Frances was the model patient. This was our first glitch. I’d told myself that it would be better not to push this. We could work on it in the next session. The only problem is that Frances failed to turn up for the next session.

I ring Frances. I don’t normally do this when patients fail to show up. I wait a couple of days and if they don’t contact me, I drop them a line. But Frances is a special case, my first cognitive therapy patient, and I’m worried about her. The phone rings on and on. I’m about to hang up when at last she answers, a slow ‘Yes, who is it?’ as though I have just woken her up.
‘Frances, it’s John. I was wondering if you were okay.’
‘What time is it?’
‘Just after two. Have you been asleep?’
A long pause. ‘Sorry. Just very tired.’
‘You didn’t make the session this morning. I wanted to know if you’re alright and if we should reschedule.’
Another long pause.
‘Are you feeling depressed?’
‘You could say that.’
‘Is that why you didn’t come to the session?’
‘What’s the point? I’m not going to get better.’
‘That’s your depression talking, Frances. You’ve had a downturn in mood. All the more important for you to see me at this time. We can work on it together and help you get out of it.’
‘I don’t know.’
‘I do.’ I’m being the decisive, no-nonsense therapist though it’s the last thing I feel at this moment. My shoulder muscles ache with tension. My heart is beating fast. At the back of my mind is the thought that Frances will kill herself. ‘How about later on today, at 6? Or tomorrow morning?’
‘No. I need a bit of space. I’ll come to next week’s session. Don’t worry, John. I’m not going to do anything stupid. I haven’t the courage to do that anyway.’
I try to persuade Frances to see me earlier but she’s adamant. She promises to come next week. I wring a further promise from her that she will contact me immediately if she feels suicidal.
What has happened? The therapy was going along really well. Is it just a blip, a random change in mood? Has something happened to Frances to trigger the increase in her depression? Was it related to our discussion of her core belief that life is meaningless? I ponder these matters but come to no conclusion.

When Frances comes to our next session, I immediately notice a change in her manner. There’s a slowness to her movements, a hesitancy that I have never seen before. She doesn’t look directly at me and when I study her face, all I can see is blankness. I ask her how she is. She takes a while to respond. She says she feels lousy, tired, depressed, no energy, completely zonked. All signs of depression.
‘I’m sorry you’re feeling so bad but I’m glad you came,’ I say. ‘It’s a chance to do some work and improve your mood.’
She looks at me and sighs. ‘The good doctor’s going to make me better. Hooray.’
‘Well, I’m going to try. Tell me right now and in all honesty what you think of coming here.’
‘A waste of time.’
‘Why?’
She shrugs. ‘Nothing works and anyway what’s the point. I get better for a bit and then I get worse. I’m just useless.’
‘Several very negative thoughts in that statement, I’d say. Do you remember how we dealt with, I mean, worked on your negative thought, I’ll never get better? We listed the ‘pros’ and ‘cons’ and came to a more realistic thought. I have it here.’
I search through my notes and read it out to her:
I can’t know that I’ll never get better and I recognise that this absolutist negative thought is a product of my mood state rather than a realistic appraisal of what will happen.
‘Do you believe that now?’
‘It’s irrelevant what I believe,’ she says in a lethargic tone. ‘Life’s meaningless anyway. We are microbes in the vast universe. Specks of cosmic dust. What does it matter? What does anything matter?’
‘Something mattered enough for you to come here today. You’re depressed, Frances. Something brought you right down in the last week. I don’t know what. But I am absolutely convinced that your view that life is meaningless is caused by your depression.’
‘It’s not,’ she says emphatically. ‘Life is meaningless. It’s not a product of depression. It’s true. And anyway I’ve always believed it so it can’t be a response to a change in mood.’
For the moment I’m stumped. I’m also feeling pissed off with Frances, with her certainty and resistance to my attempts to help her.
‘Always?’
‘Always.’
‘So you sprung from your mother’s womb with the thought Hey, why am I here? Life is meaningless. Let me back in?’ I have spoken without thinking. I’ve let my feelings show. I’ve broken a cardinal rule: don’t mock your patient. I’m a crap therapist. But a small smile appears on Frances’s face.
 

Training in psychodynamic psychotherapy, Oxford, 1990s

Sitting opposite me is Matthew, a tall young man, in a scruffy white T-shirt and faded jeans. In his hands he has a Rubik cube.  Each side of the cube is subdivided into nine coloured squares, the puzzle being to twist the arrangements to produce sides of all one colour. Matthew is fiddling with the cube, a frown of concentration on his face. He is my first proper psychodynamic psychotherapy patient. This is our first session.
“I wonder if it might be best if you put the Rubik cube down.”
I leave the faintest of inflections at the end of my remark to try and soften the suggestion. Matthew drops the cube into a battered shoulder bag that he has draped on the side of the chair.
“There,” he says, flashing me a brilliant smile. “I solved it yesterday. I thought I’d see if I could do it again. I must have gone wrong somewhere.”
I could pick up on the wider meaning of his last remark but decide that it is a bit too early to do so and, moreover, it is Matthew who should do the running, not me. I have already introduced myself and explained that we are to work together for up to a year, meeting once a week, holidays apart.
“How about you kicking off,” I say. “Just say whatever’s on your mind.”
We are seated face-to-face. There is a couch in the room but Matthew declined it. I was disappointed as the couch seemed so much a part of the psychodynamic approach.
“What do you want me to say?” he says brightly as though he is here to audition for a part in a play.
“The idea is for you to talk and we take it from there. Whatever is on your mind.”
This produces a long silence during which Matthew gazes around the room as though seeking something to latch onto.
“Crap painting,” he says pointing at a Monet print of a mother and young girl walking through a bright red poppy field. “I hate reproductions.”

Is Matthew saying something about himself in this remark, I wonder? That he is not a reproduction, but the real thing, a true original. Whether he is or not I decide not to comment. I think about what I already know about him from the assessment that Dr Franklin, the Psychotherapy Department’s senior registrar, carried out. He comes from a well-off, middle-class family. He is particularly close to his mother. She gives him a generous allowance and has let him stay, rent free, in a flat she owns in Headington. His father, a successful businessman, is largely absent from home. At school Matthew was regarded as very bright but dropped out in the 6th form. There are suggestions of drug taking and gambling. Since school, he has had periods of temporary work, mainly on building sites, though most recently he worked in an office. None of his jobs have lasted long. He is currently unemployed. Matthew’s major complaint is of extreme anxiety, often in the form of panic attacks. These have caused him to retreat to his flat, sometimes staying there for days on end, not seeing anyone.

My reverie is interrupted when Matthew says, looking quizzically at me: ““You’re not like Doctor Frankenstein. He asked me lots of questions, most of which, actually all of which, were stupid. In the end I just made things up. It seemed to make him happy.””
Jesus! Now I do not know what of Dr Franklin’s assessment is correct, which is, I suspect, exactly what Matthew wanted.
“I wonder why you did that.”
“I wonder why myself.” A cheeky smile, inviting me to join in the joke. I cannot help smiling back. There is something very disarming about Matthew. 
“When I was at school,” he says after a while, “I would make things up. Entertain the troops by telling a few fibs, playing the joker. It got to be a habit. I had this great ex-army greatcoat and me and the other lads hung about, doing dares and that. Wicked!”
He sounds about 16. Stuck in an adolescent time warp.
“Only I lost the coat. Then the bastards threw me out.”
Why did they throw you out?It’s on the tip of my tongue to ask but I stop myself. Above all, I want not to interfere, to let Matthew talk and me listen. So far he has not told me about anything serious. Not about his uncertain sexuality. Not about his intense feelings of panic. Nor about the time when he took an overdose of antidepressants (the tablets were his mother’s prescribed by the family GP). Dr Franklin had noted all these in his assessment but Matthew does not seem to want to talk about any of this. Of course they might all be fabrications (fibs to entertain the troops) but somehow I doubt it. Beneath the veneer of jokiness I sense his vulnerability and unhappiness. The difficulty might well be getting him to talk about it.

Matthew talks more about his school even though it is over three years since he left. He was brilliant at English and had two poems accepted by the school magazine. But he stopped working in the 6th form because it was all so puerile. Then the teachers tried to get him to see a school counsellor who turned out to be a real wanker. I am cast in the role of the eager listener to his tales of schoolboy derring-do. He tells a good story and I think I could just let him do that. But where would we have got to and what purpose would it have served other than to pass the time? The dilemma with the passive stance of the psychodynamic psychotherapist is that someone like Matthew could entertain the troops all day long. At a pause I venture to stir things up, unsure if I am doing the right thing and wary of how he will react.

“From what I’ve heard so far everything seems so hunky-dory that I wonder why you are here in psychotherapy at all. It hasn’t been all sweetness and light, has it?”
Matthew does not say anything, which causes my heart to beat faster. I run through the statement I have just made and castigate myself for its anodyne quality. Could I not have been more incisive?
“Hunky-dory,” he says, drawing out the word in a laconic manner. “Now that’s not a word in the psychotherapist’s lexicon, I would have thought? Or is it?” ” He looks at me expectantly, all sweetness and light of course.I feel the stiletto sliding subtly into me.” I tell myself to stay mum and then wonder at my choice of words. Mum’s the word. The phrase floats through my mind as though magically Matthew has projected it into me. Is this an unconscious communication? Do the words mean that we will be okay as long as I mother him, admire his precocity and wit, but if I, taking the paternal role, challenge him, he will hit back? All this flits through my mind in seconds, a blur of semi-conscious thought, as Matthew looks me straight in the eye and waits for me to respond. I say nothing, holding his gaze until he looks away. My beating heart gradually slows. In my previous persona as a cognitive-behavioural therapist, I would have been more active. I would have probably said that hunky-dory was certainly not a psychotherapeutic term, just a word that seemed appropriate. I would have smiled, wanting to maintain good rapport. I would have asked Matthew whether he minded the word or if he preferred another. Why do I not do this now? Because my primary role is not to be Matthew’s friendly helper, not to make him feel at ease. As a psychodynamic psychotherapist I am seeking to create a space in which we can explore deeper feelings. For that to happen I have to dispense with the niceties and tolerate the discomfort just as Matthew has to do too. I am finding this difficult. It is not just that Matthew, with his air of vulnerability and his boyish charm, invites me (and others, I imagine) to look after him. I realize I like looking after people. That is why I am in this job. Only in this instance looking after people means something very different. It is not about making them feel better, at least not immediately, but getting through their defences to the heart of their problems. To achieve this I shall have to use a few stilettos of my own.

The session stutters on. Matthew’s breezy insouciance dissolves. He retreats into scowling silences. When he speaks, there is anger and more than a hint of despair. He rails against both his parents, his father for his crass insensitivity and his mother because she is a very silly woman. I hear nothing of his brothers and sisters. He brightens up only when he talks about his best friend, Tom, who is about to return from college. Tom is going to stay with Matthew and they’ll have fun together again. I cannot help thinking that the fun will be rather hollow. A feeling of sadness pervades the room. Matthew’s defences are pretty brittle, I realize. I feel daunted at the task of treating him. After all, I am a novice at this form of therapy. Yet I desperately want to help him, not just because I am on a course and anxious to do well, but because I sense his despair. I end by saying a few words about the task ahead.
“These are your sessions, Matthew. We have up to a year to work together.”
“But what’s the point? It’s just talking. What can talking do?”
“It’s an opportunity for you to take a look at yourself, to explore how you feel, to examine what has happened to bring you to this point.”
“But I’ve told you all I know.”
“I don’t think so,” I say more assertively than I had intended. “Do you really think you have?”
A pause. “No. There are other things. Stuff I haven’t talked about. Horrible stuff. But I don’t think I’ll ever talk about that.”
“Let’s see. Next week at the same time?”
“Okay,” Matthew says. A flutter of hope, faint and tenuous. “I sit for a while in silence after Matthew leaves. I feel drained and empty.” Then I pull myself together, reach for my pen and start making the detailed notes I shall need for supervision.
 
John Marzillier
28 February, 2011

Free Psychotherapy Training

Posted on by Psychotherapy.net Team

As a psychotherapy training nerd, I’m always looking for good training opportunities.  What’s the most training one can find on a limited time and budget?  I recently talked about this with Carol Odsess, PhD.  Dr. Odsess is a psychotherapy trainer in Albany, California who specializes in EMDR and Energy Psychology. 

What trainings have the best cost/benefit ratio?  A good place to start are the many excellent articles and interviews with master therapists available at psychotherapy.net, which are free to read.  (You only have to pay if you want the CEs.)  In addition, Dr. Odsess offered a few recommendations to stretch your training dollars. 

  • Instead of going to a conference, consider buying the audio recording of the conference instead.  You save the costs of airfare and hotel, and keep your weekend!  Additionally, you get to experience every training at the conference, which is more than you would get if you went in person.  Dr. Odsess recommends listening to audios of conferences while commuting (which has the side benefit of reducing road-rage.)  I’ve been working my way through 200 hours of the 2009 Evolution of Psychotherapy Conference during my commute for the past year.  She also pointed out that having the trainings on audio makes it easier to refer to them when writing or teaching.
  • A free way to enhance your training is to videotape your own therapy sessions and review them later.  There’s nothing like getting an un-edited view of your work to improve effectiveness.  Likewise, many consultation groups are free to join, or you can start your own.
  • Dr. David Nuys produces two excellent podcasts on psychology:  Shrink Rap Radio and Wise Counsel.  All past talks on both podcasts are available for download.
  • Check with your local library to see if they can order psychotherapy books or videos through their national link system. 
  • Join a listserv related to your specialties.  Many listservs have fascinating ongoing discussions about psychotherapy theory and technique.
  • Check out the great psychology blog mindhacks.
  • A few other websites offer free trainings via the internet or teleseminars, including traumasoma, wisebrain, and dharmaseat.
                Another issue to consider is the effectiveness of trainings.  For the most powerful and effective training, Dr. Odsess recommends live supervision, where the trainer observes (and sometimes intervenes in) a live therapy session.  Live supervision activates experiential learning, which she considers much more powerful than didactic or passive learning.  I myself prefer live supervision, as I wrote about here.  Live supervision is usually not cheap, however, so those on a budget might prefer the resources above.
 
 

Preventing Psychotherapy Dropouts with Client Feedback

Posted on by Psychotherapy.net Team

“You understand me thirty percent of the time.”

“I need to you to slow down.”

“I was sad and you cut me off.”

These words of dissatisfaction are from my clients. They weren’t easy to hear, but they have changed how I practice psychotherapy and have significantly reduced my dropout rate.

Anne: A Case Study

I had been treating Anne, a Latin-American woman in her early 20s, in psychotherapy for six months. She presented with weekly panic attacks, daily cutting, severe sleep disturbances, a range of somatic symptoms that she attributed to her anxiety, and persistent interpersonal difficulties. She presented as attentive and likeable, though beneath her mask of smiling and compliance she clearly hid a tremendous amount of pain. Anne has a history of sexual abuse by multiple family members over a six-year period starting before age four. Her mother had been a prostitute for most of Anne’s life, and both her biological father and stepfather are in prison for sexual assault. Despite these and many other challenges, Anne demonstrated tremendous resiliency and had just graduated from college with a very strong GPA.

Anne had been in individual and group therapy for much of her childhood and teens, but by her own report she had never really tried to make it work. After graduating from college, Anne decided she wanted to find a solution to her anxiety, sought out individual therapy, and found me.

Anne’s treatment progressed well at first. In the first few months her panic attacks stopped, her general anxiety decreased, she stopped cutting, her somatic symptoms decreased, and her sleep gradually improved. Anne’s interpersonal difficulties, however, persisted. We had been digging into that material for a few months but had made little progress. In fact, her social and romantic life was getting worse. Anne was becoming restless and frustrated. I pulled out my two favorite “getting therapy unstuck” tools: consultation groups and additional training. Neither helped. As a dynamic therapist, I knew what I was supposed to do: work in the transference, bring insight to the dynamics in the room, monitor my counter-transference, and above all hold the frame. But “the frame of a therapy case cannot be stronger than the frame of a therapy practice, and mine was starting to splinter.”

Existential Threat

In the same month that my treatment of Anne was getting stuck, I had two new clients drop out after one session in the same week. I knew about the research that we are all told in graduate school about how the modal number of psychotherapy sessions nationwide is one, and how not every client and therapist is a good match, and yada yada. But for a new therapist trying to build a practice during a recession, having two new clients drop out in one week is an existential threat. I decided something had to change.

On my commute home one evening that week, I listened to a recording of Scott Miller’s presentation at the 2009 Evolution of Psychotherapy Conference regarding his pioneering work on feedback-informed psychotherapy. Scott got my attention when he referred to dropouts as the “largest threat to outcome facing behavioral health” in the United States and Canada. He was talking about my practice! I realized that I was not the only therapist with a dropout problem, and there was no reason to hide it out of embarrassment. I resolved to seek counsel from my colleagues and mentors.

The Ubiquitous Scourge

In the first, difficult year of building my private practice, I ate a lot of lunch. Networking lunches are like lottery tickets: one in ten results in a few referrals, and every referral was worth its weight in gold in that difficult first year. I enjoy networking lunches, because it’s fun to meet senior clinicians and hear their war stories. They tell me that they enjoy the lunches because they get to pass on the gift of mentoring that was once given to them. Senior clinicians are a generally calm, relaxed and self-assured bunch; they have established referral sources and can easily afford to lose a client here and there. Want to make some highly regarded pillars of the therapeutic community stop eating their free lunch and sweat a bit? Ask about their dropout rate. It’s as if you’re asking what sexually transmitted diseases they may have. It’s not polite. Never mind that dropouts are one of the ubiquitous scourges of our profession, affecting all diagnoses and treatment modalities. Therapy dropouts are the dirty secret of our profession: everyone has them yet few want to talk about them. Unfortunately, avoidance has not proven to be an effective solution to the problem. With few exceptions, the overall psychotherapy dropout rate is as bad now as it was fifty years ago, despite decades of treatment research and empirical certification.

What Counts as a Dropout?

For 2010, the overall dropout rate for my private practice was 37%. Unfortunately, it is hard to know whether this number is good, average or poor, because there is no general consensus in the literature on what exactly constitutes a “dropout.” The average psychotherapy dropout rate has been reported to be from 15% to 60%, or higher, depending upon whether you define dropout as quitting therapy before all treatment goals were achieved, terminating without the therapist’s agreement, or a variety of other definitions. For my own practice, I define dropout as any time a client terminates therapy without telling me that they are stopping because they have achieved enough positive results. I chose this definition because I think it points most directly to the problem I want to resolve: clients who could benefit from more therapy but choose to not be in treatment with me anymore. Of course, this definition is not precise and won’t work for all therapists. If a client terminates due to factors that make continued treatment impossible, such as moving out of town, then I do not count it as a dropout; but if the given reason is that he or she cannot afford therapy anymore, but isn’t interested in talking about a sliding scale, then I do count this.

Of course, there are many reasons a client may drop out. Most of the research on dropouts has focused on what we call client factors, such as the client’s diagnosis, demographics, rate of progress in therapy, etc. But this research doesn’t help my dropout problem because I’m trying to keep my practice full, and I don’t have the luxury of excluding clients who are at high risk of dropout. So instead I have to focus on therapist factors: what can I change about how I work to reduce my dropout rate.

Insisting on Feedback

“Of course I ask for feedback from my clients. I do it every session!” Every therapist believes they ask for client feedback. True for you too? Then tell me why your last three dropouts happened. Sure, we ask for feedback, in the same way that my previous dentists asked—as an offhand, pro-forma fly-by at the end of the root canal. “Was that ok?” And the information we get is usually as meaningful as the effort we expend asking. “Yeah, that was great,” or “You’re a great therapist,” or “I’m really feeling better.” Vague and general; even worse, polite. Just enough for the client to think that they have satisfied the therapist and just enough for the therapist to keep the specter of dropout in the closet. It’s a mutual con-job—a wink and a nod to accountability. But if we don’t embrace accountability in the therapy room, then it will make itself known in dropouts.

Sure, some clients are tripping all over themselves to give you feedback. Sometimes you can’t stop the feedback. But those aren’t the clients I’m worried about losing to dropout. Maybe some therapists are able to get meaningful information through informal soliciting of feedback, but I’ve found the hard way that if I don’t make a Big Formal Procedure out of it, I end up with empty, vague generalities.

Another fruitless session had just ended with Anne, and I was pretty sure that she was about to drop out. I handed her a feedback form and asked her to complete it. “She looked at the piece of paper, snorted and said, “Are you kidding me?”” As a beginning therapist, I have a lot of practice hiding my nervousness. I replied, “I need your feedback in order to learn how to help you better, but also to become a better therapist overall, so I appreciate your time and candor in filling this out.” Anne snorted again, rolled her eyes, and completed the Session Rating Scale, an ultra-brief tool that measures the working alliance along four dimensions. She handed the form back to me and I saw that our working alliance, as I would have guessed, was a sinking ship. I asked what specifically I could do to help her better. Anne replied, “You could listen.”

I said, “More specifically, tell me how I don’t listen and how I can help you better.”

She gave me the look clients give you when they’re not sure if you really mean what you say or if you’re just doing a canned intervention. “You understand me thirty percent of the time,” she said, visibly angry. I asked for an example. “When I mentioned my cousin you cut me off,” Anne said. “That was important.”

I couldn’t remember Anne mentioning her cousin. “What else?” I said.

“You tuned out two or three times this session. I can always tell you’re tired when we meet this time of day.” I thought I had managed to hide my mid-afternoon fatigue.

“What else?”

“There are times when I am sad that you really don’t understand how I’m feeling—even though I can tell that you think you do.”

None of Anne’s feedback struck me as accurate. Above all, I pride myself on accurate empathy. What kind of therapist am I if I don’t feel a client’s sadness?

Four Rules for Receiving Feedback

We all have areas of known weakness. Take cultural diversity, for example. I am a straight, white, middle-aged male. Anne is a young bisexual Latina. I would expect for her to tell me about culturally based misunderstandings. This would be ego-syntonic for me and not cause anxiety. But tuning out or missing sadness—that’s not me!

The feedback I get from clients that is confusing or seems inaccurate is the most important feedback I get. “Why is it that we trust our supervisors to point out our blind spots, but not the people who are actually in the room with us?” It’s odd how we spend so much effort and money getting feedback from peers and experts, yet so little effort on getting formal feedback from our customers.

I’ve come to see that there were two major problems with how I had been using feedback. First, my collection of feedback was pro-forma. I wasn’t invested in getting it, and my clients could tell. Second, I interpreted the feedback. I conceptualized it as part of the therapeutic process, which meant that it was ultimately about the client, not about me. Of course, getting and using feedback affects and informs the therapeutic process. I needed to learn, however, to set aside the process for a moment to accurately hear the feedback as it pertained to me.

Since then I have developed a four-step feedback rule. First, I make a Big Deal out of it. I use a paper form (the Session Rating Scale) because the act of pulling out the paper and pen serves as a symbolic shift in focus away from the client’s process towards my performance. If a client always gives me high marks on the form, or responds with platitudes like, “Tony, everything is great,” I’ll say, “Well, there’s always something I can improve. Can you give me one or two specific ideas on what I could be doing better?” In therapy, it’s all about the client. In feedback, it’s all about me—I’m downright selfish!

The second rule of feedback is that I don’t interpret. If I make the feedback about the therapeutic process then I am missing the actual feedback. As a dynamic therapist, all my training was telling me to interpret Anne’s response as transference or a projection: she was reliving her past pathological attachments in our relationship. But I’m convinced this approach would have caused Anne to drop out, because she would have seen (correctly) that I was ignoring her.

Scott Miller calls this kind of attribution “burden shifting”—when we misattribute our mistakes to client factors. He warns therapists that blaming dropouts on client demographics or diagnostic categories can block our insight into our own mistakes.

The American Psychological Association is moving towards requiring trainees to learn how to collect clinical outcome data. Likewise, Michael Lambert1 and others have developed tools to predict and reduce dropout by tracking clients’ session-by-session clinical progress throughout treatment. This data is valuable, but still focuses on client factors, and thus can miss important information that only the client has on what the therapist is doing wrong. I need to know my part in the story so I can stay ahead of potential dropouts. Without session-by-session feedback, when a client drops out, it is already too late to find out why.

As therapists we claim clinical legitimacy by using empirically certified treatments. We advertise our professional trainings and certifications proudly. But just as important are our personal treatment data, including our dropout rate, which we generally hide in the closet. Krause, Lutz and Saunders2 have argued that instead of having empirically certified therapies, we should have empirically certified psychotherapists. As public health providers, assessing outcome is an ethical responsibility. If we continue to hide to our mess then we run the risk of others exposing it for us. (For example, teachers’ unions across the country are getting clobbered for their resistance to incorporating meaningful outcome evaluations into their work.)

Incorporating Feedback

How do I actually use feedback? Sometimes it is easy. For example, in response to Anne’s feedback, I moved her appointment to a time of day when I wouldn’t be tired. (Now I use her previous time for a midday nap, so other afternoon clients are benefiting from Anne’s feedback as well.) Other feedback can be harder to use, especially when it is about my own unconscious behaviors. Anne insisted that I cut her off when she had brought up her cousin, but I couldn’t remember doing so. Likewise, I had no awareness of avoiding her sadness. While I did want to take her comments seriously, I also didn’t want to automatically assume her perceptions were correct.

However, feedback that points to my unconscious behaviors is also the most valuable. This is the third rule of feedback, which is the hardest rule to follow: to “focus most on the feedback that seems inaccurate, confusing, or anxiety-provoking. This is where the treasure is buried. “

When I’m unsure about the accuracy of the feedback I am getting, I use a strategy I call perspective triangulation. First, I videotape my sessions with that client and review the video myself. I then review it with colleagues in consultation groups. Comparing the perspectives of the client, myself and my colleagues usually results in a definitive answer.

In my experience, the client’s perceptions are correct at least two-thirds of the time, and I make consequent course corrections in their treatment. It is important to note, however, that even when I think the client’s perceptions are incorrect, I still have to substantively address their feedback, or else there is a growing risk of dropout.

My review of the video showed that, yes, I had cut her off. Colleagues in a consultation group watched the video and pointed out multiple instances where Anne was about to have a rise of sadness, but I had blocked her sadness by refocusing on her anger. (Later sessions revealed that the two were in fact connected, as her sadness was about being unable to protect her cousin from abuse.) This was the hardest feedback for me to receive; I never would have believed it, had it not been clear as day on the video. Investigation of videos revealed that I had an unconscious pattern of re-directing from sadness with a range of other clients in addition to Anne. I never would have found out had I not insisted on feedback.

The fourth step in my feedback process brings it back to the client. If I agree with their comments, then I make appropriate course corrections in our work. If I disagree, then we discuss our different points of view. Either way, I make sure to be clear and transparent in my process, and to let clients know that I take their feedback seriously. So in this case Anne and I had a discussion about her feedback. I agreed to be more attentive to not cutting off her sadness. She agreed to let me know, in the moment, if she saw me doing it.

I was trained to get a review of my clinical weaknesses from my trainers and supervisors. Now I also get it from my clients. They have given me an amazing gift: an empirically validated list of my clinical weaknesses. I can’t think of a better resource to prevent dropouts.

Now, six months later, Anne has made significant progress on her interpersonal challenges. She has improved her relationships with friends, roommates and employers. She started setting firm boundaries with previously abusive family members. Her sleep, anxiety and somatic symptoms all continue to improve. Every session Anne teaches me how to better help her.

Before using feedback, I had one to three dropouts per month. Since getting serious about feedback, I’ve had only one dropout in over three months. While this is too soon to draw definitive conclusions, the results so far are very encouraging.

The client sitting across from me knows something about my dropout problem that I don’t. All I have to do is ask, and listen.

2011 Update

 I am pleased to report that my dropout rate for 2011 was 18%, one-half what it was in 2010. I'm confident that getting serious about client feedback contributed to this improvement. This raises the question: how low can a dropout rate realistically go? Besides improving as a therapist, what else can help lower the rate further? (One of my clients recently suggested offering coffee in the waiting room for night sessions!) Hopefully we will find answers to these questions from future research.

Footnotes

1. Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients' progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.

2. Krause, M.S.; Lutz, W. & Saunders, S.M. Empirically certified treatments or therapists: The issue of separability. (2007). Psychotherapy: Theory, Research, Practice, Training. 44, 347-353.

Further Reading

“When I’m good I’m very good , but when I’m bad I’m better”: A New Mantra for Psychotherapists. by Barry Duncan, PhD and Scott Miller, PhD.

A Crash Course in Psychotherapy: Moving through Anxiety and Self-Doubt

Posted on by rezendevknowfully.com
"There is a way out," I couldn't help telling myself as I imagined the door to the small clinic office behind me. The room held nothing but two mismatched office chairs, a window with half-retreated, yellowing blinds, and the heavy smell of sweat, carpet cleaner and someone's lunch. My stomach was tied in knots, and air flowed in and out of my nose surprisingly easily, the way it always seemed to when my heart picked up its pace and my sinuses cleared in response.
 
There was no room in that cramped office for a break: no way Sam* and I could stretch our legs, distract ourselves by staring at titles on a bookcase, or recline in our chairs and close our eyes. There were just two feet of space between us, and I cringed at the thought of moving and accidentally having our knees bump. It was just us—his regretful disclosure, and my words that brought no comfort—that I had to be with, unless I bolted out that door.
 
I remember the simple instruction that was given to us psychotherapy interns during orientation week: Always sit in the chair closest to the door so you have a way out if your client places you in danger. This was a surprising prospect for me, a 25-year-old first-year therapist still in graduate school, who chose to work at an outpatient LGBT community mental health clinic. I pictured myself with clients struggling to come out to family and friends, coping with the loss of a loved one, or needing to heal from childhood trauma. This was, in fact, the case. But it was also the case that I would see clients who suffered paranoia, borderline personality disorder and severe post-traumatic stress disorder. “This is the way it works in the mental health field—the least experienced get assigned the most severely disordered and challenging clients”, whereas the seasoned therapists get to pick their client load, and more often than not, it seemed, stick to young women with relationship problems.
 
I stayed in that clinic office with Sam, because if I didn't, what was I proving to myself? What was I proving to my client? I could make it through this. He could make it through this. There was no physical danger, only a danger that I sensed we both felt coming from inside ourselves, screaming to us through our blood and pounding down on our chests. But this danger felt more difficult to conquer, because the perpetrator was all around and nowhere at once.
 

Sam

Two months after I started my internship, my clinical supervisor and I did an intake with Sam, who I was scheduled to see weekly for psychotherapy. In Sam's intake, he volunteered very little about himself. The soft lines around his eyes and mouth told me he was in his mid-30s, and he wore jeans and a flannel shirt. He didn't look at all like the gay men who worked at the clinic, with their pressed button-down shirts and neatly gelled hair, or the preppy Castro-neighborhood dwellers wearing pastel shirts with the collars up, tight designer jeans and Ray-Ban sunglasses. Sam came in carrying a skateboard and a messenger bag. His narrow, stubble-covered face was topped with a mess of light brown hair, and his Levi's seemed to almost fall off his scrawny body.
 
Sam refused to give us his last name, and the stiffness in his body turned to agitation when my supervisor and I asked him about his family history. "I don't understand why you need to know this," he told us, his eyes shifting around the room and his arms crossed tightly in front of his chest. We told him he didn't have to tell us anything he didn't want to—something I would find myself saying to him many times throughout our six months working together. I discovered later that day that he had disclosed more on the intake form than the interview. “The three fractured sentences he wrote under the History section spoke volumes: "Sexually abused as a kid. A lot. Don't know how many times."”
 
I already knew from his intake that Sam would be a challenge to work with. But when Sam told my clinical supervisor that he wanted to have her as his therapist instead of me, I knew I would be in for a rocky ride, and I would have to prove to Sam, despite my inexperience, that I had the clinical expertise to help him. I thought it would be easier to talk to Sam with my supervisor out of the room, and hoped he would feel safer that way since it would be just one—not two—therapists to contend with.
 
We spent the first therapy sessions with me mostly asking questions and him answering. Moments of silence brought his body to shift in his chair and his eyes to stare wide at the door, so I kept the conversation going any way I could. He told me about his boyfriend and the problems they were having. He recalled fits of anger toward his boyfriend that seemed to come from nowhere, and anxiety attacks at bars and parties. But I could see that something much darker and scarier lurked under Sam's surface and controlled his life. He continued to refuse discussion about his family and childhood, and even benign-sounding questions like "Where were you born?" would lead Sam to erect a wall of fear and anxiety between us. "I don't want to talk about it," he would say, his face turning white, his expression cold and serious. "Okay," I nodded, keeping my tone calm and even, and moved the conversation back to the present.
 

Beneath the Surface

The truth is I wasn't calm. I dreaded every session with Sam. I felt inadequate to deal with what lurked under the surface, and felt responsible for the tenseness between us. I had received basic clinical training on working with trauma survivors in school. I knew it was important to move slowly with Sam and not let too much be revealed at once, because the memories of his past could overwhelm him. But I felt like the therapy was moving too slowly, and that I wasn't reaching him at all.
 
Like a lot of new therapists, I was hard on myself. I pushed myself to be the kind of therapist Sam wanted and needed. His case consumed my thoughts: “I fantasized about having a breakthrough moment with him, where he would finally relax into our sessions and open up to me, and I would guide him through reclaiming his painful past with perfect expertise and confidence.” I often spent my entire supervision hour consulting on his case and brought what I had learned into our sessions. I taught Sam practical techniques to get a handle on his anxiety, and new ways to open up discussions with his boyfriend. I was doing the best job I could as his therapist. But the problem was, neither Sam nor I could see this.
 
About a month into his treatment, Sam came into session frustrated and anxious. He and his boyfriend had been fighting all week and were considering breaking up. When my empathic words like, "That sounds really painful," fell short of what he wanted, he turned the conversation to discuss me. He explained to me all the reasons why I was not a good enough psychotherapist: I was too young. I was inexperienced. I didn't look like what therapists are supposed to look like. I had no clinical specialty in trauma. I had no list of degrees. I wasn't a gay man.
 
I didn't know what to do other than take in all that he was saying about me. My face and body remained calm as I mentally halted the oncoming surge of panic, heat and tears about to erupt from my gut. I told him he was entitled to his feelings and opinions. I couldn't refute his accusations because they were, in fact, all true.
 
After he left the clinic, I grabbed my own belongings and sped through the clinic doors as fast as I could. I needed air and it felt as if the clinic itself were choking me. As soon as a cool San Francisco December breeze hit my face, my skin began to crawl and my stomach, arms and legs, and even my blood all felt suddenly, completely wrong. “I felt like there was a monster inside of me, and that I would soon be exposed for who I really was.” I needed to hide, and as I hurried home through the streets of the Mission District, I envisioned myself as a snake, searching for a rock to slither under.
 
Being in this state made me recall something I was currently learning about in my Severe Psychopathology class: the psychoanalytic defense mechanism called projective identification. I thought about how Sam couldn't tolerate his feelings of shame, fear, and disgust, and so was unconsciously transferring them to me. I learned that, ideally, the therapist is supposed to process these emotions to a tolerable state and return them to the patient. But I didn't know what to do with all these feelings; I didn't know how to process them and return them to him. The concept of projective identification gave me a framework to understand what was going on between Sam and me, but did not help me move through this impasse between us. I felt stuck and overwhelmed with his feelings, and unfortunately my defense mechanism of choice—analyzing, diagnosing and intellectualizing the problem—did not bring me peace of mind.
 
During the next few days my behaviors began to resemble the serious psychopathology of Sam and some of my other clients. I was hyper-aware of my surroundings all the time and hated leaving my home. When a friend coaxed me to go with her to a holiday party, I entered the house to find a kitchen full of acquaintances staring at me. “I was convinced they all knew Sam, and Sam had told them about what a terrible therapist I was. My dirty secret was out.”
 
When I peeked down the hallway I saw that the living room was full of more people lounging on couches, leaning against walls and chatting. I heard a mix of voices muddled together and I strained to pull Sam's out of it. I was convinced he was in that room talking to people I knew, even though as far as I was aware, we had no friends in common. It felt wrong for me to be at this party. I feared I would be called out: how dare I go somewhere Sam might be and put him in that terribly awkward position of seeing his therapist—his bad therapist—in public! I gave my friend who brought me there a quick goodbye, slid out of the house without anyone noticing, and hurried back home.
 
Sam couldn't tell me about his past, and about the horrible things that had happened to him. These feelings that were now overwhelming me were all I had to go on, and were the only hints about what he might be struggling with everyday.
 

Fight, Flight or Freeze?

It would be three weeks before I saw Sam again. He and I both left town for the holidays, and it was definitely a welcome break. When our next session approached, I began to panic. "I don't want to see him anymore. We're not a good match. I need another week. I'm not ready!" I told my supervisor in long, desperate attempts to cancel the session. I wanted someone, anyone, to tell me I could end the therapy with him. I wanted to be told that he was abusing me, that I shouldn't take it, and that I was unsafe.
 
My supervisor, professors and colleagues all empathized, but pushed me to continue seeing Sam. "You need to go back in that clinic room with him for you, not him," they told me. "You need to prove to yourself that you aren't going to let him run you down." I cried. I protested, and I fought it to the very end. But ultimately, I knew they were right. And so it brought me to this moment with him, locked in struggle, a wound exposed, and only myself to hold onto.
 
Sam arrived fifteen minutes late to the session, which wasn't unusual for him. I was somewhat surprised he showed at all and wondered, If he thinks I am such a bad therapist, why is he still coming to the sessions? His expression was cold and he refused to make eye contact. He began speaking almost immediately, and recounted a recent sexual experience he had with his boyfriend the night prior. As the story went on, it became quite graphic and disturbing. Sam described feeling pressured into doing something sexual he didn't want to do. He described freezing and not being able to stop it as it was happening. He was crying and I was startled by the sexual details I was hearing. There was something in me that knew that what he was doing—confessing this painful experience to me—was too sudden. My gut, along with words from the textbook on trauma lodged in my brain, were telling me the same thing: this could overload him. But at the same time, another part of me felt relieved that he was opening up to me and trusting me with the story. Was this the breakthrough moment I had been waiting for?
 
Everything moved quickly. Then, before I fully knew what was happening, he turned his face to me. His crying slowed to sniffles, and he squinted as if to focus and find something deep in my eyes. “His chin wrinkled and quivered as he said, "Now I feel like garbage—what are you going to do about it?"”
 
There was no rock for me to climb under. I had to stay there in that moment. And I had to respond.
 
"I wish there were something I could do to make the pain go away, but there isn't. I'm sorry that happened to you, and all I can do is be here with you through it."
 
"Sorry? You're sorry? That's bullshit!" he said, shifting back and forth in his seat, grabbing his hair with one hand and grinding the other one into the arm of the chair. "How can you just sit there and let me feel this way? How can you make me tell you that—make me feel so disgusting—then not do anything about it?"
 
Everything in the room came into micro-focus, and I felt pressed up against it all, like I was trying to push time forward more quickly to get out of the nightmare erupting around me. I thought about the door. I thought about what everyone told me—that I needed to get through this for me. I knew I couldn't make him feel better. I couldn't erase what had happened to him 30 years ago or the night before. I couldn't take away the pain he felt because of it. I couldn't soothe him—he wouldn't have let me even if I tried. “As his anger and accusations continued to fill the room, I repeated the only honest words I knew: "I'm sorry, there's nothing I can say to you right now that's going to make you feel better."”
 
As our 50-minute time slot came to a close, he became silent for a few moments, exhausted, with nothing else to say. Then, as if he had been watching the clock for when the second hand hit the mark, he hastily grabbed his bag, wiped his face and left the office. I didn't want to move, because moving would stir all the feelings inside me that I knew would soon erupt. I felt like I had been run over by a truck—flattened and broken. But I was alive; I could see and feel that much.
 
Finally I had to get up and leave the office because another therapist had reserved the next time slot. I went downstairs to the intern room. June, an intern in her sixties, was there doing paperwork. She read the destruction on my face immediately. "Are you okay?" she asked softly. I exploded into tears, and she wheeled her chair toward me and hugged me. I cried on her shoulder like a child who had just been beat up by a bully, crying to her mother.
 
"What's happening? What's going on?" Her eyebrows lowered, and her tone remained soft and calm, but concerned. June already knew about Sam, and had heard me process my sessions with him in group supervision, so she wasn't surprised when I told her everything that happened in the session, including what Sam said and all my responses to him.
 
"You said that? You said those things?" June perked up.
 
"Yes," I said, expecting criticism. But instead a smile broke across her face.
 
"It sounds like you did the right thing."
 
"I did?" I said, coming out of my sniffles, feeling somewhat pessimistic but more hopeful.
 
"Yeah, I don't know what I would have said . . . I mean, what else could you have said?"
 
"I don't know, but . . ." I trailed off, not knowing the end of my thought.
 
"Seriously," she repeated, "what else could you have done?"
 
I wanted to give her an answer that provided hard evidence against me: an analysis of the conversation that showed where I'd messed up and what I could have said and done differently that would have left Sam, and me, in a better place. I wanted to prove to her that I was not the right woman for the job.
 
"Not be his therapist?" I finally responded, hearing the desperation and uncertainty of my words, and realizing for the first time that I could not stay in this place any longer—needing other people to show me the way, trying to find a way out, and wanting to be someone else.
 
June laughed, threw up her arms and gave me another hug. "You'll be okay," she said. I began to laugh with her, because she was right: I was okay. In that session with Sam, I hadn't tried to escape. I'd stayed with myself, as scary as it was, and it hadn't destroyed me.
 

Truths Revealed

Something shifted in me after that. I felt like I'd won a battle, and I was proud of myself. I was tired of the fear and the self-criticism. I began to see the fruits of my labor with my other clients as they all made progress in their therapy, and I realized that I could be and was a good therapist. I began to see that “being a good therapist was not about being a punching bag or taking on my clients' pain, but about making my clients responsible for their feelings and behaviors.” I was not there to save anyone; I was there to help people help themselves, and even then, only if they would let me.
 
Something changed in Sam, as well. The next week when he came in for his session, he kept his head turned down and looked up at me with wide eyes, half smiling, searching my face again for something, but this time it was approval.
 
"Hey, I'm sorry for the way I acted last week," he said. "I guess I was pretty mean, huh."
 
"Thanks for your apology. I think last week was a challenge for both of us." I paused at this and he continued to look at me with wide eyes, now a little nervous. So I continued, "I have to be honest with you—you have definitely been a challenge for me to work with. I've spent a lot of time thinking about our sessions, and received a lot of guidance from my supervisor, and I think I've done the best I can."
 
"I think so, too . . . but the thing is . . ." I could see Sam searching for his words carefully as his eyes didn't move from one spot on the wall, "I guess I just can't trust you."
 
"Because of my age, level of experience, and stuff?" I replied easily, now feeling confident and relaxed.
 
"Yeah. To me, you're just not who my therapist is supposed to be."
 
"If that's the case, why do you keep coming back to see me?"
 
Sam paused at this and looked at the floor, rubbing the back of his head with his hand. "I don't know. I guess I didn't think I had a choice."
 
"You do have a choice, Sam."
 
"What is it? What's my choice?"
 
"You can continue to see me at this agency, or you can find a different therapist at a different agency."
 
"Like where?"
 
"If you decide that's what you want, I can give you some resources."
 
"Can you call them for me? Or can we call them together?" His leg shook as he spoke.
 
"No, you'll need to set it up yourself. I can't do the work for you."
 
At this he seemed satisfied. He made the decision to find a different therapist, and I followed through on giving him some resources. I realized that, had I been more seasoned and further along in my career as a therapist, things might have turned out differently. Perhaps I would have questioned his assumptions of who his therapist was "supposed to" be, and urged him to stick through it with me. But “as a new therapist, I looked truthfully at my limitations with a dose of self-empathy.” I also relished the huge wave of relief that washed over me after Sam made his decision. And so I felt satisfied with his decision, as well. I was helping him take responsibility for his care, as well as his feelings.
 
Within just a couple of weeks, Sam set up his therapy at an agency that specialized in trauma work. Despite the fact that he had already completed his intake and was about to start seeing a therapist weekly, he told me he wanted to continue our sessions, as well. I told him this wasn't going to be possible, since it is counter-productive to see two individual therapists at the same time. I was also curious about his desire to continue to see me, after all that he had said about me not being able to help him. So I asked him about it:
 
"Sam, why would you want to continue therapy with me since you say you can't trust me, and you have another therapist that you think you will be able to trust more?"
 
"Well . . ." he said, "you have been helpful in some ways."
 
"In what ways?"
 
"Well, like I learned how to be able to notice what happens to me before I have a panic attack, so I can stop them from happening…"
 
I nodded.
 
"And I learned how to talk to my boyfriend when I'm upset instead of letting it build up into an explosion." He looked at me matter-of-factly, like it was not new information, and not strange or surprising for me to hear that I had, in fact, helped him.
 
A part of me was tempted to bring this contradiction to his attention and say something like, "So, who's the inadequate therapist, now?" But I held my tongue. I didn't need to prove myself to him or any other client any longer.
 
Instead I smiled and said, "I'm glad I could help."
 

After the Crash, Moving Forward

“My six-month therapy with Sam, as difficult and painful as it was at times, turned out to be a crash course on becoming a therapist.” It taught me profound lessons about what my role as the therapist was, and how to sit with some of the most difficult material and still hold onto myself.
 
A year later, I saw how I had grown as a therapist from this experience. During a clinical internship in the counseling department of a Bay Area high school, I met with a student, Linda, who was in the acute phase of post-traumatic stress disorder. A few months prior, Linda had been kidnapped and raped on her way home from school. I passionately wanted to help Linda and my heart brimmed with empathy.
 
However, like Sam, Linda rejected my empathy. When I asked her questions, any questions, she would immediately tear and tense up.
 
"Please don't ask me about what happened. Please don't make me talk about it," she sobbed and quivered. Her body folded in on itself as she brought her knees and arms to her chest in the small plastic chair. I immediately thought of Sam.
 
"No one is going to make you talk about it. You can talk about whatever you want."
 
These words, and any other words from me, didn't calm her. In fact, it was clear that, from week to week, her anxiety in my office was getting worse. One week, her fear turned to anger:
 
"You're making me come here and talk to you, and I hate it! I don't want to talk to you! Stop making me talk to you!" Her body shook with fear and her eyes pierced me. I felt her anger come toward me, but I also recognized the fear that encased her body, so I didn't absorb the blame from her accusations.
 
"Linda, no one is making you do anything. You don't have to come to these meetings. It's your choice. I know you are very scared right now and I want to help you."
 
Linda continued to sob, and then, with her eyes to the floor, said in a very soft voice, "I don't want to come here anymore."
 
Linda was not ready to face the horrible demons terrorizing her. I didn't blame myself for this, nor did I take her demons on for her. I refused to cooperate with Linda's projection of me as the bad guy and helped empower her to take responsibility for what she was feeling.
 
I also knew how badly she needed help. So I asked her for one final request: could I speak to her and her mother together? Linda agreed, and I set up a meeting. Her mother poured her heart out to me about how sad she felt for her daughter, and the two of them cried and held each other together in my office. I explained to them both the symptoms and ramifications of PTSD. While Linda's eyes shifted around the room as if her mind was somewhere else, her mother listened closely to my urge to get her daughter help.
 
I left it up to Linda to contact me if she wanted to see me again, with or without her mother. I knew this would be the only way she would feel an ounce of safety in my office. However, I never heard from her again. “This time I knew that even the most skilled therapist in the world can't help someone if they don't want to be helped.” And I felt peace of mind knowing that I did all I could do: reach a safe, confident and competent hand out to Linda.
 

The Hard Way

Nothing I learned in any of my graduate classes could have prepared me for the emotional experience of being a new therapist. As they say, it is one of those things a person has to learn the hard way. Many of the difficult emotions I felt were due to a complex combination of my clients' and my own personal experiences in the world. But the self-doubt and fear were universal and part of the first developmental phase of becoming a therapist. True confidence comes with time and experience, and will only come when we dare to test ourselves and allow our clients to move us in profound ways.
 
*All names and identifying information of the clients and psychotherapists have been changed to protect confidentiality.