Two years ago, I released a song called Imposters, which explored my feeling of not belonging, especially in relationships. Fast forward to today, and I find myself still wrestling with the same theme. However, my perspective has evolved. I am no longer speaking just as a musician, but also as a therapist, a writer, and a human being actively living through this experience.
Category: Clinical Efficacy
Moving Beyond ‘How Do You Feel’ in Therapy to Release Client’s Pain
“My granddaughter wants to spend Christmas with her other grandma.” Doris looked out the window while slowly chewing on a piece of gum. “She’d rather be with Fun Grandma,” she huffed as though trying to imitate laughter.
Armed with good intentions and extensive training in cognitive-behavioral therapy, I had been a therapist for just a few months. Doris told me during our first session that she hadn’t been truly happy since her divorce 20 years earlier, and she had spent every subsequent session describing how unimportant she felt to her children and grandchildren.
“And these are supposed to be the golden years,” she continued. I felt the need to change the direction of the session and asked if she had researched local meet-up groups, something we had discussed the week before. “I had trouble getting on the internet,” she said.
Doris, I believed, needed to take action if she was going to feel better, and I believed it was my mission to motivate her to take that first step.
“It’s just that I know you’re happiest when you’re with people,” I said, “and I think one of these groups could be part of the answer.”
“I don’t think I’m very approachable anyway.”
“Why do you say that?”
“I have an uninviting face.”
“I don’t think there’s anything uninviting about your face.”
“You’re very kind.”
“I’m serious. Has anyone ever told you that?”
“They don’t have to say it. I can tell.”
Moving Beyond ‘How Do You Feel’ in Therapy
I proceeded to initiate a detailed discussion about her face. I badly wanted to lead her out of her misery and to help her to evaluate her thoughts (helping her to recognize that her face was really not so uninviting and that others were probably not judging her as harshly as she imagined) seemed like the best path to take.
That intervention, like the others I had tried, proved to be ineffective, although I kept at it for the remainder of the session. Imagine Winnie the Pooh trying to cheer up Eeyore, Pooh making one reasonable point after another while Eeyore just keeps making excuses, the conversation finally ending when Eeyore realizes he has again lost his tail.
Later that week I discussed the session with Ari, my clinical supervisor. “I’m trying so hard,” I told him, “And I feel like she’s not doing her part. She’ll ask me what she should do to feel better, but when I offer an idea, she always has an excuse.”
Ari inhaled deeply as though attempting to fully absorb what I had said. “Sometimes,” he finally said, “our clients tell us they want one thing, but deep inside they’re pulling for us to do something else. When she made that comment about her face being uninviting, I think she was trying to tell you something important about herself.”
“I get that she’s unhappy.”
“There’s a depth to her pain. I wonder if she needs you to really understand that.”
“I think I do understand that.”
“You understand her suffering on a cognitive level, but I wonder if she needs more. I wonder if she needs you to understand it on a deeper, visceral level. What’s often most helpful to our patients is the experience of being truly understood.”
The truth of his words stung. I thought back to my own times of distress and how others had often told me to cheer up and look on the bright side. Rather than cheering me up, those exhortations usually made me feel like a burden. They made me feel that my distress was intolerable and that, as long as it remained, I too would be intolerable.
I now saw that, by being the Pooh Bear to Doris’ Eeyore, I had inadvertently given her the exact same message. “She must feel so alone,” I said to Ari. “She tells me that her children are always telling her to stop being so negative. And now I’m doing the same thing.” When I next saw Doris, I asked more questions and tried to more fully understand her. When she again complained that her granddaughter didn’t want to spend Christmas with her, instead of inquiring into what exactly the girl had said, I said, “Help me to understand what that feels like, being rejected like that.” As soon as those words left my mouth, I feared that I had set something dangerous into motion, as though I had given Doris permission to step into a black hole from which she would not be able to escape.
But she did not step into a black hole. What she did instead was describe what it felt like to be a nuisance to her granddaughter, and she then shared how she had felt like a nuisance to people most of her life. She continued to open up and share more associations. While our previous sessions had started to feel like repetitions, I was now learning new things about her.
Our sessions over the next several months were too complicated for me to summarize here, but I will say that exploring her most painful emotions proved essential to the gains we made. I would later discover that Doris had developed an attachment to certain aspects of her pain that would require additional interventions. However, before these interventions had any chance of succeeding, Doris first needed to feel understood.
Questions for Thought and Discussion
- How do you resonate with the author in recounting the work with Doris?
- Can you think of one of your clients who struggles in similar ways to Doris?
- How might you have intervened differently with Doris?
Teaching Clients Active Listening Skills to Improve their Relationships
One of the most common questions I am asked when people learn that I am a therapist is, “How can you listen to all those people?” What prompts that question is a fundamental misunderstanding of what it actually means to listen to another person. In my work, I strive to make my patients better listeners, not just better at self-expression.
It is imperative that we challenge the assumptions people make about what it means to listen. Truly listening to another person so that they feel heard improves the quality of conversation and enhances the opportunity for understanding. It does not guarantee agreement, nor does it necessarily entail problem solving or changing anyone’s mind. Unfortunately, it seems that these days, people are far more interested in talking than listening, even if no one is listening to them.
As one patient said to me, “Once we stopped caring about facts, I was at a loss about what to say. Why bother to listen if the loudest person in the room always wins?” This can lead to what feels like a forced choice between joining the argument or leaving the conversation. Given the cacophony of disinformation and vitriol infecting our lives, strong listening skills are more critical than ever if we want to strengthen our connections.
It takes effort to be a good listener, but with practice the results can be truly life changing. Learning how is a teachable skill and foundational to good mental and physical health. There are five foundational components of active listening.
Five Foundational Components of Active Listening
First, an active listener must have a genuine interest in the other person, a curiosity to hear what they have to say. Too often we think we know what the other person will say before they speak, so we spend our time preparing our comeback rather than listening to what the speaker says. Or we write people off as soon as we learn one thing we don’t like about them, and refuse to listen to anything else they have to say. Consequently, our world gets smaller, and we have less intimacy.
Feeling trapped in this dynamic is a common complaint about familial interactions. For example, one patient shared, “Before I’ve even taken off my coat, my father will tell me that I must be so happy with my job. It’s because he is happy that I went into law like him. I brace myself before I get there for his greeting.” After many failed attempts to have a more nuanced conversation, she no longer tries to dissuade him of his belief but is saddened by how superficial their relationship has become.
Second, active listeners understand that agreeing to listen does not assure agreement. This needs to be recognized by both the speaker and the listener. If my goal as a speaker is agreement, I must make that clear up front. When a patient tells me about a fight they had with their spouse, I use my words to express understanding of their hurt feelings, not to say they were right and their spouse was wrong. Whenever we frame a conversation as having a winner and a loser, the quality of the relationship suffers.
Third, active listening is actually hearing what the speaker has to say and trying to understand their needs. Too often people attempt to show they are listening by trying to solve a problem. This often feels patronizing and may devolve into an argument. For example, a patient of mine reports, “When I come home from a bad day at work, all I want is for my wife to listen, not tell me what I could do differently. Tomorrow, when I am rested and have some distance from the situation, I might be ready to listen to suggestions for how to do things differently, but at that moment I just want understanding. Is that too much to ask?”
One strategy that can be helpful in these situations is for the listener to ask, “Do you want to be hugged, heard, or helped?” By clarifying the unstated need of the speaker, the listener knows the desired outcome for the interaction and what will feel like effective listening to the speaker.
Fourth, active listening involves acknowledging feelings as well as facts, without conflating the two. There is a truism in psychology that anxious people can’t listen, to which I might add, neither can enraged people. Communicating that I understand the depth of a person’s emotional state is a necessary precursor to understanding what has upset them so much.
Recently, a patient called to share that she’d been diagnosed with breast cancer. Before I asked her the stage of her cancer or what her treatment protocol would be, we discussed how she felt hearing that she has cancer. Asking about her feelings was essential to providing care for her. Later we would brainstorm how she could get the best medical care possible, but until she felt heard she couldn’t process the onslaught of medical information her physicians were sharing with her.
Finally, active listening requires listening to ourselves as well as others. By setting a time limit or voicing discomfort if someone is using offensive language or yelling, allows us to take care of ourselves as listeners and increases the likelihood we will be willing and able to engage in active listening. When being a better listener, we will hopefully find ourselves in more meaningful conversations that will enrich our lives.
***
Active listening can make us feel vulnerable. Sometimes the divide is too great and ending the conversation or ultimately the relationship is the right decision. But, hopefully, more often our efforts to listen will increase our understanding of one another and bring us closer. In our fragile world we need to honor the power of listening.
Questions for Thought and Discussion
How important is it for you to “teach” your clients to listen effectively?
Which of the author’s five components of active listening is most resonant with you?
Can you think of one of your clients who would benefit from improved active listening skills?
When to Use Unexpected Techniques with Emotionally Overwhelmed Adults
“Name it to tame it” has become a popular phrase among parents and those working with children. It denotes the principle that we can help emotionally overwhelmed children feel better by helping them put their feelings into words. Daniel Siegel provides an example of this principle. Bella, a nine-year-old girl, watched the toilet overflow after flushing it, “and the experience of watching the water rise and pour onto the floor left her unwilling (and practically unable) to flush the toilet afterward.” Her father later sat down with her and encouraged her to tell the story, allowing “her to tell as much of the story as she could,” and helping her “to fill in the details, including the lingering fear she had felt about flushing since that experience. After recalling the story several times, Bella’s tears lessened and eventually went away.” Putting these experiences into words, Siegel writes, “allows us to understand ourselves and our world by using both our left and right hemispheres together. To tell a story that makes sense, the left brain must put things in order, using words and logic. The right brain contributes to bodily sensations, raw emotions, and personal memories, so we can see the whole picture and communicate our experience.”
Putting Theory into Action in Therapy
I repeatedly experienced the power of this principle during the six years I worked with children in an elementary school. After I transitioned to working with adults, I would sometimes forget the principle. I can remember a session with Mary, a 55-year-old woman who could not bring herself to leave Harlan, her emotionally abusive husband of 30 years. She had entered therapy to find the resolve to leave, something her friends and even her grown children had long encouraged her to do. I spent the better part of the session encouraging Mary to give voice to that part of her that wanted change. She followed my lead and asserted her rights and needs. After speaking with passion for several minutes, she suddenly stopped talking and looked off into space. “I know everyone thinks I should leave Harlan, and I know their hearts are in the right place.” Her eyes fell to the ground, all the energy that had animated her just moments before now gone. “We were basically kids when we got together. We grew up together. There’s something about Harlan and me that others just don’t understand. There’s something that I just can’t put into words.” There was a heaviness to her words. She seemed to be saying, ‘Yes, on paper there are good reasons for leaving him, but these other reasons possess a power that ensures that things can never change.’ I had given Mary the space to share her story, but she was now telling me that part of her story could not be shared. She was suggesting that this part of her story, perhaps because of its ineffability, exerted a hold over her from which she could not escape. Consequently, she felt she could not move toward the goal that had motivated her to start therapy. As the session ended, her despair seemed contagious, and I too felt that she would never be able to articulate that part of her story. I thought about our session over the next week and couldn’t avoid feeling that I had failed her. Yes, I had empathized with her, and I think she felt that, but I had failed to give her hope. I shared my feelings with my own therapist, and she said something that reminded me of another popular principle among parents, one often described as, “the power of yet.” I hadn’t helped Mary put words to her feelings —yet! She and I would again talk about Harlan, and she would again say that there was something about their relationship that others didn’t understand, something she just couldn’t put into words. I would add that simple, powerful word. “There’s something you can’t put into words—yet.” Not unlike a parent, my job as a therapist is to sometimes help others find words for their experiences. Helping them find their words is not the answer to every problem, and indeed words cannot fully and adequately describe the depth of many important experiences. Yet. Helping clients put words to their most difficult experiences can be profoundly helpful. Mary could not describe a crucial part of her relationship with Harlan—yet. My work was to help her find those words. I thought back to my clinical supervisor’s statement that, when his clients struggled to describe their inner experience, he would ask if an image or even a color came to mind. The goal was not for them to provide a precise, granular description of their feelings at first, but to try to take steps in that direction, little by little, one word at a time. I now had hope, and I knew I would be able to share my hope with Mary. It might take time to get there, but with my encouragement, she would vocalize that aspect of her relationship that had never before been vocalized. And when she did so, she would feel less isolated and more empowered. I did not know what she would feel empowered to do, and neither did she. Yet. Questions for Thought and Discussion In what ways does the author’s message resonate with you? Not resonate with you? Based on the readings, do you agree that the author initially “failed” with Mary? How might you have addressed Mary’s decision to remain with Harlan?Legendary Psychotherapists Share Their Secrets to Longevity
The Pioneers of Psychotherapy Lived Long, Productive Lives
Several years ago, I authored three books and a string of articles featuring contributions and interviews with some of the greatest therapists in the world. At the time, I searched for commonalities that might be relevant. Recently, I revisited those commonalities and noticed one factor, seemingly unrelated to the psychotherapeutic process, that stood out: advanced longevity. This subject seems to be of increasing interest today.
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By examining the experts featured in my books and articles, and adding a few more world-class therapists to the mix, I reached a striking conclusion. Simply put, many of these professionals enjoyed or continue to enjoy extremely long and productive lives. Here are some examples:
- Albert Ellis lived to be 93 and completed his interview with me at age 89.
- The father of CBT, Aaron T. Beck, made it to 100.
- Muriel James, who penned the transactional analysis and gestalt classic Born to Win, lived to 101. For context, only 0.027% of Americans reach 100. Muriel was 86 at the time of our interview.
- Ray Corsini, editor of Current Psychotherapies and one of the top psychologists of the last 150 years, was 94 when he passed away.
- Suicide and thanatology expert Ed Schneidman lived to 91. Did you know Edwin Shneidman coined the term “suicidology”?
- Career counseling guru Richard Nelson Bolles, author of What Color is Your Parachute? the best-selling career choice book of all time, lived to 90.
- William Glasser, the father of reality therapy with choice theory, died at 89.
- Viktor Frankl, the creator of logotherapy and a Holocaust survivor, lived to 92.
- Robert Firestone, the father of voice therapy, was 94 and still active as I wrote this blog, but sadly passed away prior to its publication.
- Irvin Yalom, an expert in group therapy, humanistic therapy, and death and dying, is 93.
The Masters Share their Secrets to Longevity
If this phenomenon is the norm, what is responsible? Just what constitutes the magic bullet? Is helping others beneficial for the helper? Is listening and empathy advantageous to human physiology? Is it frequent sitting? (Certainly not according to any expert I have ever heard!) Is it getting up from the therapy chair, simulating an air-squat repetition performed at the beginning and end of each 50-minute hour fountain of youth? Have therapists stumbled onto their own brand of interval training? Could the benefits come from the intellectual stimulation from thinking and analyzing client behaviors?
When I asked Ellis about his secret to remarkable longevity, I jokingly asked if he had the water at his institute spiked with vitamin E or something. I inquired if he was into herbs or cranking out crunches while his clients shared their tales of woe. Was it the REBT thinking that kept him youthful?
Ellis shared that he had good heredity. His mother and her whole family lived into their nineties. His dad lived until age 80 and was one of the earliest to die in his family. Ellis insisted he didn’t use anything special, just worked on his emotional problems and avoided upsetting himself about things. He added that learning new things, helping people, and engaging with music kept him going.
But could the secret lie outside the therapy sessions? Or to put it a different way, could the answer be found in what therapists do when they are not actively engaged in the practice of psychotherapy or after the point in their career where they are no longer seeing clients?
Consider my exchange with Muriel James a while after our interview; when I inquired about whether she was still doing individual and group therapy, she told me she had branched out.
“What do you mean, branched out?” I asked.
She explained that she would get up early surrounded by a cup of java and about 50 history books. (Did she say 50 books? Yes, Howard, she said 50!)
She had discovered, at least at the time, that female history authors were discriminated against and therefore she was writing the texts using a male pseudonym. Talk about practicing what you preach. In my mind Muriel was using Born to Win self-therapy 2.0.
Yes, some luminaries in our field left us too soon, and for the 1000th time, correlation is not causation, but this phenomenon is certainly something to ponder. Just ask any therapist!
Questions for Reflection and Discussion
What are your impressions of the author’s connection between success and longevity?
How do you stay focused and sharp as you age in your clinical career?
Which one of these elder statespeople do you admire and why?
The Transformative Power of Empathy in Therapy
Therapy as a Place of Safety and Respite
Each person’s therapeutic process will be unique, as will their stories, experiences, and needs. With that in mind, the approach I take with each of my clients varies. I offer a bespoke approach, tailored to the individual needs of each client, built around their personality and presentation. But regardless of their differences and needs, I will always use, and deeply value softness.
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I have come to realise the immense importance of being gentle with my clients. Life, with all its challenges and hardships, can often leave individuals feeling battered, tired, and worn. Many of them seek therapy in a state of heightened vulnerability. It is during these moments that therapy becomes a sanctuary, one that offers them a soft place to land.
As a therapist, I believe deeply that it is my duty to create an environment of warmth, understanding, and compassion. I recognise that my clients may be carrying heavy burdens, and that it is my role to offer them temporary solace and respite from the outside world. I strive to be a gentle presence, providing a safe space where they can lower their defences and be truly seen and heard.
In this gentle space, I encourage my clients to explore their emotions at their own pace. I do not rush or push them to confront their pain before they are ready. Instead, I hold space for their vulnerability, allowing them to express themselves without judgment or criticism. I offer a listening ear, a compassionate heart, and a genuine desire to understand their experiences.
In moments of distress, I remind my clients that it is okay, and perhaps even necessary, to be gentle with themselves. I encourage self-compassion and self-care as essential tools for navigating life’s challenges. Together, we explore gentle practices such as mindfulness, relaxation techniques, and self-soothing strategies that can provide comfort and support during difficult times.
Being gentle in therapy also means recognising and respecting each client’s unique journey. I understand that what works for one person may not work for another. I adapt my therapeutic approach to meet the needs and preferences of my clients, honouring their autonomy and empowering them in their healing process.
Through gentle guidance and unconditional support, I aim to instil hope in my clients. Life may be hard, but therapy can be a refuge amidst the storm. It is a place where they can find solace, gain clarity, and develop the strength to face their challenges with resilience and grace.
In the gentle space of therapy, I strive to be a source of comfort and empowerment for my clients. I believe in their inherent worth and their capacity for growth and healing. By offering them a soft place to land, I hope to help them navigate life’s complexities with kindness, understanding, and a renewed sense of hope.
As a therapist, I am privileged to witness the incredible resilience and strength of the human spirit. Every day, I can guide individuals on their unique journey towards healing and self-discovery. One such client who stands out in my mind is a past client, Emily.
The Use of Compassion and Kindness in Therapy
When Emily first entered my office, I could sense the weight she carried on her shoulders. Her eyes held a mixture of pain, fear, longing for relief, and a need to understand and be understood. It was clear that she had been through significant hardships and was in desperate need of support.With empathy as my compass, I created a safe and nonjudgmental space for Emily to explore her emotions and share her story. I listened intently, acknowledging the depth of her pain and validated her experiences. I understood that healing begins with feeling seen and heard, and I made it my priority to provide those for Emily. Emily’s hardships had clearly and profoundly taken their tolls—she was tired, mentally, emotionally, physically, and spiritually.
Through our sessions, I encouraged Emily to delve into her emotions and confront the underlying traumas that had shaped her life. It was not an easy process, as she had built walls of self-protection to shield herself from further pain. However, with gentle guidance, she was gradually willing and increasingly able to navigate through the layers of her past and unravel the patterns that held her back.
As our therapeutic relationship grew, Emily began to trust me and felt safe enough to peel back the layers of her vulnerability. She shared her deepest fears, insecurities, and darkest moments with me. In those moments, I realized the immense responsibility I held as her therapist, and I vowed to hold space for her pain and support her in her journey towards healing. There were moments when Emily faced overwhelming emotions that threatened to consume her. She felt lost, as if she would never find her way out of the darkness. In those moments, I provided a steady presence, a beacon of hope, reminding her that healing takes time and that she was not alone in her struggles.
Together, we explored various therapeutic techniques and coping strategies that would help Emily regain control over her life. We worked on building her resilience, nurturing self-compassion, and cultivating healthier ways of relating to herself and others. It was a collaborative process, and I marvelled at Emily’s courage and determination to confront her pain and grow from it. Over time, her wounds began to heal, and I witnessed her transformation into a resilient and empowered individual. She reclaimed her sense of self-worth and discovered her true potential.
***
Emily’s story serves as a reminder to me of the transformative power of therapy. It reaffirms my belief that every individual has the capacity to heal and grow, given the right support and guidance. As a therapist, I am honoured to walk alongside my clients, witnessing their strength and resilience as they navigate their path towards self-discovery and emotional well-being.
Questions for Thought and Discussion
In what ways is the author's orientation to therapy similar to your own?
How do you assure that therapy will be a place of safety for your clients?
How do you address situations where clients enter therapy feeling very unsafe?
Honesty, Not Empathy, is the Greatest Gift a Clinician Can Offer
Despite spending years in my own therapy, attending graduate school, receiving excellent supervision, and working as a therapist for the past couple of years, I am still in the process of discovering what exactly people find so healing about therapy. Is it the experience of empathy and unconditional positive regard? Perhaps it’s the space to express repressed thoughts and emotions? Then again, some people say it’s the reparative attachment relationship. Others feel that it’s the wisdom and insight of the therapist that’s paramount.
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In my previous post, I shared my belief that clients heal most when they can express themselves fully without fear of judgment and retaliation. So, when a friend expressed that her most pivotal moment in therapy occurred when her therapist expressed helplessness and despair, I was intrigued. Didn’t she want her therapist to be strong and confident? How could my friend feel safe to be herself if her therapist was so reactive? To me, this sounded like an unethical experience of countertransference. I needed to understand more.
Countertransference or Therapeutic Transparency
Ella (not her real name) had been questioning her therapist’s care and commitment relentlessly. Despite many conversations and ongoing reassurance, Ella continued to doubt that her therapist had her best interest in mind. While she repeatedly challenged and tested her therapist, they would continue to show up unconditionally without judgment.
Her therapist helped Ella to check the facts, reflected on the possibility of transference, and continued to offer a reparative attachment relationship. Ella knew that her emotions were irrational. She would lash out and her therapist would not retaliate. What more proof did she need that her therapist was not going anywhere?
About a year and a half into their course of therapy, Ella’s therapist informed her that she would be taking two weeks off for a vacation. Ella expressed fear and worry and accused her therapist of abandoning her. Her therapist listened to her nondefensively, validated her experience, and helped her cope forward.
Ella worked through object constancy and knew intellectually that her intense emotions were a reenactment from her childhood. While her therapist was away, she used every strategy from self-compassion and acceptance skills to reframing her thoughts. She engaged in distress tolerance skills and tried to keep herself busy. She reminded herself repeatedly that a temporary break does not mean the relationship is over. But her emotions got the better of her and she texted her therapist with a suicide threat. Luckily, despite being on vacation, her therapist noticed the text. She contacted Ella’s emergency contact who was thankfully able to deescalate the situation.
Upon her therapist’s return, Ella and her therapist met for a session. As soon as Ella walked into the room, her therapist burst into sobs. Through her tears, she shared that she was overwhelmed and unsure if she could help Ella, who was expecting therapy to save her from herself. Although she had wished to help Ella, the burden was too much for the therapist to bear.
After hearing this story, I was perplexed. How could Ella have found this experience to be so therapeutic? I thought the therapist had been way too honest about her feelings. She sounded judgmental, hurtful, and perhaps even a bit self-centered. What right did she have to hijack the session with her own fears? I would’ve been devastated if my therapist were to react this way.
Ella, however, was relieved. She had experienced the tears as a piercing jolt of reality that cut straight through her debilitating insecurities. She had been unable to synthesize her rational thoughts with her internal emotional experience. While she “knew” rationally that her therapist cared about her wellbeing, she had never been able to “feel” it. She could not get herself out of the insidious loop of doubting and testing. She had been heading towards a self-fulfilling prophecy and the reaction of her therapist stopped her in her tracks.
After this incident, Ella’s behavior shifted dramatically. She and her therapist had a meaningful repair and they continued to work together for another couple of years. She shares that although she continued to struggle with doubts, both in and out of therapy, she learned to accept her intense emotions while also choosing more effective ways to navigate them.
***
I’ve learned a lot from Ella’s story. Sometimes the most powerful tool that we have as therapists is simply our own feelings. We can be the first person to be brave and honest enough to reflect on their impact. Others may have responded with anger and accusations towards them but that’s not the same as honesty. That’s defensive and retaliatory. I’m suggesting that sometimes, what a client needs is a chance to see themselves in a mirror. And when we are certain that we have built enough safety in our relationship with them, I think being vulnerable and honest enough to share our feelings may be the biggest gift we can give them.
Questions for Reflection and Discussion
Do you agree or disagree with the notion that honesty is more important in therapy than empathy?
What are your limits of expressing your feelings with a client?
How did you address a challenging situation in therapy around expressing your feelings?
The Secret to Forming Powerful Relationships that Spark Change
The very best paper on how psychotherapy works was also one of the earliest (written in 1936) – Saul Rosenzweig’s “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” It made the bold prediction that the psychotherapy relationship is much more powerful than specific psychotherapy techniques in promoting change. Hundreds of studies comparing different forms of psychotherapy (mostly done during the last forty years) confirm Rosenzweig’s brilliant intuition. Although a given specific technique may occasionally score a small win over another specific technique, the overwhelming number of randomized clinical comparisons result in tie scores. It’s remarkable how little this robust finding from psychotherapy research has impacted on psychotherapy training and practice. Most training programs focus on teaching just one narrow- gauge technique and their graduate practitioners tend to identify themselves for life by the school of therapy in which they trained. Paradoxically, then, most psychotherapy training pays least attention to what matters most in clinic practice — forming a powerful healing relationship with the patient. And psychotherapy training also often ignores the most important practical issues that help determine the nature of that relationship. If and when should a therapist give advice? What if any is the place of humor in therapy? Is it OK ever to self-disclose? What kind of contact makes sense outside of sessions and after treatment ends? We will briefly touch on these issues.
Forming A Relationship
The first session with any new patient is by far the most important — if it doesn’t get off to a good start toward a strong relationship, there may not even be a second session. And first impressions do have a very strong impact on the later ones. The patient will always regard the first meeting with a therapist as an important life event and it is important that the therapist never treat it as routine. I loved first meetings — the chance to be helpful; getting to see the world through another person’s eyes; the excitement of a new relationship; the challenge to my empathic and relating skills. Getting information is, of course, an important goal of every first visit, but getting the patient’s attention and confidence is even more important. The patient must leave the session feeling understood, that you care, and that you know what you are doing; Diagnosis and psychoeducation are part of establishing an empathic relationship. It is a great relief for patients to learn that their previously puzzling symptoms fall into a well-recognized pattern, with a fairly predictable course and well recognized, effective treatments. They are not uniquely damned; not hopeless, not alone. Treatment plans are negotiated between patient and therapist — never delivered from on high. Options are offered with an explanation of the pros and cons of each- and the patients get to choose what best fits their goals, needs, and resources. Decisions made early can always be revised as more is learned and the relationship deepens. The patient should leave the first session much more hopeful than before they arrived. This must be based on realistic hope encouraged by the developing new relationship and a sense that presenting problems have been understood and are manageable. But note; there is no room at all for phony reassurance or underestimating the work that must be done. I would often end a first session saying something like: “if you really put your heart into this, and I put my experience, I think that together we can accomplish a lot.”Is It Ever OK Ever to Give Advice?
Many training programs, and their graduates, teach and preach against ever giving patients advice. This is based on the theory that advice always reduces patients’ autonomy and ability to figure things out on their own. In support of this view is the ancient Chinese proverb, “If you give a man a fish, you feed him for a day. If you teach a man how to fish, you feed him for a lifetime.” This is sometimes good advice, especially for very healthy patients — but never say never. For contrast, my commonsense rule of thumb is to titrate advice — the more advice the patient needs, the more advice you should give. This applies especially to patients with more severe psychological problems who sometimes lack the judgment to make good decisions on their own and often don’t have other people to turn to for help. Trainers and therapists who preach most vociferously against offering advice must treat only the healthiest of patients.When Is Self-Disclosure OK?
Many training programs also preach against therapists ever telling patients anything about their feelings, lives, or experiences. This is partly based on the notion that therapists should be a “blank screen”, partly on the fear that therapist self-disclosure may be self-servingly exploitive and impede patient progress. I agree up to a point, but less dogmatically and categorically. Therapist self-disclosure is indeed rarely necessary, carries risks, and should be reserved for special situations and specific purposes. But again, this is another case of “never say never.” With grieving patients, I’ve often revealed what my own feelings were on the loss of a loved one — as an expression of empathy and indication that exquisitely painful loss is an inevitable and normal part of our shared human condition. I have also on occasion shared work, child rearing, and marital experiences as a way of role modeling methods of dealing with life situations that have worked for me and might work for the.patient. Self-disclosure must be rare and to the point lest it lose impact and risk being done more for the therapist’s benefit than for the patient’s. I have occasional seen self-disclosure become a boundary violation in itself and on three occasions it evolved into therapists committing even worse Boundary violations. So, handle with care!Can Therapists and Patients Share a Laugh?
Some, apparently humorless therapists claim that humor has no role in therapy — that, in one way or another, the joke is always at the patient’s expense or a distraction from real therapy. This attitude strikes me as being sad for the therapists who hold it and harmful to the patients who are subjected to their prim austerity. Charlie Chaplin said it best: “Life is a tragedy when seen in close-up, but a comedy in long-shot.” Seeing life in a longer shot is an essential part of any good therapy — and shared humor is an essential part of gradually gaining greater perspective. Rarely will shared humor take the form of telling a predigested joke; almost always the wisdom of humor comes from seeing the comedic in everyday situations. This is not to ignore that the patient is also suffering, but rather to achieve respite, distraction, and distance. A piece of advice I give to almost every patient is to find more good minutes into every day — and recapturing the ability to smile or laugh is a great step toward more good minutes and better days. Psychotherapy, like life, is a very serious thing, but both can be much brighter if leavened with a tincture of humor and the benefit of comic distance. Evolution surely built in the universal human capacity for fun because it has tremendous survival value. All work and no play makes therapy very dull for both patient and therapist.What’s Appropriate on Social Media?
Here I am very strict; perhaps hypocritically so. I don’t think therapists should display their personal lives on any form of social media. Unlike occasional and specific self-disclosure during sessions that is directed to the patient’s specific needs at that moment, social media self-disclosure is generic; self-not-patient centered; and has many risks with no benefit. My hypocrisy: I do often express my fear and loathing of Trump on Twitter and even wrote a book about it. Here I felt my responsibility as a citizen trumped my role as a therapist. Others may disagree with this choice — I don’t apologize for it but can’t argue against their view.When Is It OK to Have Contact Outside Sessions?
Some severely ill and/or suicidal patients definitely need out of session contact — either by phone or (I think preferably) by text. Behavior therapists routinely do sessions out of sessions- accompanying phobic patients when they are beginning to enter previously forbidden territory or situations. And I had a psychoanalyst friend who combined his usual quite traditional practice with doing runs with more seriously ill and demoralized patients who needed behavioral activation. All in all, though, I strongly discourage out of session contact except in special circumstances like these or to help patients experiencing emergencies.Is Contact OK After Treatment Ends?
I think any close nonprofessional contact after therapy ends is a bad idea and should always be off the table no matter how much therapist and patient like each other. It is just too subject to exploitation and the possibility it could ever happen is too likely to influence the therapy before it ends. In contrast, I do recommend having occasional email or text follow up exchanges with patients after therapy ends. My longest such contact has extended for 56 years since the end of our treatment — it consists of brief but mutually satisfying emails exchanged every few months. Follow-ups help me learn what works, and what doesn’t in therapy and are encouraging because most people do much better than I expected.***
As in all useful human relationships, therapy is a two-way street. We usually help our patients. They almost always help us become better people and expand our knowledge of human nature; ourselves; and how the world works. I loved the wonderful opportunity to do psychotherapy and am forever grateful to the patients who shared their lives with me. Questions for Thought and Discussion Which of the author’s points resonate most with you? Which of the author’s points are very different from your own, and why? What would be the top of your list of key elements of therapy?Creating a Safe Therapeutic Space for All Feelings
Yesterday, after a long silence, my client suddenly asked me, “did I offend you?”
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Where did that come from, I thought to myself. She had historically been so agreeable — almost too agreeable. I often wished she would occasionally say something offensive. I let these thoughts percolate as I considered how to proceed. I am trained to think twice before answering a question directly. Questions are fodder for the therapeutic process. I decided to delve deeper by responding with a few questions of my own. “How would you know if you did? What would it mean to you if I felt hurt? Have other people suggested that you’ve been offensive to them?”
A Therapist’s Secret Wish
I don’t let her know about my secret wish that she offer something offensive about me. Afterall, this was her process and I want to be careful not to project my feelings onto her, lest she become disagreeable to fulfill my aspirations for her instead of her own. That would defeat the entire purpose. Despite my success at navigating the conversation, my desire to be the recipient of a nasty comment did not abate. Perhaps I sound like a masochist who enjoys reveling in the psychological pain of being insulted. You might be thinking, is this a repetition compulsion? She should’ve gone to therapy to face her traumas not become a therapist to reenact them. Or maybe others would call me a martyr who sacrifices her own need for respect to keep her clients happy with her. She sounds Codependent. Is she in this for the right reasons? You might wonder.I definitely do not have a penchant for pain. When someone insults me, I do not like the way it feels. Despite my best efforts to hold them back, my eyes often fill with tears in response to even a minor slight. Like most humans, I protect myself valiantly when I feel judged or criticized. Were I, in actuality, to be a martyr for the sake of keeping my clients happy, it would actually be pretty devastating to hear negative feedback. It would mean they weren’t happy with me. Wouldn’t that defeat the entire purpose of the sacrifice?
Here’s the thing; I’m no masochist and I’m definitely not a martyr. However, I am invested in my clients. I believe that for my clients to heal, they need a space where they are free to say and be whatever and whoever they want — including offensive. I might be a sensitive person, however, when I’m in my therapist role, my feelings are only welcome if they are in service of the client. If they aren’t, I set them aside to work through later.
In my experience, clients don’t come to therapy to be rude or offensive, especially toward the therapist. They certainly don’t want to be perceived as an ingrate by someone whose job definition is to help them. They are often ashamed of their selfishness and deny it, not only in the therapy room, but in their lives. But here’s a little secret; if they leave part of themselves outside, then part of them won’t heal. For therapy to work, they need to give voice to all their thoughts and feelings, especially their most shameful ones.
As a therapist, it is my responsibility to make space for the repressed voices of my clients. Good therapy grants permission to express what, outside of therapy, might be labeled socially inappropriate. Lack of this permission can reinforce ineffective patterns of repressing feelings and increasing shame.
The therapeutic challenge comes when, in instances such as this one, my own feelings are at stake. It’s relatively simple to support a client when their complaints are about “other things.” However, when their pain might be related to me, even if I had no intention to hurt them and despite the feeling that they are nitpicking, I feel obligated to face the Herculean task of supporting them just the same. Indeed, this selfless endeavor may be the most important and impactful act of therapy. If I can respond to an insult with curiosity, receive negative feedback without defensiveness, and authentically validate the valid, then I am giving my clients full permission to shamelessly express themselves. I cannot think of a better way to convey unconditional acceptance. But don’t get me wrong, I’m not giving permission for people to act how they please. Actions need boundaries. However, in therapy, I believe that words don’t and that words shouldn’t, even if and when those words are offensive.
***
So, as I think again about yesterday, I hope I can find a way to convey this message, “no, dear client, you didn’t offend me, but I hope that one day you feel strong enough to take that risk. And when you do, I will not abandon or reject you. Instead, I will be honored that this vulnerable and precious part is finally brave enough to join us in session.”
Questions for Reflection and Discussion
In what ways is the therapist’s attitude in this essay similar or dissimilar from your own?
How do you address situations where your client offends you?
In what clinical circumstances might you NOT address a client’s offensive behavior?
How In-Person Sessions Create Space for Clients Unspeakable Truths
Many of us have not gone back to in-person sessions even though the Covid epidemic has passed. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on long business trips or had some other compelling reason that made them unable to come in person. But beginning in March 2020 my practice transformed — all phone (or in a few cases video) sessions. After two years of living in my “weekend” house, I sold my office in New York and accepted the fact that my practice was going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.
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Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.
John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.
A Revealing Therapeutic Interchange
[Therapist’s thoughts]: I am aware that Sharon’s crotch is in full view. She does this often when she is wearing a skirt. I am trying not to look at her crotch while she is talking to me, but I have the impression that she is not wearing underpants. I think to myself that perhaps she is just wearing dark underpants. I start to question myself. Am I really seeing her genitals? Yes, I am. How should I handle it? If I ignore her exposing herself to me, I will be doing what her mother did — acting as if she is not a female with genitals. On the other hand, I know that however I say it to her, she will be mortified and furious at me. In the past, I felt the mortification would be too much for her, but this time I feel this is much more directly sexual than her sitting this way in the past.
“Are you aware of how you're sitting?” I asked.
Sharon immediately put her knees together.
“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”
“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”
“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”
“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”
“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”
“You mean it doesn’t matter if your crotch is exposed or not?” I asked.
“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”
“You mean you feel like there’s nothing between your legs?”
“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”
“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”
“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”
“You didn’t offend me. But I think exposing yourself is a way of telling me something.”
“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”
“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”
“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”
“What about underpants?”
“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”
“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”
“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”
[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]
[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]
“You mean your mother was masturbating in front of you,” I said.
“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”
[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]
***
Sharon’s traumatic childhood experience would not have been unearthed if I was talking to her on the telephone or video (which is face-to-face). On the phone or on video, she would not have been able to engender in me the same confusion, self-doubt, anxiety, and denial that she experienced as a child; she would not have been able to communicate the unspeakable truth. Telephone sessions may be useful for many patients, but for those who enact rather than verbalize their early experiences, it is not optimal.
Questions for Thought and Discussion
What are your impressions about this author’s clinical approach with this client?
Might you have done or said something different under these circumstances?
How do you address uncomfortable situations like these in your practice?