Category: Therapeutic Issue

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

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

“Can I come over — 12:00pm?”

“?”

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

“I’m waiting,” it complains.

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

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

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

The Rhythmic Uncertainties of Therapy

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

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

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

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

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

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

The Dependency Dance

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

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

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

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

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

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

Early Mistakes in Psychotherapy

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

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

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

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

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

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

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

A Therapeutic Strategy Applied

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

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

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

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

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

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

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

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

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

The Second Conversation

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

Taking the Blame

Externalizing the Helpless Feeling

Triangulating Against the Helpless Feeling

Affirming that New Rules are for Next Time

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

Client: “- -”

Therapist: “You’re on mute.”

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

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

Client: “ – -”

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

Client: “Sorry, how about now?”

Therapist: “You’re good.”

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

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

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

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

Client: “Yeah, of course.”

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

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

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

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

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

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

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

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

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

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

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

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

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

and the second one:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

***

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

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