Tag Archives: Clients

Sharing Clients’ Pain

sunset_4In the recent weeks, I’ve had several experiences with clients which have challenged the capacities of both of us to face intensely painful feelings.  These experiences have led me to reflect on the interconnected nature of our lives with our clients’ lives even when we maintain clear professional boundaries.  I share my thoughts in the hope that they spark your personal reflections about this aspect of being a psychotherapist.

As a new therapist, I was thrilled that my clients shared themselves with me in ways that enabled me to enter their psychological and emotional world.  This gave me an experience of deep intimacy that I found fulfilling and that had been mostly lacking in my relational life to that point.  Over the years, I have shared my clients’ experiences of the vast array of emotions, interpersonal relationships, and existential dilemmas that come with being human.  I feel more touched at some times and by some clients than others, and most of the time I don’t carry the impact of my sessions outside the office.  I have well established professional boundaries and am practiced at maintaining a healthy separation between the personal and professional aspects of my life.

The recent experiences that have challenged my capacity to hold painful feelings have involved present day situations in which my clients have faced a significant health crisis with an uncertain outcome, deep disappointment and shame resulting from behaving in contradiction to their values, and a conflict between longstanding goals and the reality of living with the choices leading toward those goals.  Some of the factors that have led to the intensity of my emotions in sitting with these clients are the evolving and uncertain nature of the situations, the limited number of people with whom the client feels able to share their dilemma, and the sense that the decision they make will make a very big difference in the course of their lives.  I feel there is a lot at stake and that my clients are relying on me to witness and accompany them through the decision making process.  I hold a realistic view of my power and responsibility in these situations, not viewing myself as omnipotent or the only person in my clients’ lives but recognizing the authority and trust they are placing in me to walk beside them in these crises.

A challenge I have faced is that I am limited by my professional boundaries in sharing my painful experiences with others.  I can and have shared some aspects of these situations with my peer consultation group and have shared aspects of my own emotions with close, supportive friends.  While these interactions have been supportive and have lessened my feelings of burden and isolation, I am still ultimately alone in sessions with my clients hearing and feeling their pain with them, being reminded of my own experiences that are similar to theirs, and in the case of my client in a health crisis, anticipating the possible loss of someone toward whom I feel tremendously fond after more than a decade of working together as therapist and client.  I have reminded myself of my faith in and experience of a force that surrounds all living creatures with love, and this has been comforting.

If you are a therapist who shares some of my experience, I encourage you to reflect on the resources that support you as you sit alone with your clients and with the emotions that are stirred in both of you.

Limits of Interventions

sunset_2In my role as a teacher and supervisor for therapists in training, I often hear questions about how to choose interventions that are effective for particular presenting problems.  New therapists are often concerned about alleviating the distress of their clients and look for specific techniques to do so.  While there is value in learning specific techniques to reduce clients’ symptoms and distress, I have also become aware of the limits of these techniques in many of the life circumstances in which my clients find themselves.  This blog post will explore some of the capacities that enable us to be with our clients when technical interventions aren’t enough. 

Even when symptoms are reduced and clients are managing their lives productively, there are painful aspects of being human that remain.  A grandmother takes guardianship of her granddaughter due to her daughter’s addiction and mental illness, making decisions from week to week about how much contact is in her granddaughter’s best interest in light of the daughter’s changing symptom picture.  An older woman looks back on her life aware of the impact of her mental illness, coming to terms with what she was and wasn’t able to do compared with what she wanted to accomplish.  A man grieves the death of his wife of over 40 years and ponders the possibility of loving again.  These are circumstances that can’t be addressed by making an interpretation or teaching a mindfulness skill or suggesting a reframing of the situation.

When our clients bring these experiences into our offices, we can feel pressured to do something, to find a solution to the problem.  Sometimes that pressure comes from the client, but at least as often the pressure comes from within us.  The capacity to view ourselves and our motives with openness and honesty is crucial to insuring that we are responding therapeutically to our clients.  I have found that when I notice my reluctance to sit with the painful emotions my clients bring in, I can more easily refocus my attention on what the client needs.  More often than not when I say something like “that seems really hard” instead of suggesting a way to dampen the emotion, clients go more deeply into their experience or sometimes bring up their own way of putting the emotion into a context that is more comfortable or soothing to them.

Another capacity I have noticed as I grow in experience is humility about the limits of what I can and can’t do.  Earlier in my career I was more likely to look for change in the client as a way to bolster my sense of therapeutic effectiveness.  Paradoxically, as I have become more skilled I also recognize the difficulty of change, the complicated relationship between familiar patterns of behavior and identity, and the challenges that are inherent in our relationships with ourselves and others.  I am more humble about the influence I can have and more aware of the existential nature of some of my clients’ dilemmas.  Sitting as a witness and sharing the client’s experience to the best of my ability seems much more important than figuring out what I can do to bring about the change I might wish were possible.  Humility fosters my collaboration with my clients, conveying a respect for the complications of their lives and trust that they will find their way through these complications.

Last, I have become aware of the importance of expanding my capacity to hold intense emotions, especially those related to grief and loss.  For many of my clients, coming to terms with their life circumstances means experiencing the grief and loss of unrealized dreams, deep disappointments, and an awareness of the lasting impact of one’s own and others’ choices on our lives.  When I was a younger therapist, I looked at grief as a process that had a beginning, middle and end, and I believed it was possible to “get through” grief so that it would no longer have an impact on someone’s life.  I no longer believe this to be true, after sitting with my clients’ grief and my own.  Grief is a process that is ongoing and though it becomes less acute over time, it remains a part of one’s experience and life story.  It has been important for me to face my own grief directly in order to help my clients with theirs.

Given that much of what I’ve described here involves facing painful emotions and sitting with intense distress, the question “why would I want to do this?” may arise.  For me, the answer is that I feel privileged to talk about the things that matter, the relationships that are difficult but bring value to our lives, and the ways to find meaning in the existential dilemmas we face as humans.  I came into this profession as a way to understand myself and others more deeply and that is exactly what it has given me.  If the same is true for you, I hope you are reassured to know you are not alone in your journey.

Having Difficult Conversations with Clients

Mother and daughter having an argumentI have a client who has been 10-15 minutes late to every session since we started meeting three months ago.  My supervisor says I need to talk with her about this, but I’m afraid she might stop therapy if I confront her.  Is it possible to continue seeing her in therapy without talking about why she’s late?

I sometimes say to my supervisees and people I am training that as mental health practitioners we are in the business of having difficult conversations.  Growing into the role of clinician means developing skills to talk about issues and areas of conflict in a way that is different than usual social conversations.  I’ll discuss first some of the steps that can help us in having these conversations, then address the specific situation you describe.

Each of us comes into the clinical role with interpersonal skills that are familiar and comfortable, and these familiar strategies involve avoiding some type of discomfort.  As we work with different kinds of clients, we find that these interpersonal skills are helpful in some of the situations we face but not in others.  We also face situations with supervisors, peers, and colleagues that may challenge our familiar strategies for coping with conflict or distress.  When we can expand our repertoire of skills in managing these difficult conversations, we are capable of being effective in a broader range of clinical challenges.

In working toward greater interpersonal flexibility, it will be helpful to take some time to reflect on the situation and your emotional responses to it.  Supervision and personal therapy are good resources to use in developing greater self-awareness.  Some steps to consider are to identify 1) the specific nature of the conflict or discomfort you feel, 2) the benefits and limitations of your familiar strategy for managing this type of conflict or discomfort, 3) the fears or worries that arise when you consider handling the situation in a different way, and 4) a small step you could take to expand your skills.  Remember that change usually happens in small steps, so think about developing your interpersonal skills incrementally rather than pressuring yourself to do something dramatically different.

Applying these steps to the specific situation you mention, we start with the nature of the conflict.  It seems your supervisor is suggesting something that you perceive as confrontational, but it isn’t clear whether you perceive the client’s lateness to be a problem and why discussing it would become adversarial.  A starting point would be to explore more of your own response to the client being late and the potential meaning it might have.  This would be something to discuss in supervision as well.  It seems that your familiar strategy with managing this type of conflict is to avoid discussing it directly, so the next step would be to consider the positive and negative results of this type of avoidance in other situations in your life.  It may be that this was the most effective way to respond in your personal relationships, but remember that your job as a clinician is to help your client face and resolve the issues that are interfering with her life.  A limitation of relying solely on avoidance of potential conflict is that your client will not have an opportunity to gain insight into a pattern that may contribute to her difficulties outside of therapy.

A third step to consider is the nature of fears and worries you have about responding differently to this situation.  You express a fear that your client will stop therapy if you discuss her lateness.  This seems to reflect an assumption that she will feel judged or criticized by you and that your therapeutic alliance isn’t strong enough for a conversation about something that affects your work together.  Consider approaching the conversation with curiosity rather than judgment.  You can talk about the issue without requiring that she begin coming on time.  A small step you could take toward handling this situation differently would be to say something like “I notice that you usually come a bit later than our scheduled time and I wonder if there is anything about that you’d like to discuss.”  The client may simply say “no” and move on to another topic, but taking this step moves you into an area that has previously been fearful for you.  You can then look at the meaning of your client’s pattern and additional ways you might discuss it with her.

I hope you find these suggestions helpful in addressing difficult conversations with clients and other professionals in your clinical work.  Please email me with comments, questions, or suggestions for future blog topics.

What to do with Things that Can’t be Changed

therapyI’m working with a 20-year-old woman who has a bad relationship with her parents. I’ve been encouraging her to use better communication techniques with them but their conversations always end with the parents yelling and my client feeling blamed. She’s asked them to go to family therapy with her but they refuse. How can I help her when her parents won’t change?

As therapists, we focus on the potential for growth and change, and we maintain hope for our clients when they are discouraged. This is an important and effective trait in many clinical situations; however, it is equally important to recognize and help clients deal with circumstances that can’t be changed.

The first step I would recommend for you is to examine your countertransference. Sometimes we develop unrealistic goals with and for our clients because of personal issues and feelings. In this case, I would ask yourself if your relationship with your own parents is related in some way to your feelings about your client’s situation. You may be trying to achieve something that wasn’t possible in your own life or to replicate an aspect of your life that worked well for you. Either way, work to separate your parental relationship from your client’s relationship with her parents.

Another countertransference issue that may be present is related to feeling competent and effective. Therapists in training are often more comfortable when giving advice, teaching a skill, or proving an active intervention. Reflect on how you feel when your client follows your suggestions and reports they don’t work. If it is hard for you to sit with your client’s painful feelings, your definition of therapeutic success may be too restrictive. Talk with your supervisor about what it’s like for you to be less active in session and explore the usefulness of being emotionally attuned and present.

If you are able to sit with your own feelings of discomfort you will be better able to help your client with one of her therapeutic tasks: accepting what cannot be changed. It sounds like you and she have become invested in her parents changing their behavior toward her and that change isn’t possible right now. It will feel painful to both of you to face this, but it seems to be the current reality of her life. Acknowledging this and allowing her to express her anger, fear, helplessness, and loss will be an important therapeutic intervention. It may take time and will be painful but it is in the service of her developmental growth. Accepting the state of her parental relationship will facilitate her ability to focus on other aspects of her life. She is entering adulthood and facing decisions about work, friendships and intimate relationships. If she has put these on hold to resolve things with her parents, it may be time for her to shift her attention and energy.

Paradoxically, you may find that your client reports some improvement in her relationship with her parents as she moves toward acceptance. Sometimes relational conflict is exacerbated by an implicit desire for change that is experienced as an unwanted demand. Your client may have been communicating a more complex message than what you and she worked on with better communication skills. Her acceptance conveys a different message and may lead to a decrease in conflict.

Your question also raises an important issue related to treatment goals. Clients often enter treatment with a goal for change in something that is outside their control. You may have inadvertently agreed to a goal for individual therapy that can’t be achieved in that modality, so consider reviewing your treatment goals with your client. It sounds like a goal related to understanding her feelings about her parents and a goal related to de-escalation and detachment would be more appropriate than a goal about better communication between your client and her parents.

I hope you find this helpful in facing aspects of your clients’ lives that cannot be changed. Please email me with comments, questions or suggestions for future blog topics.

Professional Practice Decisions

therapy1I’m about to leave my counseling internship and I want to keep seeing a few of my clients.  Should I look for a private practice internship so I can continue working with these clients?

Leaving an internship is a big transition and it usually brings up many different feelings.  Transition always involves uncertainty and we sometimes deal with uncertainty by looking for something that can stay the same, to give us a feeling of security in the midst of change.  If you haven’t given thought to these issues, I encourage you to talk with your supervisor more about the upcoming change and the feelings you have about leaving your current placement.

Regarding the question of looking for a private practice internship, this is a decision to make based on your professional goals and direction rather than based on a desire to continue working with a few clients.  A private psychotherapy practice is a business that requires a significant investment of time, energy and money.  It only makes sense if it fits with your vision of what you want your professional life to be in the next several years.

I suggest asking yourself a few questions before exploring a private practice internship.  How will I feel if one or two of my clients don’t want to continue working with me after I leave the agency?  How will I feel in six months if I have no clients?  Am I avoiding some feelings of sadness or guilt about ending with these clients?  Am I worried that no one else can help them as much as I can?  Your honest answers to these questions will help you sort out your motivations and determine the right course to take.  Bringing these issues to supervision will also help you clarify what to do next.

If you do pursue a private practice internship, be sure you know the requirements of your agency in transferring clients to another setting and the requirements of your private practice supervisor in bringing clients with you into your new internship.  There are legal, ethical and licensing board issues and regulations that need to be met.  Make sure to have clear conversations with the private practice supervisor about the expectations that both of you hold about the business and clinical parts of your relationship.  Each of you may have assumptions about how you will operate, and these need to be shared to maximize your satisfaction and success.

Most importantly, use this transition as a time of personal and professional growth.  Take time to reflect on your training and supervision experiences, what you have learned and what you want to take on as your next step in training.  Think about all the clients you have seen and what you learned in working with them—about yourself as well as about clinical work.  Take time to say goodbye to your peers and supervisors as well as your clients.

Recognize what you’ll miss as well as what you’re glad to leave behind. Each phase of training contains lessons and prepares you to take on the next challenge.

Please email me with comments, questions or suggestions for future blog topics.