Tag Archives: Practicum Training

Illness and Identity

The topic for this blog post comes from my recent and ongoing experience with persistent pain that has been difficult to diagnose and treat.  In addition to living with this condition for almost four months, I have been reflecting on the parallels between my experience and that of many of our clients. 

My pain symptoms had a sudden onset, though I can see some subtle precursors for a few weeks before the onset.  This is often true for our clients, though some report symptoms that are more gradual in onset.  I have consulted with and received varying degrees of help from a number of health professionals including traditional and alternative practitioners, which our clients often do as well.   Ways in which I differ from many of our clients are that I have a high baseline of physical and psychological health, stable health insurance paid by my employer, and sufficient financial resources to pay for services not covered by my insurance.  Without these privileges, our clients face much greater challenges in managing their mental health symptoms, so I thought I would highlight some of the issues that come up with our clients who deal with persistent symptoms of depression, anxiety, PTSD, and other diagnoses.

One important issue related to living with persistent symptoms is one of identity.  This may take the form of resistance to a diagnosis (e.g., “I’m not a depressed person”), anger about the impact of the symptoms (e.g., “I want to be able to go to work without feeling panicked when I drive over the bridge”), and expressions of loss (e.g., “will I ever be able to get a good night’s sleep again?”).  We all develop a sense of who we are in the world and in relation to others, and this identity is disrupted when psychological symptoms make it hard or impossible to do the things that reflect our identity.  The client’s expressions of this disruption of identity may seem like obstacles to treatment, and we may find it difficult to empathize with the client’s distress.  However, acknowledgement of clients’ disruption and disorientation related to identity is likely to be necessary in order for them to engage productively in treatment. They may contact a rehab center for help with eating disorders or anxiety. The struggle about identity may continue for a long time, as is the case with a client of mine who has been in treatment for most of her adult life and has been receiving federal disability income for more than 25 years.  We still have conversations at times in which she says “I don’t want to have a mental illness.”  She sometimes expresses a belief that if she only tried harder she would no longer have the symptoms which are frequently debilitating.  I have come to understand this belief as an alternative to accepting an identity which seems intolerable.

A second issue that is likely to be prominent when working with clients whose symptoms interfere significantly with their daily lives is that of self-efficacy.  It is hard to maintain a strong sense of agency when symptoms feel unpredictable or uncontrollable.  It is also hard to balance self-efficacy as expressed by “what can I do to manage or improve my symptoms?” with self-blame as expressed by “what did I do to cause these symptoms or this illness?”  The first question can be helpful while the second is often unhelpful, but they are often confused in the minds of clients and sometimes for therapists as well.  When a client seems resistant to taking proactive steps to improve their condition, it may be useful to explore the question of self-blame or a perception of blame from others including you.  With the client I mentioned above who is very vulnerable to self-blame, I often say explicitly that her illness isn’t something she caused or can control directly while also reminding her of the things she can do and has done that contribute to a lessening of her symptoms.

The last issue that has become very apparent to me is the difficulty of our fragmented health care system.  Finding appropriate health care providers, making decisions about treatment recommendations, and coordinating care from multiple providers are all extremely complex tasks.  It is rare that a client has a provider who is able or willing to look at the whole picture of the client’s care, and for clients whose symptoms are moderate to severe it is rare that any single provider has the full range of expertise needed to treat their illness.  Some clients may have a family member who can assist in navigating the health care system, but this often carries other complications.  Other clients may be capable of this complex task when they are functioning at their best, but not when they are in a depressive episode or experiencing frequent panic attacks or other significant symptoms.  I would encourage all of us to coordinate our care as therapists with that of other providers when possible and to acknowledge, to ourselves and our clients, the inherent difficulty of assembling a treatment team to address all of the aspects of a particular set of mental health symptoms.  We can sometimes find ourselves feeling impatient or frustrated with a client who is struggling to find appropriate care or we may expect a client to comply with the limited options that are available based on their insurance and financial situation, without acknowledging the inadequacy of these options.

I hope my comments are helpful to you when working with clients whose disorders and symptoms require attention to issues of identity, self-efficacy and health care complexity.

Therapist, Teacher, Supervisor

sunset_4This blog post contains my reflections about the overlapping but distinct roles of therapist, teacher, and supervisor.  I have been engaged in all three of these professional roles throughout my career and will share how these experiences have intersected and how my experience in these three roles has evolved over time.

My career began in my 20’s with a goal of becoming a therapist, without an accompanying thought about teaching or supervising.  As a graduate student, though, I was able to earn additional income by teaching, so it had a more pragmatic focus than my training as a therapist.  One of my early lessons in teaching was that I enjoyed and was much more engaged when I taught material that was related to my growing clinical experience and interests.  I was also surprised to discover that I was comfortable in the role of teacher, in part because I am an oldest child and being the “expert” is a familiar role and also because my father was a university professor who modeled patience while helping me with homework when I was stuck.

After getting my doctoral degree and becoming licensed, I devoted myself to my psychotherapy practice and didn’t do any academic teaching for more than ten years.  My interest in the activity of teaching didn’t diminish, however, and I found opportunities to do trainings and workshops for psychotherapists both because of the professional satisfaction and as a way to enhance my professional profile in a market that was saturated with therapists.  I chose topics that were interesting to me in my professional growth and enjoyed the synergy with my clinical practice.  As I met challenges with my clients, I researched ways to be a more effective therapist through consultation, continuing education, and reading.  In turn, I then shared these insights with others and added my own experiences.  I found that giving a training on a particular topic sharpened my thinking because I had to understand the concepts deeply and thoroughly in order to convey them to others.  I also came to enjoy responding to questions for the same reason—answering a question required me to clarify what I thought and why.

My joy of teaching has remained while I have been in an academic department for the last five years teaching students in a master’s program.  In addition to the aspects of teaching that I found rewarding initially, I also enjoy the challenge of designing classroom experiences and assignments that lead students toward mastery of intellectual concepts and integration of conceptual knowledge with their capacity for self-awareness and insight.

Shortly after becoming licensed, I was asked to supervise doctoral students in a community based agency, which I agreed to do as another way of expanding my professional involvement.  As with teaching, I found the role of supervisor to be comfortable, and I modeled my supervisory style after supervisors and mentors who had contributed to my clinical knowledge and growth.  Initially, my approach to supervision was to share what I would do with the client being discussed if I were the treating therapist as well as how I would conceptualize the client’s issues and the therapeutic process.  A few years into my supervisory experience, it became evident to me that it was less important to help my supervisees do what I would do with their clients and more important to help them identify the optimal way to respond to clinical situations based on their own personalities, preferences, and styles.  This shift gave me a different way to use my experience as a therapist, developing my ability to help supervisees conceptualize cases and evaluate their responses to clients.

As I gained experience with my own clients, I came to appreciate the complexity and ambiguity inherent in the therapeutic process and this led me to a recognition that there is rarely, if ever, a single way to think about or intervene in a clinical situation.  Instead, there are often alternatives that are likely to be effective in different ways depending on the unique combination of therapist and client in the relationship.  My work as a therapist and as a supervisor reflected more openness and flexibility as I became more comfortable with the balance of knowledge and uncertainty in both roles.

I feel privileged to have been engaged simultaneously as a therapist, teacher/trainer, and supervisor for over 30 years.  Being able to apply my growing clinical knowledge in these three arenas has strengthened my ability in all of them.  It has also allowed me to express different aspects of my personality and interpersonal style in the three professional contexts as I develop relationships with clients, students, and supervisees.

If you have an interest in teaching or supervising, I encourage you to look for opportunities to expand your professional life and hope my comments give you some guidance in how you might share your expertise as a therapist with others.

Focus of Change

sunrise_2I have been reflecting lately on the process of change in therapy and on the complexities that may occur over time as we focus on change in different ways.  Clients often begin therapy with one of two underlying questions: “what’s wrong with me?” or “what’s wrong with my life or the people around me?”.  The first question focuses attention on the need for internal change and the second question assumes a need for external change.

When I began therapy in my 20’s, my underlying question was “what’s wrong with me and how can I fix it?”.  This question was more implicit than explicit, but I assumed the blame and responsibility for the difficulties I was facing at that time.  My therapist helped me identify my distress as linked with patterns of coping that had been in place since early in my life, and as I shifted these patterns my distress was lessened.

Like my first therapist, when I work with clients who enter therapy with the implicit question of “what’s wrong with me?” I look for ways to help them shift to the question “what happened to me and how was I affected by that?”.  This helps to relieve some of the harsh self-criticism that accompanies the original question, though there may be a heightened sense of helplessness in facing the lack of control clients had over their early life circumstances.  As they gain understanding, though, there is a growing sense of agency in developing alternative ways of managing the familiar symptoms and responses that may have been present for a number of years.

Other clients enter therapy with an implicit or explicit question with an external focus, sometimes with a desire for change in another person or in circumstances outside of their control.  When clients present with the question “what’s wrong with my life or the people around me?”, we often look for ways to encourage their awareness of the impact they have on others and the situations that are the source of distress.  This may be the client’s interpretation of events, responses that exacerbate conflict, or expectations that don’t match the current situation.  We gently explore the client’s part in the creation of distress while clarifying the differences between the outcomes that are desired and those that are possible.

Both of these questions, whether explicit or implicit, imply that blame or fault can be identified in oneself or in others and that a solution will be forthcoming once responsibility is established and the wrong is corrected.  It is easy to get caught up in this process, looking to balance the client’s misguided assignment of blame as belonging solely to self or other by pointing out other contributions to the client’s difficulty.  Someone who is harshly criticizing themselves pulls for us to point out the role of their past family experience or the actions of others, and someone who is blaming toward others pulls us to identify ways in which the client is contributing to their difficult situations.

This interplay between an internal and external focus of change may change during the course of a therapy, but it is difficult for us as therapists to avoid the polarization of blame and fault as lying within the client or within the other when the client holds a polarized view.  One of my clients had tremendous difficulty making changes in her responses to interpersonal situations, even though she could recognize rationally the need to do so.  I discovered and began to interpret that she held an unconscious belief that she was bad or wrong and that when she approached the need for change, she felt confirmed in that belief which then led her to resist the need for change.  She acknowledged that this was the case, but she continued to have difficulty following through on the steps she took that led to improved relationships.  I had only moderate success in encouraging her to take a more nuanced view of the connection between change and blame.

At other times, it may be challenging for a therapist to make a shift in focus from internal to external change, even when that is necessary. I was in therapy during a period of my life that was especially difficult due to external circumstances. I alternated between blaming myself, wishing desperately that the circumstance would change, blaming those I saw as responsible for the circumstances, and trying to shift my view of and response to those circumstances.  Eventually it became clear that I needed to make a radical change in my life in order to address the pain and distress that had begun to dominate my life.  That change included ending my therapy, which was also painful, due to my therapist’s focus on my role in the circumstances without recognizing that I had reached the end of my ability to cope effectively with the circumstances and that I needed to shift to viewing the impact of the present circumstance on my mental and emotional well-being.

I hope these reflections encourage you to look at the complex nature of the client’s focus on change as primarily internal or external.  One of the things that helps me stay on course is to notice when I begin to think in either/or terms and to remind myself that it’s usually both/and.


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.

Therapeutic Self-Disclosure

A common issue that arises in my supervision with therapists in training is whether and when to disclose personal information to clients.  There is no general rule about self-disclosure in psychotherapy, but it is important to be intentional and thoughtful in these decisions.  This blog will describe different decisions I have made and how I reached those decisions.

One situation in which I chose to disclose was with a client who is about my age and who has a pervasive sense of rejection and inadequacy.  She lives with a serious mental illness and receives psychiatric and supportive housing services from the county mental health system.  She regularly perceives service providers as being condescending and treating her as inferior.  Early in our treatment, she talked about concerns related to her teenage son, who she raised until he was ten and then gave guardianship to her brother when her mental illness became serious enough that it interfered with being consistently available as a parent.  Her tendency was to personalize his focus on school and peer relationships and felt excluded by her son and her brother.  I worked on this issue with her in many ways, but one aspect of our discussion was that I self-disclosed that I also had a teenage daughter and had experienced some of the same issues she described.  My choice to disclose to her was based on my knowledge and experience that providing less personal information about adolescent development wasn’t reassuring to her because of the intensity of her sense of inadequacy.  She was vulnerable to perceiving her son’s normal adolescent shift in attention and focus as a reflection of her inadequacy as a parent.  We had worked together long enough for me to know that she respected me but also saw me as a peer who didn’t need to assert authority over her.  I didn’t give her details about my relationship with my daughter, but simply shared that I was familiar with some of what she described due to having a daughter about the same age.  She seemed reassured by this and became somewhat less self-critical and resentful.  As time went on, she sometimes asked if I had experienced something she described and I answered her honestly.  She didn’t pry for details and I didn’t volunteer more information than she asked, but it did seem to give her more confidence in my statements about the meaning of her son’s behavior.

A second situation in which I chose to self-disclose was when I felt a client needed to know the basis of a mistake I made in her therapy.  A client who I had seen for a couple years stated she wanted to reduce her sessions to every other week, shortly after she gave birth to her second child.  She said it was too hard to arrange her schedule to come every week, and I agreed to this change in our schedule.  Uncharacteristically, I didn’t explore her decision in much detail or reflect myself on the multiple meanings this reduction in frequency might have for her.  At the time of this interaction, I had recently become an empty nest parent after my younger child went to college.  Part of my adaptation to this change in my life was to focus my attention on supporting my daughter’s independence and autonomy, despite my own feelings of sadness and loss.  A couple months after my client had reduced her session frequency, I noticed that she was reporting high levels of stress and a return of symptoms that had been managed before her child’s birth.  I mentioned this and said I thought we should consider returning to every week.  My client expressed surprise that I had agreed to reduce her sessions and said “I don’t know why you did that” with some anger.  In that moment, I made the connection between my personal empty nest adaptation and my hasty response to my client’s suggestion.  I decided I needed to acknowledge my mistake and disclose my understanding of why I had made it.  As in the previous example, I said only a couple sentences about the context and apologized.  My client said “I thought there must be something going on; it’s not like you at all.”  We returned to meeting each week, the client’s symptoms again improved, and we continued to work together productively.

In a third situation, my brief self-disclosure was in response to a question from a client.  She was describing a relationship difficulty that was similar to something I had experienced in the previous few years.  I didn’t disclose my experience, but I did use it in my response to her.  I said something like “I can imagine you might feel…” and went on to describe my understanding of what was getting in her way.  My client said “I have a feeling you’ve experienced something like this” and I responded “yes, I have.”  She then returned to her feelings and conflicts and didn’t refer then or later to the parallel in our experience.

One of the common aspects of these three situations is that I had worked with each of these clients for at least six months.  We had established a therapeutic alliance that was not based on my self-disclosure, and I had a good understanding of their issues and how they would respond to having personal information about me.  It is more difficult, generally, to be confident about the impact of a self-disclosure when it occurs early in treatment.  The potential for the client to feel distracted by knowing personal information, to feel the therapist has shifted the focus of attention away from the client, or to make incorrect assumptions about the meaning of the therapist’s self-disclosure are greater when the therapeutic alliance hasn’t been firmly established.

I hope these examples contribute to your consideration of self-disclosure in working with clients.  I’m happy to get any feedback you’d like to share with me.

Decisions to Limit Practice

There are times in the life of a psychotherapist when our own life circumstances or recent events make it difficult or unwise to see clients with issues and needs that come too close to what we are dealing with personally.  Decisions to limit our practice are individual and personal, and there aren’t any general rules to follow.  In this blog post, I will share some of the issues that have arisen for me and the decisions I have made at different times in my professional practice.

As I was completing my post-graduate hours for licensure and anticipating the establishment of my independent practice, I made a decision to limit my practice to adult psychotherapy.  I had some training in child and family therapy, though it was a minor focus for me.  At the time I became licensed, I had two children and realized that my temperament was better suited to dealing with the complexities of parenting and child development in my personal life only.  I enjoyed what was usually a somewhat less chaotic environment in my work with individual adults and couples, and it was helpful to not have the frequent need for consulting with other parties as is necessary when working with children and families while I was raising my own children.  I was both a better mother and a better therapist by keeping that separation.  When my children were older and out of the house, I saw a small number of adolescents as referrals came my way and I found it comfortable to take on the challenges of working with parents and children in that developmental life stage.

I came to a second decision when I faced a separation and divorce.  I recognized that I felt less confident in working with couples as a result of the end of my marriage, and didn’t do any couple therapy for a period of a few years.  When I felt I was ready to resume seeing couples, I got some training and consultation to add to my skill base and to ensure that I was looking clearly at the issues being presented by my couple clients.  My work with individual adults has continued to be the primary focus of my work, but I have seen a small number of couples over the subsequent years.

Another decision that arose for me was related to a single client, when I initiated the end of therapy.  I had worked with this individual for more than a year when she began coming to sessions with a pattern of regularly berating me and the therapy.  She didn’t seem open to examining the origin of her feelings or to reflecting on the meaning of her anger toward and blame of me.  I worked with this pattern for a number of weeks, then came to realize that I had begun to dread the sessions and to shut down my emotional openness to her and our therapeutic relationship.  This troubled me, since I know that I use my emotional connection with the client as the most important aspect of the healing relationship between us.  I worked with my sense of emotional distance but found I was unable to shift it.  I didn’t feel safe being open with her when I was met so often with criticism and rage.  This issue touched on experiences I had had in personal relationships, which I had resolved and were no longer active.  However, the residue of those experiences as well as my own personality and interpersonal patterns didn’t allow me to move beyond my response of self-protection.  I decided I couldn’t continue as her therapist, since I knew I wasn’t able to do my best work with her.  I shared this decision with her, telling her that I had become aware that I wasn’t able to feel open and connected with her and under those circumstances, it wasn’t ethical for me to continue working with her.  I acknowledged that this was an issue that was specific to me and that other therapists might not have the same response.  She was unhappy and angry with my decision, but I remained clear and spent several sessions completing the therapy and providing recommendations for her to continue her work with someone else.

A final issue that came up in my practice more recently was when my father had a serious health crisis.  At the time he became ill, I was in the early stage of work with a client whose father had died 4 months earlier.  She was in a very intense state of grief and her therapy was completely focused on her father’s death.  My father’s health crisis lasted a couple weeks after which he improved slowly over the next few months.  I had a few sessions with this client in which I was somewhat preoccupied with the similarity between her situation and mine, but this lifted quickly.  If my father had remained ill or had died, it would have been difficult for me to continue with this client.  I’m not sure what I would have done, but I would have needed to consider whether I could provide the treatment she needed.  Getting additional consultation might have helped, and increasing the frequency of my own psychotherapy would have been wise.  If I decided that my own preoccupation was a serious interference, I would face a decision about whether ending the therapy was in the best interest of the client.  Ending the therapy would have presented her with another loss, but continuing might not have provided her with the best care.  More than likely, I would have explained the dilemma to my client and asked her to join me in thinking through what would be best for her.

I share these examples as illustrations of how I have navigated decisions about my practice based on events and issues in my personal life.  Other therapists have navigated similar decisions in different ways.  As I said earlier, there are no general rules.  However, throughout our professional lives, we need to exercise our skills of self-awareness, seek consultation from trusted peers and mentors, and notice when our personal issues arise in our work with different clients.

Personal Experience of Therapy

dianesuffridgeI attended a writing workshop in Porto, Portugal in May 2018 and this led me to begin a new series of blogs that combine exploration of professional topics with reflections about my personal experience and life related to those topics.  This series will be posted once a month, alternating with previously published posts. I look forward to your feedback on this new venture.

Personal psychotherapy is often required or recommended by training programs for psychotherapists.  This provides an experiential perspective on psychotherapy, gives the student an opportunity to reflect and focus on unresolved issues that may arise in the training process, and serves as a support for the many questions and emotions that accompany the early stages of working as a therapist.  My own psychotherapy journey has taken place across many years and has contributed greatly to my professional as well as personal growth.

My first experience as a client in psychotherapy was in graduate school.  My program didn’t require personal psychotherapy, but most of my peers saw a therapist while they were enrolled in the program.  I was in my 20’s, had given birth to my second child within the prior year, was beginning my third year of a demanding doctoral program, and had developed symptoms of depression a few months earlier.  I recognize now that this was my third episode of depression, but at the time I was more aware of my painful feelings of despair and overwhelm than the clinical meaning of symptoms.

I had no exposure to psychotherapy of any kind before graduate school, and although I was in training to become a therapist, I held feelings of shame and fear about being vulnerable and acknowledging that I needed help.  I initially kept my shame at bay by telling myself I was doing what everyone else in my program did, and I managed my fear by seeking therapy with someone who was known to other students in my department as both a therapist and a supervisor.  My first impression of therapy was a feeling of amazement that someone would give me his full attention for the 50-minute session. I hadn’t had that experience before. My parents were overwhelmed with caring for three children under the age of 5 while they were in their mid-20’s, and the refuge of unconditional love I found at my grandparents’ house didn’t include talking about the things that troubled or concerned me.  

My first therapist helped me identify the repetitive patterns I had carried from my childhood and encouraged me to try doing things differently.  I examined the stringent expectations I held for myself as well as my pattern of only showing what I considered to be my strength and competence to others around me.  I told a graduate school classmate that I was going to take the “stop and smell the roses” path for the rest of graduate school. It turned out that this didn’t delay in my progress toward graduation, but it did allow me to make active choices rather than being compelled by unexamined assumptions.  Since that first experience I have returned to therapy a number of times, sometimes when the combination of life circumstances and my internalized patterns have resulted in distress beyond what I could manage on my own, and sometimes when I have identified areas of my internal and external life that I want to change with the support of someone wise and caring.  

One lesson I have learned from my various experiences in therapy is that it can be difficult to find a therapist who is an optimal match.  I have had both positive and negative endings to therapy relationships, and the negative ones have been very painful, ending with impasses that were irreparable despite the best efforts of both of us.  These negative experiences shook my faith in psychotherapy for myself, even as I continued to practice successfully with my own clients. However, after time passed I found myself ready to take the step of vulnerability and trust again, and I have gained something from each experience including those that ended without mutual understanding and resolution.  

Another lesson I would pass along is that psychotherapy is only one of many paths to increasing our self-awareness and to integrating confusing or conflictual parts of ourselves.  I have benefitted from mindfulness and meditation practices, somatic practices like acupuncture and chi gung, relationships with wise mentors, intimate friendships, or other friends you can get at sites like chatempanada.com.

Regardless of your own experiences with personal psychotherapy, I encourage you to stay open to opportunities and relationships that will contribute to your journey as someone who heals and is healed with others.

Therapist Fears About Silence

sunset_4My first fear as a new therapist, and the fear of every new therapist I have trained or supervised, was that there would be silence in a session.  At the beginning of our training we live in dread of the conversation getting stalled and not knowing how to get things going again.  Over time, if we are fortunate to have skilled, compassionate trainers and supervisors, we learn that silence can be an important part of therapy for some people at some times.  The universal nature of this fear has led me to reflect on what it is about silence that feels so scary and how there are many nuances to silence between two people that range from unbearably tense to deeply intimate.

In reflecting on my own fear of silence as a new therapist, I begin with my family background.  I grew up in a family that didn’t speak directly about emotionally charged issues or any type of discomfort.  I knew my mom was upset when I heard the pots and pans in the kitchen clanging with more than the usual amount of force and noise.  She was silent but the house wasn’t.  I remember being unable to speak about the many thoughts and questions I had about my interpersonal world around me, and I didn’t know how to start a conversation or keep it going with someone I didn’t know well.  When I sensed a wide gulf between what I felt or thought inside and what I was able or willing to express to others, I felt tense, awkward and embarrassed.  That was my worry as a new therapist: that I would again be faced with a moment of wanting to say something but not knowing what to say or how to say it.  I told myself I was afraid of letting down my client, but I was actually more afraid of the feelings of self-consciousness and shame that were familiar to me in moments of silence.

After I had developed the requisite skills for handling many therapeutic dilemmas including becoming comfortable with silence, I remembered that I actually had an equally powerful but contrasting experience with silence in my family.  My maternal grandfather was a quiet man.  He was a reserved Midwestern man from a farming family.  My memories of him contain few if any words but are filled with a sense of being valued and cared for.  I always felt special in his eyes, not because of what I had accomplished but simply because I was his granddaughter.  It’s hard to describe how he did this, but I felt his presence and attention without expectation or agenda.  In this way, my grandfather prepared me for the intimacy of silence in the therapy room that goes beyond words and that allows for the emergence of deep feelings that need space and time to come to light.  I never felt hurried by him, and I can embody that patient attention when I sense my client is holding a memory or emotion that is waiting to be expressed though neither of us knows in advance exactly what it is.

In my years of practicing psychotherapy, I have had many poignant and sometimes painful conversations with clients that have included words, tears, and moments of silence.  My grandfather is still with me in those moments, as I find the strength that goes beyond words.  I hope my reflections lead you to think about the different experiences you have had with silence outside the therapy relationship and how they have shaped your comfort and fears about sitting in silence with a client.

Using Countertransference

I have been working with a client for about six months, and he doesn’t seem to be making much progress.  Lately I’ve been feeling bored in the sessions, and I think maybe I should stop seeing him or refer him out for a different type of therapy or a group of some kind.  He comes every week and hasn’t expressed any dissatisfaction with therapy, but I have started to dread the sessions.  

This situation brings up the issue of using our personal responses, or countertransference, to the client to make decisions about the progress and process of therapy.  A previous blog addressed this topic in terms of understanding the client .  This post will look at how our personal responses help us understand ourselves.  The tasks that foster professional development and identity are covered in Chapter 14 of my book.

The term countertransference is used to describe the feelings that arise in us during psychotherapy, and it is an important tool in the therapeutic process.  There are many potential meanings to your feelings of boredom, and I’ll review several.  Self-reflection on your own, with your supervisor or consultant, and with your personal therapist will guide you to the meanings that apply to your experience with this particular client.  I start with the assumption that your boredom is an indication of a difficulty with this client that hasn’t emerged directly in your awareness, and I’ll suggest some areas to explore.  

The first area for exploration is whether you are experiencing emotional responses to your client, in addition to boredom, that may bring you discomfort.  In your next session, notice the full range of emotions that are present for you.  You may notice frustration, aversion, fear, or other emotions that you judge as incompatible with your therapeutic role.  Your boredom may be covering other more intense emotions that are unpleasant or uncomfortable but warrant exploration in supervision, consultation, or personal therapy.  The client may remind you of a difficult situation in your personal life or with a previous client, and it will be helpful to differentiate that past situation from your present one.  

A second area to examine is your interpersonal style regarding confronting or avoiding areas of potential conflict.  If you tend to avoid discussions about difficult topics, your boredom may be a manifestation of that avoidance.  Reflect on the therapeutic process with this client, and look for obstacles that may have arisen between you.  Example are  times when the client did things that undermined the therapy, when he externalized responsibility for his depression, or when he subtly devalued the steps you and he have taken toward progress.  If this is the case, it will be necessary to find a way to address these obstacles directly rather than to withdraw.  

A third area for reflection is whether you are feeling dissatisfied in other aspects of your work.  If so, your dissatisfaction may be reflected in feelings of boredom with this particular client.  For example, you may be scheduling more clients in a day than is comfortable, your employer may have changed some administrative requirements in ways that feel unnecessarily burdensome, or you may have agreed to see this client at an inconvenient time.  If any of these factors are present, your boredom may express your need to address your work habits or agency requirements.  

I hope these suggestions give you some ideas for how to understand the meaning of your countertransference responses, which contributes to your self-knowledge and professional development.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Unplanned Termination by Therapist

diane suffridge therapistI have been working at an agency job for a year and have been seeing a number of clients for six months or more.  I’m looking for another job, and I’m wondering how much notice I should give at my current job in order to allow enough time for termination with my clients.  

The topic of termination is covered in Chapter 13 of my book, including planned and unplanned endings that are initiated by the client or the therapist.  The situation you describe is one in which you will be initiating the termination process with clients who may or may not have completed their treatment.  It is a good idea to think ahead to the impact your job change will have on your clients so you can do as much advance planning as possible.

I recommend thinking about three tasks to be addressed: reviewing the treatment progress and relationship, anticipating future needs for treatment, and saying goodbye.  These tasks are discussed in more detail in a previous blog.  Another blog discusses the importance of processing your feelings about ending with your clients, preferably before you begin the termination process with them.

Usually it is ideal to allow 4-6 weeks for a termination process with clients you have seen for six months or more and 2-4 weeks for shorter term clients.  If you work in an outpatient setting, always assume that some of your clients will miss one or more sessions during the ending process, making it advisable to have a longer rather than shorter time to end.  When making a job change, however, you may not be able to give your clients more than 2 or 3 weeks notice, depending on the circumstances of your job search and any break you plan between leaving one job and beginning another.  I’ll discuss here how you can handle the three termination tasks mentioned above in this compressed period of time.

The first issue to keep in mind if you are ending treatment of six months or more with 2-3 weeks notice is that the ending will inevitably feel somewhat incomplete.  Since you are initiating the ending, you may feel a degree of guilt which could lead you to minimize the discomfort of the ending for both you and the client.  It will serve both of you to acknowledge that you would like to have more time to say goodbye.  In addition, you will be ending with all of your clients at the same time, which will bring up a lot of emotions for you, while you are also saying goodbye to colleagues and supervisors.  Anticipate the emotional work this will require of you and use your support system to help with your own need for processing the endings of these relationships.

A second issue to consider is that some of your clients will miss their final scheduled session, so begin the termination discussion at the time you let them know you are leaving, even if you plan to meet another one or two times.  Since the clients won’t be expecting this news, you’ll need to give them time to take it in before talking about it.  I recommend beginning the session by telling them that you’re leaving, with a simple statement like “I’d like to start our session today by letting you know that I’ve taken another job and will be leaving here on (date).  I’d like to take some time to talk today about ending our time together, though we’ll also be able to do that in our next (1 or 2) session(s) as well.”  Then wait for the client to respond, and if she/he moves quickly into another issue about her/his life, look for another opportunity later in the session to come back to the termination process.

When the termination process is brief, it is often helpful to give the client a written note with some of your thoughts about the treatment as a supplement to your discussions in person.  Many clients lack the experience of talking directly about the ending of a relationship, and this often leads to avoidance and denial of feelings of loss.  You may not have an opportunity to share everything you would like to say to the client in a session, so writing a note ahead of time gives you a chance to express yourself more fully.  It may also be easier for the client to take in your thoughts at a later time.  If the client misses the session in which you plan to give her/him the written note, you can consider sending it by mail.

One of the three tasks I recommend addressing during termination is the client’s future needs for treatment.  When you are leaving your job, the client’s continued treatment will be dependent on another clinician’s availability at your agency so you will discuss this issue differently based on those circumstances.  The other two tasks—reviewing the treatment and saying goodbye—are solely about your relationship and aren’t dependent on the agency arrangements for the client to continue or end.  Although there may be a lot to say, it is possible to accomplish these two tasks in a relatively short period of time if you prepare for these sessions by thinking about each client individually and what you can say about the nature of your work together and how you feel about ending.  It is often meaningful for the client to hear how you have been affected by the work.

These recommendations will help you in managing an unplanned ending with clients with thoughtfulness.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.