We all need to become aware of our pain and uncertainties and then grow through them. What makes a good therapist is personal courage; the courage to face one’s fears, limitations, and confusion.
A mistake I made during my training was trying to impress my supervisors with how good a therapist I was. I would present my successes, downplay my failures, and hide my confusion. This defense, similar to the one I employed during childhood, only enhanced my sense of being a fraud. I was putting on a show and gaining approval, all the while undermining my confidence and training. A breakthrough in my training and personal growth came when I found the courage to appear weak, uncertain, and share my mistakes openly
Therapists are never “done” with growth, they are simply people who should be dedicated to learning as much about themselves and others as they possibly can. The best therapists are fully human and engage in the struggles of life
The key to ongoing growth, to continue to peel the onion, is transparency and openness to feedback. In other words, sharing what is going on inside and struggling to understand your therapists, supervisors, and trusted advisors. You can’t do this alone.
It’s not about you knowing what your client should do, it’s about you providing a relationship in which he can discover himself.”
Try to keep an open mind despite the attempts of others to close it. Work with the best people you can find regardless of orientation, and, most importantly, get training in a variety of perspectives. Knowledge of a variety of perspectives is the best defense against false certainty.
When a client first walks into your office, you never know whether or not you will be able to be of help. Some clients may just be a bad match with you and, with luck, they will move on to another therapist who can help them
Your relationship with a client begins the moment you receive the initial call to set up an appointment. Your openness, curiosity, and concern are conveyed through focused attention and tone of voice. Remember, you don’t get a second chance to make a first impression! Evolution has primed our brains to size someone up as fast as possible, so first impressions have a significant and sustained impact on how others experience us.
Be mindful of the fact that all of a client’s interactions with you are a part of their experience of therapy. Billing questions, appointment changes, and calls for comfort are all aspects of the relationship and possess therapeutic value.
Begin by being openly curious about your client’s thoughts and expectations about therapy. Consider asking questions like:
Our clients need us to be strong and centered enough to withstand criticism and attacks that we may not deserve. These attacks are often forms of memory that our clients need help to become aware of and understand.
Your therapeutic stance should contain a mixture of quiet calm and alert attentiveness
In the whirlwind of activity we call our lives, listening has been demoted to a passive “nonactivity.” Ironically, while all this is going on, we all long to be listened to by a caring and attentive other
When I eavesdrop on conversations, I am often struck by how little people pay attention to one another. What passes for conversation is often alternating monologues; each person uses the other to trigger their own thoughts and associations
The most helpful listening occurs in the context of a positive interpersonal relationship that includes warmth, appreciation, and respect
This context provides a matrix in which we can articulate our thoughts and come to better understand our inner worlds. We often have to hear what we’re saying to know what we’re thinking. Your job is to be that person who listens, so your clients can learn to listen to themselves.
Even as a novice therapist, you have a distinct advantage over your clients: You aren’t them. I mean this in a good way. Simply by seeing the world through different eyes, you provide them with a different view of their words, behaviors, and feelings
The presence of an attentive therapist provides an invaluable service. It is, in fact, an essential cornerstone of psychotherapy.
of others. We are born with reflexes to turn toward others and look into their eyes. This “jumpstarts” the bonding process, triggers our brains to develop, and remains with us throughout life. Using our eyes and the facial expressions surrounding them, we communicate everything from deep love to intense hate. A roll of the eyes can cause shame, an open gaze can trigger sexual excitement, a raised eyebrow communicates our skepticism. The central importance of eye contact and facial expressions to survival has led to the evolution of extensive neural networks dedicated to interpreting their nearly infinite formations
Based on our learning histories and cultural backgrounds, eye contact can come to mean many things. The same look will be experienced quite differently by different clients. Whereas one might feel comforted by a steady gaze, another will lash out and demand that you not stare. These reactions are unconsciously interwoven with other aspects of transference. Think of the reaction to eye contact as a form of implicit memory reflecting something that is potentially important about past experiences of love, hate, or shame. It can also provide insight into your client’s level of anxiety, ability to form connections, and self-identity.
Be curious, not defensive; something was evoked within them that you want to know about. Focus on exploring their experience of you in that moment. Ask about their thoughts, feelings, suspicions, and fears. Ask them what they think is on your mind
ask your client once or twice during the first few sessions how it feels to be in the consulting room with you. This encourages them to discuss their experience of the session and their reaction to you. It also teaches them that discussing the emotional background of your interactions is a desirable part of the therapeutic process
Therapy works best if your client oscillates between low and moderate levels of arousal
If your gaze, proximity, or some other aspect of the therapy situation is activating too much anxiety, it may interfere with the progress of your work
I have asked some clients if they would feel more comfortable if I looked away instead of at them.
Try to avoid being distracted by “brilliant” ideas.
The things most people need to learn in therapy are related to attachment, abandonment, love, and fear. We are trying to access basic emotional processes that are organized in primitive and early-developing parts of the brain. The language of these emotions is also very basic; it is the language of childhood. The more complex the language and ideas you bring into therapy, the more likely you are to stimulate your clients’ intellectualizing defenses. The rule of KISS (keep it simple, stupid) may have been developed for design engineers, but it works very well for us, too
the brief and straightforward expressions of clear emotions are far more powerful. They don’t distract the client with too many words to attend to and understand. By stating an emotion and then getting out of the way of your clients’ experience, you allow them to remain centered in their own experience.
Because of these challenges, having a clear and concise way of thinking about therapy (in general) and your client (in particular) is extremely helpful.
In the process of successful therapy we learn to experience, understand, and regulate emotion. Finally, each form of therapy teaches some new way of thinking about the self, others, and the world. In this part of the learning process, a new story of the self is formed through the interactions of client and therapist
At its most basic level, psychotherapy is an interpersonal learning environment similar in many ways to proper parenting. In both, we tend to learn best when supported by a nurturing relationship with an empathic other, while being encouraged to confront life’s challenges
In most cases, the primary focus of psychotherapy is the integration of affect and cognition (feelings and thoughts). Through the alternating activation of emotional and cognitive processes, the brain is able to interconnect neural networks responsible for these two functions.
Factors common to all forms of therapy that produce positive outcomes include: • The therapist’s care, compassion, or empathic attunement • A balance of nurturance and challenge • A balance of comfort and stress • A balance of affect and cognition • A goal of increased affect regulation • The cocreation of new narratives or the development of a new story about the self
Learning the right balance of nurturance and stress for each client is a key challenge for therapists across orientations. Within this balance, the evocation of emotion coupled with the client’s ability to put feelings into words is most likely to result in emotional growth, insight, and symptom reduction
In psychotherapy, understanding is the booby prize. It is a hollow victory to end up with a detailed psychological explanation for problems that remain unchanged. On the other hand, the expression of emotion without conscious thought does not result in positive change either. Regardless of orientation, therapists will encourage clients overwhelmed with their feelings to think their way to solutions and help clients who are emotionally cut off to experience and express their feelings.
During this process, Greg and I would be developing a shared language that could come to serve as a new way for him to think about himself and his world. This “co-constructed” narrative should serve as a blueprint for future experience and behavior. How all of this plays out and the type of narrative Greg takes away from therapy will be highly dependent on my theoretical orientation
A case conceptualization is the application of your theoretical orientation to your client. It provides a way of understanding the causes and cures of psychological distress and a rationale for your treatment strategies. It places the causes, effects, and complications of your client’s difficulties in a theoretical framework that creates a guidance mechanism for therapy. A case conceptualization includes: • A description of presenting problems, symptoms, and possible diagnoses • A theory or theories accounting for how and why the problems have arisen and evolved over time • A general description of how problems are addressed and cured
Like the case conceptualization, your treatment plan will be grounded in your theoretical orientation. Working backward from the goals developed with your client, design your interventions to lead to your goals. Your treatment plan connects your interventions with your goals through gradually increasing levels of challenge that approach the goals of treatment. Therapeutic progress is measured by attaining the successive goals that guide treatment.
failures” can be reframed as “experiments” that provide valuable information for future progress.
Case notes should be brief and to the point. Although they are usually confidential, there is always the possibility that a client might read them or they may be opened for legal reasons. I suggest that case notes remain brief and avoid unnecessary and potentially embarrassing personal details. Certainly all emergency issues related to threat and danger need to be included
Keep track of the general content discussed, sessions both kept and canceled, and lateness and payment, because all of these factors may have therapeutic significance
A brief glance at your case notes before a session should ground you in the current aspects of a client’s therapy. This is especially important when you get to the point where you see many clients each week.
Clients with painful experiences and frightening symptoms are accustomed to living in a world where others avoid and reject them. Our ability to remain empathically connected to them through the expression of their suffering sets the stage for therapy to be a qualitatively different relationship experience–one where they are accepted, pain and all
Another reason not to panic is more subtle and more profound. Victims of trauma and abuse often find that sharing their experiences is extremely upsetting to listeners, so much so that they end up having to take care of the very people who are supposed to be taking care of them
Beginning therapists, unnerved by their lack of experience, often try to cover up their ignorance and don’t ask vital questions for fear of sounding stupid. It may help to realize that your admission of ignorance, genuine questions, and desire to learn about your client is most often experienced as interest and caring, not incompetence
One of my professors spelled the word assume as “ASSume” to remind us of the perils of making assumptions
Remember that asking a simple question is often not enough and what you are told isn’t always true. People tend to forget or underestimate the things they are ashamed of and overestimate and inflate those things that make them feel better
Assumptions are often based in countertransference. We may prefer not to know the truth or we may be too afraid to anger our clients by asking for clarification of potentially uncomfortable issues. Asking these questions requires the courage to experience the negative feelings in us and to tolerate the possible negative reaction of our clients.
I felt confident that I knew what I was doing precisely because I had such strong feelings about it
Instead of giving her the understanding and comfort she needed, I had become yet another authority figure demanding the impossible.
What should I have done? There were many ways to reach a better outcome in this situation. The first would have been to take my strong feelings as an indication that I was having a countertransference reaction. Instead of talking less about this client in supervision, I should have discussed her more. Second, I should have spent time having Kim educate me about her family and cultural beliefs and sought consultation with therapists of Kim’s background to help me learn what interventions would be culturally appropriate. And third, I should have understood not just how hard it must have been for her to come to therapy, but how she needed to please me as an authority figure. By foisting my countertransference onto Kim, I not only missed the opportunity to help her, but also made her feel more alone and helpless than before she came to therapy. Twenty years later, I still think of her and wish I had done a better job.
Make the decision that you are ignorant and need to learn
Anxiety about being “politically correct” leads us to hesitate to discuss sensitive cultural issues because we are afraid of saying something wrong or being offensive. This is the worst possible way to deal with unconscious assumptions. Without words and discussion, thoughts and feelings remain embedded in our unconscious. If we remain silent, we run the risk of carrying the cultural barriers of everyday life into the therapeutic relationship. Err on the side of openness in the areas of cultural differences and be ready to apologize if your ignorance does upset your client.
When discussing their lives, ask them to describe how some of their behaviors or symptoms are seen and understood by their family and understood within their culture
Important learning occurs in the hours and days right after your first sessions, while the experiences are still fresh in your mind and body. The stress of these early sessions can actually prime your brain to grow in an accelerated fashion. This is why we should spend as much time as possible listening to taped sessions and seeking consultation in the early months of training. This is also why our first supervisors are so important
A therapist who is absolutely certain he or she is doing the right thing is a dangerous therapist. Psychotherapists don’t deal in certainties but in educated guesses, intuition, and gut feelings. Embrace your uncertainty and keep in mind that psychotherapy is an art informed in equal measures by thought and emotion.
It is always easy to find mistakes when listening to taped sessions. It is much harder to spot them when you are caught up in the complex emotions during a session. Even the most experienced therapists second-guess themselves. Don’t use second guesses to beat yourself up, rather, use them to think of new ways of being with clients in the future. If you knew everything, you would have no need to go to school!
Genuine collaboration requires that you relinquish some control; this may be extremely difficult if you feel you need to be the one with all the answers
Beginning therapists tell me that they jump in with an interpretation because they are concerned about missing the opportunity to point out something to a client. I’ve found that the process of therapy (like the unconscious) is more circular than linear. You don’t have to worry about missing an opportunity to deal with a particular perception or feeling; core aspects of a client’s inner world permeate so many facets of his or her life that they are revealed in a multitude of situations. If an issue is important, it is bound to return. Seeing an issue repeatedly emerge will provide you with more confidence for a future interpretation. I will further discuss the basic elements of making interpretations later.
The fact that you will make many mistakes as a therapist is inevitable, so surrender to your imperfection. What you do have control over is how you deal with your mistakes and whether you are able to turn them to your client’s advantage. Most mistakes don’t end a therapeutic relationship; they become a part of its process and development
shook my head as I found, once again, my unconscious affecting my work. I called the client back, apologized for being so abrupt when he called, and asked him to help me see my behavior from his perspective
Your goal is not to be right; it is to help your client move in the direction of psychological health
Being right is far less important than being caring, empathic, and available
If your client feels that you appreciate the reason for his defenses, he will be more willing to explore alternative ways of being
Be willing to let go of your opinions, interpretations, and suggestions and attend to where the client needs to take you. The more you push your agenda, the more the client will resist
If you find yourself arguing with your client, you have already lost
See what they have to teach you about how they need to work
To create an interpersonal context for your client to experience the cycle of rupture and repair within a sustained relationship
The last point is especially important. Most clients have experienced a series of ruptured and unrepaired relationships. Many grow up with parents who are unable to admit their mistakes or shortcomings and have to find some way to blame everything on someone else. This communicates to a child that everything that goes wrong is a result of their imperfections. Shame, isolation, and anger are common reactions to these situations; you can provide an avenue of healing by being willing to take responsibility for problems in the therapeutic relationship. You can offer a willingness to ride out problems, continue to be concerned for them, and work diligently to repair breaks in your relationship. This takes patience, skill, and ongoing emotional availability. I try to remind myself that turning a mistake into a good mistake is a test of my maturity and an opportunity to enhance therapy.
Because of our fragile egos and our need to avoid feelings of shame, we all differ in our ability to admit when we are wrong. Receiving an honest and heartfelt apology is an all-too-rare experience. When it does happen, it can decrease our defensiveness and make us feel closer and more trusting of one another. Apologies can be therapeutic.
The therapist employs the projective hypothesis in a number of ways. By not giving the client much personal information, you yourself become a kind of ink blot. We try, as much as possible, to maintain this “neutral stance” in order to allow clients to project feelings and thoughts onto us. This form of projection, referred to as transference, results in the experiencing of emotions and expectations from earlier relationships within the therapeutic relationship. Because learning from early relationships is usually established before conscious memory is formed, transference allows access to otherwise hidden and unconscious learning. Through transference, the conflicts of early relationships are brought into therapy and can be worked on firsthand. The evocation and exploration of the transference can be a key component of successful psychotherapy.
As therapists, we are often less interested in answering clients’ questions than we are in discovering the motivation for the question or what the imagined answers might be. Questions such as “Are you bored with listening to my problems?” or “I think you want to fire me from your practice” may contain a wealth of information about our client’s unconscious. Although assuring a client that you don’t have these feelings is important, you will first want to also explore these thoughts and feelings. If you are yawning or distracted, you may well look very bored. But more often, these statements reflect the client’s past experiences and self-image, both of which are fertile grounds for exploration.
ask yourself: “What does silence evoke for my client as well as me?” Given the opportunity, each client will teach you what silence means to him or her. In so doing, clients will also provide you with information about the architecture of their unconscious world.
Some clients are unable to tolerate silence, and, in truth, neither can some therapists. If this is the case with you, it is important to discover if it is the client’s discomfort or your own discomfort that leads you to fill the silence. You may be retreating from something that is potentially beneficial for your client.
Ten or fifteen seconds of silence may feel like an eternity in social situations but should not be unusual in therapy. Silence is an important aspect of therapeutic communication, something to be seriously considered and fully explored.
Within the therapy relationship, silence provides a space for shared contemplation and mutual acceptance. Neither you nor your client needs to be charming, entertaining, or witty. Take the performance pressure off of both of you and try to create a context for self-reflection and mutual discovery. Sometimes the best strategy is no strategy at all.
AS BEGINNING THERAPISTS, we usually think of therapy as something we do to a client, like a doctor setting a bone or a teacher correcting a wrong answer. In reality, therapy is a process that we do with a client
With most clients, the biggest challenge isn’t finding a helpful diagnosis or establishing a good treatment plan, it is helping them to become open to change.
Labeling a client as resistant or pathological can be motivated by anger from our hurt feelings, frustration for not being able to solve their problems, or revenge for making us feel incompetent. This
Slow progress is actually the norm, and periods of “backsliding” should be expected. It is important, especially when progress is slow and difficult, to have a good case conceptualization and revisit it on a regular basis. We all need to be reminded of what we are doing and why. Use difficulties in the therapy as opportunities to rethink your treatment strategies and get consultation from other professionals. When you recognize stagnation in the therapy, it is time to become curious, ask questions, and seek answers.
The prohibition against physical intimacy creates a boundary that protects both client and therapist from harm. It also provides a context for the therapeutic work that would be impossible in the absence of this boundary. Yet that boundary, like any taboo, generates tension. Often unanticipated by new therapists, sexual attraction is quite common in the therapy relationship. The emotional intimacy of therapy can naturally lead to a longing for physical closeness
Sex should never be a part of any therapy relationship. It is not in the best interest of your client no matter how compelling it may be for you. For those of you who have difficulty maintaining boundaries for the benefit of your client, it may help to keep the following in mind: If you are physically intimate with a client, you are giving him or her the power to end your career. Think about all of the work, energy, and money you have invested in your training. Ask yourself if this is the kind of power you want to give to a client. If you are seriously considering giving in to your sexual attraction for a client, call a colleague, your supervisor, or your therapist as soon as possible. Think it out, work it out, but never act it out!
Regression can be important for a client, however, because it activates old networks of memory that can be key to the development of symptoms. The enhancement of regression was one of Freud’s goals in having his client lie down, face away from him, and spend time in silence. Encouraging clients to talk about their past, supporting the expression of strong feelings, and drawing parallels between therapy and parenting all enhance regression. They diminish attention to the present and allow the mind to drift backward through subjective time.
The journey inward though my own emotional world has been as important to my ability to be a therapist as everything I learned in school about the psyche and therapeutic techniques. I have also come to find that this learning is a lifelong process that will continue until my last breath.