Sunday, March 21, 2010

...on being a therapist...

I am often asked what it is like to be a therapist.  I guess people are naturally curious about a person who gets to hear so many secrets about so many lives.  So in response I thought I would just type, in a stream-of-consciousness sort of way, about what it is like (for me) to be a therapist, how I approach the work, the rewards and the challenges.  This will not be a comprehensive description of my or any therapist's approach.  That said, here goes:

First I must say that it is an honour to be graced with the gift of peoples' life stories.  It never ceases to amaze me the highs and lows people have experienced in their lives.  So many twists and turns, yet surprisingly always similar, common themes of the triumph and turmoil in a human life.

Since I do not work in a medical setting, I refer to those who come to me as clients, not patients.  As well, most people I see are not 'sick' and thus do not qualify for the term 'patient', to my mind.  If they are at immediate risk of hurting them self or someone else, I make sure they see a psychiatrist in a hospital setting  for diagnosis and treatment.  Usually, it is people who feel stuck, depressed, discontent or anxious about their lives who arrive as clients.  Most folks who enter therapy are 'regular' people who just want some help over a particular hurdle or who want to reflect on persistent patterns in their life.

I have learned over the years to pay very close attention to the first things a client says when I greet them.  While it may seem like some mundane, weather-related or getting-to-know-you remarks, they often are harbingers of issues, paradoxes, even insights that will emerge in the session.  Sometimes after the initial greetings, I will think to myself, "Well, that little law of first statements will not apply today", and invariably once into the session I will find myself making a link back to what they said when they entered the room.  It's quite uncanny.  The psyche seems to have its own agenda, quite unconscious at times for the person, but revealed in everyday comments as they enter the door.

I set my office up as a comfortable 'living-room' type setting.  There is never a desk between the client and myself as that would be a barrier or boundary which could inhibit free conversational exchange.  Perhaps there are psychoanalysts that still use 'the couch', but I do not know of any of my colleagues who do not sit across from the client facing each other (unlike the stereotypical seating-arrangement in the cartoon above).

Sometimes I have wondered at a first visit if I was suited to work with a particular client, noting that I did not find them likable, or found them somehow 'off-putting'.  Without exception, by the end of the work together, I  will have discovered many endearing, likable aspects to the person  Everyone is likable and lovable if you take the time to get to know them.  Okay, almost everyone ... but the almosts are very rare.

One could not be blamed for assuming that psychotherapy is an easy job - park yourself in a chair, listen, take a few notes, make a few pithy, well-timed, helpful remarks and you are done.  Well, from my perspective ... not quite.  Good psychotherapy requires focused attention and attunement on multiple levels.  This multi-leveled attunement requires a lot of energy.

Every client comes in with a story to tell.  As they tell their story and explain their problem or issue, as the therapist I must simultaneously be attuned to the following:

the details of their story - the words, the content, the players, their childhood history, etc. etc., so I can respond sensibly and the person can feel understood

*  the non-verbal signals - how does the way they use their body speak of their struggle(s)  -- what is their body saying that is not evident in their words/story -- are they able to maintain eye contact

what is the person not saying, leaving out, avoiding talking about  -- what might their psyche be trying to tell me that is not evident in the content of the story/words ...

what is their ego strength -- are they able to cope with the stressors in their life  --  are there ways that they are at risk (or could put other persons at risk) -- how defended are they against reflecting on the truth of their life -- how able and/or willing are they to confront their pain -- how able and/or willing are they to make changes -- how identified are they as the 'victim' in their circumstance --   Making these assessments tells me, among other things, at what speed I can proceed with the work ahead ...

what key pieces of developmental growth work are they resisting or avoiding -- what might be the underlying issue that eventually has to be addressed

*  are there immediate ways they need help to manage stress -- do they have support in their life -- how alone are they in the world

*  are there ways I can offer some immediate affirmation for how they are handling their situation

Some of the above is trying to assess, beyond their written intake history, what it is like to walk in this person's shoes and live in their mind ... This is called attunement.  Clients perceive when the therapist is well-attuned to them and their situation and this helps them feel relaxed and at ease.

Clients need to be informed of the therapist's particular approach (cognitive/behavioral; psycho-dynamic; Jungian, etc. etc.) and of the ground rules and expectations of the joint work together (honesty, no self-harm, confidentiality, etc.)  And, of course, the client needs to be able to ask any questions in order to feel comfortable enough to proceed.  I always tell clients at the beginning of a first session that they should be assessing their comfort level with me and if they are not comfortable to feel free to continue the search for the right therapist for them.  It is always evident this comment is appreciated and I don't recall anyone has taken me up on the offer - yet.

Each person enters the consultation room with their own special vibe or energy.  Some come seeking energy (without being consciously aware of it) and can leave a therapist feeling sucked dry.  I have found this feeling in myself is often a signal of a certain personality disorder in the client.  This is another area where a therapist has to attune their attention - assessing their own reactions to the client.  Their own gut reactions to the client hold a lot of information - but first the therapist must sort out whether it is truly information about the client, or if it is information about them self and the work they (the therapist) need to do!

Well, that is enough of my rambling for now.  I hope it has given you a tiny glimpse into what it is like to work as a psychotherapist.  Do keep in mind that therapists all have their own approach and style and that no two will be the same.  I know there are therapists who read this blog and there may be some screaming "but you forgot ....", and I know I have left out tons of essentials ingredients that make good therapy soup - but I have simply shared the ones that came to mind for today.  Perhaps I will write more at a later date.  If you have questions I will be glad to answer them.

The thought is quiet as a flake
A crash without a sound
How life's reverberation
Its explanation found!

~Emily Dickinson

It is a joy to be hidden but a disaster not to be found.

~D.W. Winnicott



    Great post. I too am a therapist/clinician both in and out of the 'medical setting' for over 20 years. I so enjoyed and respected your overview. :-)

    Love Gail

  2. Hi, Bonnie! Great summary! And it is obvious to me that you are extraordinarily good at what you do!! Your clients are extremely fortunate to have you!! Love you!! Janine XO

  3. Great post. I began training for this art, but decided not to go through with it. I am glad you have!

  4. Gail: Thank you!

    Janine: Well, in truth the privilege has been mine. I have learned so much from all of these wonderful people. Thank you.

    Jenn: That's too bad Jenn - although you alone know that you probably had very good reasons for your choice. I have just noticed that you have a great ability to see beyond the obvious and an extraordinary ability to pay attention - both fundamental qualities for any good therapist.

  5. really some great thoughts here...i concur...luckily with the clients i have i am able to get them out of the office...they do all have a story and many will break your heart...i have my few as well that just did not go and a scar on my forehead to remember one by...

  6. Hi Bonnie

    I can tell that you are a fine therapist, thoughtful, learned, sensitive and imaginative and above all else there for the client...

    Happy days

  7. Brian: Well, I do not have any visible scars yet - but it can certainly become volatile and physical anger is always a possibility. I have had some weird, wonderful and wacky situations in the consultation room - I may write about them at some point, but would have to spend some time making sure no identities would be inadvertently revealed. Take care of yourself out there!

  8. Delwyn: Well thank you. It would take one to know one, I think! :)

  9. It sounds to me like you are a wonderful therapist. Thank you for the work you do, and for sharing some of the process behind it.

  10. Interesting. I know if was TV, but I enjoyed HBO's series 'In Treatment' with Gabriel Byrne. Do you ever shut yourself off to this or do you find that you make a thumbnail analysis of people in general, whether you intend to or not?

  11. Hilary: Not really looking for affirmation or praise here - but thank you. Just wanted to share a bit of the process for those who have never participated - hoping it would seem a little less intimidating.

  12. Quite a fascinating post, Bonnie. I have often thought that if I had the chance to do things over again, counselling psychology would have been my choice. No regrets, but I think I missed out on something extremely interesting.

    What you said about some clients seeking energy and sucking you dry was intriguing - I suspect this is the sort of thing that has be experienced to be understood.

    I think your clients are lucky to have a therapist like you.

  13. Hi Sandra: I really enjoyed that series too. It was a good depiction of an eclectic approach. The acting was fabulous - particularly the actor who played the father of the pilot, and the girl who played the young gymnast. I particularly enjoyed Byrne's (the therapist) own therapy with his supervisor Diane
    Weiss (I think that is the actress' name). What you saw with those two, is very much my approach. The writing of that series was excellent.

    I, of course, make assessments - it's hard not to when the training is so ingrained - but when I catch myself I stop. I actually consider it invasive as I have not been engaged to do so.

    I have caught myself giving some unsolicited advice here in the blogosphere when people have disclosed distressing feelings. Probably not a good idea - so I try to keep my psychological advice out of the mix - although am not always successful.

    As you know it is hard not to offer or share something good when you have access to it and someone else does not ...

    Good question. Thanks Sandra.

  14. I think about a year into my therapy, I asked my therapist something about himself.
    He got a decidedly delighted look on his face and asked, "You want to know more about me?"
    I suddenly felt shy. I know that that point indicates *something* in the process, but what is it?
    And he never did answer me, either.

  15. Hey Deborah: I am sure you would have been an excellent candidate as a therapist. You express a lot of caring and concern in comments you make that I see on other blogger's posts.

    Yes, I probably should not even have mentionned the 'sucking dry' thing - because it is quite rare. But I have experienced it a few times and it is an interesting phenomenon. The only thing I know is that these people do not respect the time limits (are hard to get to leave when time is up) and seem to attach an invisible umbilical cord to the therapist in order to live off their life energy! Sounds extreme - but I have no other way of describing it - and that is the way that it feels. They have usually been very deprived as children and have so many unmet needs and the therapist becomes a 'good mother/father' representation for them. They do not know they are doing it consciously. I imagine they do it in all their relationships and that is why many of them do not last - people cannot take it.

  16. Hi June: Well, it would not always indicate the same thing with regard to everyone. It could mean that you have developed a solid rapport with your therapist and are suddenly aware that the disclosure has been one-sided (as it should be) - but you are suddenly just curious. The therapist is correct generally in avoiding answering and directly the session back to the client. The point of therapy is not to strike up a reciprocal friendship and should be only concentrated on the client. If you have a therapist that talks all the time about themselves, you might wonder what THEIR unconscious need is.

    Often, when a client asks a question about the therapist it is when the therapy has evolved to a point where the client needs to work on the difficult stuff ... redirecting the attention to the therapist and away from themself is a way of protecting themself from any pain they imagine will come from the hard work asking to be done.

    Hope that answers your question. :)

  17. June: Just wanted to add that most therapists will answer benign (non-personal) questions about them self. E.g. How long have you worked in this part of town? Do you enjoy being a therapist? etc. Personal questions are often deflected as they distract from the therapist being a blank screen on which the client can project their unresolved issues with important authority figures from their past. A good therapist will usually say something to the effect: "How would it help your therapy to know that about me?"

  18. Hi Bonnie
    I believe you and I could be office mates....both environmentially and philosophically! As a therapist working over 25 years...It is and has been a major part of my life.

    Well written thoughtful and caring post


  19. Great post. Very cool information. Thanks for sharing.


  20. This is a most interesting piece, I thought of YOU much more in terms of an artist.....I was in therapy...years ago....It helped just for a while, but then the sessions turned into and and scheduling the next session. NOW...I think this is that much that the doctor could do, maybe....I went to the brink of Nothingness, fell in...but they brought me back to real life, at Emergency. Fortunately...I finally found understanding and support in my family, which had been absent before, and no longer needed medicines or a therapist.
    You is not simple and therapists may or may not be attuned to the needs of their patients.....But,after all, therapists are just human beings!

  21. Many thanks for this interesting post about your profession. As someone who went through therapy many years ago, I recognised your seating arrangement immediately because it was the same one my counsellor adopted.

    Many thanks.

    Greetings from London.

  22. Linda: Well - thank you! I somehow did not know you are a therapist - but I did know I enjoyed your whole approach to life as revealed on your blog. Glad to know we have so much in common.

  23. An Open Heart: Thank you!

    Natalie: :) to you too!

  24. GABRIELA: That is so true. Therapists are just human beings and like in every profession, some are good, some not so good and probably some that are downright awful ... I have already begun to prepare a post on what to look for in a therapist. Your comment confirms that it could be a good topic.

    I'm sorry you didn't have a therapist who could help you avoid going to the 'brink' - that must have been very scary. How resilient you must be to have made your way back.

  25. interesting... both the posts & the comments.

  26. Fascinating, really. We visited a Jungian training center in Zurich and I was completely caught off guard by learning at this center that a therapist had to go through two years of intensive therapy themselves as part of this program. Maybe you'd share about the sort of training you had with us?

    I completely know what you mean about having to understand yourself and know that others can come and instantly push buttons one may not be aware they even had.

    I have no doubt you conduct yourself as a therapist in much the same way you blog... with an open mind and an open heart and much good wisdom... Its always a pleasure Bonnie!

  27. My experience with therapists in the past has been this- I go in, appologize immediately for taking up their time, say that I am alright, listen to them , hand them hefty payment, leave and wonder what the hell was that about, and go refill a scrip for anti depressants... Therapists sometimes need it more than patients...
    I love that you are helpful and honest- You are a rare gem!

  28. Hard work, indeed. I always thought that was what I wanted to do until college, when I realized I could never sit and listen to people's problems day after day, year after year. It takes a very special person to be able to do that. I think you must be very good at what you do, Bonnie.

  29. Vicky: Yes, most training programs outside of the university setting have an unnegotiable requirement that the therapist-in-training do a course of therapy them self - for the duration of the training period which is usually for 2 - 3 years.

    I had only one 6 month course in university which required that I be in therapy and journal about the experience. Outside of university in a 3 year Gestalt Therapy Training Center I was required to be in therapy and the training sessions themselves were group therapy done with the trainees. (NO WHERE TO HIDE! :)

    I also did a 3 year Psychosynthesis Psychotherapy Training outside of university that required personal therapy and written reflections on it for the 3 yr. period.

    Not only are you working out your own issues and unresolved conflicts, you are seeing how a therapist works - what worked for you and what didn't - what you liked as the client and what you did not.

    The big advantage (should I say 'essential') is that once you have healed your wounds, completed your developmental tasks, resolved your inner conflicts, confronted your fears and neuroses - you will not have those feelings arise when you are working with a client. Therapists who have not done their own personal work will unconsciously steer their patients/clients away from say their repressed anger because the therapist is not ready to confront their own unresolved anger issues.

    I have pretty much continued with updating my training once having completed my graduate work. EMDR training was done as intensive weekends spread out over a couple of years.

  30. Linda Sue: A good therapist would have teased out why you felt the need to apologize and why you were in a therapy office saying you are all right. You gave him/her the material with which to work and they did not use it - unfortunately.

    I always appreciate your comments here.

  31. Nancy: It is only hard to listen to the problems when you are in training and have not yet worked out your own personal issues. After that, you attend to 'the problems', but you know of the innate strength and resilience and you proceed like putting together a puzzle - trying to help a person see who they really are and always have been. It can be tiring - but it is exciting and delightful work ultimately.

    While I express compassion and understanding for a client's predicament and pain - I try not to get caught up in it - but to decipher the core beliefs or the arrests in development that keep them stuck in the pain. It's like offering a hand to someone on the street who has fallen down. It may be hard to pull them up - but it feels so good to be of service. You would probably have been an excellent therapist with your interest and concern for people. But obviously there are so many ways to be of service and you have clearly found yours.

  32. This is fascinating, Bonnie. The psychologist career was the road not taken; I thought I could be a better helper as a lawyer. But I finally decided the adversary system hurts more than it helps.

  33. A good, matter-of-fact, 'explanation' of the professional psychotherapist's task. It has been quite illuminating;
    To judge by some of your blog posts I see you as a very capable and competent, as well as caring and understanding practitioner of the art; it would give me the greatest pleasure to consult you; alas.. we must remain blogging partners.

  34. Meri: I think it would be challenging to always find yourself in an adversarial position. At least as a therapist, you try to align yourself and advocate for your client.

    You must have to have a very good and fast mind to be a lawyer.

  35. Friko: Blogging partners is good. Really good, from my perspective. I'm so grateful to have found you.

  36. I have a lot of admiration for what you do. Marc and I have been to counseling (a form of therapy, yes?) several times during the course of our marriage with varying results. The last time though, was more therapy than counseling. He worked with us individually and together. this man was the only one who was able to get us to the roots of the problems.

  37. Bonnie,

    I found this post really fascinating. I was struck most by the sense that you really have to rely on a broad spectrum of skills - both intuitive/empathic and analytic/rational in order to comprehend the patterns at play in people's lives and how they are cognizant of their lives.

    Additionally, it says a lot about your training that you can suggest methods for people to come to terms with problems and move beyond them. I know that's a fundamental benefit of therapy, but I wonder if we all wouldn't be helped if some of those skills were taught more publicly so we could assist in small ways.

    I had a few therapy session once, about 5 years ago, but the funding ran out before I got very deeply into my "disenchantment" with my marriage - and I returned to my old tendency to just try to work everything out on my own and it's been fine and getting better since... Anyway, it did make a difference to talk to someone and I wonder if a large part of healing our hurts can be solved by actually having someone listen. Sad testament to the isolation in our lives, that.

  38. Hi ellen: So glad you found the help you needed in counseling. I would define counseling as having more of a problem-solving approach than psychotherapy which delves a little deeper - but I may have some counselors who would disagree with me. Be glad for any clarification they might want to offer.

  39. Hi neighbor! I love saying that. Telling your story, expressing yourself without restraint, being listened to is literally healing. You are right - so much of what a therapist offers could be offered by anyone (and, in fact, often is).

    In part II of this 'on being a therapist' I address the importance of active listening. I hope you will read and comment.

  40. Hi Bonnie,
    I really enjoyed this post, and the comments and remarks that followed. I've had some cognitive behavioural therapy which I found quite helpful, and I've also been on the listening ends of conversations often enough to have people tell me that I should become a therapist. You may rest assured that I have always been aware that I don't have the training and education to act as a therapist, but I know I did these friends a service just by listening (and ONLY listening). It must be so wonderful for your clients to be listened to, and attuned with!
    I, too, was intrigued by the "sucking the energy" phenomenon; I do believe in the ebb and flow of energy between people, but had only thought of it in the context of the introvert/extrovert and their feelings of either losing or gaining energy when walking into a crowded room vs. spending time alone. Feeling the energy sucked out of you by a client must be a challenge, and something you have to work against.
    I'm looking forward to your next post!

  41. Hi Kathryn: Really attending (listening) is key. Few people get to express themselves without feeling they are saying too much, or getting cut off. As they say expression prevents depression - but one needs a kind, compassionate ear. Of course, in therapy there comes a point after the story has been told that more is required than listening.

    Again, I probably shouldn't have even mentionned the energy thing as it is so rare - I was just talking off the top of my head and something kind of irrelevant popped out. First time that has every happened! ;-)


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