What are the Limits of Telling Your Patients Something Uncomfortable?

I wrote an October post offering suggestions to make oneself more interesting: Are You Boring? Words You Should and Shouldn’t Say.

Today I’ll take this another step: what should a counselor do if the patient complains of inexplicable, endless rejection and the healer believes the explanation is that the solitary creature is boring?

Not the kind of training we get in graduate school.

Most counselors first establish the therapeutic relationship, of course. They sidestep the dullness problem. But, when the uncomfortable complication remains untouched and the individual continues to experience exclusion, what then?

The “Are You Boring” article offers both dos and don’ts. Some of those remain unmentioned in the course of a routine psychological consultation.

A UK therapist, Emma Cameron, tweeted this in response to the notion of raising the issue:

But to me this seems like a recipe for increasing social anxiety, self-judgement and shame, which many therapy clients already struggle with…

I answered,

As noted within the essay, this is a risk. On the other hand, some might benefit from recognizing and improving their interpersonal skills, of which speech is a part.

Ms. Cameron is wise, but where do her point and my counterpoint leave us?

My approach in treatment was to engage in a Socratic dialogue: use questions to lead my fellow man into the light of self-knowledge. People skills, anxiety, depression, and self-image issues were addressed, as necessary. I’d evaluate whether my patient’s present relational distress caused him to offer only the safest conversation; as if he were “hiding his light under a bushel basket.”

Indirect suggestions of routes out of his tediousness might be offered. Something like, “Have you ever thought of reading this, or studying that; visiting museum X or watching movie Y? Perhaps you might enjoy trying something new.”

But what if the forlorn fellow doesn’t have much wit or wisdom worth sharing in a relationship, yet I believe him capable of striking sparks with some guidance?

Counselors and advisors ask themselves how much information is enough, how much too great? Whether the other is open to unsettling opinion and what will happen if the fraught communication is attempted? The cause of Ms. Cameron’s hesitation is to be found here.

No challenging tidings should be offered for the sake of the truth alone. Daily choices about what to say and how to say it are made by everyone.

We are now in the domain of the unmentioned and the unmentionable. Who will tell the other he has bad breath or a failed deodorant? Does your new female acquaintance mention your comb-over looks preposterous or you bore her to desperation? No, she just takes flight.

I’ve not met a single soul who needs to know everything about himself. One minute of complete self-awareness is a scorching, lazer-like invasion of insight. Inflicting pain in honesty’s name is cruelty disguised as moral superiority. The Hippocratic oath reminds us, “First do no harm.”

Let me put this another way. What does a psychologist give you and what does he take away? Therapy involves a transaction or exchange, as in all well-functioning relationships. What do you present or withhold and at what cost? How far do you go providing anyone painful knowledge?

One must not to take something useful away (including the foundation of self-esteem) without inserting a superior substitute. Mental and emotional defenses cannot be deconstructed without peril. They serve, perhaps imperfectly, but they do serve.

Some kind and decent people gain more by learning to deal with inevitable rejection than by heightened awareness of their lack of incandescence. Not a few profit from ways of enriching their lives without the degree of friendship or intimacy desired.

Do you see the problem with what I just said? The counselor who is swift to conclude his client unable to triumph over his limitations could sell him short.

Perhaps to protect the comforter from discomfort in delivering a harrowing message, he refrains from nudging the sufferer to exceed himself and improve his life.

A therapist is like a magical juggler. Before he walks off stage, he must do his best to provide as much or little of what the patient requires to stay aloft.

And understand how much weight the client’s reinforced wings can now bear.

Thanks to Emma Cameron for allowing me to quote her tweet.

The top photo is a Security Guard Sleeping on Duty, posted by Brad & Sabrina. The second image is Prince Florimund Finds Sleeping Beauty from Child’s Favorites and Fairy Stories. Both come from Wikimedia Commons.

28 thoughts on “What are the Limits of Telling Your Patients Something Uncomfortable?

  1. Dr. S, you make an interesting point about the struggle with approaching clients that appear boring. I’m wondering about this though: In your Socratic dialogue, have you ever considered to ask the following question instead: “Is there a time in your life where you were accepted and not rejected? Is there a time in your life where people found you exciting?” Posing the opposite form of the question might allow the client to initiate the very thing you want to get at. For instance, a depressed client might respond, “No, I don’t feel like I’ve been accepted at all. I also don’t feel people are happy to be around me. Instead, I feel like I’m boring.” Thus, the client initiates the conversation on being boring, instead of you. But then there’s the issue of agreeing with the client, when the client may not want you to agree with them about their own negatives. And even if you lie, the client will inevitably know or figure it out or feel gaslit when identifying a lie. The truth does hurt, but such is the nature of therapy itself. Saying nothing is the same thing, to me, as a friend who fails to tell another friend that their “fly is open.”

    On the other hand, another response to the question I presented above might also be this: “I do have times when I feel accepted, but those times are short-lived. I also feel that some of my friends will find me exciting some of the time, but not all of the time.” This might mean that a person’s “boring disposition” is only seen with different people and/or in different contexts, as opposed to it being a defining trait. There are some who thrive in certain (safe) settings, but who cower under the boring blanket in other settings that feel threatening, intimidating, etc. Perhaps that could be something to explore, in addition to leading into the discussion on someone’s boring disposition.

    Has the client always been boring, or were there times in the past or even the present that the client is actually an exciting person. For instance, a client might be boring in the therapeutic relationship, but maybe the client thrives in intellectual circles and at conventions with like-minded people. What one person might find boring, others may not. Perhaps a desire to be someone you’re not may be the answer to why some people are unhappy in performing a role they cannot live up to. Or perhaps there are cultural explanations that have yet to be explored, such as feeling religiously or ethnically pressured to “act proper,” instead of showing more life and expressing more excitement. Additionally, perhaps a person’s physical health and disability status have changed the ways in which the person interacts with others, and the person’s mobility problems affects their energy, which therefore affects their ability to engage with excitement; perhaps their boring disposition wasn’t a constant at all, but rather an effect of physical disability. One final thought/reaction: Maybe what the therapist finds boring to him/her might mean that the therapist has an ideal of what the healthy client would look like, sound like, act like, perform like, dress like, etc. – to the extent that the client may not necessarily need to change everything in the image of the therapist’s ideal in order to be “healthy” in terms of interpersonal relationships and psychological well-being, including self-esteem.

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    • All that you’ve said are issues the therapist should explore. I do think, however, that we resist the idea that 50% of the population, by defintion, possess IQs below 100. I’m not the last word on who is or isn’t boring. I wouldn’t enter such a discussion quickly and without much prior examination, but, one must at least consider the possibility that there are some dull folks out there and a special effort on their part is required to make themselves more engaging. The same “normal curve” that makes some faster or taller also explains part of what I’m talking about.

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      • Hmm. I didn’t think about IQ as being a factor, though I’ve met some “boring” people with higher IQs, and I, myself, can be quite boring at times (but then again, I may have dropped a few IQ points, LOL, but seriously). 🙂 I do know some “boring” people whom I think have low IQs (based on their grades in college and their choice of discussion topics). I sometimes reject the “boring” ones who constantly discuss their “booty calls” with their friends or acquaintances. I suppose in their own circles they might find this amusing, but definitely not to me. I’ve been rejected, but I’ve also rejected (and not always out of defense, but really, because I don’t have time to waste on certain discussions).

        Some questions I now have for you. Here are the questions: Do people with low IQs have the capacity to acknowledge that they are boring, and would they try to work on it if someone pointed it out to them? Put a very different way, are there examples of people with low IQs who are exciting? Are the terms “boring” and “exciting” subjective? Do those with higher IQs find that those with lower IQs are more boring than exciting? Do those with average IQs find the same people with lower IQs as boring as those with higher IQs? In general, do same-level IQs find each other more exciting than those with lower IQs? Is “boring” a factor or criterion in psychopathology, and if so, how?

        (PS: I’m trying to respond differently to blog posts now, in case you are wondering why my responses are sort of different from “my norm”; I’m trying to also keep things shorter, but I’m not there yet, apparently. I’m still “me” though.)

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      • Glad you are still “you.” Good questions, but way too many to answer. Let me take you in a different direction. Part of what I hoped to offer in this post was an unconventional way of looking at treatment and its limitations. It is “talk” therapy and not easily achieved unless people are fluent. Maybe we expect too much. And yet, one of the most memorable people I treated was a man who worked a physical job for one of the utility companies. He’d served in combat. He “knew” things and if you stuck with him, he offered the substance of himself: a man’s man with nuance. He had integrity and grit. That said, therapy isn’t a cure all any more than the suggestion that college should be available for all. To me, this is a misapplication of a “one size fits all” solution to a post-industrial problem. In the absence of jobs dependent upon physical labor, and with the specter of being replaced by computers, it is a silly and ineffective answer. Kind of like the maniac who says he’ll bring back all the coal jobs. My overall point, being, in our search for hope, we often jump to simple answers we can give to our often desperate fellow-men. Therapy isn’t for all, college isn’t for all, marriage isn’t for all, etc.

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      • Thank you, Dr. S, for your reply and explanations. It’s so hard to not jump to simple answers though. But you’re right – therapy isn’t for all, and there are limitations to therapy. Your unconventional way of looking at treatment sounds really interesting, and it raises a lot of questions. I tend to go on tangents, which strays away from the topic you had intended to discuss. Sorry about that. I liked how you redirected me though, which helps! 🙂

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  2. The most boring people I’ve met are the ones who think they are really interesting and insist on taking up your time. A person in therapy is at least making an attempt to improve their life. So, I say they may become ready to hear some straight talk. The tricky part is when and how. But definitely worth a try.

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    • I enjoyed your comment on this, especially when you said “I say they may become ready to hear some straight talk.” I think clients are stronger than what they appear in therapeutic settings. I’m also an avid believer on strength-based approaches and positive psychology, even though I can be negative a lot of the time. I was also wondering the same thing – when and how to approach?

      You also brought up a good point about those “who think they are really interesting and insist on taking up your time.” I can admit that I’ve done this boring thing to others – a lot! Given factors like narcissism or showing off or proving yourself – such exhibits can impose on others by taking up their time with “boring” discussion. Sometimes I forget to engage with the other by asking them questions, becoming curious about what they think, etc. But the reverse has to also be true; the person who is constantly speaking about themselves may feel as though others do the same and leave them out, so they might inappropriately challenge themselves to doing the same. We learn how to engage with others in social interactions, and sometimes people have learned this in social settings – not just filial settings. With the advent of social media, including Facebook, Twitter, and WordPress, came the advent of what some researchers have observed as online narcissism. Take a selfie or a photo of what you made for dinner and talk about that – are these things really engaging others, or are they, instead, topics that are tantamount to children saying, “Hey, mom and dad, look at me and what I can do?” When reinforced over time, in-person relationships can become dulled. There may be many reasons why people consider themselves interesting enough to fill others’ time, which can make for an interesting discussion between two or more people if the rejection doesn’t happen first.

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      • Yes to the idea of online narcissism. Taking constant photos of oneself is surely the death of any individual substance below the surface. It is also a good start to an operational definition of a boring person.

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    • Thanks, Joan. Very tricky. One ought never to say “gee, you’re boring.” But a therapist can ask questions and be gentle, but still direct.

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  3. Wow, reading you guys is fun! Thanks! TS

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  4. Therapists really do have a difficult job. You must continuously assess your patient and make a judgment as to what they can handle and what they cannot, and any little mistake can send the patient leaving your office upset (whether it is visible or not) and they may never return. You not only have to evaluate their self-esteem but also their mental status and even though this can become second nature to the therapist, it is a huge responsibility and can be exhausting. A slip of the tongue can be crushing to some people. I do not know how a therapist would go about helping to change a dull patient. The key word is “helping” and if the patient is not taking what is being taught to them and applying it to their lives, there is nothing that can be done because in the end, it is the patient’s responsibility. This would apply to all therapy.

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    • I enjoyed reading your comment to this post, Nancy. To add on to what you were saying, however, I think the therapist also has a responsibility to know when the client may need to be referred to a different therapist who can help with issues that the present therapeutic relationship cannot. Being a therapist is a huge responsibility, and there are protective factors that can help therapists to not feel overwhelmed, burdened, exhausted, or burned out with certain clients or with the overall nature of the biz. The responsibility in a therapeutic relationship is no solely on the therapist, but it is also not solely on the client. Both must do their part; if the expectations are that one is to do all the work, then the therapy will not work. One factor in administering psychotherapeutic treatments, in my opinion, is assessing the client’s level of self-motivation toward doing the work in therapy. If the client isn’t motivated but nonetheless is there to seek treatment, then a great place to start is figuring out what motivates them. If they’re dull, motivation may be a harder issue to address, but maybe a discussion on the antithesis of your observations would help them to see within themselves what is exciting. The irony in some treatments is that one learns to see the positive affirmations without stating negatives, but the negatives are what are being addressed repeatedly in therapy. If positive psychology (e.g., strengths, post-traumatic growth, resilience) includes a discussion on what is exciting to clients (that is, if clients don’t also struggle with anhedonia), then that will help to balance the boring and negatives in their lives. If the client needs encouragement to self-motivate, that’s important, too. Dismissing clients because they aren’t taking full responsibility does a disservice to those clients who are there because they struggle with that very thing – taking full responsibility. If the therapist is not trained to treat that, or is having counter-transference issues with that, then the therapist is responsible to refer the client to a more appropriate treatment setting. In a therapeutic relationship, the therapist is responsible for some things, and the patient is responsible for others; neither one is fully responsible at all times for the success or failure of a treatment. That said, a client is responsible for taking that information and applying it to his or her life, but if he or she has difficulty in being responsible like that, that should and can be explored in therapy and with a therapist.

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    • As I suggested in one of my replies to Multinomial, therapy isn’t for everyone. Not everyone can be helped, unfortunately.

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  5. In response to Emma Cameron’s tweet, “But to me this seems like a recipe for increasing social anxiety, self-judgement and shame, which many therapy clients already struggle with…” …

    What I believe is missing from her observations as a professional is the notion that clients are not always that “fragile.” Fragilizing clients, according to certain articles online, means enabling clients to believe that they are more fragile than they are in terms of being able to embark on truths about themselves, change required to improve a person’s quality of life, and their abilities to handle social anxiety, self-judgment, and shame, etc. When professionals try to protect their clients too much, they fragilize them with phrases like, “I don’t think you’re ready…” or with non-actions like, “I’m not going to address this issue because I think it will harm the client more, or retraumatize them.” This does a disservice to clients because clients, or patients, like medical patients, deserve to hear the truth about their symptoms, disorders, and treatment options. Opening up with patients about what you are observing may mean that the therapist get rejected if the client is turned off by such truths, but that will mean that they aren’t ready for therapy to begin with, and so they have every right to terminate until they are ready. If they come back, then that’s a sign that they are willing and strong enough to work things out, even if what has been brought to light elicits anger on the part of the client. There are ways to empathize without patronizing, and address the client as a capable adult who can handle adult conversations. If clients have a tendency toward suicidal ideation, self-injury, or turning to addictive substances after hearing negative truths about themselves, then raising those truths will also help to unravel their maladaptive coping mechanisms when they hear such truths in real life. There may be a way to approach this with empathy and positive psychology, as opposed to “attack-like” therapy or responses that the client perceives or really sees as disgust from the therapist. When people are bored, or when they find a person, place, or thing boring, their reactions are similar to disgust, passive-aggressive anger, or overt anger. In classrooms, students don’t pay attention and may procrastinate when doing assignments in a “boring class,” for instance. In therapy, the therapist may have a challenging time paying attention as well to totality of the “boring” client. Indeed, it seems like a delicate issue to bring up, due to the profession’s requirement to “do no harm.” But harm could mean the absence of a necessary treatment, or the absence of disclosure about a symptom. Adult clients may present like “immature children” at times, but treating them like children in response when considering that they “aren’t ready” to hear something important about themselves only reinforces their insecurities, vulnerabilities, and low self-esteem. To build self-esteem, one must be able to accept criticisms and negative truths that are constructive rather than destructive, and to be able to distinguish the difference. The therapist should be there to construct and heal the destruction. Overall, what Cameron suggested by not disclosing or addressing the nature for which a client is boring can also bring about an iatrogenic effect because lack of disclosure can mean to the discerning client that “even their therapist does not understand them or trusts them enough to disclose what they really feel.” Clients are more aware about certain social cues than what therapists may think, and they may have more strengths than what are addressed and allowed in a therapeutic environment.

    I forget if it was Beck who said that empathy is better than sympathy, and I remember asking that (still unanswered) question – why is this? Well, to perhaps answer my own question, sympathy can be patronizing and infantilizing and fragilizing to clients who are capable of handling the truth, even if such clients have a tendency to become depressed, anxious, suicidal, or self-destructive. There’s a difference, also, between attack therapy, destructive criticism, and therapeutic criticism. Attack therapy might push someone over the edge, and destructive criticism becomes more destructively stoic than empathetic when addressing matters such as these. But avoiding discussions can be equally as attacking and destructive because it indirectly tells the client that they are too “fragile” or “weak” or “disordered” to handle the truth and discussion about those truths. Rephrasing with empathy could mean the world to “boring clients” who need to know what all their symptoms are, and who deserve to figure out how to bring more excitement, social capital, and love into their lives. If the client isn’t able to feel excited, comfortable with socialization, or feel love, that is another issue – perhaps a more antisocial or schizotypal or schizoaffective type issue. But if the client is able to feel excited, socialize at times, and desire/feel love at times, then there’s hope to address the boring issue. Limiting the growth of clients by fragilizing (and infantilizing) them can be more damaging than telling them a painful truth about themselves.

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  6. A delicate balancing act for the therapist, I’m sure. During my religious training in community life, we were told to “speak the truth in love.” It usually worked only in one direction: from up to down, much like the therapist-patient relationship. After all, we were young religious in training. When I finally got the courage to speak my truth about community life, the Mother Superior was unprepared to respond without causing harm to my fragile psyche for years to come. I was the one lacking, not the community.

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  7. Perhaps we all need to develop the ability to say difficult things — with care. Like many other abilities, it is a tool capable of being misused. I lost a few patients trying to get them to see themselves, after exhausting every method I could think of to lead them by setting a trail of breadcrumbs for them to follow. I lost one very special friend this way, too, many years ago. One can go too far. As you say, Rosaliene, this tends to work top down, not the other way.

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    • It’s very difficult to face the dark truth about ourselves, Dr. Stein. More so, I imagine, when it comes from our therapist.

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    • Losing friends or clients after saying a hard truth must be difficult, Dr. S. Maybe some people do not want to change, but rather be accepted for who they are. I am sure that therapists and friends accept the dull, even in the midst of trying to help them change and grow. We cannot help all, and friends come and go for many reasons. All we can do is be true to who we are and accept what comes in or goes out of our lives. You tried your best, and that has to count for something. When we seek absolution, we often find new insights and/or forgiveness for ourselves or others. There are ways to say difficult things, and there are ways one can choose to react to those difficult things. Dialogue works best, but some are more comfortable with walking away for whatever reason. We can only hope that when they walk away, they are able to find peace, joy, comfort, and well-being.

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      • Thanks, Multinomial. I would add this: such things are low on the list of a therapist’s tasks. He ought not to want to look at this type of issue as a first order of business. However, once having dealt with everything else, the question I’m asking is, might it be helpful for a counselor to offer guidance to self-improvement that might help the patient do better at this already stated goal of better relationships? If I were the doc, I’d also make a private determination of whether I believed the client were capable of change in the area in question. If not, then no point in raising the issue.

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      • What you say makes sense. Wowzers – I had no idea how hard your job must be until reading this because, it seems, every action or inaction you take matters. What a responsibility, and a heart to care enough to weigh all these options! (PS: I like to debate once in a while, just to see what the arguments would be on both sides – and not with the intention of stirring up negativity. I enjoy learning about all this!)

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  8. To go off on a tangent, I wonder if the dull are offended because they consider themselves an unconventional subculture, in the same manner as those who are terminally ill, reclusive geeks, aesthetically challenged with physiological abnormalities, mobile challenged, bedridden, intellectually disabled, deaf, blind, introverted, selectively mutated, etc. When it boils down to it, there is only so much one can do to improve themselves in social settings. When their limits have been reached, that is where they must find peace and contentment. Not everyone is popular, smart, socially intelligent, emotionally intelligent, talented, energetic, exciting, physically fit, attractive, or lucid. But given their limitations, they may still benefit from therapy when they can accept their limitations and find joy in something, even if that something is boring. Rejection is part of life, and people can build tolerance for the dull, boring, disabled, terminally ill, unattractive, lame, deaf, blind, insane. Not everyone in life will be fully abled, for one reason or another. Therapists are limited to what the client wants and needs out of therapy. Sometimes there are no solutions, no cures, and no treatments. Sometimes etiology matters.

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  9. Thanks for another thoughtful, interesting post. One has to consider that, from a psychoanalytic point of view, the patient being “boring” is resistance, and the response by the therapist a breakdown in empathy and a counter transference.

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    • I agree, Harvey, that a breakdown in empathy as representative of the therapist’s counter transference is a definitely possibility. On the other hand …

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