Why Therapists Search for Your “Useful Discomfort”

One of the therapist’s first tasks is to gauge the new patient’s discomfort. If he is drowning, the doctor’s job is like that of a lifeguard, to secure and elevate him straight away. But if he is treading water, head still well above the chance of a big gulp, the inexperienced counselor’s mistake must be bypassed: taking or allowing the sufferer into the swirling downspout of his emotional whirlpool.

Entrance there leads to a subterranean dark place on a high-speed descent. His well-being and stomach for counseling might be left behind.

The depth of psychic trouble will often — and often must — wait. Trust in the relationship and safety come first. Only when some grounding work is done can you best search for a place I’d call “a useful level of discomfort.”*

Useful how? The patient, assuming the distress is not entirely new, waited for some time to come to a professional. The woman or man lived a complicated life, tried self-help books or will power or faith or work or drugs or sex or each of these to better himself. Arrival at the clinic means nothing worked or worked enough.

He needs to move past his sticking point, the concerns he didn’t want to think about, open up about. If he becomes overwhelmed, however — by too much, too soon — a premature end to the office visits is likely. Stopping short of the mucky floor of his emotions is necessary. There is a zone of useful discomfort in a less acute, sustainable place higher up.

The in-session professional senses this, watches for it. Imagine the consulting room divided in half. On one side of an invisible partition sits the counselor. On the other, his client resides in a breathable, transparent fluid. Much movement occurs within the liquid, high and low, serene or agitated or depressed: the entire range of possibilities to which our hearts are subject.

The individual requires acute attention. Where he exists within his emotional space might change a dozen times before the clock suspends his share of the therapist’s face-to-face focus; in the same place or another, up or downriver.

Here is one of the reasons the doctor monitors the elapsing passage of the hour. He must, if he can, retrieve the drifting, disconsolate patient before session’s close; get him to shore. Leaving him with “useful discomfort” is often acceptable. A client who is worse off with regularity as he leaves the building is a guarantee of treatment failure. Health care professionals don’t want those in their care suffering the engagement too much.

The time is and is not the patient’s, though he purchased the visit. He owns that it happens, but the provider’s job is to manage the way it happens. Think of the latter as a traffic cop of sorts, the conductor of the flow of ideas and moods. The doctor reinforces the guard rails, keeping his charge from careening off the tracks, the chasms in his psyche through which he will fall if the session ends in the wrong place.

Those in psychotherapy possess many escape hatches. Full frontal immersion in a place they have avoided will force them to rely upon these old survival techniques and defenses. Only these, not their healer, then signal possible relief. The patient will have returned to the place of his former misery, but be glad because the prescribed ministrations, interpretations, and nudges made him worse.

The lesson of useful discomfort takes you forward, not retreating from life. Much of our flourishing depends on finding a way to tolerate unpleasant situations, not flee them. Resilience and courage incubate here. With experience, the formerly uncomfortable territory becomes less noxious. The circle of life enlarges.

The therapist should not be like a sadist slow-cooking you on a spit. His desire for your useful discomfort is to sustain your capacity for facing your issues without making the offered remedy either a feel-good waste of time or an intolerable ordeal guaranteeing a defeat of the therapeutic project. In effect, he is saying, like Dorothy in The Wizard of Oz, ‘”you are not in Kansas anymore,’ but this is the necessary place for you now. I will do my best to make it manageable.”

Like Dorothy’s “yellow brick road” Odyssey, the effort leads to discovery of the strength inside you. From there, whether home or away, new adventures are possible. You are now the master of your self.

——-

The second image is Ancient Harmony by Paul Klee. *The expression “useful discomfort” is borrowed from a recent article about climate science/

16 thoughts on “Why Therapists Search for Your “Useful Discomfort”

  1. When I think of “useful discomfort” in any given relationship, I am reminded of drill instructors and police trainers. In basic and police training, their goal for discomforting you (physically, mentally, and emotionally) is useful because it is part if training, strengthening, and building you towards a future career. They have your best interests at heart, and they do not infantilize you on a level of weeding you out of their infrastructures or isolating you to disabled land (like some therapists and even advisors do). Like you said, the useful discomfort is meant to strengthen. However, there are times when therapists belittle instead of strengthen, judge instead of understand, discriminate instead of include, and counter-transfer instead of finding ways for the wounded healer to make the therapeutic alliance work. I have had an easier time in boot camp and police training than psychotherapy. I can honestly say that I hate psychotherapy. I love support groups that are non-discriminating. But I have met too many unseasoned or abusive therapists that I have given up… primarily because they have given up on me or seriously fumbled around with trying on different treatments they had just varely learned a week prior to our meeting again and again. Newbie therapists are the worst, and that is primarily what the VA offers. It sucks.

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    • Your comment is an important message. The guidance, “first do no harm,” is as old as the oldest of the helping professions. I am sorry you’ve had such a series of awful experiences with “helpers” who hurt you, Gayle.

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      • Thank you, Dr. S. It is strange that police and military training seem easier than psychotherapy to me. Psychotherapy can make or break you, whereas tactical training is very clear about making you. When therapists isolate, undermine, or misdiagnose their clients, it breaks them without any true self-actualization. Like discrimination and segregation, therapist may suggest, for instance, that their clients should be alone for a while, or abstain from work or education for a while, or believe themselves dependent on the therapist in order to get approval from the therapist to make any and all decisions. There is no empowering or strength in those things; stability phases in treatment can be the most damaging to a person’s self-concept, self-efficacy, and self-esteem when establishing safety and trust means weakening (as opposed to strengthening) via dependency on the therapist. Evading the necessary grief work or moral injury treatment when trauma has occurred or is continuing to occur, and when trauma has stripped a person through ecological losses (career loss, job loss, social capital loss; see theories on loss of resources) on top of traumatic sequelae (symptoms, interpersonal problems, behavioral manifests) is problematic and potentially harmful to clients. Continuous traumatic stress is real (not imagined), as evidenced by studies on grief and loss trauma, microaggressions (previously known as part of slights), medical trauma, and moral injuries during or as a result of trauma. Unlike PTSD alone, or those with other mental conditions whose traumatic past remains in the past and not in the present, continuous traumatic stress requires more than validation; it requires justice where appropriate, continuous comfort in safe spaces, a rebuilding of social capital, rescue, a type of grit in the midst of resilience, the ability to weep and express righteous anger until the trauma has been completely resolved, etc. Microaggressions are traumatic and, oftentimes, chronic and continuous stressors. Minimizing the pain of those who suffer from such things is tantamount to gaslighting and further evidence of bigotry in our nation. Drapetomania was a horrible example of psychologically gaslighting slaves with a mental disorder for their slave-based traumas and desire for escaping that continuous traumatic stress. Likewise, those who continuously experience school or workplace bullying, harassment, or any Title IX violation will present with more symptoms and distress than those with PTSD alone, etc. Those youth who are constantly vigilant about their surroundings in violent neighborhoods or violent foster homes are continuously exposed to trauma as well. Those youth who never received justice from child welfare continuously suffer silently in their parent’s torture room for years in childhood and sometimes throughout adulthood. Polyvictimization is not always the responsibility of the individual. Minimizing the current traumas in treatment is adding more trauma to the client. In such cases, uncomfortable nudges like influencing clients to believe that microaggressions are molehill slights instead of injurious mountains that cripple reputations and careers is an example of an iatrogenic effect at best, therapy abuse at worst (especially when the therapist has not had any cultural sensitivity training and is unethically treating a marginalized client, or when the therapist has bigotry issues that went unresolved). To me, uncomfortable nudging should not mean ad hominem attacks, attack therapy, gaslighting, narcissitic abuse from the therapist who is insecure about his or her job, etc. Helpful and therapeutic discomfort should include things that help a person escape or find the strength to escape (or accept rescue) from a current traumatic situation. Threats to life include career and reputatuonal losses, most often stemming from microaggressions. The modal personality of bigotry that runs rampid through our nation shows a societal personality disorder and demands an extermal locus of responsibility, even when its victims can resiliently assert their own internal locus of control. The do no harm clause should extend to how therapists are educated and trained before and after their licensure. Knowing the risks of what clients face when presented with not only prescribed talk therapies but also to whom clients engage with (i.e., the personality and issues of the therapist in relation to the personality and issues of the client) cannot be understated as an afterthought of dare I say malpractice at worst or mistreatments at best. I am not the only one hurt by or afraid of psychotherapy, and I as well as others should not be pathologized for that. Continuous traumatic stress can also occur in treatment, which then makes psychotherapy a traumatic trigger and a threat to someone’s life. Threats to life are more than physical threats of death; psychosocial threats and ecological losses threaten both social and physical aspects of lives, and the social and physical aspects are interrelated, as evidenced by the relationship between environmental effects and mortality rates. Survivors know this, but sometimes therapists do not.

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      • drgeraldstein

        Much more to respond to than I can do, Gayle. To the extent that therapists work in outpatient settings (especially private practice), they might (by choice or opportunity) not see many of the people about whom you are writing. If they are wise, they practice in the area of their competence. Those who do not (as you suggest) run great risks to their patients, who will likely be unaware of their potential jeopardy. In a society where mental heath treatment (especially out of big cities) is in short supply, those who don’t have heath insurance too often have limited therapy options. I imagine those in the kinds of situations you describe were part of the reason for the outcome in the 2018 US election.

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      • Thanks again for your reply, Dr. S. What you said makes the most sense regarding those with limited incomes, and then also about the outcomes of the 2016 US election. Limited therapy options often include new therapists who are not well seasoned enough to deal with the kinds of issues that minorities and marginalized persons face, including race-based traumatic stress (see work done by Carter et al., multiple years spanning from 2007 forward), microaggressions and their relationship to post- and ongoing traumatic stress (see Sue et al., multiple years spanning from 2011, give or take), the less-studied continuous traumatic stress (a blend of post-traumatic stress from the past and ongoing polyvictimization in the present; no citations that I can think of off the top of my head, but the notion exists somewhere), poverty as an anxiety-producing stressor in terms of unsafe/violent neighborhoods and ongoing trauma exposure, discrimination in all areas of life (including, but not limited to, race, gender, veteran/military/law enforcement/government status, disability status, mental health conditions, physical health conditions, weight, appearances/dress/aesthetics, etc.). When clients are asked to challenge their thoughts and potential “irrational” beliefs against what exists in their world, what unseasoned or untrained therapists may not understand are the real (not imagined) stressors and trauma-exposing elements that do NOT exist in the untrained therapists’ world. Untrained therapists are, for the most part, NOT impoverished, not residing in neighborhoods where watching your back is the norm, not having to decide whether to socialize with friends or pay out-of-pocket for mental health treatment (whereby socialization is shown to reduce traumatic stress, but one must be able to afford outings in conjunction with ongoing therapy), being judged harshly by toxic family members, being discriminated against at work and in higher education (whereby the more affluent powers in such institutions expect more work and emotional subduing from marginalized persons than their more affluent counterparts; boundaries of the marginalized are often disrespected and questioned by both therapists and educators/employers, for instance), misdiagnoses in both mental health and physical health settings are seen as a behavioral problem (i.e., a denial) as opposed to a rational/true medical-based trauma that must be validated and addressed, and disorders that exist solely as an iatrogenic effect to misdiagnoses (e.g., increased symptoms of anxiety and depression, or latent personality disorders due to iatrogenic effects of misdiagnoses and mistreatments in early adulthood or adolescence), etc. Further, many minorities hold a cultural belief that psychotherapy is not helpful for them, that community support (collectivism, as opposed to individualism) is more beneficial to helping their communities get back on track with life. You’d rarely hear a therapist offer minority clients an option to protest, for instance; instead, you’d hear them seemingly “blame-the-victim” when individual responsibility is placed on the individual’s ability to change their thinking or modify their behaviors, as opposed to realistically seeing a systemic problem that warrants lamentations, protests, and justice-seeking. Minimizing their pain as irrational beliefs/thoughts and their lamentations as behavioral problems is akin to creating a social taboo (or stigma) against them, thus furthering their pain and their distrust in psychotherapy. Trust, if the first phase of treatment, should include the therapists’ responsibility to trust their clients’ words as “rational fact” before “irrational psychopathology/delusional thinking.” Unless there’s a factitious disorder at play, or unless clients present with both irrational and rational thought patterns (which could be the case in some, but not all, circumstances), then many marginalized clients will continue to feel harmed (not just slighted) by the documentation of psychotherapists that could prevent them from getting certain jobs in government or beyond, which further prevents them from affecting positive change in such directions. There’s a hidden layer at both the higher education level and the hiring level comprising “gatekeeping,” and psychotherapy documentation comprising misdiagnoses could itself harm clients’ outlook on life, thus bringing on a double-whammy of PTSD symptoms based on medical trauma, or whatever categorization of trauma that exists, depending on the taxonomy of trauma purported by the specific orientations at hand. Being a lawyer, government employee, etc., require mental health, but certain people who would otherwise have a better chance at a “recovered status” were made worse (and in some cases, permanently disabled) by maltreatment in therapy, misdiagnoses, stigmas affiliated with misdiagnosed labels or therapy notes, specific therapy abuses, malpractice, etc. Those kinds of losses add to threats to the individuals’ lives, and thus adds more trauma on top of medical trauma in the form of grief-and-loss trauma. These ongoing, continuous traumas are more than mere slights described as symptoms of a few mental disorders; they are actual harms that affect a person’s ability to self-actualize or maintain life as they knew it. There are many similarities to those who have suffered military sexual trauma and other non-combat military personal traumas, as well as military personal trauma and civilian-based interpersonal traumas; their victimization has affected their outlook on life, no matter how hard they try to be resilient, think rational, bow down to common accepted thoughts, withhold their emotions, bite their tongues, and accept the status quo. Anger from others is less acceptable than feeling righteous anger within, but anger itself is often pathologized as a personality disorder, as opposed to a feeling all humans get when truly being betrayed/harmed by those who are supposed to support them (e.g., boss, mentor, educator, therapist, parent, medical doctor, dentist, clergy, etc.), or when the majority of society stigmatizes a group of people (e.g., Hispanic/Latino, African American, obese, nontraditional students, veterans, etc.) and then stunts their individual, academic, and professional growth. These grievances are not only the responsibility of the individual to overcome, but also society. Untrained therapists may minimize such pains and pathologize them as behavioral problems or delusions, when in reality, they are actual representations of bigotry victimization, microaggression victimization, and other interpersonal traumas that should be considered violations of victims’ boundaries, not the other way around. When the therapeutic alliance is ruptured via arguments between an untrained therapist and a marginalized client, the marginalized client gets a written record of a misdiagnoses by the therapist, or considered “treatment-resistant,” or considered “difficult,” or considered “too complex for care.” Where’s the healing for these groups of people? And is it really that far from the statistical norm, or has research negated community-based PAR paradigms that seek participants in the community, whose voices would reveal that which traditional researchers will not find among non-complying participants? Research is limited to the data collected; there are missing data in terms of marginalized voices, as well as elitists’ voices – two ends of a polarized nation. How many people were “traumatized” by the 2016 election, and then by continuous hate-like speech in the media, and then by an uproar of structural violence as a result? How many bigoted perpetrators would be deemed as personality disordered versus their victims? In terms of statistics, victims are often given personality disorder diagnoses (often misdiagnoses, in my opinion), when in reality, the bigoted perpetrators are more antisocial, narcissistic, passive-aggressive, and cruel (which should warrant them having a personality disorder above and beyond what their victims get on paper). PTSD is heterogeneous in terms of how those in power see the “victim” as a “true victim” or as an “emotional beggar.” If the PTSD is quickly resolved, then the PTSD was “real.” If the PTSD is a lifetime struggle, then victims are seen as overly-emotional, lacking in boundaries, delusional, etc., especially when their trauma continues (i.e., is not solely stuck in the past). The past election has caused a lot of grief and trauma for victims, and it has instigated personality issues with everyone – in my humble opinion. The taxonomies of such things need more research, more work, better definitions, better treatments. It’s not enough to tell victims of hate crimes or discrimination to keep pressing forward without also comforting them in the continuous struggles that overload their limbic systems on a daily basis. Allostatic overload is an understatement when trauma is pervasive and attacks the quality of life of marginalized persons. Structural violence is challenging to see in society let alone individuals. Although there are really good therapists out there, or at least some newbies who are willing to grow with their struggling clients, there’s a huge group of people (myself included) who have been harmed. At least you, Dr. S., are willing to listen and consider the possibilities without taking these thoughts personally. I’m sure you were an excellent therapist when you were in practice. I may not know all there is to know about psychotherapy, but I know enough to share what I’ve experienced from others, with others, and by myself. I may not always be rational, but I’m more rational than not, as evidenced by my many successes among my many failures. I feel for those who have it worst off than me, and I’m saddened that I have yet to find an opportunity where my own purpose could be actualized to be able to help others, without my own life being scrutinized by well-meaning and not-so-well-meaning persons of power. I want my life and others’ lives to be meaningful, and for victims’ voices to be heard. It helps to know that you hear me, even if my arguments are flawed in some (or even most) areas. I try, and I’m learning, too. I know that therapists don’t have an easy job, and there are benefits to tensions within therapy. I just cringe from my own PTSD at the thought of uncomfortable relations in therapy. I swear that what I need is a year of trust-building and mourning in order for me to get there, but policies for treatment and orientations all around do not allow for such long-term care for victims like me. Instead, I live with the stigma from all, and I deal the best I can. That’s how I see life now. It’s sad that I’m hurting so much from the thought of psychotherapy today than I was a year ago and years before that; certain harms by certain persons of power can really change the way a person (like me) thinks – and not for the better.

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  2. I love the way you’ve described this. I often refer to it as times when my therapist gently nudged or guides me slightly outside my window of tolerance. Doing it with their support,’insight, validation and empathy makes it possible without complete breakdown. I feel safely held when I’m aware they are orchestrating this careful navigation through my useful discomfort.

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    • drgeraldstein

      Glad to hear you have a therapist who sounds like he/she is mindful of what you need. Thanks, too, for your praise of the essay. Be well.

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  3. Dr. Stein, your article sounds like invaluable advice to health care professionals, now starting out on their professional journey.

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    • Thanks, Rosaliene. As with most things, most of us learn the hard way! But, we do try to pass along what we’ve learned, and to inform patients what to expect and how to know whether their therapist is right for them.

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  4. Dr. S, BTW, I know I can be over-the-top with my responses. I’m venting mostly. I’m sorry about that. But I’m grateful for your understanding and replies, and I do see the importance in “useful discomfort” in treatment. I suppose I expected a bootcamp-like outcome to that, whereby I’m being strengthened and supported (instead of torn down and disbelieved). I’m sure there are plenty of great therapists out there, or many who learn from their experiences and grow into very helpful clinicians. Like Rosaliene said, your post offers good advice for practitioners, and like you responded, you send a message that helps not only those practitioners, but also patients and their expectations of good treatment. 🙂

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    • Thanks, Gayle. As you’ve heard me say before, in writing and in life I’ve concluded that less is often more. You have lots of good things to say, much of it from a perspective of experience that few others have (in part because they’ve been luckier than you). All of us who write must work on refining our communication so that we can find a way to make the best possible impact. Be well.

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  5. JoEllen Reaves

    Thank you for making my journey manageable…even when it didn’t feel that way.

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    • drgeraldstein

      Thank you, JoEllen. It certainly did not look easy from my end. As I hope I have expressed to you, when the subject of courage in therapy comes up I always think of you and your life both before and after you consulted me. No one else, by the way they have conducted their life both to get through treatment and after treatment, represents a greater tribute to the human spirit; no one. It was an honor to be a part of your life.

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  6. My therapist has a way of challenging me in the gentlest way, with his soft voice and manner, and he can really get me thinking about my patterns in a way I have never considered. I like it when I am challenged, or when I am spouting about something, he will pause and have me consider another way of looking at it, which will lead to an “ah ha” moment, and my belief that he is a magician.

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    • He sounds talented and just right for you, Nancy. Moreover, if he ever retires, he can always go on stage and pull a rabbit out of a hat!

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