therapeutic relationships

March 27, 2016

Can a Therapist Know How You Feel? Must He Have Courage? Thinking About Essential Qualities in a Counselor

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Does a therapist “know how you feel?” No. How could he?

But he may still be able to help you even without such knowledge.

Why don’t I know how you feel? I am not you. I am not your age or perhaps your gender. We may not share the same faith. I wasn’t born in the same place under the same circumstances. My parents made more money or less than yours, lived with extravagance or pinched pennies. They survived the Great Depression well or badly or not at all; and so forth.

A counselor is not in your skin, so can’t know the sensations which comprise your life. Yet he can have some idea, perhaps even a good one. What might that idea be based on?

First of all, you are both human and have a certain set of shared, although not identical experiences. Speaking for myself, as a seasoned counselor I talked to thousands of people who told me what they thought, revealed how they reasoned, and explained how events influenced their mood. I therefore became familiar with the range of what is possible in reaction to an enormous number of circumstances. I also read text books, received instruction from teachers, and shared in the richness of emotion, perception, joy, and adversity found in stirring memoirs, novels, plays, and movies.

Despite all of this, I am open to surprise. An example: my father died abruptly in the year 2000 at the age of 88. I’d known he was mortal at least since the time of his heart attack when I was a boy. Prior to his death I counseled many people who were suffering from loss. Still, despite dad’s advanced age, his demise was shocking. Like the flick of a switch — the “here today, gone tomorrow” unreality was too true. Unexpected fatigue lasted for months, as though the life force taken from him had been emptied from me as well. Even now, years after this loss, I can’t say for sure “I know how you feel” if you tell me about the death of your father. Your relationship with him and the circumstances of each of your lives might cause me to rely more on imagination than something closer to your lived experience.

I would argue we cannot even recall how our own pain felt once the distress recedes into the moderate or distant past. Big events do not remain unaltered in the museum of the brain. Rather, they are like a photo faded by the sun. We need painful memories to diminish, which would otherwise leave us in a perpetual state of agony. Even splendid, heavenly recollections, if remembered with their original impact, would compromise our ability to attend to the most crucial elements of each new day. To some degree we must unconsciously forget or transform our life history.

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You might ask me: “How then can you help me grieve my loss if you can neither ‘know how I feel’ nor retain an unaltered remembrance of your own loss?” In several ways. I can listen to you and bear witness to your pain. I can be sympathetic. I can accept the emotions and stories you share: the varied combination of sadness, anger, exhaustion, and sense of separation from the world accompanying the death of a loved one. I can abide with you, acknowledge your suffering, and “be there” until it passes. If you will accept the comfort, our relationship will help to reattach you to life, even while you are grieving something that rends the same cord of attachment.

You will never be what you were before your loss, of course. But, you are more likely to heal if you share your grief. Holding it in or trying to “move on” too quickly — or shedding your tears only in private — can cause your sadness to pass by inches or not at all. Human contact in the aftermath of loss is crucial. A supportive spouse, friend or therapist can help. Time does the rest.

My sympathy for you doesn’t require I first possess knowledge of your internal life any more than enjoying milk requires a prior existence as a cow. Best not to say you know how another experiences his suffering. It is enough to tell him you care. Indeed, were you to fathom every detail of the emotions passing through another without caring, absolute understanding of his pain would count for nothing. Genuine concern — not some magical power to read another’s heart — is what counts. A patient will often forgive a therapist’s momentary failure to grasp his upset, but ought not to accept his indifference even if his knowledge of the patient’s emotional state is exact in every aspect.

The counselor carries an imperfect bag of tricks. Like the wounded soul who comes to treatment, he risks failing at the task he shares with his client, even if the courage demanded of the patient is greater. The therapist also assumes the frightful responsibility of caring for another with no certainty his effort will avoid tragedy, even if his burden and terror are less than the patient’s own.

The practitioner is always practicing. He must work to learn more and attempt to heal you no matter how much knowledge and experience he has. His therapeutic arsenal is never complete. Psychotherapy research is forever making new discoveries. Fortunately, if the therapist has the knowledge, dedication, and experience along with the courage to allow your heart to touch his, what he has tends to be enough.

In accepting you as a client, he risks injury to both you and himself. Why? In short, because you do matter to him. In treatment with the best healers, that is the one thing of which you can be certain, however much your relationship history causes doubt.

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The top photo is Misty Morning by flagstaffotos.com.au/ The second image is Cirrus Clouds with 3-D Look by Simon A. Eugster. Both are sourced from Wikimedia Commons.

December 6, 2015

Why Your Therapist Will Say the Wrong Thing

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What follows might not be what you want to hear. Therapists don’t talk about it publicly. I hope, however, this gets you thinking about your counselor’s aims, what you might want him to do, and what is reasonable to expect of her or him in the effort to be the best possible healer.

Girl in Therapy recently wrote a post called How Your Therapist Signs Their Emails, reblogged by Life in a Bind with an insightful preface. The gist is captured here:

This thing, let’s call it a pet hate, is email sign-offs. You know the thing people write just before their name? And more specifically, the way my therapist signs off on an email or text.

She “hates” such closings as “kind regards” and “best wishes.” The blogger wants something different from her therapist than the equivalent of “a warmed-up, just vomited fur ball that I’ve stood on in bare feet in the middle of the night.” She is both funny and serious. Sirena (her name) desires the parting portion of a missive to acknowledge the intimacy and importance of the relationship. At least, that’s how her plea sounds to me.

Quite understandable and, based on comments to the two bloggers I mentioned, she has lots of company. The easy “solution” for a shrink called out on this point is to be more creative. Fashioning personal words is simple enough. We can all do with some small tenderness. A thoughtful parting sentiment touches the heart.

The target I want to address, however, is a problem reaching beyond text farewells. Sirena’s concerns lead to the general issue of a therapist’s delicacy in communicating with his client vs. the use of words that cut or fall flat, whether in session or in an email.

The counselor has lots going on in his head, as I wrote in What is Your Therapist Thinking?  He needs to weigh his words and avoid frank episodes of insensitivity. And yet, there are reasons he sometimes misses the mark.

Here’s why: at the same time he is trying to help you he must not be preoccupied with a paralyzing, word-by-word self-analysis of his language. Were he to do everything in his power not to injure you (by an oh-so-careful self-scrutiny) he would risk hurting you by missing a different portion of the overall picture with which you present him. Once bereft of needed spontaneity — a slow, studied, halting treatment would be a bitter masquerade for a proper talking cure.

Self-consciousness psychotherapy by the person guiding it is useless. Your doc couldn’t do his job — the job you want him to do, the job he is trying to do — with this restriction.

Think of a surgeon terrified by a possible slip of the scalpel while he is guiding the knife. Were I his patient I wouldn’t expect ignorance of the worst medical errors, but I’d much prefer him to be “in the zone,” not fraught with the potential for a literally paralyzing surgical mistake. A doctor characterized by calm, focused attention, and control is the person I’d want. This is the reason surgeons don’t operate on their own children. This is why your counselor’s concern for you might, on occasion, seem callous or inattentive. If he were your parent and therapist — both — he’d be an emotional wreck and you’d be the worse for it.

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A  counselor cannot be equally burdened by the anticipated impact of his every word and simultaneously dialed-in to all the other important events happening in session. Put differently, if the surgeon or the therapist is too self-conscious he will not leave you unscathed (pun intended) by an injury much worse than an occasional, temporary hurt feeling caused by an ill-chosen expression.

I am not saying he wants to harm you. Indeed, words matter, as does your safety, but I hope you do not put his office on surveillance by the word police. His care of you and for you cannot be like holding a priceless antique Chinese porcelain doll. If the shrink must maintain perpetual alert over possible injury, he risks infantilizing you.

We all deal with a similar challenge. How much protection should we render in conversation with our friend or neighbor? Can we expect a dinner companion to acknowledge his own tendency to misinterpret or over-think what we’ve  said? Are we alone to blame for misunderstandings?

Most patients make lots of allowance for an occasional undiplomatic comment, to their credit. Were the doctor’s office a place where nothing painful between the shrink and his client occurred, no patient could return to the world ready to thrive. The first step out the door would be like the shock of a newborn’s exit from the womb.

In summary, I’ve tried to explain the following:

  1. The therapist mustn’t steal the patient’s initiative and responsibility for owning his own part in the relationship with a counselor. Yes, sometimes a problem is all the healer’s fault, but not always.
  2. Part of growing, in and out of the treatment room, is learning what’s important, what are the little things, who is your friend (however imperfect), who the enemy, which issues will be resolved if you work at them, and those requiring only patience and time. We all need to do this. I am not immune from the obligation of trying to sift through the events of life and attempting to put everything in the proper cubby-hole, working on a few things that are my issues, setting others aside, ignoring some slights and addressing others.
  3. Whatever your work is, you can paralyze yourself (like the the surgeon I mentioned) by a too constant internal look, especially while you are in the act of performing that work. Remember, even if the therapist utters an ill-considered phrase from time-to-time, in the long run the most important things eventually get addressed by a good practitioner.
  4. If his words bother you, raise the alarm, especially when this is a continuing pattern. What seems obvious to you might not be clear to him. He should want to know of errors and improve himself. Be prepared, however, that whatever you say is potential grist for the treatment mill. Sometimes the issue is his, sometimes yours, and often you are co-owners. The percentages depend on you, him, and your interaction together.

These opinions are mine alone, though I’d guess I’m not the only therapist holding such beliefs.

Hope this helped.

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The top image is called Miedo-jeno by RayNata. The photo is Adolescent Sad Girl by stars alive. Each of these is sourced from Wikimedia Commons.

February 22, 2015

Trust: The High Hurdle of Therapy

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All relationships are either therapeutic or non-therapeutic. Or perhaps I should say, sometimes therapeutic and sometimes not. A relationship with a counselor is not exempt from this complication. Bloggers in treatment suggest that no other topic so unsettles the soul.

The heart is easily torn. A therapist tries to get inside a patient in a way more intimate than most sexual encounters. The client is expected to strip down before the healer in a metaphorical sense. Remember, our custom of shaking hands derives from the need of two souls to prove they are unarmed — that to be near is not to risk injury. Even without weapons, however, danger is there.

Partners in friendship, love, and therapy make assumptions. Sometimes these unstated beliefs undermine the possibility of understanding and trust. Trust is like a garment made out of words and expressions; actions and expectations. In the space of less than the 50-minute hour, the fabric is woven, unwoven, and back again. By a shift in the body and a smile. By a raised eyebrow and a word well-chosen, poorly chosen, or misunderstood. By silence or its lack. By whether the counselor recognizes the tiniest of tears in the corner of an eye. By whether the patient — gaze downcast and terrified — misses the same evidence she would otherwise observe in the healer.

Too often we expect the impossible of people to whom we are close: that if we are cared for, the other will know what we are feeling and thinking automatically. “He should be able to tell,” we say to ourselves. This belief shifts the responsibility for the achievement of trust and understanding to the other; whether a parent, a spouse, or a psychologist. Sometimes it is reasonable, often not, especially when both parties are adults.

Part of what makes understanding hard (even if we do not assume the other owns a crystal ball) is a question of access. No one else can get inside our head. We have knowledge of ourselves, or what we think we are, in the bright light of the mind. We possess an internal and effortless but utterly precise grasp of our own meaning. Yet for all the clarity available on the inside, our counterpart is in the dark, far from the possibility of direct observation. He cannot see within us, only the outer disguise and armoring. He may consult the dictionary meaning of our words and interpret our expressions and movements, but not more. Relationships die when the other is obtuse and insensitive, and also when too much is expected.

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No one is a mind reader. The job of comprehension leading to trust is a duet, not a solo performance. Like all good performances, it takes rehearsal. Repeated rehearsal.

Therapist and patient, when they are well-matched and both working hard, spin a spider’s web as the session begins. The fibers are fine, almost invisible. With time, the net grows. If strong enough and recreated session after session, the strands thicken and better bear the weight of personal disclosure. Yet they still can be torn and retorn.

This is not necessarily a bad thing. All of life must be tested and resilience can only grow out of disappointment. We live in a world of unreliability. Nothing is permanent and yet we seek permanence. So we weave the web — together. With familiarity, the strands are more easily rewoven when a rift develops. Confidence grows. A safety net seems possible.

Remember, this is an act of becoming, not of being. There is no “one and done” here. Repetition, persistence, and continued effort despite the fraying of hope are required.

Nothing above absolves the therapist of the need for finely tuned sensitivity, laser-like focus, and dedication. He must do his best to recognize messages often disguised; must take care not to injure. Nor does this free the patient from taking incredible risks to reveal herself, even though her history says revelation and vulnerability will result in a terrible end. Tearable of the thing we call trust, and terrible to the heart and body.

The most damaged of clients want to be known, but are afraid to be known. They are frightened to show themselves to anyone. Thus, their coded messages are misunderstood. Nonetheless, courage is essential. The unfairness of having to take one more risk carries no weight. They must do so repeatedly. Their healing is otherwise impossible.

Perhaps therapists should recite a disclaimer to the most damaged patients at the outset of treatment:

I want to understand you, but I am imperfect. I will not make a clean catch of everything you say. You might have to repeat or rephrase. You will test me, but I am helpless without your willingness to trust — to help me help you. This is asking a lot. I apologize, but there is no alternative. I will disappoint you, but I am earnest. We must keep trying to weave a beautiful fabric, like a magic carpet. One that will help carry you until you can fly without the support of a tapestry to bear you aloft.

The careful reader will be struck by how many visual metaphors I have used in this essay. I’ve tried to achieve your understanding by reference to what can be seen. In so doing, I have also been underlining how difficult it is to express oneself by abstract words alone. Put differently, how challenging is the therapeutic task of achieving understanding.

In the fairy tale, Rumplestiltskin, a miller’s daughter is said to be able to do the impossible — spin straw into gold. Such is the goal of therapist and patient, both at the wheel. They too must weave. Without even straw. They hold only the memory of pain on one side and a strained, always imperfect empathy on the other. Gold of a different kind — understanding, trust, and healing — can come of their teamwork.

Is this only a fairy tale, too?

Not if you have seen it happen.

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The top photo of a spider web on a pasture is the work of Nijeholt. The second image is a Magic Carpet created by איתמר סיאני. Both are sourced from Wikimedia Commons.