I think it's a fantastic article. I love that it emphasizes that techniques and credentials matter so much less than the relationship; all the emphasis on CBT lately tends to obscure that.
My only minor quibble would be that while you can request that a therapist not take notes during the session (and if it's bothering you, you should), but most therapists are legally required to keep notes about each of their cases, so you can't ask them not to keep any notes at all. That might have been what the author meant, but it was a bit confusing.
And I liked the beginning part about therapists not being advice-givers. I've been finding that my clients who seem the most frustrated by therapy lately are those who come in thinking I'm going to give them tips and tricks, or a checklist of things to do ("Top Ten Ways To Beat Grief!"). Some of that can be helpful in therapy, but it's kind of a side thing, not the essential part of the work.
What I found is that when people come to therapy is that they are not usually told by the therapist what the therapist will and will not do. Some therapists are advice givers and some clients need practical advice about stuff, about meds, are they dealing with a personality disordered boyfriend, dealing with ptsd.
And other therapists specialize in helping the client know their own mind, their self, which is much more subtle, a deepening process.
I prefer therapy to be a combo, knowing oneself plus dealing with practical things in life in a reality based, informed way.
Example: I went to one therapist years ago with the agenda of working on weight loss. I'd already done a lot of therapy dealing with core issues but really wanted to work on the psychological side of my being overweight and said that to the therapist. One September, after she'd been away on her August holiday I came back to the office and she was noticeably thinner. I said, wow, you look great, how did you lose the weight? She said, "Diet and exercise". I said I hoped she'd share what helped her get to that. She wouldn't share.
The session ended and I went to the rest room, she left the building. On the way out I noticed a wallet by the public phone. I picked it up and looked inside for ID (pun unintended, lol). It was her wallet. Next to her business card was one of a personal trainer. Ah ha. So that's how she let go of the excess poundage. huh. Wonder why she couldn't share that with me?
Gave the wallet to the administrator downstairs.
Stopped going to her after that. Felt like a ripoff. Sometimes it can just help to have practical tips, even if there is no one way to do anything, along with the deeper awareness.
The first time I went to a therapist I was in undergrad. It makes me laugh now, when I think of it, but I came to the session and he said "So, what brings you here?" And I told him, (which took about 30 seconds), and ... that was it. I had no idea what the next step was and he didn't guide the session at all. So we sat there in silence for quite a while and then he said that if I didn't have anything to talk about, he didn't see a point to continuing. Maybe he thought therapy was something people were born knowing how to do. I had no clue what I was supposed to have been talking about and being dismissed made me feel like a complete failure as a human being.
(Of course I felt that way when I walked in, which is why I was there, so I can't really lay it all on him.)
occhiblu, why are they legally required to take notes? That's creepy. That implies they'll be legally required to turn them over to someone someday. Ew!
There's legal CYA for the therapist (documenting issues like suicide or homicide assessments, CPS reports or calls, referrals made for issues that are outside scope of practice, etc.) and financial CYA for the therapist (it's good to have a record of how many sessions and on what dates, in case there are issues with payments); documentation also (in my opinion) creates a paper trail for both the therapist and the client so that there's an official record of what happened in therapy -- which would hopefully discourage inappropriate relationships between therapist and client and encourage helpful interventions (I know that I might let one session get chit-chatty, because sometimes people need a bit of a break, but if I start to see a pattern of no real work getting done in sessions, then I need to do something to address that).
And yeah, the notes can be subpoenaed, but all my professors and supervisors have very much encouraged writing notes that would not compromise clients if they were to be seized, while at the same time remaining accurate. So it's not like they're a minute-by-minute account of the session, more like "Talked about issues with father. Seemed more withdrawn today. Need to address med compliance next week."
On the larger issue of tips and tricks -- the trap that can happen is that the therapist who gives out tons of tricks and tips puts herself in the "expert" role without helping the client develop her own confidence. I'd rather find out what's already working for the client and start building off of that, rather than saying "X worked for me, so you should do that, too." That doesn't help the client build any competency or assert any autonomy.
I'm not a fan of the totally silent therapist, either, though. But I think you can encourage people toward healthy behaviors and healthy functioning without dictating the ways they should get there.
On the larger issue of tips and tricks -- the trap that can happen is that the therapist who gives out tons of tricks and tips puts herself in the "expert" role without helping the client develop her own confidence.
Interesting you see it that way. Presumably the client is coming to the therapist because they are expert in the field of psychology? See, that's what can be so confusing to the client. Therapists don't say, "I'm not going to inform or educate you about practical life. I'm going to prompt you obliquely to think/feel for yourself without you being educated about psychology. I'll be the educated one but hide the information from you, while judging you. You have to grope around trying to make sense of your suffering/life/relationships and pay me for that."
The practical component seems missing to me. It would make sense, imo, for the therapist to outline the path for the client(school of psychology they believe in), what they think that works as a healing process and transparently discuss what the therapist perceives as the healing process with the client from the beginning.
I see the tips more about being informed, having the information to be able to function practically, have an overview or for comprehension. Eg. no amount of being confident will substitute for a needed antidepressant or trying to comprehend the malice of a malignant narcissist.
But that practical aspect needs to be balanced with the client's introspection, feeling feelings and deeper awareness.
[On preview: Yikes, this is long. I'm hoping it's at least interesting!]
nickyskye, part of it definitely does depend on the therapist's theoretical orientation. But my favorite (and I think reasonably widely held philosophy) is, "The therapist is the expert on healthy functioning; the client is the expert on her own life. They have to work together collaboratively to transfer that knowledge to each other."
In my classes and in my various readings, I've thought a lot about the paradigm switch that's happening that's moving mental health (and medicine in general, to some extent) away from the "Old white man in white coat stands in judgment of your life and lectures you about what you're doing wrong, then gives you instructions that you must follow to the letter to get well" idea (generally called the Medical Model) toward a more collaborative "The client is the expert on what works and what doesn't work, the client's opinions about her problems and about the outcomes of interventions are fully valid and need to be factored into the treatment plan, and the therapist's role is not to harangue the client into conforming to the therapist's idea of what proper behavior is but instead to help the client find her own truth/happiness/centered being."
That shift is coming from a few different impulses, but the one that I think is affecting it the most is a growing sensitivity to treating non-white, non-male, non-straight, non-Western clients. There's been an awareness that many of the "norms" that therapists have been taught are not the only way to be psychologically healthy; the best examples tend to come from family therapy, where the model has been that each generation must differentiate from the preceding one, that over-involvement between generations is pathologized as "enmeshment," that the romantic link between the parents should be strongest link in the family unit, and various other WASPy cultural norms.
These don't translate so well onto other cultures' family systems all the time, where arranged marriages might be the norm, or a mother's relationships with her children (esp. daughters) might be seen as the thing linking the family together, or where children's obedience to and identification with parents lasts throughout the lifetime, not just until the child turns 18 (or 14).
Feminist theory also gets mixed in here, where there's a reaction against the model in which a dependent (usually female) patient goes to a powerful (usually male) doctor, and he uses his power and knowledge to judge her and fix her. (Psychiatry's history with locking women away as "hysterical" when they wanted things like meaningful work and independence makes this one resonate pretty strongly, at least with me.)
All of this combines to kind of hit therapists upside the head and say, "You have no idea whether your clients share your values and your culture. Sit back and learn from them. Don't impose your ideas of what's right and wrong, work within their own values whenever possible and be careful, respectful, and sensitive when you feel you must intervene in a way that goes against them."
So there's a push to empower clients more, to view therapists as one resource among many that clients can take advantage of rather than as saviors who are the only ones strong enough and smart enough to fix their poor clients. (This framing also helps therapists avoid burn-out -- if you believe in helping your clients get strong enough to live without your help, you're less likely to fall into a martyr complex of feeling you must turn yourself inside-out to "help" others.)
However, there is also an awareness that some people *do* need practical help, and that if you're working with clients who don't have housing or food or any sort of stable living situation (eg, abuse or extreme poverty), then you do need to address those practical concerns before anything else. And, of course, if you're working with clients with severe mental health problems or addictions, you have to factor in that their decision-making abilities might be compromised. But even in these more extreme cases, the goal should still be to empower the client, however slowly, and to work toward greater degrees of autonomy and lack-of-dependence on the therapist. It shouldn't be "I've printed out all the forms you need and filled them in for you; sign here"; there are ways to help clients while leaving them in as much control as possible.
It's not really about hiding information, it's about knowing that the information the therapist has is only about one-sixteenth of what's helpful. You also have to factor in the client's values and whether that information conflicts with them, the client's willingness to be challenged at that moment, and all the other stuff going on in the client's life and how to sort of triage this particular problem.
I think AskMe is kind of a good example of bad therapy -- you can see how defensive people get, even when they're in completely unworkable situations, about being told their situation is completely unworkable. Or even, sometimes, just being told "Do X." AskMe makes up for it because you get a multiplicity of voices giving you advice, so the asker can sort of keep their defenses up by picking and choosing what's helpful, but if an "all-knowing, all-powerful" therapist, in a one-on-one situation, made those same kind of demands, it would shut out conversation and damage the relationship.
Aaaaaaaand (getting back to the original article), the relationship is really the thing that's therapeutically helpful. Techniques are important, but 80-85% of what actually helps clients (and they've done studies on this) is just having a relationship with someone who doesn't judge them, who listens to them, and who has empathy for them.
Textbooks call this "rapport" or the "therapeutic relationship" and it's far and away more therapeutically healing than any tip, trick, or technique. It's also the one thing they can't really teach therapists, and it's also the thing that's going to vary most from client to client and therapist to therapist, because you can't force a relationship. That's why they tell you to shop around and find a therapist you click with, because that's 85% of the work right there.
That's it. That's what therapy is. Learning what an empathic connection to another human being feels like, and learning that you deserve it in your life. The rest is commentary. :-)
Dear occhiblu, thank you *so* much for your thoughts on this. I really appreciate the time you took and that you expressed your thoughts to me. Of course it was and is interesting.
One of the things that was unexpectedly interesting was that I pretty much disagree with you on most of those points. Guess we really have a different take on therapy.
Maybe the kind I'm familiar with is people who have been through the wringer, not merely neurotic?
Learning what an empathic connection to another human being feels like
In my experience of wounded people they are often intensely empathetic and may have intensely empathetic relationships with other wounded people. But that this is not necessarily a dance of authentic of emotionally well balanced intimacy because other ingredients are necessary to have a meaningful, healthy relationship, which may not have been modeled in their childhoods. Like: knowing about healthy boundaries, appropriateness, the give and take of healthy strokes, having healthy conflict, interpersonal communication styles that are based on dysfunctional family dynamics.
The "rapport" or the "therapeutic relationship" may not be able to be determined by the client if what they have known is unhealthy relationships. The therapist may have an idea what they think is a healthy rapport but how is the client supposed to know the expectations of the therapist if the therapist doesn't explicitly say this?
I like Eric Berne's idea of a mutual contract between the therapist and client, in which expectations and commitment to the contract are transparent.
AskMe isn't especially a good place for therapy questions because it's a rough house, not emotionally safe or gentle. But, that said, sometimes people need a simple reality check because they may not have that in their lives or have a blind spot and AskMe has plenty of rough hewn reality.
The values thing. It's hard to know the values of a therapist, they don't say what's on their mind. It's a gamble for the client that may takes years of sessions to find out, both costly and time consuming. I wish therapists were more straightforward in what service they provide their clients, about themselves, a thorough biography, psychological approach-preferences, their skills, what they think works and background information.
Anyway, I appreciate talking with you about this. I'm a long time admirer of yours on the blue and it's really nice to meet you here.
I agree with what you're saying, mostly, I guess I'd just say:
Things like boundaries, appropriateness, etc. seem to be best learned through modeling, rather than explicit "101" instructions. I think. I'd be willing to admit I'm wrong on that. But I think it'd be most useful for the therapist to model, and the client to bring up whatever feelings came up for them due to that modeling -- that is, the *client* needs to learn the skill of saying, "I don't understand why you're acting that way, it's making me uncomfortable." And the therapist can (and should) model that somewhat, but I think this is a case in which explicit instruction can get strictly academic and unhelpful real fast.
But you're right, I haven't dealt with severely compromised clients, and I'd be willing to imagine that my norms might change somewhat in those instances.
On the values thing, though, I don't think it should matter, at all, what the therapist's values are. Therapy shouldn't be about trying to figure out what the therapist wants and then doing it. With my clients, the only thing *I* want is for them to find ways of being that work for them (and aren't harmful in obvious ways, like being illegal or hurting other people). I want them to find ways to understand *themselves*, not understand me. I should, over time, become a non-entity in their lives. My goal is to help them listen to themselves and connect to that deeper knowing.
It doesn't matter what I know, because while I'm smart n all, I'm only a single human being. I can't know what it's like to be anyone else, to have their struggles and their experiences and their desires and their challenges. So it's all about what *they* know, and how to develop that further.
And, in my opinion, the best way to develop that capacity for self-knowledge is, from the start, to assume that a client has it and for the therapy to rely on it. Which means the client's in charge from the get-go.
As an addendum: As a client, I tend to do really well in therapy (even before I studied to become a therapist) because I tend to like to please authority figures, and I'm good at it, so I end up assigning myself therapy homework and getting really motivated to change because it's fairly easy for me to see what I need to change, and the ways the therapist can help me with that. So while I've had to deal with the feeling of being judged by a therapist (coming out of my own insecurity with not knowing what an authority figure wants of me), I've never really had a feeling of "I don't know what to do" in therapy. So that's not a frustration I've personally felt, so I may be being tone-deaf to the frustration of dealing with it.
Afternoon dear Occhiblu,
Wish I wrote empathic instead of empathetic, lol
Things like boundaries, appropriateness, etc. seem to be best learned through modeling, rather than explicit "101" instructions.
I haven't found that true, since the 50 minutes in a therapist's office are quite formal, courteous, it's a paid service one goes for, not really a two-way conversation in the ordinary daily-reality sense of that experience in which one might have to be explicit about setting boundaries or appropriateness.
Naturally, the topic of boundaries has many aspects to it, some subtle but some quite simple, which may need to be spelled out bluntly in simply worded statements like:
I have the right to say no whenever I feel something is not safe or I am not ready.
I have a right to not participate in either the active or passive “crazy-making” behavior of parents, of siblings, and of others.
I have a right to leave the company of people who deliberately or inadvertently put me down, lay a guilt trip on me, manipulate or humiliate me, including my alcoholic parent, my nonalcoholic parent, or any other member of my family.
I have a right to put an end to conversations with people who make me feel put down and humiliated.
I have a right to a mentally healthy, sane way of existence, though it will deviate in part, or all, from my parents' prescribed philosophy of life.
You said: And, in my opinion, the best way to develop that capacity for self-knowledge is, from the start, to assume that a client has it and for the therapy to rely on it. Which means the client's in charge from the get-go.
Since the therapist's belief system, in terms of what school of psycvhology they believe is valid, determines the guiding of the client in their quest for knowledge, of self and relationships between the self and others, I think it makes sense for the therapist to spell out their belief system to the client, openly, maybe in a flyer.
There are some aspects of therapy that are not necessarily about self-knowledge but may be more about practical aspects of life, such as is the client dealing with a spouse or parent with a destructive personality disorder? How to handle that, practically.
Or, if the client has ongoing depression, what part is unresolved feelings and what part is neurochemical needing meds?
The danger, imo, of people-pleasing with a therapist and knowing what would please them, because one has studied psychology, is that the client cheats himself or herself out of healing. It re-enacts an old pattern of not being true in order to feel liked by the therapist and being expert at it.
When you said: assigning myself therapy homework and getting really motivated to change because it's fairly easy for me to see what I need to change, and the ways the therapist can help me with that
I'm curious to know what worked for you in therapy homework? Are there books or techniques that you found useful/effective "homework? Were those techniques the kinds of things that you think might help others?
Once you did your therapeutic homework, how did the therapist "help" you with that?
Hope I'm not aggravating you with my questions. Whether you reply or not, thank you for the interesting and stimulating dialogue we have already had.
I think maybe the issue, overall, is that everything you're saying, I agree with, but when I think, "How would I explain this to clients?", it still comes down to such a case-by-case basis that I don't think there'd be a good standardized spiel. Even just partly because for every client I've had who wants explicit "This is what I'm doing now, and why" or "This is why you're doing that, and why" instructions, there's another one (or three) who tune out when I start with that. That actually is a technique, pretentiously called psychoeducation, and it's just one of those things that some clients find helpful and others find lecture-y, and as a therapist I need to kind of feel out what info the client wants, when, and how.
And, of course, there's always a risk that too much instruction or explanation can turn a session into head-only, without engaging any emotional content or awareness.
And I'd also say, clients should ALWAYS feel they have the right to ask their therapist for any of the things you're talking about. I don't think any of that info should be KEPT from clients, and I'd have *no* problem sharing any of that with any client who asked.
I'm uncomfortable only with the idea that *all* clients want it in the same format, or that it would be helpful for all clients in the same format.
As for my own therapy experience and "homework," it was never particularly formal, it'd just be more like I'd have a sense of accountability to the therapist and want to make sure that I had *done* something over the course of the week that we could discuss during the session. Kind of a way of putting my money where my mouth was; things like taking a risk and sharing more of myself with a friend, maybe, or really making sure that I was staying emotionally aware during an anxiety attack so that I could describe it better to my therapist. It wasn't like I left each session with a definite plan for the week, more just that I would consciously watch for opportunities during the week to put into practice things I had been talking about in therapy.
Sorry, I know that's kind of vague. I guess it's mainly that I tend to go into therapy motivated to change, and I see the therapist as someone who can talk things over with me and hold me accountable, but that the change has to come from me -- *and* that the important change is not what happens in the therapy room, but what happens outside it. So I want to use the sessions to talk about how I'm trying to change outside the sessions. Which requires that I'm trying to change outside the sessions.
oh wow. Nicely unexpected your reply. How delightful to have this dialogue with you.
What comes to mind reading your reply is that you are basically an emotionally well person, not terribly damaged and no horrendous relationship patterns but mostly needed to tweak having less anxiety, less insecurity in our life, to develop possibly deeper intimacy patterns?
I'm used to a more rugged survival terrain for myself and in the recovery groups I run online for adult children of pathological narcissists. So, in those instances, much more practical info is really needed, solid education in personlaity disorders and co-morbidity, books, ptsd survival, legal advice, forensic science books, handling the damage done by such parents with may include lots of compulsivity issues, custody issues, self-medicating for depression/anxiety with destructive behaviors and enmeshments etc. A combo of psychology, social work, 12 step meetings, family dynamics and object relations theory.
I read one of your old posts here today saying you were going up for a job helping the addicted or those with BPD. That will, I imagine, be more rugged.
What's cool I find these days about the field of psychology is that there are so many different techniques, ways to learn, to heal, Gestalt, EMDR, psychoanalysis, Adlerian, CBT, Winnicottian, Jungian, 12 steps, trauma-bond treatment...online, offline, on the phone, via email, one on one, in groups, the whole gamut.
So nice getting to know you a bit dear occhiblu. :)
Online groups would be different for me, though, than doing individual therapy. People have much more ability to absorb written info, I think, and can pick and choose on their own what to click through, what to skim, what to comment on, etc. And I, at least, would *expect* more concrete info in that situation. And even in-person groups need a bit more structure and info, I think, to keep people from feeling like they're at sea.
So what you're saying, given your format, makes total sense to me, and is probably how I'd run it, too.
And right now I'm actually working with grief counseling, so... I don't know if "rugged" is the right word, but maybe "raw" would apply. And people are certainly looking for tips and tricks... unfortunately the only "trick" is to keep feeling awful until you feel better... It's really difficult to watch people going through these awful emotions and *not* try to give them answers, but, really, there *are* no answers. Grief just tears you apart and breaks you into pieces and your job is to figure out how you want to put those pieces back together. I can tell you that exercise and meditation and journaling and talking to people help -- and they do -- but they don't fix it. They just give you additional time and energy and resources and courage to examine yourself.
ha, loved my typos last night. ack, lol.
You said in relation to grief: unfortunately the only "trick" is to keep feeling awful until you feel better...
See, again I disagree with you. Imo, it helps to know in healing that grieving is an important process with stages and that it's a meaningful part of life, an expression of what one values and is saddened by its loss. Some parts of grieving are kept and other parts fall away over time as the loss is incorporated into one's life. Grieving can feel like it will never end, some parts of grief end, change, morph and some parts remain as a tender part of one's heart, part of one's inner landscape one can always visit if one wants.
Some people are afraid that if they stop grieving they will lose their only connection to what is lost, destroying their own life while grieving, almost an attempt to go with whoever died or went away.
A site that has excellent, practical tips on the grief process:
Excellent and practical book:
The Grief Recovery Handbook : The Action Program for Moving Beyond Death Divorce, and Other Losses
by John W. James, Russell Friedman
There are, imo, many lessons in grieving. Sometimes one grieves something that was toxic in one's life, an enmeshment or an addiction, which is different than grieving a healthy relationship or loss.
A post I wrote back in 2001 to an online recovery friend about grieving the loss of her pathologically narcissistic and abusive/battering ex-husband. I feel differently now that I've been through my own grieving process, it's not a hole in my life any more, phew. Included here as an example of what I think of as practical info...
Dear Recovery Friends:
Grieving the loss of a relationship with a Narcissist has many layers. They are not the usual layers of grieving a healthy person. The problem is that some of the layers ARE the same as grieving a healthy person but then there are layers reserved only for the loss of an N relationship, which are not understood by the 'civilian' population and can ONLY be understood by those who have survived a significant relationship with a Narcissist or Psychopath.
In a healthy relationship break-up one grieves:
The dream of love not continuing.
The break in the continuity of the familiar.
The pain of saying goodbye.
The sadness of the exchange of ill will in the parting.
A sense of loss.
Living with the nostalgia of things one used to do together, broken memories of past pleasures.
Well wishing put aside for self-survival.
Those are typical feelings that can come up after a break-up of a healthy relationship.But grieving an N there are other ingredients, not available to the public understanding, such as:
The nightmare of going from being idealized to being devalued.
Discovering the web of lies on many levels.
Coming to terms with the terrible understanding that one was not an object of love but a source of Narcissistic Supply. That in itself is so painful that it has many stages of comprehension
The dawning of understanding that one's nostalgia and tender memories of affection for the N were corrupted by the N's agenda.
Not being believed by people about some of the weird things the N did and feeling isolated in one's grief more than in grieving a healthy break-up.
Discovering with some horror, mingled with relief of a strange kind, that the person one loved was not the person one thought one loved. Everything about the relationship shifts into the garish clinical light of the DSMlV. One's object of former love is now something of a lab specimen, "a typical N".
Not being able to let go with love but having to let go only with understanding. The closure itself has the sadness of knowing the ex is disfigured, deformed but always dangerous.
When one hears one's healthy ex is having sex with a new person, married, or has gone on in their life, there is a sting of sadness, the nostalgia for 'what could have been'. That itself, the astringency becomes part of the detaching. And as time goes by that sting becomes a well wishing, including the ex in one's loving prayers. The ex gets woven into the fabric of one's fond memories.
But with an xN, news of their present life always bring chills of fear and twinges of unresolved grieving. Who are they hurting now? Will they ever come into my life again? Was I not important to them, was all that for nothing?
Knowing about the N's need for Narcissistic Supply one cannot help thinking will they come back for my NS? Was *my* NS something they treasured and miss? But in the light of day, understanding the N means that one is not valued for who one IS but only as a commodity, for Narcissistic Supply, empty, meaningless NS. After the detachment is physically complete with an N there is the nagging abyss of was that all for nothing? It's a terrible loss and there is nowhere to go with that loss. It's static. It doesn't evolve into lost love. It just remains as a loss. Grieving a N is a burden, it's a hole in one's life.
The pain of grief can, imo, be 'fixed' as it heals, as any wound heals and is 'fixed' but what is meaningful about grief, valuing what is lost, remains and can also evolve over time.