One of my classmates in graduate school did her doctoral project on the process of becoming a therapist. She said that, on average, it takes ten to fifteen years to feel comfortable with yourself and feel like you know what you're doing.
I saw my first client almost eight years ago. By her reckoning, that puts me a good way through the process, but not all the way. Certainly, I feel much more sure of myself than I used to, especially since I got back from Texas. I'm feeling especially pleased because last week, I had my first successful termination; someone who came in months ago with problems, and now feels much better, that we've solved them. We spent a month or so consolidating their gains and what they've learned, and then they went away, and I may never see them again, because they got better. That feels really good, and makes me feel like I'm starting to really know what I'm doing here.
On the other hand, I'm still new enough to remember some of the things I didn't know, starting out, and that a person might like to know. So, here: fourteen things it's useful for a therapist to know.
1. The obvious things that everyone says are, for the most part, true. You should get therapy before and while becoming a therapist. You should listen to your clients, and understand that despite all you've learned, they are the best experts on their own experiences. You should get supervision, and talk about what's worrying you about your cases. You should do outside reading and consultation when working with people of a different background from you, so they don't have to spend their therapy time educating you. You should do a thorough assessment (whether with a checklist or just by keeping your ears open) of your client's history, family history and genetics, medical history, past trauma, past suicide attempts and self-harm, what did and didn't work well for them with past therapists. You should practice good self care-- eat well, sleep enough, drink water, take your meds, do enjoyable, relaxing, engaging things outside of work/school, stay close with your support network, engage in religious/spiritual practice if that's something that works for you, take time off when you need it. All of these things are absolutely true, and I'll be glad to expand on them if any of them are new to anyone. I'm trying to make most of these pieces of advice ones I didn't hear much in training, but there's a collective wisdom in what everyone's teaching you-- use it. You're almost certainly not the one shiny exception to this sort of thing.
2. Your clients will remember what they say better than what you say. They've done studies about this-- people have much better recall for what they said in a conversation than what the other person did. So your job as therapist is not so much to tell your client wise things as it is to ask the questions that lead your client to say wise things. What you absolutely do not want to do get into a drawn-out argument where you try to talk them into something you think would be a good idea. They'll remember all the arguments they made about why they can't or won't or don't want to do the thing, and it'll get even more firmly embedded in their minds.
Which is not to say that they never listen to what you say. Sometimes they listen attentively, and remember what you say for years. But be aware: sometimes they ignore what you thought was your cleverest insight and remember, deeply and meaningfully, something you just tossed off. Sometimes they remember you saying something which you have no memory of saying-- or remember saying the opposite. And sometimes you say something which they argue or shrug off-- and then, six months later, they come back to you with this brilliant, amazing insight they have thought of all by themselves, and you hear your own words coming out of their mouths. The trick there is to not say "I told you so." Because honestly, it doesn't matter what you said; it matters what they heard.
3. Make the client do most of the work. Along similar lines to 2)... it's easy to fall into the trap of trying to fix everything for the client, of working your ass off to make things better and easier for them. And there's lots of work it's very worth doing (you reading about someone's culture or disability or job or subculture can add tremendously to the work), but you can't fix their life. You have no control at all over what they do outside the therapy room. So don't waste your time and theirs trying to get them to do what you would do. Your job is to point out directions they don't know about, to ask questions they haven't thought of-- but answering the questions is up to them.
4. Emotions are not dangerous. Actions can be, especially impulsive ones. But we often want to spare our clients distress-- want to help them feel safe, want them not to be in pain, want to not get them mad at us. To a certain extent, that's good-- certainly, we shouldn't do anything on purpose to make our clients unhappy or uncomfortable, and we should try to avoid doing it by accident. We should take care, especially in the initial session, for therapy to be as welcoming, empathetic, and secure a place as it can be. But sometimes therapists mistake the goals of "helping the client feel better in life," and "helping the client feel better in the room with us." We can't be scared of our clients' feeling anxious or yelling at us or sobbing their eyes out. If we work hard to avoid those things, what we teach the clients is that their emotions actually are dangerous, that they do need to be rigidly controlled, that the emotional sides of them aren't okay. It's not the worst thing in the world if your client is upset. It may be the thing they need most.
5. Your job is not just about helping clients express their emotions. You know how sometimes you can tell someone's been in therapy, because they tell you all about their deepest thoughts and feelings and issues, often using psychobabble, and then go on to explain that because of these things, they cannot possibly fulfill their responsibilities, or be tactful with other people, or cope with whatever situation they're in? You know how, when you're not dealing with them professionally, those people can be really annoying?
I think that those people are what happens when someone has therapy that only goes halfway and then stops. It's an endemic thing in American culture, in many Western cultures, that we repress our feelings. We try to think logically, rationally, and consider feelings to be weakness, instability (possibly feminine). This leads to a lot of problems-- feelings are useful, as information about aspects of our lives we may have noticed but not consciously processed, as power-sources to motivate us and strengthen our determination. And so a huge part of psychotherapy is getting in touch with our feelings, with the parts of ourselves we felt as children and learned to ignore or dismiss. That is, indeed, really important.
But it's not enough. Our inner children are valuable, and worth listening to, but for the most part, your clients are adults. (Even if you are working with children, they won't be children forever.) Emotions matter, but they don't actually matter more than the physical realities of your clients lives-- their logistics, their jobs, their relationships, their responsibilities. Your job as a therapist is to help them find a balance, to be in touch with their whole selves, not just the neglected emotions. It can't be either-or... they need to come away able to live their whole, adult, lives, to know the emotional tolls, weigh them appropriately, and make decisions. You want your client to come out of therapy able to say, "I do not want to do this thing-- it makes me feel terrible in a bunch of ways, some of them related to my childhood. But I need to do it anyway. So I will feel terrible, and take it easy on myself in other ways, but I will still do this thing, because it needs to get done."
6. Bring a book. This one is sheerly practical; sometimes, your clients will be late. Sometimes, they won't show up at all. You want to have something else to do besides wait for them. Because there are a zillion reasons someone might show up late, or not show, and they're worth exploring and considering thoughtfully. That thoughtful exploration will be really hard if you've been sitting there stewing, waiting, wondering whether they're going to show up and why, and getting worried or annoyed or whatever else you get. So bring a book, and not just any book, but a book you really want to read, so you genuinely won't mind when they're not there right on the hour.
7. There are more clients out there for you. And more therapists out there for them. When I first started out, I would often cling hard to each potential client, because I was afraid that if they didn't come in again, it was because I was doing a terrible job-- or that they were suffering terribly, and I was their only hope. But the fact is, not every client is a good match for every therapist. Someone might just not click with you. Or someone might try therapy, and then realize that it's not right for them right now. And that's fine. Because the thing is, there are probably hundreds of clients out there with whom you would click well, people who are really interested in and ready for therapy. When you take weeks chasing someone who shows up for one appointment and then no-shows three times in a row, you're wasting the time of someone who could really use you. Sometimes it's worth trying to reach people, if you really, really want to work with them, or if they abruptly drop out after you've been working together well for a while. But keep in mind that it's not always. Sometimes, someone has the sense to get out of a therapeutic relationship that isn't going to work well, and you and they will both be happier if you respect that choice.
8. Therapy is worth the money. This one's hard. The first time I charged someone $120 to sit and have a conversation with me for an hour, I had trouble believing I'd done it. I mean... how could just talking be worth that much? But what I realized was: if a person pays you that much every week for four years, they will end up paying about what they'd pay for a new car. And if they see you that long, and do your job right, they will spend those four years learning things they will use every day for the rest of their lives. That's a lot longer than a car would last. You're not being paid just to have a conversation; you're being paid to teach useful skills.
9. It's okay for your clients to know more than you. Sometimes I will sit with a client, and it will occur to me that they are so much better than me at some important life skill. And not just things like sports or photography, where it makes sense they'd have expertise-- basic things. They dress better, they're (much, much) better at budgeting, they've been happily married for longer than I've been alive, things like that. It's troubling when I think of myself as meant to be a Wise Counselor, who can advise them on all aspects of their lives.
But that's not actually my job. Sure, I try to pick up as much wisdom as I can, from as many places as I can, so I might have some ideas about how to raise children, or find a knitting store, or whatever else. But being a therapist (as opposed to a priest, or a librarian, or a case-worker, or a medical doctor, or whatever else) means: I have expertise on how people's memories, beliefs, thoughts, emotions, and bodies interact. My job is to help them identify problems in those interactions, figure out what's causing the problems, and change them. It's true that memories, beliefs, thoughts, emotions, and bodies impact almost every other aspect of their lives, but the other aspects of their lives are not necessarily something I'll know as much about as they do. (For that matter, I won't actually ever know as much even about those things as they do-- I'll never have all their memories, or know all their beliefs, or feel exactly what they feel.) I ask the questions to help them figure it out; I tell them what studies say about what might be going on with those interactions, or what I've seen go on for other people. But I don't know more than they do about everything, I never will, and I don't have to. Which is fortunate, because if I did, I would be some sort of super-paragon, better than human, and I just can't do that.
10. Use your whole self, not just the parts of you that you think fit what a good therapist should be like. I mean, there are limits-- be polite to your clients, be professional, don't take out your bad day on them. But when you think of a good therapist, you probably think of someone kind, caring, patient, compassionate, non-judgmental. And when you find yourself sitting with a client feeling mean, detached, bored, bitchy, even hateful, you may think that you're doing it wrong, that you're being a bad therapist.
If you act on those feelings, you probably are. But just feeling them can actually be incredibly helpful, if you let it. Because those feelings may be coming from your own life, your own history (and you should have enough of your own therapy to be able to identify those, and work them out on your own-- or refer the client, if you can't). But they may also be telling you something very useful about the client's experience. If you feel nervous with someone, it may be because they feel nervous with you. If you feel bored by someone, it may be that they don't have much emotional investment in what they're saying. If you feel annoyed by someone, odds are good that many other people in their lives feel the same way on a regular basis, and that's probably affecting them a lot. If you notice your negative, "not-therapist-y" feelings, they'll give you useful information. They don't necessarily mean you're bad at the job-- they might mean you're picking up on something important.
11. The repair is more important than never making a mistake. It would feel great if we could never let our clients down-- never forget something they tell us, never be slow to return a phone call, never say anything that hurts their feelings. Certainly, we should try as hard as we can at those things. But they're going to happen, whether we want them to or not. And that's actually useful. Because ideally, one of the things that clients get from us is the experience of a relationship that's supportive and helpful. It's not exactly like other relationships-- we don't need anything from them except that they show up and pay us-- but it's still a relationship. And they will never, ever have a relationship with anyone who never makes a mistake, or who never hurts them.
The important thing, then, is for them to see what should happen when someone hurts you accidentally. To see what it's like to have someone honestly acknowledge a mistake, and apologize. To see someone hold a boundary without pushing past yours; to express anger at someone and not have them retaliate. Many people have never had that experience, or if they did, it wasn't in a way where they could examine it, understand it, and internalize it. If you and your client can get through the inevitable friction (and the friction is inevitable, simply because you're two imperfect people in a room), they'll understand valuable things about how to create a relationship strong enough to survive strife.
12. There are many useful things you can do. This is the best lesson of CBT; there are many techniques for dealing with mental health issues which actually work. There are ways of dealing with phobias, self-critical thoughts, traumatic reactions, obsessions and compulsions, ADHD disorganization-- there have been a lot of therapists, trying a lot of things, and many of them have been shown, over many trials, to work well for many people. Your clients don't have to languish in therapy for decades on end without much real change in their lives; there are effective techniques, and they're worth trying. They take some patience, but not infinite patience, and if something's not working at all after a month or so, try something else. Because people can change, become happier and healthier, and while they may not believe it (especially if they're dealing with depression), it's very useful for you to know this in your gut. This is part of why it's so useful for therapists to have good, effective therapy themselves-- you can't convince someone else they can feel better if you don't believe it yourself. But, yeah-- this thing we're doing? Works. Know that.
13. There are some things you can never fix. This is one of the most useful lessons of psychodynamic and existential therapy-- there are some things that you just need to talk about, and talk about, until they sink in, because nothing in the world can change them. You can't bring back their dead; you can't cure their physical disabilities; you can't change the discrimination they face; you can't get back all the years they spent being depressed and miserable. You can never go back in time and give your client the happy childhood they deserve, the parental love they needed and still crave. Your client is an adult, and you are not their parent, and that time is gone.
This sucks. It's something which your client can, in time and with support, grieve and get past, or at least learn to get through. But it's not what you might wish for them. And it means that one of the hardest part of the job, sometimes, is simply to sit in witness of something you can't do anything about. One of the wiser pieces of advice I've gotten is, "Don't just do something-- sit there." If you can bear to sit with the pain of your client's life, then they too may learn that that pain can be borne. If you don't bear it-- if you refuse to hear how bad it is, if you try a zillion techniques that don't address the real problem-- then you teach your clients that they're right, it really is unbearable. It can feel awful, it can feel terrifying, especially if things are so bad that your client feels suicidal. But there are some things where there simply is no way out but through, and the best thing you can do is simply give your clients some company on the journey. They probably haven't had company like yours before. It is valuable. It is worth something.
You can't fix everything. Really, you can't fix anything; only your client can fix things. But with you, they can realize just how strong they can be, just how much they can change, and just how much they can get through. And that's a lot.
14. You can do this. No, really. You can.
Go do it.
Thank you! This came at a good time. (Short version: lack of traineeship is endangering my graduation, and I'm feeling burned out and losing sight of what I'm actually doing this for.)
But be aware: sometimes they ignore what you thought was your cleverest insight and remember, deeply and meaningfully, something you just tossed off.
So true. I once used the "put on your own oxygen mask first" metaphor for self-care, thinking as I said it that it was such a cliche that the client would probably stop listening, but I couldn't think of a more original way to phrase it. Turned out that it was the first time they'd heard it and it came across as revelatory.
You can't bring back their dead; you can't cure their physical disabilities; you can't change the discrimination they face; you can't get back all the years they spent being depressed and miserable. You can never go back in time and give your client the happy childhood they deserve, the parental love they needed and still crave. Your client is an adult, and you are not their parent, and that time is gone.
Very true. And ultimately, their not being able to come to grips with this was why I fired my first therapist.
You have no control at all over what they do outside the therapy room. So don't waste your time and theirs trying to get them to do what you would do.
And that would be why I fired my second therapist. (Where the "trying to get me to do what she would do" == be more femme, stop being poly, quit being bi. .. yeaaaahhno)
Gah, of your second therapist, that is not the right thing at all. I hate when therapists do that, it is no good. Feh! and I am glad you fired her!
If I can ask, what did your first therapist do that was clearly not coming to grips with it?
How much time do you have? :)
So, I first started seeing her a few weeks after my childhood best friend and first love died suddenly and unexpectedly. I ended up talking a lot about my parents because OMG they behaved so atrociously when I went home for Michelle's funeral. So very very badly. So that's when the 'abuse' word came up, because a lot of conversations went "And then my parents did X" "And did they do things like X when you were growing up?" "Yes, they did X, Y and Z." *eyes bug out of head* "And no one called child services? Really? Where were your teachers during all this?" And I really was not ready to hear that or deal with it yet.
So yeah. For a while she tried to promote the idea that Michelle wasn't really dead because her "spirit lived on" and I could still talk to her, which um. No. I'm too much a materialist for that to have had even a tiny chance of working for me.
Then there was the "You can re-experience your childhood, and be a parent to your child self. You can replace your bad childhood memories with these experiences of parenting yourself" which again. No. Time moves linearly and I cannot re-experience childhood. Even if I could simulate particular events, I still carry adult knowledge and experiences into the simulation and nothing can make me forget the way they played out originally. And while there's a lot to be said for self-talk and speaking to your inner child (and actually, the second therapist, the gender conformist one, was really good at that aspect of my treatment), that's not where the first therapist was going with it. And she didn't even try to help me understand that much of what I was feeling was grieving for the idea of a family, for what I should have had. It was all "You can make your bad childhood not matter anymore!"
Oh, dear. Yeah, it's tricky, because all the things she did are almost a good idea, and might work well for some people. It can be a good idea for a therapist to point out that a client was abused as a kid, but you have to do it in a very, very empathetic way-- exploring what the client thinks, and helping them figure it out for themselves, not imposing it. A client who was abused will have plenty of their own anger about it somewhere-- if they're not feeling it right now, they've got reasons for that, and you need to work with them for a while rather than jumping ahead to the point where they're up for feeling it.
And the "spirit lived on" thing is great and useful if the client comes in believing that, or realizes they believe it and wants to talk about it, but... well, "what happens to people after they die" is not, as it turns out, something they teach us in shrink school. And so is not something on which a therapist has actual expertise. So... no.
And it's true that you can learn to take care of yourself, to listen to all the feelings of your childhood self and give yourself the comfort you didn't get then. But just as you say, it's not time-travel. It doesn't "replace" the old memories, it just adds new ones. You'll never be a person who didn't experience what you experienced, and if a therapist can't come to terms with the fact that no, really, sometimes bad things do happen to people, that therapist is not going to last long.
(Also, this is clearly something that happened a while ago and you've dealt with, but still-- I'm sorry about your friend & love. That really sucks. :( )
An equivalent of #6 seems to be the one I'm working on these days. For me, it's to not wrap up whatever I'm doing ten minutes before the appointment time so I can be All Ready For Them when they show up. It's to make sure I'm prepared for them to show up, and not deeply engaged in something I won't want to stop, but keep working (or whatever) till the phone rings to tell me my client is here. That's definitely helping me mind less when my clients arrive late or not at all.
Definitely the thing where you carefully craft a lesson plan, and then they latch onto the random tossed-off thing you said out of the blue instead and bring it back (occasionally as if to torment you..) on the exam.
But also that combination of respecting their contributions and expertise, what they are bringing to the table as a thinker and thus as a writer, and trying to help them discover that rather than imposing yourself on them. I'm best at teaching the writers who are already thinking much the same way I do (roughly, like an analytic philosopher...), but I am always trying to perform that careful process of discovery and encouragement of what _they_ are (or will be!) good at - and letting go of the students that just aren't going to be able to learn much from me other than the difference between "its" and "it's."
And bringing a book to office hours. (Or really, in my case, a pile of yet more papers to grade!)
Oh, and I nearly forgot the most important one! That when you're helping them revise their essays, if you tell them "here are what your key ideas are, and here is the structure I think they are trying to articulate" it doesn't work nearly so well as if you make _them_ identify the key ideas and find the structure. Even if it's not as perfect as the one you have, the resultant essay is going to be stronger anyway, because it's flowing from _their_ writing process - you're just letting them tap into that more consciously.
Is it reasonable to think about some of these with regards to just generally trying to be a good and emotionally supportive friend? 2 and 3 are not things I had ever really heard or thought about before, and they remind me of experiences I've had where I gave friends the "perfect advice" and then they didn't follow it and bad things happened. And I realize in retrospect that probably telling your friends at length what you recommend that they do is not really super helpful; they're not going to remember it, they'll feel condescended to. (I had in fact realized the point about being condescending already, but the practical point that people just won't remember lectures, and will instead remember all their arguments against you, is totally new to me.)
Is it reasonable to think about some of these with regards to just generally trying to be a good and emotionally supportive friend?
I think so, yeah. Actually, when I look them over, I suppose a lot of these are good ideas in general. Huh!
probably telling your friends at length what you recommend that they do is not really super helpful
Yeah! This one was super-hard for me to learn, but I eventually figured it out, to the point where I try to never give unasked-for advice-- or if I do offer it, make it crystal clear that I don't expect them to take it without question. The thing I eventually realized about advice is that if someone has a problem, and I see an obvious answer to it, odds are reasonably good that they can also see that obvious answer, and have already dismissed it for reasons of their own, which either they haven't told me or I'm not paying enough attention to. I mean, this is not always the case, and a different perspective can be very useful in this way. And sometimes, people go to you because they know what you'll say, and they want to be talked into that (Dan Savage says this is the main trick of a good advice column; figure out what the asker wants to be told, and tell them that. Unless all of your *other* readers besides the asker will get more out of a different answer.). But yeah... lectures, even when you're paying for them, can be hard to pay attention to.
It's just so satisfying to tell your friends what to do, though! Because their problems are so much simpler (because they probably haven't had time to tell you every detail) and you can solve them, and feel clever and helpful! It's why I love the beginning of the training year at the clinic where I work-- because all the new interns and post-doctoral fellows have these wonderful questions, like "Where are the intake forms?" and "How do I work the fax machine?" and I can totally answer those! Later, when they start asking hard questions, it gets less fun. (ETA: Okay, still fun. But different fun. "Challenging," that's the same as fun, right?)
Edited at 2012-11-15 01:40 pm (UTC)