Further Advice to a Young Therapist
Feb. 28th, 2015 10:29 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
gaudiorA few years ago, I wrote an entry called Advice to a Young Therapist. I've learned some things since then, so it seemed like a good time for another one.
In looking these over, they seem a lot more grim than the last set I wrote. The odd thing is, I think I'm happier and calmer and less in danger of burn-out than I was when I wrote the last one by a factor of about a million. I think that's because I really, really believe #10. So maybe skip to that one, if this is depressing?
1. Your client sees you through the same lens they see everyone else in their lives. You are not the one, shining exception of love and goodness in their world of terrible people, tempting as it can be to think so. If your client describes everyone in their life as being judgmental and cruel, then they're probably seeing some of what you say as criticism, whether or not you mean it that way. If your client describes everyone in their life as being incompetent and useless, then there are probably times they get quite impatient with your mistakes and imperfections. If your client describes everyone in their life as dangerous and harmful, then there are probably times they feel scared of you. And so forth. There's not much you can do about this, so don't worry too much about proving your goodness to your client. Just keep acting the way you would with any other client: keep the boundaries of the session, listen, empathize, make suggestions when they seem helpful, but mostly listen. Over time, they may come to see the world in general through a different lens, but don't get too upset when they see you the same way they see the rest of the world, no matter how much you care about them.
2. Your goal is not for you to be the most important person in your clients' life; it's for them to learn to build other relationships that they can rely on instead of you. Oh, you may be very, very important to your client. You may provide them with unique perspectives and experiences they really need; you may provide them with support they're not getting elsewhere when they start. But that's not your goal. It's not a great thing, actually-- eventually, you want your client to finish therapy and go out into the world, and you want that life to be better than the life they had before and during therapy, not worse. Besides, you are only one person, and you are mortal, and you can't be there for them always and fix everything for them.* So while they will hopefully learn important lessons in therapy about good relationships, and while they will hopefully find the support and acceptance they need, you don't want to cure them with your love alone. You want them to learn to find other people who they're closer to than you, to deepen their relationships that existed before you got there. You want them to build up a whole support network of people who understand them, who know them better than you do. You want them not to need you any more when they're done, and that's not just about them learning skills and feeling better-- that's about them having their own people, who are in their lives all the time, who they don't have to pay for it.
3. Know your frame. The "frame" is a useful term for the boundaries around your therapy session-- for example, for one therapist, the session lasts 50 minutes, it takes place in the therapy room, your client pays you their fee at the end of the hour, you don't touch them, the client isn't allowed to throw things at you, you don't tell them about your personal life, etc. And different therapists will have different frames; some might take clients on a walk outside, some might meet for 45 minutes or 90, some might shake hands or hug at the end of sessions, etc. Whatever you're comfortable with, that fits within your ethical responsibilities and boundaries, that your clients are reasonably comfortable with. But know what your usual frame is. Because it will be incredibly useful information for you when you find yourself changing your pattern, or wanting to. That will tell you a lot about what's going on with that client, between you and that client, in your countertransference, etc. It's not that you should stick rigidly to your boundaries, because there are often times that call for rules to be broken (you absolutely should touch your client if there's a medical emergency and they need first aid, it would be unethical not to), but you should always do so mindfully and thoughtfully, and know what your reasons are for breaking the frame.
4. Also, pay attention to what the frame means to the client. You know why you do all the things you do (and if you don't, you should think about them), but you can't assume your client thinks about them in the same way. And there are things-- paying fees, taking medications, the decor in your waiting room, where your chair is in relation to theirs-- that we tend to think about as background, but which may have really important meanings that your client thinks about a lot. So be open to talking about every part of the frame. Don't interrogate your client about it overmuch-- maybe they hate your squeaky door because the squeak really is that annoying-- but keep an ear out for what your client is thinking and feeling about the frame.**
5. One of the hardest things about recovering from/leaving abusive relationships is that they are relationships. It's easy to think of abusers as all bad, because you can see the damage they're doing or did to your client, and how much your client is hurting, and you feel angry and protective and sad. The trouble is, it's not likely that your client is thinking of the abuser as all bad. If they're abused as adults, then there was something that drew them to the abuser in the first place, and that thing-- intelligence, charisma, wit, skills, sometime affection, providing, etc-- doesn't necessarily go away when the abuser starts abusing. And if they were abused as kids, then odds are good that in addition to the harm, the abuser provided a lot of care-- food, shelter, sometime affection, teaching, time, attention. Even the most neglectful parents must have done a lot of care-taking in order for the kid to survive to adulthood. And these positive traits of the abuser do not excuse or make up for the abuse, not in any way. But they do exist, and it makes sense for the person who was abused to love those parts of the abuser (as well as being furious and hating the abuser and the abuse), and miss them when they're gone, even if that leaving is necessary for the survivor's safety. It is complicated. It is more complicated than it looks. Don't ever underestimate how complicated it is.
6. Your client getting better at being in therapy is not the same as your client getting better. Therapy isn't a perfectly natural environment, and there are certain things that you learn about being in it. Ideally, we try to make those things skills that will transfer to the client's life outside, and let them improve their lives. But it doesn't always work that way, and you need to be aware of that. A person who can come in and report their dreams insightfully and in detail, or a person who fills out all their homework worksheets perfectly, or a person who can name exactly what stage they're at in the addiction/recovery process, is fine and dandy. But you want to keep an eye on real-life stuff-- are they forming more secure, supportive relationships? Are they working at a job they find worthwhile? Are they taking care of their physical health? Are they having fewer panic attacks or suicide attempts or whatever else their major life-injuring symptoms are? If those things aren't getting better over time, it doesn't matter how good they are at being in therapy, something's not working. Those things might get better slowly and in small ways, they may take a long time, there will certainly be setbacks and upsets. But if there's not some change in the person's life outside the office, then it doesn't matter how "well" they're doing in their sessions.
7. Learn the difference between anxiety and fear, and stay safe. It's pretty common to feel anxious about meeting a new client, especially when you're just starting out! It's normal to continue to feel anxious with some people even after you've worked with them for a while. Because they feel anxious and you're picking it up from them, because they're intimidatingly smart or aggressive or both, because you're nervous about your own skills. That totally happens, and it's okay, and the more you face the anxiety and deal with it, the less it bothers you.
But there are some clients who will scare you. They're rare, hopefully (maybe less so if you work in a forensic setting), but... some clients are actually dangerous. And some of those are actually dangerous to you. And sometimes your gut will tell you that you're in danger, now. And that's when you need to get safely out of that room as best you can, and transfer that client to someone else, and stop working with them.
This is a really hard judgment call to make, for lots of reasons. Anxiety is so common when you're starting, and even when you're not, and you don't want to be ruled by it. It might be embarrassing to admit you're scared to work with someone; you might feel ashamed, like if you were stronger, a better therapist, you wouldn't have a problem with it. And maybe hardest of all: dangerous people also have feelings. They also may have suffered trauma; they may be sympathetic, you may feel compassion for them and want to help them. That makes sense; dangerous people are people. But they are also dangerous.
Get supervision; get advice; take your time to think about it if you're not sure. But if your gut tells you you're in danger, believe it. A client who wasn't going to hurt you, who you stop working with, may be hurt by that, but they can hopefully be helped by the person you refer them to. If a client kills you, or hurts you bad enough that you quit working, you won't help them, and you won't won't help anyone else again. Work through your anxiety, recognize your anxiety, don't run from every situation that makes you tense up-- but when it's fear, gut-level fear, better safe than sorry.
8. No, seriously, self-care. I said it before, but I will say it again, because we do not remember it. SLEEP-- eight hours a night! Eat food! Relax! Have strong relationships with important people. Have something fun you do that isn't therapy, that has nothing to do with therapy. Make friends who are therapists, and friends who are not therapists. Go back to your own therapy when you need to. Take vacations. Make sure your office is a pleasant place to be. Make sure your chair supports your back, and your computer is the right height to comfortably type at. It's so, so, so easy to forget these things. It's so hard to remember how much your body affects your mind and emotions. But it does. Take care of it. Take care of you.
9. You are a conduit for wisdom to flow from one survivor to another. Sometimes people think of therapists as having tons of knowledge, and lots of emotional health, and so being able to teach other people those things. There's the feeling, in fact, that you need to be both wiser and smarter and healthier than your clients, and otherwise, you can't help them.
That view doesn't think about where your knowledge comes from in the first place. There are thousands of books out there about psychology and psychotherapy, and we valorize theorists like Freud and Winnicott and Linehan, as if they came up with their theories all on their own.
But they didn't. They came up with their theories by talking to their patients, who were dealing with terrible shit. And over time, their patients got better, and the theorists watched how that happened, and taught other people that that's how you deal with terrible shit.
It's a partnership. In each case, it will be your client who figures out how they can deal with their pain, how to get better. Your job is to remember how you've seen other people deal with similar things, what you've been taught about how people get better, and tell your client that those paths exist, maybe guide them along. But then the way your client does it will be a little different from how anyone else has done it, and it's your job to watch that, and learn. It's your job to notice patterns, to put together what you see in different people, and have the perspective to see how patterns are likely to go. You learn from each client, and what you learn from them, you can share with your next client.
But you don't need to know exactly how it works, you don't need to have a well of shrinkly wisdom. Just pay attention, and share the patterns you've seen before.
10. Taking this directly from a comment I made on a friend's journal:You don't have all of the power or none of the power. You have some of the power. And that's scarier and harder than either, because if you had all the power, then you couldn't be hurt unless you did something to let it happen. And if you had no power, then you wouldn't have to try.
But the trade-off, the thing you get when you have some power, is that you know you're doing something valuable, but also that you can trust that you don't have to do it alone. Other people also have some power, including your clients. You do your best, and then you sit back and trust the best in your clients-- their strengths, the parts of them that want to live and grow and thrive. Amazing things can happen in therapy. People become happier, stronger, wiser. I've seen it, over and over again, so many times. People get better, through their own strength and their own efforts. It doesn't have nothing to do with me, because I helped-- I had some power, and I used it for them. It isn't all because of me, because they were the ones who did the hardest work. I knew they could, I trusted them, I encouraged them-- and they did it. And now they feel better.
Your limited power is not enough to change everything in the world. But it is enough to help.
--R
*This point was driven home by reading The Flock: The Autobiography of a Multiple Personality by Joan Frances Casey, featuring the journal of her therapist, Lynn Wilson. In this memoir, Casey describes how her therapist, and her therapist's husband, became substitute parents for her to replace her abusive ones, complete with hugs, cuddling, trips to their lake house, etc. Casey finds this treatment wonderfully restorative until the point where Wilson, pretty abruptly, decides that this is too much for her, and suddenly places boundaries. For a while, she and Casey continue to work together, but then Wilson and her husband die suddenly in a boating accident. After that, Casey declares that she is suddenly completely integrated! And totally fine! And living a perfectly good life! Well, except for the alcoholism and depression. But basically fine!
So, like, don't try to be everything to your clients. Because what if you die in a boating accident?
** There are some therapists who think that the client should start talking at the beginning of the hour, so that they talk about what's important to them, not just what they think the therapist wants them to say. That's all well and good, but you need to for the love of all the gods TELL THE CLIENT THAT. They can't telepathically divine your intentions, they haven't read the same books you have, and they have no flippin' clue why you're just sitting there staring at them. So they will come up with an explanation for it-- that you're putting them in a stressful situation to see how crazy they are, that you're a creep, that you're too uninterested in them as a person to bother simple politeness like "good morning"-- etc. This is not conducive to good therapeutic rapport!
In looking these over, they seem a lot more grim than the last set I wrote. The odd thing is, I think I'm happier and calmer and less in danger of burn-out than I was when I wrote the last one by a factor of about a million. I think that's because I really, really believe #10. So maybe skip to that one, if this is depressing?
1. Your client sees you through the same lens they see everyone else in their lives. You are not the one, shining exception of love and goodness in their world of terrible people, tempting as it can be to think so. If your client describes everyone in their life as being judgmental and cruel, then they're probably seeing some of what you say as criticism, whether or not you mean it that way. If your client describes everyone in their life as being incompetent and useless, then there are probably times they get quite impatient with your mistakes and imperfections. If your client describes everyone in their life as dangerous and harmful, then there are probably times they feel scared of you. And so forth. There's not much you can do about this, so don't worry too much about proving your goodness to your client. Just keep acting the way you would with any other client: keep the boundaries of the session, listen, empathize, make suggestions when they seem helpful, but mostly listen. Over time, they may come to see the world in general through a different lens, but don't get too upset when they see you the same way they see the rest of the world, no matter how much you care about them.
2. Your goal is not for you to be the most important person in your clients' life; it's for them to learn to build other relationships that they can rely on instead of you. Oh, you may be very, very important to your client. You may provide them with unique perspectives and experiences they really need; you may provide them with support they're not getting elsewhere when they start. But that's not your goal. It's not a great thing, actually-- eventually, you want your client to finish therapy and go out into the world, and you want that life to be better than the life they had before and during therapy, not worse. Besides, you are only one person, and you are mortal, and you can't be there for them always and fix everything for them.* So while they will hopefully learn important lessons in therapy about good relationships, and while they will hopefully find the support and acceptance they need, you don't want to cure them with your love alone. You want them to learn to find other people who they're closer to than you, to deepen their relationships that existed before you got there. You want them to build up a whole support network of people who understand them, who know them better than you do. You want them not to need you any more when they're done, and that's not just about them learning skills and feeling better-- that's about them having their own people, who are in their lives all the time, who they don't have to pay for it.
3. Know your frame. The "frame" is a useful term for the boundaries around your therapy session-- for example, for one therapist, the session lasts 50 minutes, it takes place in the therapy room, your client pays you their fee at the end of the hour, you don't touch them, the client isn't allowed to throw things at you, you don't tell them about your personal life, etc. And different therapists will have different frames; some might take clients on a walk outside, some might meet for 45 minutes or 90, some might shake hands or hug at the end of sessions, etc. Whatever you're comfortable with, that fits within your ethical responsibilities and boundaries, that your clients are reasonably comfortable with. But know what your usual frame is. Because it will be incredibly useful information for you when you find yourself changing your pattern, or wanting to. That will tell you a lot about what's going on with that client, between you and that client, in your countertransference, etc. It's not that you should stick rigidly to your boundaries, because there are often times that call for rules to be broken (you absolutely should touch your client if there's a medical emergency and they need first aid, it would be unethical not to), but you should always do so mindfully and thoughtfully, and know what your reasons are for breaking the frame.
4. Also, pay attention to what the frame means to the client. You know why you do all the things you do (and if you don't, you should think about them), but you can't assume your client thinks about them in the same way. And there are things-- paying fees, taking medications, the decor in your waiting room, where your chair is in relation to theirs-- that we tend to think about as background, but which may have really important meanings that your client thinks about a lot. So be open to talking about every part of the frame. Don't interrogate your client about it overmuch-- maybe they hate your squeaky door because the squeak really is that annoying-- but keep an ear out for what your client is thinking and feeling about the frame.**
5. One of the hardest things about recovering from/leaving abusive relationships is that they are relationships. It's easy to think of abusers as all bad, because you can see the damage they're doing or did to your client, and how much your client is hurting, and you feel angry and protective and sad. The trouble is, it's not likely that your client is thinking of the abuser as all bad. If they're abused as adults, then there was something that drew them to the abuser in the first place, and that thing-- intelligence, charisma, wit, skills, sometime affection, providing, etc-- doesn't necessarily go away when the abuser starts abusing. And if they were abused as kids, then odds are good that in addition to the harm, the abuser provided a lot of care-- food, shelter, sometime affection, teaching, time, attention. Even the most neglectful parents must have done a lot of care-taking in order for the kid to survive to adulthood. And these positive traits of the abuser do not excuse or make up for the abuse, not in any way. But they do exist, and it makes sense for the person who was abused to love those parts of the abuser (as well as being furious and hating the abuser and the abuse), and miss them when they're gone, even if that leaving is necessary for the survivor's safety. It is complicated. It is more complicated than it looks. Don't ever underestimate how complicated it is.
6. Your client getting better at being in therapy is not the same as your client getting better. Therapy isn't a perfectly natural environment, and there are certain things that you learn about being in it. Ideally, we try to make those things skills that will transfer to the client's life outside, and let them improve their lives. But it doesn't always work that way, and you need to be aware of that. A person who can come in and report their dreams insightfully and in detail, or a person who fills out all their homework worksheets perfectly, or a person who can name exactly what stage they're at in the addiction/recovery process, is fine and dandy. But you want to keep an eye on real-life stuff-- are they forming more secure, supportive relationships? Are they working at a job they find worthwhile? Are they taking care of their physical health? Are they having fewer panic attacks or suicide attempts or whatever else their major life-injuring symptoms are? If those things aren't getting better over time, it doesn't matter how good they are at being in therapy, something's not working. Those things might get better slowly and in small ways, they may take a long time, there will certainly be setbacks and upsets. But if there's not some change in the person's life outside the office, then it doesn't matter how "well" they're doing in their sessions.
7. Learn the difference between anxiety and fear, and stay safe. It's pretty common to feel anxious about meeting a new client, especially when you're just starting out! It's normal to continue to feel anxious with some people even after you've worked with them for a while. Because they feel anxious and you're picking it up from them, because they're intimidatingly smart or aggressive or both, because you're nervous about your own skills. That totally happens, and it's okay, and the more you face the anxiety and deal with it, the less it bothers you.
But there are some clients who will scare you. They're rare, hopefully (maybe less so if you work in a forensic setting), but... some clients are actually dangerous. And some of those are actually dangerous to you. And sometimes your gut will tell you that you're in danger, now. And that's when you need to get safely out of that room as best you can, and transfer that client to someone else, and stop working with them.
This is a really hard judgment call to make, for lots of reasons. Anxiety is so common when you're starting, and even when you're not, and you don't want to be ruled by it. It might be embarrassing to admit you're scared to work with someone; you might feel ashamed, like if you were stronger, a better therapist, you wouldn't have a problem with it. And maybe hardest of all: dangerous people also have feelings. They also may have suffered trauma; they may be sympathetic, you may feel compassion for them and want to help them. That makes sense; dangerous people are people. But they are also dangerous.
Get supervision; get advice; take your time to think about it if you're not sure. But if your gut tells you you're in danger, believe it. A client who wasn't going to hurt you, who you stop working with, may be hurt by that, but they can hopefully be helped by the person you refer them to. If a client kills you, or hurts you bad enough that you quit working, you won't help them, and you won't won't help anyone else again. Work through your anxiety, recognize your anxiety, don't run from every situation that makes you tense up-- but when it's fear, gut-level fear, better safe than sorry.
8. No, seriously, self-care. I said it before, but I will say it again, because we do not remember it. SLEEP-- eight hours a night! Eat food! Relax! Have strong relationships with important people. Have something fun you do that isn't therapy, that has nothing to do with therapy. Make friends who are therapists, and friends who are not therapists. Go back to your own therapy when you need to. Take vacations. Make sure your office is a pleasant place to be. Make sure your chair supports your back, and your computer is the right height to comfortably type at. It's so, so, so easy to forget these things. It's so hard to remember how much your body affects your mind and emotions. But it does. Take care of it. Take care of you.
9. You are a conduit for wisdom to flow from one survivor to another. Sometimes people think of therapists as having tons of knowledge, and lots of emotional health, and so being able to teach other people those things. There's the feeling, in fact, that you need to be both wiser and smarter and healthier than your clients, and otherwise, you can't help them.
That view doesn't think about where your knowledge comes from in the first place. There are thousands of books out there about psychology and psychotherapy, and we valorize theorists like Freud and Winnicott and Linehan, as if they came up with their theories all on their own.
But they didn't. They came up with their theories by talking to their patients, who were dealing with terrible shit. And over time, their patients got better, and the theorists watched how that happened, and taught other people that that's how you deal with terrible shit.
It's a partnership. In each case, it will be your client who figures out how they can deal with their pain, how to get better. Your job is to remember how you've seen other people deal with similar things, what you've been taught about how people get better, and tell your client that those paths exist, maybe guide them along. But then the way your client does it will be a little different from how anyone else has done it, and it's your job to watch that, and learn. It's your job to notice patterns, to put together what you see in different people, and have the perspective to see how patterns are likely to go. You learn from each client, and what you learn from them, you can share with your next client.
But you don't need to know exactly how it works, you don't need to have a well of shrinkly wisdom. Just pay attention, and share the patterns you've seen before.
10. Taking this directly from a comment I made on a friend's journal:You don't have all of the power or none of the power. You have some of the power. And that's scarier and harder than either, because if you had all the power, then you couldn't be hurt unless you did something to let it happen. And if you had no power, then you wouldn't have to try.
But the trade-off, the thing you get when you have some power, is that you know you're doing something valuable, but also that you can trust that you don't have to do it alone. Other people also have some power, including your clients. You do your best, and then you sit back and trust the best in your clients-- their strengths, the parts of them that want to live and grow and thrive. Amazing things can happen in therapy. People become happier, stronger, wiser. I've seen it, over and over again, so many times. People get better, through their own strength and their own efforts. It doesn't have nothing to do with me, because I helped-- I had some power, and I used it for them. It isn't all because of me, because they were the ones who did the hardest work. I knew they could, I trusted them, I encouraged them-- and they did it. And now they feel better.
Your limited power is not enough to change everything in the world. But it is enough to help.
--R
*This point was driven home by reading The Flock: The Autobiography of a Multiple Personality by Joan Frances Casey, featuring the journal of her therapist, Lynn Wilson. In this memoir, Casey describes how her therapist, and her therapist's husband, became substitute parents for her to replace her abusive ones, complete with hugs, cuddling, trips to their lake house, etc. Casey finds this treatment wonderfully restorative until the point where Wilson, pretty abruptly, decides that this is too much for her, and suddenly places boundaries. For a while, she and Casey continue to work together, but then Wilson and her husband die suddenly in a boating accident. After that, Casey declares that she is suddenly completely integrated! And totally fine! And living a perfectly good life! Well, except for the alcoholism and depression. But basically fine!
So, like, don't try to be everything to your clients. Because what if you die in a boating accident?
** There are some therapists who think that the client should start talking at the beginning of the hour, so that they talk about what's important to them, not just what they think the therapist wants them to say. That's all well and good, but you need to for the love of all the gods TELL THE CLIENT THAT. They can't telepathically divine your intentions, they haven't read the same books you have, and they have no flippin' clue why you're just sitting there staring at them. So they will come up with an explanation for it-- that you're putting them in a stressful situation to see how crazy they are, that you're a creep, that you're too uninterested in them as a person to bother simple politeness like "good morning"-- etc. This is not conducive to good therapeutic rapport!
