Addiction is among the most common mental health diagnoses, with estimates of 12 month addiction prevalence ranging from 15% to 61%. A 2011 analysis estimates that nearly half of all Americans experience some symptoms of an addiction within a 12 month period. More than 70,200 Americans died from drug overdoses in 2017. Most of those deaths were due to opioids such as heroin and prescription painkillers.

Rehab centers are an immersive and potentially life-changing treatment option for people struggling with addiction. Clinicians and other staff considering working in rehab face a range of challenges, but also have the opportunity to change—and even save—lives. In rehab, people work steadily to get sober, repair broken relationships, and build lives of purpose and meaning.

A variety of mental health professionals, including therapists, psychologists, psychiatrists, and social workers, may pursue careers in rehab. Some rehab facilities also employ lay peer counselors, addiction coaches, life coaches, or certified peer specialists. Addiction is a complex diagnosis, with many potential pathways to recovery, so there’s a potential role for virtually every mental health professional in rehab.

How Is Working in Rehab Different?

People in rehab face many of the same struggles as those in outpatient treatment—family difficulties, impulse control, anger management, self-esteem, body image issues, career frustrations, and more. They may have a range of diagnoses or no diagnosis at all.

What makes rehab different is that people in rehab have all reached a crisis point in their lives.

What makes rehab different is that people in rehab have all reached a crisis point in their lives. Many choose to go to rehab after a catastrophic loss, such as the end of a relationship or job loss. Rehab clients may also struggle with the physiological realities of withdrawal and cravings. This means that the average rehab client may:

• Struggle more with physical discomfort due to withdrawal
• Be adapting to a way of thinking and existing that is totally unfamiliar
• Not know what the future holds or feel much control over their fate
• Struggle with extreme emotions due to a recent crisis and the challenges of reality
• Need support distracting themselves from cravings
• Need psychoeducation about the science and psychology of withdrawal. Admonitions that the cravings will always be there are not helpful.
• Experience periods of suicidal ideation
• Not have the family support they need
• Be radically altering their life path. They may need help deciding what comes next, referral to community resources, and assistance identifying their unique skills and talents.

What Are the Challenges of Working in a Treatment Center?

Rehab, like private practice, presents numerous challenges—transference, separating oneself from a client’s needs, vicarious trauma, feelings of inadequacy, and the difficulties inherent in supporting people through life’s immense challenges.

Working in a rehab facility comes with additional challenges. People in rehab are, almost by definition, often not thinking clearly. That’s because withdrawal alters brain function and causes physical discomfort. They may be more impulsive, more frustrated, and feel more desperate to get better. Even clients who form strong relationships with their therapists may blame or lash out at them.

Some clients feel so overwhelmed by withdrawal that they want to give up. Helping a client see the value of treatment and see a path to a better life is one of the biggest challenges of working in rehab. Clinicians must develop a close and trusting relationship with each client. This relationship offers insight into the unique motivators that can help each client stick with treatment.

Helping a client see the value of treatment and see a path to a better life is one of the biggest challenges of working in rehab.

Depending upon where you work, you may encounter clients who are not voluntarily in treatment. They will need additional support to see the value in treatment and build a path to sober living.

Working in rehab may also involve supporting clients as they develop life skills, including managing serious challenges such as massive debt, job loss, divorce, child custody disputes, and other issues. Therapists should not advise clients about topics they know little about. Instead, they should offer emotional support and a sympathetic ear. In many cases, rehab facilities can refer clients to additional resources, such as attorneys and financial advisers, when they need them. Take advantage of these resources so you can better support your clients.

Are There Any Risks Involved With Working in a Rehab?

The main risks of working in a rehab center include:

• Vicarious trauma due to exposure to clients’ traumatic experiences
• Burnout and exhaustion
• Feelings of inadequacy and frustration when a clinician cannot help a client
• Uncertainty and anxiety when a client leaves treatment

There is also a very small risk of being harmed by clients. People in rehab are facing immense pressure. Some may be unstable or have poor impulse control. In rare cases, this may cause a client to:

• Verbally abuse or harass a therapist
• Stalk a therapist in treatment or after they leave treatment
• Attempt to harm a therapist’s reputation by filing licensing board complaints or leaving negative online reviews
• Assault or attempt to assault a therapist

Before taking a job at a rehab center, therapists should ask questions about:

• How the facility keeps workers safe. Is there security? An emergency panic button?
• Whether the facility screens out people with a history of violence or enacts other precautions when a person with a history of violence is admitted
• How the rehab facility supports the mental health of clinicians
• Work-life balance. Is there paid time off? An employee support program?
• Mentorship and support from more experienced clinicians
• How long the average employee stays with the company
• Whether there are opportunities for career advancement

Why Work in a Treatment Facility?

Addictions are a leading cause of death among healthy young people. Substance abuse destroys families, erodes communities, and undermines public health. Joining the fight against substance abuse can save lives and even reduce health care spending. People with addictions can be functional and happy members of their community. There’s no need for addiction to destroy a person’s life. Proper treatment can help a person restore their family, live up to their potential, and give back to their community.

Working at a drug rehab center can be a rewarding career that opens doors to other opportunities. Some clinicians eventually become administrators, while others publish research based on their work or go on to teach at colleges and universities. For early-career professionals, rehab offers access to clients with a wide variety of needs and challenges. This breadth and depth of experience can be difficult to obtain in private practice.

The work can also be emotionally demanding, and not all clients thrive or even survive. Mental health professionals should practice self-care, seek support from loved ones, and consider attending therapy to cope with the ups and downs of life as a rehab worker.

References:

1. Overdose death rates. (2019). Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
2. Sussman, S., Lisha, N., & Griffiths, M. (2010, September 27). Prevalence of the addictions: A problem of the majority or the minority? Evaluation & the Health Professions, 34(1), 3-56. doi: 10.1177/0163278710380124

We’ve all been there. We think therapy is going along swimmingly, and then all of a sudden, our client stops showing up. Sometimes we get a cancellation email or text that says they will call us to reschedule when we really know it’s code for, “I ain’t coming back.”

It is all too easy to blame clients for dropping out of therapy. We say very clinical things like, “They weren’t ready to do the work,” or “We reached a climax in treatment and it was too much for them”. There may be some truth to those statements, but as therapists, are we doing a good enough job of educating clients about the termination process? Because it is a process.

It is a privilege to walk with a client from the beginning to the end of their counseling journey, but it is often a privilege we do not get. We lose clients when one of us goes on vacation. We lose clients when life gets extraordinarily full for them. We lose clients, and sometimes, we don’t even know why.

“Where Did I Go Wrong?”

If you are anything like me, you tend to eschew any tendency to fault a client for not following through with treatment. Instead, I wonder where I missed the mark or went wrong. What could I have done differently? Did that brilliant intervention I made fall flat? Was it not as well-timed and relevant as I thought? You can see how easy it is to go down the rabbit hole of self-condemnation.

We may never know why our clients do not return for our sessions, but a fully insightful and self-aware therapist must look at how we contribute to a client’s dropping out of treatment and what we can do about it. Below are some suggestions.

Address the End of Therapy During the Informed Consent Process

Yes—talk about the end of therapy at the beginning. By addressing termination at the start, clients can better understand that counseling does have a beginning, middle, and end. The informed consent process lets the client know what they can expect from working with us.

In the midst of talking about confidentiality, payment contracts, and consents, we would be wise to address how the client and therapist know when treatment should end.

In the midst of talking about confidentiality, payment contracts, and consents, we would be wise to address how the client and therapist know when treatment should end. Ask clients to imagine what life will look like when therapy is over. What would be different? What skills would they possess that they do not currently have? This lets them know you are looking at therapy with the end in mind and shooting for a mutually agreed upon goal.

As therapists, we keep the big picture in mind and hold a long-range view. Meanwhile, clients often only see immediate concerns. Of course, goals can change as therapy progresses, and they often do. When issues sprout up that the client didn’t even know were there, we revamp and incorporate new goals into our treatment planning. Once we share that terminating is a process and not an abrupt ending, we can continually check in about how the process of therapy is going.

Encourage Open and Honest Feedback About the Therapeutic Experience

This can be done during at least two points in therapy. The first is during the informed consent process, when we can educate clients about the collaborative nature of our relationship and any expectations of them as clients.

Let them know that at times, they may be asked to do homework, and any feedback about how beneficial it was will will be helpful. Tell them you may miss the mark. When they let us know the assigned homework wasn’t very useful or effective, that gives us information to steer sessions in another direction. I make sure to provide assurance that my feelings won’t be hurt.

Secondly, directly ask them for feedback throughout the process to model the two-way exchange mentioned during the first appointment. Inquire about how opening up in a session was for them, especially after a particularly vulnerable disclosure on their part. How did that affect rapport and trust? Ask about the pace. Is it too fast or too slow? Are they seeing the kind of progress they hoped? What is working in therapy, and what is not? These kinds of questions invite feedback in a safe atmosphere.

What to Do When a Client Stops Coming to Therapy

So what do we do when clients suddenly stop showing up? Here are a few ideas:

1. Address your own feelings. Are you irritated? Worried about the lack of income or a dwindling caseload? Recognize these are your own feelings and do not let them enter into the dialogue with the client.
2. Don’t take it too personally. Often, leaving therapy has more to do with what is going on with our client than about us or anything we said or didn’t say. Technology makes it much easier to cancel appointments, and it’s easier to send a text or email than to confront us about why they aren’t coming back.
3. Reach out empathically when clients no-show or cancel. The purpose is to let clients know you available to them, not to chastise them. You are leaving the door open for returning back to treatment. A phone call is more personal, but if you hear nothing back, follow up with an email a week or so later. After that, take a hint and know you have given a safe invitation to return to treatment on their terms.

This approach is no guarantee a client won’t drop out of treatment suddenly and without an explanation, but encouraging open communication along the way may help reduce attrition.

Some clients might feel sheepish about returning to a therapist once they no-show an appointment or have an outstanding balance. These are common issues therapists must address. While I might be annoyed that I have a hole in my schedule, my bigger concern is if my client is okay.

Most of all, I’d like my clients to know I care about them. Otherwise, I wonder what happened. Was therapy helpful for them? Sometimes we have to make peace with the fact we may never know.

To gather information about the parent-child relationship, I often ask parents, “If you could wish for one thing for your child, what would that wish be?” I might also ask,“What do you want for your child as they transition into adulthood?”

Exploring a parent’s wishes for their child can help increase understanding of the parent-child relationship. This is important whether you are working with parents in a school setting or in private work.

Generally, the responses I hear do not vary all that much. Parents say they want their child to be “happy” and experience “success.” When I push parents to define what these things look like, things can get interesting. Through a parent’s definition of “happiness” and “success,” I often learn more about their family values, approaches to parenting, and the pressures a child may be experiencing.

Parents often ask me if they answered “correctly” or how I would answer the same question. I share my own greatest goal for children: That, as they transition into adulthood, they possess the skills to be empathetic and independent adults. [fat_widget_child_counselor_right]

How can we help children become independent adults? An essential step toward accomplishing this goal is educating parents about the self-determination theory and autonomy-supportive parenting.

The Self-Determination Theory

The self-determination theory explains the three basic psychological needs people need to fulfill:

1. Autonomy, or the need to feel free to choose their own behavior
2. Competence, or the need to feel capable of effectively interacting with their environment
3. Relatedness, or the need to feel close to and meaningfully connected to others

It’s important for these needs to be supported by a child’s environment in order for them to emotionally evolve and develop in a healthy way. A positive family environment can promote and support a child’s basic psychological needs. On the other hand, a negative family environment can hamper healthy psychological development (Deci and Ryan, 2000).

Autonomy-Supportive Parenting

How can we help children become independent adults? An essential step toward accomplishing this goal is educating parents about the self-determination theory and autonomy-supportive parenting.

Parents can practice autonomy-supportive parenting by creating an environment that supports autonomy. Parents who support the development of autonomy are involved in their child’s life but encourage independence and problem-solving skills. It’s important for parents to give children both age-appropriate autonomy and agency. By doing so, they help them develop at an appropriate level. This can have the effect of greater emotional well-being.

When children are autonomous, they are more likely to feel capable of making their own healthy choices. By supporting children in the development of autonomy and agency, parents also help children learn about family values, social norms, and essential rules.

Parents can support the development of autonomy by:

• Providing a rationale and explanation for family rules and behavior expectations. When children and adolescents understand reasons for rules and the context behind them, they have an easier time supporting and following those rules.
• Labeling and validating a child’s feelings and perspectives. Validating feelings is an essential component of mental health and growth. By normalizing emotions, parents can help them understand that everyone has challenging moments. This also helps children learn that strong feelings are nothing to be ashamed of.
• Minimizing judgement and control. Many parents may try to control their kids. Psychologist Dr. Ross Greene recommends parents try to influence children instead. Parents who attempt to control children can become dependent on power-oriented strategies. By adopting a more collaborative parenting style, as Greene suggests, parents make room for children to develop greater autonomy. This in turn helps children develop the skills necessary to become independent adults.
• Allowing children to make choices. By providing age-appropriate opportunities for children to make independent choices and decisions, parents are giving them a healthy sense of agency and control.
• Supporting growth and new challenges by scaffolding and practicing new skills with children. In construction, scaffolding helps supply extra support to the building being erected. When the building is finished, the scaffolding is removed, and the structure is able to stand independently. Parents who use scaffolding education offer children similar support. Scaffolding skills incorporate information and skills children already have. This approach helps foster greater autonomy and independence.
• Letting children solve problems on their own. Parents often feel as if they should swoop in and rescue their child when they encounter a challenge. But when problems arise, it’s often better to brainstorm together and list possible solutions to the challenge at hand. Offer guidance when needed but encourage youngsters to problem-solve independently.
• Letting children struggle (safely). Every child encounters failure at some point. Trying and making mistakes or failing is part of growth. If children do not develop healthy coping mechanisms around failure, they are more vulnerable to anxiety. It is essential for parents to model that failure and making mistakes are essential parts of the learning process. By letting children learn from their mistakes, we are giving them an important opportunity to develop resilience, grit, confidence, and coping skills.

If you want to learn more about how you can help your children develop autonomy, please reach out. A counselor trained in child and family counseling can offer support and guidance. [amazon_affiliate]

References:

1. Deci, E. L., & Ryan R. M. (2000). The ‘what’ and ‘why’ of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268.
2. Greene, R. W. (2017, August 15). Raising human beings: Creating a collaborative partnership with your child. New York, NY: Scribner.

In an interview from April 2018, James Comey, former director of the FBI, spoke about the difference between the language he used publicly as the director of the FBI and the way he speaks in his current book. He curses in the book because that’s how he thinks, he said. But when speaking with members of the media, he cleans up his language so it’s more socially acceptable.

Most people follow his form, watching themselves when they think they might be judged harshly for cursing and letting loose when they feel safer and more comfortable. As a therapist, I believe cursing helps connect people who are seeking help or working through issues. I have a bias towards this view, as I was taught by Dr. Albert Ellis, who, in my opinion, was the absolute best cursing therapist in the history of the profession. When I started studying with Al 40 years ago, I found it incredibly refreshing to hear him curse while explaining his theories of what he initially named Rational Emotive Therapy. (It was later renamed Rational Emotive Behavior Therapy).

Cursing as a Tool to Connect

When people stub their toe, they don’t say, “Darn!” They usually swear. Studies have shown people who curse when in physical pain experience a diminished perception of pain. There’s no study I know of that shows this to be also true for emotional pain, but I wouldn’t be surprised if it turns out to be the case. [fat_widget_right]

If we, as therapists, don’t use the language of the inner self, we risk not connecting as well. I firmly believe this. I have learned from my 40 years in practice that there are three things a therapist can do to help people feel safer:

• Model authenticity
• Dress casually (but not sloppily)
• Use real language, not a white-washed version of your speech. That means cursing, or the language people use vocally or internally, depending on the situation and who is within earshot.

Just to be clear, I am not suggesting you curse at a person you are working with. Rather, I am speaking of cursing as a tool that can help forge alliances. Not everybody will appreciate this. Some people do not swear and may be offended. This is why, when I first use a curse word, I ask the person I’m working with if they find it offensive. If they find cursing offensive, I do my best to resist the urge. My goal is to relate to the person in the deepest way humanly possible so they can feel heard, known, and respected.

Another goal I have, which is in keeping with dressing casually, is modeling what it means to be my true self with the people I work with so they can feel comfortable being their true self with me. My true self is someone who curses for emphasis and relief. I also think it’s my right as a woman to be able to swear, since men have had the freedom to curse from time immemorial.

When people feel comfortable using language they would use with a close friend or family member, they may then feel encouraged enough to let other boundaries loosen up a bit. These boundaries may have kept them from disclosing something they felt was embarrassing or shameful, for example.

Another goal I have, which is in keeping with dressing casually, is modeling what it means to be my true self with the people I work with so they can feel comfortable being their true self with me.

Cursing is simply a way I show my allegiance with the person I’m working with. I am not a dispassionate, uninvolved therapist. I really care about the people I work with. When they have a problem, I passionately want to help them. Cursing helps me convey that intention. By cursing I also give them a cosmic permission slip to feel more passionate about their own life.

In addition, I show it’s safe and okay to feel angry sometimes. It’s even fine to express this anger. In my experience, cursing does not lead to violence. It may even prevent it, as unleashing an epithet may help release some emotional heat before it builds into a violent conflagration.

Many people, especially women, think they shouldn’t show or feel anger. When I model outrage at something and the world keeps spinning on its axis, they realize they can express the same outrage. Cursing is a way people can express a negative or heartfelt emotion without any major negative repercussions.

Part of therapy is helping people feel safe being who they are. All of us have rage. Some is conscious, some unconscious, but we all have it to differing degrees. Feeling our feelings, including anger, is acknowledged as one of the most important steps in accepting and working through those difficult emotions. You can’t heal what you don’t feel.

Cursing is just another way to connect with your feelings. It’s not the only way. But some people find it allows them freedom to express how deeply they feel about something. Once we access and own the depth of our emotion, we can then work more wisely with it.

References:

1. Gross, T. (Host). (2018, April 17). James Comey to ‘Fresh Air’: The FBI isn’t ‘on anybody’s side.’ [Radio broadcast episode]. NPR. Retrieved from https://www.npr.org/2018/04/17/602849276/james-comey-to-fresh-air-the-fbi-isnt-on-anybodys-side
2. Stephens, R., Atkins, J., & Kingston, A. (2009, August 5). Swearing as a response to pain. Neuroreport, 20(12), 1056-1060.
3. Stephens, R., & Clatworthy, A. (2006). Does swearing have an analgesic effect? Poster presentation at the British Psychological Society Psychobiology Section Annual Conference, 18–20 September 2006, Windermere.
4. Stephens, R., & Umland, C. (2011). Swearing as a response to pain–Effect of daily swearing frequency. Journal of Pain, 12(12), 1274–1281.
5. Stephens, R. (2013). Swearing-The language of life and death. The Psychologist, 26(9). Retrieved from https://thepsychologist.bps.org.uk/volume-26/edition-9/swearing-language-life-and-death

The decision to initiate any interpersonal relationship is anxiety-provoking, and the decision to talk with a therapist might be uniquely so. When we decide to meet with a therapist, we are faced with numerous challenges: allowing ourselves to depend on someone else for help and support; revealing our problems; risking trust in a stranger; facing what we have avoided; and relinquishing long-held, sometimes beloved habits, to name a few.

When we refer someone to therapy, it is important to keep this in mind. Though the statement “I recommend you talk to a therapist” sounds simple and benevolent enough, we cannot lose sight of the fact our caring act is simultaneously an anxiety-provoking challenge to the would-be person in therapy. So how can we go about this in a way that doesn’t provoke any additional, unnecessary worries or fears?

The following is a list of principles one can consider when making a referral to a therapist. While these ideas do not guarantee a certain outcome, they may reduce the chances of triggering anxiety that could promote avoidance.

[fat_widget_right]

1. Make it about their needs and goals.

Therapy is much more likely to succeed if the person is there of their own free will, motivated by their own goals, trying to meet their own needs. External pressures to be there and pressures to work on problems that other people see, but that we do not see, can lead therapies to get stuck. The last thing we want to do is refer someone to therapy because we want them to change or conform to some goal that we have for them. That’s usually a recipe for someone either avoiding therapy or showing up but hating it.

Good therapy involves difficult, anxiety-provoking work, so most people will want to do that only if it is their only option for reaching specific goals. That is why it can be important for your referral proposal to include a reference to those goals, and to the way their emotional difficulties hold them back. An example could be: “Seems like the headaches you are getting are really hassling you at work, and it seems like they get worse with stress. Therapy can help with that and it might make you less miserable at work and home.” In this example, it is clear the referral is in the service of the person’s feelings and interests, done out of care and concern for them and not out of some demand or expectation by the referral source.

2. Make it optional.

I encourage you to make your recommendation optional, with liberal use of comments such as, “It’s really up to you,” “I’m not sure if I’m right, but it’s something you can decide for yourself,” and, “It’s not a requirement, just a thought.” I encourage you to phrase your referral as optional because going to therapy is optional. Therapy is anxiety-provoking enough to begin with, and we only add anxiety if we make the person feel like it’s an expectation, a demand, or a requirement.

When we approach therapy as a demand or requirement instead of an option, we can trigger a few responses that decrease the effectiveness of our referral. If the person we are hoping to refer has submissive tendencies, they may comply with our wish that they be in therapy. That will get them as far as a therapist’s office, but because they are not there of their own free will, they may not get the full benefits of the therapy. Other people may respond to our demand that they seek therapy with defiance or stubbornness. Rather than consider the option, they may say no just to spite you and to stymie your efforts to control them, even if they feel therapy could help.

Therapy has the highest likelihood of helping if the person is there of their own volition, not out of compliance, so be sure to remind yourself and the person you want to refer that the referral is optional.

If we’re clear about the reality of therapy—that the length of treatment and the level of commitment is up to them—they may find it less threatening and be more likely to try it.

3. Make it conditional.

What do we commit to when we commit to meeting with a therapist? Many people fear that by meeting with a therapist, they are committing to a long-term relationship. They sometimes also fear the therapist will decide how long the therapy lasts. These are anxiety-provoking preconceptions, and they are incorrect. When we try to refer people to therapy, it is important that we remind them of the truth—they are agreeing to one session at a time, and the length of the treatment is their choice, based on their goals and preferences.

It may help to be frank about what an initial therapy session is: a test drive. You can say, “You can meet with Maury and decide if you’d like to meet with him again. The first session or sessions can help you decide if you think he might help. You may know right away you’d like to meet with him more, but sometimes it can take a few sessions to decide if it’s worth continuing to invest in the therapy. Either way, it’s up to you how many sessions you go for. A therapist is an employee whom you can hire and fire.”

When we present the idea of therapy as a test drive, something the person can continue for as long as it meets certain conditions for them, we take away anxieties that therapy will be more of a commitment than the person may want. If we’re clear about the reality of therapy—that the length of treatment and the level of commitment is up to them—they may find it less threatening and be more likely to try it.

4. Do not make promises.

Ethically speaking, even a therapist cannot make promises, predictions, or guarantees about what they can do. We do not have a crystal ball with which to see the future. Often, my initial phone call with a new referral includes a difficult conversation along these lines:

Person: “So, do you think you can help me?”

Me: “Well, for better or worse I can’t know that just yet. We’d have to meet for you to form an opinion about that.”

Even if it’s a bit disillusioning, this is the truth. Like physicians or personal trainers, therapists can’t know whether their efforts will turn out to be helpful—only time and a careful, continuous, collaborative assessment will tell. We find out if our treatment plan is helpful once it helps.

There is great danger when a referral source makes promises about therapy or a therapist. Any expectations you give to the person you’re trying to refer can give them false hope or make them unnecessarily anxious and avoidant.

Every therapy session is, like every day of life, an experiment—we assess the problem that’s going on, pick an intervention or style of intervention we think might help, try it out, see what result we get, and adjust our treatment plan according to what works and what doesn’t. There is no magic to it, just a workaday process of trial and error, where we work hard to tailor a unique therapy to the unique person and their unique goals. In that sense, any preconceived expectations about therapy, just like in any other relationship, will be false.

For these reasons, there is great danger when a referral source makes promises about therapy or a therapist. Any expectations you give to the person you’re trying to refer can give them false hope or make them unnecessarily anxious and avoidant.

For example, a referral source could say, “He specializes in depression—he gets great outcomes.” Even if that is true, no two depressions are the same because no two people are the same. Likewise, no two treatments are the same because no two therapy teams are the same. Making promises or suggestions regarding a particular outcome can promote misleading or false hope. It may also distract from the fact it’s the work of the person in therapy, not the work of the so-called “expert in depression,” that makes or breaks the therapy.

Referral sources sometimes also make claims about a therapist’s technique when making a referral. For example: “He’s a very confrontative therapist—he’ll bust right through your defenses!” While it may be true that a therapist is capable of being confrontative, and while that kind of therapy may be appropriate for some people’s needs, presenting a referral in this way can be problematic. Good therapists base their technique on a careful assessment of the unique needs of the person in therapy, not based on what the therapist is good at or known for. Because of that, there is no guarantee the person you’re referring will ever have their defenses “confronted”—it all depends on the therapist’s assessment of what might help in the moment. Making such claims about a therapist can set up false expectations or give a person something to fear. Imagine already being nervous about letting go of certain defense mechanisms and then hearing a therapist is going to “bust right through” them.

For these reasons, when I refer someone to a therapist, I say something like, “There’s no way of knowing how it will go in advance, so the best way to find out whether the therapist can help is to go and check them out, assess how you feel with them, and make the best decision you can about whether to keep investing in the therapy. Hopefully they’ll be flexible and you two can make a therapy together that meets your needs.”

5. Let go of your desires!

If you haven’t caught it yet, my main thesis here is that while we can suggest that someone goes to therapy, or reveal our desire that they go, it is up to them. Pressuring people into doing something that is anxiety-provoking will usually lead to avoidance, submissive compliance, or stubborn defiance.

It is hard, but we must accept that we all have the right to avoid therapy and the anxieties that are built into it. No matter how badly we want to see a friend, loved one, or other person get help, our wanting it cannot make them want it. Only their inner desires can do that. So, while we can feel free to make suggestions to people about going to therapy, we must remember that they can do it only for them, not for us. Our desires for them can play only a very limited role in someone else’s therapy journey.

Example of Referring Someone to Therapy

Here is an example, based on the principles above, of what I might say to refer someone to a therapist:

“You seem to be suffering a lot and you’ve been clear that you’re not liking that, so I’ve been thinking that therapy might be useful to you. Obviously, it’s up to you if you want to go, but I do have the name of a person who I think might be able to help. Of course, that’s no guarantee, and you may have to shop around a bit to find someone who is a good fit. Either way, if you want to check this person out, they could be helpful. Do you want me to pass their contact info along?”

You can phrase this any way you like, but I think the key points for any referral are here:

1. Seems like you’re hurting, so therapy might be worth a shot.
2. It’s up to you.
3. You’re not committing to a lifetime on the couch, just one initial session.
4. There’s no guarantee it’ll be worthwhile, but the only way to find out is by trying.

Of course, this approach does not guarantee a specific outcome, but I believe it gives the best possible chance that the person will feel cared about by you, make the decision for themselves, and have the most realistic expectations possible going into therapy. Let me know if this helps!

First impressions can be crucial. None may be so important as the one your office conveys to someone beginning therapy.

People take nonverbal cues from their environment. The moment someone enters a room, they are receiving messages that can influence their actions and emotions. Some studies refer to how people perceive their environment as “non-conscious.” They may be aware of their surroundings but not realize how their surroundings affect how they feel or behave.

Depending on their practice, a therapist may want to create a space that connotes openness and healing. Others may wish to convey more structure and security. Either way, research indicates that decor should promote the right level of arousal. It should not over- or understimulate.

You may be opening your first office or moving into a new space. Regardless, how you decorate and arrange your office could influence the therapeutic relationship before anyone begins speaking. Keeping these tips in mind when you decorate your office may help maximize your productivity and enhance the benefits of therapy for the people in your sessions.

Choosing an Office

Think about the effects of shape and size when selecting your office space. Does it have many small nooks, or is it open with less barriers? Sitting in a confined space can feel safe for some but bring on feelings of claustrophobia for others.

Studies have found that an open space and high ceilings may be more conducive to emotional exploration. But too large of a room can negatively impact how people interact. This could actively discourage people from opening up during a session. In addition, a small office with big windows that look out over a beautiful view will have a much different effect than a larger office with fewer windows. Natural light has been proven to promote overall health and well-being. [fat_widget_right]

Color is often integral to striking the right tone for an office. One recent study found that a blue-teal combination was most comforting to people. Another study found that color can help bring out introversion and extroversion. Consider the color of the walls and what color may invoke in tandem with the structure of the space. Dark colors may feel suffocating, while neon colors may be overwhelming. Warm colors may stimulate and invigorate, while cool colors can invoke relaxation and subtlety. Cool colors may also inspire fatigue or sadness. Balance is key! If you cannot paint your walls, color can be incorporated through other means. Rugs, art, furniture, and other decor may help adjust the mood.

Furniture

The placement of furniture can also impact how people feel when entering your space. It can help to test a few different configurations to see what flows best before inviting anyone in. You might also read up on the art of feng shui, where open air and light with minimal clutter on surfaces are key to a healthy environment.

Depending on the type of therapy you practice, seating arrangements can be a critical element of your office. Consider how much vulnerability you’re asking of those who attend your sessions. This could influence how you position your chair and the chair or couch where the person you’re working with will sit. Most therapists find it beneficial to have seats that face each other directly. Positioning the chairs so the person in therapy can see the door may increase their feelings of safety and security.

As you choose furniture for your office, ask yourself what the style of each piece communicates. You may decide to go with clean lines and wood finishes that feel simple and unobtrusive. It can help to aim for a look that is professional without being cold. This might mean avoiding glass table tops and steel.

A bookcase can also be a helpful asset. Bookshelves can remind people they are meeting with an experienced professional, which may also increase feelings of security. As an added benefit, it can display resources you may wish to draw from or share in-session.

Plants

Studies show that indoor plants can make people feel relaxed and comfortable. It may be worthwhile to bring a few leafy friends into your office. There is no need to stress if you are notorious for killing plants—some can withstand even the most forgetful growers.

Succulents, for example, are very easy to care for and require minimal attention. Their geometric patterns and interesting shapes may offer something calming for people to focus on as they enter an office. Some varieties of cactus are also easy to care for. They can invoke the same serenity associated with peaceful desert vistas.

Artwork

Choosing artwork for your office can be an enjoyable part of the decoration process. But make sure to choose prints and photographs mindfully. Consider what each work evokes, including possible interpretations it might have. It may be helpful to avoid pieces with distinct narratives or those that feature people too clearly. Abstract art may be the most soothing and least distracting as a wall placement. Art featuring peaceful landscapes can also lend comfort to a therapeutic environment.

Therapists who practice reminiscence therapy could have other factors to consider. Reminiscence therapy may require people to recall memories from the past. It often incorporates props from that person’s past. A reminiscence therapist may collect art or decor from different decades to use for this purpose.

Animals

It is not necessary to practice animal-assisted therapy to incorporate some of the benefits of animal interaction into your practice. A fish tank, for example, can create soothing white noise and give people something relaxing to watch during your session. Some research has shown that watching fish can reduce heart rate and improve a person’s mood. Consider whether adding a small fish tank will facilitate the type of therapy you practice.

Creating a tranquil environment within a therapy practice can benefit everyone. People coming to therapy may feel at ease and ready to do the emotional work of their session when they feel the space is safe and inviting. Therapists may enjoy day-to-day work in an office they have decorated with a specific goal in mind. Even if you find yourself in a small space or dark office, it is possible to make adjustments that can uplift you and the people with whom you work.

References:

1. Boubekri, M., Cheung, I. N., Reid, K. J., Wang, C., & Zee, P. C. (2014, June 15.). Impact of windows and daylight exposure on overall health and sleep quality of office workers: A case-control pilot study. Journal of Clinical Sleep Medicine, 6(10), 603-611. doi: 10.5664/jcsm.3780
2. Bradshaw, J. (2015, June 1). The psychology of space, part 1. Retrieved from http://magazine.iavm.org/article/the-psychology-of-space-part-1
3. Chen, H., Ji, J., Liu, W., Ye, C. (2014, March 4). Optimal color design of psychological counseling room by design of experiments and response surface methodology. PLoS ONE, 9(3), doi: https://doi.org/10.1371/journal.pone.0090646
4. DeAngelis, T. (2017, March). Healing by design. American Psychological Association, 3(48), 56. Retrieved from http://www.apa.org/monitor/2017/03/healing-design.aspx
5. Gale, J. (2014, September 22). Creative spaces: Inside 25 counseling & psychotherapy rooms. Retrieved from http://jodiegale.com/creative-spaces-inside-25-counselling-psychotherapy-rooms
6. Lee, M., Lee, J., Park, B., Miyazaki, Y. (2015, April 28). Interaction with indoor plants may reduce psychological and physiological stress by suppressing autonomic nervous system activity in young adults: A randomized crossover study. Journal of Physiological Anthropology, 34(21). doi: 10.1186/s40101-015-0060-8
7. Smith, R. (2014, June 16). How to build a thriving therapy practice: Office space. Retrieved from https://rhettsmith.com/2014/06/how-to-build-a-thriving-therapy-practice-office-space
8. Todd, Z. (2015, August 19). The beneficial effects of watching fish. Companion Animal Psychology. Retrieved from https://www.companionanimalpsychology.com/2015/08/the-beneficial-effects-of-watching-fish.html

Someone recently asked me why they needed to know about the interpersonal process. There seemed to be a misunderstanding that the interpersonal process is only focused on building rapport, when stronger rapport is, in fact, a byproduct of the interpersonal process. If you have similar questions about how or why this framework could strengthen your practice, read on.

Interpersonal Process as a Framework

It is important to know that the interpersonal process is not a new theory or technique. Instead, it is a framework that can be integrated with any modality you want to use. You lay your favorite theory or technique upon this framework. This makes the interpersonal process not only versatile, but the cornerstone of any practice in which it’s used. Your modality can change based on individual needs, but the framework stays consistent.

Keep in mind that the interpersonal process comprises three core components: process dimension, corrective emotional experience, and client response specificity. Of these three, process dimension is what this article will focus on. [fat_widget_right]

The Cognitive Domain: A Crucial Component of Process Dimension

Tyber and McCluer identify three domains that make up the process dimension: the cognitive domain, interpersonal domain, and familial/contextual domain. While interpersonal domain addresses how a person experiences attachment brokenness, and the familial/contextual domain is where this brokenness is reinforced, the cognitive domain is at the origin of an person’s attachment brokenness.

The cognitive domain addresses the practical application of much of the attachment research that has been done. Under the cognitive domain, we identify the origin of the attachment style a person had or has with their primary caregiver. As therapists, we seek to uncover how a person’s values and identity were established, how they developed coping mechanisms, their covert thought processes, their beliefs about themselves and the world, how their value of self-care was determined, and what they need to restore their identity.

Therapists use these subcategories of the cognitive domain to identify attachment brokenness that occurred in response to real life experiences. To understand the importance of healing attachment brokenness using the interpersonal process framework, let us first look at how we treat attachment brokenness in children.

The Experiential Approach in Action: Play Therapy, Theraplay, and the Neurodeck

Becoming a registered play therapist requires candidates to spend 15 hours in training that specifically address attachment and how to build, repair, and strengthen a child’s ability to attach to a primary caregiver. But what is the common theme between attachment play therapy, theraplay, and the Brain Booster Neurodeck? Simply put, the common thread in these three modalities is an experiential approach. Healthy attachment is developed through experience, not reframing.

As therapists, we seek to uncover how a person’s values and identity were established, how they developed coping mechanisms, their covert thought processes, their beliefs about themselves and the world, how their value of self-care was determined, and what they need to restore their identity.

Play Therapy

In play therapy, clinicians provide experiences that support healthy, safe touch through activities such as foil hand prints, lotion on hands or feet, holding hands during activities, or working together on a task. All these activities encourage safe touch and eye contact. Eye contact in particular is important for our limbic systems to communicate and bond, as we learn from clinicians such as Curt Thompson or Louis Cozolino. Communication between our limbic systems is nonverbal; hence, the importance of eye contact.

Theraplay

Theraplay is also quite experiential; in fact, it may be the most experiential of all the methods listed. Attachment brokenness is healed through re-experiencing the attachment-building interactions that were not provided (or were insufficiently provided) during the first years of life, such as eye contact made when a baby is fed and swaddled. In some cases, the child needs to be cuddled or rocked as they would have been as an infant, a process that is exceptionally experiential. It may also be that a traumatic event broke an initially secure attachment, in which case Theraplay is utilized to re-establish the previously secure attachment style.

The Neurodeck

The Neurodeck comprises activities that build the brain from the bottom up. It begins with activities that assist with sensory integration, utilizing many of the same type of activities used in other attachment play therapy techniques. These experiential approaches harness messy play and movement. For example, they may use the lotion activity mentioned above or swing a child in a blanket to mimic the rocking movements experienced in utero. As a clinician moves through the deck, the activities become increasingly relational. This is the attachment component of the Neurodeck approach.

While it is impractical to swing an adult in a blanket to provide experiential therapy, the interpersonal process provides relational experience to honestly, yet compassionately, bring awareness to a person’s interpersonal characteristics.

The deck specifically states that certain activities should be completed in a one-on-one context before they are used them in a group setting. The one-on-one context is important in establishing safety before engaging in group work. Attachment work is rooted in laying a foundation for understanding safe and unsafe characteristics in relationships through a one-on-one dynamic. This dynamic then informs the safety of other relationships, especially relationships in a group setting. Each phase in the protocol is experiential and progressive.

Addressing Attachment in Adults

It is evident how attachment work in children is achieved through experiential modalities. The same can be said for attachment work with adults. The cognitive domain mentioned above is at the root of an person’s attachment brokenness, while the interpersonal domain is where attachment brokenness is experienced, and the familial/contextual domain is where the brokenness is reinforced. Through our work as therapists, we provide an experiential repair for broken attachment that is evaluated through interpersonal skills. A person’s maladaptive interpersonal skills provide a wealth of information about what happened in the cognitive and familial domains, as well as crucial information for effective treatment planning.

While it is impractical to swing an adult in a blanket to provide experiential therapy, the interpersonal process provides relational experience to honestly, yet compassionately, bring awareness to a person’s interpersonal characteristics. Are they interacting in healthy ways that allow people to draw near to them and create a desire for others to be in a healthy relationship with them, or are they fracturing relationships unknowingly because they lack the awareness or skills to build healthy relationships? Sharing our experience of an person’s behaviors or words can help them develop self-awareness and contemplate whether they are communicating what they intend. This approach can also help with reality testing.

Strengths of Interpersonal Process

One strength of the interpersonal process framework is the way it helps build flexibility and other-focused awareness, which allows for healthy attachments and navigating unhealthy relationships more confidently and constructively. By highlighting awareness of how a person’s communication might be perceived by others, we broaden their understanding of themselves and of others. Maintaining a broader range of interpersonal understanding ideally increases a person’s window of tolerance in their relationships and creates a desire to repair a broken healthy attachment or confidently sever an unhealthy attachment. The individual becomes better equipped to advocate for positive change in their life through a strengthened commitment to repair healthy relationships or by valuing themselves enough to part ways with unhealthy relationships without behaving destructively.

The Effective Interpersonal Process Clinician

A provider who effectively uses interpersonal process reflects truths to people that help them feel heard and known so they may heal. Those on the receiving end of these truths may not always like what they hear. However, when they work with an empathic and skilled therapist, people can hear and understand their therapist’s reflections, even if they do not like what is said.

At the appropriate level of reflection, people learn to trust their therapist. Feeling known and understood improves rapport. In this context, rapport is equivalent to attachment. A grounded relationship with an effective interpersonal process therapist is emotionally supportive so people may engage in difficult, effective therapy that greatly improves treatment outcomes.

Reference:

Teyber, E., & McCluer, F. H. (2010). Interpersonal process in therapy: An integrative model (6th ed). Belmont, CA: Brooks/Cole.

Complex posttraumatic stress, known as C-PTSD for short, is the result of prolonged series of traumatic experiences at the hands of someone the victim has a personal relationship with. The most common cause of C-PTSD is child abuse by a parent, stepparent, or other primary caregiver. However, it can result from a range of situations, including abusive relationships, abusive forms of imprisonment, and exploitative prostitution. C-PTSD has similar symptoms to posttraumatic stress (PTSD), but these are entwined with negative self-image, inability to control emotions, and certain personality disturbances.

The Rise of Cultural Competency

One of the most interesting aspects of working in the field of C-PTSD is the interface between cultural competency and complex trauma. Cultural competency has been a major trend within the mental health profession and, indeed, the health care field as a whole. The trend started as response to a number of studies in the 1970s which demonstrated that members of minority and marginalized communities were both less likely to seek out therapy for mental health issues and less likely to have successful treatment outcomes if they did so. While it had been naively thought that psychological research had revealed the nature of the universal human mind, experience demonstrated that many of its conclusions were highly culture contingent. What worked with people raised and acculturated in a Western cultural milieu did not always work with people from different cultural traditions.

[fat_widget_right]

In response to growing awareness of this deficiency, the mental health care industry began promoting cultural competency initiatives designed to educate therapists in the cultures and mores of different minority groups. For example, learning about the differences between honor-shame societies and guilt societies allowed therapists to more effectively help people of Asian origin deal with anxiety and depression. With the expansion of culturally competent mental health services, many people gained access to effective psychotherapy for the first time and we came closer to the goal of a mental health system that serves all Americans.

However, there were two problems with the first wave of cultural competency activism, one logistical and the other more profound. The first is that the sheer diversity of human culture and the internal complexity of each branch of civilization makes it impossible for any one individual to become truly competent in all but a tiny fraction of them. True familiarity with even one culture is the work of years, even a lifetime. In short, training psychologists to achieve cultural competency in all the cultures present in a diverse country like 21st century America, then distributing them everywhere they are needed, is an impossibly complicated—not to mention expensive—task.

In practice, cultural competence training combines elements of both approaches: imparting a basic level of specific knowledge about cultural traditions that a given psychologist is likely to come across in their work so as to avoid likely pitfalls and, at the same time, cultivating a general attitude of flexibility and willingness to explore.

The second problem is that the first-wave approach to cultural competence is based on an artificial model of the world as divided into discrete, self-contained cultural units. This is an oversimplification for two reasons. First, cultural units are, in reality, composed of different subcultures. One may learn, for example, about “Chinese culture,” but there are profound differences between the culture of people from the Dongbei or Huanan regions. Similarly, the rhythms of life in Georgia and Montana are substantially different even for people who share the same ethnicity, religion, or politics. Within these subcultures, too, there are substantially different “sub-subcultures” all the way down to the level of a local town or even family. Decisions about where to draw the line between one “culture” and another are often based on arbitrary or political considerations rather than objective criteria.

Secondly, the static culture model ignores the reality of cross-cultural fertilization and the ability of individuals to cross cultural boundaries. Cultures are not static entities but dynamic, constantly evolving, compound forms, which develop precisely because individuals are able to transcend their cultural origins and incorporate new elements from others or of their own invention. Putting these two considerations together forces us to reimagine our concept of culture as a sort of spectrum, making the task of cultural competence as infinitely complex as the human experience itself.

In response to both practical and philosophical objections to the static model of cultural competence, a new approach known as cultural flexibility was developed. Instead of emphasizing specific forms of knowledge about specific cultures, the emphasis came to be placed more on openness and awareness about questioning assumptions. Instead of being a barrier to communication, with the right attitude and approach, cultural differences can be used as a tool to help the development of an effective therapeutic relationship between therapist and person in therapy. In practice, cultural competence training combines elements of both approaches: imparting a basic level of specific knowledge about cultural traditions that a given psychologist is likely to come across in their work so as to avoid likely pitfalls and, at the same time, cultivating a general attitude of flexibility and willingness to explore.

Cultural Competence and Complex Trauma

One of the most difficult and fascinating areas within the field of culturally competent psychology is the issue of trauma—and complex trauma in particular. While there are many things that are so horrific that virtually anyone would be traumatized by experiencing them, it is clear there is a great deal of cultural variation in what is considered traumatic around the world, as well as how this trauma affects people. To take a superficially extreme example, among the Mursi people of Ethiopia, about a year before marriage, which often takes place as young as 15, a young woman will have an incision of about half an inch made in her lower lip, usually by her own mother (and, of course, without anesthetic). A wooden chip will then be inserted into this incision, which is replaced with successively larger objects until, finally, a clay disk of up 20 centimeters in diameter is inserted in time for the wedding day. It is safe to assume that a typical Western adolescent would find this experience at the very least somewhat traumatic. It is also apparent that, whatever we may think of their views on the relationship between the sexes, the Mursi women are not traumatized by this procedure, or, at least, do not display the typical symptoms of traumatization.

It is of course unlikely that an American psychologist will work with a person sporting a lip plate. If it were to happen, however, it would raise many interesting questions about the nature of childhood trauma. Child abuse exists in every culture and, presumably, the Mursi are no exception, but in dealing with such a case, a therapist would have to be extraordinarily careful not to project their own culturally modulated impression of what constitutes a traumatic experience. Complex trauma represents one of the most delicate and sensitive areas for cultural competence training, and more research is needed to guide best practices regarding the universality and cultural subjectivity of potentially traumatic experiences.

References:

1. Berman S. L. (2016). Identity and trauma. Journal of Traumatic Stress Disorders and Treatment 5:2. doi:10.4172/2324-8947.1000e10
2. McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10.
3. Tummala-Narra, P. (2014). Cultural identity in the context of trauma and immigration from a psychoanalytic perspective. Psychoanalytic Psychology, 31(3), 396-409. Retrieved from http://dx.doi.org/10.1037/a0036539
4. Wilson J. P. (2007). Cross-Cultural Assessment of Psychological Trauma. New York: Springer.

I was recently talking to a colleague about the topic of therapist self-disclosure and when it’s appropriate to reveal versus withhold certain details regarding personal information. My colleague referenced the term “broaching,” saying, “There is a difference between self-disclosure and broaching.” This piqued my curiosity, as I was unfamiliar with the term.

She explained how broaching is a vital and culturally competent tool and went on to give the following examples: Telling a person in therapy I am from the East Coast and not the South, thus there may be references to Southern culture I am not familiar with; pointing out I was born in the United States, therefore conveying I may not have a full understanding of the experience of someone who immigrated from China; or asking a black individual what it is like to work with me, a white therapist.

[fat_widget_right]

As she listed these examples, I was happy to realize this was a concept I was actually very familiar with and trained in. Despite not previously being aware there was a term for it, broaching is something I’ve found to be incredibly important in my work.

Broaching, as defined by Day-Vines (2007), “is more than consideration or acknowledgement of racial and cultural factors; it refers to the counselor’s explicit efforts to both initiate and respond to the sociocultural and sociopolitical concerns during treatment.”

Broaching involves the therapist mentioning their awareness of race, ethnicity, culture, and other obvious differences as a way to build rapport, invite open communication about diversity, and let people in therapy know that nothing is off the table. By broaching otherwise overlooked or unmentioned subjects, therapists demonstrate there is value in talking about all perspectives and aspects of various experiences and issues.

While I had excellent training in multiculturalism during my graduate program, I didn’t fully appreciate the importance and positive impact of broaching until I utilized the technique with someone during my internship. While working with a young African woman, I listened as she expressed frustration with an experience in trying to buy a car. She described how she felt taken advantage of by the salesman due to being young and female.

If you are a therapist who finds it difficult to use broaching or one who lacks strong training in multicultural issues, consider getting training in this area. If you are an individual in therapy and have found yourself holding back about important aspects of your life due to fear your therapist will be offended or unable to understand, take a chance and go there.

At one point in the conversation, I nodded in agreement and said, “And there may have been some racism going on, too!” Her eyes lit up and she exclaimed, “Thank you for saying that! Yes! I didn’t want to mention that because I was afraid of offending you or that you wouldn’t understand.”

This led to an important conversation about how I may be able to relate to some aspects of her experiences, but I could never truly understand it fully, especially in regard to what it is like to be an immigrant or a woman of color in our society. I invited her to always feel comfortable bringing up issues of race and our differences, and I acknowledged the reality that things like racism and prejudice are a huge part of her existence and worth talking about. It was incredibly powerful and eye-opening to see how broaching strengthened our relationship and allowed this individual to permit herself to go deeper in her work by sharing every aspect of her various experiences.

Mentioning differences and pointing out the “elephant in the room” makes uncomfortable, awkward, or taboo topics less of an issue, barrier, or obstacle in treatment. It is vital that therapists consider how cultural factors play a role in the experiences of people seeking help. While it can feel awkward to do so, it is the job of therapists to open the door for the people we work with to feel safe and comfortable enough to talk about the important aspects of their world. When done in a genuine, appropriate, and respectful way, initiating these conversations can help individuals to feel more comfortable and can lead to some rewarding interactions that further the treatment.

Broaching has the power to help individuals to feel safer, more respected, better understood, and more empowered. People tend to feel more comfortable with people similar to them, believing they will be better able to relate and understand; however, more important than sharing the same traits is the therapist’s attitude toward recognizing and acknowledging similarities and differences in things like age, generation, race, ethnicity, culture, gender, sexual orientation, disabilities, and socioeconomic status.

If you are a therapist who finds it difficult to use broaching or one who lacks strong training in multicultural issues, consider getting training in this area. If you are an individual in therapy and have found yourself holding back about important aspects of your life due to fear your therapist will be offended or unable to understand, take a chance and go there. You deserve a space where you can be authentic and 100% transparent about your experiences. If your therapist does not demonstrate an ability to handle broaching, it may be worth finding a provider who is a better fit.

Reference:

Day-Vines, N.L., et al. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85, 401-409.

One challenge that can arise for therapists is the decision whether to disclose personal tidbits of information as they become potentially relevant during treatment with the people we help. I recently provided consult to a colleague who brought this dilemma to light and gave me the opportunity to contemplate all of the aspects involved in deciding whether to share information in our work.

In this particular scenario, my colleague was conflicted about whether to disclose to a woman she was working with that they shared the same medical practice. Normally, this piece of information might be an insignificant coincidence; however, this specific case was more complicated. A large focus of what the woman was discussing in the session involved decisions she was making regarding one of the doctors in the practice as it related to the future of her health care. My colleague, her therapist, had strong opinions about this particular doctor due to a very negative personal experience she had. As she listened to the woman explain her situation, she felt conflicted over whether to speak up about the fact she knew this doctor or stay quiet and focus solely on the woman’s experience.

[fat_widget_right]

Both felt like no-win options. On the one hand, it felt awkward to take the focus off the woman’s experience by mentioning her own knowledge of the practice. On the other, she felt that simply listening and nodding without mentioning her familiarity with the doctor was like withholding a secret or being dishonest. And that felt like a threat to her credibility and to the therapeutic relationship.

As we contemplated her options, we discussed various questions, including: What if the two women ran into each other in the doctor’s office waiting room? What if the woman mentioned her therapist by name to the doctor and he revealed he knows her? If the woman somehow found out her therapist knew of this doctor all along with no mention, would she feel betrayed? Would it be a threat to their working effectively together?

I had a similar experience in the past in terms of feeling uncomfortable holding a “secret” from two people I was working with. I had a long-standing relationship with each individual. Well into my work with both, it became apparent the two had met and become friends. As the two talked about their budding relationship in their individual therapy sessions, I sat with the discomfort of being unable, due to confidentiality, to blurt out, “I know this person!”

Sometimes, obvious conflicts are apparent up front and we have the opportunity to inform an individual that, due to a conflict of interest, we are going to need to refer them to a colleague. But when coincidences and complications arise well into the course of treatment or are not obvious conflicts, our options and decisions as therapists become more complicated. We are often faced with navigating how to balance being transparent, open, and honest while adhering to boundaries, ethics, and legal codes.

When ethical or legal boundaries do not prohibit therapists from sharing information, appropriate self-disclosure can be incredibly useful in therapy. For one, sharing common experiences can strengthen the therapeutic relationship. Additionally, revealing limited personal information or mentioning mutual experiences can help make the therapist seem more “human” or “real,” which can increase the comfort level of the person seeking help.

When a therapist decides to disclose certain information, it’s important to keep in mind that the reason for doing so is to help support the person in therapy and advance the treatment. The therapist must ensure the disclosure is in the best interests of and for the benefit of the person they are helping and be careful not to turn the focus on the therapist.

A strong therapeutic alliance is one of the biggest factors in whether therapy is helpful, and some level of disclosure can help in developing this necessary rapport. Additionally, when therapists share that they personally relate to pain, struggle, or challenge, they can instill hope and help to reduce feelings of isolation or helplessness.

The key to disclosing lies in determining when it is appropriate. In line with most health care provider codes of ethics, the first obligation is to do no harm, so it’s paramount to think about the welfare of the individual in treatment and to contemplate all the ways they may be impacted by the decision to share or not share. In more complicated situations, it is important to seek outside consultation with other professionals or colleagues to ensure the therapist is looking at the situation from every angle and that personal needs, emotions, and biases are not clouding their judgment.

When a therapist decides to disclose certain information, it’s important to keep in mind that the reason for doing so is to help support the person in therapy and advance the treatment. The therapist must ensure the disclosure is in the best interests of and for the benefit of the person they are helping and be careful not to turn the focus on the therapist. The therapist should not disclose anything that may require the person they are helping to then be in a position of caring for the therapist. For example, it would not be appropriate to bring up unresolved grief or any other issues the therapist is wrestling with.

Disclosure is effective only when the person in therapy feels supported, understood, and validated, so care should be taken in the timing and delivery of the information. It is not helpful if the person feels the therapist is wasting valuable time with their own interjections or anecdotes, so therapists should consider whether disclosure can be summed up in a simple sentence or whether it would require a more in-depth explanation that takes up time and turns the focus away from the person’s experience.

Questions for Therapists to Consider Regarding Disclosure

Some questions therapists must ask themselves when deciding whether to share certain information include:

• Is the information clinically relevant?
• How will sharing the information affect the treatment?
• Will not sharing the information impede the therapeutic process?
• Does disclosing breach any lines of confidentiality?
• Does not disclosing violate any legal obligations?
• What is the intent of the disclosure?
• Is disclosing for the benefit of the person in therapy or the therapist?
• Does withholding or sharing the information cross any ethical boundaries?
• How might disclosing impact the person in therapy? Would it be helpful or harmful?
• How might disclosing impact the therapeutic relationship?

Apart from issues that involve clear legal or ethical guidelines, there is often no right or wrong answer as to whether disclosing certain information is appropriate or warranted. By considering the above questions, therapists may be better able to make decisions that are well thought out and upholding of their duty to act in the best interests of the people they help.

The first person I ever worked with in therapy, when I was a graduate student at the Veterans Administration Hospital in Danville, Illinois, died by suicide. While my supervisor and fellow clinical students tried to reassure me that his death was not my fault, that it was not due to clinical incompetence, I still felt deep down that his death was a reflection of my inexperience. This incident led me to wonder if clinical psychology was, in fact, the ideal occupation for me.

I did become a clinical psychologist, though, and in the 40 years since this initial death by suicide, three other individuals I have provided therapy services to (whether they were people I was directly working with or people a trainee under my supervision was working with) have died by suicide.

[fat_widget_right]

Unfortunately, this is not uncommon. Many mental health professionals work with people who are experiencing suicidal thoughts, and some of these individuals die by suicide.

Consider the following:

• Full-time therapists see, on average, as many as 5 people who are suicidal each month, especially those who frequently work with people who have a history of victimization and substance abuse.
• 1 in 2 psychiatrists and 1 in 7 therapists report losing a person in therapy to suicide.
• 1 in 3 clinical graduate students will work with an individual who attempts suicide at some point during their training, and 1 in 6 will experience the death by suicide of an individual.
• 1 in 6 individuals die by suicide while in active treatment with a health care provider.
• Working with people who are at high risk for suicide is considered the most stressful of all therapy practice endeavors. Therapists who lose a person to suicide may experience such a loss to the extent they would experience the death of a family member. The loss of a person in therapy by suicide can become a career-ending event.
• The distress therapists experience after losing a person in treatment to suicide can be further exacerbated by possible legal actions. Of those who die by suicide, 25% of family members choose to take legal action against the individual’s mental health care team (Bongar, 2002; Kleespies, 2017).

What Can Therapists Do After Losing Someone to Suicide?

It is important for therapists who work with individuals experiencing thoughts of suicide, are at high risk for suicide, and/or have attempted suicide to take certain steps to help themselves in order to continue their work.

Therapists who have a strong support network, who maintain a sense of hope and optimism, and who remember to practice self-care are more likely to be more able to overcome adverse events, such as the loss of a person in therapy to suicide.

One essential first step is documentation. Therapists who work with people at risk for suicide must document risk and protective factors, as well as accompanying interventions, in their progress notes.

The American Association of Suicidology offers a wealth of useful advice to mental health professionals who have lost a person in therapy to suicide. I have provide some additional suggestions to accompany their recommended procedural and psychosocial steps

Procedural steps to take immediately after losing someone to suicide: 

• Notify your supervisor and supportive colleagues, as well as the director of your service.
• Contact the hospital attorney.
• Consider contacting the family members of the person in therapy. Whether you choose to do so is likely to depend on the circumstances of the situation. You may wish to ask the family members if they would like you to attend the individual’s funeral.

 Psychosocial steps to meet your emotional needs:

• Seek support from your supervisor, colleagues, and significant others.
• Attend to your needs to mourn or grieve the loss of the person, whatever form that grieving process may take.
• Monitor any self-blame, hindsight, or biased thinking processes and utilize helpful methods of coping to deal with these and any stress they may cause.
• Use cognitive strategies to cope with the emotional aftermath of the person’s suicide, seeking help from a professional when necessary. For example, engaging in the mindful path of self-compassion can be a helpful way to cope (Gerber, 2009).

 Pursuing further education:

• Review your progress notes.
• Write a case summary of the ongoing risk assessment and the course of treatment interventions.
• Enumerate the lessons you learned from the death and share this, when able to do so, with interested and supportive others.
• Make a gift of this professional experience to others. By sharing the loss and what you have learned from it, you can help create awareness and help others learn.
•  You may find it helpful to include a supervisor, colleagues, or review groups in the process of pursuing further education on suicide and working with people who are suicidal.
• Finding ways to work with others to reduce suicide can often be a key component of this process.

Resilience is an essential component for those who work with people at risk for suicide. Therapists who have a strong support network, who maintain a sense of hope and optimism, and who remember to practice self-care are more likely to be more able to overcome adverse events, such as the loss of a person in therapy to suicide. Bolstering resilience can allow mental health professionals to become better able to cope with such a loss and experience posttraumatic growth following the death of a person in treatment.

References: 

1. Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association.
2. Gerber, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York, NY: Guilford Press.
3. Hernandez, P., Engstrom, D., & Gangseei, D. (2010). Exploring the impact of trauma on therapists: Vicarious resilience and related concepts in training. Journal of Systemic Therapies, 19, 67-83.
4. Kleespies, P. M. (2017). The Oxford handbook of behavioral emergencies and crises. New York: Oxford University Press.
5. Meichenbaum, D. (2005). 35 Years of working with suicidal patients: Lessons learned. Canadian Psychologist, 46, 64-72.
6. Meichenbaum, D. (2006). Trauma and suicide. In T. Ellis (Eds.), Cognition and suicide: Theory, research and practice. Washington, DC: American Psychological Association.
7. Meichenbaum, D. (2014). Roadmap to resilience. Williston, VT: Crown House Publishing.
8. Meichenbaum, D. (2017). Self-care for trauma psychotherapists and caregivers: Individual, social and organizational interventions. Retrieved from https://www.melissainstitute.org/documents/Meichenbaum_SelfCare_11thconf.pdf
9. Norcross, J. C., & Guy, J. D. (2007). Leaving it at the office: A guide to psychotherapists’ self-care. New York, NY: Guilford Press.
10. Pope, K. S., & Vasquez, M. J. (2005). How to survive and thrive as a therapist. Washington, DC: American Psychological Association.
11. Wicks, R. J. & Maynard, E. A. (Eds.) (2014). Clinician’s guide to self-renewal. New York, NY: Oxford University Press.

Labeling pathology in another person is easy. One teacher of mine said it’s like “shooting fish in a barrel.” Think of any person you know and, unless you’ve totally idealized them, I bet you can find some psychological diagnostic label to pin on them. “So neurotic!” “So hysterical!” “So narcissistic!” We all have the ability to spot apparent pathology. But we all, therapists included, sometimes have a much more difficult time recognizing health—the healthy strivings of others and of ourselves.

So why is so much mental health education, from graduate programs to popular blog posts, focused on helping people identify and label (aka diagnose) pathology? What problematic dynamics are evoked when the therapist and others function only as pathology detectors? How can we reorient ourselves toward detecting human complexity, the complex intertwining of “health” and “pathology” within ourselves and each other?

[fat_widget_right]

Why Is It Useful to Be Sensitive to Pathology?

Imagine if you went to your car mechanic because something is wrong—your car would not accelerate past 25 mph. Imagine the mechanic takes a thorough look at your car and says, “Well, I can’t see anything wrong. I think your car is fine.” You might be more than a little concerned about your difference of opinion with the mechanic, and you’d probably look for a second opinion.

The same is true with therapists. Some emotional problems show up in big, visible ways—a depression that makes it hard to get out of bed, for example, or panic attacks. However, some mental health conditions and—more importantly—the underlying emotional processes that contribute to them are quite subtle and difficult to detect. Without thorough and nuanced training in detecting the manifestations and drivers of people’s issues, therapists are at risk of looking a suffering person in the eye and saying, “You seem fine to me.” For this reason, we need a refined understanding of all the parts in the engine of the human mind, and we need to know how a person looks when some part of that engine is malfunctioning.

As important as it is to be able to see and understand a person’s issues, the therapeutic relationship is deeply compromised when the person’s issues are all we can see.

When All We See Is “Resistance”

Realistically, some people come to therapy in a near-total state of resistance:

“I didn’t want to come today.”

“I’m only here because my partner said I need to be here.”

“Does therapy even work?”

It can be hard to imagine how progress can be made in the face of attitudes like these. It seems like “pathologies” like defiance, passive compliance and hopelessness have totally taken over the people quoted above. It’s hard to find any overtly “healthy” dimension of their comments.

As a therapist, I encounter statements like these with great regularity, and I’ve seen plenty of instances of “resistance” and “pathology” that are even more bold and provocative. It is incredibly easy to hear these comments and become hopeless—if all we see is resistance, we may begin to doubt whether a healing-oriented part of the person even exists for us to build an alliance with.

In moments like this, we forget that, though the person’s words are defiant, passive, hopeless, or whatever else, they still arrived for their session. Not only are they present for the session despite this resistance, they are making an effort to be honest about how they feel. When we relate only to a person’s resistance and “pathology,” we forget that their sharing of their resistance and sharing of their “pathology” is a vulnerable attempt at forming an alliance with us. When we relate only to the resistance described by their words and not to their efforts to reach out through sharing, we miss an important opportunity to connect with the healing-oriented forces buried under the surface behaviors. When all we see is “resistance” and “pathology,” we miss out on the full complexity of the person we are trying to get to know.

Consequences of Seeing Only Pathology

When we fail to recognize and acknowledge the “resistant” person’s profound efforts to reach out to us by sharing their resistance openly, certain problems can plague the therapy alliance.

The person will not feel heard. Generally speaking, we can sense when someone is “pigeonholing” us or seeing us in a one-dimensional way, and we tend not to like that. Conversely, we tend to appreciate it when people have a complex understanding of us, with honesty about our inner “bad” and “good” and “mixed”-ness.

This ability to see and embrace our complexity is perhaps one of the great challenges of growth in therapy and elsewhere. Every day and every therapy session reveals new truths about us, presenting anew the challenge, “Can I accept this part of me?”

When we as therapists relate only to the “pathology” and “resistance” people show us, rather than convey our appreciation for the fact they are showing up to willfully tell us about it, they may feel, and rightfully so, only one part of them is being heard. When we fail to acknowledge the healthy efforts that emerge alongside or are veiled by their “resistance,” we relate only to their “badness,” which can have a severely negative impact on our alliance and lead people to feel more hopeless. Sadly, in cases like these, people often blame themselves for their therapist’s error: “It’s my fault the therapy didn’t succeed. I’m just too resistant!”

The person sitting across from us is already good at criticizing themselves. An expert ability to see and criticize our own foibles is part of what brings many of us to therapy in the first place. I have noticed when therapists relate only to a person’s pathology, one common response is for the person in therapy to join in with the therapist, criticizing their thoughts, feelings, and behaviors. This may look like helping a person “turn against their defenses” or helping them to “see their resistance,” but so often it is the establishment of an alliance built around change via criticism, which never seems to yield the desired therapeutic result.

The person may try to change, but not to please themselves. People in therapy tend to respond to the therapist’s tendency to notice only their pathology by trying to change. In these instances, they tend not to be changing for themselves or changing in directions they desire for their own well-being; instead, they tend to change in the direction they believe their therapists would prefer with the hope of no longer being criticized or related to as “bad.” This can be a reenactment of problematic attachments from the person’s past.

The Therapist’s “Pathology”

Your therapist’s difficulty seeing your complexity, the ways your healthy efforts coexist and intertwine with your struggles, is a reflection of their difficulties seeing and accepting their own complexity. Remember, we tend to treat others the way we treat ourselves, and to see others through the lenses we see ourselves through; as a result, the tendency of a therapist to pigeonhole a person as “pathological” suggests the therapist may tend to devalue themselves that same way.

I can only accept the complexity of the people I help to the degree I can accept my own complexity. As therapists, and as people in general, whenever we meet a new person or a new part of ourselves we are called upon to face deeper and deeper levels of the complexity that is humanity. In that moment when we meet a new person, a new truth, will we accept it in all its complexity or will we reduce it to “pathology”?

Can We Accept the Complex Beings We Are?

So how can we see each other as complex people? How can we manage to hold both our health and our destructiveness in mind simultaneously so we have the most complete information about ourselves to work with? How can we gain an appreciation for the complex intertwining of our efforts to communicate and our efforts to wall off, such that our moment of greatest “resistance” may actually be our most profound effort to reach out? Can we accept our “resistance” as simply the most health we can muster at the moment?

This ability to see and embrace our complexity is perhaps one of the great challenges of growth in therapy and elsewhere. Every day and every therapy session reveals new truths about us, presenting anew the challenge, “Can I accept this part of me?” So often in therapy, when we discover something previously unknown about ourselves, we are tempted to reject and pathologize it. It is even tempting to pathologize and reject our tendencies to pathologize and reject ourselves! The human mind is incredibly adept at making an enemy of itself.

So can we accept that? Can we accept the conflictedness about self-acceptance that is part of our humanity at this moment? Can we initiate the journey of acceptance by loving and embracing the pathologizer and rejecter inside right now? That tendency must have been important to learn; otherwise, we would not have learned it. What if the goal in psychotherapy is not about finding health or finding pathology, but about attempting to embrace all of ourselves?