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.

In day-to-day life, we often spend a lot of time holding in the feelings and thoughts we have about others. These thoughts may be about people we love, someone we’re in relationship with, those we work with, or even just people we dislike but need to interact with regularly.

Life is about relationships; the quality of those relationships can contribute to how fully alive and happy we get to be. The authenticity and honesty in our closest relationships are strong markers for a healthy life—but we still hold back.

Why Do We Hold Back?

Part of the reason for this is maturity. Many of us know what it’s like to be with a child who doesn’t have a filter. They might tell a stranger that they’re ugly or let Great-Aunt Abigail know that her birthday gift was the same as last year’s—and it wasn’t appreciated then! This child hasn’t yet learned that little white lies can be okay and that there are times we aren’t blatantly honest in order to protect the feelings of others.

Another contributing factor is that we can get so used to holding in our thoughts and feelings that we lose awareness of them. And when they do make it awareness, we often say, “Bah! It’s not that big of a deal. Forget it.”

There goes another repressed feeling.

When Repressed Thoughts and Feelings Surface

Maybe we unload into a journal or speak with a friend or partner (not about them, but about each other.) Perhaps those feelings get displaced onto others, or even somatized into physical symptoms. Suddenly, all the little things we didn’t think were important are coming out in unexpected, unhelpful, and unhealthy ways.

We must learn to bring into consciousness the small cuts that build up in our lives and hold us back from more intimate relationships.

We think, “Okay. Let’s head to therapy! That will help with my anger, anxiety, or depression.”

In a counseling session, we may talk about Great-Aunt Abigail’s cheapness and how it seems to show how little she’s cared for us all along. Maybe we talk about a demeaning boss with whom we can never express our full frustration. Perhaps we get to share about all our friends who willingly take and take but never seem to return all we do for them.

Realizing Your Therapist Is Human

We should talk about all of these issues with our counselor. But over time, something else often becomes apparent: we discover our therapist is also a human being. We begin holding back the same kinds of thoughts and feelings from them.

A few examples of these thoughts include:

• “They looked at the clock a few more times than they usually do, but maybe they’re just hungry and looking forward to lunch. Never mind that it made me feel expendable.”
• “Okay, they stumbled when remembering my child’s name—I’ve only been talking about the little brat for 8 months now. But they must have so many clients, right?”
• “That was definitely a yawn. A yawn! How dare they. Oh, come on, it’s 8 p.m. It’s not a big deal. Stop thinking about it.”

Why Should I Share These Thoughts With My Therapist?

We often censor feelings and thoughts about our therapists because we know that’s the mature thing to do. We certainly won’t make too many friends if we’re constantly telling the people in our lives how they’ve let us down. But we’re not in our “daily lives” in therapy. We’re in therapy. We’re in this experimental petri dish to get to know ourselves better, something we can only do in relationship to someone else. We must learn to bring into consciousness the small cuts that build up in our lives and hold us back from more intimate relationships.

Talking with your therapist about any of the thoughts listed above may not get them to change or apologize, although that may happen. The main purpose of verbalizing these feelings is to give you the experience of exploring how these slights, which are most likely replicated in real life and often in bigger ways, affect you and your relationships with others. Discussing these thoughts in a trusting therapeutic relationship can help you work toward spending less energy holding them in on a regular basis. It can help to find a trusted therapist near you with whom you can explore these feelings.

Over time, you may find you are not holding grudges for as long as you used to or that your expressions of anger are not as strong as they’ve been in the past. This may mean you’ve begun to release yourself from the grasp of those slights and the repressed thoughts that often accompany them.

Advice is cheap.

Advice puts the onus on the listener and not the speaker.

Advice is often a quick fix—a mere Band-Aid on a wound that needs more persistent care.

I can usually detect someone’s frustration when, as their therapist, I pointedly do not offer advice. One of the skills therapists learn early in their training is one of the hardest, for both the therapist and the person in therapy: sitting in silence. But drawing out more information from people is a psychotherapist’s most useful tool. After all, your therapist is a trained listener, not advice-giver.

That does not mean your therapist is merely looking at you and listening while you talk. Any skilled therapist will be listening acutely for specific signals, which they then use to guide the direction of the conversation over time.

In general, your therapist is listening for three things:

[fat_widget_right]

1. What You Really Want

Nobody knows you better than you. That is why advice so often fails to help you move in the direction you want to go. Ultimately, you have the answers to your questions, though they may be buried under the expectations, hopes, and dreams of others.

It is actually pretty rare that people ask us what we really, truly want. We spend so much of our energy and efforts trying to meet the needs and desires of others. This is true for concerns large and small. It has to do with how we spend our weekends, what we eat for dinner, the career paths we choose, whom we marry and when, whether or not we have children.

In a variety of ways, your therapist is asking you, “What do you really want?”

Answering that question can bring about changes you may never have expected—some joyful, some scary. But in the end, the answer comes from you and nobody else. The essence of your answers are what will guide you closer to the life you want.

2. Change Talk

Speaking of changes, I am rarely surprised when I hear someone hint at something in their lives they wish would change. When I reflect that desire back to them, people often respond as if it is the first time they had thought about it.

Your therapist is listening for your change talk. It usually starts with a tentative, “Maybe I could …” or “I wonder what would happen if …” or “I’ve always thought it would be interesting to …”

Your therapist is listening for your change talk. It usually starts with a tentative, “Maybe I could …” or “I wonder what would happen if …” or “I’ve always thought it would be interesting to …”

When I dive deeper upon hearing something like that, usually those sorts of statements are brushed off as a pipe dream. Your therapist intervening to examine change-talk statements may require you to face some of your deepest fears. This could be a fear of failure, fear that it is too late to try something new, fear that you are lacking in the talent, charm, or financial means necessary to follow this line of thinking. The reasons I hear why people cannot take even the smallest steps toward their dreams are usually more creative, varied, and unpredictable than I could imagine.

That is the point of intervention for you and your therapist. Change talk is where the work of therapy begins.

3. Your Self-Regard

Many people are shocked when they finally recognize how hard they are on themselves. Over time, we develop core negative beliefs about ourselves which we mistakenly believe to be the truth.

Your therapist is listening for those types of statements. Don’t be surprised if your therapist picks up on a core negative belief about yourself and challenges it. Such beliefs, that we are not “enough” in some way, seep into our subconscious so much that we do not even realize how critically we speak to ourselves.

Confronting those beliefs are some of the most demanding aspects of therapy. But it is possible, even likely, that if you think you are not enough, your therapist does not think of you the way you do, and they will reflect that belief to help you develop a more positive (and realistic) self-regard.

So while your therapist may guide your conversation in certain directions, it is not to offer you advice. It is so you can both learn more about what you truly want. And, eventually, so you can both learn what steps you think are most appropriate to take.

Shall we get started?

While it’s stereotypical to be asked about one’s feelings in therapy, a common counter to that question is, “I don’t know!” or, “I’m not feeling anything right now.”

Part of my job, then, is often to alert people to the possibility they are having a feeling and they may be getting in its way.

Perhaps the most important part of therapy is asking yourself the feelings question when you’re outside of the counseling room. As it turns out, there are some surprising signals that you may be having a feeling. Let’s look at a few possible tells.

Beyond the Story

Feelings have less logic than thoughts. Many people who seek therapeutic support have thought their way backward and forward about their issue, yet they may be missing the emotional aspect.

[fat_widget_right]

Stories are compelling. When a person in therapy is good storyteller, it can be enthralling. Of course, they are probably enthralling to others; they don’t need to pay me to be one more member of their audience. This leaves me with the somewhat challenging job of interjecting.

“Okay, but what are you feeling?” I ask.

Sometimes, there are physical signs of something being experienced internally.

Physical Clues to Feelings

No, I don’t think there is a deeper emotional meaning in everything.

Sometimes a cough is just a cough. But occasionally, if I’m sensing someone is clouding their emotions with some avoidant behavior, I take a chance and ask a strange (if not impertinent) question about what else is happening for them. (My hope is that the person coming to me for support will start doing this on their own, outside of therapy.)

A few examples that might be worded more carefully in the moment:

Sure, some people laugh. Some get angry. But once they sit with these questions, a good 75% of the time we discover something we weren’t talking about that we can now bring into the room.

• Burping: What’s coming up for you? Figuratively, of course.
• Drinking water/coffee/tea: What would happen if you didn’t take that sip right now? What might you be swallowing?
• Going to the bathroom during a session: Is it possible you’re pissed at me?
• Yawns or expressions of fatigue: What feelings are being put to sleep?

Sure, some people laugh. Some get angry. But once they sit with these questions, a good 75% of the time we discover something we weren’t talking about that we can now bring into the room.

I’ve been on the other end. Many times. All of this comes from years of my own therapist asking me these sometimes laughable, sometimes absurd, but often accurate and helpful questions.

Sometimes I just need to pee, but I know how much I’ve worked on my anger, so it doesn’t hurt to take a few minutes to explore if I’m holding back something. Maybe it’s mild irritation that my therapist isn’t “getting me” today. Maybe it’s full-on rage at something I’ve been stuffing.

These are just a few possible cues. You know yourself. What physical tics may be an indication of a feeling for you?

Now What?

The feedback I get after expressing this stuff to a person in therapy is usually, “Okay, now what?”

Well, now you get to let the feeling be. Now you get to come out of your story. Now you get to park your thoughts and see what might be driving. You get to examine what might be getting in the way of connecting to your partner. You get to consider what might be stopping you from following through on tasks for a boss you don’t like.

When you can acknowledge your feeling, you don’t have to spend energy squelching it and hiding it from others.

Hey, you’re one of the lucky ones. You’re in therapy. You can express that feeling without judgment and without it taking control of you.

Who knew a seemingly ill-timed burp could hold so much?

(Excuse me.)

It’s one of the most important questions in therapy. It’s stereotypical. Sometimes, it’s disruptive. It can lead to anxiety and self-examination.

And it’s not going away.

Your therapist asking you what you’re feeling is a staple of most forms of counseling, and for good reason.

What you do with the question can begin to free you.

Yes, we all know therapy is about feelings. Before any of us stepped into a therapist’s office, we probably saw a cartoon, TV show, or movie in which a therapist asked the person sitting across from them: “How does that make you feel?”

[fat_widget_right]

The thing is, people come to therapy for a million different reasons. It could be to deal with depressive or anxious symptoms, trauma, or unhealthy expressions of anger. The list could go on and on.

Few people come to therapy with the stated goal: “I want to better understand and connect with my feelings.” For everyone else, it may not seem productive to be asked each week about what they’re feeling. All they know is they want to feel better!

A common response to the feelings question is frustration and annoyance. Especially if it occurs during a the telling of an event or a story from the past. If you’re focused on something from the weekend or from work, the feelings question may disrupt your flow.

Well-timed, the question can lead to breakthroughs regarding unhelpful patterns, difficult feelings, and negative interpersonal relationships.

Of course, it could be an ill-timed question by the therapist. Maybe it would be more helpful if they waited a bit longer to move you toward reflection. Maybe not, though. Perhaps the question is coming from the therapist’s sense that there are feelings you may be unaware of.

Well-timed, the question can lead to breakthroughs regarding unhelpful patterns, difficult feelings, and negative interpersonal relationships. It can reconnect you with any feelings you may be trying to avoid by overthinking the situation.

So, yes, the question may be an attempt to interrupt and go deeper. But if it’s making you angry, tell your counselor. That’s important information too.

This Is Not a Test

A common response to the feelings question is anxiety or, worse, a sense you’re doing something wrong if you’re not sure what the feeling is. Suddenly, it may feel like you’re being “quizzed” or tested.

This, too, is important information to bring up. The intention is (hopefully!) not to make you feel like a failure. You’re in therapy to learn about yourself and how to better understand your feelings. You’re not expected to know all the answers, let alone anticipate questions. Speak up if you sense pressure to perform or expectation from your counselor.

Remember that “I don’t know” is an acceptable answer. You may not be aware you’re having a feeling because you don’t tend to stop and check in with yourself. If the feelings question comes up, it’s a chance to do that.

And maybe you’re having zero feelings in that moment. Again, good information.

The Feelings Layer Isn’t the Only Layer

Becoming more aware of how you’re feeling at any given moment is not the only aspect of emotional well-being, but it’s an important layer to explore. Knowing your feelings may help you understand your actions better. It can inform your future choices.

Becoming aware of your feelings may help you feel less helpless. It may help you feel more in control.

Perhaps best of all, knowing your feelings gives them less control over you.

Dear new client: Welcome to the wonderful world of therapy! I know it can be hard to come in for your first appointment—really hard. You are here to meet me, a stranger who will hear about parts of your life that no one else hears about, and entrust I will do everything I can to help you. To make things easier, here are 10 crucial things I want you to know.

1. Honesty is the best policy.

If you’re not honest in the therapy space, you’re missing out! This is a rare opportunity to be 100% honest without the prospect of being judged. You’re paying for therapy, so lying is counterproductive. Are you using drugs? Tell me. It helps me better understand and work with you on everything from coping skills to medication use and interactions, to social skills, to behaviors that may or may not be attributed to substance use, to relationships, to even finances. Cutting? Tell me.

[fat_widget_right]

2. Therapy is an investment in both the present and the future.

The skills you learn here, and the support and insight you receive, will not only help you with the situation you’re in, but will become part of the “toolbox” on your lifelong journey. You’ll gain knowledge that improves your ability to cope with stress and mood swings, helps your understanding of why and how you do things, and facilitates communication between you and others in your life including loved ones, friends, and business connections.

3. Keeping appointments and being on time is critical.

Part of therapy is consistency. If you’re late, we not only have less time together, we also have to think about the reasons you’re not arriving on time. Making therapy a priority is important. And yes, you may be charged a fee if you don’t show up or you cancel late. The time you’ve reserved is yours and yours alone. When you don’t show up, two things happen: other people needing help who would love to have your time slot are not able to, and I don’t get paid for my time. I rely on this in planning my family and work finances.

4. If you have any concerns, tell me.

I can’t fix or address what is wrong unless I know about it. I won’t get angry or offended or lose my cool. Therapy is all about the therapeutic relationship between the therapist and the person in therapy. If you’re offended about something I said or how you feel treated or mistreated, give me a chance to help you understand or change things. Some things that may seem trivial, such as the fear of being overheard by others in the waiting area, can be addressed and/or explored. If you’re worried because I seem angry, let’s talk about that. My thinking face can look like a grumpy face at times. Knowing your concerns and allowing me to address them is a way to work on empowerment.

5. Nothing is off limits.

Don’t be embarrassed to bring up things, even uncomfortable ones such as sexual experiences or feelings, anger or rage, dreams or fantasies. Believe me, I’ve heard and dealt with nearly everything. I’m not easily embarrassed or fazed. You can also say something such as, “There is something I really want to bring up, but I’m embarrassed.” I’ll help you work through your feelings, and even if you don’t talk about it right away, we can work toward creating a space where you feel okay sharing it.

6. Don’t worry about me.

I have support systems in place if I need help. I seek supervision from peers or others who have more expertise in a given area than I do. Therapists don’t operate in a vacuum, nor should they. I can handle your anger, sadness, and grief. I also know my limits. This is why some therapists refer people to other therapists for some issues. If, for example, I am uncomfortable working with someone who is struggling with a terminal illness because it’s outside my expertise, I will help you find someone who can better assist you.

In the case of therapy, if I were to have an outside relationship with you, I couldn’t be a productive or helpful (or ethical) therapist. Unlike a friendship where both people support each other, my only focus when we meet is you.

7. There’s a good reason I can’t have a friendship with you.

It’s the same reason I can’t be my friend’s therapist. It’s called a dual relationship, which basically means being two things at once to someone. In the case of therapy, if I were to have an outside relationship with you, I couldn’t be a productive or helpful (or ethical) therapist. Unlike a friendship where both people support each other, my only focus when we meet is you. My years of training, supervision, and experience are all focused on helping you.

8. I’m not perfect by any means.

I run late sometimes. I may miss an email or forget to return a phone call. This doesn’t happen often, but if it does, please let me know. In the case of running late, I will make up the time either at the current session or at a later time. If it bothers you, let’s talk about it. Again, nothing is off limits.

9. What you say to me stays with me, with two exceptions.

The exceptions are if I feel you are going to kill yourself or hurt someone else, or if I suspect there is child or elder abuse or neglect. This doesn’t mean if you say you wish you were dead I’ll call the police. But if you mention a plan or I feel like you are on the edge of suicide, I have to take action to ensure the safety of you and others.

10. When you’re ready to leave therapy, that’s great!

It’s something you might be thinking of or I may bring up. Please don’t just stop coming in. Let’s talk about it. If you abruptly leave without letting me know, I am likely to be both confused and concerned for your well-being. The preferred method of ending therapy is to have at least one session where we talk about what we’ve achieved and where to go from here. Closure is important for both of us. You are always welcome back—be it in a month, a year, or five years.

Again, welcome to therapy. I’m glad you’re here. Let’s start this journey together.

Sexuality is often a sensitive issue. In recent months, many people have come forward, speaking out about inappropriate, harmful, and abusive sexual behaviors and actions taken by people of positions in greater power. These abuses of power and their effects have too long been in the shadows of silence. The topic of sexuality deserves greater awareness from all of us. By taking the time for honest and open self-reflection, we can all help prevent the misuse of power.

What is inappropriate and harmful sexual activity? For the purposes of clarification, let’s say this includes any physical or verbal behavior that is suggestive, seductive, harassing, demeaning, or exploitative. When a person in therapy is attracted to their therapist, this can often be discussed in therapy without harm—as long as the therapist is not excessively affected by attraction or countertransference. The therapist must be able to focus on the sexual issues of the person in therapy only to the extent such discussion is based on their therapeutic process. It is also essential to establish and uphold boundaries, including an explicit agreement that there is no possibility of sexual relationship at the time or in the future.

Issues related to sexuality present enough challenges in ordinary relationships. When it comes to the therapeutic relationship, sexuality can be even more of a challenging and complex consideration.  Here are some things to consider when examining sexual feelings toward or from people in therapy.

Coping with Sexual Feelings Toward a Person in Therapy

It can first help to explore why you may be attracted to a particular person. Is there something about them that meets one of your needs? Perhaps it is a natural need, but it is one that must be met elsewhere.

1. Talk to a colleague who can help you sort out what you are experiencing and take appropriate steps to keep the therapeutic relationship ethical. [fat_widget_right]
2. Seek personal counseling. Working with your own counselor can help you resolve your feelings and uncover any issues in your life you may be struggling to deal with effectively.
3. If you are unable to resolve your feelings, terminate the professional relationship and refer the person to another therapist.

Coping with Sexual Feelings from a Person in Therapy

A good first step here is to acknowledge the person’s feelings as normal. Appreciate their courage and vulnerability around bringing them up or having them named. Explain that although the intimacy that often develops within the therapeutic relationship is powerful, it is best described as a kind of contextual love that is specific to the power differential relationship. Sexualizing this kind of love is detrimental to your work in therapy.

1. Make it very clear, with both words and body language, that a sexual relationship is outside the bounds of the therapeutic relationship. (Ethical codes vary in their statements of how long after termination it is considered ethical to begin a sexual relationship, if ever.)
2. Make every effort not to shame or reject the person you are working with. Track for and attend to any signs of shame or rejection.
3. If appropriate, look for therapeutic ways in which issue of sexuality can be addressed and explored.
4. When sexual feelings are unspoken or unconfirmed, use your best professional judgment to determine what would best serve the person you are working with: naming the feelings yourself or waiting for them to make the choice to do so.
5. Be prepared in advance. Consider how you might handle this kind of situation or how you might handle it with greater skill. Seek the support of supervision.

How Can We Deepen Our Understanding?

The issue of sexuality goes much deeper than simply understanding feelings and setting boundaries. These several questions, brought up by students, can help you explore this topic further in order to deepen your understanding.

• “When a client tells me they are attracted to me, I feel flattered and awkward. How can I express myself so the attention doesn’t end up on me and my response, or so my client doesn’t get the wrong impression?”
• “How do I work with clients who automatically associate intimacy with sexuality?”
• “Do I need to shut down my sexuality altogether to be an ethical therapist or body worker?”
• “How can I help a client understand the difference between therapeutic or transpersonal love and personal love?”
• “What are right and wrong uses of sexual current?”
• “Can sexual current itself be separated out from therapeutic love and intimacy? Or is it just to be “managed,” understood and accepted?”
• “Should the experience of sexual current in a session always be named?”
• “How can I tell if a client is misunderstanding my intentions?”
• “What range of control do I personally and realistically have over my sexual feelings?”
• “How can I effectively and appropriately use this control?”
• “Is there a way this client’s attraction could be used therapeutically?”

Here are a few stories for further consideration:

• “A male counselor was attracted to a female client. He knew she was in crisis and offered to meet her in a restaurant to provide professional support. Having just gone through a nasty divorce where her ex-husband had numerous affairs, she was in a vulnerable position. She talked about feeling unlovable and unattractive. The counselor placed his arm around her shoulder to comfort her and offered to follow her home to check on her safety. He offered nurture and support, and from there they slipped into a sexual situation.” This counselor, who took advantage of his client’s vulnerability, has likely been led more by unmet personal needs and poor boundaries and judgment than malicious intent to harm. Sexuality is a strong motivator, and it can warp a person’s ability to make good judgments. As a friend says, “Please stay away. My hands grow larger and my head smaller when love is before me.”
• A caregiver writes: “My point of view is that what we need most of in this world is love. Love motivates my work, and I believe it is the most fundamental of all healing energies. When I sign a note to a client, “love,” I am not worried about people personalizing it with me since everyone knows or senses that I am not being romantic or suggestive. I think we are all adults here. And I still call my clients, “darling” sometimes. No one gets the wrong idea.” These words may be compelling, but people everywhere, especially people in a lesser power role, do get the wrong idea, do misinterpret, do make words mean something they want them to mean, and do confuse personal and transpersonal love, particularly when vulnerable and longing for love and acceptance.
• As part of a process of relationship repair between a student and a teacher, the student explained her experience. “I was confused by how you related to me in terms of your body language and energy when we met at a restaurant to talk about some theoretical questions I had. Your words and lack of help in focusing me and our conversation on the question created more and more confusion and insecurity within me. I felt ashamed of these feelings. Then when you sat down next to me at the table, instead of across from me, I felt invaded and manipulated. I felt uncomfortable and expressed my discomfort and vulnerability with the “newness” of being with a man, in particular a single man in this type of context. It felt more like a date than a teacher-student meeting. I felt ignored and disregarded when you failed to respond to my concern and discomfort. I began to feel that your needs were more important. I feel angry now as I see that I was subtly forced to push my needs aside in order to maintain the relationship with you and get my question answered. I needed you to maintain the boundary of teacher and student because I couldn’t do it myself. I trusted you, and this trust was violated. My shame prevented me from resourcing myself and correcting the situation, but I hold you responsible for seeing this and doing something about it in order to care for me and protect my spirit as a vulnerable student and single woman.” The courage and clarity of both the student and the teacher in facing this situation enabled clarity and resolution. The teacher understood, apologized, and did some therapeutic work to better understand his boundary issues and lack of sensitivity and responsiveness to his impact.

These stories illustrate how important it is to both think proactively about how you will respond to sexual issues when they arise and to learn how to attend to and repair relationships when needed. When personal sexual desires get involved, thinking can become very warped.

It is especially important to seek out and use resources such as colleagues and supervision when faced with ethical dilemmas, things about which you feel ashamed, or mistakes you have already made or believe you may make. If you are unsure how to begin this process on your own, the support of a compassionate counselor can help.

Dear GoodTherapy.org,

Several years ago, my wife began seeing a therapist. After a year, she asked that I join her for a session. Afterward, I began seeing the same therapist frequently on my own and periodically with my wife (we were having marital issues). After about nine months of this, my wife terminated her relationship with the therapist because she didn’t feel her voice was being heard. She felt the therapist was constantly preaching patience and taking my “side” on most issues.

[fat_widget_right]

I continued to see the therapist for what remained of our marriage (about a year) and beyond and indeed still see her to this day. I just found out that my now ex-wife (we’ve been divorced four months) has reengaged her relationship with this same therapist. Obviously, the divorce is still fresh, but I’m feeling a lot of emotions here and I’m frankly not sure they are justified. I feel betrayed. At a minimum, I think the therapist should have told me that she had taken on my ex as a client again. I also feel uncomfortable moving forward using the same therapist as my ex. Am I justified in these feelings? —Untold Anger

Dear Untold,

Your question raises a number of concerns. The short answer is that your therapist is ethically bound NOT to let you know she is working with your ex-wife. Part of client confidentiality includes not sharing the identity of a person in therapy with another person without the explicit permission of that client.

That said, the way your relationship with this therapist evolved sounds messy. The first moment that may have been confusing was when your wife’s individual therapist also became your individual therapist and also worked with the two of you as a couple. When a therapist works with multiple members of a family system, it is essential that boundaries are clear and all parties are comfortable with the situation. Exploring the benefits and risks prior to engaging in the work is essential. Checking in regularly to ensure everyone’s needs are being met is also important. Working with individuals and working with them as a couple can be beneficial at times, but it also runs the risk of one party feeling as if the therapist is more aligned with their partner and takes their side.

In individual therapy, the alignment between person in therapy and counselor is clear. In couples work, the relationship is the “client,” and it is imperative that neither individual feels marginalized. Managing that well and simultaneously meeting the needs of both individuals and the relationship can be challenging. It seems as if your wife began to feel as if her needs were not being met and took appropriate steps to terminate her relationship with that therapist.

Whether or not your feelings are “justified,” if you are feeling betrayed it is important that you address those feelings with your therapist.

It seems as if you felt aligned with and supported by this therapist until the recent revelation that she was working with your ex. Whether or not your feelings are “justified,” if you are feeling betrayed it is important that you address those feelings with your therapist. Having the opportunity to explore what is contributing to your discomfort could be helpful. You may ultimately decide you are not comfortable moving forward with this particular therapist, or you may discover that you are able to work together. Either way, having a conversation about trust and boundaries seems important.

I do wonder about some of the roots of your discomfort. In theory, your therapist is meeting with each of you as individuals; therefore, there should not be competing alignment concerns. Your sessions would focus on your needs, your ex-wife’s on hers. Given the history you’ve had with this therapist, however, I wonder if perhaps you are concerned about her ability to remain impartial and unbiased. Are you concerned that you may begin to feel the way your wife felt before she terminated their relationship? Might you be worried that this therapist will not be able to compartmentalize information from one of your sessions and bring that bias into the other’s session?

Whatever your concerns, without safety and trust, it is unlikely that your work together would be helpful or beneficial. If you are able to address your concerns, this might be an opportunity to deepen your trust. At the very least, this feels like important feedback for your therapist so she can understand how her choices are impacting your feelings of trust and safety.

Best of luck,

Erika Myers, MS, MEd, LPC, NCC

People seek out therapy for any number of reasons: anger management, trauma, relationship issues, or anxiety, just to name a few. But whatever the issue or concern bringing a person to therapy, when they are able to express a full range of feelings they have the potential to achieve even deeper healing.

When I talk about feelings here, I’m not just referring to the person’s feelings about their own experience, especially because some people may hold off on that for a while, wanting to fully trust their therapist before they share that. I’m talking about a person’s feelings toward their therapist and the therapy experience.

It’s my opinion that many people who go to therapy are just too … nice. By “too nice,” I mean they aren’t open with the therapist about negative feelings, such as disappointment, they might develop toward the therapist. They don’t, for whatever reason or reasons, speak up and let their therapist know what they really think and feel about them. But feeling open enough to express your disappointment about your therapist to your therapist could really help your therapy shift.

Are You Protecting Your Therapist From Yourself?

Sure, I’ve got some skin in the game when I’m working with people, and I’m likely to be affected by how they express themselves to me and what they say about me. But being able to manage the transference of people expressing all kinds of negative and positive feelings is all part of a therapist’s training. And I continue to do my own work, outside of the time I spend with the people I’m working with,  as part of my ongoing upkeep. I work to know myself as well as I can because the feelings I have in response to your feelings inform how I support you. (If you’re interested, this is called countertransference.) [fat_widget_right]

In other words, in order to be fully present and helpful in the therapy room, my personal work involves sorting out

1. My feelings
2. Your feelings
3. My knowledge of systems
4. Life cycle issues
5. How people change

Part of my job is being fully present with you, and I want you to also be fully present with me. In order to be fully present with me, you will first have to be fully present with yourself and then share that presence with me. I encourage you to share those thoughts and those feelings you are having, even—especially—those feelings you may be editing out for my benefit.

A New Office

When I moved into my new office, I was excited. I got to buy all my own furniture, wall art, etc.—I got to make the space mine, instead of having to remake the space every time I came in for my day, like I had to do when renting from someone else.

Of course, one consideration with designing my own space was realizing that not everyone who came into my space (such as people coming to therapy) would feel the way I did about it. Some of them didn’t like my lamp, others had issues with my bookcase, and some even disliked the pillows I chose.

There were also some things about the office that weren’t in my control. For example, it wasn’t on the top floor of a building in the financial district, and it didn’t have a gorgeous view. In fact, it was windowless and had a rickety elevator.

Some of the people I worked with expressed their disagreement with the style choices for my office and even the location. They told me my choice in furniture was off, that they resented that my space wasn’t, well, different than it was.

My inner responses?

• First, I was angry and annoyed. “This is my space!”
• Second,  I felt like I had screwed up. “I have a horrible office. I have no taste. I shouldn’t have gotten this chair.”
• Third, I realized,“I’m so glad they’re sharing this with me.”

Now while my job is to get to that third response, I need to go through the first two responses to get there. The third response, of course, is the one I would share with the people I work with.

Part of my job is being fully present with you, and I want you to also be fully present with me. In order to be fully present with me, you will first have to be fully present with yourself and then share that presence with me. I encourage you to share those thoughts and those feelings you are having, even—especially—those feelings you may be editing out for my benefit.

The first two responses are what most of us deal with in our daily lives. They’re what tend to lead to friends and family members having arguments: “How dare you say that? Couldn’t you have said it in a nicer way?” But the third response isn’t always gotten to in life, even though it’s an important layer.

I’m not just glad you share your feelings with me for masochistic reasons. I’m not even glad because venting is good for the soul. I’m glad when you share because then we get to unpack the response and see how it lets us know more about you.

Maybe you feel you don’t deserve a therapist with a beautiful office. Sure, the initial response is to put my space down, but then this unlocks the door to talk about your sense that you never get top-shelf treatment in life. This may correspond with how you were treated as a child. Where else might you be bringing this resentment? And if I can hear your disappointment, if I can withstand it without striking back, maybe you’ll come closer to it not having such a strong emotional hold on you.

Or maybe you need to find fault because you’re disappointed you’re not making as much progress as you feel you should be making. Putting down my space allows you to, less directly, put down my work with you. In a way, you may be indirectly expressing anger that you’re still dealing with depression or anxiety. And once you express these emotions and feelings, we can, together, decide to go deeper into them.

If I can get to my third response above, then I can push for this conversation. I can assist you with a more direct expression of your feelings. And your disappointment can be just the tool you need to move forward and unblock your therapy.

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.

It is often assumed by the general public that psychological diagnosis is a normal part of therapy that always occurs. Some people who have been in therapy may be unaware they have received a diagnosis. For their part, therapists have a wide range of views and practices pertaining to diagnosis, ranging from seeing it as essential to seeing it as unnecessary. Consumers have a right to know the advantages and risks of diagnosis.

Advantages of Diagnosis

Some people find relief and validation in receiving a diagnosis, as it symbolizes they are not alone. This can decrease the guilt, shame, and feelings of isolation that often are experienced. Diagnosis can also open up resources. This may be true, in particular, for children who are struggling with challenges in their social, emotional, and behavioral functioning.

For professionals, diagnosis can be a good way to quickly and easily communicate information, helping them to be more informed when working with a person in treatment. Also, diagnosis is often required for insurance to pay for therapy, which is a significant financial benefit.

[fat_widget_right]

Risks of Diagnosis

The risks of diagnosis are less frequently acknowledged. Most people I work with in therapy are surprised when I discuss the advantages and disadvantages of diagnosis with them; almost all who previously have been in therapy note that no therapist has done this with them before. But there are indeed risks, and consumers have a right to be aware of them.

Diagnoses often stick with people. I have had people who came to me for therapy with a previous diagnosis that followed them from childhood well into adulthood. In some cases, it was quite clear they were misdiagnosed early on, yet the label stuck with them. Diagnoses can also change over time and may no longer be accurate.

Further, diagnoses can be misunderstood by those outside the mental health profession. I have spoken with many previously diagnosed people who, upon sharing this with people they trusted, found it changed their relationship and, in some cases, ended it.

What Is Diagnosis?

What constitutes a diagnosis is debated by therapists (Kinderman, 2017). In essence, a psychological diagnosis is a label placed on a group of behaviors or experiences that are often called symptoms. The determination of what amounts to a diagnosis is determined largely by what is considered “normal” or average. There are some who maintain that diagnosis almost always has a biological origin, while others believe it tends to emerge largely from personal or social experience. Many believe it may be a combination of these two.

At times, a diagnosis can lead to focusing solely on the symptoms of that diagnosis, without considering the challenges or thought processes that may be contributing factors. This can limit the understanding of you, your concerns, and what you want from therapy.

A cluster of symptoms that fit a diagnosis may emerge from different causes. For example, depression may result from having endured difficult experiences in life or may, at times, have a biological cause. Yet, some assume that, regardless of whether there is a social/personal cause or a biological cause, the treatment of a condition should be through medication. This is a concern of many therapists who have witnessed therapy, without medications, successfully treat many conditions.

At times, a diagnosis can lead to focusing solely on the symptoms of that diagnosis, without considering the challenges or thought processes that may be contributing factors. This can limit the understanding of you, your concerns, and what you want from therapy.

After the release of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, many therapists were upset with the changes (Kinderman, 2017; Robins, Kamens, & Elkins, 2017). These changes included a general lowering of the threshold of the criteria to give people certain diagnoses. Some therapists voiced concern that this could lead to medicating people who do not need medication.

In the end, psychological diagnosis is based in part on science, in part on theory, and in part on the politics of the field of psychology. There is much that remains unknown and much that is hotly debated. I generally urge caution when any mental health professional is married to any one perspective on diagnosis and does not acknowledge other views.

Consumer Rights with Diagnosis

I believe that, in most instances, consumers should be part of the decision about whether to be given a diagnosis. It is not something that should be imposed upon the consumer without their input or perspective. Here are my recommendations for consumers regarding diagnosis:

• If your therapist does not bring up diagnosis in the first session, ask if they are going to give you a diagnosis and what the diagnosis is.
• Ask what the diagnosis means and your therapist’s reason for giving you the diagnosis.
• If you do not want to be diagnosed, tell the therapist. They may be required to give a diagnosis if you are using insurance; however, you have a right to be a part of that discussion.
• You have a right to ask how the therapist will use the diagnosis.
• If you believe your therapist is treating you like a diagnosis and not like a person, discuss this with them.
• Ask your therapist how your diagnosis may impact you.
• If you are not comfortable with your therapist’s approach to diagnosis or the diagnosis they give, get a second opinion or consider finding a different therapist who may be a better fit for you.

Diagnosis can be a difficult issue for therapists and consumers alike. It is best approached as a collaborative process within the therapeutic relationship. Regardless, you have a right to know what is going on with your diagnosis.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th). Washington, DC: Author.
2. Kinderman, P., Allsopp, K., & Cooke, A. (2017). Responses to the publication of the American Psychiatric Association’s DSM-5. Journal of Humanistic Psychology, 57, 625-649.
3. Robbins, B. D., Kamens, S. R., & Elkins, D. N. (2017). DSM-5 reform efforts by the Society for Humanistic Psychology. Journal of Humanistic Psychology, 57, 602-624.

In psychotherapy, it can be useful to work from a model. It gives both participants—person in therapy and therapist—a common language and system of references. Naturally, different people are interested in different things. One of my colleagues is very taken with baseball, and derives complex and responsive imagery from that game. Several others get great results making use of popular movies and songs, and folks who work from a religious orientation find that scriptural texts can be applied in profound ways to the material they sit with. For me, mythology and fairy tales frequently provide new ways to think about things.

Because I’m drawn to fairy tales, I tend to notice when I hear one being told by the person I’m sitting with. If it’s one I already know, Cinderella or All-Kinds-of-Fur or the Golden Goose, I’ll point this out. But often it’s one I’d never heard. When that happens, I use a combination of summarization, amplification, and reflection to tell them the tale I’ve just heard them tell.

[fat_widget_right]

These fairy tales or segments of tales are artifacts of this particular therapist’s response to a particular person’s material. They’re subjective. For this reason, I want to be mindful that I’m not telling someone my fairy tale, but that, in fact, it’s theirs. My intention is to always follow up such a telling with questions. Does this feel right to you? Does it seem useful to our work toward your goals? Does it click? And, of course, not everyone likes fairy tales; not everyone has to. As always in therapy, when something doesn’t work we set it aside, and when it does we go with it.

In the discussion that follows, names have been changed and personal identifiers have been screened out in order to protect confidentiality.

The Story of Myra

Many of the people I work with want to change their relationship to alcohol or drugs, or to various behaviors that were originally rewarding but have since become problematic or compulsive. Myra is in her mid-40s, married and with a steady-if-unsatisfying job. She struggles with alcohol and substance use, with initiating numerous affairs, and with impulsive online purchases and debt. She says these behaviors result in significant levels of anxiety, shame, and guilt. For the first many sessions, we sit with the story of what she’s doing, how she doesn’t like it, and how difficult it is to do more than temporarily interrupt it before starting it up again. One afternoon, her material elicited the following fairy tale.

A woman is walking down the road with disappointment. Emptiness follows at a distance. The woman says to disappointment, “I need something. Maybe I’ll start a new affair.” “Another one?” disappointment says with a deep sigh. This isn’t very encouraging. “Well, maybe I’ll stop and have a few drinks,” she suggests. “And after that get some cocaine.” “Great,” says disappointment. “Another weekend down the drain.” “Well, then maybe I’ll go online and do some shopping,” the woman offers. “I’m sure to find something nice.” “You’ll find crap,” disappointment says flatly. “You always do.”

They come to a crossroads. The woman, not sure which road to take, stops. This gives emptiness a chance to catch up with them. By this time, the woman is tired of talking to disappointment. She turns to emptiness and says, “What do you think I need?” “I don’t know,” says emptiness. “But if you can stand my company, I’ll help you look.”

My intention is to always follow up such a telling with questions. Does this feel right to you? Does it seem useful to our work toward your goals? Does it click?

This moves us into a new stage of our work. Myra focuses on her experience of emptiness and the ways in which she had tried to fill it without having to be aware of it. It’s her repeated disappointment that drew her attention to this and originally brought her to therapy. We consider that if she can stay with the unpleasant feeling of emptiness and not do anything about it, she can increase her tolerance of it. Myra is willing—and courageous. She stays with the uncomfortable feelings. We develop a 10-minute meditation practice for her, to make her sitting a little more structured. As her tolerance of it increases, she reports that emptiness acts less like a driver for her behaviors. They seem to become less essential, and she doesn’t turn to them so readily. She begins to count days and then months of sobriety. We note she is not developing new avenues of activity, such as gambling or workaholism. The empty feeling proves to be survivable.

Later on, we notice that because she can tolerate the presence of emptiness, it acts as a support when she begins to identify and find ways to act more in accordance with her values. She begins to consider a career change, recommits to the relationship with her husband, and becomes more available to her family. Later still in our work together, we find that emptiness is not just helpful but essential in helping her explore her authentic spiritual life, which had gotten lost due to an early disillusionment with organized religion. From being an unconscious driver for problematic behaviors, emptiness became something like a sacred space in her life, in which she could consider and then meet with her highest values. It’s not that her life has become perfect. But what was originally a source of suffering, from which she fled, has become a support in making a more meaningful life.

The Story of Bill and Jay

Bill and Jay come for couples counseling. They’re both in their early 30s, employed in different sectors of the film industry. Jay describes Bill as cold, distant, and having a cruel sense of humor that he uses when Jay wants to get close. Bill notes that Jay is needy and uses emotional displays to get what he wants. I notice that Bill is adept at using figures of speech and sliding definitions (giving the same term a different meaning at the beginning of a conversation from the one it is given at the end) to evade threat. He describes being parentified along with his two brothers by their mother following her divorce from their father. He tells me how challenging it was to take care of his mother as a boy and adolescent, that both approaching her for support and not approaching her for support were negatively reinforced, that trying to take care of her and failing and not trying to take care of her were both punished by outbursts of rage. Part of my response to Bill’s narrative is the opening segment of what appears to be a longer fairy tale.

Three brothers once lived in a cottage in the forest. One day the oldest brother said, “I’m going out into the world to seek my fortune.” He set out along the path. He hadn’t gotten far when he found the way barred by an old woman, who said to him, “Shall I help you or shall I not help you?” “I don’t need anyone’s help. Don’t help me,” said the oldest brother. “Then you’ll get no help from me,” cried the old woman, and she knocked him off the path and into the forest.

The next day, the second brother also set off to seek his fortune. He hadn’t gone far when he found the way barred by an old woman, who said to him, “Shall I help you or shall I not help you?” “I need all the help I can get. Please help me,” he said. “Here’s your help then,” cried the old woman, and she knocked him off the path and into the forest.

Finally, the third brother set out. He wondered why he had heard nothing from his brothers. He hadn’t gone far when he found the way barred by an old woman, who said to him, “Shall I help you or shall I not help you?” “What do you think?” countered the third brother. “It could go either way,” said the old woman. “Well then, there you go,” said the third brother. The old woman stepped aside, and he was able to continue on his way.

With Bill’s cautious approval of this tale (“Yeah, sounds a little familiar”), we’re able to use it to identify and articulate his intense ambivalence about relationships. He feels the need for closeness, but no approach to it seems safe. He’s learned to use irony and wordplay to keep his sense of being at risk at manageable levels. These skills allowed him to maintain a relatively stable relationship with his mother, unlike his brothers, who in his words “were always getting eaten alive or eighty-sixed.” But the same set of skills doesn’t seem as useful in his relationship with Jay. Gradually, he becomes better able to take in feedback from Jay about the impact of these once highly useful skills on their relationship. He also begins to develop the ability to set them down when he chooses because he has become more conscious of what and why they are.

I believe in therapy. Yet sometimes, the concepts and the language seem best able to address us at our higher levels of functioning. And that’s not always where the issues that trouble us are found. Fairy tales, perhaps because we first heard them at earlier stages of our development, can engage us at those deeper levels, where we listen to the story in order to find out what happens next.