People come to psychotherapy because they want to feel better. A big part of a therapist’s ability to help a person feel better lies in their taking a loving stance toward that person. This stance starts with a therapist’s understanding that it takes courage for another person to come to them and their sense of feeling privileged by the trust that person invests in them. The rest of this article describes the other core ways in which therapy involves love and why this matters.

Faith and Compassion

Having faith in a person’s inherent goodness, as well as compassion for how that person’s life experiences have influenced them, is integral to helping them. This love stems in part from a therapist’s appreciation of the vulnerability inherent in being human. People are vulnerable to being hurt by others. When they are in contact with individuals, families, work environments, or even cultures that are filled with anger, criticism, premature loss, or emotional distance, it is almost inevitable they will start to internalize these experiences and develop corresponding psychological symptoms.

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Children are particularly vulnerable to this phenomenon due to their limited power to assert themselves, and they often have no recourse but to accept messages that are hurtful. When people have been hurt, they start to believe negative things about themselves (e.g. “I’m hopeless,” “I’m a failure”) as well as negative things about others (e.g., “People will hurt me if I trust them,” “No one will ever care about me”). Not surprisingly, they also experience feelings such as anxiety, anger, and shame that accompany these beliefs and tend to act reflexively on these emotions. These reflexive actions make it harder to connect with others and reinforce their negative beliefs about themselves and others.

Therapy helps people to break out of these negative cycles by allowing them to have a new kind of experience with their therapist that feels more positive and empowering. When a therapist approaches a person with a basic belief in their goodness, over time a person can feel a therapist’s faith in them and internalize it, which starts to shift what they believe about themselves. A therapist’s compassion for the person they work with also contributes to this change.

An internalized sense of being loved by one’s therapist can vastly change how a person experiences the world.

People are understandably concerned about being judged when they come to therapy. They may be afraid that a therapist is going to try to force them to change, or that a therapist will condemn them for some of the choices they make. Rather than criticizing or blaming a person for how they feel and behave, a compassionate therapist helps a person to understand how they are doing the best they can given what their experiences have taught them. They also help the person to think about new approaches to addressing their challenges that may help them feel better in the long run. This compassion is also internalized and helps people make sense of their lives in ways that are less focused on blaming themselves or others and leave more room for them to take positive steps toward change.

Patience and Humility

Therapy is inherently challenging. It is common in the course of many long-term therapies for there to be moments where a person feels stuck as well as moments where they feel disappointed or angry with their therapist. If a therapist tries to force a person to change before they are ready, or if they handle a person’s disappointment defensively, these impasses can be destructive.

Rather than blaming a person for feeling stuck or disappointed, a therapist coming from a place of love recognizes their own fallibility and tries to take ownership for any contributions they may be making to a person’s discontent. They also try to help that person see the role they may be playing in it. These moments become opportunities to build trust and for the person to gain greater self-understanding, rather than being harmful moments that reenact earlier painful experiences the person has had. Many people have been traumatically shamed and/or abandoned when expressing negative feelings toward others, and it can be a profound experience to have a therapist who does neither of these things and instead tries to patiently help them understand their pain and continues to care for them.

Conclusion

Just as people can be hurt in their relationships, they can also heal in them. Therapy is not just a set of techniques, it is a special type of relationship that is oriented toward helping people to heal from past experiences.

An internalized sense of being loved by one’s therapist can vastly change how a person experiences the world. In addition to symptoms diminishing, other people who once seemed threatening may become sources of connection and the future may seem more hopeful. Generosity and compassion flourish in those who have felt loved, leading them to touch the lives of others. Fittingly, many therapists have been touched by another person’s love in their own therapy and find it to be a deep privilege to be trusted and to pass on the gift.

References:

1. Harrist, R. S., Quintana, S. M., Strupp, H. H., & Henry, W. P. (1994). Internalization of interpersonal process in time-limited dynamic psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 31(1), 49.
2. McAdams, D. P., Reynolds, J., Lewis, M., Patten, A. H., & Bowman, P. J. (2001). When bad things turn good and good things turn bad: Sequences of redemption and contamination in life narrative and their relation to psychosocial adaptation in midlife adults and in students. Personality and Social Psychology Bulletin, 27(4), 474-485.
3. Neff, K. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85-101.

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.

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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.

Being a therapist is not easy. Contrary to what many believe, it’s not just “sitting and listening” to people all day. Yes, therapists are listening, but a competent therapist is listening for buried themes and unspoken messages. Your therapist is working to identify your strengths and how they can be used to move you toward your goals. Your therapist is making decisions about pacing and challenging you, all the while silently asking themselves, “Is this person ready for the next step?” and, “Is this the best approach for this particular individual right now?” Your therapist is constantly considering whether the interventions being used will be effective in helping you. Your therapist is working to remain present with you and ensure you feel heard while deliberating where to go next.

Another challenge of being a therapist is that we don’t always get to witness the results of our work. Some issues and problems take time to resolve, and that resolution can come after the therapy work ends with an individual. I can think of several occasions when someone I worked with told me it was after their work with their previous therapist ended that they were able to apply the insights they gained in therapy. In the absence of feedback, therapists have to trust that the individuals we serve are continuing their work after therapy terminates.

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Although being a therapist is hard work, it is not a thankless job. In fact, there are many reasons to thank the individuals we serve. Every day, we get to work with individuals who are smart, caring, and considerate. We get to sit with individuals who challenge themselves and the people in their lives to grow and be their best selves. We get to share in moments of laughter and joy. We are rewarded with expressions of gratitude and appreciation.

As the year comes to an end, I would like to take a few moments to thank all the wonderful individuals, couples, families, and groups who make being a therapist so rewarding.

Thank you for helping us help others.

Time and again, individuals come to therapy with insights that apply to the experiences of other individuals in therapy. When one person survives a particular traumatic experience or learns life lessons from a mistake, it strengthens our faith that other individuals in therapy can do the same. Not only do you help us to trust in the change process, we learn from you. So often, individuals we work with offer ideas and solutions that we, as therapists, may never have considered.

Thank you for giving us ideas and answers that help us serve the next person we work with.

Thank you for pushing us to be better therapists.

Ideally, we enjoy the work we do and want to be the strongest helpers for you that we can be. To better serve you, many therapists obtain additional or ongoing professional development training that is relevant to the work they specialize in. For example, if an individual comes in with trauma, your therapist may pursue specific training and seek consultation to improve their trauma competence. If you are of a specific faith, your therapist might investigate your religion or attend a service to better understand your beliefs and help to connect your spirituality to your needs.

Thank you for helping to refine our therapy approaches, for pushing us to expand our skill sets, and for moving us to know more about your world.

Thank you for the privilege of trusting us with your story and allowing us to help you to step into your voice.

Thank you for challenging us to be agents of change.

My personal belief (which happens to be a shared value of the American Psychological Association and other major mental health organizations) is that creating true change for the individuals we serve cannot be accomplished solely in the therapy room. To help facilitate true change, systemic change needs to occur in the environments in which we reside and work. How can a therapist holistically work with Muslim individuals without seeing the context of their lives in light of Islamophobia? Can a therapist work with sexual assault survivors without paying attention to how they might be triggered by the victim-blaming and -shaming that is prevalent in our present culture? In these cases, and many others affected by our sociopolitical climate and systemic oppression, therapists are called to advocate for the well-being of those they serve, and not just inside the therapy room. Therapists have a responsibility to be agents of change in their larger communities.

Thank you for holding us accountable to act within our sphere of influence to challenge daily acts of oppression. Thank you for helping to inform how we spend our money, vote, and participate within our communities. Thank you for pushing us to educate and train others to be culturally competent and social justice agents of change.

Thank you for sharing your story with us.

I am reminded of a quote by Maya Angelou: “There is no greater agony than bearing an untold story inside you.” So many people have been silenced into submission, depression, anxiety, and fear. So many have been made to feel as if they—or what they have gone through—is unimportant, unworthy, and that they are deserving of pain and ridicule. Working with individuals in therapy, I have seen how silence and shame devastate self-esteem and confidence. Through having the opportunity to tell their stories, individuals in therapy may challenge the stories that have been told about them or made up for them, and may begin to script their own narratives. What a joy and a blessing to be able to sit with these individuals, bear witness to their stories, and watch them move from agony and defeat to a place of acceptance and empowerment.

Thank you for the privilege of trusting us with your story and allowing us to help you to step into your voice.

Reference:

American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377-402.

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.

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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.

Every part of therapy can be informative. The moment you enter the room is no exception.

Different therapists have different styles, but in psychodynamic work there’s usually space left for you to start the session. What you do with that time is important. How you feel about that time is even more so.

This Is Not a Test

If your therapist doesn’t say anything when you enter the room—and I mean not even a “hi” or a “how are you?”—it doesn’t necessarily mean they’re being rude. It’s not a test, and it’s not meant to make you feel a certain way.

Believe it or not, the space is there so the therapist has less influence over the session. We don’t want to focus on what we think is important or, even subtly, walk over a feeling or thought you are having. Therapy time is your time.

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Do you want to pick up from last session?

Do you want to talk about that incident with your brother-in-law over the weekend?

Do you want to discuss what happened with the guy who sold you a coffee just before you arrived at my office?

It’s up to you. Entirely.

Sure, we may hope to hear about how that discussion went with your partner, the one we’ve spent months gearing up for—but we may not ask about it. Perhaps you’ve moved on. Maybe you didn’t have the discussion and our asking about it might make you feel like you should have had it—in which case the therapy becomes about whether you’re doing what you’re “supposed” to do (and suddenly we’re replicating a relationship with your dad that you’ve been struggling with).

The only real exception I make is if you’ve talked about an ill or dying loved one. I’ll probably ask about that (but maybe I shouldn’t!).

How Do You Use the Time?

Often, people say they don’t know what to talk about. Not because they don’t know what they want to talk about, but because they don’t know how to start.

In those early silences, when you’re struggling with starting the session, it’s good to become aware of the feelings that are filling that silence.

Many people who come to therapy, particularly those who often put others first, have a difficult time just jumping in and talking about themselves. A giveaway for this is when a person immediately asks about my week. They may tell me they’re doing so because it’s polite and they’re making small talk, but therapy is fully about you. You’re paying me and you want to know how my week was? It’s a nice thing to do, but didn’t you say in our first session you want to be more assertive? That people take advantage of you? Well, guess what—that’s what we’re working on by talking about what’s happening between you and me.

Pay Attention to the Feeling in Those First Few Moments

In those early silences, when you’re struggling with starting the session, it’s good to become aware of the feelings that are filling that silence. This can help us understand your (perhaps) social anxiety, your reluctance to speak up in a class or group, your tendency to “live in your head” and intellectualize everything.

Awareness of the shyness, nervousness, anger, worry, or whatever else is in the silence can inform all those other times outside the therapy room when you don’t jump in and say what you want to say. Once you’re aware of the feeling, we can explore it to stop it from getting in the way of your action (or inaction).

Conclusion

Your therapist probably isn’t trying to be a jerk by not starting the session for you. We’re aware of how difficult it can be. To that end, we may, after a time, ask a starter question along the lines of, “What’s it like to be back here today?”

Sometimes we’ll process the silence or the “how are you?” and sometimes we’ll just see where you take the conversation. The major point I’d like you to take away from this is to talk about what’s going on for you in relation to the therapist.

Tell your therapist how awkward it is and how much you wish they’d just start for you. How angry you are because your therapist should be the one to direct the session; you’re paying them for their expertise, after all! Or how overwhelmed you are because of all that’s happening and you just can’t prioritize and need help doing so.

Or, just maybe, you feel you have nothing to say. Well, say that then. We’re here to guide you, but also to do all we can to not influence you.

Structured self-help programs, which allow participants to give themselves therapy, may work just as well as psychotherapy with a therapist, according to a study published in the journal Administration and Policy in Mental Health and Mental Health Services Research.

The study was a meta-analysis that analyzed data from previous studies of cognitive behavioral therapy (CBT). CBT is a semi-structured approach to therapy that encourages participants to recognize, understand, and correct automatic thoughts that lead to painful feelings and self-defeating habits. Because CBT focuses on addressing and correcting specific thought patterns, it is possible to distill its principles into a self-help program.

The study points to the value of self-help programs for those reluctant to share their experience with a therapist, those who can’t afford therapy, or those who can’t access a local therapist.

Is Do-it-Yourself CBT Just as Good as Therapy?

The analysis gathered data from 15 previous studies of 910 participants. Each study randomized participants to receive either self-help CBT or traditional CBT through a therapist. A total of 723 participants completed the treatment program. Participants used CBT for a variety of mental health issues, including depression, anxiety, and posttraumatic stress (PTSD).

[fat_widget_right]Researchers found no differences in completion rate between self-help and therapist-delivered CBT. Treatment outcomes were also broadly similar. This suggests both self-help and therapist-based programs can offer symptom relief.

Could Self-Help Programs Replace Therapy?

The study’s authors say self-help programs could be a good first line of defense against mental health issues. They don’t advocate an end to therapy. The analysis only examined self-help CBT, so the findings don’t extend to other types of therapy. A therapist can be helpful for exploring different types of treatment options, and some people in therapy may not have the motivation to keep up with a self-help program on their own.

Outcomes varied in both groups. In the self-help group, there was greater variability. The study did not directly assess why this might be, but its authors suggest the therapist may play a key role in standardizing outcomes. The therapeutic relationship could be a valuable tool for counteracting negative emotions in therapy, and this might ensure more standardized outcomes in people seeking therapy from a therapist.

This supports past research that suggests the therapeutic relationship is a key to therapy’s success. However, the study did not find significant differences between therapists. This may mean the competence of an individual therapist is secondary to the therapist’s ability to follow a standardized treatment program and respond to negative emotions.

In terms of access to mental health treatment, the study shows self-help programs may be an effective interim treatment until an appointment with a therapist can be made.

References:

1. Brown, M. (2017, August 23). Be your own therapist? Fine – if you’re up to the job. Retrieved from https://www.theguardian.com/commentisfree/2017/aug/23/therapist-self-help-therapy
2. King, R. J., Orr, J. A., Poulsen, B., Giacomantonio, S. G., & Haden, C. (2017). Understanding the therapist contribution to psychotherapy outcome: A meta-analytic study. Administration and Policy in Mental Health and Mental Health Services Research.

People enter psychotherapy with the desire to feel better, but they are often unsure how therapy will help them accomplish this goal. A common refrain from people hesitant to enter therapy is, “How is talking going to help?” People are used to talking to other people to get practical solutions to problems, and while problem-solving does have a place in therapy, change also occurs on a much deeper and unconscious level. This process has to do with the way the human brain is programmed and cannot easily be mimicked outside of a relationship with a psychotherapist.

Our brains are always evolving unconsciously through our relationships. People who experienced painful relationships growing up have been trained to expect hurtful experiences with others. It takes a new type of relationship—in particular, a therapeutic relationship—to retrain the brain to expect more positive experiences, which is a big part of ultimately feeling better.

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Why Can’t a Therapist Just Tell Me What to Do?

To understand why the therapeutic relationship can be so valuable and cannot be mimicked by, for example, advice in a self-help book, it is instructive to look at how the human brain has evolved. Broadly, there are three parts of the human brain that represent different phases of evolution: There is the reptilian brain, which evolved first and is responsible for the automatic control of vital bodily functions such as breathing; the limbic brain, which evolved second and is responsible for the regulation of emotion and behavior; and the neocortex, which evolved last and is responsible for higher-order functions such as symbolic thought, language, and reasoning.

When a person asks their therapist or a friend what they should do about something, they are essentially asking for a neocorticol solution—something that is rational and can be consciously implemented. Often, however, their problems are a result of hurtful experiences in their earlier relationships that have caused changes in their limbic brain, and only a new type of relationship can alter their limbic brain to produce fewer negative emotions and more positive ones.

Brain Wiring in Our Youth: How Emotional Issues Begin

Our emotions are meant to help us survive in a world in which we need the help of others. Over time, our limbic brains evolved to automatically create emotions, such as anger and sadness, that are meant to help us navigate the social world. When someone mistreats us, evolution has programmed us to become angry to try and change their behavior. When someone rejects us, we feel sad so we can mourn the loss of what we wanted with them and move forward with our lives.

However, when we are young and particularly dependent on others for survival, whether our emotions actually help us navigate the world has a lot to do with how other people—our parents in particular—respond to them. A child who responds to unfair or disappointing experiences with anger and is further punished for doing so may, over time, come to unconsciously pair the expression of anger with pain. As this occurs, rather than directly experiencing anger at times of unfair treatment or disappointment, they may instead experience anxiety about having anger because their brain has been trained by their social environment to expect that anger will hurt rather than help. Their limbic system is in effect attempting to prevent further emotional pain in the form of being punished, but the cost is another type of emotional pain in the form of persistent anxiety. This can be particularly problematic when people enter into new relationships (friendships, romantic relationships) where there would not be the same costs associated with the open expression of an emotion like anger, but earlier experiences still create anxiety and inhibit its expression.

Retraining the Brain with Psychotherapy

A psychotherapy relationship allows a person to essentially retrain their limbic system to no longer expect negative reactions to the expression of certain emotional experiences, and in doing so can alleviate the anxiety and unconscious emotional suppression their earlier experiences programmed into them. The therapeutic relationship does this in part because the parameters of psychotherapy recreate the type of relationship in which a person was first forced to suppress their emotions: one where they are dependent on another person to meet their needs.

A successful course of therapy helps restore a person’s emotional flexibility and empowerment so they can have greater agency in their relationships.

Just as a parent has a daunting task in meeting all of a child’s needs, so too does a psychotherapist, especially since many people arrive to therapy wanting a conscious, rational solution to their problems when such a solution often does not exist. Therapy presents a unique opportunity to heal and feel better by the way the therapist solicits and responds to feelings such as disappointment, anger, and sadness that emerge over the course of treatment. Rather than punishing a person for having these emotional experiences in the same way that may have occurred when they were younger, a therapist can actively solicit, explore, and normalize their feelings. This helps to retrain a person’s limbic system to no longer pair the expression of those emotions with punishment. As this de-coupling unconsciously occurs, the person becomes more easily able to tolerate the experience and expression of emotions.

Thriving in Adulthood

This shift in tolerance for emotions naturally causes a person’s anxiety level to diminish because their mind is no longer fighting to ward off their innate emotional impulses. In addition to symptom relief, the beautiful part of this process is it restores a person’s ability to constructively access their emotions for their original purpose—as a way of helping to navigate the social world. It is hard to thrive in relationships when we have been programmed to believe we must accept the mistreatment of others or that we cannot show others when we are hurting and in need of care. As adults, this is often no longer the case, but our early experiences may make such underlying beliefs unconsciously feel true.

A successful course of therapy helps restore a person’s emotional flexibility and empowerment so they can have greater agency in their relationships. The result can be genuinely transformative, and studies suggest people who have been through therapy show less activity in the areas of the brain responsible for creating negative emotions. Talking, it turns out, can help quite a bit when the person you are talking to is a skilled and compassionate therapist.

If you’re struggling, reach out to a therapist in your area for help.

References:

1. Bowlby, J. (2005). A secure base: Clinical applications of attachment theory (Vol. 393). UK: Taylor & Francis.
2. Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain. New York, NY: W.W. Norton & Company.
3. Damasio, A. R. (2006). Descartes’ error. New York, NY: Random House.
4. Grecucci, A., Theuninck, A., Frederickson, J., & Job, R. (2015). Mechanisms of social emotion regulation: From neuroscience to psychotherapy. In Emotion regulation: Processes, cognitive effects and social consequences, pp.57-84.
5. Karlsson, H. (2011). How psychotherapy changes the brain: Understanding the mechanisms. Psychiatric Times, 21.
6. Lewis, T., Amini, F., & Lannon, R. (2007). A general theory of love. New York, NY: Vintage.
7. MacLean, P. D. (1990). The triune brain in evolution: Role in paleocerebral functions. Berlin: Springer Science & Business Media.

Dear GoodTherapy.org,

I am hoping you can give me an honest answer here. I have been seeing a therapist for nearly three years now and I just don’t feel like it’s working for me. I don’t feel any different than when I started. In some ways, I feel even worse, because I am discouraged about therapy not helping. It makes me wonder what is wrong with me that I can’t get better. I have read that it is highly unusual for someone to be in therapy as long as I have.

I guess I should provide some background about my “issues.” As a kid, I was molested for years by an uncle, saw my parents die, and was bullied incessantly. I have been told I have major depression and have tried about half a dozen kinds of medication, none of which have made a shred of difference. I have self-esteem problems. I can’t seem to hold down a job. I haven’t been in a relationship for five years; women won’t even look at me, and I don’t blame them. I hate my life and I have no friends. Yes, I have considered suicide. No, I am not currently suicidal. I know that distinction is important to people who do what you do.

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Because therapy isn’t helping me and hasn’t helped in all the time I’ve been in it, I want to stop. I feel like I am throwing away money. I feel un-helpable. I must be one of the few cases out there for whom there is no relief, whose problems are just too many and too major. I might be a lost cause. But I do not want to be a fool. My therapist has encouraged me to continue with therapy and to not give up hope. She says she has seen signs of progress but cannot seem to articulate them in a way that allows me to see them too. Maybe that is my failing, but I am starting to feel like maybe I’m just a paycheck for her. I don’t think she is necessarily a bad therapist. She is a nice person and she tries. She seems to truly care. I just think she isn’t helping me, I think she knows she’s not helping me, and I no longer really think anyone can.

What are your thoughts? Is she just stringing me along? Are there other people like me who don’t seem to get any better, and if so, what do you recommend in those cases? Please answer these questions. Thank you. —Lost Cause

Dear Lost,

What a great question regarding a terribly painful situation. I’m glad to hear from you about this, while so sorry to hear about all you have endured. Let me first give you my impressions in a way that “cuts to the chase,” then flesh things out a bit.

First, it is not unusual for it to take a while to find the right medication or combination of medications. (For instance, some people respond better to an older generation of medications, while others respond to SSRIs.) Have you tried more than one psychiatrist? I would encourage you to keep trying, discouraging as it has been. I have worked with a few people in therapy who were as discouraged as you, but managed to find an effective medication plan that helped them enormously.

You have been through hell and back. The fact you are still standing says something about your resilience. You have suffered enough trauma for several lifetimes, so it’s understandable you would feel this way. Your life experience has, I sadly observe, given you no tangible reason to hold onto hope. It does not mean there is none to be found, however; in fact, your letter indicates you are searching for it, itself is a glimmer of something positive.

As to your therapy question: Any therapist worth their salt would welcome any and all the feedback you have put forth here. My impression is it is time to have a blunt and honest conversation with your therapist regarding your feelings; if you’re still dissatisfied afterward, it may well be time to seek out someone new.

I would guess you had no source of true comfort after seeing your parents die. How unspeakably sad! I can hardly imagine a more hellish experience, in that the people you may have relied on most for comfort are the ones you lost. This, in addition to the other psychological injuries you experienced, leads to my amazement at your resilience. My great hope is you find, sooner rather than later, the kind of therapeutic “holding” and healing you deserve.

In the meantime, you seem to know intuitively you’re not getting what you need. I would be curious to know what keeps you in therapy with your current therapist. Have you tried telling her directly what you say in your letter? If not, why not? Is it possible she has helped as much as she can and now it’s time for a new approach? It is not uncommon, after all, to seek a second opinion medically; I believe this applies to psychotherapy also.

Sometimes people in therapy are afraid that, because they are not the “authority,” they do not have the last word on their own experience. You sound almost convinced it’s time to move on or ask directly that your therapist change her approach; I encourage you to follow your intuition. Whether or not it’s worth one last conversation with your therapist is obviously your call. Such a conversation could prove healing or just add fuel to frustration. If you feel you would benefit somehow from clearing the air, it’s worth a try. If, however, you feel it’s a foregone conclusion, you might want to move on.

Is it possible you doubt your own perceptions (not unusual with depression) in that she sees progress while you don’t, leading you to wonder if she is “right”? If the latter is true, she needs to find a way to convey her observations in a way that is meaningful to you. If your therapist insists you “hang in there” for no reason that feels solid, that’s simply not good enough; the direct experience of the person in therapy is, in my view, always front and center in therapeutic inquiry and exploration.

I don’t expect the people I work with in therapy to understand everything that flows from my lips. I have to learn a person’s language—and, to paraphrase Carl Jung, each of us speaks differently. I cannot insist on calling anything “progress” if the person in therapy feels or perceives otherwise. In the absence of mutual resonance regarding progress and therapeutic aims, the person in therapy feels dangerously alone.

Given your dwindling (or absent) faith in the process, it makes sense you are feeling alone in this relationship. It almost seems this alone-ness may even echo or parallel earlier suffering with the traumatic isolation and self-doubt you describe. I can’t shake the feeling you sense painful distance or discrepancy between you and your therapist, that she is missing something essential. I am not blaming her—nor you, for that matter. Do you somehow feel pressured to “live up to” her seeing progress? Are you concerned that if she feels disappointed or anxious about “progress,” it could be a bad sign?

Therapists seek a tricky balance between instilling hope and validating a person’s pain—mostly because, in so many cases, the latter has never been permitted or acknowledged by caregivers. Strangely, the more a pain is accepted as valid in the context of a person’s experience—with a safe other who can stay with you during and through that pain—the more healing the process becomes.

Therapists seek a tricky balance between instilling hope and validating a person’s pain—mostly because, in so many cases, the latter has never been permitted or acknowledged by caregivers. Strangely, the more a pain is accepted as valid in the context of a person’s experience—with a safe other who can stay with you during and through that pain—the more healing the process becomes. It’s when we begin to fear that emotional pain is “too much” for us or the other, or that it’s a sign of weakness on our part—that we need to “get over it already,” etc.—that it lingers like an unwelcome guest.

I believe people are entitled to all of their feelings, including and especially about therapy, because no one knows your experience better than you. I can’t imagine anything more important in your therapy than what you have bravely expressed in your letter. I am grateful you are not suicidal, but it sounds bad enough that an adjustment needs to happen, either within the current therapy or with someone new. (If thoughts of hurting yourself do resurface, please call 911 go to your nearest emergency room immediately.)

You sound very certain your therapist “knows she’s not helping me,” though I would urge you to not jump to the conclusion that no one can. The latter can be a hallmark or emotional symptom of depression—the sense one is cosmically alone in the universe, unable to connect with anyone. This feeling is, sadly, more common than many people realize. But this feeling is not objective “truth.” Your situation is not hopeless, and the fact you wrote your letter suggests you may leave room for hope, too. It is vital your therapist help you believe this more expansively.

When it comes to feedback, vital in any therapy, I try my best to listen nondefensively to where a person is or is not happy with me or how things are going with the two of us. My aim is to do no harm and be as helpful as possible. I do not assume I am always on the right track, or that no feedback means everything is fine and dandy.

There needs to be, more often than not, some mutually understood “map” of where we are going, and why—in your case, that would plainly include relief from traumatic anguish. The work can be difficult, even painful, at times, but for the sake of a treatment plan (ethically required), the “plan” needs to be something the person in therapy understands, endorses, and trusts as desirable.

Once a person begins to feel overly “protective” of the therapist’s feelings, which the therapist might tacitly encourage, the process is in danger of shutting down or becoming overly burdensome to the person, adding to their trauma and emotional isolation. Maybe the person has never had a chance to be fully honest with another, which can feel scary or even risky. The very act of sharing this disappointment can be healing, which is why I do my best to encourage it.

I would be curious to know if you are getting help with managing painful or traumatic emotions or emotional states between sessions. Do you need concrete help dealing with feelings of despair or low self-worth? There are cognitive behavioral approaches, dialectical behavior therapy (DBT), mindfulness, and other techniques to help with such moments.

Please do not give up. I wish you the best of luck in your pursuit of much-deserved relief.

Warmly,

Darren Haber, MA, MFT

Therapists go on vacation. Therapists need time off for health reasons. Therapists have emergencies.

But what does it mean for you when your therapist needs a break?

It can be difficult to wait an extra week between appointments, let alone two or three. It’s a reminder your therapist has a life outside of the office. Often, we like to think of our therapist as ours and ours alone. Are you connected with the feelings that arise when your therapist tells you they’re going to be away?

Many people tell me they are “fine” with me not being around for a session or two. Depending on the person, I sometimes ask a few more questions about that. Not for personal reasons—I’m not trying to get a person in therapy to make me feel important and needed—but to help them bridge that feeling to other relationships in their lives.

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While you may know intellectually your therapist takes time off, just like you (hopefully!) do, that doesn’t mean you won’t feel a whole swath of feelings when it happens. Some common ones are abandonment, sadness, and anger, but also happiness and even relief!

Whatever you feel upon hearing your therapist will be away, it may be helpful to dig deep to see if there is a small spark of feeling that may be familiar. Once you connect to the part of you that is angry (even just a little), for example, you may be able to bridge that to another time in your life when someone left. This is a great opportunity: You get to use the therapy session to let the therapist know how you felt back then. You get to see you can say, “I’m angry you’re leaving” and know the therapist can take it. You can have what we call a “corrective emotional experience.”

“I’m angry you’re leaving. If you really cared about my well-being, you’d make yourself available.” That might sound confrontational, but it’s actually progress.

You can even go a step further: “I’m angry you’re leaving. If you really cared about my well-being, you’d make yourself available.” That might sound confrontational, but it’s actually progress. It’s being vulnerable with your therapist, which is both really, really difficult and incredibly important.

You’re not going to change your therapist’s plans, but you’re going to know what it’s like to say how you’re feeling. It opens the door to an exploration of hurts you’ve experienced in the past—but had nowhere to go with.

Boundaries and Safety

If the prospect of your therapist going away causes anxiety or worry, talk to them about what you can do in their absence. Some good questions are:

• “Can I call or email or text you?” You need to know your therapist’s boundaries. Some therapists take calls while on vacation; sometimes, only in special circumstances. Know before the therapist goes away.
• “Is there someone else I can talk to in the meantime?” Some therapists provide the name and contact information of someone you can call if the therapist is unreachable. This is rarer, but it’s good information to have.
• “What do I do if I’m really stuck or thinking of harming myself?” If you’re struggling with thoughts of self-harm or suicide and your therapist is aware of this, you may already have a safety plan with your therapist. Go over it with them before they leave, and if you don’t have one, create one together. No matter the circumstances, if you are ever in crisis or concerned about hurting yourself, call 911 or go to your nearest emergency room.

Your therapist going away can open some old wounds and bring up surprising feelings. Listen to those feelings and bring them forward. They could lead to breakthroughs that serve you not only while your therapist is unavailable, but long after you’ve parted on your terms.

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?

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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?

Goodbyes suck.

They really do. They’re often uncomfortable. They’re also inevitable.

Goodbye experiences are as final as a death and as common as leaving the embrace of your partner to get a snack from the kitchen.

They begin the first time someone takes us out of our mother’s arms when we are born (or maybe we didn’t even get there; for some of us, they start at birth).

Well, we say, everything comes to an end. Or, harsher, we all have to learn to live with disappointment.

Our first “task” as humans is to learn what psychoanalyst Erik Erikson called basic trust. Developing basic trust means learning that even though our parents leave us in our crib, they will come back. Someone will feed us, hold us, change us, and comfort us.

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Hopefully we learn that. Not all of us are so lucky.

For those of us not given the chance to develop basic trust, goodbyes can be even harder. They’re hard because we’ve barely learned how to connect and attach to someone else and we think if we don’t attach, we won’t feel bad when the time with that person ends. Or so the theory goes for people who try hard not to connect.

Over time, we realize that strategy doesn’t work. We continue to get hurt and, worse, don’t understand why.

As a young clinician, I hated goodbyes. I resisted the idea and would have preferred therapy just end. “Oh, you’re done? Goals met somewhat satisfactorily? Good luck, so long, be well!”

But I was taught to allow people in therapy to have an ending—or “good goodbye,” as we called it. (The technical term is “termination process.”) So many people have stories in which other people just disappeared from their lives—a common core issue in therapy—that the therapeutic relationship should not only not replicate this, but heal it.

At least, that was the message I was given. But it was difficult to sit with.

This process could last three months, and the difficult part was what happened in those three months.

Have you ever noticed what happens when you know something is coming to an end? Think about the last time a friend moved. Notice anything in how you treated others?

As endings near, we get to see the stuff that was being held back. Maybe you snap at someone you never felt angry with before. Perhaps you find it important to make their final party perfect or hold out hope that when they see how much they will be missed they will change their mind. Maybe you start to see and remember only the amazing and wonderful things about this person and forget the difficult times you’ve had together.

If you’re having a really strong termination process, you’ll cycle through all of these. Because if you can move through the stages of denial, anger, bargaining, and depression, you can get to acceptance. You can really say a “good goodbye.”

Endings are powerful because, if we allow, we get to release all the feelings we’ve attached to the other person. When we do that, we are truly in relationship with them.Endings are powerful because, if we allow, we get to release all the feelings we’ve attached to the other person. When we do that, we are truly in relationship with them.

Allowing this process to happen with your therapist can be incredibly helpful—sometimes the termination may be the most insightful work you do in your therapy.

Because it’s so difficult to fully trust that someone will hang around after they’ve seen the “worst” of us, we inevitably hold stuff back. From friends, from relationships, from family, and from others. It’s rare we show all of ourselves to anyone.

When saying goodbye, there’s a “what-do-I-have-to-lose” quality at play. And we can become closer because of it.

Sometimes, we avoid the goodbye because we’re really angry. A friend of mine was telling me the other day she stopped seeing her therapist. She had been working with this therapist for several years and said the treatment was very good … at first. It was helpful to talk about much of what she’d been holding in, but she wanted something else and wasn’t getting it. So she emailed him and ended the therapy.

By emailing, she missed out on letting her therapist know how disappointed and angry she was.

Of course, she also avoided the discomfort. Why put yourself through that?

But that’s also what you’re going to therapy for: to be able to say all you feel and have it be heard without being judged. You might not get that chance anywhere else.

Your next therapy appointment is approaching, and you’re wondering what you might talk about. Nothing “exciting” has happened recently. You’re not upset about anything in particular. There’s been no drama. You’re actually feeling pretty good.

You think to yourself, “There’s no point in going. I might as well cancel.”

Here are some reasons you shouldn’t.

Therapy isn’t helpful only in times of crises. It can serve the purpose of ensuring the maintenance of healthy coping strategies. It can be a place to investigate alternative ways of looking at situations that have the potential to be “bigger” so they don’t end up being seen as flash points, but rather as manageable moments to employ useful skills and tools. In addition, themes and patterns that emerge over time might be more easily acknowledged in a session not devoted to crises.

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People I work with often mention they thought on the drive over they had nothing to talk about but were amazed to discover there was quite a bit to explore. Once more immediate challenges are dealt with, there are opportunities to dig beneath the surface and work on the core issues that underlie everyday struggles.

Sometimes, hesitating before a session signals you might be close to working on something of great importance. That hesitation might represent fear or apprehension. It’s helpful to share with your therapist that you considered canceling, as well as the feelings that came up for you.

Therapy is work; it’s not supposed to be easy. It requires being open to different perspectives, trying new things, making changes, being honest with yourself and with others, and doing things that are difficult or challenging.

You might not be aware of things your therapist is seeking to explore with you. A seemingly simple question might serve to elicit a lot of material—important content you hadn’t even realized was there.

If you believe your work in therapy is done and you’re thinking you’ll call in the future if things aren’t going well, communicate this intention in person. When contemplating terminating therapy, it’s important to discuss it in session with your counselor so it is carried out therapeutically. It is a wonderful chance to concretely take stock of the progress you’ve made and the strategies you will take with you. It’s imperative you review the supports you have set up as well as the plan you will be putting in place for how to handle stressors or triggers that may challenge you going forward. Allow for that closure. Otherwise, you may leave without full awareness of what you’ve accomplished and without being completely cognizant of the tools you have at your disposal, should you need them. It’s also the perfect opportunity to demonstrate communicating effectively something that might be difficult to express.

As a therapist, I am grateful when a person I work with feels comfortable enough to bring their uncertainty to me. It demonstrates the person is feeling strong enough to do so and is not avoiding the expression of their thoughts, often indicative of progress.

Saying goodbye is not always easy, but it is often best said in person, with the parameters for reengagement clearly mapped out. It’s possible your therapist will respectfully disagree with your assessment and encourage you to continue in therapy. It is important to hear that and consider that feedback in your decision-making process.

Wanting to cancel may be as much a part of the therapeutic process as attending your sessions regularly. It may signal it is time to review your original counseling goals to see whether they’ve been met, or whether in fact you and your therapist have gone in a different direction. Acknowledging your ambivalence can give you and your therapist an opening to get back on track with regard to the counseling goals, or the chance to create new objectives.

As a therapist, I am grateful when a person I work with feels comfortable enough to bring their uncertainty to me. It demonstrates the person is feeling strong enough to do so and is not avoiding the expression of their thoughts, often indicative of progress.

Showing up and then articulating your inclination to cancel can serve to strengthen the therapeutic alliance and deepen the work you do in counseling. It demonstrates you are acknowledging your thoughts and feelings rather than taming them into submission or sweeping them under the rug, and that you are willing to communicate directly rather than avoiding or ignoring.

If you’re thinking of canceling, show up instead, talk about it, and with your therapist, collaboratively navigate how best to handle those moments going forward.