I can distinctly remember how excited I was getting assigned to my first office for doing psychotherapy when I was a psychiatric resident. Not only was I going to be doing psychotherapy, which to me was cause for great celebration, but I also had an office to be furnished and decorated however I pleased. Yay! These were big firsts for me, and now all these decades later, I still believe the psychotherapy office is a sacred place, a powerful place, a place for great intimacy and life changing events to happen. There should be ample planning and consideration for both the physical space and the psychological events that happen there. This chapter examines the physical space of the office, the office atmosphere, the structure of therapy sessions, and the behavior of the therapist.
Thinking through step by step how you want the psychotherapy experience to be for patients will guide you in creating an office space. How would you like patients to feel while they’re in the waiting area? Creating an inviting, comforting atmosphere can begin even before the session starts. Some therapists have snacks, coffee, and drinks available in the waiting area. I’ve heard some even have chocolate available as well, which is almost cheating in my opinion. (Did you know that one chemical compound found in chocolate, phenylethylamine, actually causes feelings of sensual attraction in the brain?) Soft lighting and comforting music played at low volume can also help set a relaxing tone as the patient waits. Finally, if there are office staff working in the waiting area, training them in some interpersonal basics for making people feel comfortable can help create a pleasant atmosphere.
Your office space is where it all happens, and therefore planning it down to the finest detail deserves all the emphasis you can give to it. The primary goal is to make your patients feel comfortable. Lighting should be midrange; if it’s too bright, people will feel as though they are exposed or under interrogation, and if it’s too low, it can make some patients feel afraid or anxious. Computer screens should be neutral, and noise interruptions from electronic devices kept to a minimum. Letting the patient have an option for seating is best, with either a couch or two chairs so that the patient can choose his or her distance. When it comes to decorations, art, and personal effects, there are many directions you can go. The one thing you can be certain, whatever you choose to place in your office will be thought about intently by your patients and will occupy some of the psychological space in the room during sessions. For this reason, avoiding art or décor that’s too provocative is likely a good idea. Having said this, it should be mentioned that Freud was a connoisseur of archeological artifacts and had thousands of these in his office, including busts of Greek gods, Egyptian death masks, and totems. These items were highly provocative, yet somehow he developed the science of psychotherapy in that office, so maybe there is some wiggle room for how you decorate yours.
Now we focus on getting started: your first session with the patient. Most important in the first session is to establish the beginnings of a therapeutic alliance with the patient. If a person feels “heard” in the first session, that will usually pave the road for further therapy. Sometimes therapists will focus on getting the information they need to fill out intake forms or to get the historical facts necessary for insurance purposes. Granted, this is important; however, if patients don’t feel heard or don’t feel that they “got something” from the first session, they might decide to not follow up, and the information gathered won’t be of much use. Patients must feel that their pain was directly addressed in the first session. Toward the end of the session it will also help if the therapist lays out the expectation of what further psychotherapy will be like—a quick guide of “what to expect in your therapy,” if you will. If patients leave the first session feeling more confused, or emotionally worse for having expressed themselves, they’re less likely to continue with psychotherapy. Sometimes in the first session patients will open up about intense pain they’ve been withholding for a long time. They’ll have an emotional catharsis, and it’s then important that the therapist provide support and guidance for them to compensate from such intense outpouring of feeling. Validating the importance of their emotion and putting a supportive bandage on the wound will help them recover and benefit from the experience. Giving practical advice on some things they can do immediately to help their situation will likely solidify their first session as beneficial. If they feel that their pain was addressed in the first session and they feel understood, they’re likely to continue in psychotherapy. In a funny kind of way, one of the important goals of the first session is to get the patient to the next session.
A caveat to this is that some patients feel so much better after one session of psychotherapy they don’t return because they believe “it worked.”1 Many patients don’t have the same theoretical model of psychotherapy as the professional therapist—that is, they don’t share the concept that it takes multiple sessions and “working through” to make true progress on most psychological problems. To many patients who improved with “single-session psychotherapy,” it was simple: “I had a problem, I talked with a professional about it, they helped me feel better...end of story.” Never underestimate the power of words.
For patients who have not been in psychotherapy before, the first session is often anticipated with great anxiety. Even though most people have exposure to what a therapy session looks like on television shows, movies, and videos, sitting face-to-face with a therapist in real life is a lot more anxiety provoking. You might need to offer guidance throughout the first session to explain what will be covered and how it will be accomplished. In addition to initially explaining the process of therapy, you can lower anxiety by getting the patient to talk first about “easy” or neutral topics, for example, “Where are you from?” “What kind of work do you do?” “Tell me about your current living situation.” Such questions and requests provide structure and help ease patients into talking about themselves without exposing emotion. Once some of these basics are covered and you sense the patient is more comfortable, you can then ask, “What brings you in?” Asking about the presenting problem in such an open-ended way is nondirective (answer is not directed by the influence of the therapist) and allows you to get an unadulterated sample of how the patient sees things. If patients are able to talk about their situation without interruption for a significant amount of time, it’s worthwhile to let them do so. The free flow of what a patient tells you in this first encounter is rich with meaning on many levels. Notice the flow of their associations: What links do they put together in cause and effect? Do they self-reflect on their situation or see themselves primarily as a victim? What is their level of psychological understanding of themselves? What is the quality of their relationships?
Some patients will not be able to talk about their problems in a free-flowing manner. For these patients, you will need to provide more structure and guidance to get a robust description of the problem. The flexibility of the therapist becomes crucial in becoming a guiding and supportive force immediately in these situations, to help the patient feel anchored. The patient may find it difficult to talk because he or she is feeling intense emotions, or alternatively, may have alexithymia (inability to talk about feelings) and have chronic limitations with expressing himself or herself emotionally. Either way, your job as therapist is to adapt the interview to the patient so he or she feels guided through the process. These are the first steps for building the “holding environment” a patient will need to feel for psychotherapy to proceed.
When patients are able to talk without interruption or with minimal clarification, I let them do so for at least half of the allotted time. This is especially important in the first part of the session. It is much better to make notes of what needs clarification and come back to it later than to interrupt the flow of the patients’ ideas or emotions. In the second half of the session the therapist can complete the initial assessment by asking clarifying questions and obtaining the necessary personal history. When patients are talking, let yourself give expressive feedback in small doses to prevent them from feeling alone or abandoned. It can be a very raw experience to talk about such intimate things in front of a stranger, and patients can feel adrift quickly if not anchored by emotional feedback from the therapist. Nod your head, wince if they talk about painful things, grunt at times, and give small verbal utterances that support, confirm, or sympathize with what they are expressing. This can be done without derailing them from their train of thought (“Wow, that sounds painful”; “Oh....”; “Hmm, that must have been difficult”; “You must have been proud...”; “Oh my...”). Silently staring at the patient without any reaction for extended periods of time is discouraged in the initial session because this tends to increase anxiety.
For patients who have been in psychotherapy before, it’s vitally important to ask what that experience was like for them: “What did you find useful and nonuseful with the therapy?”; “What worked for you?”; “What did you learn from the experience?” You should reassure the patient that you will use this very important information to help guide the current psychotherapy. If the patient had an unpleasant experience in a prior psychotherapy, you should outline what you’ll do differently to make the current therapy better. This is especially important if the patient had aversive or even traumatic experiences in therapy. You can emphasize that you’ll actively try to avoid this and spend extra time to analyze what went wrong previously, followed by a plan of correction.
If the patient had an outstanding, positive experience with prior therapy, it’s important to validate this while at the same time predicting that the patient will notice some differences as he or she begins to work anew. Predicting some initial disappointment will help soften the expectation that the new therapy will immediately replicate the “holding environment” of the prior, where the patient enjoyed a good therapeutic alliance. Patients are likely to feel some loss of intimacy as they start the new therapy. For these patients with good prior psychotherapy experience, the therapist can help them grieve what they have lost from the prior therapeutic relationship. In addition, it’s sometimes helpful to discuss what “good things” they’ll likely import into the current therapy from the prior experience. Finally, the new therapist can nurture a positive perspective by pointing out that because the current therapy will be completely novel, there might be things learned that are both new and different in a good way.
In the wrap-up part of the first session, you should address any intense emotions by checking in with the patient on how he or she is doing. Immediate intervention methods can be employed, such as breathing exercises or visualization, if the patient needs help getting stabilized. This should be tended to at least 10 minutes prior to the end of session; otherwise the patient may leave feeling emotionally gutted and without a way to cope. Patients in such circumstances might feel the initial session made them worse and may not return. For such patients it’s also useful to predict that they may have some emotions surface even after the session has ended. Reviewing coping methods the patient can use for these after-session emotions is also helpful. You might suggest some activities for after the session to help the person recover—for example, meeting with a loved one, talking with a good friend, having a shared meal, or some other activity that is social but not stressful. In the final part of the session, you should give the patient a brief summary of the psychodynamic formulation, tailored to the patient’s understanding. You should look for confirmation from the patient that the initial formulation holds some fidelity (“OK, here is what I’m thinking at this time about you and your situation. How does this sound to you? If it’s off, please tell me how to make it better”). You can also present a brief proposal for how psychotherapy will proceed from this first session onward, including types of personal material that will likely be covered, frequency of sessions, scheduling and cancellation policy, and possible “homework” assignments.
One of the most freeing aspects of doing supportive psychotherapy is that therapists can “be themselves.” But what exactly does this mean? In supportive psychotherapy the therapist is not the emotionless “blank screen” onto which the patient projects his or her unconscious conflicts. The therapist doesn’t have to act “neutral.” Instead, the therapist can be a friendly, warm, nurturing person who has inflection in his or her voice and conveys a genuine concern for the well-being of the patient. The therapist can be emotionally expressive, including being especially sensitive and tender when the patient is expressing pain, as well as expressing joy with patient gains or triumphs. Most trainees find their “groove” when starting supportive psychotherapy because they finally feel they can use their genuine good will and caring in a therapeutic context. The joy of healing is an important part of what makes many people enter into the psychotherapeutic fields of work. You can finally let yourself be you and a psychotherapist at the same time.
Trainees in psychotherapy (e.g., psychiatry residents, social work interns, psychology interns) often feel anxiety with their lack of therapy expertise and sometimes worry that patients will see them as inexperienced and therefore ineffective. These anxieties can be inflamed further if the patient draws attention to it: “You’re a trainee, right? Have you done this before?” There are a few ways for psychotherapy trainees to cope with this. First and foremost, trainees should not deny their inexperience and should admit it without apology. This can be coupled with the information that they will have supervision throughout the therapy. Even more important, however, is to impress upon the patient that they want to do a good job and therefore will learn whatever they need to in order to be helpful. “Yes, I’m a beginning therapist and I want you to know that I’ll have a faculty supervisor at all times during my care for you. Even more important for you to know is that I really want to do a good job, so if what I’m doing doesn’t seem helpful, I want to learn how to make it better. During our therapy together, I’ll be checking in with you frequently to make sure you feel you’re making progress.” In my experience supervising psychotherapy, I’ve found that the far majority of patients enjoy the keen interest and enthusiasm of psychotherapy trainees and that the inexperience of the therapist rarely becomes an issue during treatment. Interestingly, studies looking at therapist experience and psychotherapy outcome often do not find a significant correlation.2
In supportive psychotherapy, there is an important distinction between being friendly versus being friends. The therapist-patient relationship is not a friendship. There is no reciprocity with the patient: the therapist doesn’t rely on the patient, expect anything personally from the patient, or ask the patient for anything. Often when the therapeutic alliance is especially good, the patient might consider the therapist a friend. Occasionally patients will state, “I consider you a good friend” or ask, “Are we friends?” It’s important in these circumstances to validate the intimate, good feelings the patient has about the relationship while at the same time mentioning how the relationship is not reciprocal, and therefore not a friendship. Therapists can emphasize that they will do their job so much better because the relationship is not, in fact, a friendship (“It allows me to focus solely on helping you”). Sometimes the discussions around this issue of friendship lead to rich material that can yield good psychotherapeutic dividends.
As we discussed in the prior chapter, a good therapeutic alliance is the essential ingredient for successful supportive psychotherapy. Like most relationships, the therapeutic alliance will ebb and flow over the course of the therapy. The time spent during psychotherapy in a positive therapeutic alliance is like putting money in the bank: it builds on itself and might need to be drawn upon to help during more difficult times (“We’ve worked through a lot together; we can get through this”). The empathic, flexible, and nurturing qualities of the therapist will maintain the equilibrium of the therapeutic alliance, bringing it back to the positive when it’s disrupted. Disruptions or problems in the therapeutic alliance should be viewed as opportunities for learning rather than negative events. In fact, sometimes turbulence in the therapeutic alliance can be an indication that important issues are brewing in the therapy (the storm before the calm). Repairing the therapeutic alliance in and of itself is often a correctional emotional experience.
An important component of doing supportive psychotherapy is taking care of the patient’s emotional well-being during the psychotherapy. The therapist is responsible for eliciting emotions from the patient, modulating the degree to which this occurs, and anticipating how it might affect the patient after the session. Exactly how much elicitation and modulation occurs in the therapy depends upon numerous factors, including: How well does the patient handle strong emotions? Does he tend to act out with strong emotions? How well does he compensate after getting in touch with difficult emotional issues? What is the patient’s history of coping? Does he have a tendency to harm himself or others when distressed? Does he abuse substances as a way to cope? Have healthy ways to cope and self-soothe been addressed in the psychotherapy?
Answers to these questions are vital in determining the degree to which emotions are opened up in the sessions. First and foremost is to ensure that patients have healthy ways to cope with strong emotions outside of the therapy sessions. This can include a variety of nonspecific and specific techniques. Generic coping methods can include mantras, self-affirmations, relaxation techniques, journaling, and cognitive reframing. More specific coping plans are tailored to the patient and can include a wide range of activities. Some examples are talking with a support person (e.g., best friend, someone in their inner circle), exercising, taking the dog for a walk, watching specific videos, or listening to music. The patient can be a consultant to figure out which coping plans will work best, because sometimes activities outside of the therapist’s expectations might be soothing for the patient (e.g., handling a pet snake might be comforting to some while a terrifying thought to others). The bottom line is that when patients leave the session, they have been educated to expect “after-shocks” of emotions and have coping methods at their disposal to deal with them.
Navigating the balance of how much to “open up” and how much to “cover up” is difficult terrain for psychotherapists, especially with beginning or novice therapists. The art of doing good psychotherapy is based upon how well the therapist handles this balance. Having strong emotional catharses is important for healing, and the more comfortable the therapist is in sitting with someone in pain, the better he or she usually is able to handle it. It can be very distressing to witness emotional agony, and therapists can modulate the emotional expression to the level they feel confident in working with. It’s important for therapists to remember that they’re in control of the session. They can bring in techniques to help calm or soothe the patient as need be, to keep the emotional level tolerable for the patient. If the amount of catharsis appears to be getting out of control, or the behavior of the patient becomes alarming, the therapist can assertively give directives to take deep breaths and focus on their physical presence in the room (“grounding”) as a calming measure (“Take a deep breath and let it out...you are here in the room with me...look around the room...feel your feet on the floor...you are safe here”). Another subtler technique used to decrease the level of emotional intensity is to shift from discussing feelings to exploring facts. For example, asking patients, “How long ago did this happen?” or “Where were you living at the time?” will surreptitiously decrease their emotional intensity while they begin to give the factual answers. The therapist should control the time of the session, so that if strong emotions or traumatic material is uncovered, there is ample time to help the patient compensate before the end of the session.
On the other end of the spectrum, sometimes the therapist will be utilizing methods to help patients “open up” more to their emotions. There are many reasons a patient might be resistant to expressing emotion; however, at the basis of most are anxiety or fear of pain. Assuming a good therapeutic alliance, the therapist can coach the patient into allowing the feelings to emerge if they appear near to surface but the patient is resistant. Encouragement mixed with safety statements can help the patient to experience the emotion, for example, “It’s OK, I’m here with you, and we can handle this,” or “It’s OK to have these feelings...let them come. They’re a natural part of you.” These statements reinforce the notion that the patient isn’t alone, that the therapist can handle it, and that the patient is in a safe environment for the feelings to emerge.
It’s natural for people to want to avoid pain, even if that avoidance is causing other painful symptoms. Sometimes the job of the therapist is to provide the “nudge” that patients need to move into a different emotional position, one that will allow healing. This means taking patients into unpleasant emotional territory, getting them out of their “comfort zones.” Having a strong therapeutic alliance (nurturing holding environment) will allow this nudging to occur.
Case Example
Isabel is a middle-aged woman with chronic depression, low self-esteem, and guilt. She is rarely able to feel good about herself. She lost a twin sister in a drowning accident when they were children, an accident that she survived. Despite carrying inappropriate guilt about this event for decades, she has actively avoided talking about it in psychotherapy. The therapist believes her persistence in guilt is an important contributing factor that keeps her depressed. She has been in psychotherapy for a year, and there is a good therapeutic alliance.
ISABEL: I’ve told you before, I don’t want to talk about it.
THERAPIST: You’re right, you’ve told me that before. I’m trying to respect your wish to avoid that, but I feel you carry it inside in a way that keeps you depressed. I keep wondering if it might help you heal to talk about it.
ISABEL (looking anxious): You might be right, I don’t know...?
THERAPIST: What are your worries about what will happen if you do talk about it?
ISABEL: I don’t know, I just know I don’t want to talk about it.
THERAPIST: My guess is it’ll be painful to talk about, and you’re naturally avoiding the pain of it. I think it might be like letting some pus out of a wound. It’ll likely hurt some, but then it’ll allow the healing to take place. But maybe just talking about what your fears are would be a beginning. Let’s try that....
ISABEL: I just know I’ve always kept it down, sort of like if I don’t talk about it, it won’t hurt as much. They tried to get me to talk about it after it happened. Took me to a therapist. But I wouldn’t talk, and they eventually gave up on me.
THERAPIST: Yes, you were protecting yourself. You were probably traumatized by it, and my guess is you feared being overwhelmed in some way. What is it like keeping silent about it—how’s that for you?
In this example, Isabel has been traumatized by an event in her childhood and strongly suppressed a number of emotions related to it. She likely suffers from posttraumatic stress disorder, and her depression is epitomized by guilt and the chronic suppression of unpleasant emotion. The goal of the therapist is to get her talking about it in a marginalized way, to begin the process of accessing her guilt. In the example, Isabel has started talking about it in a way that’s tolerable. The therapist has nudged her into this uncomfortable emotional territory. Over the course of another year in psychotherapy Isabel is eventually able to examine the traumatic events of her childhood and come to a better understanding that her guilt was excessive.
The pacing of psychotherapy is another core skill of the therapist that is hard to define but critical to good therapy outcomes. Pacing of how much to nurture, how much to explore, how much to confront, how much to “open up,” and how much to “close up” is the rhythm of psychotherapy. More seasoned therapists develop a good sense for pacing based on years of experience; however, even for veteran therapists, each and every person is unique, and what has worked for many may not work for a particular patient. A good rule of thumb for how to handle most perplexities in psychotherapy is for the therapist to get a consultation from the patient. Checking in often with how therapy is going for the patient and how he or she is doing outside of the sessions can provide help for pacing. In fact, frequently checking in with the patient is a useful technique both within and between sessions (it’s hard to do too much of this). Some patients are not capable of providing such consultation feedback, but most will give at least some information that can be useful for the therapist. Generally, patients will have a gut feeling for if they’re making progress overall, or if the therapy feels bogged down versus too intense. If the therapist experiences frequent boredom with the sessions, this may be a clue that therapy pacing is too slow. It may also be an indication that the patient is evading a sensitive topic. More active confrontation or elicitation of feeling may be indicated (e.g., “It seems to me that we have been stuck lately; does it feel that way to you? Any thoughts about this? Are there some things that you’re uncomfortable talking about...maybe avoiding? What can we do to make this better?”). Contrary to this, if the patient seems to become destabilized frequently during or after sessions, it may be an indicator that the pacing is too fast, and efforts should then be made to strengthen defenses and shore up coping skills. One adage for psychotherapy is to teach patients how to cope before opening up things they need coping for. This is a worthwhile adage; however, like most things in life, it should not be seen as a rule, because sometimes issues arise and need attention “out of order.”
Patients bring a wide variety of themes, personal material, and emotions to the sessions. Although the therapist is sensitive to the patient’s needs, this should not be confused with allowing all directions to occur in the psychotherapy sessions. Some patients will talk on endlessly about mundane matters that do not seem much related to their problems. Some will attempt to talk about current events, political or otherwise, to engage the therapist in conversation and avoid talking about themselves. Some patients will have problems with thought processing and simply can’t talk in an organized fashion. The psychotherapist is the one responsible for structuring the sessions and making them worthwhile. At times, this might mean interrupting the patient to redirect him or her to more meaningful thought content. At other times, it might be slowing down the emotional catharsis so that the patient can learn some coping skills. The therapist is the ringmaster of the psychotherapy, making sure the “acts” flourish but controlling the flow and sequence of events. In general, every session should have an opportunity for the patient to speak freely without interruption, an opportunity for the patient to experience emotions, an opportunity for the therapist to provide nurturance or feedback, and a “wind-down” toward the end of session for the patient to compensate.
In some ways the qualities of a good psychotherapist are like a good parent—allowing expression and encouraging growth and self-sufficiency while maintaining proper boundaries. Boundary maintenance is an important psychotherapeutic technique both in what happens with the patient and in what happens with the therapist. In the strictest sense boundary maintenance refers to keeping a professional boundary with the patient; that is, no personal gain or financial or sexual relationship should exist outside of the therapy. In rural or remote regions, this may be impossible because there will be an overlap of roles due to the small or isolated population. For example, the therapist may be treating the daughter of the sheriff in a small town, where both therapist and sheriff often interact in a professional capacity and have developed a casual friendship. Under no circumstance is a sexual relationship with a patient, past or present, ever condoned. The trust, dependency, and intimacy that develop naturally with the patient in the course of psychotherapy make the patient vulnerable to emotional exploitation. Simply put, developing a romantic relationship with a patient is an abuse of power by the psychotherapist. Sadly, this is not a rare occurrence mostly because of therapists who do not keep a healthy emotional balance in their own lives (we discuss this further at a later point in this chapter).
Boundary maintenance also includes enforcing some rules for patient behavior in psychotherapy. This can include not meeting with a patient who is intoxicated from drugs or alcohol (the patient can be politely informed to reschedule the session for a time when they are not intoxicated). If a patient becomes physically, sexually, or verbally threatening in a way that is not redirectable, the therapist will need to terminate the session and act to ensure his or her safety (fortunately, this is an uncommon occurrence in psychotherapy). A psychotherapist cannot do therapy if feeling threatened or afraid, and these conditions are acceptable grounds for termination of treatment.
In distinction from the strictest definition just discussed, boundary maintenance includes many more nuanced behaviors that need the proper management by the therapist. First and foremost is time management. It is the therapist’s duty to keep track of time during the session so that the sessions end appropriately, both with actual clock time and with the patient’s emotional state. Sometimes patients will thwart even the most rigorous time management efforts by the therapist by bringing up an important issue at session end. These “doorknob” issues must be handled with calm measure. If the issue can wait until the next appointment, the therapist can say, “This sounds like a very important issue that we should give ample time to discuss thoroughly, let’s start with it next session,” or “If you want to schedule another session soon to discuss this further, we can do that.” If the end-of-session issue is a true emergency—for example, the patient reports imminent suicidal ideation—the therapist must address it immediately regardless of the chaos it will cause to the schedule (so, you wanted to be a psychotherapist?). Often patients will want to get more time with the therapist than what is allotted. There are many factors that contribute to this phenomenon, but overall it’s sufficient to say that time management skills by the therapist are a very important part of boundary maintenance. Good boundary maintenance is not just a function to keep order in the therapy; it also serves as modeling for patients to learn healthy boundary setting in their own lives.
Psychotherapy is a very emotionally intimate undertaking, for both patients and therapists. For some patients the psychotherapy hour occupies the most intimate moments of their lives. Part of the naturally occurring process of psychotherapy is for patients to want more intimacy from the therapist, to know them personally or in a special way. Boundary maintenance also includes handling attempts by the patient to develop a friendship, as well as what the therapist personally reveals about themselves. The amount of personal information revealed by therapists covers a wide range, and there is no set standard with what is considered appropriate disclosure. With psychoanalysis the therapist reveals practically nothing about themselves, and this opacity encourages transference, which is a vital process for successful psychoanalysis. With the evolution of supportive and other types of psychotherapy (interpersonal, cognitive-behavioral), therapists have become more transparent in a personal way. Some therapists give patients substantial personal information about themselves, including their private cell phone numbers or social media connections. In the 1960s, some unique therapists encouraged both patient and therapist to be completely nude for the sessions in order to encourage transparency and intimacy by having “nothing hidden” between them in the therapy.3 While intriguing, nude sessions can, I think, be placed in the “outlier” category (even if that approach is fun to think about). But questions still remain: How much personal information is too much? Does more disclosure help the therapeutic alliance? Should therapists answer questions about their religious beliefs or sexual orientation? Can therapist disclosure help a patient in unique ways that other methods do not?
The best guiding principle for answering these questions is for therapists to ask themselves two critical questions: “Is the purpose of giving this personal information for the benefit of the patient?” and “Is the patient the driving force for this disclosure?” The biggest dangers for therapist disclosure are when it occurs for the benefit of the therapist and when the therapist wants to disclose for his or her own personal reasons. As mentioned earlier, psychotherapy is an intimate process, and therapists will often develop warm feelings for their patients. It can be very tempting at times for the therapist to share personal information with a patient, especially when both therapist and patient have a mutual fondness for each other. The need of the therapist to share can be based on his or her countertransference. By focusing on answers to these two questions, the therapist will have a guide to appropriate disclosure.
Information about the psychotherapist that is public knowledge—professional credentials or experience—does not pose a boundary maintenance issue. For example, questions such as “Where did you get your degree?” or “Do you have much experience in treating people with bipolar disorder?” can be answered readily. There are other situations in which therapist disclosure might seem straightforward and easy to address. For example, if the patient asks, “What side of town do you live on?” or “How long have you lived here?” these questions might be answered without much ado. More personal questions might include, “Are you a Christian?” or “Are you married?” Therapists can decide whether they want to share more personal information such as this. If they do, answering in a straightforward manner without much added information will usually suffice. Some patients will feel less likely to engage in therapy if the answer is not what they wanted, for example, if the therapist does not share the same spiritual belief. In these circumstances patients can be comforted that their spiritual beliefs are important and will be integrated into the therapy. These patients can also be reassured that psychotherapy can work even if the religious beliefs between therapist and patient are not the same. If the therapist chooses to decline an answer, he or she can do so in a supportive and boundary setting manner: “Sorry, but I’d prefer to keep my personal information out of your therapy. I believe it actually helps us in working together if the focus is on you.”
The therapist can choose to answer inquiries about their personal information by asking the patient, “What would my answer mean to you?” This gives the patient an opportunity to articulate a core belief, for example, “I can only trust a Christian person; therefore, my therapist must be a Christian.” This can lead to useful discussion as well as an understanding of emotions or experiences underlying the belief. It can also give the therapist time to think as well as additional information about how he or she wants to answer the personal question. For example, the therapist might answer, “Well, no, I’m not a Christian, but I believe I can understand and appreciate how important your Christian faith is for you, and integrate that into my work with you. If that’s not enough, I’d be happy to help you try and find a therapist who is also a Christian.” Sometimes the actual answer from the therapist is less important than patients feeling safe that they can express their beliefs in a supportive or accepting environment.
The patient may ask personal questions of a much more intimate nature, for example, “Are you gay?”; “Have you ever been abused?”; or “Do you have any personal experience with mental illness?” Answering these more intimate questions will have powerful effects on the therapeutic relationship, and the therapist should give ample consideration for how he or she answers. If the therapist chooses to answer the question, great care should be taken on how much detail is shared, with special concern for not using the opportunity for their own catharsis. Patients sometimes feel a deepening of the therapeutic experience when the therapist discloses intimate information, and this can be quite beneficial for the therapy. In this way therapist disclosure can enhance the corrective emotional experience. Alternatively, sharing such personal information can sometimes affect patients in ways that are countertherapeutic. If the patient has a strong negative reaction to the personal information shared, it can damage the therapeutic alliance. For example, if the patient believes strongly that only a heterosexual therapist can help him or her, it’s sometimes difficult to overcome this barrier when the therapist doesn’t conform to the patient’s preference. There are few absolutes with therapist disclosure, and a useful exercise for therapists is to decide their own boundaries for answering personal questions before they occur.
Case Example of Appropriate Therapist Disclosure
Rachel is a 30-year-old military psychologist who was employed overseas in the Iraq war. She developed an aggressive form of breast cancer and returned to the United States for medical treatment. She had served several consecutive stints overseas and developed a romantic relationship there. Her life was fully engaged there, and once back in the United States she felt lonely, isolated, and depressed. She did not have much family support and had considered her social network in the military as her primary support. Her military “family,” and her boyfriend, remained in Iraq. She started seeing a psychotherapist and developed a good therapeutic alliance.
RACHEL: Everything seems surreal being back here. It’s so different there, in the war. I just don’t connect with anybody here. I’m in a whirlwind of medical appointments for the breast cancer, but that all seems unreal too. Except for the part about dying...that’s terrifying. I’m in a depressed fog.
THERAPIST: Have you considered attending a breast cancer support group? A lot of people have gotten tremendous benefit from the support groups, and there is even some evidence it can affect the outcome of the breast cancer in a positive way.
RACHEL: Yes, I was referred by my oncologist, but I just feel that I wouldn’t really get benefit given that I’m a professional psychologist. It seems those groups are more aimed for laypeople. No offense, but I think I’m above that level by being a psychologist. I doubt I would fit in.
THERAPIST (who is a psychiatrist): I can see why you might feel that, Rachel. I must tell you, though, that I once derived great benefit from being in a public support group where I was the only professional. I’m sure I thought about things differently than most people in that group, given my psychiatric training. But the emotional focus of the group, the benefit of being with people who shared the emotional experience for traumatic events as I had, was helpful to me.
RACHEL: Wow, really? I wouldn’t have expected that. I just wrote those off as not likely to be helpful given my professional expertise. What was it like for you being in the group?
THERAPIST: I initially wanted to keep that I was a psychiatrist a secret, because I didn’t want to make other group members uncomfortable. As part of the group introduction, however, we all had to talk about what we did for a living, and so I shared that I was a psychiatrist. There was some initial surprise and a few jokes, likely triggered by some unease with having a “shrink” in the room. But eventually that seemed to fade away, and I became just like any other group member.
RACHEL: Was it hard for you to share your emotions there?
THERAPIST: Initially, yes, it was hard to get out of the groove of wanting to help the others in the group, many of whom were in life circumstances much worse than mine. One group member actually called me out on this, said that I was being too much a “helper” and not helping myself. I was then able to make the switch and focus on myself, on my needs. And yes, I was then able to share my feelings in a genuine way.
RACHEL: Maybe I’ll give it a try.
In this example, the therapist decided to disclose his personal experience with a support group, hoping that Rachel would find some benefit from his disclosure. The patient was not requesting the information, so it was a risky intervention for him to choose. It may have been partly motivated by his countertransference, especially as he liked Rachel and felt a professional closeness to her. He felt that because he and Rachel shared some collegiality of both being mental health professionals, it would likely help. The therapist hoped that by sharing his experience, and modeling the challenges of doing it along with the potential benefit, Rachel would be more likely to pursue it. The amount of personal information shared was “just enough” to achieve this goal. Although Rachel had some exploratory questions, the therapist did not give specifics on his traumatic experience or go into great detail of his emotional catharsis. He gave her enough information to resonate with his experience and possibly move forward with her own. Rachel actually did start attending a breast cancer support group and found the experience immensely helpful.
Case Example of Inappropriate Therapist Disclosure
Myra was a psychiatric resident working for a training program under an educational visa (she was an immigrant from her native Syria). The Iraqi war was ongoing, and most of her family were remaining in Syria, under considerable danger from the war. Myra was doing psychotherapy with a narcissistic man who spent the majority of the sessions lamenting the various injustices of his life. He was what some people might call a “chronic complainer.” As Myra listened to him berate people for relatively minor offenses, she became angry, thinking about the grave danger her family was in compared to the trite issues he was so worked up about. It became intolerable to Myra, and she finally burst out with, “My family is getting shot at as you speak...do you not understand that so many of your ‘injustices’ are really very petty and you need to let them go?” The patient became very silent. He and Myra had enjoyed a good therapeutic alliance, and he had never seen Myra react this way before. He genuinely asked about her family, and she spent the remaining part of the session telling him the very precarious situation her family was in. He left the session with his head bowed.
Myra discussed these events with her supervisor. It became clear that she was in an emotional crisis, and the possibility of her taking a leave of absence from work was discussed. She was able to discuss how her disclosure was coming from her emotional need and not from the patient. The possible consequences on the patient were anticipated, including that he might feel guilt or shame for his “petty” grievances but also that he would be hurt or angry from feeling attacked by her confrontation. Myra did not take a leave of absence, but she did get some extra support from her training program. She resumed psychotherapy with her patient and attempted some repair from her disclosure session. This included her giving an apology to the patient and explaining in generic terms that she was undergoing a personal crisis. She also told that patient that he should not need to weigh the importance of issues when talking with her. With subsequent sessions he appeared to complain less and asked periodically how Myra was doing.
Although it is difficult to evaluate in total whether this example of therapist disclosure caused damage to the therapy, it was clear that the patient talked less about his troubles, which likely was a negative outcome.
This last example of therapist disclosure brings up a vital point for psychotherapy, namely, that the mental health of the therapist is correlated with psychotherapy effectiveness. Qualities of the therapist shown to positively influence psychotherapy outcomes have included emotional intelligence, empathic capacity, effective management of interpersonal ruptures, and effective management of difficult emotions.4 Given that the therapeutic alliance is the cornerstone for everything that is built in psychotherapy, and that the therapist is the “anchor” leg of the therapeutic alliance, it makes sense that good mental balance in the therapist will be linked with success. Doing psychotherapy can be intimate, intense, and evocative for the therapist. When deep emotional scars are opened with the patient, the process is likely to trigger similar feelings in the therapist. The therapist should have a host of methods to cope with feelings that arise in therapy in order to keep his or her balance and continue to work without developing what has been labeled “compassion fatigue.”5 Coping methods for working with the job-related stress of doing psychotherapy include strategies for at the office and outside of the work setting. To directly address compassion fatigue, the therapist should have ample opportunity for supervision, a chance to talk about cases in a confidential fashion with a mental health professional. It is best not to do this with an administrative supervisor, because therapists must feel free to talk about things in the therapy that might not be going well, or feelings they might not want an administrative supervisor to hear. The purpose of supervision is for both learning and decompression for the therapist, and this is best accomplished in an atmosphere of openness and trust with the supervisor.
Methods to address emotional tension and stress during the busy workday can be built into a therapist’s schedule. Sometimes after a particularly emotionally “draining” session, the therapist can do some relaxation techniques or physical movement before the next session. This can include just a few minutes of yoga breathing or posture, or any other movement that allows the feeling of decompression. After an intense session, especially when trauma has been discussed, the air in the room can feel thick with emotion, and I find it useful to walk out of the room, leaving the door open to allow wafts of the lingering emotionality to escape prior to starting the next session.
Often during my career people have asked, “How do you do it? How do you listen to all that pain and suffering without letting it get to you?” In addition to the methods just discussed, I’ve implemented a number of boundaries to keep myself mentally healthy and fresh for doing psychotherapy. During the workday I almost always take lunch while doing something relaxing and non-work-related, such as talking with a colleague about non-work-related things or reading fun or relaxing material. I attempt to keep this strict boundary unless something interferes beyond my control. Having a break during the workday from exposure to pain and suffering is essential for regaining perspective. I also do not bring any patient-related work home with me, preferring instead to stay later at the office if need be. I might work on a scholarly enterprise while at home, but I do not work on anything patient related after leaving the office. I contain any “on-call” (after work hours) emergency issues to the minimum required, taking care of the situation on hand and subsequently placing my notes for the encounter out of sight, so as not to be reminded of the patient issues later. I don’t discuss work matters about patients at home, even if kept confidential. Essentially, I make every effort to contain the association of working with pain to my physical work site. These efforts help to keep the monumental pain and suffering of my patients from contaminating my thoughts and feelings outside of work. I believe keeping these boundaries decreases compassion fatigue and allows my empathy and nurturance to blossom while I’m with patients. Now, in the twilight of my career, I’m just as excited to do psychotherapy as I was at the beginning.
Keeping mental, spiritual, physical, social, and cultural health will help overall to decrease compassion fatigue and increase psychotherapy performance. Having a hobby, robust social network, and regular exercise can all contribute to good mental health balance. Humor can also help coping and mental health maintenance.6 Earlier we discussed the situation in which a therapist violates the ethical professional boundary by having a romantic relationship with a patient. In many of these circumstances, the therapist was lonely and depressed and developed a belief that he or she would help the patient by providing the “true love” the patient needed.7 When we examine these boundary violations in retrospect, it is easy to see that the therapists were meeting their own needs for intimacy while talking themselves into believing it was healing for their patients. Had these therapists been taking better care of their own emotional health, it might have lessened the chance of their boundary violations with the patients.
While pointing out the importance of keeping your own good mental balance in being a psychotherapist, I must emphasize this does not mean having no mental problems of your own. Rather than striving toward a notion of static, perfect mental health (I doubt such a thing exists), you might instead work on understanding your strengths and vulnerabilities as well as your unique life story that has brought you into becoming a psychotherapist. Your life story will continue to evolve as you do psychotherapy with your patients. The better you understand yourself and how people affect you, the better you will employ your unique personality as a healing force in psychotherapy. We discuss this concept with greater detail in later chapters of this book.
1. Rockwell WJ, Pinkerton RS: Single-session psychotherapy. Am J Psychother 36(1):32–40, 1982
2. Goldberg SB, Rousmaniere T, Miller SD, et al: Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. J Couns Psychol 63(1):1–11, 2016
3. Nicholson I: Baring the soul: Paul Bindrim, Abraham Maslow and ‘nude psychotherapy.’ J Hist Behav Sci 43(4):337–359, 2007
4. Kaplowitz MJ, Safran JD, Muran CJ: Impact of therapist emotional intelligence on psychotherapy. J Nerv Ment Dis 199(2):74–84, 2011
5. Figley CR: Compassion fatigue: psychotherapists’ chronic lack of self-care. J Clin Psychol 58(11):1433–1441, 2002
6. Gremigni P: Humor and mental health, in Humor and Health Promotion. Hauppauge, NY, Nova Science Publishers, 2014, pp 173–188
7. Denman C: Boundaries and boundary violations in psychotherapy, in Abuse of the Doctor-Patient Relationship. Edited by Subotsky F, Bewley S, Crowe M. London, RCPsych Publications, 2010, pp 91–103