Becoming a good therapist

How do I become a good therapist?  I remember asking myself this while I was in school (truth be told I still ask myself this). Of course this is part of who I am….all about being good or even the best I can be at something.  Sometimes in my life this drive can get in my way, but in my profession it’s really helpful.  It helps me keep being better at what I do, moving forward, changing what I do and looking for different ways to do good therapy.

The longer I work in this field, the more I know “not all therapists are created equally”.   You may be saying….well duh Alice…but really, the community doesn’t always know this.  When you are hurting and you are desperate for help, you reach out trusting you will get that help.  The truth is, there are some in our profession that are not helpful at all.  And then there are some that are very helpful.  Luckily, there are researchers out there who have looked at the difference between the two.   Wampold and Imel give us a body of information in their article The great psychotherapy debate: The research evidence for what works in psychotherapy.

What Doesn’t Matter:

Theoretical Orientation – They all work

Experience – Therapists earlier in their career are actually better than those with more experience

Therapist characteristics of age and gender

Therapists rating

How many of us spend time trying to get more experience, or working hard to find the best theoretical model?  We spend a lot of time and money here.  Research tells us, at the end of the day, these things don’t matter when it comes to being a good therapist. 

What Does Matter:

Alliance - Learn to form a collaborative working alliance with a range of clients (even challenging clients)

Make it Simple – Can explain aspects of therapy effectively and succinctly

Attuned – Can recognize metacommunication happening as it happens (example picking up on body language, seeing facial expressions that are in discord with words)

Grounded- warm, accepting, empathetic, modulate own emotional response while staying focused on client and his/her problems

Humble- questioning our own effectiveness and work to improve

Understanding- offering an explanation for client distress and a means to overcome it. (why do they do what they do and how do they minimize what is limiting them?)

So if you are like me, and you want to be the best therapist you can be, spend less time doing what doesn’t matter and more time doing what does.  If you are not sure about your ability to build an alliance with all clients, get training in that.  If you struggle taking hard concepts and making them simple, get coaching on this.  If you are not very good at being attuned to clients, consider extra learning in that area. 

To summarize, to be a good therapist, evaluate how you do on what matters. Spend less time and money on what doesn’t matter, and more time and money on the things that do. 

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate:  The research evidence for what works in psychotherapy (2nd ed.). New York: Routledge.

Wampold, B.E. (2016 September/October)  Can we become better therapists? Yes, we can!. Family Therapy Magazine, 15(5), 16-19.

Taking it Home

“This client is really driving me crazy.  I don’t know what to do with them anymore.  No matter what I say they have a reason or an argument for why it wont work.  I find myself dreading the session”.

Anyone else been here?  At some point in our careers we all find ourselves in this place.  Sometimes it’s with the ‘resistant’ client.  Sometimes it is with the client who is really good at asking for help….over and over and over….and only from you.  Sometimes it’s with the client who is in so much pain and hurting that it’s hard for either of you to see any light at the end of the tunnel.  What do all of these have in common?  No matter how hard we try, these are the clients that follow us home (figuratively…I hope). 

So what do we do with them? Respond vs. React.  More often than not, when these clients are in our room, one of them triggers us into our own stuff, which causes us to react out of our old patterns.  This reaction sets off a chain of events and before we know it we are in really deep, feeling what they feel, imagining what they imagine, carrying what they carry.  All of these are reactions.  For us to do our best work, we are called to empathize without taking it on.  The best way I have found to do this is with the notion of response vs. reaction.  So here are some tips on how to respond…

11)      Setting up the internal awareness- Take a moment to close your eyes, center yourself, and then imagine an object out in front of you that represents what it is with this particular client that seems to stay with you.  As you get an image of this object, keep it out in front of you and notice it’s shape, size, texture.  As you take time with this, notice if there is a color.  Then take a moment to position your arms around the object as you currently feel like it is positioned in relation to your body.  Notice how uncomfortable that feels.  When you are ready, push the object out away from you so that it is just the right distance out. Where ever you place it in the room is just right.  Now hold your hands up like a boundary and position them just how you need them to be so that the object stays out from you vs. on you.  Anchor in that position to where it feels ‘known’.

22)      Get perspective – Consult with a colleague, see if they can offer any insight on counter-transference that you may be experiencing that pulls you in.

33)      Prepare before the session – Prepare in a way that allows you some time before the client comes to ground/center yourself into the most professional and wise self you have to offer.  Do your internal awareness exercise to put the object in it’s place. Remind yourself of your clinical goals for the session.

44)      Consider your own therapy – If the issue continues, consider exploring what it is about this particular client dynamic pulls you in.  Having the perspective of a therapist to help you work through this pull can benefit you and your current and future clients.

We are all human, and with that humanity brings the pull to connect with others.  Sometimes that connection is a reaction which is unhealthy for us and the client.  Choosing response vs. reaction is a hard choice and sometimes not one that comes easy.  However, this choice lessens the consequence of ‘taking it home’ which is something I know many of us strive for. 

The Power of Why

The Power of Why?

One of the things I have realized I do in my practice is ask myself “why?” This is really a powerful question.  I remember in school they always said avoid the question why.  So my starting off with this simple but complex word my trigger some of you or completely put off others.  If you can stay for just a few more seconds maybe an opportunity will open up for you. 

When a client comes in my office I immediately start an internal question of “why are they here?”  Really this word is motivated by curiosity, and curiosity keeps me grounded and objective.  Then as they share in the initial session of why they are here I’m asking myself “why is their problem a problem?”  Then as I form a hypothesis about this I ask myself “why are they sharing what they are sharing?”

All of these ways of asking why begin forming a hypothesis in my mind to help inform my exploration and treatment with clients. As treatment begins, I continue with the “whys”. The “why” helps me with evaluating countertransference, transference, resistance, success.   Consider curiosity to help ground you in the following treatment steps.

·       Setting client goals: “why are they here?”, “Why is the problem the problem?”, “why does the problem continue to be a problem?”

·       Client Stuck Place: “Why is the client stuck in this specific way?”, “How could this problem be helpful?”, “Why would this problem have been helpful to them at some time in their life?”

·       Countertransference: “why does this client bother me so much?”, “why do I dread this client?”, “why do I look forward to this client?”, “Why am I bothered when the client doesn’t meet treatment goals quickly?”, “why do I feel relief when the client does this?”

·       Transference: “Why am I the one the client keeps calling?”, “why is the client yelling at me?”, “why did they choose me as their therapist?”, “How is what they are doing right now normal for them?”,  “What purpose doe s this serve for them?”

·       Success: “Why did they get better?”, “Why did this work for them?”

Asking the question of why and staying in a curious place can help inform every phase of treatment.  If you ask the question why and are struggling with the answer maybe be curious about that, or call a colleague and see if they can help with exploring why.  If “why” is just too difficult for you,  try “How” or “what” inserted in the same type questions and just see what happens in your treatment process. 

The Complexity of DID

The Complexity of DID

Dissociative Identity Disorder (DID) is such a complex and highly controversial diagnosis in the field.  There are many in the medical community who deny its existence and even some in the field of mental health who are skeptical.  Despite the skepticism, it continues to find its way into the DSM and into our offices.  As a professional, I admit having a mostly healthy fascination with this disorder.  Early on in my career I began focusing most of my practice in trauma, and therefore have probably seen more than the average number of clients who would fit into the category of having DID.  Once you’ve seen this disorder play out, it’s hard to hold on to the skepticism and disbelief.  Believe me!

I find it so unfortunate that a lot of the individuals with DID who come to my office, have been through years of facilities, multiple diagnosis, and various therapies which has been in so many ways more harmful than helpful to them.  Clinicians who work with trauma, specifically complex trauma, are ethically bound to know the signs of DID.  This will allow for quick, accurate diagnosis that can then make smooth the decisions of treatment planning, treatment placement, and scope of practice.  Colin A. Ross, recently published an article in the Journal of EMDR Practice and Research, about how to notice the signs of DID and accurately diagnose.  Below are the early indicators Dr. Ross identifies for when to suspect DID.  For diagnosis, I have referenced the article below for further reading.

When to Suspect DID

1.       Trauma History  - A reported history of extensive, severe childhood trauma (which does not have to be corroborated).  This trauma does NOT have to include sexual abuse

2.       Borderline Personality Disorder – Prior diagnosis of BPD, criterion for BPD currently met or subthreshold.  It is common for depression and PTSD to be comorbid with  BPD.

3.       Voices- Auditory hallucinations which are usually chronic.  The voices may or may not have names and ages and often meets DSM-IV Criterion A for schizophrenia.

4.       Blank Spells- Discrete periods of missing time lasting anywhere from minutes to days (without use of drugs, alcohol, or medical condition).

5.       Switching- Sudden changes in behavioral state

6.       Prior Diagnoses – Extensive history with the mental health system, numerous prior diagnosis often including: BPD, bipolar disorder, schizophrenia, schizoaffective disorder, PTSD, substance abuse.

Ross, C. A., (2015) When to Suspect and How to Diagnose Dissociative Identity Disorder.  Journal of EMDR Practice and Research, 9(2), 114-118.  

As you continue in your practice, learn to see the signs that further assessment is needed for the possibility of DID.  Some helpful assessments include the Dissociative Experience Scale (DES),  Dissociative Disorders Interview Schedule (DDIS) , and for children/adolescents the Child Dissociative Checklist.

Accurately recognizing and diagnosing DID can be such a relieving experience for clients.  It also helps you, the clinician, make the best possible decisions for the client about treatment moving forward.  For more information on this article see Ross, C. A., (2015) When to Suspect and How to Diagnose Dissociative Identity Disorder.  Journal of EMDR Practice and Research, 9(2), 114-118.  

The ‘Stuck Place’

One of the most frustrating things that can happen in therapy for clients and clinicians alike is getting into a ‘stuck place’.  That place where the client is reporting no progress, the therapist is running out of ideas, and a camaraderie of hopelessness can be born.  The ‘stuck place’ can also be a petri dish for clinician and client shame (also known as transference and counter-transference).   The clinician may cycle into blaming self; ‘I’m not good enough’, or ‘I’m just too new at this’, or ‘I’m a failure and should change jobs’.  Alternatively the clinician may cycle into blaming the client ‘they are not trying hard enough’, or ‘they have a personality disorder and can never change’, or ‘they just don’t want it bad enough’.   The ‘stuck place’ is that place that everyone wants to avoid, but finds themselves on occasion throughout their career. 

I’ve found that when a client and I land in a ‘stuck place’, getting back to the basics in counseling help us get movement one way or another.  Below are some strategies to help you and your clients if you ever find yourself in the ‘stuck place’.

1.       Call it out!-  Meaning begin your next session with “I feel like we are in a stuck place, and I’m wondering if you have noticed the same thing?”.  Get the client’s thoughts and feelings about where they may be stuck and strategize together on getting movement. 

2.       Reassess Client Goals – I’ve learned that one of the fastest ways to move through the stuck place is to go back to the client’s original goals.  If I cannot clearly identify what the goals are, then the next session is spent working with the client on identifying specific measurable goals. 

3.       Evaluate therapeutic Alliance – Have a conversation with the client about how they feel about coming to therapy.  Ask if they feel like the current relationship is working for them or if they may desire something different.  Strategize with the client about other options that may be out there that have not been tried (e.g. medication, other treatment modalities, more intensive services if needed).

4.       Consult – Our profession can be a lonely profession.  Having a small community of professionals whom you can meet with regularly and staff the ‘stuck places’ with, not only helps you professionally, it benefits your clients tremendously.  We are never so seasoned that another perspective can’t be helpful.

So the ‘stuck place’ doesn’t have to be a scary place, or a petri dish.  The ‘stuck place’ is actually an opportunity for growth clinically and personally as it challenges us to get back to the basics of good ole fashioned therapy.  The ‘stuck place’ creates space to slow it down and reevaluate.  So remember the next time you find yourself there, return to the basics 1) Call it out, 2) reassess client goals, 3) evaluate therapeutic alliance, and 4) consult. 

Binge Resting

As I consult and supervise with clinicians across the country a theme that regularly comes up is that of fatigue.  Some call this fatigue all the classic signs of burnout; dread going into the office, tired of doing what your doing, frustrated with clients, frustrated with self, and just plain weary.  Approaching this topic as most supervisors would, I look for a personal balance for the clinician around self care.  What I have found is a pattern of what I coin Binge Resting.   When rest is explored a little more I hear things like “I’m just holding on till summer vacation”, or “I have a weekend planned in the mountains”, or “If I can just make it till….”  The pattern appears to be work, work, work till exhaustion, binge rest, work, work work till exhaustion, binge rest, etc.  The end result is never feeling rested.  It has become quite the phenomenon however, and one that if we look at it clinically, is just as unhealthy as all the other things that can be ‘binged’ on. 

So we have to challenge ourselves to think about it in a clinical way.  If you ate the way you rested, what would that look like?  If you drank the way you rested, what would that look like?  If you shopped the way you rested, what would that look like? And so on and so on….  You may find alarmingly that your rest life fits into one of the following categories: anorexic resting, binge resting, balanced resting. 

What is healthy rest?  Other cultures do this well.  In some cultures there is a mid day ‘siesta’ or ‘rest time’.  In other cultures one day a week is devoted to rest.   Individual rest life can be personalized.   Below are some things to consider when examining your ‘rest life.’

1   

--       * Examine your priorities: What are your priorities in life?  Does your current work life, play life, social life, rest life fit nicely with those priorities?  Or are they in conflict?

2    

      * Get a clear picture of balanced rest. How would a balanced rest life look in YOUR life?  If it were possible to imagine having a balanced rest life, how would you know it was happening?  What would be different? How would you see yourself being with others? What would be present if stress and anxiety were not there anymore? How would I know by looking at you that you were a rested person?

3      

      * Set small goals: Start daily.  What is one thing you can do each day that would be restful?  A space of time where you are not DOING anything (including watching t.v. or reading books).

4       

      * Consider starting a daily mindfulness or Prayer practice for at least 30 min.:  Research supports the use of mindfulness and prayer in the reduction of stress, anxiety, and burnout.  There are many user friendly apps, books, and videos on how to do mindfulness exercises with guided options for first time attempters.  There are also books and videos on centering prayers which act in the same way as mindfulness exercises. 

Our goal driven, product driven culture lends itself to setting anorexic and binge resting as the norm.  As a profession that works to help promote health and balance, I challenge us to set a new standard of balanced rest.  Begin by 1) examining your priorities, 2) get a clear picture of what balanced rest would look like for you, 3) set small goals, and finally 4) consider starting a daily mindfulness/prayer practice.  

Compassion Fatigue

“How do you listen to those stories all day long then go home to your family?” 

“How do you separate work and home?”

These are questions I get asked all the time by clinicians and non-clinicians alike.  The answer isn’t an easy one.  It’s actually more of a journey.  I have spent more than 12 years working in some capacity with trauma victims.  The terms ‘compassion fatigue’, ‘secondary trauma syndrome’, ‘burnout’ have all been thrown around, trained on, and warned about throughout my entire career.  I learned early on what this was when I would go to dinner with my husband and space out thinking back on a client’s session I’d had that week.  Or when I would jump when someone would hug me, preparing for them to attack me.  Then there were the times that I would wake up from a nightmare in which I experienced my client’s ‘story’ as they had told it to me.   Quickly I learned that something had to change about what I was doing in order for me to keep helping in the field I loved.  I was so fortunate to have great mentors who spoke into me early on in my career and whom I felt safe enough to ask for help.  What I learned from them are 5 ways to help prevent compassion fatigue. 

1.      Set Boundaries – With clients and with your friends and family.  You should not be the only one your client relies on.  Use community resources and hotlines, create safety plans that involve other numbers and people to call other than you.  Set boundaries with your friends and family by not going to gatherings if you need the rest and self care time.  Find other resources to help your friends and family so that you are not the main provider for them as well as your clients.

2.      Set a ritual to leave it at the office- For me I bow my head and offer up each of my clients I’ve seen for the day in prayer.  I give them to the Great big God that I serve who can help them a lot better than I can outside of the office.   I then get up and literally leave it there in God’s hands.  As I leave my office I turn my mind over to what needs to be done when I get home and call my husband to switch gears into home life.   Setting some kind of ritual for yourself that you do every time you leave your office as a way of ‘Leaving it there’ can greatly increase your separation from it when you leave.

3.      Create your own container- In EMDR Therapy we use a resource called a container where we use guided imagery to create a container of any shape and size needed to contain disturbing materials for clients.  I have my own container for the hard stuff I hear.  When I can’t seem to stop thinking about it, I close my eyes and send it to my container in my office to be pulled out and examined when I have time and space set aside on a work day.

4.      Practice Mindfulness living – Learn the art of gently bringing yourself back to the present moment.  When you catch yourself recalling a session with a client, gently let it fade out of consciousness and pull your focus back to the present moment focusing on the 5 senses of sight, smell, taste, touch, hearing.  Continue to do this whenever you catch yourself and let yourself truly feel the moment you are living in.

5.      Seek your own therapy if needed- One of the greatest forms of self care is realizing that you may need some help getting past either your own story or a client’s story.  Finding your own therapist to process with and learn some additional tools to help separate it can be very beneficial to both you and your clients.

As you continue to listen to the hard stories and struggle with figuring out ‘can I keep doing this?’ know that it is possible to do this work and stay separated.  Know that there are strategies available for helping make that easier.  And know that it is a journey.  A journey that can begin by implementing the 5 prevention steps mentioned above 1)boundaries, 2) setting a ritual, 3) creating your own container, 4) practicing mindfulness living, and 5) seeking your own therapy.

If you are wondering if you may be struggling with compassion fatigue or secondary trauma, Click Here for a helpful assessment resource that you can take, score, and then help guide you as you begin your journey to self care.