What Makes Therapy Work?

To start writing a blog about, “What Makes Therapy Work” by describing one’s friends may seem strange, but bear with me.

I have approximately 20 friends, 4-5 really close friends……. and I additionally have 3 best friends. First, in alphabetical order by first name, comes Eve. Eve lives in San Diego. She moved there about 6 years ago and I still mourn her departure. She is a self-proclaimed writer/nerd/geek who lives with her nerd/geek husband and son, John and Julian respectively. During the time they lived in Boston, they were my second family, the place that I turned to for comfort, love and Sunday mornings bagels, coffee and lox. Secondly, my longest term best friend, Jane – artist and cartoon animator with a women-only animation collective in Leeds, West Yorkshire, UK. We rarely talk, our lives have gone in different directions, and with vastly different interests. But when we see each other and spend time together (times which are all too infrequent) the connection returns quickly. Last, but by no means least, my dear friend, Dr. Kathy McMahon - sex therapist and clinical psychologist, mentor, stellar Professor, envelope pusher par excellence, thinker and all round wonderful human being, who lives in Western Massachusetts. I visit her as much as is humanly possible, usually for long weekends. I never tire of talking with her, her wonderfully beautiful, sardonic and sarcastic daughter Sarah, or her too-smart-for-his-own-good husband, Daniel. Kathy pushes me to be honest, demands that I go past my comfort zone and hangs in there with me as long as it takes.

And then, in a class of her own, there’s Kelly. Kelly is beyond a best friend. Kelly is a mystic, a metaphysical scholar, a self-described “brain on legs” who only lives to learn, to read, to study. An auto-didactic scholar, she is constantly cruising the internet, while listening to a police scanner, reading a book and watching the History Channel on cable TV. Kelly’s the kind of friend that you have and will never lose, no matter how much you may screw up, mess up with each other, or anger and annoy each other. You fight. You disappoint each other, get your feelings hurt, apologize and then move on. Sometimes this means taking a break, only to come back together and just resume where you left off, only without the “sucky” feelings. Kelly reads this blog avidly, not just because I’m her friend, but because she loves ideas and learning, and therapy is about learning and incorporating new ideas. So this morning she was asking me (via instant messaging online) things she didn’t know about being a psychotherapist and we ended up talking about what makes therapy work. Kelly said, “I'd love to hear about your inner efforts to like a client. Or what gets tripped up inside you about their stuff. That would be a great read. Also what has gotten more healed in you as you be their therapist. Have you ever sent a client away because you just couldn't like them?” I realized that this would be a challenging blog to write, for these are tough questions to ponder and answer.

The truth is that in the early days of being a therapist, there were several occasions whenI was tempted to refer clients out to another therapist, because I was struggling to like them. However, when I stopped to think and was honest with myself, I realized that part of the problem was that I couldn’t figure out how to help them. Coming face to face with your own fallibility is a humbling experience. But the only way for me to grow as a therapist, to become more helpful to clients is to look truthfully at my own shortcomings, to look inside at my own struggles, not to blame it on clients as their fault for being “difficult” or “resistant.” There were a few occasions when a couple of clients I was finding it difficult to “like” (i.e. help) stopped coming. In retrospect, I see that not as their failure, but as mine. I think they knew that I was stuck as a therapist. It made sense for them to move on. They didn't like themselves and I believe that witnessing that self-dislike was painful and made it hard for me to figure out how to like them too. What I learned, the knowledge that enabled me to grow as a therapist and heal more as a human being, is that I need to be honest with myself and my clients at all times. No short measures. Avoiding confrontations because I or my clients may feel something uncomfortable is not a place in which I can feel self-respecting.

So, my job is to figure out what is likeable about people, to understand their strengths and not be drawn in to obsess (like these clients themselves are often compelled to do) on their shortcomings and deficits. My job is not to be their worst nightmare, the proof that they are unlovable, that they don't deserve respect. People need to be able to tell that their therapist will go to the mat for them, will figure out how to find their loveable qualities and not be scared off by the ‘baggage.’ People coming to therapy need somebody to reflect back to them what is loveable in a way that they can internalize, and assist them in making that sense of lovability knowable and useable to them.

So, the sixty-four thousand dollar question, “What Makes Therapy Work? Research shows that when therapy works, it does so because the client can tell that they are genuinely liked and respected by the therapist. Fancy interventions are a little helpful, intelligence definitely factors in…but you just gotta like folks. It doesn’t meant that I’m not tough on people who come to see me; it doesn’t mean that I don’t push them to look at places that hurt, that I don’t challenge them and occasionally ask them to skate on therapeutic thin ice. But they comply, they take risks, they are willing to put on their skates and pirouette because they are deeply respected and deeply and warmly liked.

Which brings me back to my friends.

The only reason that I am willing to tackle challenges, show my vulnerabilities, take risks and get real with the friends I’ve talked about is because I know deep down in my bones that these people love me unconditionally. Having Kelly in my life helped me learn to be honest because there seems to be nothing I can do that would cause her to reject me. I was accepted into Eve's family wholeheartedly, entrusted with loving their dearly beloved son, blessed by their care and respect and had the experience of choosing family, of feeling chosen and feeling wanted. Being best friends with Kathy has taught me that I am worthy of effort, that I see myself reflected back through her eyes as interesting, intelligent, funny and smart and I can internalize that as real for myself. I am willing to make changes in my life, listen to hard truths about myself that may be painful to hear and why? Because my friends gosh-darn love me and respect me. Therapy and therapeutic relationships may be governed by different rules, but you have to know that somebody has your best interests at heart. Without unconditional love and acceptance neither deep abiding friendships, nor caring, effective therapeutic relationships would work. Through the experience of being cared about and accepted by my friends, I learn more about how much my clients need that, though in a different form, from me.

So, that’s why therapy works. I’ll bet my life on it.

How Many Clients Do You Have?

I received some basic, but important questions via email about what is involved in being a psychotherapist, and thought I'd respond to two of them in this blog.

How many clients do you have and how often do they come and see you?
The number of clients I have tends to fluctuate. At the moment I have 27 clients, and they include couples, families and individuals. This is about as many clients as I can see in any given week. (If my practice is full, I compile a wait list. If the length of time a client must wait is more than one month, I keep a referral list of other therapists that I recommend to potential clients.) Anyway of this 27 clients about half are couples, with one or two families and the remainder are individuals. I generally work Tuesday through Friday. 25-30 hours of my work week is spent with clients face-to-face. I spend 5-10 hours per week attending professional meetings, peer supervision with colleagues and paid supervision with other experienced professionals, conducting research, talking with "collateral" agencies (this means other professionals who are involved in clients' lives, such as psychiatrists, other therapists, social workers, teachers, etc.) marketing my practice, book-keeping and answering/returning phone calls. When I started my private practice, I was determined not to burn myself out and decided that a four day work week was probably a more humane approach to working. I pride myself on being a very conscientious therapist and spend a lot of time reading and researching on different issues that clients raise. This might mean learning educating myself about another culture, another religion or spiritual practice, learning about the stressors attached to various professions that clients have, consulting with other clinicians with a particular expertise, etc.

Some people come to see me once each week for a therapy "hour" which is generally, but not always, 50 minutes long. For busy couples, especially those with children and the accompanying headache of finding regular babysitters, I usually suggest that they attend a 2 hour session every other week. Clients in crisis will often request extra sessions during the week, although unless the client is in an emotional crisis or is very depressed I usually suggest that they only come in once a week. While coming to therapy can be very helpful for people, becoming dependent on your therapist is not. (I'll write a whole blog about this in the near future!) I often encourage clients to build supports into their lives in the form of friendships, communities, support groups and/or 12 step programs. It doesn't take a whole village just to raise a child - adults need villages of caring support also. Oh, and the reasons that therapists, including myself, will see clients for 50 minutes is that we often need to have ten minutes before the next client. This allows me time to jot down any notes that I need to remember, check my messages and return any urgent calls and clear my head before the next person comes in to the office.

How long do people stay in therapy?
Some people who come and see me will come with a specific goal in mind. There are as many reasons for people to attend therapy as there are people on the planet: a parenting challenge; the death of a parent; a sexual problem; a miscarriage, etc. These people may spend 3-6 months in therapy and leave. Often they will come back in for a "refresher" later on, or they will return to therapy if another issue comes up that they think I could be of help with.

Some people come in with bigger challenges: long-term depression; a marital crisis that has come about as a result of years and years of marital neglect and estrangement; families recovering from the effects of a family member's long-term alcoholism and new sobriety; people with a lifetime of struggle, who are just beginning to realize how much they have been affected by the family they grew up in and want to learn how to make different choices for themselves; men and women with histories of sexual abuse who want to learn different ways of being in the world. These issues are often more long term. I have some clients who have been with me for 4+ years. Others stay for a year or more and then leave, possibly returning later if they feel it would help them. Sometimes people come in to therapy and are not yet ready to do the work. I always leave the door open for these people to return. I know from personal experience that it can take time to pluck up the courage to sit and face your demons. (This topic will also be covered in a blog entitled, “Clients Who Freak Out And Leave Therapy.”)

To Share Or Not To Share: Therapist Self-dislosure

“To disclose means to unveil, to make manifest, or to show. Self-disclosure is the act of making yourself manifest, showing yourself so others can perceive you. Sidney M. Jourard. (1971).”

The idea that the personal is political was at the heart of the Second Wave of feminism in the mid 1970’s and my belief in this tenet is no less true today than it was 30 years ago. As a result, I believe that whatever is taking place on a deeply personal, vulnerable level in a client, whether male or female, is political on a larger, societal level. Some of the cornerstones of the early grassroots feminist psychology movement evolved out of these discussions, for example a belief in the importance of relationship. Most of my early forays into counseling and therapy, beginning in the mid to late 1970’s, involved leaderless, hierarchy-free groups such as peer counseling groups and feminist consciousness-raising groups. These groups were a self-disclosing free-for-all. (I shudder now when I think about some of those sessions!)

In my first experience of formal therapy, I barely knew the therapist’s last name and she revealed nothing personal about herself. I avoided group therapy situations, preferring the challenge of individual therapy from which there was no escape! (Remember from my earlier blog, that I am reclusive in groups!) This therapeutic relationship was short-lived thanks to managed care. Following this, I wailed and howled my way through years of individual therapy with a wonderful psychotherapist, (Linda Schmidt, LICSW, now retired) in whose rooms I worked on family of origin issues, and the struggle to identify a strong and differentiated sense of self. My therapist’s style was reserved, but highly empathic and extremely involved. I learned slowly about very small pieces of her life over the years, sound bytes of information that were always well-placed and well thought out. Her self-disclosure never felt inappropriate and was a wonderful model for me of how to conduct a therapeutic relationship.

My particular therapeutic style has evolved thanks in part to the willingness of those therapists who did self-disclose in sessions with me, as it was in the coming together of therapist and client that my most healing work happened. Now, as a psychotherapist myself, my primary focus is to be present for my client. I have to think about what effect my self-disclosure will have on my client – who will benefit from the information I share? The client or me? My desire to connect with clients means doing everything in my power to be “with” them therapeutically in all that this suggests. Integrity and authenticity are central concepts for me as a clinician. My client’s willingness to share extremely personal, vulnerable details about his or her struggles deserves an honest response from me. Not a response that claims the therapeutic space as mine, but one that involves inviting the client to swell into the space our joint vulnerability creates in the room. Therapy should not be a mystery, and a mysterious therapist, silent, benign and enigmatic, is not a role model for a client. And, while there appear to be as many theories on therapist self-disclosure as there are therapists, so far, what feels true for me is to reveal whatever, in my estimation, is in the service of the client’s move towards growth. There have been times when showing the soft, white underbelly of a particular vulnerability I have worked through in my life has been useful for a client struggling with a relevant issue.

At all times, I am conscious that my client may be looking to me for guidance, so my answers should never hinder the process of emergence that my client is going through. I have direct personal experience, from the other side of the couch, of how powerful personal stories of transformation can be, and I hope that some of my clients will draw strength from knowing that I have been able to overcome obstacles in my life similar to their own struggles. At the point where my experiences touch on their present-day struggle, the possibility of a transformative connection exists. When a psychotherapist makes a decision to tell something personal about himself or herself to a client, it’s about making one decision that creates the possibility for a thousand others.

Friday May 27, 2005

Okay, so it's not an auspicious beginning to my first ever blog to use the date as a title! I will aim for increased creativity as I get the hang of this thing. To start with I, as an ex-pat Brit, am drawn to the name "Blog" because it reminds me of the Brit term "Bloke" (which is translated from the American "Guy"!). Plus, being full-time self-employed in private practice as a Sex Therapist and a Licensed Marriage and Family Therapist, and a full time married woman, mother and grandmother clearly leaves me with way too much time on my hands!

I began this blog on a whim. My colleague in the office next door, Dori, has a blogspot, and reading hers has been inspiring. I thought it would be fascinating to keep a blog about my work. Sitting here now the reality of what I have chosen feels somewhat overwhelming. My work is by nature shrouded in confidentiality, so I won't be writing about my clients (I can hear them all breathing a collective sigh of relief) but I thought it would be interesting to write about psychotherapy from MY perspective of being "not on the couch" hence my blogger handle. To anybody who is not a mental health professional, this probably sounds like an easy task. But one of the things about being a psychotherapist is that a certain amount of mystery is involved in the role. Revealing information about oneself has to be at all times strategic. This is not because we are more fascinating, interesting and important than the people who entrust their psyches to us, but because it has to be clear that psychotherapy is about them, not about us. It's a complicated dance to figure out what things would be useful for clients to know about you, and what would be detrimental and unhelpful to their own psychotherapy. (I'll go into all this in much greater detail in later blogs.)

Anyway, welcome to my "Not On The Couch" blog. More to come...