You don't have to tell your therapist everything

It’s an often-told joke amongst people in my life that I provide way too much context when I tell a story. To explain how I know someone to a mutual friend, for instance, I go all the way back to before we met and the circumstances which led us to one another. I’m apparently not capable of saying, “we used to work together” and leaving it at that. So I truly understand the desire that sometimes comes up in therapy to tell your therapist every single thing that has ever happened in your life. But I’m here to release you from that.

This is not to say you have to censor yourself; on the contrary, you can say anything in therapy. My argument is that you don’t have to. There are some things you can keep to yourself. Everything that has ever happened in your life or throughout the week in between sessions does not have to be hauled out and mined for content. If your therapist asks you about something that doesn’t feel relevant, you can say so. You decide what to talk about; you can also decide what to leave alone.

A lot of people who are new to therapy believe that they have to begin at the beginning and carefully examine everything in their lives. Sometimes that’s helpful. But just as often, it’s necessary to start at today and visit other details as you go along. In doing that, you may find that certain subjects don’t bear revisiting. Being in therapy doesn’t mean watching reruns of your life and trying to figure out what went wrong. Instead, you get to decide what’s important to you now, right this minute, and see where the conversation goes. You’re in charge. Which means, ultimately, that some stuff can stay out of the therapy space. Nothing is off limits but that doesn’t meant that everything is up for grabs.

"I don't know what to say in therapy."

Let me begin with a small personal confession: this is the longest I’ve ever attended therapy as a client.

Maybe that doesn’t seem like such a big deal. But as someone who has made a living explaining why everyone should attend therapy actually, it feels mildly embarrassing, like forgetting the name of an acquaintance at a cocktail party. “Therapy is wonderful!” I’ve told people over and over for more than a decade while also not actually going myself for longer than 3-5 sessions. I’m a hypocrite, is what I’m saying.

I’m confessing my hypocrisy because I suspect a lot of people are like me: an acute crisis or some other event occurs that leads them to a therapist. They attend anywhere from one to maybe even ten sessions. The crisis passes; things get a little better. And they think, “well, I guess there’s nothing else to talk about.” So they stop seeing their therapist.

I hear this from clients sometimes: “I don’t know what else to say.” Or, “I don’t know what to talk about today.” Or, my least favorite, “what do you want me to talk about?” At that last one, I usually smile and reply, “that’s up to you.” I imagine my clients are not fond of this response but it’s the truth! I can’t see inside your brain. You have to tell me what’s in there that you want to explore.

All that being said, I get it: sometimes I struggle with what to say to my own therapist. She asks me how I am and I say, “I’m good!” and then immediately wonder if that means I should stop going to therapy. The crisis that brought me back to the proverbial couch almost a year ago has passed; I am good. But that doesn’t mean there’s no more work to be done.

The other week, when I really did feel ok, I felt myself about to say those dreaded words “I don’t know what to talk about today.” Instead, I told my therapist that sometimes I’m afraid that I won’t have anything to say and she’ll tell me I don’t have to come back. She laughed (kindly but still, she did laugh because it was ridiculous). She assured me that she wouldn’t say such a thing. And that was all I needed to find a new place to begin. The storm that brought me in has passed but now is the perfect time to do some deeper mining: when I feel well enough to really explore the deeper stuff.

So if you find yourself in therapy at a loss for words, that’s ok. In fact, it’s good! It may be the beginning of a new phase of your work in that space. Hang in through the lull and you may find you can feel even better.

Can crying be part of practice?

I'm reading a lovely book about narrative therapy called "Retelling the Stories of Our Lives," by David Denborough. So much of it is surprisingly moving to me: not just the case studies but also how he describes the practice of retelling our stories in order to regain some control over our lives. One particular passage just struck me as I was reading. Dr. Denborough recounted a situation where the client began to sob during a phone call; this display of emotion brought Dr. Denborough to tears. That's all he says about it: his client was overcome with emotion and he was as well. I was both charmed and startled by this anecdote. Charmed because it is the great joy of our work to be deeply moved by our patients; and startled because this is something I think about a lot. Specifically, I often wonder about how much we should share with our clients and when and how we can do it effectively.

Crying with my patients is particularly interesting to me, not least because I just spent the last five years doing hospice work. A supervisor I had in my graduate school internship once told me that it's ok to cry in front of your patients, as long as you aren't crying more than they are. To that end, I'm usually able to maintain a certain amount of distance in emotionally charged visits while also remaining compassionate and open. But once in awhile, someone's story moves me unexpectedly and I feel those little pinpricks behind my eyes that signal the start of tears. Is it ok then if my eyes well up during a visit? Is there a way to be (slightly) tearful and have it be therapeutic for the client? Is there an appropriate amount of tears? Are any tears acceptable?

This is a tricky question for me. I think that part of what draws people to social work and other helping professions is a certain amount of sensitivity to others. In fact, we need to be sensitive and vulnerable with our patients in order to allow them to be vulnerable with us. However, we also have to protect our clients and ourselves. We cannot cry at every sad story; if that's happening, it's a bright red flag of compassion fatigue. At the same time, we are only human. There will be moments when we feel overwhelmed with emotions. My question is, what do we do at those times?

As with most things, there are lots of variables. Regarding Dr. Denborough's example, there are two indicators that crying was appropriate in this case. First, this was a client he had a fairly long relationship with; therefore he would have been able to judge how his own feelings would impact his client. In this case, I suspect the client felt validated and touched by his therapist's tears. Second, this took place during a phone call. Not being in the same physical place is a good thing here, so that the therapist could be discreet about his reaction if the client was startled or upset by it.

I'm always interested to hear about how other people handle this. When I worked in hospice, my own rule of thumb was to take a deep breath when I felt those pinpricks and examine my reaction later. I suspect the same rule will apply in my new role. But I reserve no judgment for practitioners that allow a little tear here and there. Tell me, is crying ever a part of your practice?

Narrative therapy or, what do you DO exactly?

The most common question my patients ask me when I first meet them is, "so what does a hospice social worker do?" A lot of people get nervous if I describe myself as a counselor or a therapist so I'm careful in how I describe my work to my patients. I tell people I'm a part of the hospice team, another set of eyes, support for them and for their families. The actual clinical work I do is more in depth than what I describe; it involves some education about disease process, a knowledge of family systems, narrative therapy, and even some mindfulness. Sounds pretty thorough, right? But I have a confession to make: until recently, I wasn't sure how to name the theoretical approach I use in my work.

It was when I started supervising my MSW student that I started considering naming the approach I've been using in my clinical work. My student was deep in her practice class and we often reviewed what theory she was studying and how it would be useful or not in her hospice practice. She mentioned narrative therapy and I thought, that sounds familiar... (Graduate school was a long time ago, after all). 

So I did some research (my go-to when I'm feeling insecure about my skills). Narrative therapy fits me as a clinician. It's about telling the story of your life. The therapist's role is to partner with the client, objectifying the problems they're experiencing and reframing them in a larger context. It's about autonomy and personal drive. It meets the client where they are, as we're told to do in school, while also helping to move them forward. 

It works beautifully with hospice patients, who are often examining the meaning in their lives, and I believe it also works beautifully in supervision. So much of this work is about self-reflection and self-awareness. Narrative therapy within the context of supervision encourages the social worker to tell the story of his or her work and identify the strengths and areas of improvement that shape that work. 

So tell me: do you have a theoretical approach to your work?