When trauma shows up

I am not a trauma therapist. My training is in grief; in life-limiting and chronic physical illness; in medical social work; in aging; but not in trauma. And yet, because many of my clients are new to therapy, I hear a lot of trauma confessions.

I don’t call them confessions because trauma is something to be ashamed of or hidden away. But it often is hidden from view. Often I’ve been the first or second person to hear about a traumatic event from decades prior. The next thought from my client, after they share this awful, horrible thing that happened to them that they’ve hidden away for all these years is: “why is it still bothering me now?”

I’m not a trauma therapist but I have an understanding about why we avoid dealing with traumatic events in their aftermath. The reasons are many: there’s a sense of shame, a fear that what happened was your fault; there are expectations of our family and friends, a fear that they won’t respond helpfully; there’s a self-protection our brains do, to minimize, to block out, to ignore what has happened in order to keep going, to survive. The list goes on; there are many, many reasons not to disclose a traumatic event.

Valid as those reasons may be, they will not make the trauma go away. 

Since I am not a trauma therapist, there will be a limit to what I can offer if I see someone with a trauma history. There may be a point where my client and I decide they’re ready to move on to someone who is trained to work with their particular trauma. Or we may decide to consult with an EMDR therapist (a magical therapy I know very little about; but luckily I have a wonderful network of colleagues who are both skilled and trained in it). 

All that comes later, though. What comes first is this: thank you for telling me. And: of course it’s still bothering you, that’s normal. It won’t bother you forever. Starting therapy is the first step to figuring out how to move forward. 

So if you’re ready to start and you’ve found someone you like, just start. If it turns out you can only go so far together, that’s ok. You’re only taking a first step.

When your therapist makes a mistake

Therapists mess up. We are only human, and so sometimes we make mistakes. Unfortunately those mistakes can cause harm to our clients, a thing we try very hard to avoid. That being said, it does happen. I'll spare you a bunch of academic language about therapeutic rupture and repair. And I'll spare you the times that I've messed up as a therapist–that's for my own supervision. What I really want to explore is what to do when your therapist messes up in session. Therapists are entitled to have bad days or bad moments. The question is, when it happens to you, as the client, what can you do?

There are a few options here. First, you might choose to not return. If it’s someone you’ve only seen once or twice, for instance, and they’ve already made a misstep, you might just want to find someone else. In that case, consider that whatever mistake they’ve made as a gift; you know they’re not the right fit for you.

But if your therapist is one you’ve been seeing for a long time and you don’t want to leave, you can—and should—address the issue.

I know that’s easy for me to say, sitting here at my dining room table and not in the therapy room (virtual or in person). That space is sacred and heavy and sometimes fraught. A power dynamic exists. Therapists are trained to be aware of that dynamic and try to make it an equal partnership but it still exists. So it can be frightening say to your therapist, “I am upset with you. You said something that hurt me. I’m frustrated,” etc. It takes an enormous amount of vulnerability and a little bit of risk.

Let me assure you though, if you have a good therapist, they want to hear it. They don’t want you to silently resent them or just disappear and not return. It can be scary, sure, but ultimately it will make things better and allow you to do the work you came to do. Your therapist is going to mess up sometimes; give them the opportunity to apologize so you can both move on, together.

When does therapy end?

In my very first social work class in college, our professor taught us that termination begins during the first session. It shouldn't be a surprise to anyone when the relationship between social worker and client ends; it should be an ongoing conversation from day one. Sounds reasonable, right? After all, the relationship–whether it’s traditional therapy or case management or some other social worker/client situation–is finite. There is a goal that both parties are trying to achieve together. It’s not going to go on forever.

In real life, I don’t necessarily start talking termination in the first session (with apologies to that favorite professor of mine!). I have my reasons. First, for a lot of my clients, starting therapy is a giant step that they’ve often taken only reluctantly. Before they even start they’re looking for a way out. Talking about termination when they’ve just screwed up the courage to begin therapy may be enough to tip them over the edge into quitting.

Also, endings are hard. Ending a relationship whose major purpose is to dig deep into some very personal, vulnerable, and sometimes scary stuff feels even harder. Some people choose not to terminate in the traditional way (including me! Full disclosure, I have absolutely terminated via voicemail. I just wasn’t ready and I didn’t want to talk about it so I took the easy way out). I’ve also had clients feel really anxious about terminating and instead prefer a slow fadeout: first a session every two weeks, then every month, then… See you later? 

In fact, that’s a way to make termination much less frightening: you can always come back. I’ll be here. And if you’re nervous about starting therapy, maybe knowing there’s a time to end it will help. It’s one session at a time. You can start–and stop–whenever you’re ready. 

Say no: Setting boundaries when you're grieving

Therapists love to talk about boundaries and I am no exception. Boundaries are wonderful! There are so few things we can control in our lives; setting limits with others is one of them. That being said, knowing we can make our own rules in this way is easier than actually doing it.

Setting boundaries can be frustrating, to say the least. That’s because most frequently, the response you get from others when you set a limit with them is not ideal. It is not, “oh, thank you for telling me! I will honor your request with good humor!” Instead, setting a boundary or a limit with someone in your life often leads to hurt feelings and frustration. Asking someone to give you space or not bring up a certain topic or whatever can be difficult for a number of reasons: you’ve never said no before; or the situation has been the same for so long, it seems weird to suddenly ask for a change. Likewise, the person who is being asked to step back or stop a behavior often feels defensive: what’s wrong with the way things are? Why are you suddenly changing the game on me?

But life is always changing (which is out of our control) and we need to be able to make changes that suit us (which is in our control). This is especially true when we are grieving.

Grief is exhausting. It takes up so much of our energy, mentally, physically, and emotionally. In a grieving period, we need to be able to tell others (who may be well meaning) what we need. Most often, what we need during our grief is to say no.

I don’t mean you should hide away in a cave until you feel better (though there may be days when that sounds appealing). Rather, I mean you don’t have to go on as if everything is normal. It isn’t, for you. Your life has changed and you need time to adjust and figure out how you want to move forward. People in your life may not understand this; they may want you to show up in the ways you used to, at work, in your family, in your social life. I’m giving you permission to sometimes say no, without guilt. Your grief deserves your full attention. You deserve to honor it by asking for what you need.

Can I swear in therapy?

If you’ve ever wondered if you can swear/curse/cuss in your therapy session, I have great news for you: the answer is (mostly) yes!

I’m not suggesting you walk into your therapy session ready to use every foul or vulgar word you’ve ever heard. But there is evidence—actual scientific research!—that cursing can be helpful when we are in pain. Sometimes other adjectives fail us and the only way to explain how we’re feeling—the depths of pain we find ourselves in—is to switch to the four letter words.

Additionally, therapy is not the place to censor yourself. Therapy is meant to be a safe space to say whatever you are thinking, however it gets best expressed. For some people (myself included), cursing is a key component of that expression. Sometimes the only words that can accurately describe our pain are the “bad” ones. As a therapist, it’s a relief to me when my clients drop a swear word here and there because it shows me that they’re comfortable with me. The relationship between my client and me is the most important part of our work together; being able to express yourself naturally, without apology, is key to the foundation of that relationship.

Not everyone needs to express themselves this way, of course. Personally, I grew up with an Irish Catholic mother who could make a sailor blush if she was really on a streak; cursing was normal in my house. As with all therapy-related topics, your mileage may vary. But if you’re in a room with me and you want to explore your feelings by swearing, go nuts. I’ve heard (and said) all the words before. I may even join you.

Doorknob communications

The first time I heard the phrase “doorknob communication” was from a student I supervised. She was a little shaken when she brought it up, having just had a client confess something major to her at the end of their last session together (get it? The therapist’s hand is on the doorknob when suddenly the client says the most important thing). That original blog post still exists but it was time for an update. Now that I’m in private practice, I have a much deeper understanding of what the phrase means, why it happens, and what it feels like for both therapist and client.

Let’s begin at the beginning: my therapy sessions are 45 minutes long. Both the client and I know that from day one. That being said, the first few sessions we have together can run a little longer. Some people come to therapy ready to absolutely spill their guts; that 45 minutes flies by when someone starts talking and can’t stop until they get the entire story out. A new client is often on the brink of something—the depth of their grief; the physical and mental toll of a lengthy illness; the weight of caregiving—making those first few sessions a kind of stream of consciousness. And it’s quite often that it isn’t until around minute 43 that a client gets to the really juicy stuff.

This is partly my fault: once someone starts to get close to an important point or a long-held secret, I really don’t want to cut them off. But when I don’t, I’m left scrambling at minute 46, telling them that while I appreciate we’ve just opened a door, we have to slam it shut again until next week; our time is up.

Extend your session time, I bet you’re thinking. But here’s the thing about the doorknob communication: it happens right before the clinician wraps up the session, no matter how long the session is. When clients do this, they're giving themselves a way out. If they decide they don’t want to deal with whatever it is, they don’t have to; they haven’t left enough time to talk about it. There’s nothing forcing them to come back next week. For some people, they had to tell the thing and then they have to bail out, like they’re on a sinking ship.

But most people do return (one of my clients warmly reminds me every session to write down where we left off so we can continue in that same spot next time, like one long conversation split up into weekly installments). And as they keep returning and the relationship continues to grow, the doorknob communications lessen. It becomes less scary to say the Big Thing(s) to someone you trust.

So if you are just starting out in therapy and you find yourself only getting to the Big Thing(s) at the end of the session, hang in there. As you get to know your therapist, the harder stuff will come up more easily, leaving you more time to dive in. And, best of all, you get to tackle it together, in however much time it takes.

"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.

You can say (almost) anything to your therapist

This week, in my series about what to expect from therapy, I want to dive into what may be off limits to talk about with your therapist. The short answer is, pretty much nothing!

There are exceptions to this of course: if your therapist thinks you’re going to hurt yourself or someone else, or that you already have harmed someone, they’re obligated to do something with that information. But otherwise, you get to say whatever you want. You don’t have to be on your best behavior when you’re talking to your therapist. Therapy is a relationship but it’s not a friendship or a conversation at a cocktail party; you don’t have to come armed with your best stories or convince anyone of how delightful you are. In fact, once some trust is established, you can be on your worst behavior if you so choose. In therapy, you get to explore the darkest and meanest parts of yourself. It’s safe there.

Still, it feels risky to open up to someone, even a professional. On the one hand, you’re seeking out therapy because you need to talk to someone and presumably, you’re ready to do just that: talk. On the other hand, there may be a fear that you’ll say something so dark, your therapist just won’t like you anymore. Generally, we want people to like us; we’re only human. So it can be difficult to drop the social niceties we’re practiced at performing. For instance, hearing “how are you?” from your therapist is different than hearing the same question from a co-worker. And yet, for many of us, the automatic answer is the one that comes out: “Fine, thanks, how are you?”

This isn’t to say you can’t be nice to your therapist. Believe me, we’re happy to be asked how we are, even if we won’t tell you the actual answer. I’m only saying that in that therapy session, you are released from surface-level social stuff. You can talk about whatever you want.

Which brings me to another caveat: you can also NOT talk about whatever you want. You don’t have to recount every dark thought that has ever entered your mind. You don’t have to review every embarrassing moment or delve into something that feels too tricky to explore. In that session, you get to decide where to begin and where to stop. When your therapist asks how you’re doing, you can tell the truth. And if the conversation starts to go somewhere you aren’t ready to go, you can say no. You don’t have to worry; you can say (almost) anything to your therapist.

Where do we start?

How does therapy… start?

Some people come to therapy fully ready to spill: they’re like a pot of water ready to boil over. Those first two or three sessions are just full of words and feelings and sometimes tears. That’s been my personal therapy experience and it’s one I really understand: talk until you can’t talk anymore and then we can figure out where to go next.

But not everyone is like me (thank God). Some people enter therapy reluctantly or cautiously; they are not in fact ready to spill their guts to a stranger. It’s not that they don’t know why they came, it’s more that they don’t know how or where to begin. Or they start and then get stuck. Or—and this one is the toughest for me as a clinician—they want an immediate answer.

There’s good news and there’s bad news, here. The bad news is, I do not possess a magic wand. I can’t make sisters or lovers or children behave better; I can’t bring back a loved one from the dead; I can’t give you a secret code that will make your anxiety disappear into thin air. But—and here’s the good news I promised!—there are going to be answers. We can find them together, by sifting through the past and the present. We can find a way to set boundaries with the misbehaving family members; memorialize the dead loved one; understand and quell the anxious thoughts that plague you. In short, we can start wherever you are that particular day, that particular moment, and see where we end up. We just have to start.

Stuck in the weeds

There is not enough money in the world for me to ever consider doing couples therapy. Honestly, I’ve always felt that way; I know what’s in my comfort zone and what’s not. The reason I bring it up today though, is because I found myself thrust into that role and it. Was. Tough.

I’m not in love with my current job but there are perks. For one, it’s short-term so even if the patient I’m seeing is incredibly difficult, I have a nice out: we only have to see each other a handful of times and then either we’re done or I’m referring out to a community therapist. Another perk is that although the majority of my referrals are people with anxiety and/or depression, I encounter a variety of situations. I’ve seen someone with a bridge phobia; recently met a woman struggling with her fiance’s infidelity; and have provided education about a possible Bipolar II diagnosis (a few times, actually). For all my complaints about this job, it’s been a good opportunity to enhance and vary my skill set. Hospice had its variations, of course, but I was there for five years and I was pretty comfortable with my role. This job has a whole other set of challenges and even a year and a half in, I’m still facing new and tricky situations.

Like yesterday, for instance! A woman called to schedule an appointment for her partner (which always puts me on guard because how motivated are you if you aren’t even making your own appointment?) and then they all showed up together: the patient, the partner, and their small child. Which is fine, in theory; a lot of people prefer their loved ones to be with them at doctor’s appointments. But about fifteen minutes in, it became clear to me that my patient and his partner need some serious marital counseling that I cannot provide. First, because my role doesn’t allow for it. Second, it’s very much out of my scope of practice. And third—probably most importantly—the counter-transference was suffocating.

Photo by Hutomo Abrianto on Unsplash

This is not to say that my marriage is in shambles and I didn’t realize until this session; it wasn’t that Freudian. It was more that in my heart, one person was SO wrong and the other was SO right and it made me feel sort of thought-blocked. Like, I knew I couldn’t say that out loud but I also was really having trouble navigating my own feelings. I spent a lot of time saying, “It sounds like you’re saying X and you’re saying Y, and you’re not really in agreement about the basic facts.” It was not my most insightful work, friends. But afterwards, as I’m processing and debriefing and writing this all out, I’m not sure there was anything more I could or should have done.

This many years into my career, I’m comfortable telling people I don’t know the answer. But every so often, a session gets a little bit away from me and before I know it, I’m trying to navigate a situation I don’t really have a handle on. In those sessions, I have to get back to basics: here’s what I can do, here’s what someone else may be able to do, what do you want to do? I’m left with another good reminder to be mindful of what the goal of the work is: to help, whenever and however we can, and to know when we can’t.

Who's doing what?

Yesterday I met with a fairly resistant client. Everything I said—every suggestion, every reflection—was met with, “probably” or “I don’t know.” It was frustrating but I tried to pull out some of my (rusty) motivational interviewing skills and get her to state her own goals. We managed to come up with a couple of strategies to reduce her isolation and improve her mood; I was feeling pretty good about our limited progress. Then she hit me with this response: “So it’s all on me, huh.”

YES. YES, IT IS.

This has been a frequent experience lately in my practice: my patients want answers but they don’t want to change anything. Listen, I hear that. I want to lose weight but I don’t want to stop eating whatever I want. I have no trouble empathizing with that impulse, of wanting to get better without actually doing the work. What I’ve been thinking about during and after these interactions is whether I’m being clear about how therapy works. Namely, which one of us is doing the work here.

As clinicians we often want our patients to do what we think is best: quit smoking; leave an abusive partner; practice some deep breathing. But our patients don’t want to do those things. They want to feel better, sure, but they don’t want to make any changes. We meet at this impasse a lot of the time and try to figure out how to move forward together. We are both resistant. We both want the other to do the lion’s share of the work.

And who’s right? As a clinician, I’d say I am of course! (Ha.) I can’t do the work for people. I can’t put down the cigarette or leave the boyfriend or do the deep breathing (I mean, I can breathe deeply obviously, but not for someone else). But my patient wants to feel better right now. And they think the key to feeling better is making other people do some work.

Of course, I don’t do nothing. Ultimately I try to gently lead someone towards the things that are in their control instead of allowing them to focus on the things that are out of their control. I try to get them to see that they have to do the work, even as they wish that I would do it for them. I wish I could, too. Sometimes they don’t come back, maybe because they’re not ready. Or maybe because I’m not the right fit for them. I have to do my own work there, not to take it personally and use every clinical experience I face as a chance to reflect on my practice. As I told a patient this morning, I’m growing too. That is the gift of the work.

Being the bridge

My role in this job is to see people for short-term issues. Think insomnia, smoking cessation, mild anxiety due to stress, etc. But maybe a third of my referrals are for patients who have a long history of mental illness. These are people who have been disconnected from mental health care for a long time. Part of my job is to be a bridge for them: connecting them to care and hanging with them until they can get into a therapist’s office.

So I have this patient who has seen about a dozen different psychiatrists over the years; in and out of psych in-patient, in and out therapist’s offices, in and out of intensive out-patient programs. To protect her privacy, I won’t go through the laundry list of diagnoses that follows her. But I will say that she has a handful of very complicated diagnoses coupled with a trauma history and a history of substance use. Very much out of my scope, both in this role and in general. But we started meeting anyway, every couple of weeks, to tackle her anxiety and (on my part) try to reconnect her to more intense help.

I like this patient; she has a good sense of humor and we just hit it off. But some of what she told me was just so far out of my experience, I didn’t know what to do. So I went to supervision.

It’s not that I didn’t know what I should do. I knew that she needed a higher level of therapy than I’m qualified to provide. But I didn’t know how to convince her of that. This is a woman who has been in and out of therapy for 30 years; she is deeply distrustful of psychiatrists and very reluctant to meet yet another therapist. But meeting in supervision helped me craft the right words: that while I like her very much and enjoy working with her, I’m not the right therapist for her.

Much to her credit, she was gracious and understanding. She appreciated my honesty and agreed to try it with someone else. So I referred her out to a therapist with a trauma background who was also trained in EMDR. I talked to the therapist myself; she had experience and she was taking new patients. What could go wrong?

It should not shock you, dear reader, that it did not work out. My patient called me after she had her session with this therapist to tell me that the therapist “couldn’t help her.” At first I thought maybe my patient was misrepresenting what happened (read: I thought she was lying to me). Again, I went to my supervisor. He pointed out that there are bad therapists; what she said could be true. I had to ask more questions.

More conversation with my patient made it clear to me that she didn’t misunderstand or misrepresent the session. She met with the therapist for an hour and it ended with the therapist saying, sorry, can’t help you.

Some self-disclosure here: I’ve seen bad therapists. I’ll spare you the details, but I have certainly left a therapist’s office wondering why they had chosen this profession; their rapport building was so subpar, their attitude so shitty, I felt worse than when I went in. So maybe the therapist I sent my patient to was one of those. Or maybe she wasn’t having a good day. It happens; we are, as I keep writing on this blog and saying out loud to the women I supervise, only human. Still, I was disappointed. I had convinced this patient to see someone else, only to have her be shown the door.

Luckily for me, my patient trusted me and she agreed to try again. This time I was a lot more diligent. I made about ten phone calls. I gave an in-depth report about my patient’s history (with her permission) to the people I spoke to. Just before I was about to give it up for a while, I connected with someone who agreed to see my patient.

This patient stopped in the other day, after she saw her doctor. She’s been going to therapy weekly, which was thrilling for me. She thanked me for my support and my help. She looked good. We got to share a moment of mutual admiration and respect that carried me through the rest of my day.

I know it won’t always end this way. I know I’ll make referrals that patients won’t follow through with or that won’t work out for some other reason. But man, I am holding on to this small victory for now. The combination of supervision and doing some extra leg work paid off and I’m so happy for my patient; she’s getting the help she needs. Often the best thing we can be for the people we meet with is a bridge to something better. And how fortunate we are to be that bridge.

Replacing "I'm sorry" with "Thank you"

Photo by Nicole Honeywill on Unsplash

I went to a Motivational Interviewing training the other day (highly recommend; it was super helpful and engaging). Lots of pieces of the training struck me but the one I keep thinking about is the power of saying “thank you” instead of “I’m sorry.” Let me explain: a big tenet of motivational interviewing is reflecting what a patient has said to you, the practitioner. Sometimes we misunderstand our clients, since we’re only human, and our reflection is off base. When this happens to me, I typically apologize. This trainer explained that when she misunderstands a client and they correct her, she likes to say “thank you” instead. That really stayed with me.

It reminded me of something I read on Facebook a while ago. (I usually ignore those positive meme/message things but this one caught my eye). It said, to paraphrase, “Instead of saying I’m sorry to friends, I’ve started saying thank you. If I’m late for instance, I’ll say, thank you for waiting for me.” I find that idea so powerful. It takes away the blame factor and invites the person on the other side to feel appreciated for being gracious rather than annoyed. And that’s important both in our professional and our personal lives. So much of this work is about relationship building. Won’t it build a stronger relationship if we foster graciousness rather than blame and apology?

There is a time, I believe, to apologize in therapy. Sometimes we unintentionally offend our clients. I, for one, am sometimes guilty of making a joke that doesn’t land very well that I have to walk back. In those moments, apologizing seems like the right thing to do. But if we reflect something back to a client and we just misunderstood, saying “thank you for clarifying that” seems like a more helpful response. We’re inviting our clients to continue to be honest with us. We’re encouraging them by thanking them for their vulnerability. Saying sorry can make things awkward; saying thank you is like opening the door a little wider.

Ultimately that’s what we want to do, whether we meet with a client one time only or once a week for a year: open the door. Invite honesty. And being grateful rather than apologetic may be one good way of doing that.