Setting up therapy for someone else

One of the worst parts of feeling depressed or anxious or grieving is that it’s really hard to do stuff. When you’re not feeling well or like yourself, everything is a chore. Finding a therapist to help you may feel like the last task you could possibly manage. Sometimes, enlisting the help of a trusted friend or family member to do the leg work is exactly what’s needed to get you connected with someone who can help.

At least a third of my referrals come from the friend/adult child/partner of the potential client. I’m grateful when clients have that kind of support and are open to using it. That being said, would this be a blog post if I didn’t add a huge caveat??

Occasionally—though not always—the friend or family member in question wants the client to have a therapist more than the client does. The client may be willing to call me themselves or even set up an initial visit, but their heart really isn’t in it. Sometimes it’s because they honestly don’t need to talk to a therapist; their loved ones are trying to help (or trying to manage their own anxiety) and they want to check the box of THERAPY. This is most often the case with adult children, who have a totally different experience and understanding of therapy than their parents. There’s much less stigma around mental health support for younger generations, which is wonderful! It also can lead people to think that everyone needs a therapist at some point and that just isn’t always the case.

Another good indication that therapy isn’t going to work out when someone besides the client has suggested or arranged it is because said client simply isn’t ready. As I’ve written before, therapy is work. If you aren’t ready to dive deep into some stuff, or being emotionally vulnerable sounds horrific to you, you probably won’t benefit from therapy at this moment. Which is ok! You wouldn’t take an antibiotic if you weren’t sick; you don’t need to go to therapy if you aren’t ready to explore or make a change.

All of that being said—caveat upon caveat!—if someone you love wants you to see a therapist, they usually have a good reason. You may want to give the therapist a call, just to see what they say. Sometimes we need a little push in the right direction. And if it doesn’t work out or you don’t like the therapist or whatever, you don’t have to go back. It’s your choice, even if someone else is doing the administrative work for you.

Your grief in the dark, dreary days of winter

Listen, I am naturally an optimist. I really do see the silver lining the majority of the time. However. Here in Southeastern Pennsylvania, it has been dark and dreary and rainy for what feels like years (I also can be a little dramatic). When the weather is like this, it’s nearly impossible to remember that the days are actually getting longer; that soon we’ll spring forward; that winter actually does not last forever. Don’t get me wrong, all of those counter thoughts can be helpful. After all, nothing hard lasts forever!

That being said, this is a really difficult time for a lot of my clients.It’s especially difficult for those who are sick or old or grieving (or all three), isolated by those circumstances and the addition of bad weather. The usual self-care suggestions fall flat this time of year. Go outside! It’s disgusting out, no thank you. See friends! People can’t always drive in inclement weather. Or they don’t feel particularly social when they’ve been hanging on to a chest cold for a month. Exercise! Ugh. Don’t even get me started.

I don’t mean to say you should avoid all those things and hibernate for the winter. If you can find the energy and motivation to do that stuff, then you’re in better shape than me! Go forth on the journey. For the rest of us, let me just validate that it’s harder to do the usual self care stuff when the weather is bad, as it has been here. When it’s harder to make ourselves feel better, we can get caught in a shame cycle: “I should be doing X but I don’t feel like it, I’m useless/lazy/awful/whatever.” I’m here to tell you, you are not useless or lazy or whatever other horrid adjective you want to use to describe yourself. You are a normal person having a normal reaction to a very long and dreary time of year.

And if you are grieving, whether it’s the first year or the fifth or the fifteenth, you may find that your grief is heavier than usual. No matter how long it’s been, that is normal. Grief can be exacerbated by any number of things, including but not limited to post-holiday blues, gross winter weather, and increased isolation.

So if you are having a harder than usual time right now and all the usual coping skills are falling flat, I have good news: the days are getting longer. Soon we’re going to spring forward. Winter doesn’t last forever. And neither will this hard time. While it lasts, consider reaching out to someone—a friend, a therapist, some nice strangers on the internet—and let them share the burden. You don’t have to do this alone.

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.

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. 

In Defense of Denial

Like most therapists, I'm a big proponent of feeling your feelings. (In fact, if you’ve met me in real life, you’re probably well aware of this, as I share every feeling at every moment). Experiencing your emotions (namely the tough ones) is a key part of good mental and emotional health. After all, ignoring your feelings doesn’t make them go away. In fact, your feelings don’t care that you don’t want to deal with them; they will find a way to make themselves known.

All that being said, sometimes denying our feelings, for a little while, is a necessary coping mechanism. Remember Kubler-Ross and her stages of grief? The first stage is denial. You know, “this can’t be happening, there has to be some mistake.” There’s a good reason we start there when hit with bad news: some experiences are just too hard to process all at once. Instead, we sometimes have to pretend they’re not happening until we’re ready to handle them.

Notice that last sentence: denial needs to be a temporary response. At some point, you do have to acknowledge what’s happening, be it a poor prognosis or a financial crisis or a death. You can’t ignore your circumstances forever. But you can sort of ignore them temporarily. Our brains are not made to withstand constant distress. Denial exists so that we can continue to function while bad things are happening to us.

So if you need, for a little while, to live in the land of Denial, be my guest. It can be a really pleasant and helpful place to visit. Just make sure you aren’t there to stay; those feelings you’re avoiding won’t stay hidden forever. Better for you to the be the one who decides how to deal with them.

Caring for yourself as you grieve

It is easy to list for ourselves all the things we didn’t start or finish in any given day. “I should have called my sister/run a load of laundry/exercised today;” the list is endless. When we are grieving or in a depression or having big anxiety, the list also comes with some serious self-judgment: what is wrong with me? Why can’t I do anything?

In those moments, I invite you to remember that there are very few things you must do every day. You have a set of basic needs: food, water, and shelter. If you’re really feeling ambitious, you can add personal care (showering, brushing your teeth) and socialization (as much of it as you can handle; even just texting someone hello is good enough here). On days when your emotions are heavy, when you are weighed down by grief or pain, you do not have to accomplish anything except very basic self care.

Self care conjures up images of bubble baths and good chocolate. That’s lovely but it’s not what I’m talking about. I’m talking about some Maslow’s hierarchy of needs stuff. Remember your intro to sociology class? I shall refresh your memory, just in case:

See how those physiological and safety needs are at the bottom? That’s because you can’t reach the other levels without first meeting the basic needs. It’s easy to get lost in the weeds, especially when we are not well. Instead of berating yourself for not doing enough, look at what you can do: get out of bed; feed and water your body; try to connect with another human being or a pet or a plant or a book. Focus on what you need to stay alive. Everything else can be done tomorrow.

Try breathing through it

Imagine you’ve stubbed your toe, or banged your shin on the coffee table. When that pain hits, you suck in your breath and hold it for a second. Your brain has sent a signal to your body that you are in danger. You freeze.

Now imagine the way you exhale after that moment of intake: slowly and steadily, right? When you breathe that way, the pain subsides a little. Breathing is the best way to remind your body that it is safe. But when we’re in pain–be it physical or emotional pain–we don’t necessarily remember that. Our lizard brains can only report DANGER and so we hold our breath. How can we make the change and remember to breathe when we are suffering? Only with practice.

Here I should tell you that I am not good at practicing this in my real life. I won’t pretend here that I am an expert in mindfulness or even deep breathing. Just like doctors make for bad patients, therapists are not always beacons of mental health ourselves. But that kind of work–being mindful, and present in your body, and taking deep breaths when you are dysregulated–is a practice. That means you don’t have to do it perfectly or even all the time. It means you can practice doing it as you are able. It can be a process made up of small changes; you don’t have to become Zen Master You. The goal here is just to try it out.

So the next time you are in pain–a stubbed toe or a broken heart–take some deep breaths. Remind your body that you are safe. See how it feels. And if you don’t do it perfectly, or every time, it doesn’t matter. What matters is the practice of it. What matters is caring for yourself.

Creative ways to explore your grief

People who are grieving often ask, "what should I be doing?" Usually I reject the premise of the question: there's nothing to do except experience your grief. You have to feel your feelings, even (especially) the hard ones.

That being said, I do appreciate the idea that there should be an action that accompanies grief, something to help move through it. There are any number of options in that vein. What follows here is a (small and not at all comprehensive) list of creative ways to experience and honor your grief. If they make you feel weird or too silly, don’t do them! But let me encourage you to consider doing something a little different (and maybe a little weird) in order to give your grief the attention it deserves.

1. Write a letter to your person. It can be about whatever you want: a list of things you miss about them; an update about the family; a rehashing of an old argument. You can write as much or as little as you want. You can burn it after it's done or tuck it away or share it with others. The object here is to connect with the person you love and miss, keeping a part of them alive for yourself.

2. Tend to a plant. I say "a plant" because I have a black thumb, not a green one, so an entire garden feels off-putting to me personally. But maybe gardening is your thing! Take your grief there. Tend to the living, green things; put your hands in the dirt. Talk to the flowers.

3. Write a song or a poem or a haiku or paint a picture. It doesn't have to be Pulitzer or museum-worthy. It doesn't have to be shared with anyone else, though it can be. Again, the only objective is to take some intentional time with your loss and find what’s beautiful in it.

4. Make a shrine. (This is my personal favorite). It can look any way you want. It can be tucked away in a corner or right in the doorway of your home. It can have pictures and ticket stubs or candles and symbols. Spend some time building it and looking at it so you can honor the memory of this person that you love so much. It’s a gift for you both.

Remember, in grief there is no way out but through. You may as well find a way to make the journey a little more interesting. And if you’re feeling particularly brave, share what you’ve created. I, for one, would love to see it.

Therapy is work

Sometimes people aren’t ready for therapy. They think they are. They make the phone call, schedule the appointment, show up and answer the first session questions. But then, when the work really begins, it turns out they’re just not ready to do it.

I confess, I have sometimes been one of these people who thought I was ready and then… wasn’t. I have walked into a therapy session, confident in my ability to get down to business, and then discovered it’s actually really hard. And I didn’t always have the bandwidth to do the hard stuff.

There’s no shame in that. It’s just a fact: if you aren’t ready to really look at yourself and do some work with what you find, you aren’t ready to be in therapy.

Notice I wrote that the work is “on yourself.” This is an important distinction: some people come to therapy because they want to change someone else. They want their marriage to get better, their mother to apologize, their best friend to commit to something important. But that’s not what therapy is for. You are the person in the room. You are the one who has to look at your own stuff and figure out what to do with it.

There are a lot of reasons not to commit to that; it’s expensive, it’s time consuming, it’s emotionally taxing. And yet, when you are ready, when you have the time and the resources and the mental and emotional space, it can be life changing. So if you aren’t ready now, take heart: you will be one day. And when you are, you are going to do great work.

Grief before loss: Anticipatory grief

Most of the time, we think about grief in terms of a death loss. After a death, your grief may be all consuming but it’s also clear: someone you love is physically gone and their absence is painful. But sometimes we lose someone before their body dies. That grief—the more ambiguous, murky loss of loving someone who leaves us by degrees—is called anticipatory grief.

Just as it sounds, it’s the anticipation of a loss before the loss itself. Perhaps the person you love is still physically present but they’ve had a major change in their functioning. I don’t just mean dementia, although that has its own devastation. It can also be that your loved one has cancer or ALS or some other illness that is changing their mind and body over months or years. It can be that you’ve lost the person you knew to their addiction or a traumatic brain injury that’s changed their personality. The person you love is technically alive but they aren’t themselves anymore.

In some ways, anticipatory grief is even more difficult to deal with than the grief that follows a death. When someone dies, there is a clear date to point to as the “beginning” of your grief. There are milestones to mark: one month without them, six months, a year. When your loved one slowly leaves you, it’s harder to name your grief and figure out how to cope with it.

That naming is the first step. Acknowledging anticipatory grief will help you move through it. Remember, we don’t “get over” grief, no matter what kind it is; instead we learn to grow around it. Rather than trying to ignore it or avoid it, speak it aloud; share it with others; carve out the space and time to honor it. Anticipatory grief is normal, even if it’s hard to wrap your mind around, and it deserves your attention. Reach out for support; you don’t have to do this alone.

Therapists don't give advice

I love advice columns. I always have; even as a kid, they were my favorite part of any magazine. My Google tiles are mostly suggestions for Dear Amy and Dear Abby and Dear Prudence. I have a subscription to the Savage Love newsletter. I am addicted. I love that the problems are concise and (mostly) straight forward and that the answers are the same: here’s what to do!

But as a therapist, I don’t get to give advice. Don’t get me wrong, it’s sometimes tempting to just tell someone what to do. As your therapist, I have the benefit of objectivity; you may not know why you’re having such a hard time but it’s usually rather clear to me. I’m able to clarify and reflect back what you’ve told me so that you can decide how you want to move forward. It’s not advice but a different perspective.

This difference can be a tough distinction for clients to make. Often at the end of a session, my client asks, “so do you have any advice for me?” Of course the short answer is yes! I have very strong opinions about many things! As I said, the temptation to tell my clients what to do is sometimes very powerful. But advice is often best for the person giving it, not the one who receives it. Tempting as it may be, as right as I think I am, therapy is not like an advice column. The goal of therapy is to help my clients come to their own conclusions and make their own path.

You may not get advice in therapy but I think what you end up with is even better: trust in yourself to figure out how to change or move forward or let go. You know the answer; you just need someone to help you see it. Even Dear Abby agrees.

The Grief Wishlist

When my mother was dying, I was pregnant with my first baby. As you can imagine, there were a lot of complicated feelings swirling around: joy and relief (it was a process for me to get pregnant; this was a very wanted kid) mixed with grief and anxiety and also hope that my mom would be alive when the baby came. As close as we were, it was almost impossible for us to talk about the idea of her dying before I became a mother. Mostly we didn’t talk about it at all. Then one day she suggested that I write down a list of questions for her about babies and she would write down the answers. Just in case.

I never did it.

Not because I didn’t want her answers; I wish I could go back in time and write down a hundred questions for her. But at the time I didn’t know what to ask and honestly, I didn’t want to admit to her or to myself that she wouldn’t be with me when I had the baby.

I wish I had written down something.

I’m sharing this story because it is typical of grief. “I wish” can be followed by any number of should have’s or could have’s, if we had only known that the person in question was going to die. I hear it from my clients: “I wish we had spent more time together” or “I wish I was more patient.” The grief wishlist can be unending if we let it be. There is always some regret when we lose someone we love.

The question is, what to do with those feelings? When I hear my clients say they wish they hadn’t spoken sharply to their loved one, or they wish they had been more present, I don’t wave it away and say it doesn’t matter. Instead, we sit together with the sadness and the regret and the guilt. We acknowledge all the things that can’t be fixed or changed once someone is dead. We talk about what the wish really means, which is usually, “I miss this person. I want them back. I wish they hadn’t died.”

Feeling our grief is the only way through it. When you find yourself saying, “I wish” or “I should have,” don’t run from that feeling. Tell someone you trust (ahem, like a therapist!). Write it down. Acknowledge that your grief is complicated and nuanced. Consider your grief wishlist as a tender, loving tribute to the person you miss. Personally, when my grief wishlist feels heavy, I talk out loud to my mom. It’s a private conversation so I won’t share it with you but I will tell you that doing that helps me. There’s something that will help you too; you just have to find it.