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.

Not a rupture, but a tear

Over the years, I have grown comfortable with what I can and cannot do for my patients. I think often of my early hospice career, when I once called my dad after leaving a visit, sobbing because my very young patient was going to die. (I’m sure I’ve written about this before but it has shaped my practice so much in the past six years, I feel compelled to mention it again). The short story is, I told my dad that I couldn’t do anything for her because I couldn’t stop her from dying. And my dad kindly reminded me that I could do something: I could be with her.

It’s a lesson I carry with me into the saddest cases as well as the most mundane days. It’s how I do my work without being drowned by the suffering of others. Also, it’s true! I can’t stop people from dying but I can bear witness and be still and that is mostly enough.

But then, there’s this patient.

I’ve been seeing this lady every two weeks since July. She and her family were told by the doctor, in July, that she had hours to days to live. Another wise thing my dad has told me my whole life is that doctors don’t know everything and they definitely cannot accurately predict when death will come. Here, case in point: she’s still alive in November. And she’s not exactly thrilled about it. I can’t blame her: she’s mostly confined to her bed, she barely eats, and she feels like a burden on her children. When I visit, we talk about those things, but also about her life and her accomplishments and her family. We have a good rapport and I think she enjoys my visits.

Last time I saw her, she was having a particularly bad day. I used all my active listening and therapeutic presence skills and I thought, when I left, that I had been at least a little helpful. When I called this week to schedule our normal visit, she declined. This happens, don’t get me wrong; sometimes people aren’t up for a visit, especially if it’s “just to talk.” But there’s a little nagging voice in my head that is telling me she said no because I can’t do anything for her.

This isn’t a therapeutic rupture exactly but it does feel like a little tear, or a crack maybe. And again, I may be projecting, but I heard in something in her voice when she said “not today.” I heard, “you can’t do anything for me, so why bother?” And that’s the part of the job that scratches away at my confidence and my resolve. I can’t change things for her. What I can offer, she doesn’t want right now.

It’s taking everything in me to type the following: THAT’S OKAY! It is okay that she declined one visit, one time. It’s okay that she’s depressed. It’s okay that I have no magic wand. (Maybe if I write these words enough, they’ll come true). It’s okay to not be all things to all people.

This is mostly my stuff because I’ve been having a hard time getting people to agree to visits, especially new patients. That’s a thing that happens in this job; after six years, you would think I could sit comfortably with it. But at this moment, I’m struggling with it. And honestly, that’s okay too. It’s not a rupture in my work, just a stumble. Carry on, my grandfather used to say, and so: I will.

Photo by Namnso Ukpanah on Unsplash

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.

On returning to work

I went back to work on Wednesday this week. I haven’t been completely without work during my maternity leave; I’ve been doing some supervision for the past few weeks but an hour here and there having a conversation about someone else’s job hardly feels like work. It’s deeply enjoyable, in fact, and I get to do it on my own couch. Going back to my full-time gig is a different challenge. My maternity leave was a lovely interlude wherein I got to watch every episode of West Wing and clean my house.

I’m not a terribly organized person so this was a good chance to go through some junk and de-clutter. (Anyone who has ever lived with me or seen the inside of my house is laughing right now, I know it. But I made some good progress!) In the process of straightening up, I stumbled across a professional portfolio I made a few years ago during my hospice tenure. There was a case study about one of my most important cases (a young hospice patient, of course). Reading it brought me to tears. I cried for the patient I lost, and for her family, who had suffered so much. And I cried, selfishly, because I really miss that work. As sad as it sometimes was, as awful as it could be to witness tragedy so often, it felt meaningful and important in a way my current work sort of… doesn’t.

Part of what I’m working out here is a feeling of being stuck (a theme in my clinical work, as you may have noticed). I’m stuck in my current job. I have two little kids and my current schedule works for our family. I can’t do the nights and weekends that hospice requires; it doesn’t make sense logistically. So what do I tell my patients and my supervisees when the feeling (or reality) of being stuck starts to interfere? Make it better where you can. For me, that means I have to find some meaning instead of comparing what I do now to what I did before.

And of course, I can find meaning in helping people manage their anxiety or quit smoking. More than that, I’m finding meaning in raising my daughters and enjoying this very short season of my life. Still. These past few weeks, as I look at my old papers and remember the joys of my old work, I find myself longing to focus on my career in a different way. I chose to have children and I’m thrilled that I did; they are the great joy of my life. But it has slowed me down a little, professionally. That’s hard to wrap my mind around. It’s going to take some time to adjust to the idea that I have to pause a little and make the best of what I have: a flexible 9 to 5 and a young family that needs more of my attention than my career does right this minute.

Next time you hear from me, I hope it’ll be about a complex case or an interesting supervision question. Until then, keep me in your thoughts as I adjust to going back to work, having two kiddos in daycare, and try to live my normal life.