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.

Find the light

It has been literally quite dark the past few days here in the Philly suburbs. Between the rain and the time of year, the sun feels like a distant memory at the moment. However! It is also the holiday season, which means there is (other) light everywhere. There are intricate light displays on homes and businesses. There are sparkles and sequins in shop windows. There can be candlelight. There is brightness to combat the dark.

You don’t have to celebrate a religious holiday this time of year to bask in the glow. Light can be found and celebrated without having to subscribe to Christmas or Hanukkah. It can be found in being with others; in volunteering your time or money (if you have it to give); in window shopping; in fancy light displays or wandering through your neighborhood. In the cold, wet winter—when it is mostly dark and often difficult because of grief or family or winter blues or any number of other things—I want to remind you that you deserve some light. If you can’t find it, create it. If that’s beyond you right now, ask someone else to help. And remember, darkness passes.

Have a joyful holiday season—and if that’s beyond you as well, just get through it. Wishing you all light and lightness as we enter the new year.

Grief can be complicated

For many of us, grief is straightforward: we feel sorrow and sadness and our loved ones can understand our mourning process. For other people, it’s much more complicated than that. If there are past traumas, if you were estranged from the person who died, if the relationship was challenging or abusive, your bereavement is not a straightforward period of sorrow and sadness. And because your grief isn’t typical, it can feel isolating and confusing.

It isn’t easy to talk about this kind of complicated grief with others, even those who know you well. That old adage, “don’t speak ill of the dead” is deeply ingrained in us. When someone dies, it’s tempting to only view them fondly and warmly; they can’t defend themselves from criticism anymore so the default is to not criticize. But death does not make saints of everyone. Sometimes people are abusive or addicted or they made mostly bad choices, or they were barely present at all. Then, when they die, it’s difficult to find the right words to explain your grief.

The good news is, you don’t have to explain your grief (or lack thereof) to anyone. You don’t have to be sad about someone’s death if ultimately their death is a relief to you. Instead, your grief can be about what you never had from that person, and what they will never be able to repair for you. You can decide how you want to forgive them—if that’s what you want. You can decide how to move forward and how to mourn. Your loss is your own. Your grief is your own. Other people don’t have to understand it or accept it.

Photo by Ian Stauffer on Unsplash

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.

When someone we love is suffering

The problem with loving someone—there are many but let’s start with this one—is that sometimes the person you love will suffer. They will have pain or disease or grief or distress and you will not be able to magically take it away from them. Watching someone you love suffer, physically or emotionally, is awful. And yet, it’s part of the whole deal.

Once, after my mom died, I told a colleague, “I just don’t want my brother and my dad to be sad.” I ended up laughing instead of crying because of the way my sweet colleague stared at me and said, “Elizabeth.” It was, in fact, a bonkers thing to say. It was also true. My own grief was hard enough to bear; I couldn’t stand that the people I love were also suffering.

This is a common theme for my clients, whether they are caretakers or bereaved. Their own grief is awful, all-consuming, exhausting; and yet, they cannot bear to think that other people in their life are also having a hard time. Ignoring the grief and pain of others is doable but doesn’t feel great and also can be hurtful to said loved ones. On the other hand, taking on the pain of others also feels awful and doesn’t take anyone’s pain away. So what to do?

The answer, of course, depends: on what kind of day you’re having; on how the relationship usually functions; and on the cues you’re getting from the other person or people. But in general, as I’ve written ad nauseum, our grief is much easier to bear if it’s shared. You are not protecting your loved ones if you deny your grief or theirs. On the contrary, talking about it opens the door gives them permission to grieve with you instead of protecting you.

We don’t want the people we love to suffer but they will; that’s a part of life. And if that’s true, we may as well suffer together.

How to talk to someone who is grieving

The prevailing reaction from people when I tell them what I do for a living is, “ugh, how do you do that?” Which, I get: listening to people talk about their grief all day sounds like it would be depressing. It certainly can be at times. But it’s also an honor to hear people’s love stories, which is what grief pretty much amounts to: ongoing love for someone who has left us.

That being said, I realize not everyone feels the same comfort when talking about death, grief, and loss. So if you aren’t a grief therapist, what on earth are you supposed to say to someone who is grieving?

First, let me release you from the idea that you are capable of curing someone else’s grief. You are not. Grief does not have a cure, nor does it have an expiration date. This is not to say you should throw up your hands in despair and ignore someone else’s grief entirely. Rather, I want you to let go of the idea that you are responsible for fixing someone’s grief by knowing the exact right words to use on them. There are no exact right words.

There are, however, some less right words. By this, I mostly mean stay away from cliches like “she’s in a better place” or “it’ll be ok.” I know those phrases are tempting to use; they’ve become cliche for a reason after all. But that doesn’t mean they’re particularly helpful. You may sincerely believe in your heart that someone is “in a better place” but you don’t have to say that out loud to the bereaved. Likewise, you don’t have to say that “everything is going to be ok” or that “they wouldn’t want you to be sad.” Again, those things may be true but they aren’t useful to someone who is grieving a loss.

What is useful for grievers is to be truly heard. This means listening without trying to come up with an answer. You aren’t fully listening if part of your brain is working on a response. There’s also no rush to reply immediately with a profound and heartfelt speech. “That sounds so hard,” is enough. Or, “I wish you didn’t have to go through this.” Both of those statements convey that you hear what the bereaved is saying and that you aren’t going to try to convince them of anything. You’re just going to let them be sad. And if they’ve said something that you really don’t know how to respond to, admit that! “I don’t know what to say” or “I don’t know how to help” are both completely reasonable responses to someone’s grief. Sometimes there are no words.

That doesn’t mean we are powerless to help. When someone is grieving, even if you can’t think of the right thing to say, you can sit beside them and help shoulder their burden for a little while. That, I think, is far better than talking.

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.

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.

The pain and comfort of shared grief

This is not what I wanted to write about today. In fact, I had started a totally different post yesterday. But this morning, whatever I had written before seemed pointless in the face of yet another senseless tragedy.

When a tragedy occurs—a mass shooting, for instance, or a racist murder—we experience grief, even if we haven’t been directly impacted. I don’t personally know anyone who was killed yesterday in Texas, or in any of the other violent tragedies that have taken place over the last several years, but last night I found myself crying in my husband’s arms, thinking about the devastation of those families and communities.

I’m not a big fan of the five stages of grief (the most commonly cited and probably most poorly understood theory of grief but that’s a discussion for another day). Despite my rejection of the five stage model, those first three stages describe my feelings at the moment: stage one, denial (this cannot have happened again); stage two, anger (why does this keep happening, what is everyone doing, someone should DO SOMETHING); and stage three, fear (we are not safe. My children are not safe).

I am rattling around between these three stages, both drawn to the news and social media and also wanting to hide from it. I want to talk about it at length with others but also can’t bring myself to discuss it out loud. I am alternately disbelieving, furious, and terrified. I want to do something useful but also feel paralyzed and useless. I am, in short, experiencing grief.

I know I’m not alone. So many of us who are parents talk about holding our babies close after this kind of event and that’s certainly something I did last night: I watched my children sleeping peacefully and thanked God they were safe. In my sadness and fear, I imagined parents all over the country doing the same thing. And I imagined all of us reaching out to hold each other up, clasping our hands together and sitting with the enormity of this tragedy and all the others that preceded it.

When something does not directly impact us, it can be easy to turn away from it (denial again, right? “That will never happen to me, ignore ignore ignore”). And there can be some turning away: we cannot sit only with pain all day, every day. But there can also be some turning toward each other. We can grieve together. We can hold space for each other in moments like this, acknowledging that witnessing suffering and tragedy is nearly as bad as experiencing it for ourselves. We can call what we are experiencing grief, even if it is not our personal loss to bear. We can be still in this moment and feel the wave of anguish, of anger, of fear. It won’t swallow us if we hold on to each other. It brings me a measure of peace to believe this; I hope it does for you as well.

Talking to kids about death

I grew up in a house of death.

Which is not to say it was a sad or morbid place. On the contrary, my childhood was full of joy and happiness. I only mean that talking about death and grief was normal in my house. This was partly because my dad is a doctor, from a family of doctors. And it was partly because my mom had lost her father very young and she kept him alive for us with stories and memories. Later, our family suffered more tragic loss—a blog post for another time—and so talking about death and grief and loss doesn’t really stress me out. On the contrary, it feels like a natural part of conversation.

It turns out that this isn’t typical for everyone. I can tell because of the way people’s faces contort when I casually start talking about death and dying. It kind of freaks them out. And if adults are so freaked out or uncomfortable talking about death, it stands to reason kids would be as well.

But the thing is, kids are remarkably unphased by death. There are a few reasons for that. First, most of early childhood is a time of pure self-centeredness; kids can only understand the world and its events by how they are directly affected. (I don’t mean this derisively; it’s an appropriate developmental step). Second, and I would argue most importantly, kids take their cues from the other people around them. They don’t always listen to our words (as any parent can attest) but they do often mimic what they see us do. How we model big emotions—and grief is a big one—means more than the words we use to describe it.

We do also need words, of course. There’s a tendency to talk around the mystery of death, to use flowery metaphors instead of using the real words: dying, death, dead. Euphemisms may feel safer but they can be confusing and misleading. Shrouding death in secrecy like this isn’t fair to kids. We don’t have to tell them everything but we have to tell them something. We have to use the words: this person that we love, their body died. And listen, there will be follow up questions; namely “why?” (The whys are endless). And also, how? And—this one can be really tough—what happens when we die?

I know that all sounds intense. There’s a fear that of scaring kids or making them sad. But death is generally sad! Part of our job is to show kids how to handle big feelings. Basically, kids need to see that it is ok to discuss death and it is ok to grieve. I give you permission to cry in front of your kids; to say “I miss our person;” to explain that bodies die and to offer them a space to ask questions about that.

Talking to kids about big stuff—and death is one of the biggest—can be daunting. But I assure you, you won’t scar them for life by being honest and clear. You don’t have to make your home a house of death (not everyone is as cool as my family or origin). Start with the basics, don’t over explain, and most of all, let there be space to have big, tough feelings. For yourself, too.