Recently a reader shared this lovely insight into times when she knew something was up with her therapist. She gave me permission to pass on her words. (Photo, Flickr: Dennis Jarvis CC BY-SA 2.0)
From a Reader:
“I have had several therapists over the years, and there have been a number of times when I have walked into the therapy room and immediately become aware that something is bothering or distracting the therapist. I can’t always explain how I know; it seems to involve a set of non-verbal signals. I tend to ask either, “how are you?” or “Are you OK?” Almost invariably the therapist will answer, “I’m doing fine. How are you?” It would be extremely rare for the therapist to actually answer this question with much thought or honesty, and I think that’s true for most therapists. The response really means, “we’re here to focus on you, not for me to tell you about myself.”
For a more withholding therapist with more strict boundaries it might also be motivated by an awareness that this question, asked sincerely, is inappropriate as it violates the boundaries of the therapy. At the same time, the response shuts down further inquiries. If I have a strong sense that something is wrong, I may ask, “no really, are you OK? You seem off.” A particularly astute therapist or one with a lot of experience with me may recognize this as a “therapy issue” and pursue how I am affected by what I perceive, but most of the time the therapist will reiterate the initial response (reinforcing the boundary) and then ask what (else) I want to discuss today.
I think therapists have very legitimate and appropriate reasons NOT to disclose personal problems, and ultimately that type of disclosure is not what the patient needs. On the other hand, denying that the therapist is distressed in some way can create a repetition of the dysfunctional and mystifying communications of an abusive home in which children may be told of an abusive parent, “Daddy loves you and is proud of you” or “You’re lying. Mommy would never hurt you” or “Your arm doesn’t hurt. You are just acting like a baby” or “Mommy is fine. There’s nothing wrong.” The effect is to convey to the patient (as the parents may have conveyed) that the problem is in his or her perceptions rather than in his or her dysfunctional expectations about the effects of other people’s emotions or dysfunctional behavior in response to other people’s emotions.
The most therapeutic responses I have gotten have generally been honest statements that either something outside the therapy is affecting the therapist or that the therapist isn’t aware of anything but recognizes that it’s still significant that I perceive that something is off, followed by a discussion of how this impacts the therapy that day. If the therapist either feels it’s inappropriate to share details or is uncomfortable doing so, it can be very helpful just to hear that it’s not about me and that the therapist doesn’t expect the issue to affect the course of my therapy, if those things are true.
The least therapeutic responses have been ones that convey either directly or indirectly that the therapist is unwilling to engage with me around my perceptions of the therapist’s affect. In those cases the dysfunctional pattern of fear and avoidance in response to another person’s affect tends to be reinforced and I see the therapist as a direct threat. Then I either dissociate completely, try to placate the therapist to avoid perceived potential violence, or stumble along getting very little done and then use that as an excuse to leave the therapy session early (all counter-therapeutic avoidance behaviors). I’ recognize the possibility that I am misperceiving the situation, but both of my long-term therapists have acknowledged that usually I am correctly picking up on something going on with the therapist.”
First, she raised the issue of patients who have suffered early relationship trauma being particularly sensitive to the moods of their therapists. Absolutely true! I realized this a long time ago, and came to the conclusion that for those patients, I was quite transparent and should relinquish any thought of my emotional state being private. It’s no wonder. For children, emotional needs are as necessary for survival as the physical ones. These children understandably develop an exquisite ability to read others’ moods and emotional states. And the sensitivity is all the more intense in relation to a therapist, instinctively seen as one who might fulfill those needs. This sensitivity may cause some difficulty, but really it is an asset. Being sensitive to others is a burden, but also a skill that can help a lot in delicate interpersonal dealings. Someone once pointed out that many therapists come from a family with a depressed parent.
This situation happened recently in my practice: Some time ago, I had abdominal surgery. It went well, and I was proud of coming through with flying colors and going right back to the office for a few days before leaving on vacation. My very sensitive patient e-mailed while I was away, just to keep a feeling of connection. I responded, and added a sentence that I realized I had been more affected by my surgery than I had known when I saw her.
That sentence was the only one that mattered. In fact, during the session before I left, she was dealing with her own distressing medical issues. Sensing that I was not fully at ease with mine, she didn’t dare bring up hers. Any break in the connection needs to be repaired for therapy to go on. On my return, it took some more work to get to where she could feel confident that I was really ready to hear about her concerns.
Returning to the reader’s experience, it is so true that therapists usually do brush off questions about their mood. I think it’s a combination of professional reticence to burden the therapy with the therapist’s issues but also, being more at ease with giving than with receiving attention. Unfortunately, a light brush-off may be all it takes for a sensitive patient to shut down. I hope all the participants in this blog are ready to push themselves, like our reader, to insist on a real response. Being a little “pushy” gives a good therapist a better chance of realizing that what is happening is a “therapy issue.”
As for the therapist who thinks this is a matter of boundaries, it simply is not. The boundary issue, as she astutely points out, is about whether the therapist should share the cause of the mood. Giving that kind of personal information is rarely useful. Mostly it is distracting, making the conversation about the therapist, not about the patient. It is really no different than if the therapist abruptly came in with a big bandage on his or her head. Would it be a violation of boundaries to have a brief conversation about what happened? A minimal explanation would be all that was needed, then on to the real issue: whether and how it might affect the work. So if your therapist tries to insist on boundaries, please tell him or her that boundaries have nothing to do with it, you don’t need to know the details of your therapist’s life, not really.
What about the fact that my patient knew about my surgery? I made a judgment in her case and a few others that it was simpler and less mysterious to give a real explanation for my being out of the office. I think that kind of boundary judgment is a matter of balance between being secretive, which attracts as much attention as telling, versus revealing too much detail. I took pains to address the real question, making it clear that it didn’t affect my readiness to be there for my patients. The problem was that I was in some denial, myself, and my sensitive patient picked that up.
I think the most important take-home is that therapists do have moods and issues in their lives that have subtle effects on how they act in session. Sensitive patients will pick these up, and, predictably, will interpret them in the light of their own experiences. These reactions represent a huge opportunity if they are explored, and an unfortunate break in the relationship and the flow of the therapy if they are not. It is both the patient and the therapist’s shared responsibility not to miss the chance to pay full attention to the therapy issue and, in the end, to harvest a deeper empathic understanding.