Psychology Today Blogs - Ryan Howes, Ph.D.

Terminating Therapy: What, Why, How? Part I

Ryan Howes, Ph.D. — Tue, 30 Sep 2008 11:15:23 -0700

Part I: What is Termination?

"Termination" is clinical jargon for the last phase of therapy. It has its own fancy term and deserves three posts because it's that important. In fact, for some it's the most profoundly healing, meaningful and transformative phase of therapy. But many clients split before they're able to reap the benefits of a good termination.

One hat I wear is supervisor for graduate students who rotate each academic year at a community counseling center. Most have clients who stay with them all year. In the Spring, students remind their clients that the rotation ends in the Summer and they will terminate or transfer to an incoming therapist. Most clients respond to this news with nonchalance, saying they knew this was the case and it's no big deal. But as the final session draws near, interesting material begins to emerge. My students notice their clients start talking about breakups, death and other endings. Their dreams reflect themes of abandonment and loss. Other clients suddenly "get better" or have a financial crisis and terminate via voice mail. In some cases a conflict arises and the clients leave angry. While some of this may be coincidence, the yearly repetition of these patterns seems to support the idea that termination pushes buttons on a deep, perhaps unconscious level.

We don't like to talk about termination; it brings up uncomfortable feelings for clients and therapists alike. Many of life's endings - breakups, divorce, graduation, getting fired, moving, death of a loved one, etc. - provoke feelings of sadness, anger, grief, rejection and/or abandonment. If successful therapy requires a meaningful connection between client and therapist (as my fellow bloggers and I claim), then we should expect these painful emotions when therapy ends. When we avoid termination, these thoughts and feelings may go unexplored, preventing a healthy closure. I've even heard of clients who go to therapy to grieve their previous therapy.

There are other reasons we avoid termination. Clients may fear they'll be told they aren't ready to stop, or are concerned their leaving will hurt the therapist's feelings. They worry that saying goodbye will be awkward, sappy or painful. Some avoid the sting associated with endings from their past - pain they felt before and don't care to revisit. As a result, they terminate via LMB or a voice mail message: "Hi, it's Jane. I won't be able to make it this week, I'll call you for my next appointment." And that's it, we never hear from Jane again.

Therapists may equate ending with a loss of revenue and shrinking caseload. Their business brain is afraid to mention termination out of fear they're planting a seed. Many attach their success as a therapist with their appointment book, so losing a client means they've failed. Some might avoid the topic because it's an uncomfortable conversation, and we don't want our clients to feel uncomfortable. Or maybe they're too emotionally attached to their clients and don't want to let them go. Either way, their silence colludes with their clients, resulting in a denial that termination will ever happen. By avoiding the topic their clients might not even know there is such a thing as a termination phase, and that it holds great value. In these cases, the "see ya!" voice mail is really no great surprise.

Clients (and therapists) who avoid the termination process are missing out on some of the best material therapy has to offer. For example, many issues clients raise in therapy include an element of loss. During termination, therapy becomes a laboratory for experiencing, processing and coping with those feelings first hand. What kind of model is therapy if we preach dealing with and accepting loss, but practice denial? Can we rationalize spending a year working through grieving a loved one, yet end our relationship via voicemail? Since all therapy must come to an end, shouldn't a high quality ending be part of each treatment plan?

Termination is a time to evaluate the work you've accomplished, celebrate the progress, talk about which goals weren't reached and explore any disappointments with the process. It's reminiscing, an exit interview and saying goodbye wrapped up on one. Sometimes this overview helps it all come together, as seeing the work in the rearview mirror lends perspective. Insights like "Ah, I'm glad you didn't tell me what to do," or, "That explains why I felt frustrated sometimes" are common to a good termination. Yes, sometimes this discussion opens a new can of worms, potentially resulting in more therapy. But it may be a can worth exploring.

We don't have enough good endings in life. The nature of therapy and strength of the relationship should provide clients with this one final gift: a corrective emotional experience regarding endings. Clients and therapists who avoid it are depriving themselves of the insight and healing the termination phase provides.

Coming next: Part II - Why We Terminate

Can We Talk About Disability?

Ryan Howes, Ph.D. — Mon, 15 Sep 2008 22:53:24 -0700

Perusing the blogs of my esteemed colleagues here on PT, I find a glaring omission: disability. We have some fine health and pain blogs, but nothing addressing physical disability in general. With current estimates of 12% to 20% of the US population qualifying as disabled I think the subject is certainly worth a few posts. So this week I set aside my crusade for the empowered client, give Jane the week off, and take a look at this important topic. My hope is to kick start some much needed dialogue.

While I might recognize the need for more discussion in this area, I have no expertise. My medical files are relatively thin and health psychology wasn't my cup of tea. I'll have to adopt the role of reporter for this one.

Fortunately, I've had the pleasure of knowing Dr. J. Galen Buckwalter for the past 15 years. He's a research psychologist and C6-7 quadriplegic following a dive into a shallow river when he was 16. I'm not surprised if you recognize the name. He is Chief Scientist for a little dotcom called eHarmony. He's the lead singer of an L.A. indie-punk band named Siggy. He's also one of three subjects/co-directors of an award winning PBS documentary titled Rolling, produced by MacArthur "Genius" Award winner Gretchen Berland. Maybe you heard about it on NPR. Or read Galen's account in the New England Journal of Medicine. He gets around.

Rolling follows the lives of three normal people living under extraordinary circumstances in wheelchairs. Cameras were attached to their chairs for two years of filming, giving incredible point-of-view cinematography as they encounter the challenges of healthcare, relationships and a wheelchair-unfriendly world. If you haven't had the chance to catch the PBS showing, I highly recommend you take a look. It streams online here. I think it should be standard viewing for every mental and physical health care provider, whether you work with disabled people or not.

Galen has been kind enough to grant me an exclusive interview. We're old friends, so forgive the informal nature.

Ryan: Nice film, dude.

Galen: Yeah-the little film that won't stop. It's gone through more edits than a Siggy CD but I am quite proud of it. Thanks.

Ryan: Before I get started: crippled, handicapped, disabled, differently-abled, etc. Your thoughts and preferences?

Galen: Just not ‘late to dinner.'

Semantics are certainly relevant in some civil rights issues but when you are talking about chronic physical differences there are so many flavors that trying to find an overarching label is somewhat akin to trying to find a label for all of the types of music that suck right now. I mean does shoegazer really differ from emo, and does emo differ from dreampop? It is all music and unless you like a particular type in a profound way it really doesn't make much difference. My personal preference for my specific condition tends toward the more descriptively confrontive. Gimp, cripple; they both seem to describe how I am physically different from the norm and they also imply that my physical anomalies underlie social stigmas. And they both have a bit of punk rock flair about them, no?

Ryan: Uh ... yes they do. I can already see the comments section filling up. I'll start with a softball. This PT site doesn't currently have a blog dedicated to physical disability. Do you think disability has a place in the discourse of psychology, or should it be left to medical forums?

Galen: If my experience is to be taken as representative, leaving disability to the medical community will guarantee we continue to receive inconsistent care. But perhaps a more profound consequence of psychology's decision to ignore the range of disabling conditions and chronic illnesses as an identifiable human condition is that psychology will continue to fail to learn from the experiences of literally millions of people. The lessons these people, myself included, have learned from coping with issues that are so challenging to so many people, such as physical trauma and social isolation, should not be ignored. If psychology is going to understand coping mechanisms we best get comfortable talking with and studying those who are in a position to understand it.

Ryan: Well said, and not just because you agree with me. But that's nice too. Speaking of coping, how have medical, psychological and/or relational interventions helped with the loss of function and chronic pain you've experienced?

Galen: The most critical day in, day out medical need I have stems from the pain I experience as a result of extensive spinal column deterioration. There is no way to manage the level of pain without the use of hard core medications. So my pain management folks help me balance that fine line between not seeing double because of the pain nor from the medications.

I am fortunate enough to have found a doc who has seen a ton of folks starting to age with spinal cord injuries. His experience is invaluable, he is determined not to let my kidneys take me out so he watches them like a hawk. He pretty much goads me into taking care of my skin, which does seem to be my responsibility. I came to the realization a long time ago that if I am going to live I have to accept the responsibility for a lot of my medical care; I need to use effective methods of cathing and keeping my caths clean; I have to take care of my skin; if I am going to make it I have come to realize that I do need to be my own doc in a number of ways. But honestly my wife is as much my own doc as I am. The way I understand surviving SCI is that my doc has to coach the team, but the players are indispensable.

Ryan: Hmm. Players who listen to the coach. Sound advice for your beloved Eagles as well.

Galen: Bite me.

Ryan: Sorry man, low blow. In the film you talk about how you are expected to "feel and act disabled." Could you expand on that?

Galen: Just try sitting your ass in a wheelchair for a day and you'll see what I mean. The perception seems to be "if you're not walking, you're not thinking." Everyone has their assumptions about what your abilities are. People see someone in a chair and jump to conclusions - many of which are false.

Ryan: Okay, last question. Let's say you're struggling with a heavy door that doesn't have an automatic opener. If someone walks by, what would you like them to do? Offer help or leave you alone?

Galen: Damn! No more softballs, apparently. This one is difficult because it depends on the day and the situation. It's like any social dance where two people are dealing with their own circumstances. I never feel any antipathy against walkies who offer assistance; but I know some gimps do. Some days I want to conquer that door myself, while other days it's the last thing I need. It's one of those dances that's hard to call: sometimes you lead, sometimes you step on the poor girl's foot. That's the bite of disability as with many other things in life: the answer is not always clear cut.

My deepest gratitude to my buddy Galen for putting up with my newbie journalism. Alright, PT, that should get the ball rolling. Your turn.

The Last Minute Bomb in Therapy

Ryan Howes, Ph.D. — Tue, 02 Sep 2008 11:36:42 -0700

Jane and I are having a good, productive session. We seem to have a solid connection, interpretations are flowing, neurons are firing and the unconscious is becoming conscious. I notice the clock is at 48 minutes past the hour, so I begin to summarize our work and shift in my seat, preparing to close the session. Jane, noticing my body language, appears struck by a revelation. "Oh," she says, "I almost forgot ..." The payload doors open and something like this falls out:

... I've decided to break up with John.
... I quit my job today.
... I was really mad at you last week.
... I think I have a tumor.
... my mother died last night.
... I'm feeling like hurting myself.
... this is my last session.

My jaw drops. I'm the latest casualty of the Last Minute Bomb (LMB). This all-too-common phenomenon occurs when clients divulge a full-session-worthy topic in their last 30 seconds. Experienced therapists have seen dozens of LMBs, but experience doesn't make them any easier. They're frustrating for client and therapist alike because they typically result in rushed or postponed management of the issue.

This being a user's guide for therapy, I'll first discuss a few factors that contribute to clients dropping LMBs then talk about my response. So why would a client drop an LMB?

Time Management - Sometimes clients have several items to cover and do a quick internal survey right before the session. They might have two minor issues and one major issue to discuss and decide to get the smaller ones out of the way before tackling the big one. But then the minor issues take up the majority of the time and they have no choice but to drop an LMB. It's best to just start with the major issue. If you're concerned that the minor issues won't get any air time, sharing your outline with the therapist at the beginning of the session is a good compromise. It might look something like this: "I've got a couple small family things to talk about and one big health concern. I'd like to talk about the health issue and come back to the family stuff if we still have time." This way you're letting your therapist know your outline, and if the smaller issues are pressing, you'll revisit them.

The Passive Approach - Some client/therapist relationships get into a pattern of the therapist asking questions to draw out the client. As I stated once before, this may be helpful as a last resort if you're feeling stuck in therapy, but if you truly have a critical issue this approach may fail. The therapist could poke around all session with questions about your family and friends while you need to discuss getting fired. Don't be afraid to set the agenda for the session. The best therapies are collaborative - you tell your therapist what you want/need to talk about, and she helps you learn about yourself in the process. Waiting for your therapist to finally ask the right question is a waste of your valuable time.

Reluctance - Most LMBs include material that is uncomfortable to talk about. It's human nature to seek pleasure and avoid pain, so I'm not surprised that some people bring up difficult material at the last possible moment. Let's see, 50 minutes of feeling bad talking about my divorce, or 30 seconds? The problem is, by dropping an LMB you prevent yourself from reaping the full benefit of therapy. You end up avoiding the treatment as well as the pain. In order to grow in self understanding, we need to learn to tolerate the discomfort of vulnerability, intimacy and strong emotion.

Testing - Whether conscious or unconscious, it seems some LMBs are a test of the therapist's boundaries. Clients pay for their time, and each minute beyond that eats into the therapist's time. Some clients may want to know if they or their dilemma are important enough for the therapist to give their personal time to attend to it. This "are you willing to break the rules for me?" test is a dangerous slippery slope. If you wonder how your therapist feels about you, ask. You'll learn and grow a lot more by putting this question into words rather than acting it out.

Slipped My Mind - Sometimes, the issue really doesn't occur to you until the last minute. You're as perplexed as the therapist as to why you didn't think of it sooner. Now you've got two concerns to tackle: your repression of the topic and the topic itself. Has this happened before? It's not uncommon for people to repress highly emotionally charged material, but it's definitely worth exploring with your therapist. You may want to ask for an extra session to allow time to cover both these areas if you'd rather not wait a week.

Back to my response to LMBs. I've got two choices: end the session as planned, adhering to the agreed-upon boundary of time, or scrap the rules and discuss the new material, certainly losing the 10-minute cushion between sessions and possibly eating into the next client's time.

Of course, my response depends on the severity of the issue. If someone's wellbeing is in jeopardy (meaning there is a threat of harm to her or someone else) I'll certainly take the time to discuss the issue. But apart from that, I'll need to end the session out of respect for her time, my time and the pre-established boundary. I'll offer an additional session later in the week, time permitting, but today's session must end. While it might seem harsh, the jolt of ending abruptly today may help us prevent LMBs in future sessions.

Is Psychotherapy Dying?

Ryan Howes, Ph.D. — Thu, 07 Aug 2008 17:03:36 -0700

I've heard the murmurs for a while now. My professors back in graduate school often bemoaned the decline of private practice. They said managed care and Big Pharm threatened to render psychotherapy obsolete (to a room of aspiring clinical psychologists, no less). Glancing at the msnbc.com headline Monday, you'd think those predictions were coming true.

The article, titled: "In era of pills, fewer shrinks doing talk therapy" suggests psychotherapy is losing ground to medication in the treatment of psychological disorders. It refers to a study published this week in the Archives of General Psychiatry illuminating a trend: American psychiatrists are moving away from psychotherapy in favor of psychopharmacology. The study reports statistics showing fewer patients going to psychiatrists for psychotherapy and fewer psychiatrists providing therapy. The article cites "the expanded use of pills and insurance policies that favor short office visits" as possible reasons for this shift.

So is psychotherapy dying? Some assorted thoughts I have on the topic:

- Not necessarily; at least this article doesn't support that idea. All it says is fewer people are going to psychiatrists for therapy. With a growing number of masters and Ph.D. level clinicians providing psychotherapy at lower fees than MD's, I'm not at all surprised patients are going elsewhere. Also, psychiatrists earn more for medication management than therapy, so it makes financial sense for them too.

- According to Psychology Today's own 2004 study, more than 27% of all adults (an estimated 59 million people) received mental health treatment in the two years prior. Of this group, "47% report a history of medication, but no therapy; more than a third (34%) report a history of both medication and therapy; and 19% report a history of therapy, but no medication." That's 30 million people in psychotherapy during that two year period. Medication clearly has an edge over therapy, but therapy appears to be alive and well.

-However, the article does raise a question for my blog colleagues (blolleagues?) over in the Psychiatry department: is psychiatry dying? If psychiatrists are losing their chops or interest in therapy, and psychologists obtain prescription privileges (as a passionate segment of psychologists are lobbying), psychiatry could face an identity crisis.

-I need to make a disclaimer here. A psychologist commenting on psychiatry is professionally analogous to the Red Sox commenting on the Yankees. There's a tenuous relationship at times between the two fields. I have nothing but respect for my psychiatrist colleagues, and personally have no desire to prescribe. Since I've been around I've understood psychiatrists to manage medication and only occasionally provide therapy. And if they did provide therapy, it was psychoanalytic. I personally adhere to psychoanalytic principles and understand the process and outcomes are not always amenable to insurance companies' desire for quantifiable progress. There's no medical code for Resolution of Oedipal Conflict. This may help explain why "fewer shrinks [are] doing talk therapy."

- Who gets to be called "shrinks" anyway? I thought all therapists were shrinks. I'm a clinical psychologist, and I've been called a shrink for years. This article implies only psychiatrists are shrinks. Now I'm having an identity crisis.

So is therapy going the way of the VCR? Will mapping the genome, designer pharmacology and Internet-based treatment render the couch obsolete?

In my incredibly biased opinion, no. I think therapy is here to stay. At least long enough for me to save up money to retire without the benefit of Social Security. Here are five reasons I believe therapy will be around a while:

It's natural: In this era of organic food, hybrids, naturopathic medicines, vaccine phobia, carbon footprints and Whole Foods, we're more wary than ever of what we put in our bodies. We have a treatment for psychological problems that doesn't involve ECT or chemicals, and is generally understood to be as effective: therapy. It's sitting and talking with another person, the most natural interaction you can imagine - no preservatives, no carcinogens, no mercury, no child labor, no cholesterol, no fossil fuels. I'd call it green, but you still need to drive to your appointment.

It's relational: We're creatures in need of contact. As much as we love technology, human connection is essential. A great number of psychological problems are created or exacerbated by our significant relationships. Would it not make sense that the treatment would be relational as well? With our significant relationships dwindling by a third over the last 20 years, it seems relationships are more essential than ever.

It's old school: Therapy has really only been around for the last century, but it feels like we have a deep therapy tradition in our culture. For many emotional issues, people first choose therapy. Couples wanting to get married or divorced tend to go to therapy. People looking to find meaning in life go to therapy. Turn on the TV and you'll find Tony Soprano, Bob Newhart and Betty Draper all participating in therapy. For better or worse, it's woven its way into our culture.

It's evolving: It would be difficult to eliminate a field that is so eager to adapt to the times. Flipping through the program for the upcoming APA conference, I'm struck by the number of new, innovative, creative theories and applications being unveiled. Generation X & Y shrinks aren't ditching psychotherapy, they're using research and technology to improve upon it.

It works: Insurance companies might not want to pay for it, but they can't deny its effectiveness. If it ain't broke....

Confidence Shaken: Therapy, Confidentiality and Earthquakes

Ryan Howes, Ph.D. — Tue, 29 Jul 2008 17:49:28 -0700

July 29th at 11:42am Pacific Time, a 5.4 magnitude earthquake hit Southern California. This being L.A., there were probably 1000+ people in therapy sessions who were shaken out of their chair. What thoughts raced through therapist's minds?

Safety was certainly the primary concern. Veterans of earthquake-prone regions know what temblors feel like and have their routines - quickly heading outdoors, seeking shelter in doorways or other havens safe from falling objects. Some just stay put and ride it out. Regardless of their behavior, therapists initially wanted to ensure physical wellbeing.

But that's not all. Their client's privacy was another major concern.

I work on the fourth floor of an eight-story office building holding nearly 100 therapists. It's therapy central. The elevators do all their work between 50-minutes past and the top of the hour. We should all chip in for bulk Kleenex.

When this old building started rocking at 11:42 and kept swaying for the next minute, people got out of their chairs and went to the hallway, down the stairs (no one trusts elevators in an earthquake) and out to the street. Picture it: clients and therapists scurrying together, equally anxious, hustling down the stairwell and outside to a busy sidewalk.

This is where things got a little awkward for everyone.

Confidentiality is essential for effective psychotherapy. It's necessary for building trust, which is crucial for allowing honesty, and without honesty we're wasting our time. Confidentiality is mostly about keeping information and details private; keeping what's said in therapy between client and therapist. But for many people, it extends beyond the secrets, stories, feelings and fantasies. A man might want the fact he is seeking psychotherapy to remain private. A woman might want the identity of her therapist to remain private. Some people don't want to be seen entering or leaving a therapist's office. Many of us have separate entrances and exits for this purpose.

So here it is, 11:44am on a Tuesday, clients and therapists hanging out together on Colorado Boulevard. Some therapists who know one another start chatting: "Any of your pictures fall down? Think that was a five-pointer?" Meanwhile, clients stand by, some continuing to talk with their therapists, some talking on cell phones, some just standing quietly. Before long the group splits up, some returning inside and others parting ways - session time is over. Mercifully, for many.

I doubt there were any ethical breeches here today. No therapist blurted: "Hey, I'd like you to meet my client John - he's got the most interesting fetish!" But there was a lot of discomfort. The safety of the therapy office had been intruded upon, the relationship temporarily left the four walls, and for a moment the hidden was exposed. I wonder who felt more awkward, therapists or clients. I hope they remember to talk about how it felt the next time they meet. The safety of the room and relationship needs to be rebuilt.

(Me? I had that hour free. I was going to use it to write my blog, but was procrastinating.)

Say Anything

Ryan Howes, Ph.D. — Thu, 17 Jul 2008 16:08:17 -0700

Therapy is one place you can talk about anything you want. There's no need to censor yourself, be overly polite or avoid conflict. Still, many clients have a lot to say and don't. Why?

I've heard a ton of complaints about therapy. Friends, acquaintances and strangers upon learning I'm a shrink spill their guts about the misunderstandings and miscommunications they've experienced in their own therapy. Things like "I don't see her point" and "why would he say that?" and "what does she think about me?" and "I hate the way he clears his throat." I always respond with the same question: "Did you mention this to your therapist?" Unfortunately, the typical answer is no.

Throughout this blog I've done a lot of talking about client empowerment and helping people get the most out of their therapy. One key point is this: if a problem arises in therapy - talk about it. Unspoken questions/gripes/concerns result in wasted time and money, unnecessary frustration, and may even draw therapy to a premature end.

What kinds of roadblocks am I talking about? How about when your therapist:

- says something that makes no sense to you
- tends to be late for sessions
- made a face, gesture, or comment that brought up a strong emotion for you
- has an annoying quirk
- is taking therapy in a direction you don't want to go, or don't understand why
- seems too chatty, or says too little
- reminds you of someone you love or hate
- didn't seem to get your point
- looks like he's got something else on his mind
- etc.

The list could go on and on. Basically, any time something occurs and you feel like talking about it, you should feel free to do so. This is easier said than done.

For example: my client Jane was upset with how the last session ended. She gave me a compliment as she walked to the door and I didn't seem to acknowledge it. My "stoicism" is frustrating for Jane, and she has been thinking about this all week. In fact, she's frustrated with a lot of things about me: I don't make small talk with her, I don't offer up a lot of details about my life, and when she asked me a direct question about her boyfriend I didn't give a direct answer. She's been talking a lot with her friends, griping about me and therapy. But when she shows up for our session, I hear nothing. She's ten minutes late and seems a bit reserved, but when I ask if there's anything wrong she says no and launches into a recap of her week. When we end this session, I have a vague feeling something isn't clicking between us, but I have no idea what the problem is.

There's so much great material for us to dive into. We could explore why she feels frustrated and how she copes with disappointment, find other places in her life where she feels similarly, examine how she tends to react and when she learned to respond that way. We might discover that what she is feeling in therapy is similar to how she feels in many relationships - frustrated with others for not giving enough, frustrated with herself for needing too much. We could see how her past contributes to this frustration, and how some of her thoughts and behaviors perpetuate it. We could crack this case wide open.

But not if Jane doesn't talk about her frustration, we won't. Not today, anyway.

Every meaningful relationship encounters roadblocks. Misunderstanding, miscommunication and stepping on toes is inevitable. Therapy, being all about communication and intense emotion is no exception. In fact, therapy is so intense there may be more of a risk, and therefore more need to discuss these slights and understand them. Many clients do feel free to vocalize their questions and concerns, but certainly not everyone. Why not? Here are some possible reasons:

Confrontation is scary: Telling your therapist his interpretation makes no sense, or you think he charges too much, or you're afraid he's falling asleep is a confrontation. I'm not surprised if it raises your heart rate a little. But keep in mind a few things. By telling the therapist how you feel, you're giving him more information about you, helping him to understand you better. Also, facing conflict may be a part of your problem, and therapy can be an ideal laboratory to learn to practice confrontation in a healthy way. Finally, you're the customer, and if you're not getting the service you want you have every right to speak up. Most therapists know how to handle confrontation in a non-reactive, non-defensive manner. And if they don't, you can always take your business elsewhere.

"She's the expert:" Some clients keep quiet because they figure the therapist must know what she's talking about. Who are they to question someone with a doctorate and years of experience? So the therapist continues to use jargon and miss the point and the client feels increasingly lost. Yes, therapists have a certain amount of clinical expertise, but if you're not tracking with her, then she has yet to attain expertise in communicating with you. By speaking up, you're teaching your particular owner's manual - the ways in which you learn, communicate and relate the best.

It's impolite: You may be going against the etiquette you use at dinner parties, church or the courtroom - but therapy doesn't play by those rules. The purpose of this time is better understanding your thoughts, feelings and behaviors, which occasionally means talking about issues you would overlook in other social situations, particularly the ones that create a visceral reaction in you. I'm not suggesting you mock or act blatantly rude to your therapist, just say what's on your mind.

Vented already: Jane had plenty of gripes about me, but after venting to her friends for a week the issues didn't seem as pressing. Sure, she was still upset, but by blowing off steam the issues weren't urgent enough for her to confront me. Sometimes it's best to keep the energy of these minor frustrations between you and the therapist, rather than dissipating them by running them by the committee. Certainly, for major conflict (to be discussed in a future blog) a second opinion would be warranted; but the minor frustrations mentioned here are best handled directly with your therapist.

Ignore it, it'll go away: They say the little things that bother you early in a relationship tend to grow into big things later on. This is true for all relationships. Whether it's your second session or 200th, if there's something bothering you I encourage you to bring it up.

I already did: You've already told your therapist you need to end on time because you have to return to work, but he keeps letting the session run over. You're afraid to bring it up again because it feels futile. If it's a problem that is getting in the way of your work together, I suggest you bring it up again. Therapists are human, with as much fallibility and forgetfulness as the next person. There's a chance this reminder might help you get the desired outcome, or perhaps you can find another solution together (set an alarm?). Either way, you've taken care of yourself by talking about it, as uncomfortable as that may be.

Need help getting started? Try this:

"I'm a little uncomfortable bringing this up, but when you _____, I felt _____."

Hopefully you'll see it's not so bad. At the very least, you've spoken up, faced a fear and gotten something off your chest. At best, you've taught the therapist something about you, initiated a change in the therapy, and created an opportunity to learn more about yourself.

Shouldn’t psychotherapy make me feel good?

Ryan Howes, Ph.D. — Sat, 05 Jul 2008 15:50:11 -0700

It's the end of our third session and Jane gets up and walks to the door. After the customary "see you next week," Jane adds:

"Thank you so much for these sessions. I really feel a lot better afterward."

Uh oh.

A common misunderstanding about therapy is that its function is to help us "feel better" each week. Many equate psychotherapy with the day spa where we enter with tension and leave feeling relaxed and refreshed. Sometimes this is the case. But much of the time we leave with a greater understanding of the gravity, severity and prevalence of our issues. We think we have one problem but realize we have five. This doesn't always feel better; it can feel much worse.

That's why my response to Jane's comment is "uh oh." If she's expecting to always feel good after her sessions, she may be setting herself up for disappointment.

In the first few sessions the therapist and client are getting to know one another and explore the issues. If there's a good connection between them, clients often feel relieved, supported and hopeful. The issue they've held inside is finally being addressed, the therapist seems to care and understand without judgment, and there's a real sense that progress can be made. This feels good.

As the work continues, things often get worse before they get better. In his book The Heart of Psychotherapy, psychologist George Weinberg writes:

"In the course of psychotherapy, we help the person see the generality of his problem...As patients see, 'This problem is more pervasive than I thought,' they are occasionally disheartened somewhat...And to the extent that the problem was broader than they thought, the gain is greater when it is resolved." (p. 18)

Jane entered therapy to better understand her difficulty with dating. She describes herself as a "serial monogamist" who dates men until her suspicions lead her to believe he is untrustworthy. In these first three sessions, she's been able to tell her story, vent a bit about her lousy relationships, and feel that I am working to understand and assist her. She truly feels better after the session because she was heard and supported. But our future sessions may go into uncomfortable territory. We might discover that her suspicions have cost her many friendships as well. We could find that painful events in her childhood made trust very difficult to maintain. We might even find that her issues extend to herself - that she has a hard time trusting her own thoughts and feelings, and she projects this onto other people. These harsh realizations won't leave her with a spring in her step. This is the "disheartened" feeling Weinberg mentions.

I've seen many clients get to this point in therapy and decide to stop. We've opened several cans of worms and they simply feel overwhelmed. I don't blame them for feeling this way, but encourage them to stick with it. This is the pain we endure to achieve the gain. I equate this process with a person organizing a long-forgotten basement or closet - when you start pulling stuff out it's easy to feel overwhelmed by the clutter and sheer volume of material. Leave it now, and you're stuck with a big mess on your hands. But push through and you'll see gradual progress and eventually a more organized space.

I believe the goal of psychotherapy is to help each client grow in awareness, understanding, responsibility and acceptance. Rather than helping her "feel better" an hour a week, I hope therapy helps Jane know who she is, why she does what she does and feels how she feels. I hope it helps her realistically appraise her strengths and limitations, giving her the freedom to choose relationships, jobs and activities that bring her joy, accomplishment and contentment.

So in the end, I also hope therapy helps Jane feel a lot better. But I recognize we have some hard work to do before we get there.

Fundamentals of Therapy #3: The First Session

Ryan Howes, Ph.D. — Sat, 28 Jun 2008 11:53:44 -0700

We've covered who goes to therapy and how to find a therapist, so welcome to your initial appointment. I hope to demystify what can be an anxiety provoking experience and help get your treatment off to a good start.

I'll assume you've done your research on the types of therapists and therapies available, you've made some initial contact with the therapist to get a feel for his/her style (possibly even "test driving" a few with questions over the phone or in person), you've chosen your top pick, and are ready to get started. This first session is important for setting the tone of your work together - the more involved and collaborative you are, the sooner you'll reap the benefits.

Due to some necessary formalities and introductions, the first session doesn't look like those that follow. Here's what to expect, and how to make the most of the time:

Logistics: If you haven't been there, allow for enough travel time to find parking and locate the office. Therapy offices don't often stand out like Starbucks, they usually have a low profile. The waiting rooms tend to be small and comfortable with a few chairs and magazines. There may be music, a fountain or a white-noise machine to mask voices from the office, protecting the confidentiality of clients inside. Sometimes offices have a receptionist, others might have a "call light" switch - flip this to let the therapist know you're here.

***While you wait, want to guess how long your therapist has been in private practice? Take a look around the waiting room - we don't redecorate very often. A Miami Vice theme? Probably a mid-80's graduate. Wicker? 70's. Pottery Barn could be a recent grad or someone who actually does redecorate.

Forms: You might want to show up 10 minutes early to read through and sign any paperwork. These typically include consent forms, a notice about the confidentiality of treatment, any policies the therapist has about cancellation and billing information. You can request a copy of these forms for your records.

Introduction: You're sitting in the waiting room, your heart is pounding with anxiety and anticipation and the door creaks open. In comes your therapist, looking vaguely similar to his Find a Therapist photo. A handshake is typically offered, along with the standard: "Did you find the office okay?" We all ask this.

Business: Your therapist may want to go over the consent form with you and discuss payment. This is a good time to set a precedent for future sessions. Pay and take care of other business (session times, cancellations, insurance, etc.) at the beginning of the session. This helps prevent the awkward we-just-had-a-powerful-moment-and-now-I-need-to-write-a-check-while-crying scenario in the final minute of the session.

Your Story: With business aside, the therapist will ask something like: "So, what brings you today?" Here's where you give a thumbnail sketch of your story. Don't plan to give a full autobiography, just a rough draft. You'll have plenty of time to fill in the gaps. You can go about this however you'd like: starting with where you were born and moving forward, or starting with your current issue and moving back. Either way, your therapist will help by asking questions that help her understand who you are and what problems you're facing. Here's where you'll really get a feel for therapy - how it feels to talk about yourself, how well she pays attention and how comfortable the conversation feels.

Feedback: In the last few minutes of the session, the therapist may want to summarize what you discussed and give some feedback. According to his experience and therapeutic orientation, he may want to let you know how he conceptualizes your story and how the two of you might go about addressing the issues. He might ask if you have any particular goals you'd like to achieve through therapy. This is your time to begin collaborating on a plan.

Time's Up: You don't need to watch the clock, your therapist will let you know when the session is over. Hopefully, by this point you've worked through any first-session anxiety, you've got an idea of how the process works, you've been able to tell some of your story and you're beginning to formulate a plan of action with your therapist. You can cover a lot of ground in 50 minutes.

Reflect: I suggest you take some time after the session to think about what was said and how you felt. Were there any red flags? Did you feel comfortable being open and honest? Were there questions you forgot to ask, or info you weren't able to share? What do you want to talk about next time?

If your first session went well, great. If not, you can either choose another therapist or discuss your concerns with your current one. You're not stuck in this therapy, not now, not ever. If you decide therapy isn't right for you at this time, or if you get a bad feeling about this therapy, you can always call and cancel further sessions. Hopefully, there's a good match from the beginning, and you're quickly getting the help you need.

Small Talk in Therapy

Ryan Howes, Ph.D. — Tue, 10 Jun 2008 11:53:48 -0700

Jane bounces into her session.

"How are you? How's your week going? I guess that's your question, huh?" She smiles and stirs her coffee. "Can you believe this weather? I mean, wow. It sure is hot." She settles into her chair. "Did you see the Laker game Sunday? I don't know what's wrong with them. If they don't start playing D, the Celts are gonna sweep the series. Like Boston needs another championship. Is that a new shirt?"

Jane is making small talk. She's chitchatting, chewing the fat, shooting the breeze and/or bull. Astute insight into the NBA Finals aside, Jane seems ready to discuss everything except herself.

In the vein of client empowerment, I've got three things to say about small talk:

1. Clients are allowed talk about anything they want
2. Clients should never feel obligated to make small talk
3. If it becomes a major part of therapy, there could be a problem

You're welcome to shoot the breeze with your therapist. It's your dime and your time, you can talk about anything you choose. Weather, sports, fashion, politics, TV shows, trivia - all sections of the newspaper are fair game. Some therapists may ask why you've chosen today's topic, or suggest other items to discuss, but you don't have to bite. Small talk is not forbidden, you can steer the boat in any direction you'd like.

Having said that, chitchat in therapy can be a colossal waste of your time and money. Let's say you banter for the first 10 minutes of each session, you pay $100 per session, and you're in therapy a year. Your casual conversation will cost you around $1000 for the year. In our inflated economy, that's like 12 tanks of gas or two tickets to a Laker game. It's also eating up the equivalent of 10 sessions of your precious time that could be spent addressing your issues.

Some clients believe they need to make small talk. It's tempting to apply the same social customs from other relationships to therapy. When you enter a store or meet someone new, it's appropriate to break the ice with harmless banter. But therapy works differently. No therapist would be offended or consider it impolite if you dismissed the pleasantries and got right down to business. So why do some feel it's necessary to kick the session off with small talk?

Perhaps they feel the need to make small talk for the therapist's sake. They might feel sorry for this isolated professional, alone in their office all day with no one to chat with at the water cooler. Even if this is true, it's not your job to take care of the therapist's feelings. Therapists need to find time to meet their social and support needs through friends, family and colleagues outside their work. We require socializing as much as the next person, but not at your expense.

Some clients feel their own socializing needs aren't met outside therapy, so their session becomes their own water cooler. It would be worthwhile to address this in therapy - the lack of a social or support network could be an important issue to tackle.

More often, small talk is related to the discomfort of starting the session. As I wrote last week, it can be difficult to downshift into therapy mode when you're rushing in from the busyness of life. Small talk provides a transition - we're together, we're talking to each other, the content is light and non-threatening. The chitchat can help you relax, reconnect with the therapist and prepare you to dive into deeper issues. Each are important, but there may be a more efficient way to accomplish these same goals.

It can also be a way to stall. It's no secret that some work in therapy is painful and laborious. One part of you knows you really need to dive into difficult material, while another wants to kill time with chitchat to avoid the sting. The desire to avoid pain is human nature and nothing to be ashamed of. But sometimes you need to tolerate pain to experience growth and relief.

I encourage you to roll up your sleeves and make the most of your therapy session. Save the banter for other acquaintances and get down to business in your therapy. But like I said: it's your choice, your time, your money.

If you feel stuck in this pattern of chitchat, here are a few pointers:

Show up early to collect your thoughts, relax and think about what you'd like to address in the session. This might allow you to downshift before entering the session.
As you relax in the waiting room, ask yourself: "What did I notice about myself this week?" Your answer could be the opening line for your session.
If you find yourself in a gabfest, ask yourself if there's something you're avoiding. Don't be surprised if your therapist beats you to it.

Therapy Constipation

Ryan Howes, Ph.D. — Sat, 31 May 2008 19:18:50 -0700

Jane Doe looks concerned.

"Okay, I'm here. We've talked about my history, my family and the symptoms I'm experiencing. But I'm stuck. I don't know what to talk about next. What should I say?"

If you've ever spent time in therapy you can probably relate. In one session things are moving along fine - you're discovering things about yourself, flashbulbs of insight are going off all around you and the conversation between you and the therapist is rolling at a comfortable pace. There are so many thoughts and ideas coming to mind you wish you would have booked a double.

And in the next session, you draw a blank.

You're not sure where to start. None of the topics you covered before seem very interesting, and nothing new comes to mind. You start to worry that you're wasting your time and money. You ask yourself if maybe therapy isn't working, or if you've done all you can and maybe it's time to stop. You even worry about disappointing your therapist; that he or she will start to see you as a difficult client. While these thoughts race through your head, you're aware of the ticking clock and the awkward silence in the room. Part of you wants the session to end mercifully soon, while another part wants to figure this out and get back to the good work you were doing last week.

Ever been there? I don't know if I'm the first person to use the phrase "therapy constipation," but that's what I'm calling this phenomenon. The emotional, relational, intellectual information is in there, it just won't come out. Those of us sitting in the other chair might call it "resistance" or a "defense", but that could be an overstatement. You may just need the emotional equivalent of a bran muffin to get the system moving again. Here are some tips I've found helpful for occasional therapeutic irregularity:

Talk about it: Rather than trying to push away the "stuck" feeling and trudge through other material, try talking about it with your therapist. All those thoughts and feelings mentioned above are worthwhile therapeutic topics. Furthermore, since you are experiencing them at this very moment, you could gain some insight into why you feel blocked. Does this stuck feeling happen in other settings? Could it be that "stuckness" serves some function in your life, protecting or sabotaging you somehow? Is there a problem between you and the therapist that needs to be addressed? Why feel stuck today? All worthwhile material for a session.

Take the whole hour: Many clients show up right at their appointment time; straight from work, traffic, and trying to find parking and are understandably unprepared to dive into their psyche. It's hard to downshift into therapy mode when you're in a rush. Instead of the typical 50 minute therapy session, plan to show up 10 minutes early to sit with yourself, relax and collect your thoughts. I'll take it a step further and suggest you don't dive into the magazines in the waiting room. That's right, I'm saying don't get lost in the very magazines we leave for you. Try sitting without distraction for a few minutes - what you need to discuss in session may come to you.

Journal: A common statement I hear from clients: "Oh! I had something I wanted to talk about today but I can't remember what it was." Pick up one of those cool journals from the bookstore, carry it with you and jot down important thoughts, ideas or questions that come to you during the week. It doesn't need to be a long, drawn out "Dear Diary" entry each day - just a few words or sentences will do. It's particularly useful to journal after your session to help record the insights you just learned before they evaporate in your busy life. Another bonus comes after you've been in therapy for a while and re-read some of those early entries to see your progress.

"What do I want?" and "How do I feel?": Most therapy sessions boil down to these two essential questions. They can serve as a "home base" for you during sessions. If you reach a moment where you feel stuck and don't know what to say, you can always come back to these questions. You can even say them aloud - it will help the therapist know what you're thinking about.

Sit with it: My Zen-friendly readers and fellow bloggers might know what I'm talking about. So you find yourself temporarily stuck, not sure what to talk about. Rather than push to fill the space with words, how about you just sit in silence for a little while? Silence in therapy is not uncommon and is nothing to fear - if you and your therapist can handle just being quiet, you may find yourself relaxing and eventually the words will come. Some people have such a strong need to perform and achieve that doing nothing for a few minutes may be the hardest (and most enriching) work they do in therapy.

The bail out: Occasionally, Jane will want me to bail her out: "I don't know what to talk about today - could you just ask me questions for a while?" This isn't a bad thing, Jane recognizes her dilemma and is asking for help. Sometimes I'll oblige. But my chances of asking precisely the right question to address what Jane needs to talk about today are slim. We could fill the time with me asking Jane about the issues I think are important, but then the session becomes less about her ideas and more about mine. On her drive home she'll be thinking, "Well, that was interesting, but what I really needed to talk about was ______". I encourage clients to take the time to assess their own needs before resorting to the bail out.

I guess you could say the first five are bran muffins and the bail out is a harsh laxative. It's helpful in times of great discomfort, but use it with restraint.