Nine Ideas I Wish I Had Known as a Beginning Therapist

by George Rosenfeld, Ph.D.

As a baby boomer psychotherapist approaching retirement I have been thinking about the need to preserve some of the useful ideas that I fear are in danger of being lost to the next generation of therapists who are being trained to provide short-term, evidence-based treatment. If I had honored these ideas earlier in my career, I would have been a better therapist. CAUTION: Some of these ideas may be untested or untestable by research.

Become aware of your countertransference reactions. Psychotherapy involves a struggle to notice and manage the therapist’s personal feelings so they can be therapeutically helpful. Defined broadly, countertransference refers to our conscious and unconscious reactions that are awakened by the experiences and feelings of a client and our interaction with the client. All our        responses in therapy are, in part, influenced by countertransference. As Anais Nin put it, “We don’t see things as they are. We see things as we are.” So, wherever you go, you bring yourself along; and you open your mouth and your Mother comes out. Our understandings, assumptions, and feelings during therapy are filtered through our needs, expectations, limited experiences, past dramas, life scripts, lessons taught by previous clients, and the role models living in our basement. Like Whack-a Mole, our needs and biases keep poking up and can interfere with our attempts to be present and objective; so that instead of reacting to the client and what is happening in therapy, we may be responding to other situations and less attuned to our clients than we think we are.

For example, presently, but particularly as a beginning therapist, I worried about being competent. This led to anxiety, secrecy, pushing clients too hard and fast, not pushing enough, and being too goal-oriented. This worry is fairly typical in beginning as well as experienced therapists. Now I am more comfortable sharing my doubts about appearing and being incompetent. To become competent, therapists would do well to nurture the ability to share their worries about treatment with colleagues. It is stressful enough dealing with clients in pain. Hiding ones doubts compounds stress and contributes to isolation. This is a profession that requires self-care and learning from mistakes; and consultation facilitates these practices.

Have realistic expectations for change.   As a beginning therapist I had unrealistic expectations for treatment: I intended to fix and to cure. Now I seek doable treatment goals. Today therapists are trained to expect changes after brief treatment, and they read about legendary therapists who provide treatment techniques that generate major changes in one session. However, our interventions are not as powerful as outcome studies would lead us to believe. There are many reasons for the divide between treatment and research. A main one is that the research on therapy interventions is based on populations that are different from treatment-seeking clients. Typically research studies exclude subjects who have severe or multiple psychological problems, co-morbid physical problems, substance abuse, suicidal ideation or intention, a personality disorder, or are an ethnic minority. In other words, they exclude clients. 

It is naive to feel we should be able to understand and help everyone who walks into our office irrespective of their age, intelligence, the flexibility and rationality of their thinking, sexuality and gender; their cultural, medical, neurological, genetic, ethnic, spiritual and educational backgrounds; their social class; the intensity and duration of their problems; their motivation to change; their abilities to handle anxiety; and their resources to overcome the obstacles to regularly participate in therapy.     

Often I told clients not to expect magic, but it took me years to understand that this warning applied to me as well. I know how difficult it is for me to change myself, my habits, fears and expectations, even when I am highly motivated to change them. Imagine how difficult it might be to change someone else who may lack motivation, knowledge, and emotional resources, and be embedded in an environment that does not support or even frustrates change.

Seek feedback about the session, course of treatment and the state of the therapeutic relationship. To improve outcome one of the most powerful things a therapist can add to what they already do is to seek feedback from the client. This is very scary to do. Bravery is required to ask clients if the session was helpful, if we covered the things they wanted to talk about, if we are going in the right direction, how they are feeling about the therapy and the therapist, and if we are making progress. Seeking feedback conveys an interest in responding to the client’s dissatisfactions and prompts the client to voice them.

In business, success and failure can be objectively measured in money, while in psychotherapy we rely on subjective reactions. I can be a poor judge of how treatment is going and have been surprised by the client’s feedback. For example, I had been seeing an anxious parent for Child Guidance for over six months and was quite pleased with our progress. Because of her anxiety I avoided silence and kept our conversation going by bringing up issues when the conversation stopped and she failed to initiate another topic. Probably because I expected a response that indicated her satisfaction with treatment, I asked her if there were issues that she wanted to talk about, but did not have the opportunity. She said there were. This feedback changed my treatment approach. We were able to identify our contributions to the problem (her anxiety and lack of assertiveness and my controlling the session) and concluded that we needed to share more equally the responsibility for generating topics for discussion.

When I have asked clients what has been helpful they often surprise me by saying things such as: “I loved the time we laughed about…” “You didn’t get mad at me when I said…” or “I didn’t realize I was depressed” or “I knew you cared when you…” Usually their responses are unrelated to the treatment techniques and interventions I have been crafting. Therapists can be unaware of their most therapeutic as well as damaging responses.

Client feedback can help to avoid the scenario in which the client leaves treatment and the therapist does not know why and did not have a chance to deal with the client’s frustrations. Without feedback, it is easier for ruptures in the therapeutic relationship to go unnoticed and sabotage treatment. Repairing ruptures can be one of the most productive events in therapy, because ruptures can provide an opportunity to directly identify and correct the client’s transference distortions.

Don’t beat yourself up if you miss dealing with something in a session.  Now I am less upset when I notice an error, because I expect that another opportunity will come around again. I want to focus on repetitive patterns that are so robust they innervate many aspects of the client’s life. If what is missed is important, then there will be other opportunities to deal with it. If the issue does not reoccur, then it may not have been important.

I am not immune to missing opportunities to provide perfectly timed interpretations. I used to think the best therapy involved fostering insight that would lead to behavioral change. But often intellectual understanding is not necessary or sufficient to create change. And it is difficult to know when the client is ready to accept interpretations. Often they are most ready when they are close to discovering it by themselves and our role may be to support this process of self-discovery. Many times clients are most able to benefit from an interpretation after they have made behavioral changes.  

Capitalize on both horizontal and vertical therapy.   Jay Haley divided psychotherapy into horizontal and vertical. He described vertical time as greeting the client, walking from the waiting room to the office, and getting settled prior to beginning “the therapy.” Alluding to Freudian psychotherapy during which the client lies on the couch in a horizontal position, Haley characterized the part of the hour labeled, “therapy” as horizontal time. When “the therapy” stops, the client returns to vertical and pays the bill, talks further about different content, and is accompanied to the waiting room where doorknob comments are made. Haley suggested that perhaps the most powerful things get said in vertical time when the defenses are down; participants are in less formal, rigid and artificial roles; and the client might be the most revealing and receptive to the therapist’s comments. I heighten my observation of the client and make interventions during the less formal, vertical time. Sometimes I end the horizontal time early and stall in the office to extend this less structured vertical time.

A corollary to this concept involves slipping information in under the defenses by placing it in subordinate clauses. For instance, saying, “Meeting people can be scary, even for an approachable person like you,” can implant the thought that the client is an approachable person. The client might not challenge the thought because his or her attention is focused on how meeting people can be anxiety provoking.

Develop a menu of useful interventions to draw from and keep evaluating their effectiveness.   I frequently ask the Miracle Question. To motivate clients and help them identify reasons to change I often ask them what their life would be like if they did not have the problem they are working on. I look for the client’s past solutions and see if we can build upon them. I seek opportunities to normalize, reframe and externalize problems. Most therapists have their personal favorites.            

Don’t buy the medical model. It assumes a passive client and a beneficent therapist who provides the intervention of choice that causes the change. This model ignores most of what is therapeutic. It marginalizes the contribution of the two most powerful forces in psychotherapy: the therapeutic relationship (Lambert & Barley, 2001) and the client, each of which is sufficient to create change as well as to derail treatment. The medical model minimizes the client’s role in fostering or limiting change, because it does not adequately focus on the client’s level of motivation and capacity to change that can determine outcome. Some clients are so motivated to change that the therapist’s role is to keep out of the client’s way. Some clients cling to irrational thinking and are so defended and embedded in their patterns that change is elusive. Interventions are the most powerful when they are tailored to the client’s goals and motivation to change. The effectiveness of interventions can depend on the clients’ anticipation that an intervention will be of benefit because it makes sense to the client. That is, the intervention matches the client’s theory of change and beliefs about the causes of his or her problems. My greatest error in therapy has been to offer interventions before the client is ready to use them.

Furthermore, the concept of a treatment of choice for particular problems may not be supported by the research. The Consumer Reports survey (“Mental Health,” November, 1995), the National Institute of Mental Health (NIMH) Treatment for Depression Collaborative Research Program (Elkin, et al., 1989), and meta-analyses of comparisons of active treatments (Luborsky, et al., 2002; Miller, Wampold, & Varhely, 2008) indicate that there is not a significant difference in the effectiveness of different treatments based on different theoretical orientations. Because the difference between therapies is small or nonexistent (about one-tenth of a standard deviation of the difference between treatment group means), the sources of change appear to reside in the factors that effective treatments have in common, not in the unique aspects of each treatment.

Go slow. Especially at the start of treatment I feel a pressure to initiate rapid change and clients wanted me to help them right away. But for some clients their symptoms protect them from discomfort that can overwhelm them. Their symptoms may be defenses that they need. We should not ask them to abandon a lifeboat until another comes along.

I hesitate to challenge established defenses until clients are armed with the skills necessary to handle new anxieties. Before being exposed to anxiety, clients may need the skills to handle the anxiety generated by change. These stress-management skills might include being able to: 1. Self-soothe (breathe, deep-muscle relaxation), 2. Pace (regulate stimulation in session and in life) 3. Use grounding skills, and 4. Obtain and utilize social support. Also, it is important to make sure they leave the office stable enough to deal with their world.

I have had clients who thought their role demanded they reveal their past traumas early in treatment.  In the process of trying to be a good client, they exposed themselves to more anxiety than they could handle and they left the session in a dissociated state. In ignorance I thought we had had a great session because they shared so much, and I was surprised when they failed to attend the next session. I should have slowed them down, supported their defenses, taught coping skills, and more actively managed their exposure to anxiety.

I want to monitor the client’s anxiety and keep it at a level that motivates him or her to productively participate in treatment. If clients do not have enough anxiety they are probably not motivated to change. If they are too anxious, they cannot benefit. John Briere conceptualized regulating the client’s anxiety in terms of keeping the client within “the therapeutic window.”  He described effective treatment as needing to take place within the space between (a) too much anxiety when the client’s self-capacities are overwhelmed with affect so that the client cannot benefit from the session, and (b) not enough anxiety when the client lacks motivation and the therapist provides support in a way that interferes with needed desensitization or the processing of anxiety-provoking material.

Use active-listening as a primary and fallback strategy. When I am not sure what to do I channel Carl Rogers and try to provide emotionally attuned reflecting of the client’s emotional state. This is not easy. It can be a challenge to remain present and focused on the client in the face of the feelings the client elicits. Attunement is not totally expressed through language, but by almost instantaneous responses of tone, gesture, and posture similar to the way parents mirror and soothe their pre-verbal child. Therapists who have not experienced this type of caring in their life may find it more challenging to provide this to their clients. It has even been speculated that they may not have fully developed the neurological structures to easily provide the accurate empathy that helps clients to feel seen and accepted.  As we help our clients to build these neurological pathways, perhaps we are building them in ourselves.

Conclusion: Irrespective of our stage in our careers, we can strive to be more effective psychotherapists if we cultivate the abilities to listen to and respect each client and his or her theory and pace of change; manage our anxieties; foster hope, reasonable goals, expectations, and a therapeutic relationship strong enough to allow uncomfortable emotions to be processed; and develop the courage to pursue self-awareness and seek feedback from our clients.

Dr. Rosenfeld is a Clinical Psychologist who teaches at USF, Sacramento. He is the author of Beyond Evidence-Based Psychotherapy: Fostering the Eight Sources of Change in Child and Adolescent Treatment. Routledge, 2009.  He can be reached at geo.rosenfeld@gmail.com

References are available from the author upon request.

The views expressed in the Special Feature Articles do not necessarily reflect the Sacramento Valley Chapter of CAMFT or CAMFT. They should be understood as the personal opinions of the author. No information in this articles will be understood as official.  Other views and commentary are welcome and will be published as long as they are respectful and stick to the topic.

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