Good Practice, Good Care for Professional Psychotherapists

Where Have All the Clients Gone?

2010-01-26T09:13:00.000-08:00

Well, they have not gone far. Not all of them anyway, but a few therapists are noticing that some clients have strayed away over the holidays and not come back. And we are talking about this here at Good Practice.

Some questions we've been studying are:

What disrupts treatment?
What gets in the way of clients telling us directly if they have a bad feeling about us, or about the work?
What if we are more interested in doing the work then the client is?
What is subjective countertransference and what is objective countertransference, and how do they affect our work?
What can we learn about ourselves to help clients to stay and do good meaningful work?

And really...when someone is coming on a regular basis and then they don't want to schedule again, or they say..."I'll call you..." What do therapists do? How do therapists decide when to help a client to stay and when to let go. And how do we do this?

What exactly is the balance between rejection and intrusion? Between holding onto the work and going deeper, and following the contact, the surface presentation that a client makes?

First things first. And case by case we think. We must know our own intentions. And we must know our fears. Many therapists I know are ruled, in some way, by their own fear. They fear being too forceful. They fear being solicitous. Or being rejected. In an effort to not act on their own fears, they sometimes do the opposite of what might really be called for.

We do filter things through our own lenses and experiences. One therapist in our groups terminated treatment with her own therapist, who then called her every few months to see if she wanted to return. This gave our colleague the idea that her therapist was pursuing her for money, or because she was bored, or needy. "It gave me the feeling I was just a paycheck to her," she told the group, "and I don't want to do that to my clients."

So how do we know what's really going on when clients disappear? Look back, we think. Look back and see if possibly we've hit the wrong note. If we may have implied that they have to talk about their father when they don't want to or are not ready. Or perhaps they thought that we were sick of hearing about that relationship that ended three years ago, and they should not talk about it anymore. Perhaps they don't even know the source of their discomfort. Of course clients project their feelings onto us, but we have to be good catchers. It helps to study the feelings, and see who is tired of what and why.

Are we understanding of client's narcissism? That they are not trained to notice us, to know that we exist. Our existence may be frightening to them. The connection may be too strange, the relationship not understood. We may have to tend to this. To help them talk about it, about us.
Do they feel too cared for, or not cared for enough. We never really know the effect we have.

Sometimes, not pursuing a client who leaves can feel rejecting to the client. While clients need to be able to say everything to us, sometimes they need to go at their own pace. We may be going too fast. One client I know recently said to me, "If you keep helping me, I will stop coming." So we talked about how I was helping her, what I should stop doing and what might be a better way to talk.

Talking is, after all, what we are here to do. It is still curative, still productive, still life giving and relieving.

Its hard to know which resistances are treatment destructive and which are not. And when to join such resistances and when not to. Its hard to know who is feeling bad and about what. But we study. We ask. We can even prevent. We can ask sometimes, about how the work seems to be going. We can remind clients about the the five topics, which includes the treatment itself, that can be discussed in treatment, so that we can create a space to talk about everything, including everything about the treatment.

There is an ebb and flow to private practice. Things shift; They are fluid. Life is fluid. We have to talk. We have to take good care of ourselves. We have to take note of our fear of being abandoned. Our fear of being disrupted. Of being bumped around. We are supposed to be trained to study and tolerate our own feelings. To use them to advance our good work. We cannot always call it right. There is so much ambiguity in our business. But we can let people know they can tell us whats on their mind. We can build our resiliency and our own knowledge and we can stick together and advocate for our work, on its own merits, and for its own sake. We can hold the hope and the value of what we do, and not let go of what we know to be true: that its worth it.

Say It Here

2009-11-17T09:23:00.000-08:00

"If I can't bring it up here, where can I?" P.L. , psychotherapist, Illinois, about our groups

True and yes. Our groups are where to bring it up. Its amazing how much we wish we could say but keep to ourselves. And how useful it always turns out to be. To talk, for sure. But also the exchange of ideas, the practice studying cases and feelings, transferences and doubts all adds up to better practice.

What's been on everyone's minds here? Fees, always and still, a hot topic. Missed sessions, insurance issues, and erotic transference. And appreciation for the continuum of following cases over a longer period of time and getting to know ourselves and the dynamics of treatment in new and deeper ways.

It feels good to work together, to connect and to talk.

Group Success, Practice Success and What If it Feels Like Selling? ..... Resisting Resistance

2009-10-20T09:15:00.000-07:00

No doubt about it, group works. I am just reflecting back on the last few months in some of our professional peer supervision and consultation groups. We have indeed been busy. Connecting, talking, analyzing, laughing, schmoozing. Presenting issues, cases and new ideas. And we have been progressing. Somehow, someway, group works.

What we have been doing: We have been talking about everything. And we have been studying what we want, professionally, personally, sometimes, and what's in the way of getting it. We have been talking about cases, and about what feelings come up, and what to do with them.

We help each other talk. Together we worry. We find relief. We wonder if feelings are contagious. Is ambivalence solvable. What are we afraid of and why. Can we, do we, how do we, know what feelings are in the room, whose are they, and what do we do with them? We are never out of things to talk about. We are awake, interested and engaged. Okay, sometimes we are not, but then we talk about that too.

Some participants have doubled their practice. Some have started groups of their own, for sufferers of chronic illness, for women in midlife transitions, for women considering divorce, for parents of special needs children. And more.

We have moved forward through ambivalence, resistance, fear, edgy feelings, and even good ones, that might get in the way of us connecting and growing.

What happens if we ourselves don't know if we should stay or go, in our groups? Or join one? Or start our own therapy or supervision. And how does this translate into our work?

So this is what's come up recently: If we help a client to stay with us, are we selling? And by the way, if we were, what are we selling, and what would be wrong with that? Why do some of us feel like we should not "sell" therapy? And why do some go so far as to readily agree with clients or group members who want to leave? To defend against their own wish that the client stay?

What's the problem really? One therapist I work with tells me that she is so fearful that if one person leaves her practice, everyone will leave. That leaving is contagious. She says that the moment a client talks about leaving, she feels panic. First, she feels that she needs the money, and then she feels guilty for that feeling. Then she feels that she must not being doing a good job, and she feels bad about that. And then she feels that she should take care of the client and ignore her feelings. And she thinks she should be supportive of the client. So she goes along with the client's statement about leaving and the therapy ends.

Too bad, really. Maybe, of course, it was time to end. But we don't know. We don't know what was really bothering the client. We don't know if the client really wanted to feel wanted, and wanted to be helped to stay. We don't know if the client leaves other situations abruptly, without warning or discussion. We don't know if there is something amiss with the treatment that talking about would benefit the client enormously, helping the client to express discomfort safely and honestly, and be well received. And even to effect change and feel effective.

If we agree readily with resistance and go along with it too quickly because we don't know enough about our feelings and thoughts, we all miss out. We are selling, I suppose. We are selling life, and progress, recovery, maybe even intimacy, self knowledge, resiliency and substance.

But not everyone wants this, or is ready for it. Some folks need to stay where they are, for a while, maybe a long while. And then we can study that too. But we don't have to go along with the ending. We can hold out, even against our own feelings, or theirs, of wanting to bolt. We can check in about it.

And we can take ourselves to group, to therapy, to supervision and let ourselves be sold.

For your reading enjoyment, on treatment destructive resistance, and other good words, check out this blog by Jim.

Late

2009-09-13T11:48:00.000-07:00

In one of our supervision groups this past week we were discussing lateness. Of course we were discussing this because someone came in late. By about half an hour. What happens when this happens?

Well, different groups handle it in different ways of course. This group was silent for a few moments after our late-comer arrived. The person who was speaking stopped speaking, and then felt derailed (which we learned later). So we turned our attention to what kept our colleague from arriving on time. It was after all the elephant in the room.

Like all elephants, it appreciated being discussed. A few good things came out of it. First, our late comer fessed up that he was late a lot, for a lot of things. And that he was late for his own therapy and late starting sessions with his clients. And we got to unpack a bit what this might mean to him, to others.

Lateness, we decided, is a resistance. It has many meanings. Each individual, but many universal, and all human. On the possibilities list: perhaps lateness is a signal of protest of some kind, an unconscious communication from the self to the self about desire, or lack of it to be somewhere, or with some one. Or perhaps its a communication to others, that there is something they are missing or paying too much attention to. In one case I have worked with, a group member arrived late because she felt, after we discussed it, that she would otherwise not get any attention at all. She did not know how to ask for it. We of course have helped her to ask for what she needs more directly now. In another instance, a member was late because he feared being criticized by another member of the group whom he thought to be on the attack at times. He had to wrestle with himself to come to group at all, and could not find the words to articulate it, even to himself. But when his late entries were analyzed, we were able to understand this, and help him out.

One woman I know fesses up that she is often late as a way of drawing out pleasure or anticipation. She feels very stimulated by group and looks forward to it. In fact, she finds herself attracted so much so to another member, that she loves to draw out the waiting, To heighten the thrill, and rev up the feeling. All of this is only partially intentional, but bringing it to light expands our knowledge of ourselves, others, and our work. It gives us a deep appreciation for the unconscious, for humanity and humanness.

Lateness, while simplistically may signal ambivalence or conflict, is something we can really put to use in session as well as group. But there is some suffering. Late comers do not want to be late, really. One late comer shared with me that he knows much about his lateness, but he can't seem to stop. Its like an addiction. With him, in group, after studying for several months the possibilities, the group decided to embrace his lateness, to allow it, expect it and even love him for it. For some reason, he stopped coming late after that.

Not to be forgotten, the person who was talking when the late comer walked in, and got upstaged by the late comer, learned a few things too, about herself. She noted to the group that she easily gives up her time, to men especially. She stopped what she was saying about herself, and what she needed, and turned her attention to the late comer, as did the group, only noting it with very little time to spare at group's end. I wondered why she did not just keep talking. In fact, she was thoughtful about this and said that believes that she has to do a lot of listening and deferring to men while hoping that she will get a little back at some point. She is afraid to put her needs first, for fear of seeming selfish or depriving. She recalls getting all kinds of good feelings by catering to men and their needs, and giving them the good feeling of being heard and admired, attended to and important. Something she would like to learn more about, and perhaps use to work better with herself, her colleagues, her patients.

Much to ponder. And all toward our good work together. And a good reminder that all things can be studied gently, unpacked, talked about and incorporated into our practices and lives for the better.

Necessary Conversations in Therapy (Effectiveness, Outcomes and Research))

2009-06-08T21:00:00.000-07:00

I had the pleasure this evening of tuning into a teleconference call with Bill O'Hanlon. Bill interviewed Bob Bertilino on effectiveness (the research supporting it) in psychotherapy. A subject near and dear to my heart, and one which is very much on the minds of the therapists I work with.

Some great ideas, and CEU's to boot (alas, we all need them!), the call was chock full of exactly what I had been hoping for...info and research on the importance of being open to evaluating what we do and what works for our clients. (And what helps them stay long enough to get something out of our work, and to really discover what that might be!)

Admittedly, I am a bit research adverse, it seems like a different language to me, but I must confess that I found the discussion lively and to the point...we do want to be effective, and there is research to help us understand what is effective and what is not. I also have to admit that there seem to be many variables in our work, and lots of dynamics to figure in....but:

The bottom line: feedback from clients is essential. And so is the therapeutic relationship. And, my own take, feedback helps move the therapeutic relationship along. Bob's got a new book coming out on the topic and there are other good reads out there as well, and check out http://www.talkingcure.com/ for some more stuff on effectiveness.

The research, according to Bill and Bob, supports the value and effectiveness of therapy. (good news!) And interestingly enough, effectiveness is more about how we are in the room than what approach we use. Helping clients to be with us requires an openness to what their agenda is, how they perceive the treatment, and what they consider useful and important in their sessions.

Though the call offered up several good ideas, and a few (buy-able) tools to help therapists along in the evaluation process, there was not enough time to delve into all the reasons that therapists hedge the issue of feedback in sessions. (Hint to Bill for another call on the topic).

My thoughts: I think we tend to be a self conscious bunch (surprise surprise), hardworking and interested in good outcomes for our clients, and subject to the many feelings that abound in the treatment room, but many therapists are uncertain about how to introduce the topic of feedback to clients, and even more unclear about what to do with it. Some therapists wait for some kind of acting out or resistance to show up (lateness, not paying, not coming to a session, problems with fees), to address the issue of how the therapy is going for the client. Until some behavioral communication happens, a discussion of the therapy itself rarely happens.

Some therapists I know ask for feedback all the time. And they do it in object neutral language that creates a safe way for the client to talk about the therapy without thinking s/he will offend the therapist ("How are the sessions going?" "What are your thoughts about our work so far?" "Are you getting what you had hoped for from therapy?") . Others prefer to give written questionnaires, but the key is to have the conversation or do the evaluation early on and ongoing and in a way that fits nicely into the session.

It requires, I think, some bravery and commitment on the part of the therapist to really use feedback as a tool for information gathering and rapport building, or as we say in analytic circles, establishing a narcissistic transference. But we can use it to help us tailor our work. I would even say that we should study the effect that asking for and getting feedback has on the client and on the treatment.

And, as always, to help the client say everything to us, including everything about the therapy itself, to allow ourselves to be open to their experiences and to learn about them and what they need is not only key to building good therapeutic relationships and doing good workbut evaluating effectiveness and getting client feedback is (point made by Bill and Bob) an ethical responsibliity.

Lots of good things to study. A big thank you to Bill for the great call, (and for taking my question!) You can check out the call on Bill's site if you are interested. Well worth it!

Are Interpretations a Sign of Annoyance? (or the Fine Line Between Understanding and Critisizing)

2009-05-06T20:07:00.000-07:00

At lunch with a group of colleagues today, one of us was telling a very detailed story of some trouble he had gotten himself into, and his emotional pain over it. About ten minutes along in his tale of woe, the others, who appeared to be listening intently, began to interrupt him with interpretations. Now imagine how much fun this could be for a group of therapists, a few of whom are analytically trained, to want to jump in and interpret the problem for our troubled fellow. And each of us did have the idea that we understood something, more than something about this guy's problem, about his life circumstances, even his repetitions and defenses. We knew he had money troubles, and women troubles. A forceful, but slightly absent father. We knew he never felt very effective in business and struggled under the shadow of a talented and much accomplished brother.

We were sympathetic to him, though. We wanted to help. We wanted to be helpful. We wanted to help him understand something about himself, and about how he interacts with the world. And with us. And about how he may be inviting the world to interact with him. It was going to be, quite possibly, a good time for all.

Until one of us spoke up and ruined it. She put a big hand up and halted the help party just out of the start gate, and before it could reach a satisfying gallop. Before we could tell him things about himself, and the people he was in trouble with. The halt began with a question. "Is everyone transfixed by Sam's story?" We all nodded. "Is anyone feeling anything?" We stopped. We said no. We just want to help. And then....well, one of us said, yes. He was annoyed, a little, maybe. And another said, she was angry. And another said she was jealous. Sam seemed to have such colorful problems.

And so then, we departed from Sam's story a bit, and went to discuss why some therapists offer up analyses and other's don't. And what is helpful and what is not, and how to know.

One of us said that, come to think of it, when her own therapist gives her an interpretation, or an analysis, she feels criticized. She said that she thought she would feel understood, known, but that, in fact, the bulls eye evaluation of her defenses, her psyche, her emotional operations,was actually too keen, too accusatory, too unsettling. Instead of feeling understood, she felt undressed.

So, things to ponder. Sometimes telling someone something about themselves, or about who or how they are is akin to saying, "You know what your problem is, you...." And we would most likely not, with our therapist's hat on, do that. So we may have to be aware that sometimes interpretations to clients are simply a costumed way of delivering a punch. And the temptation to do so is a red flag that we, the therapist, may be experiencing a feeling that may seem intolerable to us.

True too of the impulse to be helpful. So what to do? We are suppose to be helpful right? So my friend who stopped us mid track admits that she does have her interpretive guesses about clients, but that she usually keeps them to herself. Or she wraps them into a question. That way the client can say yes or no. Or can consider it, and if it rings true, they can take to it, and if not, of its too unsettling and not supportive of needed defenses, they can reject it without shame or fear, or worry of hurting the analyst.

Sometimes, our job, I suppose, is to keep quiet. To study what's going on in the room. In ourselves. And not come forward with our ideas too fast. We may be missing out. Or having an impact that we are not aware of.

Our guy Sam, he was glad for the turn in conversation. He learned something about himself after all, and in a way that felt useful to him. Turns out that he learned something about how reality is not what it appears to be, and that when we slow down a bit, and ask questions, we can save ourselves a lot of heartache, and do much better work.

Wish List (Do What You Love)

2009-04-27T12:36:00.000-07:00

A psychologist friend of mine recently called to say that she was going on a professional wish binge. She has a solid practice, which she built many years ago by making good contacts, giving talks and teaching a few courses around her town. She does not take insurance, does not even give clients a statement to submit to insurance. She gives them a receipt and if they want a bill, they can make it themselves and she will sign it. She has not availed herself to the many good ideas of the practice building coaches or product development folks who are taking the practice of psychotherapy to new and broad based marketing levels, advocating multiple streams of income, selling e-books and audio downloads, phone coaching, etc. She happily practices straight forward psychotherapy, charges what she charges and makes fee adjustments rarely.

Already sounds good. So what's the wish binge. She now wants to work only with clients who are serious about working on their stuff. Who not only come on time, pay full fee and talk about their stuff, but and and who are thoroughly engaged, interested in their psyches and unconscious, and who are at least occasionally interested in her interpretations and analyses.

She does not want to absorb their bad feelings, or hear their complaints. If they want to vent, that's fine, but she does not want to have any hostile, angry, rebellious, demanding, frustrated, depressed people. And she wants progress. No chronic depression, unending anxiety or endlessly dissatisfied fighting couples.

She no longer wants to work with resistance. That's the wish binge. She wants the feeling of effective good work in each session. And if not, good bye. She does not want to have to broker all the feelings that come at her, that come up in more difficult cases. Or even in less difficult ones, where times are really tough.

Okay, I know. Maybe she is burnt out. Maybe she is dreaming. Maybe she's got too many clients. Maybe she is just a brat. Actually, at her own admission, she has said this is a possibility, but she has earned it. She has been working long and hard. And wants to be more selective, much much more selective about who she works with, and what kind of work she does.

I am always the first to say that we should not work with anyone we don't want to work with. We don't all have to work with anger or depression or fighting amygdalas. We can see if things are a good match when we meet someone initially. Only, the problem is, sometimes all the regression and progression doesn't show up so early on....

Its a freedom, though, I think. To be able to be choosy. To decide what degree of difficulty we want, and to say no when we would rather not encounter so much resistance. But resistance is unavoidable, largely, and I tell her this. To which she replied that while she appreciates my candor, she is going to do what she wants anyway. But she'll think about being more patient with the slow movers in her practice. And she will enjoy her wishes. She will even analyze them with her own therapist. Always a good idea.

Still and all, I like the topic. Going beyond all the "ideal client" marketing jargon and really giving ourselves permission to learn about what kind of work we really want to be doing. Not just what kind of client we want to work with or issues we want to hear about.

With so many options these days for how to practice and where to direct energy and spend time, I think it comes down to doing what you love. Really doing what you love. Really really. Figuring out what it is, even if it changes from time to time, and doing it. And weeding out the distractions and unnecessary tasks, and committing to pouring your heart into what you want to be doing and doing it. Brat and all.

P.S. On a slightly different note...Don't miss this article on Effectiveness at Psychotherapy.net

Phone Supervision: Unpacking Resistance

2009-03-24T19:13:00.000-07:00

Given the benefits of supervision/consultation in general, from a supportive ear, to a place to talk, reflect on cases, and unpack thoughts and feelings so that everyone thrives and progress is made...it is often a point of curiosity as to why more clinicians don't make supervision a regular part of their work routine.

In an informal survey of Good Practice Institute Phone Consultation Group participants, the following resistances to supervision were identified:

lack of time or money, feelings of general competency, and
the idea that supervision was only necessary for new professionals or for very difficult cases.

These ideas were further analyzed and understood to be, in part, a defense against fear of appearing incompetent or unknowledgeable, anxiety over professional presentation (how they will be viewed by supervisor or group members), fear of rejection by peers, fear of having to share personal information, fear of conflict with other members (in group supervision), supervisor, or group leader, a wish to be seen as the expert, attachment to a fantasy that others always know how best to work, or that they as the therapist ought to know how to work without having to reflect on their cases and feelings. Though many therapists do regard consultation as a necessity for good practice, and as normative for therapists at all levels of experience and skill, the same resistances to in person supervision apply to phone supervision.

Therapists also mentioned that with in person group supervision, feelings of competition and territorial thoughts often come up. Therapists may hesitate to share marketing ideas for fear of losing business, or giving away ideas that they feel are sacred to their own work.

Though with phone group supervision, where participants are usually from different parts of the country or world, and where the customer base for online or phone counseling is seemingly unlimited, feelings of market competition are lessened greatly.

It is interesting to note that therapists who do participate in supervision over period of time report a general feeling of satisfaction and progress in their professional growth and practices, as well as a feeling of "rightness" at having a space to say everything on their mind about the work they are doing. There is a reported sense of relief at being heard, validated and understood, and having their cases discussed in a proper and supportive fashion.

The use of the phone to access supervision serves to help resolve some the resistances in its convenience, efficiency, simplicity and accessibility to colleagues, consultants and learning opportunities without regard to geographic limitations.

As one therapist recently said, "I was hesitant to try it, hesitant to stick with it, but could now not imagine my work without it."

Staying Power (and a little more on money)

2009-02-17T07:37:00.000-08:00

In one of my groups recently, we were wondering about our own staying power. Not with clients, though that's certainly always a great topic. But our staying power with our own supervision and therapy. We were pondering the following question: How can we help clients to stay and do good work if we ourselves don't stay with our own supervision and therapy?

Somehow, I think there is an aura to all of this. Over the last fifteen years of my practice, I have had ups and downs in my caseload, a swelling of more difficult client issues, and times where things felt a bit lighter. But I always had the notion that my own supervision and therapy should remain constant, both to support my work and to benefit my clients. And of course to model good treatment consistency and cast my vote, feet first, for the benefits of staying the course and reaping the rewards. And I think it pays off.

What happens when we go to extremes or let our own anxiety dictate our decisions to stick with our own work? Do we speak the truth to our advisors about what is bothering us about our treatment or work with them? Can we remain committed to our own work even if our caseloads drop? It may very well be the overall, year in year out dedication to our own ongoing progress and work that will serve as the platform for a solid practice.

And a bit more on money, but not fees from Richard Trachtman,PhD: Beyond The Fee: Addressing Non-Fee Money Related Issues in Psychotherapy and Psychoanalysis. recently published in The Candidate: Perspectives from an Evolving Psychoanalytic Community.

Internet Infidelity

2009-02-04T21:06:00.000-08:00

Lately I am seeing a growing number of folks who are having virtual affairs. Interactive porn, email or IM relationships, fantasy exchanges. Some are pretty involved, and may even be considered addiction, while others fall more into the range of exploration. Most spouses who are using the Internet for either emotional connection, or fantasy are keeping it secret from their spouses, as are the folks who are engaging in more sexual or erotic based exchanges. Very few of the people I see are using the Internet as a couple to enhance their sex life, emotional connection or bolster the relationship, though certainly this may be an unconscious goal of some.

Most of the time, by the time I see the couple, or the hurt spouse, much pain has been caused. And most disclosure has happened "accidentally," by a spouse finding an email, site history or record of some kind.

First on the list of many hurt spouses is trying to figure out if the affair was ever actualized in person. In cases where it has not been, the question becomes: Does this count as being unfaithful?

While many of the feelings and the reactions of each spouse are mirrored as if these Internet affairs were actually physical (the need for details, loss of trust, anger, shock, pain, betrayal), and of the acting spouse (fear, remorse, shame, denial, anger, confusion), and while many therapists tend to look at infidelity of any kind as a symptom of marital discord, message sending, expression of some deep frustration, insecurity, anger or other feeling, the question becomes: Is online cheating really cheating? And how much does it matter when treating the fallout?

Given the enormity of any discussion on infidelity, I am just noting here that when we work with Internet infidelity we may have to take extra care to study the emotional experience of both spouses, both in the marriage and in the internet experience, and be curious in our work as to why this venue was the chosen one. I have unpacked many reasons, and think that couples can heal if the right approach is taken: understanding, interest, hope, for starters.

I welcome your thoughts!

More And On: Fees Fees Fees but The Love Is Free

2009-01-14T19:30:00.000-08:00

Still a hot topic. Money. And thanks to those of you who have contacted me about the earlier post on lowering fees. And to the good folks at http://www.psychotherapy.net/ for publishing a full blown article (that I wrote) on the topic. http://www.psychotherapy.net/article/lowering_fees_in_hard_times

I am reminded of practice building coach Casey Truffo's story that she tells about how she made many mistakes starting her own practice, how she spent money on the wrong things, got herself into debt and had to do a complete turnaround. (which she did). And I am reminded of the opening chapter to her book, Be A Wealthy Therapist which she electronically gifted to anyone who wanted it, "The Love Is Free."

And I quote:

"There is a parable about a kindly psychiatrist treating a very depressed
and lonely woman. Through tears, the client tells the therapist, “I don’t like that I
have to pay you to love me.” And the psychiatrist says, “You pay me
for my education, my efforts, my time, and my commitment. the
love is free.”

I think that some clients actually relish paying our fee. It makes them feel confident, competent and worthy. And it gives them permission to go right ahead and use the time as they like. To speak out all their stuff, demand, rant, cry and keep our rapt attention for the full 50 minutes. The fee gives them full out freedom to be a client. They are paying and can feel free to take the attention they came for.

So, I used to think it was just me. I felt so loved when someone "treated" to coffee, or did not charge me for something. As if not having to shell out some cash translated into me holding some special status, or being understood in a deep and profound way.

I have long been studying money issues and have come to understand that: a) Lots of people feel loved when they don't have to pay; b) And fear is often right next to love at the heart of money issues.

An old friend of mine used to say that money regresses us all back to infancy when we could just get our milk free and clear in the loving arms of mama. We could demand, and we would get fed. At least at the beginning. I think many folks really are afraid on both ends, of not having enough, and of having too much.

One woman I know gets an anxiety attack whenever she makes a purchase. Getting new couches almost sent her to the ward. Of course after having unpacked this with her therapist, many good nuggets of knowledge came out of it, such as learning of her fear of having more than her parents did, not being worthy, maintaining a feeling of safety in the familiar feeling of having less than than her sister. Lots of good stuff.

I think there are lots of ways this translates into practice for we clinicians. Not just on the receiving end, but the giving end as well. How many of us have feelings about paying our therapist? (How many of us are in therapy?) Do we invest in ourselves and pay our therapists and supervisors happily? Do we talk about it with them? Do we feel loved if they reduce their fee for us?

Or victorious?

So what's Casey's point. Right. Pays to invest in good information. Pays to be generous.

Mine: Pays to talk it. Always more to learn.

Spa vs. Therapy (The Risks of Lowering Fees)

2008-12-15T20:10:00.000-08:00

I suppose we are all hearing about the economy from at least some of our clients. In one of our groups recently, up came the topic of priorities. The topic of fees and money in our work is so central and worthy, and one that is (oh, forgive me) rich with possibilities for understanding much about the client, how they communicate, what they need and fear and how they deal with change. But of the many, many facets to the discussion of money and therapy, the subject of how we therapists view therapy was pretty fascinating.

Is therapy a luxury? Is it a necessity? Who decides this and how? Some of you tell me that you feel guilty charging your fee when people are having a difficult time. And some of you tell me you have difficulty paying your fee to your own therapist.

Should we help clients to come and stay? Is that too sales-y? Do we slide our fee? (Does the massage therapist?) Do we really believe in what we do? Is it possible that coming to therapy actually helps people prosper? And make more money? Why are we hesitant to conduct business as usual?

I am not at all saying that we should encourage folks to come to treatment that they cannot afford. But I am asking us to consider what afford means. What is our work worth to us and why? And what is it worth to them?

I think that these are things that can be discussed in session. I have seen many solutions. Some people have to come less often, some have to take a break for a while. Some of you have reduced your fees when the need was clear, and with the understanding that when things get better the fee will be returned to it's regular status.

There are many possible answers, but I don't think we can get to right ones, or the highlight the choices without some good discussion about our own ideas. What does it mean to us to lower a fee or change a schedule? What message are we sending? In some cases, we may be sending out the idea that things are indeed pretty bad, and they won't get better. It's an emotional message, not a verbal one, when we agree to a fee reduction or frequency change.

Sometimes it's a message of despair, not of understanding and support. Sometimes it may signal that we don't value the work, or value the client, when we lower the fee. Not always, we can't be sure unless we really talk it. We can't be sure what message we are sending to the client about their worth, their potential. Or our interest in working with them. We can't be sure what message we are sending to ourselves. And sometimes lower fees leave us resenting the client. Also not good for the treatment.

Lots of therapists have the idea that they are being supportive, or practical, loving even. And it may be so. Just not so fast I think. Our relationships with clients are important. Our time with them is sacrosanct. Not to be dramatic, but we work hard, and with concentrated effort and dedicated time. We are not (well, I don't think so) the mani or the pedi that could be done at home.

And what about our fears? Of losing clients, of financial insecurity. It's difficult enough to have your own business, and have your paycheck change from week to week. To have to bring in business on top of doing good work. How much do we know about our own fears and the effect they have on our decision making when it comes to fees? Do we think we must slide to keep business?

I think that we all prosper when we give ourselves permission to really talk out our ideas to a good ear, and to study what's operating underneath. We do not have to act quickly. I think sometimes we want to resolve things fast. It's hard to stay with uncertainty, uneasy feelings. We so humanly go for the good feeling, but I think we miss out on a lot of good information when we do this. Not to mention the opportunity to model patience, curiousity, tolerance for bearing some discomfort, and the value of talking, consulting and understanding something more fully. Even in our business, I think we sometimes forget we can benfit from studying even, maybe especially, the basics!

So, to know where we are coming from, and to unpack what's influencing our choices, when we are working toward the best idea in difficult times. And to take a look at our own ideas about therapy, and about our own therapy, and about what we consider valuable and priority and worth it's weight. It's key, I think for our own good care and toward the well being of the client, the work, and even the economy.

Exactly Where Did He Put His Hands?!? (Clinical Protecia When Working With Infidelity)

2008-11-19T19:49:00.000-08:00

Details. Details. I have been working lately with a lot of couples that are attempting to recover from the atomic bomb of an affair. And lately, more women who have gone outside the marriage than men. In all honesty, I must admit that I hold true to my stance on most all human behavior, which is that actions and feelings are worthy of study, not judgement. And of course in the tricky maze of couples work, we can study what was going on in the relationship that contributed to the affair; we can help them talk; we can help them rebuild trust, or repair the relationship without rebuilding trust (yes this can be done!). On and on, we can do our good work.

So amidst the ocean of things to be curious about as I work with my hurting couples, I have been studying two things in particular. One is why the spouse who was not unfaithful is so obsessed with the details of the affair, down to which toll booth on the highway his spouse and her lover drove through (and no I am not kidding).

And the second is what effect do all the feelings in the treatment room have on the therapist. Here we are sitting with rage, hurt, betrayl, disappointment. To name a few. And then we are more than likely reminded of our own marriages, our own desires, our own fantasies, fears and theories on life. A lot to keep track of, I think.

So of course, with a nod to the way men and women respond differently from a generalized gender basis, and another nod to the fact that each couple has a different dynamic and needs to be worked with in whatever way is good for that particular couple, I am still thinking about the obession for details.

It seems to strain the marriage even further. This incessent need to know everything. And we therapists are often left feeling a range of feelings from stupid, to rageful, to useless to terrified. To compelled to fix things fast, or help the obsessive (often battering) need for detail cease before it does any further damage to the marriage.

So here's what it is, in part, at least. We have to pay attention to how we feel (yes, yes, the countertransference), especially when we are working with couples who are trying viscerally to communicate to each other and to us, how absolutely destroyed they really feel. And tortured. And we may have to tolerate feeling destroyed ourselves in order to do good work at the right pace. Consider the possiblities. In what ways do the couple torture each other. What ways do they torture us? How do they function as a couple, and how do we stay with them?

One idea: obsessing about the details, which feels battering and tortureous to the spouse who went out, is the faithful spouse's way of retaliating and letting the spouse know just how bad it feels to have been bombarded. It's a communication of pain. Insane pain sometimes. And it can make the therapist feel insane sometimes as well.

Other theories? The hurt spouse is trying to gain control, reestablish trust, punish their spouse, punish themselves, find something to hold on, or to distract from the pain. Many possilbilties, and of course, and much more to say.

But on to how we therapists manage. We must talk. I know, here I go again. We must tell our story to someone who will hear us, hear our reactions, our guesses, our feelings. For their sake, for our sake, for our own marrriage's sake. For goodness sake.

We can get caught up in the trying to fix the relationships that we may move too fast. We may want them to let go more quickly than they are able to. For some, the symptom of obession is necessary for a while. It is serving a purpose, just like any other symptom does. And trying to work too quickly may actually not be good for anyone. Even if we the therapist want to move them along.

We have to check our own ideas out, talk them through. Case by case. It's protectia, I think, for our own psyches. And our own relationships.

Left Holding the Bag (of feelings) Or The Guessing Game

2008-10-25T19:05:00.000-07:00

A pal of mine called me yesterday to kvetch, complain, vent, sigh out loud to a good ear. She got a strange message. A new client of hers, who she had seen once, called and left a message cancelling the next appointment. She did not leave a phone number on the message, nor a reason, nor a request for a call back. Not even an "I'll call you to reschedule." Just an "I am cancelling. Goodbye."

When my friend heard this she experienced a deep pang of disappointment, hurt and something akin to anger. And bewilderment. The first session had gone well. The client expressed her thanks at being able to talk privately to someone. She had said she was looking forward to talking and thought it would be a good idea to come regularly. She paid. She said she would see my friend the next week. Same time.

So my friend decided that even though the woman did not leave a number on the message, or a request for a call back, or a number, that she would contact the woman anyway. Just to see. She had after all felt a connection to the woman, and thought that treatment was going to being. And she said, "I just had to find out why."

When she reached the woman, she got a cold reception. The woman said that she had to take her child to an appointment at that time. "Should we find a different time then?" My friend asked. "No. " She would call if she wanted to reschedule. My friend was feeling persistent that day, and asked her straight out, "Is there some other reason for your change of mind? Perhaps we could work it out?" "No," was the answer. And then goodbye. My pal gave up at that point. And called me for a little company.

My friend's practice is full. Brimming actually. And she does not really feel the need to take on more people at this time, she tells me. But she hates to be disappointed. And does not like feeling left. She is fairly confident in her clinical abilities, and is open to looking at something she may have said or done wrong to put the woman off, but she really got the idea that the session went well and they would be working together. She reminded herself that sometimes people get frightened or change their minds. They are just not ready to be patients yet. And certainly they may not be able to say the truth yet. Especially if they are new, and the relationship is not even off the ground yet. Even long time patients have difficulty telling you what you did wrong or said wrong in session. Though that is a sure sign of good work and progress.

A thousand guesses. Mine? The woman was frustrated and disappointed and feeling helpless. In life, not just in that one session. And she needed to be mean in order to get relief. She needed to transfer all those bad feelings to someone else. So she nailed my friend. Perhaps this is what this woman's life is like. A series of bad choices, or cold shoulders. Unanswered questions. Aborted possibilities.

Okay, who knows really. We can only guess. But the feelings stayed with my friend for a bit. Some people really do leave us with powerful feelings. And we are such good recipients. That's part of why we do what we do. And why we are good at doing what we do. And why we get paid.

Sometimes it's all we can do really, guess. And vent. So she vented, my friend, to me. And then she went back to her day. Back to work.

Marry Me

2008-10-08T08:09:00.000-07:00

From one of my groups this week came a collective sigh of frustration, bewilderment and, well, I think I would call it, urg-ness, over the state of unions. Marital unions. Although the state of the country is something to sigh over at the moment too.

Many of us are doing a lot of couples work. Marital. Some of us love it, and some of us hate it. For many of us, it stirs the pot of our own desires, morals, wishes, ideas and longings more than any other work we do. It seems to drudge up our confusion about how to be most effective, how to help two individuals as well as the relationship that is seemingly being brought before us for repair, replenishment and relief.

In the vast sea of treatment approaches, techniques and interventions, many therapists are feeling frustrated. We are seemingly and collectively noticing an increasing amount of visitors to our offices who have fallen out of love, fallen into love with someone else, gone outside the marriage for sex, attention, affection or entertainment, or to send a message to their significant other, or even to themselves. And it has many clinicians puzzled on many levels.

We are getting the idea that relationships are disposable. And we are called in to treat relationships by folks who may have already decided that they want to follow the lead of their current desires or longing, and leave what they currently have behind.

Some of us are feeling mandated to fix and help cleanup the wreckage of broken trust, anger, disappointment and fear. And deep hurt. Of course this feeling could be the transference. It could be induced, coming from one or both members of the couple. Still and all, we are feeling things deeply. And we are thinking of our own marriages, morals, ethical callings.

Some of us consult with the couple: "Should I help you to stay together or help you to seperate?" "Have you already decided what you want?" "Can you (can I, the therapist), live with uncertainty, lack of trust, fear and hurt for a while until we get it sorted out?" Words. Words. Words. Helping them to put it into words. And giving ourselves the space (okay, broken record, I know) to put into words our own frustrations, beliefs, musings and longings.

We must talk it. I really think we must. Because it stirs us up, all of this crazy behavior, and mind changing and family wrecking. And it makes us think about our own mandates, and choices and what exactly our job is anyway.

How do we help them stay? And talk. Even if they have already dropped a bomb into the relationship. I think we have to help ourselves stay first. So many of you are telling me that your couples are finicky. Flaky. Lots of drive by sessions. And then on to whatever they go on to. How do we make it possible for them to keep on keeping on, and figure out what's the best course when there are so many things flying? And at what pace?

I have one couple who comes to see me once a month. It's all they can handle. My idea is that they should come weekly, but I see them pull away when I suggest this. I have stopped suggesting this. One couple will only come together, even though my idea is that they may have more to say seperately for now. But that's my idea. And I am keeping it to myself for now. I checked in briefly with them about it, but could see that it would be a deal breaker.

This is what we do. We tolerate all the ideas and feelings our clients have. And we tolerate all the ideas we have, including the moral ones, the burdensome ones, even the clinical ones. And we talk it amongst our own support network. Perhaps the more staying power we have, the more staying power our couples can have. Whether they stay in the marriage or they leave.

Words. Words. And more words. In a safe place, for both the clients and for us.

It's a topic I don't take lightly at all. Unions.

So What's the Problem? And Why do Case Presentations Take So Long?

2008-09-27T19:46:00.000-07:00

Why is it that case presentations take so much time? One analyst I work closely with is fond of telling supervisees to just say what the problem in the case is, and not go into all the background noise of how old the client is, what the diagnosis might be, symptoms, family history, yatta, yatta. Just cut to the chase, she advises. Say what's bothering you about the treatment, the work, the session. In other words, get to the counter transference right away, so the discussion can center around it. But this, I find stumps some therapists for a sec. We are so used to going into long drawn out explanations of the client that we are often at a loss when asked to just say how we feel, or what is bothering us.

In one of my groups recently, we spent the better part of the hour hearing the story of one client's troubles and character issues. And when it came time to really unpack what the therapist needed, we did not have as much time as we would have liked. Of course, there is always the next group, but still it left me wondering more about efficiency. And about why most therapists, when presenting cases, spend so much time telling the story, and not much time telling what's bothering them.

I think, now, that this is exactly the point. Just like the clients, we, too, have to tell our story. We have to tell their story in order to tell our story. Or do we? Sometimes yes, sometimes no. It helps to be understood. And we who practice alone, sometimes need to know that someone understands what it's like to be in the room with a particular person.

One therapist I know called me to consult on a case where she was working with the couple and the man was really a tough guy. He was mean, confrontational, and kept telling her how she was not helping them, and had better think of something or they were going to leave therapy. As she was telling me this story, I commented that her client was a bully. (or at least acting like one in her office). The therapist felt so relieved at hearing me say this. She did feel bullied, but was afraid to say so, even to me. She had to first tell her story. She could not come right out and say, "I feel bullied by this client. He makes me feel awful and defensive." She may not have even known she felt that way until she told her story to another good ear.

So why don't we start with our feelings? Well, maybe it's a defense. The telling all about the client, with all the factual details that usually don't matter that much. It's our way of delaying the nitty gritty good stuff, like how we feel in the room, or what thoughts go running through our head when we are working with them. Do they make us hungry? Or tired? Or feel like quitting and becoming a mailman? Do we feel inadequate, bored, excited, important? What feelings do we have to tolerate in order to do good work with them. How willing are we to just say what are really feeling in order to really get some useful ideas from our supervisor or group? It's not easy. We really do have to be a bit vulnerable to do it. But I think it pays dividends in our own growth and our client's.

The more we look at how we feel in the room, the more we can get clues to what is going on with a client. The more we can learn about how to be useful. And I think it builds our tolerance, our perceptiveness and our confidence as clinicans and healers.

So we do need to tell our story. But I do like the idea of starting with the problem. With our problem. It goes right to the heart of the work. We can fill in the important details later. Can we get used to thinking about things this way? I think it usually goes to us wanting to feel good about the work we are doing. And to wanting some company, some validation, and some talking time of our own. We learn so much about our own stuff, our work and about the client when we take time to reflect and talk this way.

Cancellations, Fleeing Clients and "Oh, yes, I did say that"

2008-09-18T19:38:00.001-07:00

I own it. I say the wrong thing sometimes. Rarely, but it happens. Rule of thumb: When a client cancels for some reason that makes little or no sense, or a lot of sense but it just does not feel right to you, then its a good idea to take a look at the last session. Yes, yes, I know, there are a million and one resistances. And we try to study them and work with them. Yadda Yadda. But how often does it happen that a client comes in and tell you, "you know, you said a really dumb thing last week, and you made me feel like garbage." Not often. It does happen, either with the very narcissistic or the very well, or well trained patients, who know they are suppose to tell you when you say or do something they don't particularly like.

I had a wonderful client of mine try to flee recently. All the sudden the time wasn't good for her, the sun was too bright, it was too expensive, she feels better suddenly. Fortunately, she was willing to come in and chew it over one "last" time. (Not that I suggest trying to get someone to stay if it's not clinically indicated...but) So I asked her, "Did I say something last time that bothered you?" (or for the more defended, "Was there something troubling about the last session?" Or "Was something said that was bothersome?" ... Keeping all egos as safe as possible).

Yes, in fact, I had suggested (gulp, me? suggest? really?) I suppose I did, suggest, that she change jobs. It's just that she had been complaining about her boss, her salary, her commute, her work load, her opposition to the morals of her company, for oh, lets say, about three years. Well, maybe not, but seemed like it to me. Must be I hit the wrong note. So I said this. "Must be I hit the wrong note." And she said that I most certainly did. With all the stress she is under, for me to then say that she is not good at what she does and should stop doing it!" (did I say that?) Well, it's what she heard. And it was right there in the transference. I think I was thinking that she should change jobs.

Okay, so just goes to show. We don't always know where we are walking. Or how our words will be interpreted. But we sorted it out, and she's back in the groove. And I am reminded of how important words are, and how attentive we need to be when using them. They really do make an impact. More than we realize sometimes.

Good to know.

Failure

2008-09-10T19:43:00.000-07:00

How do we know what kind of job we are doing? Today I had lunch with a colleague who was telling me that he did not really feel like he was of any value in the room. He is new-ish to private practice. Been working for about two years. And he tells me that he is not feeling like he does much for his clients.

Heavy sigh.

So we unpacked it a bit. Looked at the possibilities. (Over tuna fish). Sometimes feelings of failure and uselessness are induced feelings. Best to look at each case to see what feelings are flying around. Maybe he is suffering from the human and mostly universal need to be effective, acknowledged and helpful. Though it's good to flag this need if it is going to get in the way of doing what is best for the treatment.

Maybe it's that he never felt useful or successful as a child, and he is repeating this experience in his practice. Maybe it connects him to his father, or gives him a reason to get out the field, or not get down to the business of marketing his practice.

Then we hit a good one. (We are working hard over Rye bread). He fessed up that his own experience in his own therapy was never really satisfying. In fact, his supervision was not useful to him either. He never felt he could say everything to his therapist or supervisor. He was often told what to do, or how to proceed. He sometimes liked that, but he mostly felt criticized by it, not helped. In fact, he felt useless as a patient, and angry at his therapist. And he did not really believe that therapy was all that beneficial anyway. If people don't do what you say, what's the use?

If we got into this business to help people, to fix them, to solve their problems, we might be in for a long day. What about listening deeply, showing up, holding off on the "here's what you need to do." (Not that we do that, but we do that.) We do not want to fail. Or flail.

One therapist I know says she becomes unraveled when a client tells her that the therapy is a bust. It's not helping. She says she never knows what to say that, so she springs into "performance mode," and starts trying to offer advice or feedback. Like my lunch partner, who thinks it's his job to have and employ great philosophical ideas and perform great interventions that transform and cure.

I think its great when a client says treatment is not helping. First of all, they are still there, so it can be talked about. (Why am not helping you more? What kind of help would you like? What's in the way of you being helped, etc.) Questions to help things along. If a client feels good enough with you to tell you what a failure you are, then you are doing a great job.

So my lunch pal has to go back to his therapist and tell him what a screw up the treatment has been. Let the bad feelings fly. Everyone will survive. Maybe even move forward! Wouldn't that be a good thing!

It was a productive lunch. And as a treat for you guys, if you haven't seen it...I am posting a link to JK Rowling's speech on the Benefits of Failure, given to the Harvard University graduating class of 2008.

Bon Appetite!

Contact Anxiety Amongst Ourselves

2008-09-07T19:49:00.000-07:00

Okay, it's a little unexpected, but altogether very human, no? When therapists are anxious about contacting or connecting with other therapists. I find this to be true in the groups that I run as well as the ones that I participate in, as well the phone calls I get, the supervision requests, and the plain ole "hey, got a question for you" emails.

In fact, email seems to be easier, and some find that listservs, blog posts and message boards are the more comfortable way to go. But the phone seems to have become larger than life for some. Just outright frightening. I am really studying why this is. What is it about live contact with a colleague that makes us jittery?

From what I hear, it's pretty surface, and very deep. Both. We are wanting connection, but we are unsure about what that will mean. How will we viewed. Will we be competitive? Will we seem smart, approachable, capable? If we say everything we think, will we be liked still? Respected? Admired? Will we have the good feelings we seek? Should we avoid conflict, or swim through it to the other side? Will we get hurt? How vulnerable should we seem, how likable are we? How do we sound? Will we feel a connection or a disconnect?

Even at conferences, maybe especially at conferences, our defenses seem to soar. How do we give off the air of confidence, friendliness, professionalism, and yet ask for something we might need. Like help with a case, a new idea, a good ear. A feeling of being in the know.

I do hear a lot of therapists tell me that they are often times hesitant to reach out. We are so used to practicing alone. It becomes almost a badge of honor. I always joke to my kids that if I am late to work my boss will get mad at me. They say, "Ma, you work for yourself!" And I say, "Exactly."

But I think it's more than that. I think we think we are suppose to know and not need. It seems silly to say it, but I think its true. We have this pesty little idea that because we do what we do, we are suppose know what to do, what to say, how to be. We are not suppose to feel ill at ease, clueless or needy. Or anxious. We are suppose to have our feet planted firmly, be successful, competent and trained.

Well and most of us are. Mostly. We sometimes get reved up in the presence of each other. I'm thinking it's okay. I'm thinking that as as long as we sort of know it, and it does not get in the way of reaching out for what we need, or getting the connections we can benefit from, that the rev is not so bad. Just being mindful of it its helpful.

That, and that we are all, most of time, in the same boat.

Slow Drip

2008-09-04T19:58:00.000-07:00

Now that the school year has officially begun, and everyone is getting back into the swing of things, or trying to, I am experiencing the all to familiar tug of urgency. Generally speaking, its not my own. And its not my clients' either. It usually comes (understandably) from spouses, parents of younger clients, from the psychiatrist (of all places!), or from some other permission granted cook in the kitchen, like the general practitioner, or the guidance counselor.

I must digress to include a brief a story. I recently sent a very troubled client of mine to a psychiatrist for a psych and med evaluation (that is why they go, no?). After signing all the necessary releases, the psychiatrist calls me to confer on the case. Sounding somewhat panic-y, she thanks me for the referral, but says she is not sure what to do, and do I know that this person is really a little scary and difficult, has a lot depressive symptoms and was quite disturbed? And I said yes, of course, I knew this. And then she asks why then did I send her? And I am thinking because you are a psychiatrist!

I did say I was sorry for sending on someone who was so difficult, and suggested that she does not have to treat her, of course, if she feels uncomfortable. I suggest this to therapists all the time, that you never have to work with someone you don't want to work with. But I do think that most of the time with some good support, you can work with most people and most issues quite successfully, if you want to. Alas, I sent the client to another psychiatrist who does work with crazy people, and I made a mental note to only send healthy non symptomatic clients to this doc.

So I am taking this opportunity to remind myself and all the people who want things to be fixed already, that urgency is for the bladder not the brain. Therapy is generally a slow moving vehicle, and for good reason. It's not really recommended to make someone give up something that is serving them or protecting them in someway. Not until or unless its clear that something worse won't take its place. Its best to support defences, not come crashing through them. That usually doesn't work anyway.

Not to say that we can't attempt progress or interventions that bring on change, it's just that its good to know a lot about the effect our words might have on people. And that sometimes things take a while to go from the brain into the heart, where progress is made. Sometimes, some folks (present company included) have a slow drip. Any faster could be jarring, if not impossible.

Just thinking how this is okay. And we can take the time to study the process, be in the room and not try to hurry things along, for our sake, their sake (how do we really know, anyway?), and certainly not for anyone else's sake.

M I A: Missing in August and Feeling It!

2008-09-01T20:29:00.000-07:00

It's a funny ole therapist's tale around here in New Jersey that you can't find a therapist in August. I have to say that for me this has been a little too true. At Good Practice Institute our groups have run through August, though we have had a few vacationers out here and there. But here in Jersey, live and in person, my groups have not met. The institute where I study, The Academy of Clinical and Applied Psychoanalysis (ACAP) has been pretty quiet in August, and I am feeling it!

At first when the folks there that I meet with decided to take the annual month long siesta, I was sort of happy. One therapist I know says she is glad when her clients take a vacation and don't come. She says we all need a break. Off to the beach! (or where ever!). Forget about the loss of income, the break of pace, the feelings of abandonment. Go!

I smile when I think about this. I hear so much from therapists about how difficult it is to miss out on our fee, or to reschedule folks, either for their time off or for ours. And how afraid some of us are that if either we go or they do, that no one will ever come back. I think it drags up so many early feelings of fear and separation for a lot of folks.

But somehow we manage. And everyone comes back. And the work continues. Some of us make it a point to talk about all this in session, or to at least check in on it. And some us roll right over it like we are off-roading and don't need to study the bumps too closely. Either way, it's good to know that we might be feeling it in some way, and that our clients might too. Sometimes the feelings show up in missed appointments, or forgotten checks, or late arrivals. Good to study and ponder.

For me, I was feeling it. Not meeting with my some of my own colleagues in my normal routine really made me realize how much I rely on the talking and consulting I do with them. And on the camaraderie, sense of togetherness and connection that comes from regular meetings and discussions. I was feeling a touch of "compassion fatigue" the last few weeks, and I think I know why. I think it's because my workload was blessedly high, and my talk time was not so blessedly low. And I was feeling it.

Ah. September. Glad to be resuming my regularly scheduled program.

More Than Practicing Therapy: Something New to Do

2008-08-18T20:44:00.000-07:00

Last week I met with a colleague friend of mine. August in New Jersey, two hot Lattes, and some talk on what to do with our lives. She is leaving her longtime job at an agency. And she wants to do something different. Something new. She wants an angle, a niche, a venture. She wants an audience.

She is a talented therapist. I've run things by her from time to time, over the years. I am interested in the idea that she does not want to be practicing "only therapy" anymore. I understand the itch to do more than what we do. To use a different part of the brain. I've been hearing this from others lately, the idea that being in our chair is not enough. Not from a financial standpoint, but from a creative one.

Many therapists are venturing out into, well, ventures. Some are providing services for other therapists, some are going techie, and some are going to the general public. One guy I know is in the tee shirt business. Another is starting a call in line for parenting help. And still another is doing teleseminars on marriage.

For those of you who are thinking about expanding your horizions while taking care of your practices, here are few interesting links:

The Zur Institute

Alex Mandossian.com

The anti 9 to 5 guide

Staying the Course with Practice Building

2008-08-10T19:00:00.000-07:00

Last Thursday evening I joined Casey Truffo on her "Town Meeting" call. I must say I was impressed with the number of therapists who showed up and weighed in on the issue of forging forward in private practice without taking managed care. Casey is still a believer in making private practice with private pay clients work, and I am too.

She did ask if anyone was thinking of quitting and getting a job. A few said yes. I have to admit that a number of years back, I came home one night from a very difficult session and went right to the computer to look for a job. Was thinking about maybe...postal service.

Of course, after unpacking it with my supervisor, we figured out that one of my clients was really projecting her own worthlessness and emptiness on to me, not to mention a strong sense of failure! Learning how to work with this client on these unspoken but powerful feelings, that actually caused me to act, though not act out in session with her, proved very useful for the treatment.

As I learned to tolerate her feelings of inadequacy and my own, I was able to study what was in the way of her getting the things she wanted, and what attachment she had to failure. Was a good experience all round. And the client is moving ahead in her life and career now.

But back to the practice. It does take, as Casey says, at least a year or two to really get a practice up and running. Planting seeds, studying marking, and developing your style. And learning to tolerate difficult feelings, have patience for process and stay the course.

Of course its worth it. Just get plenty of support, for marketing and for clinical process. Yes, I am always on that horse: don't go it alone! Talk, talk talk.

As for the highlights of the marketing tips, well, more of learning how to use the web, google ad words (this guy is said to be worth the bucks), and getting yourself in line with all the tricks the coaches recommend.

I say keep at it. I have found over the years that consistency and presistancy end up paying off. I also have to admit that I pray. Whenever anyone asks me who my referral source is I say "G-d." I am not a religious counselor, but I believe in the power of prayer. I also find that even when I make some effort, put something out in the universe to nourish my practice, that it always pays off.

Casey also reminded everyone that we have to believe in what we do. We are a worthy profession. We have to own it. Whether you look at marketing like Casey says, as the business part of the business ("you are your marketining department"), or as a great suprvisor of mine says, that "you are working with people's resistance and helping them to become good clients," you do have believe that treatment is a good thing!

I, of course think that everybody needs therapy. Its good to talk, but you know that already.

Write Away! Ideas and Links

2008-08-06T06:50:00.001-07:00

Many of the therapists that I talk with are also writers. Or wannabes. (some of you are still in the closet about this). Over the summer I have been taking a great writing class online. I wanted to pass along some really useful links to those of you who are thinking about writing, or wanting to take your writing to the next level.

I have found that in the process of all the listening we do, that we really have a lot to say, about a lot of topics. For me, its a new dimension to the work I do, as well as a creative outlet, a way to reflect and process, and prosper. The emotional benefits are an added bonus. As my most favorite writer on writing, Anne Lamott says, "writing can get you to start paying attention, can help you soften, can wake you up." She says to write your truth, and write "shitty first drafts," and go back and edit later, that "almost all good writing begins with terrible first efforts. You need to start somewhere. " Just get something down on paper. And go from there. And go freely, don't "reign yourself in." Not at first anyway.

Writing is a great boost to our practice; there are lots of ways to get our work and our words out if we want to publish. We all hear the hype about writing newsletters, blogs, articles, mailers, websites, (maybe a book!) to attract clients. Frankly, maybe these things do bring us business, I tend to think they might, depending on how you use them.

At my training institute (http://www.acapnj.org/), there was just a wonderful showing of photos, paintings and writing of my fellow students. What a joy to see everyone's creativity on display. To remind us that we are all so multi-dimensional.

So what gets in the way of actually doing it? And sticking with it? Many therapists tell me that they are hesitant to put themselves out there, afraid to make the time commitment, fearful that they know a lot about therapy, but not a lot about writing. Or that they are so busy, don't know where to start or how to get over their resistances.

Lamott talks about quieting all the naysayers in our head. The voices that tell us we can't or won't. That we are finished before we start. Who better than we to know about the effects of negative thinking, fear based thinking and resistance to progress?

Consider the freedom in letting yourself be a beginner. And giving yourself permission to fly on a page. I have, and its wonderful.

I really encourage those of you who are thinking about a creative outlet for all that you are holding inside to take the next step, take a writing class, use a different side of your brain, and write away!

Check out the following sites:

http://www.mediabistro.com/

http://www.writersonlineworkshops.com/

http://www.billohanlon.com/

And Anne Lamott's book on writing (and life): Bird by Bird

Difficult Feelings in Session, Easy Does It in August

2008-08-04T16:57:00.000-07:00

I recently took an informal poll of my supervisees and colleagues, asking "What are the most difficult feelings to tolerate in a session?"

Here's the list, in most popular order: Feeling:

Incompetent

Ineffective ( read: worthless)

Fearful (afraid client will leave treatment if the wrong thing is said)

Abandoned (the client does leave treatment)

Aggression (client is angry at therapist)

Disappointed (client is suppose to make progress and they do not...leads to therapist feeling incompetent)

I think these feelings (communications from the unconscious) are one of the most important reasons that we get paid. To study, tolerate and use our feelings and the client's feelings to understand what the client wants, and what's in the way of getting it.

Recently, a colleague friend of mine told me that she was just furious that her client canceled again, after she had specifically discussed the meaning of cancellations, the consequence (would be billed for the session), and had done her therapeutic duty of studying the communication. (read: she thought about the last session or so, and reviewed if she, the therapist had said anything that may have upset, angered or frightened the client) and did not see that there was yet anything of the sort, though you never know unless your client both knows and is able to tell you).

Process is process. What happens when our best efforts at intervention and analysis are just falling flat? Can we give ourselves a little slack? Permission to just sit back, study the case, and keep listening?

So often I hear therapists putting so much pressure on themselves to "do something." Its as if tolerating the process, the difficult feelings and helping our clients to keep coming, say everything and anything they need to say, and just being there is not enough.

Every so often I think its a good idea to take stock of our worth. That our value does not come from or depend on people making great strides. Yes, we want them to do well. But we show up to work to be with people in whatever state they are in, and to understand, listen, learn.

That's enough sometimes. For some, that's the best intervention there is, our just being there.

I once read a quote by the late father of Modern Psychoanalysis Hyman Spotnitz, "Patients get better despite brilliant analysts." Just food for thought on the pressure to know more than we know at any given moment.

I am thinking that for now, easy does it in the deep "dog days"of August when cancellations abound and for some, pressure mounts to see more tangible results.

This is a good time for reflection. Long walks, easy talks and sunshine.

Peer Group Supervision Anxiety

2008-08-03T19:27:00.000-07:00

In one of my supervision groups, (on the phone! don't practice alone!) we started off in the most wonderful way....putting it all out there about how we were feeling in the moment, and at the start of a new group...and we were feeling anxious! Anxious that we did not know each other. Anxious that we would say something wrong, sound dumb, admit to saying or doing things in our work that were just off the mark...

The more we talked about how worried we were about how others would percieve our words and our work...the more we learned about how universally normal these feelings are. And how reassuring and connective it is to talk about them. It never ceases to amaze me how those of us who have been in the field of psychotherapy for many many years, can sometimes have as much concern about how we are viewed and how we come across as the newcomers among us.

Its heartening really, I think, so long as it gets talked about. On our group calls, I always ask that everyone brave it and say what they are experiencing. We are afterall, interested in studying the feelings and dynamics that go on in the room. And if we can help ourselves to talk freely (in the right place), then we can help our clients to do the same. And progress flows for everyone!

Saying It All

2006-12-12T20:23:00.000-08:00

Welcome!

I am delighted to announce the founding of the Good Practice Institute (http://www.goodpracticeinstitute.com/) for professional psychotherapists. I have always been a staunch believer that good therapists who provide good therapy need good care and good supervision.

Our job as clinicians is to make it possible for our clients to tell us anything. We are to create an environment for reflection and curiosity, with an air of hope and understanding. Is there any doubt at all then, that we therapists need to have such a place of our own?

My work has always focused on the gentle understanding of human problems. Most of us in this field have had our own share of challenges and pain, of progress and practice bearing very difficult feelings.

A wonderful modern analyst I know says that the best thing we can do for ourselves and our clients is to continue to get trained to tolerate all our feelings. And to help people talk.

Saying it all, to someone we trust, who is trained to help us understand, observe and go gently forward is one of the most healing experiences I know of, for clients and for ourselves.