Topic 8b: What Therapists Don’t Talk About [Part 2] {by 3/23}

Based on the readings and lecture recording from 3/19 consider the following three discussion points: (1) All therapists can be “triggered” by our clients (e.g., anger, fear/anxiety, sadness, frustration).  This may be due to our own insecurities and/or past life experiences.  How we respond to such triggers can impact the therapeutic relationship (and perhaps says more about ourselves than our clients).  What are your thoughts about the importance of self-awareness, including how you monitor and recognize your own response to being triggered?  (2) “Therapy Adrift” and “Repetitive Therapy” can be experienced by any therapist, especially those early in training.  What can you do to assure that you stay focused and purposeful with your clients?  (3) Our clients should always remain clients (i.e., not our friends or more…).  What are some possible indicators that a therapeutic relationship may be drifting from a therapist-client relationship to something more? If noticed, what can be done to address this drift? Your original post should be posted by 3/23.  Post your two replies no later than 3/25.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

36 Comments (+add yours?)

  1. Amanda Russo-Folco
    Mar 20, 2020 @ 11:12:05

    1. I feel that self-awareness is very important especially when we acknowledge that we are being “triggered” by our clients. For example, one of my clients was discussing about cheating on their partner and this is something that does “trigger” me because personally, I do not believe in cheating at all. So ever since my client was discussing about this, I noticed myself becoming a little frustrated in session and I had to do a quick check in to myself because I was aware of what was happening to me. The way I monitored and recognized my own response to being triggered was that I was noticing I was dozing off while my client was speaking about it and I was not actively listening, when I knew I should have been. This is when I realized I was triggered by something my client was saying and I had to quickly change my response so I could actively listen to what my client was saying to see where they were coming from. Now that I am aware of why I was being triggered and how I was responding to this, I can change my thoughts and behaviors around it. I also talked to my supervisor about this which helped as well. So being aware of the trigger is super important because then once you are self-aware, you can monitor and recognize your response, so it does not affect the therapeutic relationship in the end.

    2. While I was listening to the lecture about these topics combined, it helped to receive some tips on how to not get caught up with repetitive therapy. I agree that having a plan and structure each session can definitely help with these topics because like what was said in the lecture, it is important to stay on track with goals that are created for clients, specific interventions that are utilized and having session plans. However, personally with one client, I do notice that it is challenging sometimes to stay on track in session because the client likes to get on tangents about topics and I have to work on redirecting the client to get back on track. But now that I know how I can address this, I can be more reflective of this and check in to see what I can do to help the client stay on topic more often so that way they can reach their treatment goals. For example, I could let the client talk for the first 10 minutes of session and then stick to the session plan afterward. However, listening to the lecture did help me to feel better knowing it is normal to sometimes get lost in session but now knowing how to address this issue, I can fix this issue to try and reduce the chances of repetitive therapy and therapy adrift from occurring.

    3. Some possible indicators that a therapeutic relationship may be drifting from a therapist-client relationship to something more is if they request you on social media, or want to have therapy sessions in other settings such as restaurants or coffee shops or diners, or when the clinician is disclosing just as much information as the client is to them. If noticed, it is important to be self-aware of what is happening in sessions and to change the dynamic between the client and the therapist. It is important for the therapist to also be self-aware of their anxiety or fear of being a therapist and that it is normal to feel anxious in the beginning when doing therapy with clients. But, just because the therapist is anxious, does not mean that the therapist should see their clients as their friends. If this becomes an issue, the therapist could talk to their supervisor about this to work through their own anxiety about doing therapy with their clients. Personally, I was very anxious to do therapy with my clients because I felt like I did not know what I was doing, but I always knew not to let my anxiety get the best of me and I was able to work through this because I was aware of what was happening to me.

    Reply

    • Liisa Biltcliffe
      Mar 22, 2020 @ 10:47:27

      Amanda, I agree with you that a client-friend relationship can develop into something more complex if it’s not checked and reined in. The most dangerous development of course is if the relationship develops into something sexual. It’s a slippery slope, and one therapists shouldn’t want to go down. That goes back to the Appendix data where some of the data was, to me, alarming. I also really like your idea of using a white board to stick to the agenda. That’s a really great idea! We use a white board for the agenda for DBT group in internship and it works very well.

      Reply

    • Jayson
      Mar 22, 2020 @ 11:57:26

      Amanda,

      I can relate to your comment, “I do notice that it is challenging sometimes to stay on track in session because the client likes to get on tangents about topics and I have to work on redirecting the client to get back on track”. I do struggle with this same issue with a few of my clients. They come in session venting about something and it is hard to know when to interrupt them because you don’t want to be rude, but at the same time, you would like to continue with your agenda as much as you can. During my experience at my internship, I think I have gotten better a little at redirecting, but I still have much to learn!

      Reply

    • Rachel DiLima
      Mar 22, 2020 @ 14:30:41

      Amanda,

      You bring up a good point about social media requests. I hadn’t thought about that, but after reading your comment I pictured receiving a friend request from a former or current client and literally felt my face scowl. I think that for adult clients, it may be easier to have the conversation of “you know I can’t be your friend on FB, right?”, but for those of you who work with younger people, the conversation may be more difficult. Maybe? But now thinking about it, its mostly our parent’s generation that is on FB all the time…Either way. I think the current culture revolves around social media, and there is the possibility that a client friend requests you out of a desire to be validated. It would be an interesting topic to explore with the client, “What did you hope for by friend requesting me?” Regardless of the client’s motive, not accepting current or former clients on social media is a protocol I plan to adhere to.

      Reply

    • Alyce Almeida
      Mar 22, 2020 @ 21:22:26

      Amanda, your point on clients trying to add you on social media is definitely an indicator that boundaries and therapeutic relationship may be shifting. What I didn’t even think was your point on the settings therapy is being held and how that can even shift the therapeutic relationship. I was a therapeutic mentor/in-home therapist so we did therapy really anywhere in the community or at home and I noticed the way kids interacted in any of those settings can be quite different and difficult in comparison to say an outpatient agency. Great point!

      Reply

  2. Jayson
    Mar 20, 2020 @ 21:01:25

    1. Self-awareness is very important when recognizing when we become triggered by something a client has said to us. Back in my early internship days, I remember one time when my client began to talk about a relevant issue that I am also experiencing and then I began thinking about my problem and had urges to disclose about my similar personal problems too. At first, honestly, I began to disclose a little bit about my similar problems, but I never got too deep in my own problems with my client. However, even when I was doing it, I felt uncomfortable and wrong to do it. I was able to become self-aware about this habit of disclosing and I began to speak to my supervisor about it. Without becoming self-aware of my habit of disclosing my own problems to a similar problem my client was having, then I probably would have continued disclosing even more to my client which is unethical because the therapist should be there for the client’s problems and not theirs. Some triggers I realized is I lose my train of thought and begin thinking about myself and simply having that awful gut feeling when I get triggered. Whenever I get triggered during session, I always tell myself, “Think about the client, focus on the client” and then I’ll deal with my own problems later, but the important thing is to focus on the client during session.

    2. I have experienced “Therapy Adrift” many of times. It is a constant thread I notice during my sessions with my clients. I usually have my session outlined in my head which usually begins with a check-in for about 10 minutes depending on the severity of their issue and then dive into my agenda and usually at the last 10 minutes we summarize. However, it usually never goes how I plan. Sometimes the check-in goes on for too long and by the time I realize, it is already 40 minutes into our session and not leaving enough time for us to get to my planned agenda activities. I usually feel a little disappointed that I did not get through the agenda again. Something that I have been doing lately that has been helping us stay more focus is I bought a small little white board and leave it standing on my office desk with the agenda written down. Whenever session starts, we always go through the agenda by looking at the white board just so my client can know what we will be doing today. Aside from the agenda list and staying focus, I sometimes tend to draw things on the white board such as the Cognitive Triangle just as a refresher for my client to help them understand some concepts a little more since it seems that my clients learn a lot better when they can visually see the concept drawn out. From my experience of using my white board, it has helped both of us stay on track in session by visually seeing what the agenda is. It not only helps us realize what will be spoken about during session, but it reminds me what I need to complete during session as well.

    3. Some indicators that I have noticed is that some clients tend to avoid discussing their problems during session and talk about other interest they have. For instance, there is a client of mine who has very severe PTSD and most of the time she spends showing me videos on her phone of things like her dancing with her family, showing pictures of her grandchildren, or simply having me watch a Netflix video. Sure, this can be seen as her avoiding talking about her trauma or building a therapeutic alliance, but I have already seen her for about 6 months, and I think we already have a good relationship. One thing to note is I never push her to talk about her trauma, but the more we talk about other things like her family or what they likes to eat, I feel like she is losing that mindset that this is supposed to be a professional relationship where we discuss problems she is experiencing. The only thing that I usually do is I always tell her or remind her of how is all of the things she is showing me affecting her recovery? After that, she usually answers with “It doesn’t” and then we begin discussing more about her recovery. It just seems that if I have client who talks about other things aside from their problematic experience, I think they seem to be beginning to forget our professional relationship.

    Reply

    • Liisa Biltcliffe
      Mar 22, 2020 @ 10:41:15

      Jayson, I can really relate to what you said about sharing too much with a client. I always worry I am sharing too much, and I do think about it afterwards just for a short time after if I have shared something personal, just to be sure I think it has some therapeutic value to the client. I mean I think about it beforehand as well obviously, but sometimes the sharing happens so quickly, you know. A therapist friend of mine who has years of experience told me it’s okay to take the time to pause and collect your thoughts, that it’s better to do this and that includes thinking about whether what we will personally share is therapeutic or not. You know? Thank you for sharing your experience.

      Reply

    • Amanda Russo-Folco
      Mar 22, 2020 @ 12:00:54

      Jayson,

      In terms of “therapy adrift”, you are definitely not alone. I feel like many of us have experienced this and as time goes on, things will get easier for us. We will learn how to set boundaries and to refocus our clients’ attention back on the topic we were supposed to discuss. I really like that idea you shard about getting a whiteboard so your clients can visually see what the agenda is for their session. Personally, that would definitely be a benefit for both the client and I because it would help both of us stay on track for the session. I appreciate you sharing your own personal expereince in terms of self-disclosure, self-awareness and client-friend relationships.

      Reply

    • Dee
      Mar 22, 2020 @ 19:18:04

      Jayson,
      I love your idea about the whiteboard! I too use a visual reminder of what the agenda is to keep client (and myself!) on topic. I find this is especially effective for my young clients, as they really respond well to the structure (or alternatively poorly to the lack of it). ALSO, I love your idea about the triangle, mostly because I do the same. For each client I make an age appropriate CBT triangle with their personalized thoughts, behaviors, and emotions, laminate it, make 2 copies, and use it throughout treatment. I find that visuals are super helpful for structure and learning!

      Reply

  3. Alyce Almeida
    Mar 21, 2020 @ 11:05:21

    1. Self-awareness goes a long way in this profession and I think may be the most important aspect for yourself and the therapeutic process as a whole. Self-awareness is important because you are able to be honest with yourself, reflect, and understand what exactly you are feeling, reacting, and the way you’re behaving overall. I think it’s normal to feel multiple emotions or become triggered while working with clients – shows that we’re human! I think the biggest part is recognizing that you are experiencing those feelings and being honest about it with yourself and then discussing it with a colleague or supervisor. I think once we do this full time for the rest of our lives we’ll be able to pick up on any shifts in our feelings rather quickly. But I think the way we respond and monitor our reaction also says a lot about self-awareness. I struggle with showing my emotions all over my face, so I myself have been very self-aware of that especially in a group setting when you really don’t know might happen next. But I think being genuine and owning it (expression, emotion, response- whatever it may be) is really the key for self-awareness.

    2. Therapy Adrift and Repetitive Therapy is something I have definitely noticed towards the end of my internship experience. Avoiding therapy adrift can be rather difficult in my setting since I’m lucky I can meet with my patients for more than 20 minutes. I’m a planner so I always go into sessions with an agenda and options for where the session could go. I struggled at first when sessions wouldn’t go as planned and feel like I messed up somehow. What I’ve picked up on is that adrift for clients can mean different things, like it could be a way to avoid certain topics, or their rambling could say a lot on how they may not get to really talk much about their issues outside of treatment or ever. Just understanding the meaning behind the adrift could really help in steering in a different direction or maybe uncovering more for that session than you anticipated (in my perspective of course). With repetitive therapy thats something I’ve definitely struggled with which I think any and every therapist will experience at some point. I’ve personally tried to make the same intervention more unique to the client and their interests, or even the way I present it be different and thats helped a bit. I always bounce new ideas off of fellow interns and my supervisor too to make sure my “new and creative” ideas aren’t too whacky, but one thing that I stick with is having an agenda and multiple options that we could focus on and have the client really choose and navigate what they want and go from there. Could help with avoiding adrift, but if it does get there possibly be a way to get back on track and also avoid repetitive therapy.

    3. This question itself makes me nervous because I would hope that it would never happen since I stress boundaries so hard since I’m working with clients my age. But there have been times where I have noticed that once clients are more comfortable they tend to be more “loose” than normal or maybe a comment will slip out and I am like “what in the world was that.” But I think indicators is definitely their presentation in general, and what they’re choosing to talk about and not talk about. Any shift in presentation could mean many things, but a drastic shift could mean a shift for the clients perspective on you and therapy as a whole. What they talk (or don’t talk) about is a huge indicator too, maybe avoiding certain topics, talking about more “surface topics” like netflix or something like that. Though talking about that show would be great, if I feel any sort of concern of confusion on my clients presentation or topic of discussion I think thats a good indicator right there – trust your gut! I think in order to address it you have to be careful in how you present it to the client. I think reiterating the role you both have in therapy and expectations for the relationship will definitely need to be reminded, but further exploring the clients perspective on the relationship could be beneficial for the client in regards to possibly some issues or themes they can pick up in their lives or diagnosis (attachment or abandonment for example!!). I think it’s always important to challenge them too – so how does this/that affect/benefit you in treatment? Of course get supervision first because it will help you feel more prepared and supported if needing to address this to a client.

    Reply

    • Jayson
      Mar 22, 2020 @ 12:03:52

      Alyce,

      I can relate to your comment, “With repetitive therapy thats something I’ve definitely struggled with which I think any and every therapist will experience at some point. I’ve personally tried to make the same intervention more unique to the client and their interests, or even the way I present it be different and thats helped a bit”. I have about 12 clients and I made my own treatment cheat sheet that I use when I am developing their treatment plan with them, however I am just starting to realize that every time I complete a treatment plan, I don’t make it specifically towards their client. I realize that every client is different and their interventions, objectives, and goals will be different. I tend to simply copy and paste what is on my treatment cheat sheet, but I never realized that I am not making it unique to the client. I definitely struggle with this, but now being aware of it and knowing I will need a lot of work to get better at it, I hope at some point it won’t be as difficult creating these unique interventions, objectives, and goals for the different clients.

      Reply

    • Shannon O'Brien
      Mar 23, 2020 @ 00:49:28

      Alyce – I also wrote about facial expressions and body language! I never felt that this was something i struggled with or that people were able to notice. However, I’ve had clients point out when they know I’m about to ask them follow up questions or when i appear confused. I try really hard to manage my shocked or annoyed face though. I think those faces could be most detrimental to a relationship. I think it comes a cross as “I don’t approve of what you just said” kind of thing sometimes. I also really liked your closing comment about the feeling/expression being genuine however. That as a really insightful point! No need to feel/express something that isn’t real!

      Reply

    • Mikala Korbey
      Mar 23, 2020 @ 11:28:58

      Alyce, I really appreciated and related to what you said regarding therapy adrift. I too am lucky to get 20-25 minutes with my students and initially found it difficult to adjust. I agree that being “adrift” can mean different things for different clients, I have found that most of my students just want to avoid talking about certain things so they will just avoid my questions or will ramble on about random topics so that they get us off track. It took me a long time to figure out their tricks and work around it, but I finally feel like I can navigate around their adrift, because I know them well enough by now to see right through it. I think avoiding adrift also comes with time and getting to know your client.

      Reply

    • Becca Green
      Mar 23, 2020 @ 13:30:43

      Hi Alyce! As you (and the rest of class probably) know I often show my emotions through my facial expressions as well. I had my supervisor observe during one of my sessions and she actually pointed out that she was surprised at how well I maintained a more neutral expression or matched the client’s expression. I was shocked because that is something that I know I need to work on (all the time, not just for work). I bet you aren’t as expressive as you think, but definitely something you need to be mindful of still!!

      Reply

    • Marissa Martufi
      Mar 23, 2020 @ 16:07:48

      Alyce, I totally agree with you regarding the therapeutic relationship drifting in regards to working with clients our same age. I think that is something that has always made me nervous! Although it is probably extremely reassuring and less intimidating for clients because we are similar in age and they may feel that they can probably relate more, it is something that I worry about impacting the therapeutic relationship. Like you said, supervision is so important when it comes to this because it can become difficult to navigate. I like what you said about trusting your gut! For me, I sometimes want to give clients the benefit of the doubt and that’s not always best so going with your gut will help you to trust your instincts and reflect on this in supervision too. At the end of the day, we always want to do what’s best for ourselves and our clients so reflection and supervision are helpful in navigating these situations.

      Reply

  4. Liisa Biltcliffe
    Mar 22, 2020 @ 10:27:59

    1. I think that self-awareness is really important when it comes to monitoring being triggered in sessions and for a number of other reasons as well, including being able to set good boundaries and balancing being directive with being empathic. I tend to be a person who sometimes can react big to a client’s revelation and so I am learning to tamp that down. What I mean is that in my personal life when someone shares something sad or especially upsetting I tend to react strongly with empathy. That carries over into my professional life and I am learning to not do that so much, but still have the empathy. Because of my especially tough childhood and even the events in my 20’s, there are a lot of issues that can trigger me, so I work hard at managing them by attending weekly personal therapy sessions, and by practicing regular self-care at home. I think, too, that because of my tendency to react so strongly with empathy to clients’ issues, it can come across as more of a “client-friend” relationship rather than a professional one, which is also something that I am working on, something that I am definitely aware of.

    2. So I’ve thought quite a bit about this since reading it because I feel that I have a tendency to fall into this pattern of just “shooting the sh*t” with clients and not having a clear structure to sessions. I was not really aware I was doing this until I read about it, and I think that part of the issue (and maybe this is a cop-out) is that the clients I am working with mostly have symptoms related to psychosis and schizoaffective disorder and/or bipolar disorder. In other words, my clients tend to ramble, or they hardly talk at all, so the structure to the session tends to be more difficult to provide, I feel. Not that this should be an excuse…I’m just noticing it. I feel that preparing a bit ahead of time, before each session would help me to avoid this phenomenon and give the sessions more structure, getting them back on track. I think it will be better when I have clients whom I am in charge of for myself. Right now I am part of a team and I am the low man on the totem pole, meaning I don’t set the agenda/treatment goals, etc. I can still look at the treatment goals and set the sessions according to those, however, like I said, most of the clients I see tend to either just ramble or don’t talk at all.

    3. Well, I notice for myself like I mentioned earlier that I tend to have big empathic reactions to a client’s stories of what is happening in his or her life. Those big reactions are better kept for my personal life with friends and family, but I can still be empathic with clients by nodding my head and expressing concern for their feelings and well-being with words. In addition, oversharing about one’s personal life is an indicator of becoming too friendly with a client. I was sitting her trying to think if I had done that with any of my clients, and I think I keep a professional distance with sharing about myself. I could see how it could happen about oversharing though. I have had different personal therapists in my life and I find that those who share some personal aspects, but keep it to a minimum and to make a point to me are the ones I connect with the most. So that is something I try to keep in mind when working with my clients. Does what I want to share have therapeutic value to the client?

    Reply

    • Marissa Martufi
      Mar 23, 2020 @ 16:16:57

      Lisa, I can totally relate to what you said about reacting to clients and reacting strongly with empathy. I think while that is such a great characteristic to be empathetic and responsive, it can impact therapy with clients too as you mentioned.I remember an instance with a client and coming to supervision and sharing this with my supervisor and him reminding me to focus on the client’s experience and validating that, but also focusing on how I can help the client process this in session rather than becoming too invested in the emotions of it. Making an effort to recognize this and identify ways to navigate that such as personal therapy and self-care is so important. We of course want to help our clients while being empathetic and responding to what they are going through or sharing, it can be difficult to set that boundary and stick to it. For me, I tend to be the same way- very empathetic, and I tend to really invest myself into what other’s are going through/feeling and I’ve recognized how unhealthy this is for me.

      Reply

  5. Mikala Korbey
    Mar 22, 2020 @ 10:59:26

    1. I think that the therapists own self awareness is so important in session. Clients often put therapists on a pedestal and the last thing I would want is for a client to think a certain way about something because of a reaction I gave. Also, I think not being self-aware and monitoring our reactions to things can affect how we view the client and could in turn affect the therapeutic relationship. I also think that having self-awareness while sitting in front of clients is something that gets easier over time and we would improve our skills in doing so as we get more exposure to clients with various issues being brought up. When thinking back to the beginning of my internship experience and some of the sessions, I have a student who only wants to talk about video games, and there were times where he would talk about video games for 10+ and I was bored out of my mind but had to control my facial expressions. Eventually, I figured out his trick to avoid talking about anything related to feelings and the agreement we made was he could have the last 5-7 minutes of the session to tell me the intricacies of his video games. Honestly, I during those 5 minutes, I have to be very self aware in my reactions because I usually have trouble following what he is saying, but want to convey to him that I am listening and care to hear him. I learned really quickly, that I need show him I am listening otherwise he will notice.

    2. I think what Dr. V brought up in the video is really important, and that is to plan out sessions. I also remember from 708 that making an agenda with the client was really stressed as something that is important to do. Setting an agenda not only helps the therapist stay on track but also helps they client know what to expect as well. I know that in the beginning of my internship I had difficulty keeping my students on task, but once I really honed in on planning and setting a “to talk about list” with the kids, it helped both us of us stay on task and make progress! I definitely struggled a little some sessions as I was building rapport with my students to keep on task and not feel like I accomplished nothing. Overall, I think planning prior to the session and agenda setting with the client can be really helpful in ensuring progress forward is being made.

    3.Some possible indicators that a client is becoming more like a friend than client are, sessions are occurring outside of the office, the relationship feels more like a friendship, the “therapist” shares as much information to the client as they are sharing, and playing games with your client. If you notice this is occurring, you can seek out help from your supervisor about how to handle this and eventually address it directly in therapy. This requires a lot of self-awareness to ensure that you do not cross that line from client to friendship.

    Reply

    • Amanda Russo-Folco
      Mar 22, 2020 @ 11:52:36

      Mikala,

      I agree with you that over time, self-awareness will become easier with the more clients we see and the more experience we get. I also think that if we start to become more self-aware now, it will help us out in the long run as well because we are constantly trying to train ourselves to be self-aware of us so we can help our clients in the best possible way. I also really liked how you called it a “to talk about list” because that is something that would definitely help us stay on track because I had a difficult time staying on track as well in the beginning. But now, sticking to the plan has gotten a little easier over time.

      Reply

    • Rachel DiLima
      Mar 22, 2020 @ 14:15:46

      Mikala,

      I SO FEEL monitoring facial expressions! I am also a very expressive person, and I have had to control surprise, disgust, and yes, boredom, on a few occasions. I still wonder if I have been successful every time…likely not. I have also been told that I have a very serious expression when I am listening, and that my face can come off as mean or intimidating. It’s something I never thought I would have to control, but here we are. I also wanted to give you kudos for recognizing that kiddo’s diversion tactic, and finding a way to work around it. Keep up the good work!

      Reply

    • Alyce Almeida
      Mar 22, 2020 @ 21:15:23

      Mikala I SO agree with the monitoring of facial expressions! I am one who’s emotions are all over their face so I definitely have learned to be more self-aware about it. I think you make a good point of just being very self-aware while sitting with our clients whether it be our body language, and how to be flexible with every client you see.

      Reply

    • Becca Green
      Mar 23, 2020 @ 13:33:20

      Hi Mikala! I know I mentioned this in class too, but the videos and stuff from 708 have been super helpful to me as well. I know he mentioned it in the video, but it can be so helpful to keep a running tab of the to-do lists and check that there isn’t too much overlap as well. Definitely a good idea! I can’t imagine how much more challenging this is to do with kids. I admire your ability and desire to work with kids!!

      Reply

    • Nicole Plona
      Mar 25, 2020 @ 16:35:44

      Mikala,
      I didn’t even think about my facial expressions during session, but that’s definitely something super important to keep in mind when monitoring ourselves during sessions. I am usually pretty good about controlling my facial expressions, however if I’m already starting to get burnt out or triggered by a client/ something in session, I might end up visually expressing more. Definitely something I’ll be thinking about more moving forward.

      Reply

  6. Rachel DiLima
    Mar 22, 2020 @ 14:09:47

    1. Self-awareness is something that I think can be easy to talk about doing, but in practice it can be difficult. I remember Doerfler’s self-monitoring project, and what a pain it was, yet also how much I learned about myself. I began to make connections to thoughts, situations, and feelings that I never had before. It helped me learn to listen to my body, too. I began to understand how food, sleep, and positive social stimulation helped me to be a more present and empathetic listener. I guess what I’m trying to say is that self-monitoring and self-reflection should be done prior to conducting treatment as it can help us identify what may trigger us. I have a client that has very deep, ingrained delusions that can be disturbing. I have found, through self-awareness, that if I do not have enough time between this client that the previous one, I can become impatient with the client’s delusions. Through MORE self-observation, I realize that this impatience comes from a place of concern, frustration, and mental fatigue. This is a challenging client, with a difficult diagnosis, who requires that I stay on my toes. If I’m hungry, or tired, or mentally drained (or god forbid all three), I’m not going to be able to give this client the therapy they deserve. I think this kind of self-awareness prepares us to treat individuals that may remind us of ourselves or perhaps someone we care to forget.
    2. Like many of the comments I read, I have also experienced “therapy adrift” and “repetitive therapy” during my internship. Sticking to an agenda really helps, and I’ve found that writing down the agenda collaboratively with the client helps them to stick it. That being said, there was one time where I had to challenge the client about why they were coming to therapy. This resulted in defensiveness from the client, and a response of “sometimes I just want to talk about things, is that not allowed??” It wasn’t a fun conversation, but I’m glad we had it. I was starting to feel burnout from dealing with this client because there was no direction, and I felt like I wasn’t doing anything productive or helpful for this client. In the end I directed them to Psychology Today and told them she was likely looking for a client-centered or supportive therapist.
    3. This is tricky, but I think that some indications that a therapeutic relationship is slipping into something more include texting outside of scheduling or check-ins, too much self-disclosure, and thoughts about the client outside of the session (not including thinking about the best ways to treat the client.) I think this is a tricky question to answer because I can’t imagine a situation where it isn’t obvious lines are being crossed. I also think its ok to like clients. I think the most important thing is to maintain professional boundaries from the beginning. I’ve had to confront texting boundaries with a client before, and I liked that client, but a conversation had to be had after one too many late night texts to my work phone about things said in session that they NOW just thought of, and was bothering them. I think if a counselor is starting to have feelings for a client outside of the professional relationship, seeking supervision would likely be the best 1st step to assuring it doesn’t go any farther.

    Reply

    • Dee
      Mar 22, 2020 @ 19:11:30

      Rachel,
      As always I really appreciate your posts. You often make comments or points that make me reflect. So thank you for that! Your statement about monitoring our sleep, diet, and mental/emotional fatigue, as deficits can impact our clients, but if well tended to, can great benefit our listening and therapeutic performance. This spoke to me on many levels. Recently I was struggling with my patience with a client and made the connection that the days I was seeing this client was when i would have very late nights prior at school, and an early session with them. I was not giving myself enough rest before seeing my client, and it was clearly impacting my therapeutic effectiveness. I, like you, have been keeping an eye on how I take care of myself to make sure that I am at my best for my clients.

      Reply

    • Shannon O'Brien
      Mar 23, 2020 @ 00:41:30

      Rachel – I am so happy you mentioned Dr. Doerfler’s self-monitoring project! I forgot about that! I also found that to be helpful and insightful surrounding my social media use. I have kept some (not all unfortunately) of by better habits from that project. I serves as a reminder how powerful self-reflection is and now monitoring does actually work, even through just a two week period. I think this also speaks volumes about the importance in participating in things we ask our clients to do. That way we can be truly empathetic about the process, while also being able to explain the process clearly as well a model the task and the benefits.

      Reply

  7. Dee
    Mar 22, 2020 @ 19:05:51

    (1) Personally, to make sure that I am self-aware of possible triggers from clients, I utilize supervision to the fullest extent. I’m very open with my supervisor and if I feel that a client may stir some emotions in me that could impact my effectiveness or our session, I report this to my supervisor, monitor it, and engage in coping skills/therapeutic skills to better manage my own thoughts/behaviors. For example, recently a family member of mine was undergoing substance rehabilitation. It had made a great impact on my father, and myself, as I am his main emotional support. I reported this event to my supervisor to ask that she, like me, monitor that I do not allow my personal struggles to impact my therapeutic effectiveness. Likewise, when a client reported a family figure struggling with an alcohol addiction, I monitored my own thoughts and feelings and reported possible bias/impact to my supervisor. Essentially, I am constantly checking that I am keeping appropriate boundaries between my personal and professional life so that either or do not hinder or impact the other. Self-awareness really is key, otherwise you may have counter-transference, or even be impacting sessions due to decreased effectiveness from emotional or cognitive strain from personal experiences. Our clients are seeking our help. It would not help them if our own problems are starting to impact our ability to assist clients with their problems and symptoms. Unfortunately, counselors can take on a lot of weight on their shoulders. Thus, monitoring our own thoughts, feelings and emotions, and managing and processing them, is crucial so that they do not carry over and impact our therapeutic relationships and effectiveness. It’s the burden we carry, to make it dramatic. Or less formally, “getting our $#** together.

    (2) I can say that with one client I did experience a session or two of “therapy adrift”. This client had experienced great symptom improvement after working on symptom management with me since I started treatment with her. She had for a session discussed recent events instead of her symptoms, and I had allowed us to get off topic. Keeping in pace with this, our next session was the same. I had assessed that this was a good opportunity for her to have a “therapy break” in that she could discuss successes in her life and something other than her constant worry or life difficulties. To an extent, I had assessed that this was helpful for her and allowed us to build some rapport and self-esteem. But to another extent, we certainly got off topic. To address this, I gently mentioned that for past sessions we discussed many interesting and fun things and that I was happy for her that she seemed to be enjoying more things in life lately. I had refocused our attention to the goals and problems that we were to work on next, and by that means we focused ourselves on where the client still could work on improving parts of her life causing distress. Essentially, I was direct with my client, mentioning that we were off topic but that it is okay every once in a while, so long as it does not interfere with treatment (which it really hadn’t). To keep myself and my clients focused I set up an agenda for every session and unless a crisis or significantly distressing problem, comes up, I and my client stick to that agenda, so long as we both agree to it (I allow my clients to collaborate with me in places in the schedule/topic where there is room to do this). After each session I also do a bare bones agenda for the next session or at least a “lesson plan” so that I have some idea of where I want treatment to go and what goals to address.

    (3) Many of my colleagues have already touched upon what I was going to say for this response, but a big hint that a therapeutic relationship may be drifting from a therapist-client relationship to something more is if the client (or therapist) is no longer treating therapy as such (e.g. clients are requesting meetings outside of the regular session location, the client is frequently off topic and eliciting personal information from the clinician, the client is treating the Clinician differently (romantic advances, “shooting the breeze”, not utilizing therapy as such). If noticed, the readings and Dr. V expressed that the change in relationship should be addressed, processed, and corrected. Whether that be by restating the Clinician’s role and what the client wishes to get out of therapy (and how to do so in session), or by structuring therapy more, and even making professional boundaries clear to client. I would argue that being preventative and not allowing for there to be such changes to a therapeutic relationship is one of the best was to keep such a scenario from occurring, but this may not always be the case.

    Reply

  8. Shannon O'Brien
    Mar 23, 2020 @ 00:21:56

    (1) I think self- awareness is important when it comes to balance. More specifically, it helps to balance our ability to effectively create/maintain healthy boundaries while also remaining empathetic and invested in our clients. I feel like I better understand my self-awareness after I leave supervision. I guess what I mean is, I become self-aware a lot during sessions. I feel like I am able to sit in a session and monitor my feelings/triggers pretty well – whether that is sad, annoyed, or uncomfortable (all things I know I have felt). However, what I do with that later sometimes gets lost until I am able to fully process it during supervision. What I do with that self-awareness is most important. That way I can be most productive and present for my client instead getting too caught up in how I am feeling in that moment. I had a client early on disclose relationship/domestic issues with her ex-SO. A little self-disclosure here – my family was going through some tough stuff with very similar issues earlier in the year. I had a very hard time sitting with this client for a couple sessions. I felt so sad and angry for both her and myself/family. I was really happy that I could identify these feelings though and bring them to someone’s attention. I was so fortunate to have a supervisor that even that early on I felt I could talk to. A final maybe more funny thought, is regarding body language or facial expressions. I think about this A LOT. I definitely have a “tell” when I want to challenge or have a client expand on something because I am confused (they’ve pointed it out haha). It has become a joke with a few of my more humorous clients, but I really try to keep my body language and facial expressions in mind.
    (2) I have TOTALLY struggled with therapy adrift at times. I feel like this mostly happens when a client comes in with a lot to talk about or presents for agitated than usual. I think this is mostly due to the fact that cutting people off is really hard for me. I have seemed to master it at my job, so I thought is find this easy during a therapy session, but I just can’t seems to get a hold of reigning the session or group back in sometimes! I co-lead a Seeking Safety group and for a few sessions it was kind of going off the rails because both the other clinician and I were struggling keeping the group on task due to a few strong personalities (one client also suffers from untreated ADD). We had a “pow-wow” two weeks ago to really go over group rules/expectations again. We also decided that establishing a group plan for the day will be beneficial for everyone. I am hoping (once this virus goes away and lets us run groups again) we can get group back on track and remain therapeutic! Anyway, these factors really affect therapy adrift for me. I am hoping with more experience I’ll master this better!
    (3) I think about this a lot. During Dr. V’s lecture video he touched upon the idea of having thoughts such as. “wow this person is pretty cool.” My supervisor and I have talked about this as well. We have both had thoughts like, “I might be friend with this person if they weren’t my client.” Linking back to self-awareness – these thoughts are normal as we know, but being self-aware and effectively processing them and moving forward therapeutically is the goal. Also linking back to those “clues” (like obsession) we talked about in the last post will be important! One of my clients recently had a baby. I knew that she was going to bring the newborn into our next session, which I was totally comfortable with. However, even before the session came, I knew she was going to ask me if I wanted to hold her baby. The other interns and I had supervision together a few days before and I was glad to talk about this with all of them plus a supervisor. My gut reaction was to not hold her baby and I was also comfortable with that, but I wasn’t sure if I was overreacting. My fellow interns and supervisor assured me that I was probably making the best call for a few different reasons (what if we have to terminate her, holding a week old newborn is pretty intimate thing, etc…) When the session came, she did ask me, (as much as I wanted to because I do love babies) I told her that I was not comfortable with it and she jokingly replied, “What Shannon, you don’t wanna hold my kid???” We laughed and moved on.

    Reply

  9. Nicole Plona
    Mar 23, 2020 @ 10:15:11

    (1) I feel as though self-awareness is extremely important while working in this profession. This is what allows us as clinicians to check ourselves while providing treatment for our clients most effectively. If we are being triggered by something going on with our client and it’s causing us some type of negative reaction/emotion, being self-aware would allow us to identify the issue and take appropriate steps to deal with it. I have found that good supervision goes a long way when dealing with being “triggered” in a session. Through supervision, I can be honest and identify what might be bothering me to receive feedback from my supervisor on how to move forward in the process. I try to monitor myself by paying attention to my listening skills and ability to focus during the session. When feeling a negative emotion, I tend to “zone-out” or have a harder time focusing on a conversation. By being able to recognize this behavior in a session, I can better identify what is bothering me and reach out to my supervisor for help.

    (2) Similar to other comments and posts so far, I have also dealt with “therapy adrift” and “repetitive therapy” during my internship. It was nice to hear I had been doing most things “right” after listening to the lecture and hearing some of the tips on developing plans and structuring each session. I have tried my best to have a general plan going into session or not talk about the same topics. However, the session doesn’t always seem to follow as planned with certain clients (more specifically younger kids). I will often go into a session with an activity/game/plan while working with the younger clients but depending on what their level of motivation or focus is for the day the plan doesn’t go as scheduled. Often, kids will change the subject or rush through a craft or not have the ability to focus on new topics. It becomes hard to move beyond the general psychoeducation stage of therapy because of this. I think that when it comes to kids, it would be beneficial to start small with changes to the session plan or listing out what will happen next. This could involve challenging the client to spend at least 5 minutes on whatever new topic or therapeutic intervention is being used that day before going into the “fun” part of the session.

    (3) There are several possible indicators that the therapist-client relationship is becoming something more. Like others have mentioned this could include excessive self-disclosure from the therapist, the client requesting to meet/connect outside of the office space, or therapy conversations going outside the boundaries of what is therapeutic or beneficial for treatment. As mentioned during the lecture and in the readings, these types of changes in the therapeutic relationships should be addressed/corrected immediately. The best way to go about this is to receive appropriate supervision through the process as well as remind and restate the limits and boundaries between a clinician and a client.

    Reply

    • Mikala Korbey
      Mar 23, 2020 @ 11:39:43

      Nicole, I agree that with good supervision it is significantly easier to handle “triggering” situations. We all have certain situations that elicit negative emotions within us, and sometimes it can be difficult to maintain a good face during these times. I have found that discussing some of these triggering topics with my supervisor, she can help me navigate how to best move forward. Supervision is so important in so many ways.

      Reply

  10. Becca Green
    Mar 23, 2020 @ 13:27:09

    1. Self-awareness is one of the most important skills that I need to continuously work on. Because of my own anxiety/panic disorder I need to be extremely aware of my own mental/physiological state. This year I unfortunately had several stressful events happen (3 deaths, 2 car accidents, and 3 family members in the hospital) and I can’t say that I perfectly monitored and effectively handled everything. There was one day, after I came back from taking a couple of days off after my grandmother passed away, that a client talked about how they were excited to bake with their grandmother over the holiday break. I was afraid to open my mouth because I really thought I was going to cry in session. Luckily, they had a long story to tell and I was able to just breathe and calm myself down without them noticing that I wasn’t saying anything. I talked to my supervisor immediately following that session to debrief and talk about what else I could be doing to manage my own triggers in session. Supervision has been important for me, as well as going to therapy, in managing my own triggers and own anxiety. As challenging as it may be it is crucial that you understand your own triggers so that you can learn how to manage them without impacting the therapeutic relationship. Using subtle deep breathing and other mental grounding techniques has been extremely helpful for me.

    2. I know I have been saying this a lot… But SUPERVISION. Supervision and actively talking about each of your clients can be an easy way to make sure that things are continuously moving forward. I also feel that using assessments throughout therapy can help push you in making changes to the treatment plan if there is no positive progression for the client. Staying on top of notes and reviewing the previous note before the next session can be helpful in reminding you of what is being worked on and what plan was discussed in the previous session. Planning for each session and being prepared is important. Don’t. Get. Lazy.

    3. Clients should remain clients and I have noticed that not all clinicians practice appropriate boundary setting with all of their clients. I think when people start taking work home too much, talk with clients frequently outside of work hours or outside of session, and have sessions that feel more like a casual conversation than a productive session then you know that the relationship is drifting. I think clear boundary setting is very important at the start of therapy. Doing a mental check of the relationship with each client is important to notice differences between clients in terms of boundaries. Naturally we are going to feel more comfortable around some clients than others, but the professional relationship should remain the same. While there are instances that the specific things I mentioned could be professional (i.e. calls outside of work hours for someone who is experiencing active SI) in general these are things that therapists should avoid. This is why I don’t get how people used to (and still do) have home offices that they practice therapy in. I would never feel comfortable with having a client in my house, even if it were a separate entrance. That is more of a personal rant, sorry. Regardless, being honest about the boundaries between therapists and clients and regularly checking in to make sure that those boundaries are being upheld can help you avoid getting too far beyond the point of fixing it easily.

    Reply

    • Nicole Plona
      Mar 25, 2020 @ 16:14:38

      YES!! Supervision is so important. I feel as though that has been my answer for just about everything so far but it’s true. I also like how you mentioned using different assessments to track progress and change treatment interventions when needed. This is a super important step to take when creating/ updating treatment plans to be most effective for the client’s overall progress during therapy.

      Reply

    • Sarah Mombourquette
      Mar 25, 2020 @ 22:52:02

      Hey Becca, something I hadn’t thought about when processing the importance of self-awareness is how essential therapy is in that process. I agree that supervision is also key, but I believe all therapists should experience therapy at some point, if not all the time, in order to be able to fully process those triggering moments. As to the second question, I liked your point about how staying on top of notes can allow you to be continuously moving forward with clients because it allows you to be consistently evaluating the purpose and function of the work done in sessions. I agree with you that clinicians need to be wary of bringing work home with them because that opens doors for boundaries to be crossed, even if the boundary is limited to taking up personal time or self-care time that the clinician needs.

      Reply

  11. Marissa Martufi
    Mar 23, 2020 @ 15:34:59

    Self-awareness is obviously extremely important in this field of work. I think without having self-awareness you are unable to identify the things that make you uncomfortable, anxious, fearful, etc. and you are unable to identify how these things impact or effect you and the work you’re doing. I have learned that I am VERY self-aware and I sometimes see this as a bad thing. I am very easily able to identify the things that make me anxious or nervous, and even uncomfortable and I have found that this can sometimes hinder the work I am doing because I may find myself overly thinking about it or maybe just focusing too much on the way I am feeling rather than being in the moment and working through the particular situation (…if that makes sense). One thing I have learned and recognized I need to work on is that there will always be situations or topics that make me uncomfortable or are “triggering”, however I believe that is good to be able to recognize these things but it is especially important to learn how you can manage and work through this. That is where supervision is particularly critical. How I was able to recognize I am being triggered is that I have found myself to play with my jewelry (sliding on my rings on and off) or even slightly disengaging or not actively listening and begin thinking about what I was going to say/how I was going to say it in response to my client. Through supervision, I was able to recognize this about myself and understand why I responded the way I did and work to correct that. Since that experience, I have become more aware of the things I do when I am triggered or uncomfortable and have become mindful of that in session.

    After reviewing the readings and listening to the lecture, I really related to the topics of “therapy adrift” and “repetitive therapy” because in the beginning, I felt like I really had no clue what I was doing and remember feeling so nervous and feeling like I was all over the place during the session. I do agree that it is very important to have a plan for sessions and to be purposeful in the work you do each session. Something that really helped me to do this was to review treatment goals and what the client particularly wanted to work on and come to each session prepared with these things in mind. Sticking to treatment goals and being mindful of what your client is hoping to gain from therapy is important. It is very reassuring to hear that it is normal for new therapists to feel like they are getting lost or maybe not doing effective therapy in the beginning. However, supervision is extremely helpful in this aspect and allowed me to identify this issue and learn how I can fix it going forward and with future clients.

    Recognizing the therapeutic relationship may be drifting to a something more than a therapist-client relationship is so important. I cringe just thinking about therapists who fail to recognize this or allow clients to become like ‘friends’. From the start of this program, we are taught how important the therapeutic relationship is and how critical it is to build rapport with your clients and maintain professionalism. I think some possible indicators that a therapeutic relationship may be drifting to something more is the client may become very “relaxed” or “extremely laid back” in sessions and maybe share things that they would share with a friend (or someone their same age if working with adolescents). I also think an indicator may be the client choosing to talk about surface level topics such as a tv show or maybe what they did over the weekend rather than diving into what is really going on for them and what they should work on. I think coming to session each week with a gift or the client coming to session to “shoot-the-shit” may also be indicators. It’s difficult because obviously we want to help our clients and be a positive and helpful person in their lives but I do not think it is helpful to create or support a friend-like relationship in sessions.

    Reply

    • Sarah Mombourquette
      Mar 25, 2020 @ 22:43:54

      Hey Marissa, I agree with how important it is to have adequate supervision in order to process situations in sessions that are triggering to us. I think it’s really admirable that you were able to recognize small behaviors that you were doing in sessions that were disengaging you from your clients. I think those kinds of things can be incredibly hard to identify in ourselves, especially if they become habitual behaviors or stress management. I also liked your point about how a therapist and client might be entering a different form of relationship if specific content is kept from the session. It highlights that the client might be embarrassed or uncomfortable sharing the information anymore because the relationship has shifted out of the therapeutic alliance into a more casual relationship that would not normally revolve around the more challenging topics.

      Reply

  12. Sarah Mombourquette
    Mar 23, 2020 @ 22:22:48

    I think that self-awareness is incredibly important and something that must be consistently reevaluated. Working with kids with trauma histories, I often am interacting with parents who are perpetrators of abuse or neglect towards their children. In originally processing how I felt about working so closely with these caregivers, I found that supervision was the most helpful space to discuss my own reactions toward these caregivers. My original supervisor opened my eyes to reflecting on the fact that every person has a trauma history, and in recognizing the cycle of abuse that can exist within families, I began to find it more manageable in working with caregivers who are perpetrators. Ultimately, I feel that adequate supervision is one of the best ways to maintain self-awareness. I also think it is important to monitor our behavior and thoughts when triggered so that we are able to understand our own “warning signs” before we become triggered by other clients. I think that ignoring being triggered can be incredibly harmful, so being sure to take time to process the triggering experience is essential for ensuring that harmful reactions do not occur again.

    I think that one of the most important features of ensuring that you do not fall into a repetitive therapy trap is to make sure that treatment plans are individualized from the beginning. I think it can be easy to have a “treatment plan template” that you make tweaks to for each client, but for effective therapy I believe each treatment plan needs to be formatted specifically for the client. Going further, one of my supervisors told me that when doing therapy with kids, there needs to be a specific purpose for every “game” that is played. Furthermore, each “game” should be reflective of something within that individualized treatment plan. Ultimately, I think that a way to remain aware of repetitive therapy is to check in and see if you are doing the same activities with the same intention for every client. While it is true that some clients might have similar goals and needs, it does not seem accurate that every client would have the same exact goals and would respond to the same interventions effectively. Similarly, I believe that it is helpfully to regularly review and update treatment plans to ensure that each client is receiving individualized services.

    I think that one sign that a therapeutic relationship has drifted to something more would be if the client feels comfortable reaching out to the clinician outside of regularly anticipated communication. Beyond the client’s behaviors, these lines could be blurred if the therapist is equally involved in these exchanges. I also think that another sign that the therapist has become too lenient with therapeutic boundaries would be if the sessions started to involve content revolving around the therapist’s life and challenges. That seems more like an exchange between friends (I tell you about my life and you tell me about your life) than it does an exchange between a client and a therapist. Another sign would be if the therapist was prioritizing the client over other clients not due to the client’s needs, but due to the therapist’s attitude towards the client. Finally, if the therapist is asking the client to meet in spaces that are outside of the office, this would indicate a relationship that extends beyond the therapeutic relationship.

    Reply

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Adam M. Volungis, PhD, LMHC

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