Jeff Levy, LCSW
Mental Health, Relationships, Trauma, Identity
Jeff Levy, LCSW
(originally posted on Branching Out: The Live Oak Blog, June 2015)
During my first meeting with clients, I try to allow time to talk about what is bringing them to therapy while still saving time at the end of the meeting to talk about how I think therapy works. Sometimes, I don’t have to reserve time for this, because my clients will ask even before we talk about anything else. Other times, I may not be able to do this in the first session, but I try to do it as early in our work together as possible.
Part of the reason I share my thoughts about the process of therapy is for people to get a sense of my philosophy and orientation. I hope that this knowledge fosters informed decisions about goodness of fit. I’ve also found that for some—even those who have been in therapy at other times—sharing my perspective on how and why I think therapy may be helpful is not something they’ve heard in the past.
The Present Moment in Therapy
One of the most important reasons I share thoughts about how therapy works however, is to introduce the idea of the present moment and how our relationship—the relationship between the two of us in the room—may sometimes feel like relationships outside the room. I share how the content of what we talk about is important, but equally important is the process.
The process—how we talk about what we talk about—and the way our relationship evolves, provide opportunities to look at other relationships. Looking at and understanding our present moment interactions can foster an awareness that allows us to change patterns in the room, with the hope of generalizing those changes to our relationships outside the room.
It may sound premature or maybe even too prescriptive to talk about our relationship so early in the process of therapy. I’ve found, however, that even if it doesn’t make complete sense as we begin, frontloading the idea of our relationship as a laboratory for understanding other relationships provides a bookmark to which we can return in later conversations.
As the process of therapy unfolds, when I notice something about our relationship, I can return to that bookmark. Sometimes it is a reminder. Sometimes people don’t remember me sharing anything initially. Usually however, when I begin to ask questions about our relationship, having spoken about it earlier avoids an element of surprise. It can often feel like a natural and expected part of our process, albeit uncomfortable.
Meg Communicating What She Needs
Meg’s history of neglect was pervasive. Born to parents with multiple addictions, she was quickly handed off to her aunt, whose physical disabilities made it difficult to care for her. While there were others living in her aunt’s home, none were particularly interested in taking care of a baby. Meg moved between multiple relatives until she left for college. “I never had my own room and never my own bed,” she explained when talking about her childhood. “I slept wherever there was space, and sometimes that was the floor of my aunt’s living room.”
Because of scholarships and part-time work, she was able to put herself through college and later graduate school in business administration. She came to therapy because she was excelling in her career, but felt lonely, isolated, and anxious in her personal life, despite having a husband she experienced as loving and accepting. “I feel like no one understands me and I’m always let down by people, “ she lamented in one of her first sessions.
As therapy progressed, I noticed I was feeling more and more inadequate. On multiple occasions, as our session was almost over, Meg would be silent for a few minutes, and share some variation of the following: “I don’t think my therapy is helping me. Why should I keep coming?”
Initially, I found myself exploring this with her, but I also attempted to be a therapy “cheerleader,” expounding the value of therapy and what she could get from continued attendance. I also almost always ran over our allotted time. I knew neither Meg nor I felt satisfied and I also noticed that I began to feel frustrated running over our allotted time when these conversations arose.
I committed to bring this up to her, but the opportunity didn’t seem to arise until one day, in the middle of our session instead of the end, she asked again why she should continue to come to therapy when it wasn’t helping her. “I keep telling you what I need,” she said tearfully, “but you never give it to me.” I was astounded. I didn’t ever remember her telling me what she needed from me.
“It makes sense that you don’t see the value in coming if you don’t feel like I’m giving you what you need, “ I responded. “I have to admit though, I feel a little surprised because I don’t remember you asking anything specific of me. I’ve sensed that you weren’t getting what you want from me, but didn’t have a clear sense what that was.”
I thought about Meg’s history and her goals before I continued, “Do you feel like this with your friends and husband as well; that you’ve told them what you wanted or needed and they didn’t respond the way you’d hoped?”
“Yes!” she responded vehemently. And then our interactions began to make a little more sense to me.
“I know you see yourself as being very clear about what you need with your friends, your husband, and with me. At the same time, I don’t know that I’ve gotten a clear sense of what it is you’re wanting or asking for. If that’s my experience and you don’t see me as ‘getting it,’ do you think it’s possible that you believe you’re being clear with your friends but they have trouble ‘getting it’ as well?
We sat quietly for a few moments before Meg responded. “I didn’t think about it that way, but now as you ask, I’m almost positive that’s what happens. I think I’ve said what I need, but I’m pretty sure that I don’t do it directly. I’m scared to ask for anything because I may not get it. In fact, not only might I not get it, but I’m afraid someone will tell me I don’t deserve it.”
We continued to talk about this dynamic, also taking time to consider how Meg’s questioning the value of our relationship paralleled her questioning the value of her friendships and romantic relationships. I wondered if others in her life felt increasingly inadequate and increasingly frustrated. And if this was true, I asked her if she thought it might lead to her ending relationships because people weren’t understanding her, or if it led to feeling rejected by others because she wasn’t “good enough” to get her needs met.
Another instance where the relationship in therapy paralleled other relationships was in my work with Adam. Adam was in the process of a divorce after 15 years of marriage. He and his wife had separated amicably, but Adam found himself feeling increasingly criticized by his wife, especially related to the extent to which she could depend on him.
In the months following their separation, they were trying to share custody of their three sons equally. Adam had the boys for three and one-half days per week, and his wife had them for the other three and one-half days. They also had established a tentative agreement about finances including child support and spousal support.
As the length of their separation grew longer, Adam used his sessions to talk about his frustration with his wife. “I don’t get it,” he said one day. “We were doing so well when we started this divorce, and now Charlene (his wife), is telling me how she can’t trust me to follow through on things. She says she can’t depend on me!”
I asked Adam to tell me more about what he thought Charlene meant. With some gentle questioning, he admitted that he had been over two weeks late paying child support for the past several months. He also said that it was hard for him to pick his sons up at the predetermined time. He had established a pattern of being late to get them, late to bring them home, or frequently asking to change their schedule with very little notice.
As Adam shared all of this, I realized that he had not been on time for his appointments with me for close to two months, and I’d also had several last minute calls either canceling or asking to reschedule. The opportunity was there for me to invite our attention to how our relationship was evolving in the same way that his relationship with his wife was evolving.
My history with Adam was long, and we’d discussed difficult things in the past. I still felt my stomach knot as I readied myself to bring attention to our relationship. “Well,” I paused, “I know there are many things that are different about your relationship with Charlene and your relationship with me, but as you’ve been talking, I realized that I’ve had feelings that, in certain ways, I can’t depend on you either.”
“WHAT?” he almost shouted. “How can you say that to me? You’re my therapist and you’re supposed to support me and I’m supposed to depend on you! You shouldn’t need to depend on me! Whose therapy is this?”
I reminded myself to breathe and settled a bit in my chair. I affirmed Adam’s statement that I am, indeed, his therapist and this is absolutely his therapy. At the same time, I reminded him of the conversation we had when we began our work together. I asked if he remembered me talking about how the relationship that developed between he and I might have some of the same patterns as his relationships outside of therapy. Begrudgingly he acknowledged that he remembered.
“And so we have this opportunity,” I continued. “I was noticing some of the feelings I’ve had related to you being late for sessions and canceling with short notice. And the more I thought about them, the more I realized that I might be having some of the same feelings Charlene has, that your sons have, and maybe that others in your life have. If we can look at this in our relationship—understand it and make any changes you’d like to make—it might also be an opportunity for you to make some of these changes with your family and others you love.”
This was obviously difficult feedback to sit with, and I could tell Adam was ambivalent about acknowledging the parallel. Still, the more we talked about it, the less defensively he responded. While he still told me he was angry, he also began to understand how his relationship with me could be a window into the world of his relationships with others. At the close of our session, eyes to the ground, he said: “I don’t like this, but I get it. And I want to change it.”
The Present as a Blueprint for the Future
It is challenging to bring our relationships into the room as a topic for conversation. It’s especially challenging when we notice patterns evolving in our therapy relationship that we hypothesize may be happening in other relationships as well.
When I’m consulting with other therapists and I see these patterns emerging in their work, I try to ask if it’s possible those same patterns are occurring for their clients in other relationships. When the answer is affirmative, I usually ask if the therapist would consider being explicit about these parallels. For most people, it is uncomfortable at best, and often frightening. I understand—because I feel similarly.
In preparing to bring the topic of conversation to our relationship in the room, I notice some of my internal dialogue: “He’s going to be angry with me,” or “I’ll hurt her feelings,” or “This will destroy the trust I’ve worked so hard to build.” I do listen to these voices, but at the same time there is a part of me that knows if I don’t talk about our relationship and its parallels to relationships outside of therapy, I stay in a space of comfort but not necessarily one of intimacy.
We come to therapy to make changes. Often those changes relate to our relationships in the world: our partners, our children, our friends, and our co-workers. We can talk about these relationships and gain understanding of their dynamics. I’ve come to find, however, that one of the most powerful opportunities for relational change comes when we are able to use our therapeutic relationship as an ever-evolving blueprint for the changes we hope to make with others in our world.
Won’t you stay, we’ll put on the day, and we’ll talk in present tenses.
All AIDS Anger Apologizing Asking Questions In Sessions Authenticity Beginnings And Endings Being The Expert Boundaries Boundary Crossing Boundary Violations Breaks From Therapy Collaboration Between Therapists Coming Out Compassion Fatigue Contact Between Sessions Continuity Between Sessions Courage Crying Death Depression Disclosure Disclosure And Technology Dogs Email Emotional Support Animals Emotions Empathy Ending Psychotherapy Endings Expectations Experiments Failure Finances Forgiveness Framing Therapy Fraudulence Gifts Goals Grief Happiness Healing Rituals HIV Holding Back Homework Honesty Hope Human Animal Bond Identity Imposter Injuries Interpersonal Neurobiology Intersectionality Long Term Therapy Loss Loving Yourself Memory Metaphors In Psychotherapy Microaggressions Money Multiple Identities Neurophysiology New Information New Normal Normal Not Knowing Pain Physical Contact Positive Emotions Present Moment Priorities Privacy Questions Rage Real Relationships Resentment Resolution Rites Of Passage Rituals Rupture And Repair Sadness Safe Spaces Safety Safety Plan Safety Versus Comfort Secrecy Session Structure Short Term Therapy Silence Stigma And Mental Health Suicide Survival Strategies Themes In Psychotherapy Therapist Client Relationships Touch Trauma Trigger Warnings Values Vicarious Resilience Vicarious Trauma