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When you have nothing to say

emforsterI remember when I was in my early 30s and seeing a therapist to process my experience with infertility. At the beginning I had so much to say that I didn’t know how I would make it between sessions. Then after (I thought) I had said it all, I would worry before appointments that she’d be disappointed because I didn’t have an idea about what we should talk about.

I used to plan our topics. All week I would store up events or musings and I’d have them neatly prepared. I would continue to do this even after I realized that during most of our appointments we’d end up talking about something completely different. She’d ask about something we discussed the session before or in our casual opening we’d end up on a subject I hadn’t even considered. But I’d wrench us back around to the topic I had planned even if it fell flat because I thought I was supposed to.

I didn’t know then that it was more than OK to just show up. I didn’t have to have a topic prepared. I didn’t have to know what we were going to talk about. I could let the conversation happen organically and trust her to help me figure out what I wanted to say.

Therapy is a lot like writing. Sometimes you come to the page with a plan and sometimes you don’t. Sometimes you have it all outlined and mapped out and sometimes you’re free writing whatever comes into your head no matter how messy and disorganized and ungrammatical it might be.

You can’t have too much of one or too much of the other. Yes, you do need to have goals and you need to pay attention to your goals but you also need time when you’re sitting in the chair riffing on whatever comes up.

You and your therapist are working in collaboration. You don’t have to come up with every topic and she’s not going to always lead the way. The two of you will discover what it is you’re working on through the course of your conversations. If you do too much editing (especially if you’re not bringing things up because you are afraid she will be upset or bored) then she’ll be working with less material than she needs. If you try to plan your topics because you’re afraid that she will be annoyed if you sit there blankly saying nothing then you may lose the opportunity to see what the silence will bring to you.

(Sitting in silence with a person who is wholly tuned in to you can be very powerful. Try it sometime.)

Therapy is collaborative creation and growth. Trust the process and give yourself permission to allow the session to unfold however it will.

No need for sorry

open-insideTherapy is a good place to talk too much about yourself. Or cry a lot. Or get angry and petty and small.

You don’t have to be your best self in the counseling office, just be your most honest self. Sometimes they will be the same selves and sometimes they will not. Therapy is a good place for figuring that out.

I was thinking of this because clients will sometimes (often) apologize for being too much (too sad, too angry, too self-centered) in my office. But that’s what counseling is for and I need you to be real with me so I can help. I know it feels scary and vulnerable but if you’re able to share your honest self with me then we can get down to doing some good work.

Being real in session means you’re nailing this counseling thing so instead of feeling lousy or worried about being self-indulgent you can give yourself a pat on the back.

I got into this counseling gig because I’m genuinely interested in other people and I want to hear what you have to say. Sometimes (often) clients — particularly at the beginning — will say something like, “I’m sorry I just babbled so much” but I’m thrilled when clients babble so much. My job is a lot easier when people talk. I love it when you talk!

When clients come in with trepidation, afraid of letting go, and then they do let go, I know we’re at a fragile place. It’s scary to talk a lot or cry or get angry and petty and small. Sometimes the client won’t want to come back afterwards because it was all too much or too hard. But we can pull back if you feel like it’s going too fast. That’s ok. Usually the natural rhythm of therapy will throw us a gentle session after a super hard one even without our effort. But you can be explicit about slowing down.

Sometimes clients don’t come back after a heavy session. At first they don’t want to come back because that heavy session was scary. And then maybe the scariness wears off and they do want to come back but they’re afraid that I’m mad at them for disappearing or that they’ll need to make excuses. To heck with that, just come on back. Your therapist will be happy to process your need for a break with you and you can just say it outright, “I thought you would be mad” or “I was mad at you for pushing.”

More realness, which is more goodness. As my father-in-law would say (and he does, often), “Bring it on!” We love that stuff. No need for sorry.

Playing with the sand tray

sandcastle-insideWe used to have two gorgeous handmade wooden sand trays at our agency but when our boss left she naturally took her toys with her and that included the sand trays. I knew they were leaving but didn’t think much of it because I figured we’d get out the old Rubbermaid boxes we used to use and I thought, well, they aren’t as lovely but what the heck, they’ll work just fine.

Funny thing, though — they don’t work nearly as well.

An official sand tray is wooden and is painted blue inside (to symbolize water). They come in different sizes (and some of them are round) but the standard size is around 24″ x 30″ and about 3″ to 4″ deep. The reason they’re so big is they’re meant to hold an entire world. The reason they’re not even bigger is that they’re meant to hold that world in a space small enough that the child can see all of it without turning her head.

The Rubbermaid containers are smaller and they’re not as pretty. The small size matters because the kids who are used to the bigger trays are annoyed to find the worlds they make are now all cramped up. And the prettiness matters because the toys we use are our means to communicate with our clients and the better our tools, the more we are conveying our respect for what they have to say. I believe that the respect that comes with working in a solid, lovely sand tray makes a difference in how welcomed the child feels in our sessions together and the Rubbermaid fix — while workable — doesn’t have that same gravity and consideration.

I didn’t have a sand tray for my private practice because I was holding out for a good one and they’re not cheap. I kept thinking about giving in and buying something makeshift but I didn’t want to compromise. Once I saw the difference our switch to the Rubbermaid containers made in my sessions at the agency, I became even more determined to wait until I could get a good, solid, wooden tray.

Then I found these instructions for making your own. Hurray!

Now I’m not handy so I knew that I wasn’t up for the task but when I was talking to my father-in-law about it he volunteered to make me one. And he did and it is beautiful and I am thrilled.I’m still working on building up my miniature collection and exploring ways to display it to make it accessible (right now it’s a jumble). I’m thinking about using molding to create shelves for the figures but want to make sure that they’re not prone to tumbling off before I start drilling holes in the wall.

I love using the sand tray with my clients. It’s such a great way for a less verbal child to communicate with me and it calms down the sensory seekers like nothing else (except maybe play dough). Children who are feeling shy about choosing toys in the playroom will generally dive into sand tray work much more quickly and then it seems once they’ve established their place in the sand then they are able to transfer that sense of ownership over to the rest of the toys.

It’s also a useful way to get a better understanding of relationships since families can create trays together. Watching two brothers negotiate a world together gives me a glimpse of how they work together (or don’t) at home.

A sand tray is an important investment for anyone doing play therapy and getting a good one is definitely worth the time or money. (I tried to talk my father-in-law into making himself available for building one for local friends but he said that while it was an easy project, it’s not something he’s rushing to do again. But he does encourage the handy among you not to be afraid of trying to build your own.)

When clients disappear

thoughtful-insideI was talking to another counselor last week about clients leaving therapy and how sometimes clients graduate and the two of you are happy together and celebrate her accomplishments and it’s great. And then sometimes they choose to leave by no showing on an appointment and not returning your call about rescheduling.

I don’t like it but I get it. When I was a teenager and hunting for my own “change my life” therapist I tried a couple of counselors who really didn’t work for me and I told them so by disappearing. I couldn’t imagine actually telling them with my actual voice that I wasn’t coming back. For one thing, it would be embarrassing. For another thing, what would it help? What if they tried to talk me out of it? What if they acted sad or hurt or angry? I didn’t call and I ducked their messages because it just felt way too scary to face them when I’d already decided to walk away.

Obviously, I get why some of my clients do that, too.

I can usually tell if my client is at risk of not coming back. After a particularly good (i.e., hard) session, I know there’s a chance that a client will realize she wasn’t ready to go so deep. I try to let her know that this might happen — at the end of the session I’ll talk about possible residual effects from working so hard.

Or if my client has a lot of barriers to coming in (unpredictable job schedule, demanding kids, etc.) I know that counseling may not fit into her life right now. I try to talk about that, too, and discuss creating a schedule that may work better rather than the traditional once a week at the same time every week.

And then there are some times when we just don’t click, the client is looking for a therapist with a different kind of expertise or a different couch-side manner or whatever. I can tell when that’s happening, too. If a client is phoning it in at the very first session then I know there’s very little chance of her coming for a second visit.

In all three cases I’d rather they called instead of no-showing because we might be able to address their concerns.

If the session was too heavy then we can dial back for awhile (and I notice that often sessions happen that way naturally — big epiphany and then a breather for a session or two) or we can talk about post-session planning so that she won’t be overwhelmed.

If her life is too crazy-busy, we can talk about changing our schedule around or pick a time somewhere in the future where we’ll check in again to see if things have opened up at all.

If she simply doesn’t click with me, I can find out what she’s looking for and give her some referrals. That’s totally ok by me. Recently I met with a client who wanted a therapist who does energy work, which I don’t do. I happily sent her off with referrals to other counselors because I have no desire to take money from someone who would be happier working with someone else. Truly.

I think this is true of most counselors (at least the counselors I know). If you don’t want to come back and don’t want to tell them why, I get it. I’ve been there and I’ve done that. But if you are able to talk to them, give it a go. You might get some support or some changes or help heading in another direction.

It’s worth a try.

A Diagnosis Discussion

toomuchthink-insideAt the community mental health center where I work every single person I see gets a diagnosis. There’s a preliminary diagnosis after the first session, which I may write without even seeing the client. (When we do an intake on a child we see the parents without the child for that first diagnostic assessment so the preliminary diagnosis is based on the parents’ report.) The preliminary diagnosis isn’t set in stone; it’s considered a starting point. Clients at the clinic use insurance or Medicaid to get services and they require a diagnosis to open the case so we give one based on the information that we have.

Then a few more sessions in we write the actual diagnosis. By then we’ve seen the client, we have a fairly full history and we can make a full five axes diagnosis. We base that diagnosis on the client’s symptoms and history and when we write the treatment plan we refer back to it and it all works very nicely.

The reasons behind diagnosis are pretty clear — when we make a diagnosis we are creating a picture of the client for ourselves, for other clinicians who might work with her, and for the client herself. As we design treatment plans and measure progress we can refer to the diagnosis to get a better understanding of the work we’re doing together. When we case consult at our clinical meetings we can use diagnosis to better communicate the issues for our client in order to get appropriate feedback to improve her care.

That’s all good, right? Usually it is good. But sometimes it’s frustrating.

Diagnosis is an imperfect art. You know that old joke about rabbis? Here, I’ll tell it to you: What do you get when you have three rabbis? Four opinions. Same goes for therapists. Sometimes a person is experiencing such clear symptoms that it’s very easy to say, “Ahh, yes! Recurrent, persistent and intrusive thoughts? Behaviors meant to neutralize these thoughts? Repetitive hand washing, counting and rules about light switches meant to stave off distress? That’s 300.3 Obsessive-Compulsive Disorder!” Easy-peasy. Everyone gets it.

But other times you can have a client and it’s not nearly as clear for lots of reasons. Like clients may not really know their own history. They may exaggerate or understate the length of time they’ve had symptoms or the severity of those symptoms. Sometimes I get a client’s records and find out she’s had several different diagnoses (this is especially true for children). This speaks to the fact that it is all open to interpretation.

A diagnosis doesn’t just exist in the clinical setting; our clients live with it. I’m not talking about the symptoms or history that lead to the diagnosis; I’m talking about the label. The diagnosis doesn’t just live in her file, all nice and neat and detached from real life. The diagnosis lives in her experience of herself.

Part of working with a client around her diagnosis is helping understand that she isn’t her label. She is not “a depressive” or even a “depressed woman;” she is a “woman with depression.” Even if her illness dictates some of her choices (medication, counseling, etc.) it is not HER. But it can be hard, particularly when I have a client who has been living under the shadow of a diagnosis for some time.

This is especially important when it comes to teenagers. Teens are already trying to figure out who the heck they are and getting a diagnosis in the middle of that can be heady stuff. A diagnosis can be used like a shield to protect her from expectations, to excuse herself when she hangs back, and to rationalize her failures. She may become her diagnosis, reading information on the internet and shaping herself to fit the criteria.

I have a lot of clients who come in with a self-diagnosis based on reading magazines, talking to friends or just a general understanding of what a label actually means. (Lots of clients use words like “anxious” and “panic attack” and “bipolar” without understanding their clinical definition.) They sometimes feel very defensive when I tell them that they don’t actually meet criteria. Feeling sad about a pet dying is not clinical depression; it’s appropriate grief. Feeling nervous about going on a first date is not social anxiety disorder; most of us are nervous before a first date. Feeling happy one day and sad the next is not bipolar disorder; it’s part of the human condition. Our sadness and our fears and our struggles do not need labels to be real.

When I give a client her diagnosis I first give her a rundown about how we got to it. I explain that a diagnosis is a label for a cluster of symptoms and that our focus will be on addressing symptoms. I tell them that a diagnosis is just a way for us all to communicate with each other and it’s not more real than what they’re actually experiencing. It’s a tool, I say, OUR tool, THEIR tool and we own our tools; our tools do not own us.

I don’t take insurance in my private practice and one reason is that it allows me the freedom to give or not give a diagnosis. A diagnosis should serve the client and sometimes I think a client is best served by not being given one.

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