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Does my therapist care about me?

heartWhen I was in my late teens I began seeing a counselor because I was depressed. I was taking a full load of undergrad classes at OSU and working 40 hours a week and living by myself without roommates or family for the first time ever. My weekly visits to Barbara (my therapist) quickly became the center of my schedule. I’d drag myself to work and school, grind my way through my day, all the while focused on that bright spot, once a week, when I would sit in her office and feel safe.

I loved Barbara even when I didn’t love therapy, which was hard and often painful. I didn’t always leave her office feeling better. There were days I left feeling raw and fragile, my face swollen with tears. I started scheduling my work so I had the day off on therapy days so I could come home, curl up in bed and sleep away my emotional exhaustion. I could feel myself growing stronger and straighter but it was hard going.

I think I saw Barbara for about a year, maybe a little more, maybe a little less. I saw her weekly and then I saw her every other week and then we agreed I didn’t need to see her anymore at all. But for the time I was in her care, I felt very dependent on her and I wondered how it was for her because she may have been the person I centered my weeks around but I was just a client on her schedule.

I wanted her to call me up to have coffee. I wanted her to like me best of all of her clients. I wanted her to lean in one day and whisper, “My sessions with you are my favorite!” And I was free to want that as much as I liked because I knew it would never happen. It was a little like Lisa Simpson’s copies of Non-Threatening Boys Magazine; a celebrity crush, all safe and worry-free. I knew I could tell her anything and she’d have to like me — or at least pretend to like me — because it was her job.

But I always wondered if she cared about me for myself and not just as a name in her appointment book.

Now I know because I have my own appointment book (well, iCal calendar — same difference) and I can tell you that yes indeed, Barbara cared about me and your therapist cares about you. But we care within the boundaries our profession sets for us and those boundaries are what allow us to serve you. It’s not like caring for a friend or family member because it has specific limits and in other ways it is limitless. The space we hold together in the counseling relationship is full of unconditional positive regard (loving acceptance of all you are), which is harder to maintain in real life relationships. In that way the counseling relationship is boundless. On the other hand, I would never call a client up and say, “I’ve been thinking of you; let’s have coffee on Thursday.”

I remember when my son was very small and I heard about a preschool teacher who made space in her evenings to think about every single one of her students for a moment, hold the thought of each child close and then let it go. This is a little bit like how it is with clients. Before work, I review my schedule and mentally and emotionally prepare for the specific clients I will see that day. Each night, before I leave my office, I review them (usually as I write up case notes) and then on the way home, I give myself permission to stop thinking about them by the time I arrive home. This is because it’s easy to worry about a client going through a particularly tough time and worrying does neither of us any good. When I do catch myself feeling anxious about a specific client, I take a page from the preschool teacher and give myself permission to sit with my thoughts for a discrete time. This helps me come to my sessions fresh and focused instead of wrung out and worried.

So this love and caring I have for my clients — and that Barbara had for me — is not the love and caring I fantasized about when I was in therapy (there are no intimate coffees, there were no confessions of favoritism from Barbara) but it is good and solid and dependable.

Play therapy looks like playing

play therapyUsually I let my kid-clients decide whether or not they want their parents to come into their play therapy sessions with them. (Some situations require parents be an active participant but most don’t.) The littlest children always want a parent to sit in the room, which is absolutely fine.  The kids and I play together and the parents watch or read a book or play on their smart phones.

I know that sometimes parents are sitting there watching us have a tea party or race cars or build with blocks and thinking, “I drove all this way for this? Took time out of the day, got the other kids childcare, took time off of work, took my kid out of school for this?” Because play therapy looks an awful lot like playing.

I try to head this off by explaining how play therapy works at the intake session but it doesn’t always sink in. And then we’re all in the office together and their child is playing and I’m watching (because I don’t play unless I get invited to play — my job is facilitation and observation) and … well, I’m not surprised when the question comes up, “What exactly are you doing anyway? And how is it helping?”

What I tell parents is that talk therapy is facilitated exploration through discussion and play therapy is facilitated exploration through play. Play is how kids communicate.

What makes the play therapy space special are the same things that make the talk therapy space special:

  • Unconditional positive regard (I accept you, I appreciate you, I see the good in you no matter what you do or say);
  • Safety (with rare exception what you share is private and stays in that room);
  • Concentrated focus (I am paying sharp attention to what you do/say and trying to both understand you better and help you understand yourself better);
  • A commitment to helping you move forward (I am actively looking for ways to help you grow through your experience);
  • A particular kind of loaded environment (comfy chairs, quiet, tissues at the ready and specific toys that encourage sharing).

Unlike most adults and bigger kids who can learn through give and take discussion, young children lack the insight and the vocabulary that allows them to discuss their experiences and feelings. Through play they are able to share what is causing them concern and work through it.

Many of the children who come see me play the same game over and over, trying to make sense of something so they can move forward. Just as talking something out can help, playing something out can help, too.

A common example is a child who heads straight to doctor’s kit every session because she’s working out her feelings about her last well-child visit. Having an understanding witness who gives voice (through her unbiased observation) to the story helps the child take control of her narrative.

Boundaries in counseling

brightcushions-insideLast week I said that I wanted to write about how the boundaries in counseling make the therapeutic relationship possible and so here I am! Writing about it!

The first time I really got the value of those boundaries was when I was driving away from a particularly tough session with a particularly tough client who also happened to be one of my very first clients. Without going into specifics that would compromise confidentiality, I will tell you that this was a client who seemed to have a black cloud of gloom and disaster following her. It always seemed like if a rotten thing could happen to her, it would. Some of this was of her own making but some of it was simply bad luck.

It made me miss being a case manager because as a case manager I’d have clear directives for her. We would be working a program together and I’d be bossing her around a little bit. I’d also have bus tickets and other program directors on speed dial to hook her up with other agencies (there’s an insider thing to case management that doesn’t seem to exist in community mental health agency work unless there’s a case management program there, too; like I can’t get a client free furniture but as a case manager in Portland I had access to those kinds of programs).

But I wasn’t her case manager (she had case managers), I was her counselor. And as her counselor I felt so helpless because I’d see her and she had so many challenges and I couldn’t do much but listen. I would meet with her and pay attention and help her make decisions and help her consider her options and help her process her emotions and I gave her all the unconditional positive regard I had at my disposal but it didn’t always feel like enough. I sure missed being able to hand over those bus tickets.

Unconditional positive regard is at the heart of counseling. When I am with a client, I am with them. I’m listening hard. I’m loving their humanity no matter what they’re saying. I’m seeing the human being that they are and I am accepting who they are even as I’m trying to help them to be their better selves.

So back to my tough session with my tough client.

I was driving away and I was thinking about something she’d said to me. We were talking about a pretty big barrier she was facing and I was itching to be the person in her life to be able to give her bus tickets and referrals and feeling pretty damn helpless to be just sitting there listening. I was having to work hard to not get lost in my feelings and instead stay there with her, present in her struggle, remembering that it was her struggle and not mine to fix. And she said, “This hour when we meet, it’s special to me because it’s the only time that’s all mine, all about me. It makes it so I can get through the rest of the week.”

That really brought home to me the value in “just” listening.

As I drove away I was thinking about how having nothing but my therapeutic self to give her — because counselors ethically can’t do the things case managers do. Ethically, counselors need to be very very very careful about handing out transportation or free furniture. Sure, we can give referrals to programs that do these things and there are times that stretching beyond ethical guidelines on gift giving is appropriate. But with this particular client, it was clear to me that any impetus I had to go beyond those limits would be about me and my fervent wish that her life be better and my feelings of helplessness in the face of her struggle.

I realized, too, that unlike the other helping people in her life (of which there were many), I was the only one who wasn’t asking her to do things. Well, that’s not entirely true — I did ask her to keep her appointments or at least call to cancel. And I did ask her talk to me. But these things happened more or less on her terms. She made the appointments at her convenience (within the bounds of my schedule). She talked about the things she most needed and wanted to talk about. We had a dialogue; I didn’t lecture and I didn’t make demands. She wrote her own treatment goals and we worked towards the things that mattered most to her with the context of her beliefs and values.

Because the boundaries of counseling dictated our relationship — that I not give her bus tickets, that I see her at this prescribed time in this prescribed way — I was able to fully be there with her.

If I had been her case manager I couldn’t have been with her as freely. Case management is all about moving someone through a case plan.  I also would have had to answer to the limits of our funding sources, which dictate which people a program can serve and how that program may serve them.

If I’d been her friend, I surely would have become fed up with the way her own decisions made her bad luck worse.

But as her counselor, I only had to be with her.

Our counseling relationship ended sooner than either of us would have liked due to some practicalities in her own situation but in the time we saw each other I did see real change in her attitude toward herself and towards her circumstances. Which is what cemented my faith in the value of the therapeutic relationship. Even if it doesn’t come with bus tickets.

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