How Psychotherapists Learn to Get Comfortable Talking About Sex

Considering how common sexual problems are for individuals and people in relationships, it's surprising that most postgraduate psychotherapy training programs don't even offer one course about sex (see my article: What is Sex Therapy?).

Psychotherapists Learn to Get Comfortable Talking About Sex?

Even the more progressive programs might offer only one elective course that isn't nearly enough to deal with all the sexual issues that clients deal with on a daily basis, including (but not limited to):

• sexual desire discrepancy 
• difficulty talking about sex in a relationship
  
• sexual arousal issues
• an orgasm gap in a relationship
  
• arousal nonconcordance
• guilt and shame about sex and sexual fantasies
• the paradox of love and sexual desire
  
• sexual fluidity
• ethical nonmonogamy (also called consensual nonmonogamy)
• negative body image

And so on.

Even many couples therapists aren't trained to deal with sex-related problems, which is even more surprising.  Many believe that if they help couples to be more emotionally intimate, this will automatically resolve their sexual problems, but very often it doesn't.

Worse still, clients usually sense when their therapists are uncomfortable about certain topics, especially sex, and they avoid talking about it--to their detriment.

Unfortunately, this can reinforce the idea that sex is a taboo, shameful topic to discuss--even in therapy.  This confirms the messages clients often get throughout their life--in their families, culture, religion and in society in general (see my article: What Does Sex Positive Mean?).

Clients can go through an extended period of time in therapy without the topic of sex ever coming up.  This is usually because both the therapist and the client avoid bringing it up--sometimes consciously and often unconsciously.

In addition, since sex isn't a topic covered in most postgraduate psychotherapy training programs, psychotherapists often don't know about their own blindspots, prejudices, countertransference and possible unresolved sexual trauma.

What Can Psychotherapists Do to Get Comfortable Talking About Sex?

As previously mentioned, when you avoid talking about sex, this can increase a client's shame and guilt about their sexual issues, which is not what most therapists want to do.  

So, what can therapists do who aren't sufficiently trained or comfortable to talk about sex with their clients?

• Get Professional Training: There are sex therapy postgraduate training programs that provide sex therapy certificates for licensed psychotherapists.  If you don't want to get certified in sex therapy, institutes like the Institute For Contemporary Psychotherapy (ICP) in New York City or the Modern Sex Therapy Institutes offer continuing education courses you can take on specific topics, including basic principles and practices of sex therapy, problems with sexual discrepancy issues in relationships, sexual arousal issues, countertransferential issues, and so on.  Many of these courses are online and they are taught by recognized sex therapy experts in the field.  

• Get Clinical Supervision From a Certified Sex Therapist: If you know you lack training, seek supervision from a skilled sex therapist who can provide you with clinical guidance.  

• Keep Up With the Sex Therapy Literature: There are excellent books available that you can read to educate yourself. The following is a list of some of the many books which are available:

• Come as Your Are By Dr. Emily Nagoski
• So Tell Me About the Last Time You Had Sex by Dr. Ian Kerner
• Transforming Sexual Narratives by Dr. Suzanne Iasenza
• Mating in Captivity by Dr. Esther Perel
• Tell Me What You Want by Dr. Justin Lehmiller
• The Erotic Mind by Dr. Jack Morin
• Becoming Cliterate by Dr. Laurie Mintz
• Better Sex Through Mindfulness by Dr. Lori Brotto
• The Leather Couch - Clinical Issues With Kinky Clients by Stefani Goerlich, LMSW
• Becoming a Kink Aware Therapist by Caroline Shabaz, MA and Peter Chirinos, MA
• Polysecure: Attachment, Trauma and Consensual Nonmonogamy by Jessica Fern, MS
• Open Monogamy by Dr. Tammy Nelson

• Listen to Podcasts: There are excellent podcasts available for free on many contemporary sex issues, including:

• Sex and Psychology with Dr. Justin Lehmiller (he also writes a blog)
• Foreplay Radio with Dr. Laurie Watson and George Faller, LMFT
• Sexology with Dr. Nazanin Moali
• Sluts and Scholars with Nicoletta Heidegger, LMFT
• Sex With Emily with Dr. Emily Morse
• Sex With Dr. Jess with Dr. Jess O'Reilly

• Know Your Blindspots and Seek Help in Your Own Sex Therapy: Without a doubt, therapists can't be experts on every topic, but it's important to know your own blindspots that could get in the way of helping your clients, and to seek help for yourself if necessary:

• Do you have your own sexual issues or problems in your relationship that you're still struggling with that require professional help? 

• Were you raised in a traditional family where sex was considered sinful so that you struggle now with sexual issues?

• Are there particular sexual issues that make you cringe which could add to a client's guilt or shame?

• Work Within the Scope of Your Expertise and Know When to Refer Out: As previously mentioned, there are so many issues in contemporary psychotherapy that clients bring into treatment so that no therapist can be an expert in everything.  Without even realizing it, many therapists provide clients with the wrong information that doesn't work for them. This will leave clients feeling like they have failed or, worse still, that their situation is hopeless. So, if you know you're not professionally trained or personally equipped to talk about certain sexual topics, know when to refer out to a skilled sex therapist.  You'll be helping your client and yourself.  Also, most sex therapists are willing to do adjunctive therapy with your client where you can remain the primary therapist for other issues and you and the sex therapist can collaborate if this is agreeable to your client and to you.

About Me

I am a licensed New York City psychotherapist, hypnotherapist, EMDR, AEDP, EFT, Somatic Experiencing therapist and Sex Therapist.

I am a sex positive therapist who works with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW.

To set up a consultation, call me at (917) 742-2624 or email me.

 

The Erotic Countertransference: The Therapist's Sexual Attraction to the Client

In an earlier article, Psychotherapy and the Erotic Transference: Falling "In Love" With Your Psychotherapist, I discussed clients' erotic feelings (also known as transference) for the therapist, the struggle that clients often have with these feelings, and how these feelings can be worked through with the therapist in a way that furthers the work in therapy.  As mentioned in the earlier article, a client's erotic feelings for his therapist is a common issue in therapy.  In this article, I'm focusing on the therapist's erotic feelings (also known as countertransference) for the client.

The Erotic Countertransference: The Therapist's Sexual Attraction to the Client

Psychotherapists who have been trained psychoanalytically are aware that they can develop erotic feelings for some clients. Knowing in advance that this will occur at some point and being trained on how to deal with it in an ethical way helps therapists to be prepared for these encounters, and it allows them to handle these issues in a way that isn't harmful to the client or their work together.

Before I go any further, I want to make it clear that psychotherapists know that it would be a serious boundary violation to get sexually/romantically involved with the client whether that involvement occurred during their work together or even after the client terminated therapy.  Unfortunately, although the vast majority of therapists are ethical, there are some therapists who act unethically.  Fortunately, they are in the minority (see my article: Boundary Violations and Sexual Exploitation in Therapy).

A therapist who has in-depth psychoanalytic experience, knows how to attune to what's going on in her internal world, with the client, and in the intersubjective space between the client and therapist.

She is also able to  momentarily dip into her own subjective experience in a way that's useful for the therapy (see my article: Psychotherapy: A Unique Intersubjective Experience).

For instance, as an example having nothing to do with sexual attraction, while she is listening to the client, a particular song might pop into the therapist's head, and she would ask herself if this song has any relevance to the client or the therapy session. She would ask herself if this is a way for her unconscious mind to give her more information that she might not be picking up on consciously? (see my article: Making the Unconscious Conscious).

There can be many reasons why a therapist might feel sexually attracted to a client.  On the most basic level, some people, including clients in therapy, naturally exude a certain sexual magnetism.  Since part of the therapist's job is to be attuned to the client, she could be picking up on this magnetism.

Another common reason is that the client might be flirting with the therapist as part of a defense mechanism to divert the conversation from things that make him uncomfortable in the session. For an experienced therapist, this is usually easy to see and would need to be addressed by the therapist in a tactful way.

Another issue might be that the therapist might be at a point in her personal life where she is not romantically, sexually or emotionally fulfilled.  As a result, she might experience these unfulfilled needs in the therapy room with the client.  This is why it's so important for psychotherapists to be attuned to their own personal needs so that they don't make ethical mistakes.

The Erotic Countertransference:  The Therapist's Erotic Feelings For the Client
The following fictional vignette is based on many different clinical cases.  It illustrates how the therapist attunes to her own internal experience and how she uses this attunement to discover the meaning of her experience and how it relates to the work with the client.

Gina
Gina, who was an experienced psychotherapist, realized that she felt a sexual attraction for Jim, after their first session together.

As a seasoned psychotherapist whose original training was in psychoanalysis, Gina knew that it was common for both clients and therapists to have attractions for each other.

Not only had she learned about the erotic countertransference in her original analytic training and in her extensive supervision, she also experienced this occasionally with other male clients.  She and her colleagues also discussed this phenomenon in their peer supervision group.

Although she was clear that she wouldn't act on her attraction based on ethical and clinical reasons, there was something different about this experience as compared to other earlier experiences that concerned her.

So, rather than ignoring her sexual attraction, she paid attention to it, and after her second session with Jim, she thought about whether there was something familiar about him that might be triggering these feelings.

She also talked to her own psychotherapist about this sexual attraction in her next therapy session.  Since her therapist, Ruth, knew Gina well from having worked with her in her analysis for over 15 years, Ruth listened intently as Gina described the sexual feelings that came over her during the first two sessions with Jim.

As Ruth listened to Gina describe this attraction, she realized that Jim had similar characteristics to Gina's husband, who died several years before.  She knew that even though Gina had gone through a period of grief and mourning, she still missed her husband a lot.  She also knew that Gina had been unable to motivate herself to begin dating again even though several years had passed, which left Gina feeling lonely.

As they talked about the similarities, including appearance, between Jim and Gina's late husband, Gina felt a deep sadness come over her that she had not felt since Jim died unexpectedly.  Although she saw the striking similarities between Jim and her late husband, Gina also saw the differences, and as she began to differentiate the two men and her feelings towards them, she began to feel a little better.

These feelings for Jim were also a signal to Gina that she needed to take better care of herself and that her loneliness signaled that she might be ready to explore dating again--even though she had mixed feelings about it.

During her next several sessions with her therapist, Gina explored her ambivalence about dating.  Part of her hesitation was that she continued to feel loyal to her late husband, and she wasn't sure how she would feel dating someone new.

But she agreed with her therapist, Ruth, that she could take it one step at a time, and she was under no obligation to date anyone.  So, she thought of her foray into dating as a way to explore her own feelings and the next step in her mourning process, which included an acceptance that her husband would never come back.

This acceptance that her husband was gone forever brought a new and deeper wave of grief for Gina. She knew from her own training and clinical experience that this was a normal part of grief and mourning as time went on.  So, she continued to talk to her therapist to address her own emotional needs in her therapy and separate out these needs from her work with her client, Jim.

As Gina took care of herself emotionally by talking to her therapist about her emotions and to her friends, who were also colleagues, about her attraction to Jim, she noticed that her attraction began to diminish.  Her work with Jim continued without interruption to his clinical process in sessions, and the therapy was going well.

A few weeks after Gina started seeing Jim as a therapy client, she noticed that she no longer felt an attraction to him.  She could see the resemblance and similarities to her late husband, but she also saw Jim clearly for himself as an individual.

Four months later, Gina began dating again.  She met a man who was also a widower and who understood her mixed feelings about dating.  As she continued to see him, she realized that her feelings for her late husband would never change, and there was room in her heart for both her late husband and for the new man that she was beginning to really like (see my article: A New Relationship: Understanding the Loyalty Dilemma For Someone Whose Spouse Died).

As her emotional needs were met in her therapy, with friends and colleagues and with the new man that she was dating, Gina felt more emotionally fulfilled.  With time, her client, Jim no longer reminded her of her husband because, although there was a physical resemblance, she could now differentiate more clearly that they were two very different men.

She was glad that she took care of herself and used her resources in therapy and among friends and colleagues to deal with the countertransference issues related to her therapy with Jim.  She recognized that, in many ways, it was similar to what occurred occasionally with other clients in the past, but she also saw why her feelings were so heightened with the similarities to her husband.

Conclusion
Both clients and therapists can develop sexual attractions for each other.  It's usually related to transference for the client and countertransference for the therapist.

Therapists have an ethical responsibility to be aware of their feelings and, for the sake of the client and the integrity of the therapy, not to act on their feelings.

Occasionally it happens that a therapist, who sought help in her own therapy, in supervision and among colleagues, is still unable to handle the countertransference, she has a ethical responsibility to refer the client to another therapist rather than act on her feelings or continue to be in conflict about them.

It's of utmost importance that therapists have a strong sense of self awareness and engage in self care so that they don't compromise a client's therapy.  As in the fictional scenario above, this means that the therapist must have the necessary skills and training to self reflect on her own internal process and do what she needs to do to take care of herself.

Although it was not discussed in this article, there are times when both the therapist and the client have a sexual attraction for each other.  In those cases, even if the client behaves in a seductive way, it's the therapist's responsibility not to cross a boundary with a client.  She must analyze her own feelings as well as the clients to understand the root of the issue for each of them and then proceed in an ethical manner to do what's best for the client while taking care of herself.

Getting Help in Therapy
Most well-trained psychotherapists are aware that they will occasionally feel an attraction for a client.      This is a common experience.  Most of them will also know that this probably has less to do with the client than it does with whatever is or isn't going on in their life.

Although sexual boundary violations do occur from time to time, most therapists take their Code of Ethics, which states that therapists cannot be in a dual relationship with a client, seriously.  They know it would be devastating to the client, their work together and it would also jeopardize their professional license if they crossed this ethical boundary.

If you're already in therapy and some of the issues in this article resonate with you, you would probably benefit from discussing them with your therapist or, if you're not comfortable with that, seeking a consultation with a different therapist to discuss what's going on in your therapy.  Most of the time these issues can be worked out, but if you tried and they can't be resolved, you can also seek help from another licensed therapist.

We all need help at some point in our lives.  If you're not in therapy and you're struggling with unresolved issues that are creating obstacles in your life, you deserve to get help from an experience licensed mental health professional.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR, AEDP, Somatic Experiencing and Emotionally Focused therapist, also known as EFT (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

How Contemporary Psychotherapy Has. Changed - Part 2

In Part 1 of this topic, I gave a history of the early psychoanalytic views of psychotherapists' reactions to clients (also known as countertransference) and gave an overview of more contemporary views on this subject.

How Contemporary Psychotherapy Has Changed

There are many ways for psychotherapists to share their reactions with the client--too numerous to write about in one blog article.

In this article, which is Part 2, I provide an example of contemporary psychotherapy with a fictional clinical vignette which illustrates one way that the psychotherapist's willingness to share her views with the client can accelerate the work in therapy and help to heal the client.

Fictional Clinical Vignette: Psychotherapists' Reactions to Clients

Nina
After struggling on her own for years with low self esteem, Nina began psychotherapy again to deal with this issue which was getting in the way of her personal life and her career.

She had been in therapy a few times before in the past and, although she developed intellectual insight into her problems, nothing changed for her.  Overall, her experiences in her prior therapy were not good because her psychotherapists tended to remain silent, and this made Nina feel uncomfortable.  But she decided to give psychotherapy another chance with a psychotherapist who was recommended to her.

As Nina was providing her psychotherapist with a family history, she discussed feeling unlovable in her family, especially after her younger brother was born (see my article: Overcoming the Emotional Pain of Feeling Unlovable).

She explained to her therapist that she found out as an adult that after her birth, her mother was depressed and unable to care for Nina, so Nina's maternal grandmother and various aunts took turns caring for her.

She also found out that after her younger brother was born a year later, her parents were ecstatic to have a boy.  They had always wanted a boy to carry the family name.  And, whereas Nina continued to be shuttled off to various relatives for care, her brother was treated as precious and special throughout his life.

Apparently, by the time Nina's brother was born, the mother was no longer depressed, but she never bonded with Nina.  Her focus tended to be on the brother.  Her father also doted on the brother.  So, from a young age, Nina felt there must be something wrong with her since her parents practically ignored her, and she grew up feeling unworthy of love.

Although she loved her brother, Nina felt angry and resentful towards him.  Intellectually, she knew it wasn't his fault if her parents favored him over her but, on an emotional level, even at a young age, she had fantasies that he would die from a mysterious cause and then her parents would love her more.  These fantasies, which continued into adulthood, caused Nina to feel guilt and shame.

Although she dated in college, at the age of 33, Nina had never been in a long term romantic relationship. Whenever a man expressed interest in her beyond casual dating, Nina would begin finding faults with him in her mind and, eventually, she would end their dating relationship.

At the same time, Nina said, she was very lonely, and when she wasn't dating anyone, she longed to be in a serious relationship.  She would tell herself that she wouldn't be so critical of the next man she dated, but it was an ongoing cycle (An Emotional Dilemma: Wanting and Dreading Love).

Psychotherapists' Reactions to Clients 

The psychotherapist listened to Nina's history with compassion.  She recognized that Nina was caught in a dilemma of wanting love at the same time that she dreaded it.  She wondered if Nina would be able to form a therapeutic alliance with her to do the work or if the therapeutic relationship would be too threatening to Nina.

She also recognized that Nina used the defense mechanism of avoidance in her relationships with men. She could see that this was a necessary emotional survival strategy that Nina developed unconsciously when she was child to ward off the overwhelming feelings of hurt and still maintain a tenuous attachment to her parents (see my article: Understanding Internal and External Defense Mechanisms).

With regard to her career, Nina explained, she lacked confidence in her ideas in a field that was very competitive.  As a result, junior staff, who had much less experience but who were more willing to take risks in presenting their ideas, were getting promoted ahead of Nina, which was discouraging for her.

In the next psychotherapy session, the psychotherapist noticed when Nina spoke, she tended to defensively avert her gaze, and she decided to ask Nina if she recognized this about herself.  At first, Nina hesitated, and then she responded that other people also told her this.  When her therapist asked her if she had any insight into what caused her to do this, at first, Nina said she didn't know (see my article: The Therapist's Empathic Attunement Can Be Emotionally Reparative For the Client).

Her psychotherapist decided to explore this further with Nina, and asked Nina if she feared what she might see in her therapist's eyes.  In response, Nina looked directly at the therapist and then looked away again.

Her therapist asked Nina what she saw when she looked into her eyes, and Nina responded that she saw a lot of compassion and empathy, which she liked, but she was not accustomed to it.

Her psychotherapist decided to share her reaction with Nina regarding the neglect that Nina experienced when she was a child by telling Nina that she was moved by what she said in the first session.  By sharing her genuine reaction about Nina, her therapist hoped this would be the beginning of a positive relationship, although she was aware that Nina might feel a little uncomfortable.

The therapist's disclosure to Nina was in stark contrast to the more traditional stance in psychotherapy  that she had experienced with her prior therapists.  In the traditional stance, the psychotherapist wouldn't disclose any personal reactions about the client because it would be considered "overly gratifying."  But, in this case, the psychotherapist, who worked in a contemporary way, used her clinical judgment with the hopes of forming a positive relationship with Nina.

When Nina heard her psychotherapist's words, she looked up and smiled, "Thank you.  No one has ever said that to me. I can see that you really are moved, and that feels good."

As they continued to work together in therapy, the psychotherapist saw that Nina sometimes minimized the neglect that she experienced in ways which Nina, unknowingly diminished her own self worth.  Minimization was another defense mechanism that Nina used.

One day Nina talked about something that occurred when she was five years old.  She said she overheard her mother tell a maternal aunt that she felt Nina was a "burden." Her psychotherapist could see that there was a moment when Nina felt sad.  But then Nina swept her feelings under the rug by minimizing the incident, "My mother was probably having a bad day, so I shouldn't feel bad about that.  Anyway, it happened a long time ago."

Rather than allowing Nina to discount her own feelings about overhearing such a hurtful remark from her mother, her psychotherapist said in an empathetic tone, "That would be a nightmare for a five year old to hear her mother say" (with emphasis on the word "nightmare").

Nina seemed surprised by her psychotherapist's reaction.  As she allowed her therapist's words to sink in, she began to cry, "Yeah, it was.  I went back to my room and cried myself to sleep.  You're the only person that I've ever told this to."

Her psychotherapist explored with Nina what it was like for her to hear her therapist express her reaction to what happened as "a nightmare."  In response, Nina said that it felt good to have someone who understands what it was like because, back when she was five, she had no one.  She said she felt it gave her "permission" to feel her emotions rather than trying to ward them off.

Then, her psychotherapist explained that, even though this incident and many more like this happened a long time ago, these experiences had a significant impact on Nina emotionally and they were at the root of her problems (see my article: Understanding Why You're Affected By Trauma That Happened a Long Time Ago).

During the course of her therapy, there were many more instances where Nina's therapist used her reactions to Nina to help her to overcome defensive strategies that worked when she was a child but were now creating problems for her.

Over time, Nina was able to catch herself as she was about to use a defense mechanism to ward off uncomfortable feelings.  This allowed the work in therapy to deepen.

When Nina was ready, her psychotherapist suggested that they use EMDR therapy to help Nina to overcome her unresolved childhood trauma and also work on current problems (see my article: Experiential Therapy, Like EMDR Therapy, Helps to Achieve Emotional Breakthroughs).

The work in therapy was neither quick nor easy.  But over time, Nina became increasingly comfortable with her psychotherapist's more contemporary way of working, as compared to the more tradition way of her prior therapists.

She found her psychotherapist's expressions of compassion and empathy to be healing, and this allowed Nina to open up more in therapy.

After a while, Nina was able to feel on a deep level that she had been a lovable child, and it wasn't her fault if her parents were so unloving towards her.  This understanding was not just an intellectual understanding--she felt it deeply.

Gradually, Nina became more self confident.  She no longer feared developing a loving, committed relationship with a man.  So, when she met someone that she really liked and who cared for her too, she didn't push him away like she did in the past.  She allowed the relationship to grow and flourish, and she was able to accept her own feelings and that he cared about her without feeling threatened by the emotions.

She also became more confident in presenting her ideas at work, which her director noticed.  Eventually, she received the promotion that she had wanted for such a long time.

Conclusion
In traditional psychotherapy, psychotherapists don't divulge their reactions to their clients.  They attempt to maintain a neutral stance.

In my clinical opinion, there is no such thing as a neutral stance--no matter how much a psychotherapist attempts to hide what s/he feels.  Even if a psychotherapist attempts to maintain a neutral stance, clients can be very perceptive and sense what a psychotherapist is feeling.

Attempting a neutral stance is not only outmoded, in opinion, it's actually hurtful for the client, especially a client who was raised in an abusive or neglectful environment as a child.  In many ways, attempts at therapist neutrality are often retraumatizing for the client.

But, even though the field has progressed, many psychotherapists are still being trained to be neutral with their clients, as I was when I was trained more than 20 years ago.

This doesn't mean that a psychotherapist should share whatever comes to her mind without regard for how it will affect the client.  That could be equally hurtful.  Instead, a psychotherapist needs to make clinical judgment calls with each client and in each session with each client as to what would be helpful for the therapist to share and what would not.

For many clients, as in the fictional vignette above, having a psychotherapist who can, in effect, go back in time with them to explore the client's history in a compassionate and empathetic way, is a healing experience that they might never have experienced before.  It helps the client to open up and accelerates the work in therapy.

Getting Help in Therapy
Many people, who experienced early trauma, never come to therapy because they're fearful of being retraumatized (see my article: The Benefits of Psychotherapy).

A skilled psychotherapist with good clinical judgment and who is trained in trauma therapy can provide the client with a healing experience that allows them to work through early traumatic experiences (see my article: How to Choose a Psychotherapist).

If you have unresolved trauma that is having a negative impact on your life, you owe it to yourself to get help from an experienced trauma therapist.

Working through your trauma can free you from your history and allow you to live a more fulfilling life.

About Me
I am a licensed New York City psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I am a trauma therapist, who works with individual adults and couples.

I have helped many clients to overcome past and current trauma so they can move on to live happier lives.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

How Contemporary Psychotherapy Has Changed - Part 1

In the past, in classical Freudian psychoanalysis, as it was practiced in the United States, psychoanalysts in training were taught to be neutral towards their clients and avoid any outward display of their personal feelings about the client (referred to as countertransference).

How Contemporary Psychotherapy Has Changed

At that time, the psychoanalyst sat behind the client with the client lying down on the couch. The idea was that the client wouldn't be distraction by seeing the psychoanalyst, so the client could free associate, and the psychoanalyst could focus on listening to the client rather than looking at the client.

How Contemporary Psychoanalysis and Psychotherapy Have Changed
Of course, as most contemporary psychoanalysts and psychotherapists know these days, Freud may have espoused a neutral stance on paper but, by all accounts, he was warm and personal with his clients in person.  He would often walk with them in his garden or have them over in his home.  But American classical psychoanalysts followed Freud's written word rather than his actual practice.

I believe this is why traditional psychoanalysis came to view the psychoanalyst's reactions (or countertransference) to the client as being something to overcome rather rather than the reactions being useful clinical information about what the therapist was intuiting about the client and their therapeutic relationship.

Fortunately, this has changed significantly and most contemporary analysts and psychotherapists view their reactions to the client as being a useful part of the therapy which can be shared with the client when it is clinically appropriate to do so.

In many ways, this has freed up the psychotherapist to be more emotionally accessible to the client.  It opens up a new avenue for the therapist to use him or herself in a new way.  It also helps to create more of an egalitarian relationship with the client when the psychotherapist is more accessible and shares reactions when they are useful to the client.

In addition, for clients who grew up in an abusive or neglectful environment as children, interacting with a psychotherapist who is free to be more open and emotionally accessible is a welcome change from what traumatized them as children (see my article: The Psychotherapist's Empathic Attainment Can Be Emotionally Reparative For the Client).

But it also makes being a psychotherapist more complicated.  Without the strict practice of the psychotherapist taking a neutral stance with the client, the psychotherapist has to make many more clinical judgment calls about when and how to be more open with clients.  There is always the chance that if the psychotherapist shares his or her reaction to the client that the psychotherapist might make a clinical mistake and share something that the client isn't ready to hear.

Although there is room for error in this more contemporary and open way of working in psychotherapy, I believe it's a refreshing change from the old traditional way.

Under the traditional way, too many clients, who grew up in abusive or neglectful homes were retraumatized by psychotherapists who remained silent most of the time, and these therapists only made occasional comments or interpretations, which could take a long time--weeks, possibly months.

I believe that, generally, clients in psychotherapy need a more empathetic and emotionally accessible psychotherapist who is comfortable sharing his or her reactions to the client when it is clinically appropriate.

I say "generally" because, occasionally, there are clients who still want a traditional stance of neutrality and prefer that the psychotherapist not speak or speak very little.  

Although this is not what most clients usually seek, there are some clients who felt so impinged upon by one or both parents that a psychotherapist who is more interactive would feel like another impingement to them.  In those cases, it's up to the psychotherapist to respect the client's wishes or, if this way of working is so foreign to the psychotherapist, s/he would have to make a referral to another psychotherapist.

The Psychotherapist's Responsibility For Ruptures and Repairs in Psychotherapy
With regard to the possibility of the psychotherapist making mistakes, mistakes can usually be repaired between the psychotherapist and the client (see my article:  Ruptures and Repairs in Psychotherapy).

In fact, it's inevitable that, as a human being first and a psychotherapist second, a therapist will make some mistakes with some clients, especially since psychotherapy is as much an art as it is a science.

Hopefully, these "mistakes" are few and far between and don't involve ethical issues or boundary violations (see my article: Boundary Violations and Sexual Exploitation in Psychotherapy).

Aside from ethical mistakes, which are more serious than the usual mistakes, the mistakes that I'm referring to are clinical mistakes, possibly with the regard to the timing of a comment or a misunderstanding between the client and psychotherapist.

Whatever is involved with the clinical mistake, it's up to the psychotherapist to acknowledge the mistake and make reparations by giving a heartfelt apology to the client and working together with the client to repair their therapeutic relationship.

Most clients are aware that psychotherapists make mistakes at times, and they are able to work through these issues.  If they came from homes where parents never acknowledged mistakes, let alone make attempts at reparations, the process of reparation in psychotherapy can be a healing experience for clients.

In my next article, I'll continue this discussion with regard to the types of reactions or countertransference that contemporary psychotherapists often share with clients (see my article: How Contemporary Psychotherapy Has Changed - Part 2).

Getting Help in Psychotherapy
Attending psychotherapy is a unique experience that provides an opportunity to get to know yourself better, overcome traumatic experiences, and work through current and past problems (see my article: The Benefits of Psychotherapy).

Choosing a psychotherapist often involves meeting with more than one psychotherapist to determine who you feel most comfortable with before you begin the therapeutic process (see my article: How to Choose a Psychotherapist).

If you have been struggling on your own with an unresolved problem, you could benefit from working with a skilled psychotherapist who can help you to work through your problem so you can live a more meaningful an fulfilling life.

About Me
I am a licensed New York City psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work in a contemporary way with individual adults and couples, and I provide a empathetic and supportive environment.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy

In a prior article, Why Your Psychotherapist Can't Be Your Friend, I began a discussion about the roles of the psychotherapist and client in therapy, which included the concept of mutual enactments in therapy.  In this article, I will delve deeper into the concept of mutual enactments with a clinical vignette that illustrates these concepts.

Mutual Enactments Between the Client and the Psychotherapist

Before I go any further, I think it would be helpful to have a definition of "enactments" in the therapy setting.

Although there are various definitions for enactments, depending upon whether psychotherapists are Classical or contemporary Relational psychotherapists, I prefer the definition given by Fonya Lord Helm in a chapter, "Enactments Leading to Insight for Patient, Therapist and Supervisor" in Enactment: Toward a New Approach to the Therapeutic Relationship edited by Steven J. Ellman and Michael Moskowitz, which is:

"An enactment is any action occurring during the psychotherapy or psychoanalysis that repeats an earlier similar experience or fantasy and communicates feeling...by nonverbal means in a way that will draw the therapist or analyst into a nonverbal communication" (p. 157).

In the past, the term "acting out" was used instead of "enactments," and this usually referred to the client's impulsive and improper behavior.  Although the emphasis was on the client's acting out behavior, it's also generally understood that psychotherapists can act out as well.

The term "acting out" is used less these days because of its pejorative connotation and also because the behavior is viewed from the psychotherapist's perspective in the type of hierarchical therapy where the therapist is seen as being "neutral" and "abstinent" as opposed to a more contemporary relational view of mutuality between therapist and client.

The contemporary view of enactments is that they are generally unconscious on the part of both the psychotherapist and the client.

In the past, enactments were seen solely as "mistakes" in therapy.  Now enactments are viewed most by therapists as an unavoidable part of therapy.

Whereas the ideal is to strive for no (or few) enactments, from a practical and therapeutic perspective, the reality is that there will be enactments, whether they are big or small and, once they occur, the therapist can discuss these enactments to further the work.

Although the focus in this article is on enactments between psychotherapists and clients, it's important to understand that enactments occur in everyday relationships, including romantic relationships, familial relationships, friendships and work relationships.

At this point, in addition to the vignette I provided in the last article, the following vignette will shed light on this dynamic between therapists and clients.

Fictional Vignette:  Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy:

Liz
Liz, who was in her mid-30s, started therapy because she had longstanding problems in romantic relationships.

Although she had no problems meeting men, her problems began once the relationship became serious because she had difficulty trusting men in intimate relationships.

Her lack of trust in these relationships would manifest in her insecurity and jealousy with Liz imagining that her boyfriend at the time was cheating on her--even when she had no objective reason to think this.

When Liz began to feel jealous and insecure, she had difficulty separating her feelings from facts (see my articles:  Overcoming the Insecurity and Jealousy That's Ruining Your Relationship and Discovering That Your Feelings Aren't Facts).

Instead of observing and exploring her feelings with her boyfriend, she behaved as if her feelings were true and accused him of cheating.  She was so caught up in her emotions that she had no awareness that she was projecting her feelings onto the situation.  As far as she was concerned, when she felt her boyfriend was cheating, it must be true.

The pattern was that she would feel overwhelmed with jealousy and insecurity, accuse her boyfriend of cheating, he would be genuinely shocked and then he would try to defend himself against these accusations.

But no amount of denial or proof would dissuade Liz of her convictions that her boyfriend was unfaithful to her.

The more her boyfriend denied cheating and showed her proof, for instance, that he was with male friends at a basketball game, the more convinced Liz was that her boyfriend was lying.  And if her boyfriend refused to respond to her accusations, she also saw that as proof that he was guilty of infidelity.  So, there was no way to resolve this problem.

This is an example of an enactment in an intimate relationship.  It has many of the same qualities as enactments in therapy, which I'll discuss later.

As would be expected, this dynamic tended to erode the positive aspects of the relationship and would soon doom the relationship.  Her then-boyfriend would accuse her of being jealous and controlling, and she was convinced that he was trying to turn the tables on her when he was really the guilty one.

After each relationship was over, Liz had some insight into the fact that her accusations were irrational and she would have regrets.  But, by that time, the situation had gotten so bad that her ex-boyfriend no longer wanted to hear from her--let alone resume the relationship.

Every time Liz began to a new relationship, she vowed to herself that she wouldn't ruin it by making baseless accusations of infidelity.  But when she became jealous and insecure, the feelings were so powerful that she would lose all perspective.

These unconscious feelings overpowered her.   Once these feelings dominated her, she believed them to be true until she was out of the relationship.

When she discussed these dynamics with her therapist, she expressed sincere regret for the heartache that she caused in her boyfriends and herself and a strong desire to stop this behavior.

Mutual Enactments Between the Client and Psychotherapist

Her therapist sensed that Liz's regret as well as her sorrow for destroying her relationships. Her therapist was aware that, since this dynamic was unconscious at the time when it occurred, Liz was unable to control it.  She was also aware that Liz lacked the objectivity as well as the verbal skills to address this in her relationship when she was overwhelmed by these feelings.

Her therapist recognized Liz's behavior in her relationships as being enactments.  She also knew that there would probably be enactments in the therapy, and she would need to try to be aware of as they occurred.

Since Liz had been in therapy before, Liz knew that her family history, which was chaotic and dysfunctional, contributed to her inability to sustain romantic relationships.  But knowing this did nothing for her in terms of her enactments in her relationships (see my article: Intellectual Insight Isn't Enough to Change Problems).

From Liz's perspective, her prior experiences with therapy were disappointing.  The pattern was that the therapy would go well at the beginning, and then Liz would realize that she didn't trust the therapist.

Since she was unable to communicate her feelings of mistrust directly to her prior therapists in the past, she aborted therapy without discussing it, and she didn't respond to their outreach calls or letters (see my article: When a Client Leaves Therapy Prematurely).  These abrupt endings to her therapy were also enactments on her part.

After hearing about her previous history in therapy, Liz's therapist was aware that Liz might end this therapy abruptly too if she developed negative feelings towards her (also known as the negative transference).

Her therapist also wondered how much the prior therapists contributed to these enactments because of their own frustration and negative feelings about these dynamics.  She was aware that she would need to be vigilant about her own feelings about their therapy (known as countertransference) to minimize her own unconscious contribution to mutual enactments.

During the first few months, therapy went well.  Liz showed up on time for all her therapy appointments, she was compliant with paying her fee on time, she reflected on their sessions between sessions, and she discussed her reflections at subsequent sessions.

Her therapist enjoyed working with Liz and looked forward to their sessions.  Liz was intelligent and articulate about the issues they discussed, and she even kept a journal between sessions to write down her thoughts (see my articles: The Benefits of Journal Writing Between Therapy Sessions and Journal Writing Helps Relieve Stress and Anxiety).

But a month before her therapist was due to go on vacation for two weeks and she mentioned that she would be away, her therapist noticed an abrupt change in Liz's demeanor.  Whereas normally, Liz was relaxed in session, immediately after her therapist told her about the break, Liz looked tense and suspicious.

Her therapist mentioned her vacation in a month's time at the beginning of the session because she wanted to allow time for them to discuss any feelings that Liz might have about the break.

Her therapist could see from the abrupt change in Liz's demeanor that Liz had a negative reaction to the upcoming break, but Liz refused to talk about it when her therapist asked her about it.

From her silence and refusal to talk, her therapist was aware that she was witnessing an enactment on Liz's part, and she hoped not to get caught in a mutual enactment.

Based on Liz's history of relational problems, her therapist knew that Liz's reaction was probably unconscious on her part and Liz lacked the necessary insight and communication skills to talk about her feelings rather than enacting them in her sullen, uncommunicative behavior.  She knew it would be useless to explain this to Liz at the moment because Liz wasn't receptive to hearing an explanation.

Her therapist was aware that she was on the horns of a dilemma:  Liz was unconsciously trying to control her in the session by not talking and trying to make her feel guilty about leaving Liz (similar to how Liz tried to control her relationships with her former boyfriends).

Her therapist was also aware that, similar to Liz's dynamics with her former boyfriends, if the therapist attempted to encourage Liz to discuss her feelings, Liz would resent her and view her with increased suspicions.  But if she remained silent, Liz would feel that was too emotionally depriving and interpret that to mean that her therapist didn't care.

Ether way, her therapist would be engaging in a mutual enactment so she would have to decide quickly in the moment which course of action would be least disruptive to the therapy and might result in furthering the work.

Her therapist decided to share her dilemma with Liz, "I can see that you have feelings about the upcoming break in our therapy sessions.  I'd like us to be able to talk about that, but just now when I encouraged you to talk, you've remained silent.  I feel myself on the horns of dilemma.  Just like the dynamics in your romantic relationships, on the one hand, if I encourage you to talk, you see that as further proof that I'm doing something wrong and I don't care about you. But if I remain silent, you see that as proof that your feelings aren't important to me and I don't care about you.  Either way, you think I don't care.  Can you see my dilemma?"

Listening to her therapist express her dilemma softened Liz a bit.  She seemed to relax a little, and she nodded her head as if she understood what her therapist meant.

In the past, her therapist had spoken to Liz about what happened to her when she became jealous of her boyfriends as her being caught in a "vortex" of overwhelming emotions.

This idea of being stuck in a vortex came to Liz's mind now, and she told her therapist that she wasn't sure what she was feeling, but she felt as if her emotions were overpowering her.

Recognizing her new ability to even verbalize that she was overwhelmed and caught up by powerful emotions in the here and now represented significant progress for Liz.

Her therapist asked Liz to describe the vortex to her and she said she hoped to be able to help Liz to step out of the vortex.

Liz described feeling like she was in a whirlwind of powerful emotions that threatened to overtake her.  She said it was like being in the middle of a storm and she described those feelings.

Her therapist pointed out that Liz's ability to describe this whirlwind meant that Liz wasn't completely caught up in it--part of her was somewhat objective and could step out of the storm, even if it was momentarily, to observe herself in the storm.

Liz gave a barely perceptible nod to indicate that she agreed that she sensed a shift in her--something she had never experienced in the past.  She was able to say that, she wasn't sure why, but she felt unhappy about her therapist's announcement that they would be taking a break for two weeks when her therapist went on vacation.

Although Liz was unhappy about the upcoming break, she was pleased that she had achieved some objectivity about herself and her feelings by being able to observe herself, and she attributed this to their work together so far and her therapist telling her about the dilemma.

In the sessions that followed, Liz and her therapist continued to deal with Liz's unhappiness about the upcoming break and how abandoned she would feel (see my article: Coping With Trauma: Becoming Aware of Your Emotional Triggers and Old Abandonment Issues Can Get Triggered When Your Psychotherapist is Away).

Gradually, Liz made tentative connections between her feelings about the upcoming break and her distrust of her parents, especially her father, whom she described as a "philanderer" and "a rolling stone" who often disappeared from the household for months at a time (see my article:  Reacting to the Present Based on Your Traumatic Experience of the Past, Understanding Why You're Affected By Trauma From a Long Time Ago and Overcoming Trauma: When the Past is in the Present).

Liz also made connections between her feelings of abandonment with her boyfriends when she felt jealous and her feelings of abandonment with her father.

With the help of her therapist, she realized that in the past, on an unconscious level, she sabotaged her relationships because she feared being abandoned, and she would rather end the relationship herself than endure the pain of being left (see my articles: Fear of Abandonment: Leaving Your Relationship Because You're Afraid of Being Abandoned and Fear of Abandonment Can Occur Even in a Stable Relationship).

This realization led to Liz's recognition that, on an unconscious level, she behaved similarly with her therapists.  Her fear of being abandoned by her therapists resulted in mistrust and caused her to leave therapy abruptly.

Liz and her current therapist talked about the possibility that Liz might be tempted to leave this therapy, in much the same way that she left her prior therapies, when her therapist went on vacation.

In the past, Liz had never contemplated this possibility prior to leaving therapy.  Instead of talking about her fear of being abandoned by her therapists in the past, she enacted her fear instead by leaving.  Unconsciously, her fear caused her to leave them before they left her.

Liz told her therapist that she didn't want to leave this therapy, but she had a fear that her therapist might not come back.  She knew this fear was irrational, and she discussed this with her therapist, but the feelings were so strong, she didn't know how to keep them from overwhelming her.

Her therapist taught Liz some self soothing techniques to help her to take care of herself (see my article: Self Soothing Techniques to Use When You're Feeling Distressed).

She also encouraged Liz to continue to write in her journal between sessions to have a way to discharge some of these emotions.

In addition, prior to going on vacation for two weeks, her therapist gave Liz the name of a therapist who would be covering her cases in case Liz needed to talk during their two week break.  Then, they confirmed their next appointment in two weeks.

During the two week break, Liz struggled with her fears of abandonment.  She knew that the intensity of these feelings were triggered by her earlier experiences of being abandoned again and again by her father when he went to live with other women for months at a time.

But, even though she recognized the origin of her feelings, she still felt overwhelmed.  She thought about calling the therapist who was on-call while her therapist was away, but she didn't feel comfortable doing this.

Each day Liz's feelings about abandonment got stronger, and she wrote about her feelings in her journal.  She hoped the days would go quickly so she could talk to her therapist about these feelings when her therapist returned.

But on the day when Liz was supposed to return to therapy, she "forgot" to go to her session.  The day came and went without Liz realizing that she missed her appointment.

When Liz came in for her next therapy session, she and her therapist discussed why Liz missed her appointment, which was another enactment.

Liz recognized that she had unconsciously forgot her appointment because she was angry that her therapist was aware and she felt abandoned.

Being able to talk more comfortably about her feelings was further progress for Liz in therapy.

Mutual Enactments Between the Client and Psychotherapist

At that point, her therapist recommended that they begin work on the trauma that was being triggered in Liz's relationships and in her therapies, which was her family history, especially her history of being abandoned over and over by her father (see my articles: Healing Old Emotional Childhood Wounds That Are Affecting Current Relationships ).

Liz agreed that it was time that she dealt with the source of her problems.

Conclusion
In the clinical vignette above, both the psychotherapist and client engaged in mutual enactments in the therapy.

Even when the therapist anticipated that there would be enactments, based on Liz's history, she found herself in a dilemma in the therapy where an enactment would be inevitable, and shared her dilemma with the client.

When the therapist shared her dilemma with the client, the therapist attempted to make the unconscious conscious for Liz by putting the dilemma into words rather than just behavior.

Even though Liz wasn't able to discuss the dynamic at that point, she began to become aware of her feelings and how they affected her therapist and the therapy.  This was a major shift for Liz, who had never recognized these dynamics before.

Recognizing a mutual enactment won't necessarily prevent future mutual enactments, as illustrated in the above vignette.

The therapist was aware of the possibility that there would be probably be an enactment on Liz's part after the therapist came back from vacation.

Due of their professional training and their own psychoanalysis, most therapists are more aware of mutual enactments prior to their client's awareness.  But, being human, psychotherapist also engage in enactments from time to time, as illustrated in the vignette.

Many psychotherapists agree that it's not a matter of if they and their clients will occasionally get caught up in enactments--it's more a matter of when.

What's most important is how therapists use these enactments, after they have occurred, to shed light on the unconscious processes that are going on between the therapist and the client. The therapist can then use this new awareness to further the therapeutic work and help the client to make breakthroughs.

Getting Help in Therapy
Mutual enactments are common in relationships of all kinds.

When mutual enactments occur in personal relationships, the people in the relationship often don't have the wherewithal to make these unconscious dynamics conscious, so they continue to engage in enactments which can be damaging to the relationships.

When enactments occur in psychotherapy, they are usually related to the client's earlier personal history.

The behavior related to the enactment will continue to repeat itself until the therapist helps the client to become aware of the enactments and they work on the underlying issues instead of enacting them unconsciously.

If you realize that you continue to engage in destructive patterns in your relationships, you might be enacting unconscious behavior from the past.

Rather than continuing to behave in an unconscious way that has a negative impact on your relationships as well as your sense of self, you could benefit from working with a psychotherapist who is skilled in identifying and working through enactments, including mutual enactments (see my articles: The Benefits of Psychotherapy and How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individuals and couples (see my article: The Benefits of Integrative Psychotherapy).

I have helped many clients to learn to recognize unconscious feelings so they can discuss them and work through them in therapy rather than enacting them.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Should Psychotherapists Be Required to Attend Their Own Personal Therapy?

Many people are surprised to discover that psychotherapists aren't required to attend their own personal therapy (as of this writing).  It would seem to be a "no brainer" that psychotherapists, who provide psychotherapy services to clients, would benefit on many levels from having the experience of being in therapy, especially at the beginning of their mental health career when professional inexperience and a lack of insight about how their own issues could affect their work and lead to clinical and ethical mistakes with clients (see my article:  The Benefits of Therapy).

Should Psychotherapists Be Required to Attend Their Own Personal Therapy?

While psychotherapists are required to have a certain amount of clinical supervision to get their license, as of this writing, unless a clinician with a graduate degree goes on for additional postgraduate psychoanalytic training, they're not required to be in their own therapy.

In my opinion, this is not only unfortunate for their clients, it's also a mistake for clinicians, who also might be getting poor clinical supervision, especially if they're practicing in a social service setting.

When I completed my graduate school training and became certified, I knew that the clinical training that I received in graduate school was inadequate to begin seeing therapy clients, so I trained for four additional years at a psychoanalytic institute starting in 1996 where I was required to be in my own three-time a week therapy.

The list of approved therapists that I was given had a minimum of 15 years of postgraduate clinical experience, so they were seasoned professionals who had experience as psychotherapists to therapists in training.

While I enjoyed the rigor of my classes, my individual and group supervision, and seeing clients at the center, the experience of being in my own therapy was, by far, the best part of my training.

Not only did my own analysis help me to work through personal issues, it also helped me to distinguish my own personal issues from the clients' issues.

While, at first glance, it might seem like it should be obvious for a therapist to distinguish his or her personal issues from the client's, therapists, like anyone else, have unconscious emotional blind spots.  So, it's very easy to inadvertently allow countertransference issues to get in the way of clinical work.

With fewer clinicians going on for postgraduate training these days, I'm very concerned about what this means for the field and for prospective therapy clients, especially for new clinicians who are getting inadequate or poor quality clinical supervision.

Even in cases where clinicians might be getting good clinical supervision, supervision isn't the same as being in your own personal therapy.

Should Psychotherapists Be Required to Attend Their Own Personal Therapy?

Clinical supervisors are usually careful about maintaining a boundary where they don't discuss in detail a clinician's personal history with regard to how it might relate to the clinical work.  So, many relevant issues that could be affecting the work wouldn't be explored.

To illustrate some of the possible pitfalls of therapists not attending their own personal therapy, I've included a fictionalized vignette below:

Ann
After Ann completed her graduate school training, she began working at a social service agency for low income clients.  This was the same social service agency where she did her second internship where she received supervision for her individual and group work with clients.

As a full time employee, she was supervised by a different clinical supervisor, who also supervised 20 other clinicians.

Whereas Ann had a small caseload as an intern, she was given a much larger caseload as a full time clinician.  She was also expected to work more independently as compared to when she was an intern.  In addition, she was expected to keep up with a lot of required paperwork.

Within a short period of time, Ann realized that she was in over her head.  But, whereas when she was an intern, she had easy access to her clinical supervisor for questions and problems, her current supervisor was often tied up trying to handle whatever clinical crises arose on a daily basis.

Should Psychotherapists Be Required to Attend Their Own Personal Therapy?

Ann's coworkers were also overwhelmed with their own caseloads, so they also had limited time to help her with problems that came up with Ann's clients.

When Ann had an opportunity to meet with her supervisor, she discovered that the emphasis was on getting paperwork done and not on clinical issues.

The agency was audited by a number of entities and would be sanctioned heavily if the cases weren't properly documented.  So, Ann's supervisor informed her that they had already been sanctioned hundreds of thousands of dollars in the past for missing paperwork.  She warned Ann to do whatever she needed to do to get the paperwork done before the auditors arrived the following week.  If this meant that Ann had to stay on her own time to complete the paperwork, so be it.

When Ann attempted to talk more in-depth about clinical issues, she felt that her supervisor only provided her with minimal assistance and she was often left on her own to handle problems.

Working long unpaid hours and plagued by doubts and insecurities, Ann went home exhausted but she was often too anxious to fall asleep.  So by the time she came to work the next morning, she was feeling irritable as well as anxious.

Ann and her colleagues talked sometimes on those days when they actually took a lunch break, but these times were few and far between.  So she was often felt alone with her anxiety.

Within a few months, Ann felt like she was burning out.  She was determined to stay at the social service agency long enough to meet the requirements to get her license, and then she hoped to open her own private practice.

As soon as she became licensed, she set up a private practice office and gave notice to her employer.  With brand new business cards and a well furnished office in a central Manhattan location, she went to her office and waited for clients to come.  But no one did.

After a few months of paying a high rent but not seeing any clients, Ann wasn't sure what she was doing wrong, so she decided to participate in peer supervision where she learned the basics of setting up a private practice and how to try to get clients.

Colleagues from the group referred a few clients to Ann.  One of the clients was involved in an emotionally abusive relationship, and Ann felt herself becoming annoyed, judgmental and impatient with this client.

Should Psychotherapists Be Required to Attend Their Own Personal Therapy?

As she talked about this client in peer supervision, one of the more experienced therapists told Ann that she thought Ann's countertransference towards this client was getting in the way of her clinical work.

She suggested that Ann hire an individual clinical supervisor.  In addition, since she knew that Ann had never been in her own therapy, she also suggested that Ann get into her own personal therapy because it seemed like the client's issues were triggering personal issues in Ann.

At first, Ann was surprised and a little offended that this senior therapist would suggest that she get into her own therapy.  She agreed that she could benefit from individual supervision, especially since the quality of supervision she received from her former employer was so poor.  But she didn't think that anything was getting triggered in her personally.

At that point, her biggest concern was that her small income from her private practice wasn't even covering the rent.  How could she afford to hire an individual supervisor as well as be in her own therapy?

Ann chose Mary, a supervisor who was recommended by several senior clinicians in her peer supervision group, and met with her an hour every week for clinical assistance.

Within a short time, Mary could see that there was something about Ann's client, who was in an emotionally abusive relationship, that was affecting Ann on a personal level.

Distinguishing individual supervision from personal therapy, Mary told Ann that it was obvious to her that Ann was getting emotionally triggered by this client and this was why Ann was so impatient, judgmental and irritable around this client.

She spoke to Ann about this in terms of countertransference, and recommended that if Ann was going to continue to do this work, she needed to be in her own therapy so she could distinguish her own issues from the client's.

Ann respected Mary's clinical expertise so, reluctantly, she followed her advice, and she was able to find a therapist who provided sliding scale therapy.

Within a short time, Ann realized in her own therapy that her client reminded her of her mother, who was emotionally abused by Ann's father.  She also realized that her reaction to this client was based on her own unconscious unresolved feelings towards her mother.

Rather than do this client any more harm, Ann decided to refer the client to a more experienced therapist who had worked with many similar cases.

Ann also realized that while, on paper, she was qualified to be a licensed therapist, she had a lot of personal clinical work to do, so she decided to disband her private practice and take a job doing administrative work until she did her own clinical work in her personal therapy.

Should Psychotherapists Be Required to Attend Their  Own Personal Therapy?

After a couple of years in her personal therapy where she worked through many of her own unresolved issues, both she and her therapist agreed that she was in a much better position to consider starting a private practice again.

Conclusion:  Psychotherapists Should Have the Experience of Being in Their Own Therapy
Licensing requirements for therapists vary from state to state.  Most states require a certain amount of clinical experience and clinical supervision.  Although it might seem like basic commonsense for therapists to have their own personal therapy, most states don't require this for licensure.

The fictionalized vignette above demonstrates some of the pitfalls when a therapist hasn't been in his or her own therapy.

Here are some reasons why personal therapy is beneficial for therapists and, in my opinion, should be required for licensure:

Therapists who have been in their own therapy:

• tend to have a more empathic understanding of what it's like for their clients to be in therapy
• tend to be more attuned to the client's needs
• usually work through their own personal issues so that they don't impose these issues on their clients
• usually have a better understanding of their clients' transference and their own countertransference issues 
• are less likely to have an attitude that therapy is for "other people," but they don't need it
• have a place where they can deal with the unique stressors of being a therapist
• often gain a better understanding of their clients in therapy than in individual supervision
• usually learn to be a better therapist from their own therapist 

Even though personal therapy isn't a requirement for therapists to become licensed, this isn't to say that many therapists don't seek out their own therapy.  Many therapists do opt to go to personal therapy because they know that they and their clients will benefit from it.

Getting Help in Therapy
As a consumer, who might be considering attending therapy, it's important for you to be informed.

Many therapists have the same degrees (LCSWs, Ph.Ds, MDs, etc), but you can't tell from their degree alone whether they went on for additional postgraduate training or if they've ever been in their own therapy.

When you're choosing a psychotherapist, it's important to ask the right questions (see my article:  How to Choose a Psychotherapist).

You can't assume that just because a therapist has a shingle outside his or her door that s/he has worked out his or her own personal history.

During the consultation, you can ask the therapist about the type of training that s/he did as well as if s/he had the experience of personal therapy.

While it wouldn't be appropriate to ask detailed questions about the nature his or her own personal therapy or what issues s/he worked on, if the therapist isn't comfortable answering basic questions about this, I would look elsewhere.

I would be very wary of seeing a therapist who has never been in personal therapy.

When choosing a therapist, you owe it to yourself to make the best possible choice.

The therapist's professional training, licensure, experience and personal therapy do make a difference in the quality of care that you'll receive, so be an informed consumer and make good choices.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individual adults and couples.

To find out more about me, visit my website:  Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.