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.

Learning to Communicate Effectively With Your Therapist

In a prior article, I discussed how there are often ruptures and repairs in therapy between clients and their therapist (see my article: Ruptures and Repairs in Therapy).  As I mentioned in that article, what is most important is that the client and the therapist take time in person to clear up any misunderstandings, miscommunication or an empathic failure on the therapist's part.  In this article, I'm addressing a related topic:  Learning to Communicate Effectively With Your Therapist.

Learning to Communicate Effectively With Your Therapist

Learning to communicate effectively in therapy can be challenging for clients who have problems communicating in their daily lives.

Although it's wonderful to have the ease and comfort of email in daily life, sending email when you're upset or angry can also create problems because there's a lot of room for misunderstandings with email.

I've heard so many stories from clients where they're communicating about important issues with their significant other via text and email, including long drawn out arguments and even breakups.  In many cases, they found out that there were misunderstandings that could have been avoided if they had communicated in person or, at least, over the phone.

This is one of the reasons why I encourage clients to talk about anything that is concerning them about our sessions in person or, if it can't wait until the next session, to call, rather than communicate via email or text.  It's easier to sort out problems in person than going back and forth by email.  Also, email is not necessarily confidential.

Learning to Communicate Effectively With Your Therapist

Clients who are uncomfortable talking about their concerns in person with their therapist often had similar problems in their family of origin.  Often, direct communication was either discouraged or even punished, so they never learned how to communicate their feelings effectively because they feared that there would be negative repercussions.

Although it might feel "safer" in a sense to communicate indirectly with email or text, you're missing an opportunity, even though you might be afraid, to express your feelings, to be heard and to work through whatever issue you might have.  If you weren't able to do this when you were growing up, it can be tremendously healing experience.

If you're concerned about something that came up in therapy, it's best to talk to your therapist when it happens rather than allowing your feelings to fester.  It also gives you and your therapist a chance to not only clear up whatever is bothering you but to also see how it might relate to your earlier history in your family.

Tips For Communicating Effectively With Your Therapist:

• Take responsibility for your therapy.  Although your therapist has clinical expertise, training and skills, only you know for sure what's going on in your mind.  Don't assume that she knows that there's something bothering you because she might not know.  It's up to you to bring it up--even though it might feel uncomfortable.
• Plan what you want to say by thinking about it first.  It's often helpful to write down for yourself (as opposed to being reactive and sending out an email or text) what you want to say and, if you have time, sleep on it to see if you feel the same way the next day.   This helps you to clarify for yourself what's bothering you rather than being reactive and sending out an email in anger or upset.  It also helps to prepare you to communicate in a clear way if you're anxious about bringing up your concerns.
• Bring up your concerns at the beginning of the next session so that you and your therapist will have time to talk about it.  This is a lot more effective than waiting for the end of the session or making a "door knob comment," which is a comment that clients make as they're on their way out of the therapist's office.
• Try to stay calm while you're telling your therapist what concerns you.  You might feel angry or upset, but if you can remain calm, you're more likely to express yourself clearly so that your therapist can understand what's bothering you.
• Be open to hearing feedback.  You might feel sure that you're "right" about whatever the problem is, but if you're open and flexible, you might realize that there was a misunderstanding or miscommunication.
• Recognize that therapists are human and they make mistakes.  Most therapists will acknowledge their mistakes and try to repair the situation.  If your therapy has been going well until now, give your therapist a chance to repair things between you in person--rather than leaving therapy prematurely (see my article: When Clients Leave Therapy Prematurely).

Very often, once misunderstandings are cleared up, the therapeutic relationship improves because you and your therapist got through a difficult patch where you felt uncomfortable.  Not only will you feel better for having expressed yourself in an effective way, but your therapist will understand you better.

Learning to Communicate Effectively With Your Therapist

Even if you do end up leaving because you and your therapist turn out not to be a good fit, you'll feel better about yourself for having expressed yourself directly, calmly and maturely.

Getting Help in Therapy
If you've been unable to resolve your problems on your own, you could benefit from working with a licensed psychotherapist who can help you to work through your problems.

It takes time to build a rapport with a psychotherapist and, along the way, there might be times when there are ruptures and a need for repair.  Even though this might feel scary and hard, it's worth the effort to communicate your feelings to your therapist and to do it calmly in person.

About Me
I am a licensed New York City psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individuals and adults.

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.

Empowering Clients in Therapy - Part 1

Many people, who are depressed, anxious or traumatized, avoid coming to therapy because they feel ashamed of their problems, they fear they'll be overwhelmed by opening up emotionally in therapy or they feel a sense of helplessness related to a history of trauma (see my article: Overcoming Feelings of Helplessness Related to Childhood Trauma).

Empowering Clients in Therapy

As compared to the number of people who need mental health treatment, only a small percentage actually come to a therapist's office.

This is all the more reason why it's so important for psychotherapists to find way to empower the clients who, although apprehensive, come to therapy.

Empowering Clients in Therapy
There are many ways to empower clients in therapy, including:

Helping Clients to Feel Safe
As I've mentioned before, for many people coming to therapy is an act of courage.  It's not easy coming for a consultation with a stranger, not knowing what to expect.

The therapist sets the tone, especially at the start of therapy, and it's important that s/he create a safe, comfortable, respectful environment (see my article:  The Creation of a Holding Environment in Therapy).

An emotionally attuned therapist can make all the difference to clients who feel apprehensive.  Empathy and respect are the hallmarks of good therapy and help clients to feel comfortable (see my article:  The Therapist's Empathic Attunement Can Be Emotionally Reparative to Clients in Therapy).

Providing clients with information
Many clients who have never been in therapy before don't know what to expect.  They might not understand about the treatment frame regarding regular appointment times, lengths of sessions, fee arrangements, therapist's education and skills, and so on.

Empowering Clients in Therapy

Even if clients have been in therapy before, each new experience will be different.

After therapists get to know clients, clients need help to understand their problems.  If they've never spoken to anyone about their problems, they might feel that they're the only ones who feel this way or who have had these experiences.

As much as possible, it's important for therapists to normalize clients' experiences so they know that they're not the only ones who have ever gone through these problems before and that other people have been able to work through these issues in therapy.

This empowers clients so they don't feel ashamed and guilty about their problems.  It might also help them to feel hopeful that they can also work through their problems.

Talking to Clients About Their Expectations and Goals
Clients who are new to therapy (or new with a particular therapist) might not know what to expect in treatment or they might come with misconceptions.  For instance, they might think that the therapist will provide them with "answers" to their problems rather than being someone who facilitates their development and growth in treatment.

Even if they've been in therapy before, they might have had bad experiences and they are, once again, summoning their courage to give it another try.

Empowering Clients in Therapy

Discussing their expectations and what they would like to accomplish in therapy encourages them to be active participants in their own treatment.  This is something which might be new and unfamiliar at first but, ultimately, it can empower them.

Some clients might need help formulating goals and strategizing how to accomplish their goals.  They might need help to understand that, for some people, setting goals are a work in progress, and that's okay.

Other clients might not even feel that they are entitled to want anything or to set goals because of their early history of being subjugated in their families.  Just the idea that they have choices might be a new experience.

Offering Clients Choices in Therapy
There is no one-size-fits all treatment, especially when it comes to mental health issues.

It's important for therapists to be skilled in different treatment modalities so that clients have choices.

This can be empowering for clients in therapy, especially since many clients didn't have choices when they were growing up.

Listening to the Client
Many people have never had the experience of really being listened to by another person before they came to therapy.

It's important that therapists be willing to listen to what is being said and also to what is not being said, which could be just as important.

It's also important for a therapist to learn from clients (see my article:  Psychotherapy: Listening and Learning From the Client).

For instance, the client might have a different perspective about a situation because s/he is from a different culture.  No therapist can know about every culture, so listening and learning from the client can help the therapist to see things from the client's point of view.

Repairing Ruptures Quickly When They Occur
Even the best therapist will make mistakes at times.  No one is perfect.  It's important for therapists to repair ruptures in treatment as soon as possible.

Empowering Clients in Therapy:  Ruptures and Repairs in Therapy

This can be empowering to clients, especially clients who grew up in households where they were hurt, emotionally or physically, by parents who never made amends.

Often, after a rupture is repaired between a client and a therapist, the therapeutic relationship is strengthened and it is better than before the rupture (see my article: Psychotherapy: Ruptures and Repairs in Therapy).

Aside from these basic ways of empowering clients in therapy, there are also clinical ways to empower clients, which I'll discuss in my next article:  Empowering Clients in Therapy - Part 2: Clinical Issues

Getting Help in Therapy
Asking for help is never easy.

Considering therapy might be a new idea that you've never considered before or you might be returning to therapy after having been away for a while.

There are many different types of therapies and many psychotherapists with different orientations to therapy and different levels of skill and experience, so I recommend that, if you're considering therapy, ask for a consultation first to find out about the therapist, to see if you're comfortable with him or her, to give an overview of the issues that you would like to work on, and to ask questions.

You might need to see a few therapists before you find someone that you're comfortable with, and most therapists will understand this.

For more information, see my article:  How to Choose a Psychotherapist.

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.

Psychotherapy: Ruptures and Repairs Between You and Your Therapist

In the last two blog articles, I discussed transference in psychotherapy in the context of the erotic and the idealized transference( Psychotherapy and the Erotic Transference and Psychotherapy and the Positive Transference). I also mentioned "ruptures" in treatment and discussed this briefly. 

In this post, I would like to focus on the effect of ruptures in treatment and how they can be repaired so that the therapeutic relationship between therapist and client can be preserved and, in many cases, even thrive after a rupture.

Psychotherapy: Ruptures and Repairs in Therapy

What are Ruptures in Psychotherapy?
In any long-term psychotherapy, there are bound to be treatment ruptures. Usually, these ruptures occur when the therapist unwittingly commits an empathic failure with the client. Even the most empathic psychotherapist will, at times, either misunderstand what a client is saying or give a response that is less than empathic. This is usually not intentional. It's a mistake.

When a client, especially a client who might be emotionally fragile, feels that his or her therapist has been either insensitive or doesn't hear or understand what the client is saying, the client often experiences this as a rupture in treatment. 

Sometimes these ruptures are small, as when a therapist forgets a particular small detail of a client's history and this becomes obvious to the client. And sometimes, these ruptures can be big, and I'll give an example of this later on.

Whether the rupture is perceived by the client as big or small is determined by many factors, including the strength of the therapeutic relationship at the time of the rupture, how fragile the client is feeling what the therapist actually did or said and so on

If the therapeutic alliance is strong and there haven't been many ruptures in the past, clients can overlook a therapist's mistake, especially if the client knows that this was a mistake. 

However, if the client and therapist have just begun to work together or if there have been frequent ruptures or if the client has a personal family history where he or she was neglected or abused, any kind of empathic failure can lead to a big rupture between client and therapist.

If there are egregious offenses by the therapist, like sexual boundary crossings or other serious offenses, this not just a rupture. This is a serious ethical and legal breach, and that's not what I'm referring to in this article.

How Can Ruptures Be Repaired?
If we consider that in most long-term psychotherapy treatments there will be inevitable and unintentional empathic failures or mistakes on the part of the therapist, how can these empathic failures be addressed and repaired so that the rupture doesn't lead to the failure of the treatment?

The most important part of repairing a rupture in treatment is for the therapist to be able to acknowledge that he or she made a mistake. Except for the most narcissistic psychotherapists, most therapists can and will do this. Even if it wasn't originally perceived as a "mistake" by the therapist, once the client feels misunderstood or not heard, the therapist needs to acknowledge and take responsibility for it.

Almost any rupture, if it's not egregious, can be repaired in treatment if the therapist acknowledges that he or she either made a mistake or failed the client in some way. For most clients, the acknowledgement on the part of the therapist that there was a mistake or the client was hurt in some way is often enough to repair the treatment.

Ruptures in Therapy Can Be Repaired

Many clients have grown up in homes where their parents never owned up to mistakes they made, so the experience of having the therapist take responsibility for an empathic failure can be reparative in itself, especially if the client feels that the therapist's acknowledgement is heartfelt.

Even Experienced and Skilled Therapists Can Commit Unintentional Empathic Failures:
I remember early on when I was training to be a psychotherapist at a psychoanalytic institute, my peers and I were very concerned about making mistakes in treatment. As therapists in training, most of us feared that our inexperience could lead to irreparable damage to clients.

In the context of a discussion about empathic failures, one of our instructors, who was much admired, told us a story about a rupture in treatment due to an empathic failure that he had committed with a client. 

Before I discuss what the empathic failure was, I should mention that not only was this instructor much-admired by the psychoanalytic trainees and faculty, but most of the trainees had a strong idealizing transference for him, which relates to my prior blog post.

Most of us, at the time, were very surprised that someone of his talent and skill could make such a mistake. This is another example of the effects of the idealizing transference between students and instructors.

Our instructor was well aware of this and he used the story he told us not only to show that ruptures can be repaired in treatment but in his humility, to show that even seasoned and skilled therapists can make mistakes in treatment. He didn't want us, as therapists in training, to be so afraid of making a mistake that we would be too self conscious with clients, which would have, in and of itself, interfered with treatment.

His main point in telling us about a mistake that he made was: While it's not great to make mistakes with clients, in most cases, it's not so much about the mistake that leads to the rupture-- it's more about how the therapist handles the mistake and repairs the rupture.

To that end, he told us about a time when he forgot about a client's appointment and he left the office. The client had been coming to treatment for a few years, and he had a great deal of difficulty trusting people, including his therapist.

During these sessions, the client often talked about wanting more from the therapist in terms of being more like friends rather than client and therapist. Since this would be an ethical breach of the treatment frame, the therapist explained, as gently and tactfully as possible, that this wasn't possible and explained the reasons why.

Most clients would understand that the client-therapist relationship, albeit caring and, at times, intense, is still a professional relationship. However, some clients, for a variety of reasons (sometimes, due to a history of neglect or abuse), want more from the therapist and it's up to the therapist to preserve the safety of the therapeutic relationship and the treatment to maintain the treatment frame.

All of this is to say that, even after a few years of treatment where the client came multiple times per week and kept his appointments, the therapy sessions were often rocky because the client wanted a more personal relationship with the therapist and, in some ways, he felt deprived that the therapist would not give in to his wishes.

So, in a nutshell, that's the background of the case, and you can picture many sessions where the client attempted to get the therapist to break the treatment frame and the therapist was holding the line for the sake of the client's emotional safety, although the client didn't realize it at the time.

One day, the therapist received a call from his young daughter's school that his daughter was sick and he needed to pick her up from school. At the time, the therapist had a very busy schedule that included a full-time private practice; being an instructor and supervisor at the psychoanalytic institute; involvement in various professional committees, and so on.

Tired, distracted and focused on his concerns about his daughter, he left the office completely forgetting about the client's appointment. He picked up his daughter, brought her home, and called the pediatrician. Fortunately, it turned out to be only a cold, and his daughter went right to sleep.

Relieved that his daughter didn't have a major illness, the therapist began to relax after a busy, stressful day. It was only then that he realized that he had forgotten about his client, something that had never happened to him before in his many years of practice.

Being very concerned, he called the client to apologize, but the client was too upset to accept the apology. He didn't tell the client that he had to pick up his daughter. It would have been too hurt for a client, who wanted more of a personal relationship from his therapist, to feel that the therapist's daughter took precedence over him. He simply apologized and told the client that he was called away from the office, he forgot about his appointment, and he was deeply sorry.

As an aside, one could speculate as to whether there was an unconscious wish on the part of the therapist to avoid dealing with this client on this particular day. While this might have been a factor, if and when that occurs, it's up to the therapist in this situation to do some self-analysis to explore this question.

In any case, the client was unable to accept the therapist's apology immediately. In fact, he focused on this empathic failure and the rupture in the treatment for about two months in every session. They were unable to move beyond this problem and it consumed the client's thoughts. Not only was the client very angry, but he was very deeply hurt that the therapist forgot about him.

This empathic failure fed right into his worst fear that the therapist really didn't care about him and he wasn't important to the therapist which, of course, was not the case at all. However, for a client who grew up with emotional neglect, he was very sensitive to any kind of empathic breach. In many ways, he was always vigilant and suspecting that this would happen because he found it difficult to trust people. So, in terms of empathic failures, this couldn't have happened to a more emotionally fragile client.

The therapist knew the client was unconsciously"testing" him. The therapist needed to withstand the client's anger and hurt to show the client he cared about him. 

After a few months of the client venting his anger and hurt and, together with the therapist, making connections to how this empathic failure triggered his history of emotional neglect, over time, the client and therapist were able to repair their relationship.

What's more, the relationship was more than just repaired to its former state, it was actually enhanced. 

Over time, the client was able to see that his therapist actually did care about him a great deal and that the empathic failure was an unintentional mistake. He realized that his therapist was human and he let go of some of his idealization (much as I and the other psychoanalytic trainees did on the day when our instructor told us this story).

Feeling cared about, over time, the client stopped demanding that the therapist be his friend. He realized that it was enough that the therapist was compassionate and cared about him.

As psychotherapists in training back then, we were much relieved to hear that, even a therapist who was known to be highly skilled, could make such a mistake. It served to take a lot of pressure off us, and I've always remembered this story.

For most clients, a sincere and caring apology can go a long way to repairing a rupture in treatment. And, in many cases, the reparative experience is more important than the rupture.

About Me

I am a licensed NYC psychotherapist, hypnotherapist, EMDR, AEDP, EFT and Somatic Experiencing therapist.

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 or email me.