Old Heaters & Extra Doorknobs

I recently opened a new  counseling office at St. Philip’s Episcopal Church in the Donelson area of Nashville.  (I am not doing counseling there myself, but am renting that office to other therapists.)  I did the re-decorating of the office myself.  When I first went to the office, it needed a little work.  There was peeling paint, missing trim on the walls, and old light fixtures.  There were also some peculiar things in the office.  The remnants of an old wall heater remained attached to the wall and oddly, there was a second doorknob on the door to the office.  I could see why the heater had been abandoned and why it would be a challenge to remove from the wall without having to do major repair to the wall, but that extra doorknob, I could only imagine how that might have come to be.  Only one of the two doorknobs actually worked.  So, I imagined that at some point the original doorknob had stopped working and was replaced, but the knob was not replaced in its original position, but a new doorknob was placed above the first on the door.  I could not remove the non-functioning doorknob without replacing the whole door.  So, I painted around them both.  

The Work of therapy is not unlike the office.  Like the new office bore the marks of those who had inhabited it previously, our lives and relationships do bear the marks – positive and negative – of our previous experiences.  When we take time to tend to the needs of our internal world, there is much work that can be done to bring about change.  We can replace things that used to work, but no longer work.  We can add things that are missing – new skills, new understandings, and the like.  The work that we do on ourselves can radically change who we are. I could have written about how sometimes, we avoid working on things in our lives because the task seems too big or we fear it will cost too much to do the work we think we need to do.  That might have been a valid reflection, however, I began to think about how in the work of therapy, there are sometimes things about us that just do not seem to change.  For an individual, there seem to be some things about our core personality that remain true no matter what.  John Gottman, in his study of marriages, has noted that two-thirds of the things that couple’s fight about are things that cannot be resolved.  They are issues that cannot be changed or issues that have no easy resolution. 

Part of the work of therapy, is realizing that some things about us or our situations cannot be changed. Such things must be examined and understood as best as possible, but the work of therapy becomes acceptance of the given reality and to working with it.  This can be challenging depending on what the issue is.  However, we can learn to accept and adapt.  We cannot always remove the extra doorknobs of our lives or repair the ones that are broken.  We cannot always remove the things that no longer work without doing more damage or creating more difficulty.  So, we learn to make peace with what is.  We stop fighting against what cannot change and learn to accept.  This may mean accepting certain things about ourselves or about those close to us that are difficult, but it is possible to learn to make peace or adapt. 

If you would like to see before and after pictures of the office, visit https://www.counselingatstphilips.com/news

 

Why Should I Pay to Talk to You?: Reflections on the "Process" of Psychotherapy

A recent conversation prompted me to revisit this question. This post is an edit of a 2013 post on "Content vs. Process" in psychotherapy.  

When meeting new clients (and others), I encounter a variety of comments that reflect common misconceptions about psychotherapy.  One is that the focus of therapy is for me to evaluate the client and tell them what to do.  Many people start their therapy a bit defensive because they are fearful of my judgment or correction.  Some people have mocked the process of therapy by saying that therapists never tell you what to do and only “Listen”.  Others have said to me, “Why am I paying you to listen to me when I could just be talking to a friend or family member?”  The difficulty with all of these assessments is that they assume over-activity or inactivity on the part of therapist.  People have experiences with other "advisers" in their life in which they seek advice and receive a plan on what to do for their particular problem and they expect therapy to be like that.  There are also distortions of the therapeutic process portrayed in film and television that perpetuate misconceptions.  Unfortunately, there are also a number of people in the world practicing some type of counseling who contribute to these stereotypes by their methods of practice.  The very terms we use for this type of care are also confusing – counseling, therapy, psychotherapy, psychoanalysis, etc.   (In a previous post, I commented on the technical differences in these various terms).  Many people think that seeing a therapist is helpful because the therapist is supposed to be a neutral third party.  However, what makes the process of psychotherapy different from talking with a friend or other type of helper is the attention to the process of therapy. Because this part of the relationship is often managed in subtle ways, people often perceive that the therapist is not doing much, but the reality that is that the process is rich with reflection.

Fundamentally, what makes any type of counseling or psychotherapy beneficial is the quality of the established relationship and this is true regardless of the therapist's theoretical orientation.  However, attention to this "process of therapy" is particularly meaningful to those who practice psychoanalysis, psycho-dynamic psychotherapy, and traditional Pastoral Psychotherapy. In these types of therapy, the therapist is mindful of the dynamics of the relationship, monitors these things, and uses them (hopefully) for the client’s benefit.  These types of dynamics can exist in other relationships with friends, etc, but it is more rare.  Psychotherapy is, by definition, a relationship between two (or more in the case of couple or family therapy) people for the benefit of one of them.  Everything the therapist does or says should be for the benefit of the client.  In order to do this, the therapist must be aware of many dynamics that are simultaneously at work in the counseling office.  Friendships are generally more mutual in nature.  

What is the "Process" of Therapy? 

When a person comes to therapy, the issues they wish to discuss and the struggles they have with these issues constitute the “content” of the session.   However, the forces that motivate a person’s behavior are also important.  The therapist should be reflecting on the selection of material presented and the content of the material.  After a particularly painful session of dealing with something like grief, a client may come in the next session and talk about more mundane or superficial issues.  The therapist’s job is to note the shift in tone and help bring to awareness the change.  When a client presents a memory of events, the therapist is focusing on how the person was affected and how they behaved in the events presented, but he or she is also focused on how the person seems to be feeling as they are presenting the material.  The therapist should not make assumptions about what the client felt, how they are feeling, or why they behaved in a certain way.  The job of therapist is to note that such feelings and motivations exist and to ask questions to raise the client’s awareness.  This is why it has become cliché for a therapist to ask questions like “How did you feel when that happened?”

The Therapist should monitor his or her own feelings during a session

Completely out of the awareness of the client (at least it should be) is the therapists’ reflections on another set of dynamics in the room – his or her own.  As the client is sharing, the therapist is also monitoring his or her own feelings about what is being shared.  He or she is monitoring the experience of the person and noting what they observe and hear.   The therapist is monitoring how his or her own story is connected to the client’s story.  The goal for the therapist is to be able to separate his or her own experiences from the experiences of the client.  In order to do this effectively, the therapist should have done sufficient therapy for their own personal issues and to receive adequate supervision and/or consultation on their work. The therapist becomes less effective when he or she assumes what the client will or should feel instead of allowing the client to discover what they actually feel.

Therapy is meaningful when the therapist is NOT giving advice

While the therapist may provide some education on common dynamics of interaction or personal development, their primary goal is to allow the client to discover how he or she plays out these dynamics in their own life.  Any intervention or action on the part of the therapist should be in the service of this self-discovery or to help provide an environment that contrasts the clients’ previous hurtful experiences.  By observing the clients actions, monitoring feelings, and dealing with the dynamics of the client’s relationship with the therapist, the therapist creates the opportunity for growth and healing.  The client’s experience of the resulting relationship between therapist and client can then grow beyond the walls of the therapy office to the other parts of the client’s life.  The goal for the therapist is to create independence for the client and not to foster dependence.  Advice-giving and such activities, while helpful, only keep the client dependent on the counselor.  When the therapist helps the client discover his or her own ways of dealing with things, then they are able to apply that understanding to novel situations.  The experience of this growth within a therapeutic relationship is generally experienced by client and therapist as deeply meaningful.  In pastoral psychotherapy, this growth and self-reflection will often include reflections on faith, God, and spiritual development and the process of the therapy itself can be experienced as quite spiritual or holy. 

So, far from doing nothing or doing everything for a client, the therapist works with the content of the client’s issues while monitoring the internal and relational process of therapy. The therapist should maintain a calm exterior, but should always be actively reflecting internally.  I have found this process personally, professionally, and spiritually enriching.  For most events in life, the support of a good friend or trustworthy family member is invaluable.  A good friendship can have wonderful therapeutic value and can be very helpful in many of life's difficult situations, but for me, there is no true substitute for a meaningful therapeutic relationship.

Content vs. Process

When meeting new clients (and others), I encounter a variety of comments that reflect common misconceptions about psychotherapy.  One is that the focus of therapy is for me to evaluate the client and tell them what to do.  Many people start their therapy a bit defensive because they are fearful of my judgment or correction.  Some people have mocked the process of therapy by saying that therapists never tell you what to do and only “Listen”.  Others have said to me, “Why am I paying you to listen to me when I could just be talking to a friend or family member?”  The difficulty with all of these assessments is that they assume over-activity or inactivity on the part of therapist.  With the distortions of the therapeutic process portrayed in film and television, I cannot really blame people for these misconceptions.  Unfortunately, there are also a number of people in the world practicing some type of counseling who contribute to these stereotypes by their methods of practice.  The very terms we use for this type of care are also confusing – counseling, therapy, psychotherapy, psychoanalysis, etc.   In a previous post, I commented on the technical differences in these various terms.  However, what makes the process of psychotherapy different from talking with a friend or other type of helper is the attention to the process of therapy.  Because this part of the relationship is often managed in subtle ways, people often perceive that the therapist is not doing much, but the reality that is that the process is rich with reflection.

Fundamentally, what makes any type of counseling or psychotherapy beneficial is the quality of the established relationship.  However, in the process of psychoanalysis, psychotherapy, and Pastoral Psychotherapy, the therapist is mindful of the dynamics of the relationship, monitors these things, and uses them (hopefully) for the client’s benefit.  These types of dynamics can exist in other relationships with friends, etc, but it is rare.  Psychotherapy is, by definition, a relationship between two (or more in the case of couple or family therapy) people for the benefit of one of them.  Everything the therapist does or says should be for the benefit of the client.  In order to do this, the therapist must be aware of many dynamics that are simultaneously at work in the counseling office.

When a person comes to therapy, the issues they wish to discuss and the struggles they have with these issues constitute the “content” of the session.   However, the forces that motivate a person’s behavior are also important.  The therapist should be reflecting on the selection of material presented and the content of the material.  After a particularly painful session of dealing with something like grief, a client may come in the next session and talk about more mundane or superficial issues.  The therapist’s job is to note the shift in tone and help bring to awareness the change.  When a client presents a memory of events, the therapist is focusing on how the person was affected and how they behaved in the events presented, but he or she is also focused on how the person seems to be feeling as they are presenting the material.  The therapist should not make assumptions about what the client felt, how they are feeling, or why they behaved in a certain way.  The job of therapist is to note that such feelings and motivations exist and to ask questions to raise the client’s awareness.  This is why it has become cliché for a therapist to ask questions like “How did you feel when that happened?”

Completely out of the awareness of the client (at least it should be) is the therapists’ reflections on another set of dynamics in the room – his or her own.  As the client is sharing, the therapist is also monitoring his or her own feelings about what is being shared.  He or she is monitoring the experience of the person and noting what they observe and hear.   The therapist is monitoring how his or her own story is connected to the client’s story.  The goal for the therapist is to be able to separate his or her own experiences from the experiences of the client.  In order to do this effectively, the therapist should have done sufficient therapy for their own personal issues and to receive adequate supervision and/or consultation on their work.  The therapist becomes less effective when he or she assumes what the client will or should feel instead of allowing the client to discover what they actually feel.

While the therapist may provide some education on common dynamics of interaction or personal development, their primary goal is to allow the client to discover how he or she plays out these dynamics in their own life.  Any intervention or action on the part of the therapist should be in the service of this self-discovery or to help provide an environment that contrasts the clients’ previous hurtful experiences.  By observing the clients actions, monitoring feelings, and dealing with the dynamics of the client’s relationship with the therapist, the therapist creates the opportunity for growth and healing.  The client’s experience of the resulting relationship between therapist and client can then grow beyond the walls of the therapy office to the other parts of the client’s life.  The goal for the therapist is to create independence for the client and not to foster dependence.  Advice-giving and such activities, while helpful, only keep the client dependent on the counselor.  When the therapist helps the client discover his or her own ways of dealing with things, then they are able to apply that understanding to novel situations.  The experience of this growth within a therapeutic relationship is generally experienced by client and therapist as deeply meaningful.  In pastoral psychotherapy, this growth and self-reflection will often include reflections on faith, God, and spiritual development and the process of the therapy itself can be experienced as quite spiritual or holy. 

So, far from doing nothing or doing everything for a client, the therapist works with the content of the client’s issues while monitoring the internal and relational process of therapy.  The therapist should maintain a calm exterior, but should always be actively reflecting internally.  I have found this process personally, professionally, and spiritually enriching.   I know that the quality of a good friendship can accomplish similar purposes, but for me, there is no substitute for a meaningful therapeutic relationship.

Tending to Feelings is Key to Happiness

           This past weekend we took our youngest daughter to college.  We now have two kids in college and no kids living at home.  It would be easy to wax nostalgic about this life transition and how wonderful it has been to be the father to beautiful, intelligent, and humorous young women, but something else struck me about the past couple of weeks.  

            As the time approached for this monumental weekend, there were a number of significant stressors in my life.  I wanted to focus on my daughters’ leaving and enjoy my time with them.  I did not want to get overly emotional, but just appreciate every moment we had as a family.  What I now realize is that the more I tried to deny the stressors going on in other parts of my life and the more I tried to deny my feelings about what was happening, the more irritable and stressed I felt.  I found myself more frustrated in traffic and easily annoyed by others.  I knew I felt overwhelmed, so I tried to isolate at work to avoid additional stressors.  Engaging with others was difficult.  Instead of finding a way to enjoy my last couple of weeks with kids at home, I more survived it; not what I really wanted.  

            There are times in life when the stress of life gets to be too much and we find ourselves more surviving than thriving.  However, there are times when I think we do a disservice to ourselves by trying to avoid our feelings – by trying NOT to feel what we obviously feel – through a variety of means.  I know some people just isolate or become mesmerized by T.V. program or such while others try to avoid feelings by numbing with substances.  Still others try to avoid their feelings by staying so busy that they don’t think about the underlying stressors or feelings.  At different times in my life, I have been guilty of all of these.  Though I lost sight of it temporarily (again), I know that it is better to acknowledge the feelings and allow myself the opportunity to express them.  It takes more courage and it is more difficult, but I think it ultimately leads to more happiness.  When some people take time to be still and look inward, they do not like the things they find.  Guilt, shame, embarrassment, anger, disappointment, etc. can be hard to acknowledge and difficult to know how to manage. 

            I am grateful for various friends and therapist I have had through the years.  Friends can be a great source of support and help if they listen well.  My therapists have always listened well and have been beneficial in helping me identify underlying feelings and processing them until the power of those feelings is gone.  During the past few weeks, I cut down on my own counseling because I thought I was too busy.  In fact, I should have made more time for it and perhaps even gone more often.  I did not practice the very self-care that I would encourage in others.  This is my note of confession, but also an encouragement to others to tend to your inner world of feelings.  It definitely helps make living in the moment easier and more enjoyable.

Psychotherapy: Empathic Failures, Great & Small

There is no fun in psychiatry. If you try to get fun out of it, you pay a considerable price for your unjustifiable optimism. ~ Harry Stack Sullivan

            Despite the quote above, Harry Stack Sullivan seems to have a great deal of optimism about the human condition.  He does not believe that our emotional lives are fixed in the first few years of our lives, but created in every moment of our lives.  That is hopeful.  As a therapist, my goal is to enter into relationship with people, join them in that journey of their life, and hopefully help co-create a new reality.  There is nothing more meaningful and humbling than when this occurs.   Sullivan is also the person that points out that as therapists, part of the therapeutic process is recovering from a series of empathic failures on our part as we attempt to connect with our clients. 

            From the moment when the client enters our office for the first time, we attempt to get to know them and their situation.    We try to not overwhelm them by spending too much time on the intake paperwork.  We try to communicate our best understanding of what the client is dealing with and what he or she may be feeling.  In subsequent sessions, we sometimes forget small details of the client’s story and that may feel like a failure to the client who wants to be understood and remembered.  At times, we may presuppose a client is feeling one thing and not be attuned enough to them to realize that they feel something else.  These little failures on the part of the therapist can create small set-backs in the therapeutic process, but Sullivan suggests that the process of therapy is the recovery of the therapeutic relationship from such failures.  I am not an expert in Sullivan’s theory of Interpersonal Psychiatry, but I would imagine that when we begin to recover from such empathic failures in therapy, it helps us to be better equipped to deal with them outside of therapy and even be more tolerant when they occur.  Life is full of little disappointments and the ability to not define any relationship by those moments seems critical to the survival of relationships and authentic happiness.

            Then there are those OTHER moments.  From time to time, our emotional reactions or our misjudgments as therapists result in us having a huge lapse in empathy and completely missing our clients.  In 15 years of doing therapy, my experience has been that after my early years of training, these larger lapses in empathy were fairly rare.  When they occur, however, they often result in clients leaving therapy altogether.  This is one of the most difficult things to deal with as a therapist.  There are some therapists who tend to blame their clients for “lack of readiness to enter therapy” and there may be times when that is true, but as therapists we have to admit that sometimes we mess up.  I am not talking about the gross misuse of a client or horrible bending of the therapeutic boundaries, but the failure to connect with our clients in way that is meaningful. (The client may be fully justified in leaving, especially if the miss is egregious or happens a number of times.)  Many times these types of failures occur when we, as therapists, fail to keep our own emotions and relational “baggage” out of the therapy with another person.  Therapy is about the person in front of us and not about us.  A good therapist must have gone through some process (like their own therapy or another self-reflective experience) to maximize his or her ability to avoid these big empathic misses. 

            Each empathic miss, large or small, becomes an opportunity to learn.  It is a chance to learn more about our clients and more about ourselves.  The therapeutic process at its best is an interaction of two people for the benefit of one of them.  The therapeutic process is co-created by therapist and client and it is the therapist who needs to always be mindful of the process and tending to the client.  We are obviously not perfect at this.  Some are obviously better than others (and some are really bad), but the good therapist recognizes these failures, seeks supervision, does the hard work of introspection, and continues to seek to be better.  Our clients help us and help themselves when they realize that there is a process and that the process is co-created.  Conversation and connection create the holy space for both of us.

The Sky is Falling and It's All Your Fault

I have two primary theories that inform my therapy with my clients; object relations theory and family systems theory.  I am acquainted with a number of other theories.  What I have learned through the years is that what theory you use with a client is not as important as establishing a good relationship with the client.  There are several qualities that make for good rapport, but none more important than being a “non-anxious presence”.  The term “non-anxious presence” comes from the family systems theory, but has such a broad potential for application.  Being the non-anxious presences means that as the person in front of you is getting more and more anxious that you resist the urge to join them in that intensity.  Being a non-anxious presence means that when the person with you discloses something that is shocking to you on the inside, that you don’t show it on the outside.  Being a non-anxious presence means that you do not jump to conclusions, you don’t overreact, you don’t judge and you don’t get lost in your own emotions.    

To be really good at doing this, a person must have done sufficient work on their own internal world; tending to their own hurts, their own biases, their own beliefs, and their own arrogance.  To be good at  being a non-anxious presence requires a degree of humility.  It means entering into the other person’s world so that you can understand things from their perspective without losing yourself.  To do this, you really have to know yourself, but not be hung up on yourself.  Being open to the other requires allowing others to explore their own thoughts and make their own choices (and live with their own consequences).  It does not mean that we don’t express our thoughts or concerns, but it does mean that we don’t try to control the outcome for the other person.  To be a non-anxious presence, we have to tend to our own fears, manage our own emotions, think through our own actions before we become “reactive”.  Being present with another person in this way, demonstrates our inherent trust in the other person and God to ultimately figure things out.  Being present in this way means not trying to control another person’s life and dictate the outcome of their story; it is seeking to be loving.  For me, it is the way that God demonstrates love to us.  Allowing us to figure things out and learn from our choices, but supporting and loving us on our journey.

The opposite of this can be seen in so many places, but it is particularly disturbing to me to see it in families, churches, and politics.   It seems that social media like Twitter and Facebook and 24/7 news coverage provide people the opportunity to comment on events and people without careful reflection and complete understanding.  When we reduce people to sound bites, exaggerate their views (or flat out lie about them) to create fear we are being emotionally reactive and manipulative.  When we reduce people to labels and belittle them for their thoughts we are separating ourselves from the image of God in another human being.  When we ostracize others because they are different than us we are denying the freedom of each person and the interdependence of our lives.  I am continually saddened to see religious leaders – conservative, moderate, and liberals – who demonize those who are different from themselves and respond with knee-jerk reactive comments.  I am disgusted by politicians that create unrealistic fears to emotionally manipulate the public.  In our families, in our churches, in our society, we need more people who are willing to do the difficult work of introspection in order to offer the world a more non-anxious presence.  I know it brings healing in a therapy relationship.  I know it breeds healing in personal relationships.  I don’t know why it would not benefit society as a whole.

Counseling, Psychotherapy, and Pastoral Counseling

I have been a part of several conversations recently that involved questions about the perceived difference between counseling, psychotherapy, and pastoral counseling.  There are volumes and volumes written on each of these things and the differences between them.  I don't know that I have a great deal to add, but I would like to offer my general reflections.  In common usage, counseling and therapy are used interchangeably.  However, technically there is a difference.

Many occupations and disciplines use the concept of "counseling".  For the most part, counseling does involve listening to a person and helping them with some decision, skill, or problem.  For the most part, counseling involves less in-dept responses.  Counseling involves applying a particular body of knowledge to a particular problem.  Counseling is more technique-driven and would be more instructional.

Psychotherapy also involves listening to a persons problems and does operate from a particular base of knowledge, but is generally more focused on insight.  A psychotherapist is going help a client reflect on various aspects of his or her life that might provide insight into the person's current complaints or struggles.  Which aspects of life become the focus of conversation will usually be driven both by the person's presenting issues and the theoretically orientation of the therapist.

In Tennessee, Pastoral Counselors can be licensed.  Those who are licensed are called Clinical Pastoral Therapists.  These therapists or those who are certified by the American Association of Pastoral Counselors are a special type of psychotherapists that use the spiritual resources of faith in their understanding of their clients.   There are numerous books written on pastoral counseling and what makes it unique -- each with its own twist - and each is often quite deep and theoretical.  This is why pastoral counselors often have difficulty articulating what it is that they do that is different from other therapists.  Below is my latest attempt to summarize what we do.  Even in reading this, there are questions about what this theory actually means in practice, but it is an attempt to capture it.  The statement below was recently written for a congregation in Nashville to help them better understand the work of the Pastoral Counseling Centers of Tennessee.



The question about what makes the counseling at the Pastoral Counseling Centers of Tennessee (PCCT) unique is a common one.  The short answer to the question involves some version of the fact that our counselors have a theological education and we offer financial assistance with our fees. The identity of our therapists as representatives of various faith groups is part of our identity; however, exactly what that means is more complex.   The training and experience of our therapists means that they attempt to understand their clients and do therapy with them in a way that is different than the counseling or therapy offered at other places.

In a world where diagnostic labels abound and managed care dictates modality of treatment, length of treatment, and frequency of treatment, PCCT offers something more personal.  We are capable of using the common diagnostic labels of our mental health peers, but we intentionally seek to see each person beyond those labels and understand the richness of each person’s life and how the various components of a person’s life interact to influence their faith, mental status, emotions, and relationships.  This holistic approach to therapy seeks to understand the underlying issues of a person’s presenting problems.  This approach to therapy requires attention to the development of a relationship that goes beyond the application of a particular technique.  This approach to therapy attempts to see each person in the fullness of what they were created to be and help them identify and overcome obstacles to living into that potential. We often refer to this as “Seeking to embody God’s healing presence.”  In the process of relationship, we use the tools that other qualified psychotherapists might use, but we also can call our training in theology, scripture, church history and the traditions of our faith when they might be helpful.  Our goal is to sit with clients as they sort out their struggles and make meaning of their lives.  We do not rush to answer the difficult questions for them and we do not leave them alone and lost. 

The style of therapy that we foster and promote has proven again and again to be healing and meaningful for our clients.  We believe it is the most excellent care.  We are committed to the idea that God does not just love those or offer healing to those with financial means, but God reaches out to all people.  For this reason, we seek to offer our services with financial assistance for those that cannot afford our regular fee.  We want to make our style of therapy available to anyone who wants it.  Because we want to represent the faith traditions in which we were nurtured and the community of faith as a whole, it is part of our identity and mission that we be intimately connected to local congregations.  Our offices are all located in space provided by local congregations.  We seek to offer training and other benefits to local clergy and the congregants they represent.  We are grateful to each individual and each congregation that supports us through their prayers and through their financial gifts.  Through this support we are able to bring God’s healing to the community of Middle Tennessee.