Ann Arbor Psych Blog

The therapeutic relationship in counseling is a beautiful and complicated thing. When the relationship is a good fit and the client feels they can trust the therapist to handle their issues with care and without judgment, therapy can prove to be an incredible foundation for the client to grow and thrive. If you are entering therapy for the first time and come across this writing, this may provide some answers to questions you have going in. If you are seasoned in therapy, you may simply find it interesting. Either way, here are five common questions asked in therapy:

  1. “How do I know if we are a good fit? Will it hurt the therapist’s feelings if it isn’t?”

This is a fantastic question. Before you shell out hundreds to thousands of hard-earned dollars it is important to question whether the therapist is going to be a good fit. The first step in determining this is to contact the therapist via email or phone. Many therapists will offer about 10 minutes of consultation so you can ask about their style and methods and determine if it is worth setting up an appt. Here at Ann Arbor Psychiatry our admins will help determine a fit based on the issues and availability. Our Prescribing Nurse Practitioners may refer you to one of the clinicians for talk therapy as well. Once you are in session you will get a feel for how you jive with the therapist. Your therapist should be compassionate, alert, professional and non-judgmental. While you may be nervous in the initial session (this is COMPLETELY NORMAL, btw), you should be able to tell if this is someone you will be overall comfortable with over time. 

Does your therapist listen to you? If you come in and tell them you want to address a certain issue such as Weight Loss but they spend the entire session focusing on anything else but that, they may not be a good fit. Let me add an exception to this rule: there are times in therapy where diversions take place- for example- a client’s issues with weight loss may be extremely connected to childhood issues which will need to be worked through so in such cases those diversions contribute to a very productive session. However, this usually happens after a relationship has been established and trust has been built. 

Is the therapist from a similar background? Do you feel you can connect to the therapist? For some people, they prefer a therapist with similar life experiences as them or from a similar culture or background, and that is totally OK. Some clients don’t care about the race, culture, gender or background and can spill all gory details about their lives with whomever they are placed with, and that’s OK also. 

The therapist’s feelings should not be hurt if you don’t feel it is a good fit. Any good therapist cares about your well-being and wants the best for you. If you are someone that needs a completely structured session chalk-full of homework assignments such as a straight CBT therapist, then a more laid-back and eclectic therapist may not be the absolute best fit for you. A good therapist will also let you know if they feel ill-equipped to help you and will often refer you to someone who may fit better. Just please don’t blatantly insult the therapist or throw tomatoes at them on your way out (if you must throw something, we prefer you throw chocolate).  

  1. “Are there any off-limit topics?”

This is a loaded question. It is my personal belief that a client should be able to discuss anything on their mind and not worry about being judged negatively by their therapist. A good practice for any therapist is to practice Unconditional Positive Regard toward their client- a concept by Carl Rogers- that any therapist should accept and support what the client says and does. I must qualify this though- this does not mean the therapist will encourage negative behavior (however we will not shame you or treat you negatively). Also, if you are planning to harm yourself or others we have a duty to warn and report said behavior to authorities. We also are mandated to report child abuse. Unconditional positive regard toward you as the client means we will remain compassionate and positive toward you no matter what because we support your development. You are in therapy because you want to grow and shed the negative and we want to help you, so we regard you positively at all times. 

There are some therapists that will not discuss sex with their clients and that are uncomfortable with topics so personal. This could be due to religious beliefs or other reasons, and I guess in that case they are not a good fit for vast amounts of clients but may be a good fit in rare cases. Most other therapists, myself included, believe humans are deeply complex beings with thoughts, feelings, and ideals as numerous as the stars above. It is because of this complexity that a therapist needs to be comfortable discussing any topic the client needs to. 

Please don’t be offended if the therapist shows surprise at something said, laughs at something humorous or asks questions about something. For example- when I have clients that identify as ‘non-binary,’ ‘trans’ or similarly, I always ask them to define that for me. The terminology regarding sexual orientation and gender is vast and ever-changing and to better help the individual client I need to know what their identification means to them personally. 

  1. “Why won’t my therapist give me direct advice?”

This is another super loaded question with several answers. There are cases in which we do advise. Examples: 1. If we believe you may need psychiatric care 2. If you contact us during an anxiety attack and need direct advice for handling it in the moment 3. If you come in for short term counseling with minor issues and have made it clear you are seeking advice about things rather than longer term therapy 4. Therapists seeing children will give direct advice to the parents to help set up the system which will benefit the child’s long term therapy.

There are cases in which we don’t advise. One example would be advising a client to break up with their significant other. If the significant other is abusing the client we may advise in this circumstance to get the client out of danger but in most other cases we won’t directly advise the client to break up with someone. There are many reasons for this, one being that most of the time clients don’t take direct advice. Better we ask questions to help the client come to terms with their feelings so the decision to stay or leave their SO is genuinely theirs. We want our clients to grow and make decisions more confidently and independently, and that won’t come if we are constantly throwing advice at them. 

  1. “Do you ever wish you could be friends with your clients? Why can’t we become friends?”

This is a common question and it is a fun one! Yes, every therapist has clients in their practice they would just love to hang out and be friends with. On more than one occasion I have thought to myself “Damn- if only I could have met this client years ago before I joined this profession!” I have a lot in common with some of my clients- some have the same sense of dark humor that I do, while others love horror movies or Nintendo just like I do. That being said, as much as it would rock to hang out with one of those clients, it can’t happen. Not only would it be unethical, it would hurt the hard work done in therapy. Here’s why:

The therapeutic relationship depends on the client’s ability to disclose any and all things buried in their history or in the forefront of their minds. A client struggling with something serious such as past sexual abuse needs a safe and confidential place to work through the issue. Often when a person discloses something such as sexual abuse to their friend the friend is sympathetic. However some friends may become awkward and unable to handle the information and this will strain the friendship. A therapist is trained to handle such information with compassion and care, and the client can rest assured their confidentiality will be kept.

Confidentiality is often the biggest ethical factor in therapy. If a therapist runs into a client in public, the therapist won’t acknowledge or address the client unless the client has addressed the therapist first. You may not want your boss, friends or family knowing you are in therapy so we are trained not to approach you unless you approach first. If a therapist and client were friends the therapist would never be able to contribute much in conversation with the client’s peers present for fear of violating confidentiality. Also, the client may potentially alter their behavior with their friends and family while around the therapist due to fear of being judged by the therapist. 

If the therapist got to know the client as a friend it would create a bias on both sides: the therapist is going to see behaviors in the client they were unaware of and question the direction they took with the client in therapy. The client would end up learning things about the therapist that may change their entire view of the past relationship and this could undo the hard work in the prior therapeutic relationship. These are just examples of why your therapist cannot be your friend. 

Therapy is work. While it can be fun and sessions enjoyable, the therapist is there to help guide you as you learn more about yourself. At times the therapist may need to confront you directly and challenge your thinking and ideas. Sometimes these challenges and confrontations hurt and are painful, but they are small seeds that can provide huge growth as you wrestle with them. This type of work cannot be done in the context of a friendship with the therapist. 

One final reason is the inability of a client to return to the same therapist if a friendship has developed. If you are like me and it took several therapists before I found a good match, it would be harmful if I needed to return to my therapist but couldn’t because we crossed that boundary. I would have to start over from square one with a stranger. 

 

The therapeutic relationship, while not a friendship, can provide strength for a client and even benefit the therapist. It is a working relationship that while boundaried, can be treasured by both the client and the therapist. By understanding the nature of the therapeutic relationship and respecting its boundaries, therapy can help you grow in a capacity you never thought possible.

In Part I of The Therapeutic Relationship, we answered common questions about subjects such as boundaries, determining if a therapist and client are a good fit, and whether or not there are off-limit topics in the therapy session. Now, in Part II we are going to look at the client’s role in therapy. Look out y’all- this is gonna’ be blunt. 

I have heard people say that the work done in therapy is half therapist, half client. I have heard others say that the client should be doing 80 percent of the work and the therapist 20. I agree with the 80/20 view: The client should be doing the majority of the work. The tasks of the therapist include:

1.Providing a clean, safe and comfortable space with which to conduct sessions.

2. Listening intently to the client’s issues, asking questions to clarify information as needed.

3. Being mindful to what the music is behind the lyrics- what is at the root of the issue?

4. Getting to know the client to determine how to best meet their needs.

5. Offering whatever services we have been trained to depending on client need (i.e. CBT, DBT, Person-Centered Therapy, EMDR, Hypnosis).

6. Being ethical with the client- if the therapist is not trained in the issues the client needs help with (such as something specialized like Schizophrenia) the therapist refers the client to a therapist trained in such things.

7. In some cases a therapist may meet for Walk and Talk sessions or in public places for various reasons.

8. Conferring with colleagues (NEVER using client’s names or other identifiers) to get other perspectives on what might best help a client.

9. Continuously educating ourselves.

10. Some therapists encourage clients to reach out when depression or anxiety becomes severe (some therapists discourage contact between sessions to maintain boundaries).

11. Some therapists will check on certain clients between sessions if they are in crisis. The above description barely scratches the surface of what entails the therapist’s role. What about the client? Perhaps you are reading this because you have been frustrated with therapy and are wondering why you aren’t getting better. Perhaps you just dig these groovy blog posts. Either way, read on- it’s about to get real. 

Know what you’re getting into. Let’s liken entering therapy to taking on the responsibility of a new pet. You are making a commitment that is going to take effort, time, nurturing, work, and money. It is going to be frustrating and fun and sometimes you will have to clean up some shit. And much like having owned that pet, when you graduate from therapy-despite the pain, hard work and strain on the wallet- you know that you wouldn’t trade that experience for anything. Therapy is often a slow, expensive process. This isn’t Staples and there is no ‘EASY’ button. But-if you come ready to work- it may prove to be the best thing you’ve ever done for yourself. 

Communicate your needs to the therapist. Some clients want a therapist who discloses (shares things) things about themselves and is more conversational. Some want to know as little as possible about their therapist. Some days the client may need to sit in silence and simply be in the present moment with their therapist. Every client is different and every session is different. If you’re frustrated with something your therapist is or isn’t doing, tell them. Your therapist will work with you as much as possible to resolve the issue, but they need to be made aware that there is an issue. We don’t bite- I promise!

Show up to sessions. If you can’t make it or don’t plan on showing, at least text, email or call. Put yourself in your therapist’s shoes: imagine waking up at 6:30 a.m., getting dressed and sitting in rush hour to get to the office and make sure it is ready for your first client at 9 a.m. 9 a.m. comes and goes and they don’t show. Now imagine your next client isn’t until noon. This happens to every therapist. Not only is it frustrating (we could have slept in, enjoyed time with family, watched Stranger Things, had coffee, given another client that time slot), but it can be damaging to the therapeutic relationship. Here’s an example from my time interning: I had a client who came to see me due to issues in relationships (friends and romantic). I was really surprised to hear that- after all- they were friendly, intelligent, pretty, outgoing and upbeat. It became clear over time: they no-showed on our second session. On our third session they showed up twenty minutes late, and checked their phone the entire time. On our fourth session they showed up thirty minutes late and even took calls from their boyfriend. At the end of that session they said they didn’t want to come to therapy anymore because their relationship wasn’t improving. If their behavior was indicative of the way they treated others it’s no wonder their relationships were failing! Show up to therapy. It helps build a positive relationship with your therapist. 

Pay on time. If you pay by card, please keep it current and update the information with your therapist as needed. This is another loaded topic and it can get uncomfortable for both therapist and client. The policies regarding payment are made clear by most therapists at the beginning of the therapeutic relationship. At Ann Arbor Psychiatry copays and payments are usually taken the morning of session and the cancellation policy is pretty strict. It may seem cold but it’s better than the therapist having to ask for payment at the end of session. Here’s why: consider a client (we shall call her Rose). Rose comes in for issues regarding having survived a massive sinking ship. As session goes on it’s revealed that Rose is really suffering from guilt. She had fallen in love with a young man, Jack, who taught her to live and love and helped her survive the ship’s plummet into the water. Rose and Jack had found a door floating in the ocean, and Rose realizes that although they could have both fit onto the door- only she took the door, leaving Jack in the water, doomed. He held her hand as he froze to death. Rose discloses that she is traumatized by her last few moments with Jack- vigorously prying his corpse off her while telling him she’ll “never let go” and flinging him into the icy water. As Rose is sobbing uncontrollably her therapist notices that time’s up and says “that’ll be 90 dollars please.” 

Ok, so a good therapist will be more tactful than that. As a therapist, I do what I do because I love it and care about people. The charge for sessions allows me to help people but also pay my rent, car, and buy groceries. As a client you are paying for self-care and a relationship that will challenge you and foster growth in a way that a friendship won’t. We aren’t and do not work for Tony Soprano- we don’t want to repeatedly call or text you for payment. 

Do the things. Embrace the cheese. If you experience severe anxiety, your therapist may encourage you to practice breathing exercises or do daily meditation. They may ask you to keep a journal detailing when anxiety hits and at what time in the day it occurs most. If you experience depression your therapist may suggest hypnosis, daily walks, or taking up a new hobby. All too often clients come back week after week, still feeling the same, but haven’t tried any of the suggestions. I encourage you to embrace the suggestions, no matter how cheesy they seem. We understand depression is hard. We know anxiety is frustrating and debilitating at times. We know living with ADHD is frustrating. And we are happy to sit with you week after week and be your sounding board but you must take steps to facilitate your growth and healing. We care and want you to succeed, so do the things. Embrace the cheese

Stay tuned to Part III in the Therapeutic Relationship: Deepening the relationship 

Part I explored common client questions about the therapeutic relationship and reasons for various boundaries. Part II looked at the client’s responsibility in the therapeutic relationship. In this next part we will briefly discuss the deepening of the therapeutic relationship as well as the termination process.

It is said that no two snowflakes are alike. The same goes for EVERY therapeutic relationship. Each relationship has its own dynamic and deepens at its own rate for varied reasons. I believe the biggest factors that foster growth are the client’s trust in the therapist and the therapist’s continued unconditional positive regard.

There are levels of trust. You may be saying “Hey- I completely trust my therapist! I tell them everything!” That could be true. But there are levels. Has your therapist ever made an insight or asked you about something that you felt embarrassed by or caused you to want to side-step the question? Perhaps they got a little too close to something and without even realizing it you put your defenses up. It happens to most people at some point in therapy, no matter how much they trust the therapist. A good therapist will poke and prod a little bit to try and bring your issue to light but will back off if it is too distressing for you and you are absolutely not ready. Rest assured your therapist’s feelings will not be hurt by this: we know and understand that disclosing hurtful and embarrassing information about ourselves is extremely difficult and we will be there for you when you’re ready. 

When you have reached a point where you have absolute trust that your therapist does not judge you negatively and that you can disclose the really tough stuff to them the relationship will deepen and you, the client, will have unstoppable potential. Think of your therapist as a roller coaster platform: a safe and sturdy base with which you can go on a frightening, fun and rewarding journey full of heights and drops and twists, embracing your fears, knowing that there is a safe base you will return to. If you are like me, climbing to the top of the ride to step onto it, chickening out and going down the exit stairs- that’s ok also. The platform (your therapist) will be there, unconditionally and without judgment when you’re ready. 

Termination: This is an emotionally charged subject both for the client and the therapist. Ideally, termination occurs after the client has resolved the issues they originally came in for. Some clients stay in therapy for years to work on general growth and self- actualization and not for specific issues, although specific issues will arise during the course of therapy. 

The weeks leading up to termination can be difficult for both the client and the therapist. The client has spent an amount of time confiding and building trust in this other human, and the therapist has spent that time both caring for the client and getting to know them perhaps more intimately than even some of their own family or friends. Therapists do have clients and yes there are sometimes favorites, and it is difficult when they terminate. That being said- it is also a very positive and heart-warming experience for the therapist. Your therapist has watched you grow, embrace your fears and become a better human. We love releasing our clients back into the wild, but we do shed tears as we do it! 

Termination does not always mean an absolute break in the relationship. Often a client will return in a few months to check in or have a “tune-up” to make sure everything is still going well. If needed- the client can return to therapy. I cannot speak for every therapist out there but as far as the ones I know, they gladly welcome a client back for tune-ups or needed continuing care. 

The final termination session should be a positive one. Of course these sessions differ for other therapists and clients, but generally the therapist will review the relationship with the clients. They will discuss the issues that brought them into therapy and the tools the client learned to navigate those issues successfully. They may discuss frustrations and funny things that happened and reminisce about the time spent together. Many therapists will end with a hug or a handshake. 

Enjoy the dance. Embrace the weird. Do the things. Try the cheese.