4 years ago · Galya · Comments Off on When Therapists Make Mistakes

When Therapists Make Mistakes

By Dr. K. Kolmes

We don’t often talk about therapeutic blunders, although they happen all the time. There are so many ways for therapists to fail clients. There is probably the most common: a mismatch of styles, or a therapist who is not really helping her client. Then there are those moments when perhaps we fail our clients by not responding in the moment in the way the client might desire. Maybe we sometimes challenge when we should nurture. Or we nurture when we should challenge. Or we may do any number of subtle things, perhaps below the threshold of consciousness, not even fully acknowledged by our clients, but which create distance, disappointment, or detachment. Some examples of this are the stifling of yawns, spacing out for a moment, or failing to remember an important name or detail and the client feels we are not really fully present or engaged with them. This lack of connection may trigger feelings of disappointment, loss, or abandonment. For clients with relational traumas, events such as vacations, emergencies, or even adjustments in session times may also cause feelings of loss and abandonment.

Recently, I was having one of those weeks. The details aren’t important, but I’ll acknowledge that I had taken on a few too many things. Top it off with having a few people needing to meet at different times. Add to that one way I manage client confidentiality: putting client names into my hard calendar (which I do not carry about with me) and then transcribing the sessions later to my iPhone calendar simply as “client,” to preserve confidentiality in the event that my phone is lost or stolen.

The result?

I mistakenly transposed a client session time from my hard calendar to an hour later in my phone. And, yes, I missed the client appointment. A client arrived at my office, waited in the waiting room, perhaps knocked on my door, wondering about my whereabouts, and I wasn’t there. The mistake was realized within the hour and I phoned her and we spoke.

But still. I was confused and felt bad that it had happened.

After eleven years of becoming accustomed to some clients not showing up, some clients canceling last minute…this was new. Never before had I been the one to miss the session.

Therapy is about being present. Being witness to your client’s emotional life, and literally, being awake and engaged for fifty minutes at a time, taking in all that your client shares and responding based upon your knowledge of the history of this person. What then, do you do when you fail to be present in the most obvious of ways? By actually not showing up?

This event brought me back to 1992:

A year into therapy with my therapist, I show up at her office, which also happens to be her home. As I pull my car into her long gravel driveway, deep into the woods of Pittsboro, NC, I notice that her car isn’t there. Hmm.

Maybe her car is being serviced?

The front door of her home is unlocked, as usual and I open the door and let myself into her office and sit down on her couch to wait. Her orange tabby cat pokes his nose into the office and then rubs his body against the doorframe as he sways back into the recesses of the house.

I wait for about ten minutes, but I think I knew she wasn’t there from the instant I’d arrived. Still, it slowly dawns on me that she’s not just running late…but she probably isn’t coming to our session at all. This is….different.

I stand and walk into the hallway and hover there, weighing the threshold between her therapy office and the rest of her home..the edge where her work life ends and her real life begins. I look for the first time into her living room…forbidden territory which I’ve never had a real glimpse of before. I scan the room, taking in all I can from my vantage point in the doorway, looking at signs of her lived life: a blanket on the sofa, books and magazines on the table, pictures on the walls, a coffee cup on a side table. I call out her name. Nothing. Nobody home. I note the desire to walk further into her home and poke around. This seems such a unique opportunity to learn more about her, but the thought of being discovered wandering around her home is a strong deterrent. I slowly leave her house, get back into my car, and drive home.

When I get home, I call and leave a message: “It’s Keely. I think you forgot our appointment today.” She calls back later that day to apologize and I joke on the phone,”Well, I was going to discuss my abandonment issues with you today, but you didn’t show up.” I appreciate how it feels completely okay for me to make this joke because she has been there for me, week after week, for over a year. It is clearly a joke, and her missed appointment this day is a clear aberration. I know she will laugh at my joke. And she does. And that feels good. I know she knows it’s not a big deal to me, and that she is forgiven.

I can’t even remember if we spent any more time of it other than a brief acknowledgment at the beginning of the next session.

Back to 2009:

But here I am, 17 years later, a therapist myself, who is earlier into treatment with some clients who do not yet know or trust that I will be there for them. When we make mistakes as therapists, how do we convey both our regret, and the reassurance that this is not typical. And, more importantly, despite the fact that (hopefully) mistakes of this nature are atypical how do we position ourselves to be fully available for the range of our client’s feelings, whether they be rage, despair, sadness, or blame over the fact that we have let them down? Some clients may shrug off a mistake as no big deal, but for others it can be a very big deal. We cannot let our own desires for forgiveness and understanding get in the way of our first job to our clients which is to be present for their feelings.

Many of our clients have long histories that involve being let down by others. When a therapist fails the client in any way, this often ripples on the theme of being let down by others. It can be important to show up and be present for the processing of how this affects our client. Patients can also use their own responses to therapist errors to explore past failures by others in their own lives. When a therapist hides or denies her mistake, she not only risks avoiding an opportunity to move the therapy forward, but also creates a second breach by showing she cannot be trusted to model appropriate responsibility or, even, the ability to enact human error.

This brings me to my other point: the awareness that for some of my clients, a big piece of the work is about perfectionism and self-forgiveness. How do we allow ourselves, as therapists, to be both present for our clients, and, at the same time, models of real human beings who are imperfect? Is my self-flagellation a lesson I want to share with my client? Or would it better benefit her for me to be self-forgiving? Where does one find the balance, and how much of this can we convey to our client? How do we create appropriate space to talk about mistakes without spending too much time on them? Do we make it clear that the client can return to it, if we move on and she later finds it’s still nagging at her? Difficult questions and likely the right response depends upon each particular client.

Another factor for consideration: my office policy explains that I charge my full fee if a client does not adhere to my 24-hour cancellation policy. I do not feel it bodes well for the therapeutic relationships if we convey the belief that we value our own time more highly than those of our clients. This can be an interesting conversation to have with a client. What would she think is fair in the event of a therapist missing the session? A free session? A half-fee session? An extra fifteen minutes at the end of one session? A free pass for a same-day cancellation in the future without the penalty of full-fee? What is appropriate for a therapist to offer and what veers again into the zone of being too repentant? This exchange can be a rich opportunity for exploration with clients who wish to engage in it. Again, this can also bring up deeper issues related to fairness and resolution connected to other issues in our client’s lives.

In the end, an important lesson for me as a therapist was that sometimes unintended things happen. We may strive for consistency and perfection, but we are all imperfect. We hope that over time that our consistency and responsibility will become apparent to our clients. But one goal of therapy is to reach a safe attachment in which one can weather disappointments and unintentional blunders without either party (especially the client) having to experience the threat of losing the relationship. Mistakes do happen and sometimes it’s just as important for us as therapists to remember this as it is for our clients. And, as in all relationships ― not just the therapeutic ones ― it’s often not about whether mistakes occur, but how they are acknowledged and repaired that really counts.

4 years ago · Galya · Comments Off on On the Difference Between Therapy and Giving Advice

On the Difference Between Therapy and Giving Advice

By Dr. K. Kolmes

“But what should I do?”

It doesn’t happen often, but once in awhile, I will meet with a client who asks me some variation of the above. The thing that is most challenging (to me) about clients who directly ask what they should do is that they are usually those who are experiencing the most pain and confusion. It makes sense that people who are struggling, hurting, or experiencing despair would want someone to tell them what to do to make it stop. And, often, I would like to help them make it stop too, so there is a strong pull to give an answer.

But giving advice is not psychotherapy. Therapy is a place to explore your feelings and learn about yourself. It’s a place of self-discovery. It’s a place to find out how you have become tangled up and a place to learn how to untangle yourself. It’s a place to gain a better understanding of your inner world and your relationships. This process is what people come into therapy to learn. It’s what mental health professionals go to school to learn how to provide. Sometimes it takes time and reflection to see the patterns and it isn’t a quick fix, as much as both therapist and client sometimes wish it were. Sometimes just acknowledging and sitting with that pain, confusion, and wish for an immediate answer is the best thing we can do.

This does not mean that I withhold information from clients when I think it might be helpful. If I notice a theme or have some concern that a client may not be acting in their best interest, I speak up. It also doesn’t mean that I am non-directive. There are times when I get very directive with clients. I integrate cognitive-behavioral interventions in my work and I tend to use them when people need symptomatic relief or when people are trying to break habits. At the most extreme that can happen when someone is in danger and I need to get them into the hospital or go over a safety plan with them. In these cases, we may make a list of people to call and things to do when they are feeling actively suicidal.

Less extreme versions of my being directive may include encouraging a client to make an appointment with a psychiatrist. Or I may develop a plan for a client to do breathing or relaxation exercises when she or he is anxious or call a friend to go to the gym when depressed. With my couples, I often prescribe “homework,” which includes communication exercises or plans to notice positive aspects of one another or the relationship. In my dissertation support group, I will sometimes make suggestions to counteract procrastination.

But these are specific treatment approaches to specific problems and not the same thing as telling a client what to do with major life decisions. If you want a therapist to tell you what to do, as opposed to helping you figure out what is right for you, it could be worth thinking twice about what you’re seeking. Some people want others to tell them what to do because it means not having to take responsibility if things don’t work out. Friends and counselors can give you advice. But if what you are looking for is just someone to give advice or tell you the things that have worked for them, it may not be psychotherapy that you’re looking for. Conversely, if you are going to therapy and you find that your therapist fills the time with advice, suggestions, or anecdotes about their life, it could indicate that they have some discomfort with allowing the therapeutic process to unfold. Be aware that you can find someone else who creates the space for your process of becoming conscious and finding the answers that are right for you.