Becoming a Therapist

1. Empathy and the Therapeutic Alliance: The Bedrock of Healing

The psychotherapeutic relationship itself is involved in the healing process.

Empathy as the cornerstone. The therapeutic relationship, built on empathy, is central to healing. It provides a model for mature interactions and fosters problem-solving skills. The therapist's ability to understand and validate the patient's experience is paramount.

Building the alliance. A strong therapeutic alliance is cultivated by:

• Active listening and asking detailed questions
• Validating the patient's feelings
• Framing the consultation as a collaborative task
• Explaining the therapeutic process

Beyond techniques. While specific techniques are important, the therapist's genuine care and understanding are what truly facilitate change. The patient needs to feel heard and accepted to explore their vulnerabilities.

2. The Consultation: A Structured Beginning

We view the first few sessions with a patient as a consultation, not the beginning of treatment.

Purpose of the consultation. The initial sessions serve as a consultation period, allowing the therapist to gather information, assess safety, and formulate a preliminary treatment plan. This approach provides an exit for both parties if the fit isn't right.

Key elements of the consultation:

• Establishing a therapeutic alliance
• Assessing suicidality and safety
• Collecting psychiatric and medical history
• Explaining the process of psychotherapy

Balancing structure and empathy. While gathering information is important, it's crucial to balance this with creating a safe and supportive environment where the patient feels understood. A rigid, overly structured approach can hinder the development of trust.

3. The Frame: Boundaries for a Safe Space

Safeguarding your own time is a crucial part of being an effective therapist.

Defining the therapeutic relationship. The "frame" consists of guidelines that differentiate therapy from a social relationship. These include consistent meeting times, session length, fee arrangements, and limitations on self-disclosure.

Importance of boundaries. Boundaries create a safe and predictable environment, allowing the patient to explore difficult emotions without feeling overwhelmed. They also protect the therapist's objectivity and prevent exploitation.

Common frame issues:

• Scheduling conflicts
• Telephone calls outside of sessions
• Late arrivals and departures
• Requests for personal information

4. Money Matters: Fees, Billing, and the Therapeutic Contract

The payment defines the relationship as a working entity, rather than as a substitute for other sustaining relationships.

Money as a therapeutic tool. The exchange of money for services is an integral part of therapy. It defines the professional nature of the relationship and can impact the patient's investment in the process.

Discussing fees openly. It's crucial to discuss fees and billing procedures early in treatment to avoid misunderstandings and resentment. This includes:

• Setting a clear fee
• Discussing insurance coverage
• Establishing a payment schedule

Addressing non-payment. When patients don't pay their bills, it's important to address the issue directly and explore the underlying reasons. This may involve financial difficulties or resistance to the therapeutic process.

5. Navigating the Phone Line: From Crisis to Dependency

A suicide assessment is the only part of the psychiatric consultation that should not be postponed to future meetings if the patient has any risk factors.

The telephone as a boundary object. Phone calls can range from simple scheduling to emergency interventions. The therapist must discern the nature of the call and respond appropriately, balancing availability with the need to set limits.

Assessing emergencies. In crisis situations, the therapist must assess the patient's safety and risk of self-harm. This may involve:

• Evaluating suicidal ideation, intent, and plan
• Contacting emergency services if necessary
• Providing support and guidance

Managing dependency. Frequent, unnecessary phone calls can indicate a regressive dependency. The therapist needs to set limits empathically and encourage the patient to develop alternative coping mechanisms.

6. Time Management: Respecting Boundaries of Session Length

Therapy differs from other medical visits because you can depend on it to start and end on time.

The session as a container. The 50-minute hour provides a structured container for the therapeutic work. Starting and ending on time creates a sense of safety and predictability.

Responding to late arrivals. When a patient arrives late, the therapist must decide whether to extend the session or end on time. Extending the session can reinforce lateness, while ending on time can create an opportunity for exploration.

Addressing "hand-on-the-doorknob" moments. When patients bring up emotionally loaded topics at the end of the session, it's important to acknowledge their concerns but also maintain the boundary of the session. This can be an opportunity to explore the patient's difficulty with endings.

7. Confidentiality: The Sacred Trust

By calling my patient’s name in a common waiting area, I would have failed to safeguard her identity.

Protecting patient privacy. Confidentiality is paramount in therapy. The therapist must take steps to protect the patient's privacy from the moment they enter the office.

Limits to confidentiality. While confidentiality is essential, there are limits. The therapist is obligated to break confidentiality if the patient is at risk of harming themselves or others.

Informed consent. Patients need to be informed about the limits of confidentiality, including the therapist's obligation to report abuse or threats of violence. They also need to know if the therapist is consulting with a supervisor or presenting their case at a conference.

8. Substance Abuse: Recognizing and Responding

If a new patient doesn’t have any risk factors for self-harm and she has a clear focus on her future, asking about suicidality may be in response to the clinician’s needs rather than the patient’s.

Screening for substance abuse. It's crucial to identify active substance abuse early in treatment, as it can significantly impact the therapeutic process. The CAGE questionnaire is a useful tool for screening.

Modifying the therapeutic approach. Psychotherapy with active substance abusers requires a different approach. The therapist needs to:

• Confront denial and minimize
• Set firm boundaries
• Encourage abstinence
• Address underlying emotional issues

Integrating addiction treatment. Psychotherapy alone is often insufficient for active substance abusers. The therapist should encourage the patient to attend support groups like AA or NA and consider medication.

9. Integrating Psychopharmacology with Psychotherapy

The roots of Becoming a Therapist: What Do I Say, and Why? took hold during an innocent conversation at the Massachusetts General Hospital (MGH) cafeteria with Dr. Edward Messner, a primary mentor and teacher at MGH with a special ability to explain arcane psychotherapeutic concepts in a clear and concise manner.

Balancing biological and psychological perspectives. The therapist needs to integrate both biological and psychological perspectives, recognizing that experiences affect biology and biological changes affect experiences.

When to consider medication. Medication may be indicated when:

• Symptoms are significantly impairing daily functioning
• The patient has a history of mania or psychosis
• The patient has current manic symptoms or psychosis

Addressing patient concerns. It's important to address the patient's concerns about medication, including fears of personality changes or side effects. The therapist should provide accurate information and support the patient in making an informed decision.

10. Therapeutic Impasses: Turning Stumbling Blocks into Stepping Stones

The process of psychotherapy is all about “not knowing” and having the patient teach you about her experience.

Recognizing impasses. An impasse is a pause in the progress of therapy. The therapist must recognize when the treatment has stalled and avoid ineffective tactics like giving advice or assigning homework.

Understanding the dynamics. The therapist needs to understand the dynamics of the impasse through careful listening, gentle inquiry, and empathic responsiveness. This may involve exploring the patient's resistance or the therapist's countertransference.

Resolving impasses. A resolution may be reached by means of clarifications and interpretations. The therapist should link the patient's past experiences with their present difficulties and help them gain new insights.

11. Transference and Countertransference: Unveiling the Unconscious

The roots of Becoming a Therapist: What Do I Say, and Why? took hold during an innocent conversation at the Massachusetts General Hospital (MGH) cafeteria with Dr. Edward Messner, a primary mentor and teacher at MGH with a special ability to explain arcane psychotherapeutic concepts in a clear and concise manner.

Transference as a lens. Transference occurs when the patient unconsciously transfers feelings and expectations from past relationships onto the therapist. The therapist can use the transference to help the patient understand their relationship patterns.

Countertransference as a tool. Countertransference refers to the therapist's emotional reactions to the patient. If understood, these reactions can provide valuable information about the patient's inner world.

Managing transference and countertransference. The therapist needs to be aware of their own feelings and avoid acting them out in the therapy. They should also create a safe space for the patient to explore their transference reactions.

12. Termination: A Meaningful Ending

Personally, I still think this approach makes perfect sense. In psychotherapy, words and sentences are the tools of intervention.

Termination as a process. Termination is the ending phase of therapy. It should be a gradual process, allowing the patient to consolidate their gains and prepare for independence.

Types of termination. Terminations can be mature (when the goals of therapy have been attained) or premature (when therapy must end for other reasons).

Addressing feelings about termination. The therapist needs to acknowledge and validate the patient's feelings about termination, which may include sadness, anger, or anxiety. They should also help the patient develop coping strategies for managing these feelings.

Last updated: March 3, 2025