Case Study

Bursting the Bubble of Individual Therapy

The Need to See Your Clients in a Relational Context

Magazine Issue
January/February 2022
A therapist and client in a bubble

Many therapists have long-term clients. Some stay with us for years, even decades. Others see us on an as-needed basis, or simply just to check in. For these clients, therapy is both a familiar touchstone and a regulating force, providing insight and comfort throughout life’s ups and downs.

But as the years pass, is it possible that the more we work with these clients—helping them make progress and establishing a strong therapeutic relationship—the more we might overlook bigger issues that aren’t being addressed in the work? Are there parts of a client’s personality and functioning that we can’t help but miss if we only see them individually? In the end, how much can we really know about how our clients navigate the world outside the therapy room?

These are questions I found myself pondering after my work with Renee, a long-term client I’d been seeing for individual therapy and, taking a risk, for couples therapy as well. Although I thought I knew Renee well from our individual work together, treating her and her partner together allowed me to see new (and disturbing) aspects of her personality that I hadn’t understood previously. Now I know that, as much as a strong bond between therapist and client can further the work, it can obscure our vision of larger problems at play in other relational contexts.

The notion that I’d missed something massive in my long-term work with Renee surfaced during a telephone consultation with my colleague Kevin, who’d seen Renee and her husband, Joe, in couples counseling for a few sessions. I’d referred them to Kevin after hearing bits and pieces about their marital discord from Renee, although I’d never actually met Joe. As far as I knew, Renee was a joy to work with, and always open to therapeutic feedback. But for Kevin, that couldn’t have been further from the truth.

“Frankly, Laurie, your client’s rage and the way she treats her husband are extremely disturbing,” Kevin said, sounding exasperated. “Renee has been very difficult to work with. Every time I try to confront her, she goes off on me. Honestly, I don’t think I can do much good for their relationship. Renee’s the most dysregulated client I’ve ever seen.”

I couldn’t believe it. Renee? My Renee? I’d known her for more than 30 years. She’d recently mentioned a few tiffs with Joe here and there. But rage? I’d never seen that once from Renee.

My initial response was denial. Perhaps Kevin’s own buttons were being pushed. Or maybe he was overreacting. “I’ve never seen this in our individual work,” I admitted to him.

I asked Kevin for more detail, and as I listened, my denial turned into embarrassment and then self-doubt. How could I have missed this? I thought.

Forging a Connection

I went back to the first time Renee and I’d met. It was 1992, and I was working at a counseling agency. On her intake form, Renee had written about a problem with her boyfriend. In our first session, she barely spoke, curled into a fetus-like ball, and sobbed. I followed my instincts and was simply present with her, interjecting a few supportive words. It didn’t feel like much, but at the end of the session, when I asked if she wanted to come back the following week, to my surprise, she said yes. Our next few sessions were the same: Renee would curl up in her seat and look away while I intermittently broke the silence to tell her I cared about what was happening with her.

Eventually, Renee spoke, telling me about the childhood physical and sexual abuse she’d experienced at the hands of her older brother, and about how her mother had turned a blind eye. She described the physically and emotionally abusive relationship with her boyfriend, who’d persuaded her to join him in robbing gas stations. Her shame was palpable.

“What do you need from me right now?” I asked her once.

“Would you hold my hands?” she asked.

I slid my chair forward and took her hands in mine as she continued telling me about the horrors she’d endured. For the first time that session, our eyes met. The moment was a breakthrough, and as the weeks progressed, I saw more and more of the intelligent, gracious person beneath all this pain.

Eventually, she told me, “You’re the first grown-up I’ve ever trusted.” I was only 10 years older than her, but she clearly saw me as older and wiser. Older and wiser than I felt, anyway.

We spent 10 months developing a strong bond—so strong that when I decided to leave the agency to open a private practice, the clinical director at the agency agreed with me that leaving Renee would be damaging. So I offered Renee the option to switch to another therapist or see me privately. As predicted, she chose the latter.

Over the next five years, we continued to deepen our relationship, and her progress continued. She left her abusive relationship, gave up drinking, and began attending AA meetings. As part of her step involving making amends, she even secretly went back in the middle of the night to the gas stations she’d robbed, leaving envelopes in the mail slots containing every dollar she’d stolen from them. She enrolled in college, where she earned straight A’s and eventually matriculated in a top-ranked PhD program.

As Renee got ready to leave town for this new journey, we agreed she could always call for a therapy appointment when in town, that she could write to give me updates on her life, and that I’d write back. We set boundaries around these contacts, clarifying that they couldn’t be akin to long-distance therapy. At the same time, I made sure to set her up with a good therapist in her new town.

In our last session, she asked me to walk her to her car, hug her goodbye, and stand waving until she could no longer see me in the rearview mirror. She told me this would make her feel like I was the loving mother she’d never had, sending her off into the world for success. I honored her request, and while she could see me waving as she drove away, she couldn’t see the tears streaming down my face at the pride I felt in her growth.

Renee never broke our predetermined boundaries, but she did stay in touch, writing when major milestones occurred, like when she received her PhD, got married, and landed a prestigious faculty position. Year after year, she sent Christmas and Mother’s Day cards, often writing in the latter how I’d become the caring mother she’d never had and crediting our work for how far she’d come. And whenever she happened to be in town, with a release from whatever therapist she was currently seeing, she came in for a session or two.

A Leap of Faith

After hearing Kevin’s comments about her behavior in couples therapy, I racked my brain trying to recall similar observations from Renee’s other therapists. None had mentioned anger problems. Like me, they saw only Renee’s severe trauma, extraordinary intelligence, resilience, and powerful drive for growth and healing. Several commented on how staying in touch was totally appropriate, given the progress she’d made with me.

At one point, Renee had asked to see me again for treatment. This time, she’d said, her childhood issues were being triggered by a male colleague at work, and she believed I’d be the best person to help. Since I happened to be licensed in the state she resided in, we began to meet virtually. Then, after dealing with her work situation, she confessed that she was desperately unhappy in her marriage—which was why I’d referred her and Joe to Kevin.

Only three sessions in, Renee and Joe decided to leave therapy with Kevin, who secretly expressed his relief to me. “To be honest,” he added, “I doubt that their marital problems will ever be completely resolved.”

“Kevin only saw what I’m doing wrong,” Renee told me over video chat. “He blamed me for our problems. He didn’t see that Joe willfully and cruelly ignores me.” Then, she asked if I could see her and Joe instead.

Despite realizing that most of my colleagues would never take the risk of seeing a long-term individual client in couples counseling, I decided to discuss this thoroughly with her and Joe, together and individually, to see if it was even a possibility.

With Renee, I discussed the possible harm to our relationship. “There’s no doubt that sometimes in couples counseling, I’ll confront your role in the problems,” I explained. “This could be triggering for you, perhaps making you feel like you did when your mother didn’t protect you. I fear it could damage the way you view our relationship.”

“I don’t think there’s anything we can’t work through,” Renee said.

With Joe, I discussed the danger of him feeling like the odd man out, given my history with Renee. “I’ve known Renee for a very long time, and our relationship is very important to her,” I explained. “I’m only now just meeting you. The couples counseling might feel unbalanced, since I know Renee so much better than I know you.”

Joe said he trusted me, based on what he’d heard from Renee. I also got a nod from two trusted colleagues I consulted, both of whom felt that the risk might be worth the benefit, especially given that Renee had respected boundaries in the past. Renee, Joe, and I decided I’d first see Joe for a few sessions of individual, get-to-know you therapy. Then, I’d begin to see Renee and Joe for a several-week trial of couples counseling.

The Bigger Picture

A few sessions in, I saw exactly what Kevin had been referring to. Renee consistently berated and belittled Joe, blaming him for everything wrong in the relationship. She also labeled him as abusive. It became clear that she was seeing his tendency to shut down in the face of her anger as willful and cruel neglect.

“He constantly ignores me,” she complained. “He doesn’t touch me. He doesn’t look at me. He makes me feel like I’m invisible.”

Getting Joe to express any reaction was difficult, and I could see why. He lived in constant fear of Renee’s criticism and rage. Whenever she expressed her displeasure, he’d look down and say nothing. Sometimes, he’d agree with her as he looked away—clearly a self-protective strategy.

Still, they insisted they loved each other, and said splitting up wasn’t on the table.

I saw Renee and Joe for nearly three years, during which I tried everything in my therapist toolbox, and then some. I taught them communication and conflict resolution skills. I prescribed daily hugs and affectionate statements. I instructed Renee to practice pre-prescribed periods of time saying nothing critical to Joe, while instructing Joe to “overcommunicate” and express himself more to Renee. I called attention to their body language with each another, as Renee tended to lean forward aggressively while Joe would lean back and look away. I tried to enhance their shared joy, finding activities they could do together.

Each of these interventions resulted in small changes, but many in- and out-of-session blowups occurred. Often, sessions would end with Renee yelling and crying and Joe looking visibly upset but saying nothing. Given these meltdowns, I felt more intensive treatment was in order. After discussing this with Renee and Joe, we decided to add ongoing individual sessions for each of them. I wanted to better understand the cycle of Renee criticizing Joe, Joe withdrawing, the withdrawal spurring Renee’s rage, and then Joe withdrawing further.

I saw no indication that Joe was trying to hurt Renee by withdrawing. Eventually, we got to the core of Renee’s belief that Joe was purposefully hurting her: it was a byproduct of the abuse she’d suffered in childhood and the resulting vigilance she’d adopted to guard against being hurt and gaslighted.

“Would you talk to me like that if I upset you?” I asked Renee on several occasions.

“No,” she replied. “Because I know you’d never hurt me on purpose.”

“I need to ask you to take a leap of faith,” I told her later, “and believe me when I say that Joe isn’t purposefully trying to hurt you. I can promise you that I don’t see this and would tell you if I did. Your relationship won’t change until you let go of this view of Joe as a manipulative abuser. He’s not your brother. He’s a good man who loves you, and I need you to trust my assessment that he’s indeed worthy of your trust.”

“This is very hard for me to believe,” Renee replied. “But because I trust you, I’ll try this on and see what happens.” It was clear that she trusted my judgment and rightfully believed I had her best interests at heart.

Still, my interactions with Renee became more complex. She sometimes told me she felt angry with me in couples work, something she said she’d never felt in our individual work. “Sometimes it feels like you’re taking Joe’s side,” she’d say. “You’re making me out to be some kind of monster and Joe as the blameless one.”

In these instances, I’d express empathy for Renee’s pain, but wouldn’t back down from confronting her. “I can see how deeply painful this is, and my heart is with you. But I wouldn’t be helping you if I didn’t point out your role in the equation. I need to tell you this precisely because I care so deeply about your wellbeing. When you say these things to Joe, it isn’t going to bring you closer. This is a destructive way of expressing your feelings.”

In my individual sessions with Joe, he told me that watching how I stood up to Renee was good modeling. “When I see you interact with Renee when she’s going off, I can see that it’s better than just shutting down,” he said.

Eventually, I learned that Joe’s tendency to shut down was due to his own childhood trauma. He’d grown up with an angry mother, and his way of avoiding her rage was to say nothing and retreat to his room. Individually, I worked with him on understanding that a stance that had once helped him was now harming him. I coached him to stand up to Renee by practicing saying things like, “I see your point, but I can’t hear you when you’re yelling at me like this” or simply, “It hurts me when you talk to me like this.” In return, Renee practiced simply saying, “I appreciate you letting me in and telling me how you feel.”

In one especially powerful couples session, Renee owned her past abusive behavior of Joe and offered a heartfelt apology.

“I can now see I’ve been abusive to you. Angry and critical. I want to treat you better,” she said through tears. “I want to show you my love, not just my hurt and anger.”

Joe not only accepted the apology, but took ownership of his tendency to withdraw. “I’m still a bit fearful of your anger, and it’ll take me time to heal from the past and build trust,” he said, taking Renee’s hand in his. “But I know you didn’t hurt me on purpose, and how my shutting down made your pain worse.” They both vowed to continue helping each other heal.

I still feel some shame at having missed the fact that Renee’s trauma had resulted in her lashing out whenever she felt hurt or ignored. “Your long-term therapist you think is so skilled missed something quite massive,” I told her teasingly.

“Well, I never showed it to you because I never felt unsafe with you,” Renee responded. “Then again, if you’d never seen me interact with Joe, I never could’ve moved forward. I never would’ve learned to trust someone else—someone besides you.”

We’re bound to miss things in our work at times. But I think we rarely consider how, by not seeing clients in a relational context, we can miss big things—behaviors and reactions to old wounds that can make or break relationships and more. As deeply as we can come to know our clients, individual therapy has its limits. That Renee felt as safe as she did with me prevented her from showing—and me from seeing—how she behaved when she didn’t feel safe.

At the same time, the strong, safe bond I’d built with Renee allowed me to go where Kevin couldn’t. Did I take a risk in deciding to see Renee and Joe for couples therapy, given my history with Renee? Certainly. But I believe that often, our clients know what they need, and I try to honor that. Plus, I’m now quite certain that had I simply referred Renee and Joe to another couples therapist, no change would have occurred. Sometimes, taking risks like these pay off. In the end, I’ve come to realize that a powerful connection can be as much of a limiting factor as the reason our work succeeds.

Case Commentary

By Donna Baptiste

Laurie Mintz deserves kudos for her vulnerability and courage in sharing this case, which brought up several questions for me. On my first reading, I felt a mishmash of emotions: compassion and admiration for Renee, and incredulity toward Mintz and Kevin. Subsequent readings softened my sentiments, as this therapy showcased a tangled web of self-needs, possible blind spots, and powerful transference processes. I found myself curious about the therapists’ motives and reactions, as well as the clients’. It made me reflect and ask myself some valuable questions about how I work with clients like Renee.

Mintz provided expert help to Renee to recover from deep trauma. I recognize the features she describes of a grateful and somewhat dependent client. I, too, have had clients who expressed appreciation, stayed in touch, provided updates, and remained tethered to my practice. Mintz is right about a need for boundaries and vigilance each time a client returns. That begins with the therapist asking themselves a few questions: In this new cycle of therapy, how can the client benefit from continuing with me? Why am I saying yes to this return? Might another therapist be more helpful?

There are promising signs Mintz asked these questions and exercised good judgment in being mindful of boundaries. She encouraged Renee to work with other therapists and consulted peers to maintain ethical lines. But I wonder if Mintz is aware that a predominant image stamped on this narrative is that of a therapist-mother keeping an eye on a client-child. Regardless, Mintz benefitted from this relationship, and Renee received help—which is most important.

Two things worried me, however. I had little admiration for Kevin’s disdain in working with Renee, and I wish Mintz had asked him about whether Renee had activated any of his triggers. I was curious about Kevin’s values about women as partners and whether he’d examined them. When we don’t ask these questions of colleagues who refer to us, we can unintentionally collude with their views.

I was also surprised that Mintz decided to do couples work with Renee and Joe after such a complex therapy relationship with Renee. I, like many other therapists, know firsthand why such transitions should be avoided: it risks complications like unbalanced alliances and a tendency to maintain an intrapersonal emphasis on a client well known to the therapist. Indeed, as Mintz suggests, she may have known Renee too well, which created blind spots. And now that Renee has seen Mintz for couples therapy, there’s no going back to individual therapy for her. Might another skilled couples therapist, with no prior history with either client, have done more work with fewer potential complications?


Author Response

By Laurie Mintz

I want to thank Donna Baptiste for her thought-provoking comments. It’s clear, however, that we have different perspectives. She asks if I’m aware that “a predominant image . . . is that of a therapist-mother keeping an eye on a client-child.” In this case, I believe I was successful in offering Renee a reparenting experience, ultimately allowing her to soothe and reparent herself.

Baptiste also suggests I should’ve questioned Renee’s desire to return to individual therapy. Indeed, after raising these questions, internally and with Renee, I not only concluded that seeing Renee was appropriate, but that turning her down for more individual counseling would’ve been harmful, resulting in feelings of pain, abandonment, and rejection from a caring mother figure—repeating her childhood experiences.

Baptiste states that I knew Renee too well to successfully see her in couples therapy. But the heart of my case study is that this deep knowing and the security of our therapeutic relationship allowed me to help Renee recognize and change her role in the relational discord. While our powerful individual therapeutic relationship prevented me from seeing Renee’s relational range, it was this same strong therapeutic alliance that allowed me to intervene in a way that other therapists could not. Had I followed Baptiste’s implied rule that therapists should always avoid seeing individual clients in couples therapy, I wouldn’t have been able to intervene in this way.

I prefer a collaborative approach in which all the risks and benefits are vetted, both with the clients and with other consulting therapists. After such thorough vetting, I believe the benefits of moving from individual to couples counseling can sometimes outweigh the risks.

Baptiste states that now that I’ve seen Renee in couples counseling, there’s no going back to individual. To the contrary, Renee and I are currently working in individual counseling (with intermittent couples sessions, as needed). We both perceive our individual therapy relationship as even more productive now because I can see and can work with all of Renee.

Each of these decisions were carefully considered, and I believe the therapeutic outcome speaks for itself.

Donna Baptiste

Donna Baptiste, Ed.D., LCP, LMFT, is Department Chair and clinical professor of the master of arts degree program (online and on-campus) at the Family Institute at Northwestern University. She sees couples and families in her practice.

Laurie Mintz

Laurie Mintz, PhD, is a therapist and TEDx speaker, as well as a professor at the University of Florida, where she teaches the psychology of human sexuality. She’s a regular contributor to Psychology Today, as well as the author of two books, Becoming Cliterate: Why Orgasm Equality Matters—and How to Get It and A Tired Woman’s Guide to Passionate Sex: Reclaim Your Desire and Reignite Your Relationship.