Q: Sometimes I regret how I handled an issue in therapy: either what I said, or didn’t say. How do I deal with these feelings?
A: A couple of months ago, I got a fever that wiped me out. After a negative COVID test for a breakthrough infection, I found myself in a familiar professional limbo. Obviously but not severely sick, and lacking a diagnosis, I was reluctant to cancel or reschedule a whole week’s worth of clients, especially since many of them were virtual. So I ended up moving a few clients but seeing the rest. These sessions didn’t go well. I was exhausted, and it showed. The following week, I was diagnosed with viral pneumonia.
Worse than the pneumonia was the regret. Why hadn’t I listened to my body and given myself a break? I’d never even acknowledged to my clients that I wasn’t feeling my best, though I’m sure many of them noticed something was off. I still cringe thinking how my client Jim must’ve felt when I didn’t ask about the family reunion where he’d seen his estranged brother for the first time in years.
Most therapists, at one time or another, struggle with guilt and self-blame related to the work. But instead of suffering silently, I’ve found helpful ways to handle these thoughts and feelings, and even leverage them so we can grow in our work.
Many therapists—myself included—are self-critical perfectionists, for whom self-compassion doesn’t come easy. That’s why we need to make self-compassion a practice. In doing so, the first question to ask yourself is: “What does my regret tell me about my work?” Feeling regret after you don’t show up as your best self is usually a testament to how much you do care about your clients, and how much of your mental energy is devoted to them. Next, bring compassion to your suffering during these moments of regret. Name where the regret is percolating in your body and notice any recurring thoughts. Then bring an attitude of acceptance to both.
An acceptance practice that I’ve found particularly helpful is channeling my Balkan grandma, who always provided unconditional love via food, touch, and talk. I’ll close my eyes and visualize standing next to her over the hot stove, as I did most days after school, sharing my heartaches with her. When the memory of her embrace comes alive, amid the comforting aroma of stew, I’ll hug myself and say, as she did, “This is all part of the music. If you didn’t have lows, you wouldn’t be able to recognize the highs.”
I might also let myself experience the full range of caring and acceptance that I feel for my husband, and then see if I can redirect it toward myself for a while. I’ll talk to myself the way I talk to him when he’s stressed: “I’m so sorry this is happening to you. It’s okay to feel pain, and I’m here to hold it with you and support you.”
Physical self-compassion can also soften the hard edges of self-reproach. A hot shower, some favorite scents, a hike, sex—all are good starting points that embody your intention to ease your suffering.
Look for Patterns
If you’re regularly feeling regret after sessions, it may be time to check for unhelpful patterns in your work.
My clinical focus is on exposure therapy, and after almost two months of sessions in the car with my client Serena, there was little change in her debilitating driving phobia. At first, I chalked her unrelenting anxiety up to our cautious, gradual approach. I comforted myself with her increasing trust in me, even remembering research that says an in-session reduction in anxiety during exposure therapy isn’t necessary for long-term success.
But then, four months in, it dawned on me that the way we constantly talked while she was driving had likely provided a powerful distraction from her anxiety behind the wheel. Her mind and body hadn’t been experiencing the anxiety fully, nor learning that the experience of it could be safe and tolerable. I’d been denying her that essential anxiety-reduction ingredient that Jung described when he famously quipped, “What you resist persists.”
I was wracked with guilt for not realizing this and correcting it sooner. I’d learned Jung’s mantra eons ago, and it echoed in my head maddeningly for weeks after my realization. How could I have been so foolish?
After a particularly restless night, during which I couldn’t shake the image of Serena’s damp hands ferociously gripping the wheel, I knew I needed a double dose of self-care. I got out of bed and listened to a self-compassion meditation while wrapped in my grandma’s shawl. Being kinder to myself eased my guilt enough to allow me to face my mistake and make the necessary changes in my work with this client.
The next morning, I felt ready to ask Serena to forego driving for part of session time and come into the office so I could discuss our progress, or lack thereof.
Shift Patterns in the Room
With enough self-compassion and self-acceptance, we therapists can look inward and investigate the entire variety of patterns that might be affecting how we relate to our clients in unhelpful ways.
Do you have particular sorts of clients with whom regret shows up more often for you? Perhaps you’re on edge with certain psychological problems or personality styles? Is the regret a sign that your therapeutic relationship needs repairing or a harbinger of worse outcomes?
If patterns do emerge, first look inside. Your own history might be taking you away from being properly present and responsive. Consider practicing some mindful self-reflection about why you’re triggered by these clients and make a point of discussing this in supervision or your own therapy.
Closer examination of your regret might also reveal that you’re prone to judging yourself when using techniques that are new or don’t fit with your general therapeutic style. I ruminated about those exposure sessions because I thought they required cheerleading, which conflicted with my demeanor and approach. It was only when I could see the importance of what I was doing, by framing the exposures as us facing fear of death and existential uncertainty together, that I could show up as my authentic self and reduce my regret.
Finally, know your Achilles’ heel when it comes to doing therapy. If your experience tells you that sleep deficits or certain kinds of personal turmoil affect your therapeutic presence in sessions, it’s paramount that you prioritize appropriate self-care. And if you’re sick, as I was, consider canceling sessions altogether, however tempting it might be to conduct them virtually.
When does it make sense to bring up your regrets with clients? After you’ve determined that your guilt about how a session went is related to more than your personal factors, it’s worth thinking about discussing it with your client. You should be clear ahead of time about the purpose of this discussion and how it will advance the therapy process and therapeutic relationship. You’ll want to share that purpose with your client.
If your regret is linked to the tenor of a session and points to a rupture in the relationship, start with something like, “I was thinking about our last session, and I feel I could’ve done better to. . . .” Allow yourself to stay curious about where the confession takes you and your client. You’ve just revealed to them your courage and care, and how important they are to you. It’s often a fruitful moment in a therapy relationship, but be ready to step in if your client begins to try to take care of you and ease your regret. If this happens, acknowledge it and express gratitude—and use the opportunity to discuss the benefits of accepting unwanted emotions and model your willingness to do so.
After that sleepless night obsessing over my failures with Serena, my driving-phobia client, I began our in-office session by explaining I wanted to talk about her progress and her perception of how therapy was going. Though she acknowledged that her driving anxiety was still mostly high, she thought the therapy was going well. I brought up my hypothesis that my constantly talking could be serving as a “safety behavior” and impeding her progress.
“Yes, of course it’s easier when you’re in the car with me,” she said. “But I like you being with me, whether you’re talking or not.” We smiled at each other, and then she shrugged. “It’d be good if I could drive my kids to baseball after school, though,” she added. “Let’s try driving in silence for a bit.”
“Fair enough,” I said. “And then, if you’re willing, I can try sitting in the back seat for a while?”
After a few sessions in which we experimented with talking intermittently, me sitting in the back seat, and her sharing the full range of fear she was feeling, Serena became more confident. Within a month, she was driving alone.
Zoom Out for the Big Picture
As you work through your regret and attempt to learn from it, it’s important to occasionally step back and try to see the misstep in the context of the totality of your work with a particular client. How much did that specific thing you did or didn’t do, said or didn’t say, truly matter to the relationship? And how much does one particular session matter in the context of your accumulated clinical work?
Everything matters, you might say. Of course that’s true, in the sense that all notes, however discordant, are part of the music of life. But try to remember that therapy is much like making music. Taking our missteps, imagined or true, in stride can model for our clients an acceptance of the imperfect nature of humanity that still manages to hum.
Jelena Kecmanovic, PhD, is a clinical psychologist, the founding director of the Arlington/DC Behavior Therapy Institute, and an adjunct professor at Georgetown University.