There’s no bones about it: therapy is hard work. But what are therapy’s biggest challenges, and how do therapists overcome them—or maybe just weather them? No two answers are the same. Some therapists find their biggest challenge to be logistical. Others say their biggest frustration is the lack of answers our “time-tested” modalities give us when the rubber meets the road. Some cases leave us scratching our heads, flipping fruitlessly through the DSM when a never-before-seen problem arises. And of course, who could forget about the “new normal” COVID has foisted upon us all? Here, five therapists share the clinical challenge that tested them, frustrated them, continues to stump them, and made them the therapists they are today. Whatever your biggest clinical challenge may be, you might just find yourself nodding along.
1) Collecting Payments
I’m fortunate to say that my biggest challenge is collecting fees. I just don’t like tracking late payments. My policy is simple: pay for the service you receive at the time you receive it. Most clients comply; some don’t. Since I have a lot of clients, I end up tracking a lot of money. I’d use a program or a service, but I find the direct exchange of money for service helps clients recognize the investment they’re making in their own healing.
But sometimes, it gets tricky. For example, my client Jenny always forgets her checkbook. And during the pandemic, she’d forget to Venmo after a Zoom session. Together, we explored her “forgetfulness.” Was she resentful at having to buy my friendship? Did her parents use money as leverage? Did she not like being told what to do? Were there cultural considerations? After many ongoing discussions, Jenny still didn’t always pay on time. I never allowed her bill to run up, but the push-pull of collecting money became my therapeutic nemesis.
Over the years, my approach to the business of psychotherapy has changed. Rather than do a deep dive into unconscious motivations and transference issues, I just focus on the outcome. I label these issues as “manufactured problems.” In other words, something completely within the client’s control. Unlike issues and patterns that are pressed into us when we’re young, or matters such as trauma or marital discord that are often beyond our control, manufactured problems can be corrected with some thoughtfulness, planning, and determination.
Once I told Jenny she was creating a problem that didn’t have to exist in our relationship, she became more consistent. Framed this way, it was easier for Jenny to see that her “forgetfulness” was wasting a lot of her time and, ironically, her money.
Larry Laveman, LCSW
Solana Beach, CA
2) When Modalities Aren’t Enough
My client Jammi sits on my office couch and scrabbles around in her large quilted purse to find her phone cord. When she stands up to plug it in, loose Cheez-Its from her bag fall from her lap.
“Am I wearing too much perfume? I look ugly, don’t I? I’m so depressed right now. They’re not going to lease me another car. But how will I go to Doctor Barber for meds without a car? My cousin Pete murdered three people. Did I tell you that already? It was in the news. Do you have satellite radio in your car? You’re not going to fire me, are you?”
“How long until the car lease is up?” I ask, pitching forward so I can jump into the conversation, one filled with steep switchbacks as Jammi climbs her tidal wave toward a pinnacle of worry and despair.
“Are you grading me on the axis?”
“No,” I reply. She laughs.
“You’re poking me now,” I say, laughing too. Laughing is the best thing we do together.
With “deep divers” like my client Joe, there are other challenges. His aversion to intimacy turns out to be a protective smokescreen for his fear that a woman he likes could never love him back. Now, we can work on the lovability issue.
With my client Sarni, we unpack the painful Russian nesting dolls of internalized racism. She fears her boyfriend loves her because her skin tone is lighter and her hair smoother than other Brown girls’. “How do I know he loves me for my real self?” she asks. Together, we discover what’s important to her in a relationship, and what it means to be seen and heard by a romantic partner.
Okay, CBT, DBT, ACT, ERP, EFT, NLP, IFS—where are you when I need you? Sometimes, none of these theories or their strategies seem to work. Although each modality may be “evidence based,” they often fail in practice. We therapists sail across the vast ocean of the psyche, surrounded by tumultuous relational and social terrain, looking for a welcoming harbor: therapy tools may provide direction, but they don’t always bring us home.
Jammi opens her phone mid-session. “This is an emergency,” she blurts out. “Ron just blocked me on Facebook. Do you think it’s because I wouldn’t have sex with his brother last night?”
In therapy, I try to help my clients’ voices become unmuzzled, to help them breach the barriers in front of them, to portion their problems into workable parts. To help hope find its wings.
But in the meantime, as Jammi and I bob and slam over the waves with no GPS, I wonder: Is it the laughter that keeps us afloat enough?
Lisa Friedlander, LICSW
3) Working from Home
On March 19th, 2020, after a full day’s work, I walked to my car ready to blast some music to unwind, just like usual. On the surface, this looked like a normal day. But afterward, I wouldn’t be returning to the office. Like so many therapists, I’d be working remotely because of COVID.
My professional life and my role as my family’s sole breadwinner changed that day, and my concern for my clients became compounded by my concerns for my own health. In between disinfecting every grocery item, I called my young clients’ parents to tell them I wouldn’t be seeing them in-person for a while. It felt daunting.
It reminded me of the time my office flooded during Hurricane Ike in 2008, forcing me to relocate in less than two weeks. Prior to COVID, I’d considered this to be my biggest professional challenge. But in hindsight, it really wasn’t. A hurricane has a beginning, middle, and an end. Needing to replace a few soggy books and collectibles pales in comparison to what we’ve been dealing with for the last 21 months. My coping skills shifted into overdrive. Adrenaline rushed in to help me turn my bedroom into a quiet, private counseling room. In no time, I was running a therapy practice from home. How was this possible? I wondered. Daily, I watched from my bedroom window as neighbors walked outside, looking like a trapped Rapunzel waiting to be rescued.
On my social media accounts, there’s a banner on my profile that reads “I’m a telehealth counselor,” as if this was something I’d planned all along. But I’ve been moving as fast as I can to stay afloat. But that’s what we therapists do, right? We have to adapt, cope, and survive.
Sally James, MA, LPC-S, NCC
4) Working through Clients’ Pain
One of the most common challenges I encounter in my work is my clients’ fear of feeling pain. They’re in pain and want to be out of it but worry they’ll have to feel even more pain to get to the other side. That’s one reason I’ve always been drawn to using creative tools. In the act of creation, nobody knows what will come out of it. They only know it feels good to express themselves in this way. And even if it brings tears, they often feel gentler and more self-compassionate afterward.
I remember one client who needed help moving through significant blocks in her life. She was smart, highly educated, and a very talented writer, but she was also cynical and sarcastic, and couldn’t bring herself to confront her deeper issues, and experience the anger and sadness that bubbled underneath them.
In one session, we decided to try an exercise where I gave her a prompt to draw something that symbolized her biggest block. What she drew became the first breadcrumb on a trail she soon became intrigued to follow. It was from this place of curiosity that she began to open up and ultimately discover the root of what had been blocking her. When the tears finally began to flow, we both knew the block had been dislodged.
There was a book she’d been longing to write that had gotten stuck behind the block within her. She’d wanted to write it from the deepest place in her soul, but the emotional memories she’d buried had kept her from it. By doing more creative work, she was finally able to own the narrative that had owned her for so long.
Helping clients work through pain can be difficult, for the therapist and for the client. But I’ve found it beautiful to watch someone illustrate their challenges—literally—and find their own healing path with the simplest of tools, like crayons and a piece of paper. It offers a look inside to people who’ve lost sight of how much magic lies within them.
Kathy Curtis, healing artist
Fort Wayne, IN
5) The Dissociated Client
One of my biggest challenges is detecting the subtle presence of dissociation. It requires patience on my part and a mindset to look beyond assumptions. While I‘ve worked with clients with intense cases of dissociative disorder in the past, with compartmentalized ego states, periods of lost time, and deep mystification at their conditions, it can be difficult to identify dissociation when it’s less apparent. Sometimes, the client has been trained by culture, family, and experience to avoid their inner states, and they often have no idea how disconnected from themselves they are.
My client Ben, in his early 30s, first came to me looking to process feelings around his recent divorce. Growing up, he’d felt loved by his family, suffered no significant traumas, and had, by his own account, a somewhat charmed life. He’d been a competitive squash player, attended an elite college, was successful at work, and married his college sweetheart. In therapy, Ben was vocal, responsive, and eager to understand his relationship problems. Our sessions were comfortable, interactive, and enjoyable. But therein lies the challenge: It’s very easy for me—and other therapists, I imagine—to coast in the ease of compelling dialogue and rational analysis. I’d believed Ben had good contact with his emotions and was gaining insight every session.
But this was not the whole story. Only over time did I see his dissociation. Whenever I invited him to connect with an emotion, I noticed him tilt his head and shift his posture. With coaching, he began to notice his body, sensations, and feelings, and when he did, he began to report sadness and cry. But another fascinating thing happened: In subsequent sessions, he’d have no recollection of our previous meeting. Good naturedly, he’d ask upon sitting down, “What happened in our last session?”
When I’d recall the session, he’d tilt his head and ponder. But to him, the sessions felt like fragments of a dream. “Yeah, I think I remember…maybe.” Soon enough, I began to see him disconnect in real time. He’d be talking about an emotional topic when his demeanor would shift. “Ben, what are we talking about?” I’d ask. He couldn’t say.
What had seemed like a straightforward case surprised and challenged me. I eventually found that what helped Ben the most was a meticulous focus on his immediate experience, and a step-by-step re-introduction to his feelings and body sensations. Ben was one of my most challenging clients, but he not only taught me about the power of dissociation, but about what it really means to be aware for our clients.
Lee Hockman, PsyD
Photo © iStock/Nuthawut Somsuk
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