Am I Accountable for Her Feelings?

I’ve been seeing my therapist Avigail for a bit more than a year now. I feel like we’ve built an amazing rapport and I feel safe, understood, and — uh oh! — attached to her. Avigail is sincere, brilliant, empathetic, super personable, and… very sensitive. When I give her a compliment or tell her how she has helped me I can see she genuinely takes it to heart. Naturally, it’s not only the positive that she takes so seriously.

Several weeks ago Avigail pushed off our session by two days with very short notice. I was in an emotionally fragile place and felt angry and betrayed by her. I shared my unfiltered emotions with her via email, breaking every rule on effective communication.

When she brought up my tirade in our next session, she shared her hurt feelings over the words I used and mentioned that there needs to be accountability on my part. After all, she’s a human being.

We discussed it at length, and then went on to talk about a prior incident when I similarly felt that she wasn’t fully there for me. We each apologized, and I walked out of her office feeling understood and heard and — uh oh — attached.

I feel like I’m lacking clarity on where my accountability lies as a client. Is there anything I cannot share with my therapist? Should I be expected to keep her sensitivities in mind when I interact with her? Was my expectation of her being able to absorb my anger reasonable, or was that unfair and part of my general problem of having super high expectations of the people in my life? (Hey, I’m not in therapy for nothing.)

Dr. David Ribner responds:;

Decades of research have underscored the point that despite differences in approach and technique, it’s the clinical relationship that determines the potential for a successful treatment outcome. Creation and management of this relationship rests with the therapist, who should have sufficient training and supervision in this often intense aspect of the helping process.

In this case vignette, Avigail, the therapist, has conducted herself in a less than professional manner. Clients should justifiably expect that therapists will encourage and tolerate an atmosphere that allows for the freedom to express all emotions, with the possible exception of statements designed to abuse the therapist.

In this case, the emotions you expressed should have been raw material leading to further understanding and intervention on the part of the therapist. Instead, Avigail insinuated her own issues into the treatment room, leading you to wonder unnecessarily if you need to worry about offending the sensibilities of your therapist.

This client wonders if it’s reasonable to expect her therapist to be able to absorb her anger. It’s not only reasonable, it’s essential. Doing otherwise would imply that clients should be wary of expressing any intense emotion that may lead to therapist discomfort. What, then, is the point of therapy?

An additional problematic facet of this situation, given the context, is your felt the need to compliment Avigail and Avigail’s seemingly overt grateful responses to those flattering remarks. Avigail should see these interactions in the context of the transference/counter-transference dynamic, at the very least seeking to determine if her client is picking up a message from her that continuing treatment is dependent on such accolades.

Because this client perceives the therapeutic relationship as essentially positive, there may be no simple solution to this dilemma. Perhaps showing Avigail this question/response may promote a level of awareness beneficial to both parties.

Becoming a therapist is not everyone’s occupation of choice. Those considering working in situations that can engender intense client responses should be certain of their capacity to maintain professional stances in charged situations. Being unable to do so is the pathway to client confusion and frustration, and likely early professional burn-out.

Dr. David S. Ribner is the founder and chairman of the intimacy training program in the School of Social Work, Bar-Ilan University, Israel and is in private practice as a marital therapist in Jerusalem. He’s authored some 40 articles and book chapters and writes and lectures extensively on cultural sensitivity and intimacy.

Should My Therapist Treat Us as a Couple?

I’ve been seeing a therapist for eight months for several issues. The difficulties I’m experiencing in my marriage keep coming up, and my therapist has suggested that she see us as a couple in addition to seeing me individually. I realize our marriage needs help, but I’m torn over how to go about this.

On the one hand, this therapist knows and understand me well, so we can dive right into the work, without needing to begin an entirely new relationship. On the other hand, she’s become my confidant and ally, and I realize that if she sees us as a couple, that dynamic will inevitably shift. She’ll need to try to stay impartial and be equally supportive of both my husband and me — which, inevitably, will mean a lessening of the support I’ve come to expect from her.

In general, is it a wise idea to see the same therapist for both individual and marital therapy or is it better to use two or three different therapists (a variation on his, hers, our)?

Mrs. Michelle Halle responds:

Based on how you posed your question, it seems you trust your therapist and feel attached to her. That means you’re doing good work together. Your therapist suggested working with you and your husband in addition to working with you individually and you feel “torn how to go about this.”

You write that you understand your marital relationship could improve from working with a marriage counselor, yet also identify a feeling of loss when thinking about sharing your therapist with your husband.

You trust your therapist, which means your experience with her has shown that she understands you, accepts you, and is able to help you. Why not bring your concerns directly to her? I imagine that you’ve already started this conversation, yet you’re still confused. Spend more time exploring this topic with her. One or two sessions may not be enough time for you to understand what this means to you on a deeper level. Explore your fear of losing her.

Here’s something else to think about. What drives you to seek advice from an anonymous therapist on these pages? I’m curious to know more about why you’ve chosen this approach. Is looking outside the relationship (yours and your therapist’s) typical of the way you resolve issues in other relationships in your life? Might you have had an earlier experience in your life when sharing was equated with, or resulted in, loss?

You suggest that working with your current therapist will make it possible for you to dive right into the work without needing to start an entirely new relationship. What about your spouse? Won’t it be a new relationship for him? Will he be comfortable working with your therapist, or will he feel she’s more aligned with you than him? While an experienced marriage counselor will know how to balance the session so that each one of you feels understood and supported, if he has an objection to working with her, his feelings are valid.

When couples start marriage counseling, it’s common for the therapist to meet with each spouse individually after the first or second couple’s session. There may be other times during treatment when individual sessions will be appropriate as well.

You asked whether it’s wise to work with the same therapist for both individual and marital therapy, or whether it’s better to work with two or even three different therapists. There’s no one right way to do the work. Some therapists, like yours, view this model as a good one. Other therapists recommend that you remain with your individual therapist and work with a different couple’s counselor.

If you do decide to work with another marriage counselor, remember to take everything into consideration. In addition to looking at the therapist’s skill, the underpinning of successful therapy is trust and compatibility. There are many highly skilled therapists, however, if they’re not a good fit for you, then look for someone who is. Compatibility is a subjective experience, so trust your gut. Most likely, it won’t lead you astray.

Michelle Halle, LCSW, is a psychotherapist with a practice in Lakewood, NJ. She works with individuals and couples helping them live a more connected and meaningful life.

Are Clinics Really the Answer?

The “Who Can Help Me?” article quotes a professional who stated that clinics have an advantage over private practice, as quality supervision is built into the institutional structure, and that the care at clinics is often identical to the care in private practice. I’ve worked at three clinics, and I beg to differ.

While clinics provide an incredible resource for people who may not have the funds to pay for private therapy, the supervision and care at clinics are often not compatible with private practice, for the following reasons:

• Supervision at clinics may be more focused on paperwork and audits, rather than client care.
• Since supervisors are higher in the hierarchy at the clinic, therapists may be more focused on their apparent performance over client success.
• Therapists who work at clinics are generally new to the field, and while passionate, they may be missing out on crucial experience, skills, and knowledge.
• Many therapists at clinics are unable to afford to take advanced trainings.
• Red tape and paperwork at clinics may be an impediment to successful work.
• There is generally bureaucracy in clinics about which medications can be prescribed.
• Clinics may be unable to provide the optimal frequency of sessions with a psychiatrist/nurse practitioner.
• Some clinics have shorter session durations than what is considered the norm in private practice.
• Therapists at clinics may have more clients than they can realistically handle, as they are just trying to make ends meet.
• And honestly, let’s face it: If one can get paid about $200 for a service, and, for the same service, get paid a fraction of a fraction of that, which client is a therapist more likely to place his or her energy in?
• I believe that while at times the care at clinics can be comparable to private practice, often the care in private practice is significantly better.

Mrs. Sarah Rivka Kohn responds:

Thank you for your letter that raises some very important points. A couple of years back I wrote a letter to Family First in regards to clinics, and I explained why I didn’t refer families there most of the time. I received invitations from a few directors of clinics to come down, observe, and perhaps learn something new.

I did just that, which led me to do further research: Why are some clinics doing such a wonderful job while others still can’t offer the level of care you speak of? I’ll try and address some reasons by highlighting the important points you bring up:

• Supervision at clinics may be more focused on paperwork and audits, rather than client care.

I find this comes down to:

1. Leadership: Has the director been in private practice? Does the clinical director continue to see clients in private practice? Sometimes directors who have never experienced practice outside of a clinic can’t imagine how it could be different. They may not know or remember what it’s like to focus on the person versus the paperwork. Stepping out even once a week can help one remember what it’s like. I’ve spoken to many clinicians who’ve worked at several clinics over the years and this seems to be a recurring theme.
2. System versus Stand-Alone: This is a biggie. Have you ever gone to Walmart and tried to compare the customer service to that of your corner shop? In Walmart you’ll often hear, “I wish I could help you, but this is company policy,” whereas in the corner shop there may be more flexibility as even the little guy can quickly get access to the owner who can override policy. Many clinics are part of a larger system and their directors, through no fault of their own, have to abide by policies. These policies are often set by people who have never practiced therapy but sit on a financial board. The smaller, boutique clinics can sometimes offer clients and clinicians more flexibility.

• Therapists who work at clinics are generally new to the field, and while passionate, they may be missing out on crucial experience, skills, and knowledge.
• Many therapists at clinics are unable to afford to take advanced trainings.
• Some clinics have shorter session durations than what is considered the norm in private practice.
• Therapists at clinics may have more clients than they can realistically handle, as they are just trying to make ends meet.

Generally, all of the above boils down to one thing: money.

The average NY- or NJ-based clinics pay their clinicians a grand total of $30–40 an hour. And while some offer benefits, few people with significant loans to pay off can afford to stay at that pay grade, let alone spend money on trainings. That’s why the majority of clinicians in clinics are men and women who are new to the field.

Having said that, I’m happy to report that there’s some change happening. Some clinics (especially those who are part of a FHQC, Federally Qualified Health Centers) are beginning to pay clinicians more per session and, most importantly, have some funding to provide their clinicians with trainings.

In terms of shorter sessions — that’s a huge pet peeve of mine. Many insurances approve only 30-minute sessions. That means a clinic that wants to bill well will have two sessions an hour. In private practice a standard session is 45–50 minutes. Most clients find it takes 15–20 minutes simply to open up; to be shooed out after just 30 minutes is very difficult.

Some clinics (and some clinicians in clinics) completely ignore this and spend 45–50 minutes with the client, but many stick to the 30 minutes, which many people find painful. Additionally, if you want to bill well, you’re going to have to see many clients. That might not be beneficial to the client because the therapist may not remember all the clients. This can happen in private practice too; no matter the environment a therapist needs to learn to say “no.”

• Clinics may be unable to provide the optimal frequency of sessions with a psychiatrist/nurse practitioner.

This one surprised me. If there’s one type of client who generally does better in a clinic than private practice it’s the client who needs close communication between therapist and psychiatrist. In my experiences, I’ve found that barring those who need hours of psychiatric care a week (and probably need more than a clinic can offer), this is usually a clinic’s strength.

After my observations at eight clinics in NY and NJ I advise the following:

• If you have multiple family members who need therapy it’s often helpful to use a clinic not only because of convenience but also because cohesive supervision for all can be very insightful.
• If there is any need for other government agencies involvement (e.g., ACS) sometimes a clinic is a better resource.
• If a teen or adult is conscious about privacy, it’s often challenging to use a clinic, and I wouldn’t advise pushing them. However many clinics that are now part of a greater healthcare facility have the advantage of a waiting room that has clients waiting for dentists and social workers all in one room so nobody knows who is seeing whom.
• If someone is looking to do long-term work or needs clinicians that are very well trained in a particular modality or with a particular specialty, he or she most likely won’t be a good fit for a clinic.
• Ask about the clinic’s policies in terms of: length of session, supervision, psychiatric care if that’s what you’re going for, communication with the parents, communication with clients between sessions, what the waiting area is like, can you request a particular clinician, can you request to have someone who is not interning, how long is it from intake to getting a session (some can have you wait up to six weeks!), what kind of questions children get asked on intake (with liberal views taking center stage, the forms clinics are forced to review with clients can horrify parents. There are some frum clinics that have figured out ways around it.)

Not all clinics are created equal. Be clear about your goals and research your options.

Sarah Rivkah Kohn founded and directs Links & Shlomie’s Club, an organization servicing children and teens who’ve lost a parent. One of the services offered to grieving families is therapy referrals and to that end she and her team interviewed hundreds of clinicians and visited nearly a dozen clinics. Disclaimer: Her husband, who works as a social worker at two clinics, was not interviewed for this piece.

Do I Need to Have Goals?

A big part of why I’m in therapy is because I benefit from being able to talk to my therapist about anything and everything going on in my life. However, reading your articles really highlighted for me the fact that I don’t have a lot of goals that I’m actively working on in therapy. It made me wonder if I am wasting time or money.

I don’t think so. I have a closer connection with my therapist than I have with my close friend. She knows me pretty well, knows what to say, and knows when to set boundaries that are helpful for my growth. At one point, I was struggling, so I started seeing her twice a week. When I was in a better place, she suggested we go back to once a week even though I wasn’t happy about it. I also used to email her sometimes with things that could wait until the next session so she asked me not to email her unless I need to change an appointment. Those two boundaries helped me so much. They’ve helped me see that I don’t need her as much as I thought I did. Now I end up having a lot to talk about at our weekly sessions, and we’re more focused in therapy. I even wrote her a thank you note recently, and mentioned that it’s almost like I want more boundaries.

My question is: Do I need to be more focused on goals in therapy?

Dr. Shula Wittenstein responds:

A strong therapeutic alliance is central to successful therapy. Clearly you have that. “It made me wonder if I’m wasting time or money,” you wonder. “I don’t think so.” Your feeling that therapy has been satisfying and rewarding shouldn’t be underestimated.

Still, while that’s an important piece, it’s not the full picture. Let’s address the topic of goals. There is the goal of therapy, and the goals in therapy.

Some people use their therapist as a mentor of sorts. They see therapy as an empathetic place, where they can obtain ongoing support from a skilled professional. They discuss the dilemmas they’re facing, benefit from a listening ear, and get direction.

If this is what you feel helps you face the world, and it’s clear to both you and your therapist that your having a place to share is what helps you navigate life’s challenges, then that’s your therapeutic contract/goal.

Generally, the purpose of therapy is to provide a safe, supportive, non-judgmental space to work through life issues, difficult feelings, and learn new skills. This should lead to a more functional and fulfilling life.

Common goals in therapy can be broken down into three basic categories:

1. Interpersonal: To create and maintain stable relationships
2. Functioning: Changes in functioning through behavior modifications
3. Intrapersonal/Spiritual: Cultivating self-efficacy, empowerment, and heightened agency

You’ve stated that the main purpose/benefit of therapy is to have a place to share and connect.

This is a prerequisite, not a goal.

You feel that your therapist is more connected than your close friend. While comforting, this gives little indication of your therapy’s effectiveness. In reality, it may be an indication of an unhealthy dependency. Sensing this, your therapist has wisely set important boundaries to safeguard your wellbeing.

While sharing emotions and feeling heard is an essential element in therapy, going to therapy solely to share feelings is an incomplete and potentially dangerous goal. You may become overly dependent on your therapist; it can clip your wings, and keep you from growing as you can.

The therapist serves as an agent for change. The client meeting the measurable goals they’ve set up together will determine if the time and money were well spent.

In your case, one therapeutic goal may be to explore why and how therapy is your only safe place. Next would be learning skills to create a safe environment in other relationships.

The connection and empathy you experienced and modeled in therapy could then serve to help you nurture and maintain meaningful relationships.

Therapy, though valuable, should be a small chapter in the book of your life. When used correctly, it can afford you an opportunity to tap deep into your potential. Greater understanding of yourself and the role you play in your relationships, combined with new interpersonal skills, can empower you, enabling you to take risks and build stronger relationships. It’s then up to you to move forward and use your own wings to fly.

In conclusion, it would be worthwhile to set some goals that will translate into relationships far beyond the walls of therapy.

Dr. Shula Wittenstein, Psy.D is an expert in CBT and EMDR. She specializes in couple therapy, and also treats trauma survivors, anxiety, and depression. She has a private practice in Jerusalem.

Can I Get My Child Back?

So much has been said regarding recognizing one’s own therapist and making the decision of whether they’re toxic. My angst is a direct result of watching my child be brainwashed by a therapist she found through a friend. The purpose of her seeing a therapist was to repair the relationship with the family, but based on the two and a half years she’s been in therapy (the therapist’s reputation, when I asked around, is that she likes to keep her clients on as long as she can) all that’s happened is more damage. Not only that, but I’m expected to pay for this therapist; my refusal to do so would only underscore to my child and the therapist what a controlling parent I am. This child is of legal age and the therapist will not speak to me without her permission. What recourse do I have?

Mrs. Esther Gendelman responds:

Just as family closeness is a priceless gift, family strife causes tremendous pain. Even when there’s conflict, most families can achieve some level of connection. Hashem designed the world where imperfect parents raise imperfect children and it’s through this bond that we learn how to create healthy attachment, maintain it, and repair the inevitable hurt when people who care for one another make human mistakes.

It’s extremely hurtful and frightening when parents feel they’re being misjudged, that their care and love is being questioned, their child is being alienated from them — and they’re powerless to stop the process.

I wonder if you can acknowledge the pain while still focusing on your choices — that’s all we can ever do in a relationship. You don’t indicate if your daughter still lives at home or the current level of communication between you. Would she be open to a letter or a messenger whom you both trust letting her know you miss her, informing her of what you love and appreciate about her, and sharing your willingness to listen to anything that pains her as you acknowledge and understand that parents make mistakes?

This attitude in no way indicates that whatever caused the rift in the relationship is exclusively your fault. Your daughter might very well live in her own emotional reality. However, her reality is where you need to meet her if she is to feel heard and understood.

Sometimes we focus on the frustrating parts we cannot control, which direct our emotions toward someone else. Of course, if this is a toxic therapy relationship, you have every right to be concerned, yet the most important element is your connection with your daughter.

You seem to be focusing on this therapist’s damaging impact on your daughter in several ways. First, you’re concerned that she keeps her clients longer than necessary for their own well-being. Second, you perceive her as worsening your daughter’s relationship with the family, instead of repairing it. Additionally, you feel trapped into paying for therapy you believe is harmful because if you refuse, it “proves” that, in fact, you are controlling. Lastly, you’re shut out of the process as your daughter is a legal adult and thus needs to give consent for you to get directly involved with the therapist.

If you can help your daughter hear your willingness to be part of the process, you might have the opportunity to meet this therapist, as opposed to hearing about her. I’m unsure how anyone can know that she keeps clients longer than needed as the work is confidential and no one knows what the client is bringing into the sessions. You also have no way of knowing if the therapist is actually encouraging the continuation of the relationship or if your daughter isn’t yet ready to terminate.

Even if your daughter does have a toxic relationship with her therapist, the steps I’ve outlined are still your best recourse. Your daughter is already attached to her therapist; if you try to terminate their relationship, or launch a campaign against her therapist, you’ll only further alienate your daughter.

If there’s some healthy communication with your daughter, it’s certainly reasonable after two and a half years to ask — either directly or through a mutually trusted messenger — if she feels she’s being helped and her goals are being addressed. Remember that as an adult, she may have not shared all of her reasons for seeking therapy with you and thus you might not see areas of progress.

Usually, when the parent is able to demonstrate empathy and validation, and remain the mature adult even in the face of pain, it creates a turnaround. Children of all ages generally crave closeness with their parents and want to remove the obstacles.

Focus on getting the support you need to lead the way towards changing what is in your power. Im yirtzeh Hashem, your daughter will hear your love and respond accordingly.

Esther Gendelman, MS, LPC, CPC is a licensed psychotherapist and certified professional coach who specializes in working with relationships. A veteran educator and motivational speaker, she has a passion for helping people grow and maximize their potential. She is the coauthor of The Missing Peace by Menucha Publishers.

Can I Talk To My Therapist’s Supervisor?

I appreciate the good that therapy can do, and its potential to transform lives, but I can’t help but think that the current model needs improvement. I’m currently in therapy, and my therapist has repeatedly told me that she’s alarmed by certain dynamics in my relationship with my best friend. I don’t feel that there’s anything alarming there — but unlike for a medical issue, there’s no simple way for me to get a second opinion.

A few years ago, I went to therapy (for an entirely unrelated issue, with a different therapist). I liked my therapist and felt that she was skilled, but I didn’t feel like we made much progress. I wasn’t sure if that was due to the complexity of my issues, whether we weren’t a good match, or whether what was going on was in fact normal. After over a year, I stopped going to therapy. I was fine, I guess, but I still have no idea if that was the right thing.

With therapy, the client is really at a loss when it comes to knowing if they’re receiving effective help. Referral agencies like Relief may be the first step, but they’re not enough. The therapeutic world needs more oversight. Yes, most therapists have supervision but the supervisors only get to hear what and when the therapist chooses. There needs to be more communication between therapists, clients, and supervisors. Mentors and rabbanim have to be more involved. Therapists need to answer to someone so that clients have a safety net before handing their souls over to complete strangers.

All this is my dream for the future. In the present, in my little corner of the universe, what can I do? Is it rude to ask to meet with my therapist’s supervisor? Can I suggest a three-way meeting? How, as a client, can I protect myself and ensure that therapy will be helpful, not harmful?

Rabbi Dr. Lerner responds:

You make a number of interesting points. I’ll do my best to address each one.

Firstly, it’s important that from the outset the patient and the therapist have agreed upon goals. The therapist needs to know exactly what the patient expects and the patient must understand the therapist’s treatment objective. If there isn’t expectation alignment there will certainly be disappointment with the process.

Secondly, psychology is a “soft science,” therefore it can be difficult to establish measurable success criteria. In the non “woke” world of reality certain things are understood as facts. Sixteen ounces equals a pint. An accurate scale shows your exact weight. The moon appears at night and the sun during the day (assuming that it’s not overcast). Those are simple facts.

Nevertheless, there are circumstances which don’t change the facts, but might alter outcomes. For example, an accountant works with numbers. Numbers are exact, but sometimes the person supplying the numbers has recorded his accounts incorrectly. A lawyer can represent your position in court, but your view of the facts and the other litigant’s view may be vastly different. In the realm of mental health there are many opinions and some facts. Emotions are hard to quantify.

When you aren’t feeling well, you go to a doctor and describe your symptoms. Using his knowledge and experience, the doctor may immediately know what the problem is. Sometimes he may order a battery of tests to help diagnose the problem. Nevertheless, despite the best of intentions, medical mistakes happen. When they do a revised treatment plan is put into action.

The mental health professional will often use the DSM-5 (Diagnostic Statistical Manual) as a basis for diagnosis and treatment. Sometimes a person’s symptoms are “textbook” in nature — sometimes not. Occasionally, the therapist, like the medical GP with the best of intentions, may make a mistake. A symptom is missed, or the patient fails to disclose some potentially valuable information, and as a result the treatment plan may not be effective.

Not knowing you leaves me at a disadvantage because I have no background information to help me understand what, exactly, motivated your query. The best I can do is offer a general response.

The questioner states that the current therapeutic model “needs improvement.” I’m not sure the model needs improvement, but there are certainly therapists who do. You have concerns about your current therapist due to her concern over the dynamics of one of your relationships. In addition, you were less than fully satisfied with your previous therapy experiences. You point out that getting a second opinion isn’t easy — and that you changed therapists “for an entirely unrelated issue.”

From my holistic perspective all “issues” are somehow related, and getting a second opinion may be inconvenient, but shouldn’t be all that difficult. You say you feel “at a loss when it comes to knowing if I’m receiving effective help.” Immediately following those statements, you state: “The therapeutic world needs more oversight,” and suggest that “there needs to be more communication between therapists, clients, supervisors, mentors, and rabbanim.”

There are good, bad, fair, and excellent doctors, lawyers, accountants, and therapists. When choosing any professional it’s important that a rapport is established and that you feel that you’re being heard and understood. If you don’t feel comfortable, move on as soon as possible. If you’re ill and are uncertain about your doctor’s diagnosis do you ask to speak to the doctor’s mentors and professors — or do you simply seek another physician’s opinion?

Involving “supervisors, mentors, and rabbanim” to evaluate your therapist sounds like a pretty bad idea. If the patient chooses to speak to others, that’s his prerogative. Generally, too many opinions do not help to clarify most situations. In fact, the patient who is already dealing with some confusing challenges may wind up even more confused.

As far as “Is it rude to ask to meet with my therapist’s supervisor?” — no, I don’t think it’s rude, but if I’d be asked that question I’d say, “No, my supervisor works with me and I work with you. If you’re dissatisfied with my treatment I understand that you may wish to move on.”

Essentially, you want assurance that your therapists are being properly supervised so that you can trust them. It might be that you have a trust issue, and seek confirmation and validation. Nevertheless, if a patient doesn’t feel that they’re being treated properly, then by all means, find a more suitable therapist.

Regarding “handing your soul over to a complete stranger,” that’s your choice. You choose the “stranger,” you choose what to “hand over.” The next step depends on whether you and your therapist agree to treat symptoms or whether the goal is to delve deeper.

Some patients are afraid to explore an issue in depth and aren’t interested in confronting the core problem because doing so may be too painful. As a therapist, I sometimes hold back from asking my patient to look at something more closely if I feel that they aren’t ready to deal with that issue. Maybe, when your current therapist challenged you about your relationship with your best friend, you weren’t ready to confront it, and instead chose to confront the therapist.

You conclude by asking how to protect yourself and ensure that therapy will not be harmful. Obviously, you can check out the credentials and references of the therapist. As mentioned, if after starting therapy something doesn’t feel right, move on.

That said, I’ve sometimes found that there are therapy shoppers. Those individuals are mostly looking for validation and support. In the early sessions, they often feel good because they feel validated. As the sessions move on, they sometimes become uncomfortable when they feel challenged by a therapist who wants to help them confront something they’d rather avoid.

This is why it’s important to set up therapeutic expectations at the first meeting. There have been times when I’ve told someone that, unfortunately, I can’t meet their expectations. Additionally, your desire for a therapeutic “safety net” may reveal an inner struggle with being able to appropriately trust others. You may want to explore this issue further.

Finally, I wish you good health, peace, and wellbeing.

Rabbi Dr. Ivan Lerner, a former day school principal, is the Rabbi Emeritus of the Claremont Hebrew Congregation in Cape Town, South Africa. He is a past chairman of the South African Rabbinical Association. He is also a psychologist specializing in communication and conflict resolution. Currently Dr. Lerner consults for a variety of businesses and organizations including JLE in London and Meor in the United States.

Which Therapy Is for Me?

I appreciated the sidebar in an earlier installment that went through the certification levels and what they mean. Can you give us something similar for the types of the therapy and what issues they’re most effective in treating?

Abby Delouya responds:

That’s an excellent question; unravelling what works when was the impetus for my “Therapy Toolbox” column.

Therapy is for people who have experiences that are beyond their level of coping and have therefore created a pattern of maladaptive reactions. These reactions eventually reach a point where they no longer serve the client.

Every reaction gets imbedded physiologically and needs rewiring. All therapy models can be effective in rewiring as long as they cover these primary areas:

1. thoughts and beliefs
2. emotions and sensations
3. behaviors and reactions.

Different therapeutic models will have different entry portals. The primary portal is determined by the therapist and is dependent on the therapist’s competence as well as the needs of the client. It’s crucial to match the therapist and the client.

Below is a list of popular interventions. This list isn’t conclusive — There are dozens of modalities, but this covers the broad categories and can serve as a general guide.

Psychodynamic           • Depression

• Anxiety
• Eating Disorders
• Substance Use
• Somatic Symptoms Explores the connection between unconscious mind and actions.

Client learns to examine emotions, relationships, and thought patterns.       Longer-term approach to mental health treatment.

Trauma-Informed Approach   • Acute stress disorder

• Post-traumatic stress disorder (PTSD)
• Complex PTSD
• Substance abuse
• History of neglect or abuse • Seeks an awareness of the widespread impact of trauma on life experience and relationships. It recognizes trauma’s role in the outlook, emotions, and behavior of a person with a trauma history.
• Focuses on behavior, beliefs, and desired relief so the client can do repair work at the deepest level to make the change long-lasting.
• A trauma-informed approach attends to the underlying trauma from any cause. Different types include:
• Eye Movement and Desensitization Reprocessing (EMDR): designed to alleviate the distress associated with traumatic memories
• Trauma-Focused CBT (TF-CBT) designed to help children, adolescents, and their parents overcome the impact of traumatic events.
• Sensorimotor therapy: a body-centered approach that aims to treat the somatic symptoms of unresolved trauma. Based on belief that trauma may be trapped deep within the body, with those affected sometime unaware of its existence.

Cognitive Behavioral Therapy (CBT)            • Mood disorders

• Anxiety and phobias
• Eating disorders
• Obsessive-compulsive disorder (OCD)
• Insomnia
• Based upon the concept that feelings or beliefs one has about oneself and life situations can lead to distress.
• Identifies patterns and learns how they might negatively affect the client.
• Spends less time addressing past events. Instead, focuses on addressing existing symptoms and making concrete changes. • Short-term approach to mental health treatment.
• CBT can also be very helpful for certain conditions when combined with medication.
• Dialectical behavioral therapy (DBT) uses CBT skills, but it prioritizes acceptance and emotional regulation. Work focuses on developing skills to cope with challenging situations and difficult emotions.
• Trauma Focused CBT (TF -CBT) designed to help children, adolescents, and their parents overcome the impact of traumatic events.

Humanistic Therapy    • Self-esteem issues

• Difficulty coping with chronic health concerns
• Effects of trauma
• Depression
• Relationship issues
• Substance Use
• This approach looks at how a person’s worldview affects the choices she makes, especially choices that cause distress. Based on the belief that the client is the best person to understand her experiences and needs.
• Spends time exploring ways to grow and increase self-acceptance. Therapist acceptance is key.
• Client directs the sessions, therapist does active listening. Three broad types:
• Existential therapy: more philosophical, looks at responsibility of choices and meaning in life.
• Person-centered therapy: Believes emotional distress comes from criticism. Therapist offers acceptance, empathy, and guidance to help heal and work toward self-acceptance.
• Gestalt therapy: Looks at unresolved issues like family conflicts. Often involves present moment, role playing, and visualization.

Behavioral Therapy    • Anxiety

• Phobias
• Attention Deficit Disorder (ADD)
• Obsessive-compulsive disorder (OCD)
• Oppositional and defiant behaviors • Focus on ways to change behavioral reactions and patterns that cause distress.
• Less time spent talking about unconscious behaviors Three different types:
• Systemic desensitization: relaxation exercises and gradual exposure to something you fear.
• Aversion Therapy: associates the behavior you want to eliminate with something that’s unpleasant.
• Flooding: desensitization is done quickly.

Marriage Therapy       • Difficult communication

• Poor conflict resolution
• Lack of closeness and friendship in marriage
• Lack of skills including parenting and blended families
• Improving trust and confidence in marriage
• Couple attends session together.
• Provides an objective view through obtaining information about the couple’s unique patterns and issues. Popular Forms:
• Gottman Method: uses interventions to decrease conflict, deepen emotional connections, and create shared meaning.
• Imago Relationship Therapy: examines the root of negative behaviors in the context of childhood experiences, and uses structured dialogue techniques to address rifts.
• Emotionally Focused Couples Therapy: short term; seeks to secure a tight bond between partners.
• Narrative Therapy: seeks to separate the problem from the person by externalizing problems and uncovering strengths.

Family Therapy  

   
Useful in any family situation that causes stress, grief, anger, or conflict.    Believes it’s beneficial to address the structure and dynamics of the broader relationship system. Changes in behavior of one member are likely to influence the way the family functions over time.

Family Systems Therapy holds that individuals are inseparable from their network of relationships.

Within systems therapy, there’s structural family therapy, strategic family therapy, and intergenerational family therapy.

(Originally featured in Family First, Issue 745)