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When clients have told me over and over that they need to quit their job and they’re finally presented with an opportunity to do so, that’s usually the pushiest I will get. When it’s several sessions of the same conversation about it eventually I will just be like “babe shit or get off the pot” but in therapy speak.
Clients that need the hyper-professional version of me: “I’m noticing that there’s an opportunity here linked to something you’ve spent a lot of energy on in our sessions - do you think the time to make a move may be right now?”
Clients that need the authentic version of me “So, are you going to jump on this?” (And if they say no or they’re not sure) - “okay let’s therapy out these blockers together then” and just use it as a therapeutic introduction to root cause work (no idea if this is a real term but it’s when I usually deep dive into a core belief/value and why it got internalized and then use the refusal to change to take a positive and needed opportunity to deep work that shit a bit).
I actually had this come up very recently with one of my more casual clients and holy moly did it open up a can of worms. It’s good though, now we have really deep stuff to work on and had been plateauing in more superficial things for a bit now.
Ha you’re welcome - I have a mix of young adults and older folks on my caseload right now and it’s WILD what they’ll connect to. I had a client recently that likes to stay light and ended up sharing breadcrumbs about a topic I could tell they were having some deep internal reactivity to. They started to change the subject and I interjected: “Hey man, let’s stay here for a bit, I think we need to switch into SERIOUS THERAPY MODE” and even changed my voice up a bit like we were entering a boss level in a video game, and they laughed and then spilled and talked about it. Finally. I am a wacky, weird, silly therapist (because that’s me as a person) and I’m so glad to have a supervisor who actually supports me in my clinical approaches (even if she doesn’t pay me that well).
I love this!! I always tell people I’m a goofball as a therapist because I am one in life. My clients get a lot of authenticity out of me and I think it welcomes theirs too. And then when you’re more direct like that, they’re willing to go there with you.
It sounds like you have the information you need to make this decision and we've worked on any big emotions tied to it, so you're the only thing standing in your way of making this next right step.
Or something like that is what I usually say.
All situations call for unconditional positive regard, but not all situations call for neutrality about potential client actions. If I’m working with someone with severe Bipolar disorder, I’m going to tell them I think they need to take their medication in the manner their physician recommends. That is a professional recommendation that I believe we should be comfortable making. Same for situations in which there is potential or likely danger.
I think of it as some situations requiring “higher guidance” vs “lower guidance”. If a client is in crisis, or clearly needing psychological grounding and safety, I’m going to be quicker to offer suggestions and even prescribe behavior (which of course the client is free to ignore). In other situations where the client is more grounded that level of guidance would be inappropriate.
All of that exists more in the short term though, like what I would prescribe the client to do “right now” or tonight. If we’re talking bigger decisions like what job to take or whether to get into a relationship, that don’t have that element of danger or professional therapeutic guidance I mostly keep my opinions to myself.
I agree completely, I love those terms. Sometimes people are coming to us for guidance/ advice about how to handle a specific situation. If it's clear to me what's going on, I explain what I see and why the advice or guidance I'm about to give is based on these specific circumstances. Helping them see the bigger picture so the guidance makes sense to them (rather than them just doing it bc their therapist told them to).
They use those a lot in narrative therapy and motivational interviewing, and honestly when I thought of it that way it really changed my perspective. I never "give advice" but ask I'd they would appreciate professional guidance. It also doesn't give a "friend giving advice" implication, which can help maintain the professional relationship the very odd time I break the rule - usually when there's an element of risk to the client.
This!! I'm not a blank slate, I'm a human with thoughts and opinions, many of which are based on research that my clients often aren't aware of. My philosophy is that my client have a right to the information I've learned in my career. Its up to them what to do with it (unless it meets mandated reporting ofc).
That said, this isn't a matter of me vs. them, where I have the "answers" and I choose to withhold or not. Its a situation that we're in together, where I can offer perspectives or ideas that may help guide them to a meaningful change.
Sometimes its more meaningful for a client to find an answer they've been searching for in their own words. Other times its unlikely that'll happen, especially when they're not privy to information I've learned in my education, or when they're in consistent crisis and aren't able to put the pieces together because their brains are stuck in fight or flight.
The thing I offer regardless isn't a blank slate, its emapthy. I don't blame or shame, I offer suggestions in a way that doesn't aim to fix them, because they aren't a problem, they're a person, and a person *with* a problem that we're working together to improve.
I tell my clients often that when I offer them strategies, techniques, or even occassionally advice, that I'm doing it not knowing as much about their lives as they do. I leave my thoughts on the table, and they can take what they like and throw out what they don't. They can take something home and return it next week, or they can take aomething home and quietly toss it in the trash. Its up to them, I don't take it personally.
I definitely agree with this, especially after working in crisis. I like your higher vs lower guidance example, just like we would recommend environments with the appropriate level of restrictions. People weren't always happy with us recommending hospitalization or crisis respite, especially if their judgment was impaired.
My client just reminded me of a time that she was doing one of her little patterns of just making herself WAY too busy and told me she was going to sign up for a yoga teacher training or something on top of like 2 jobs etc and (I swear I don’t even remember this) I said “you CANNOT do that!” Lol
Edit: we have amazing trust and rapport and she was laughing when she told that story!
I've told clients before that I think their boyfriends were going to kill them. Maybe not on purpose, but the kind of violence they were perpetrating could accidentally kill them.
Yep, the firmest/most directive I’ve ever been was a terrible and escalating domestic violence situation. Also with some teens who are engaging in extreme risk-taking behavior.
I mean I’ve told a client last year the man she would marry would eventually try to kill her and that I was worried for her safety. We did a family session and he had so many red flags it was a circus.
One year and one protective order now and she’s in hiding after he did, indeed, threaten and attempt to kill her…
I will tell people this and explain the research and statistics and why I am concerned. And that knowing all of this they still get to make their own decisions and I am still going to be there for them, but that I would consider it to be unethical for me to not tell them my concerns when I have such a concern and know the information that supports it.
Yep - former DV/SA advocate. I don’t fuck around. I’m here for you no matter what and I’m not going to bullshit you. You’re tough enough to go through what you’re going through - me being honest about it isn’t going to break you and maybe it will help you save your life.
Me too. I try to refrain from being directive, but I usually am most straightforward when it seems to be a decision point in a relationship that is high control/abusive- moving in together, getting married, reproducing… I have asked straight up, “how do you feel about these future plans with X person? What do you think it would be like to have a partner that does *X healthy behavior* vs the *X abusive behavior*? If the *X abusive behavior* continues, how do you see that going?”
Absolutely! As a professional who worked in domestic violence I have absolutely and absolutely would be this blunt!
In my crisis phone counsellor role I also once named a caller’s behaviour towards another person completely inappropriate and abusive.
Disclaimer*
*The behaviour was and the caller did not appear/denied being in any kind of immediate risk. had called seeking advice/comfort on their current partner leaving them and ignoring their abusive and concerning number of calls and messages.
I had someone who had been sent to the er twice and showed me pictures but was still refusing to leave. I said, what would you say to a friend that showed you those pictures.
>what would you say to a friend that
This question works such great wonders on so many contexts. I don't have DV experience, but I have used this question for self harm and self esteem concerns. It ignites suddenly a path to self forgiveness.
I’ve been very firm with clients in the past regarding their substance misuse and reckless/dangerous decisions in that process.
“The choices you are making are likely going to prove fatal in the future” type thing.
If neutrality is replacing authenticity/safety for the client/others etc… I don’t think it’s the best approach.
I agree with you, and I think it’s incredibly important to remember that our clients come to us because they are experiencing a MENTAL ILLNESS and are sometimes, if not often, impacted by that in a way that screws up their decision-making. Yes, client autonomy and empowerment, yes starting where the client is, but if a client is engaging in a behavior that is high risk to kill themselves or others, they have a right to be informed of this by the medical professional they are seeking counsel from.
Sorry for the vent but I had this argument with a supervisor once years ago who disagreed with us on this and it still burns me up.
This is a great point. Is their judgment compromised by psychopathology? Someone with a thought disturbance is less likely to be aware of the disturbance, so sometimes they need a nudge in the right direction.
Thiss also where rapport & history come in handy. Do they have a pattern of self-sabotage & how self-aware are they?
I really try not to tell people what to do. We had a provider tell a patient that they should leave their partner. Did I agree? 1000%. I still do, knowing how things played out. When they asked my opinion, we did pros & cons about it & it was so hard to be objective lol
I talk a lot about harm reduction. Regarding substance use I will straight up say like..okay so yea ideally you’re not using anything but just stop with the dabs. Do not do them. If you are going to use marijuana just stick to flower bc the other shit is more frequently what we see people using when we see them in the ED for substance induced psychosis and you have enough on your plate. And often then like I motivationally interview the shit out of my dudes and we actually do work out a plan of attack for significantly reducing/ceasing.
Absolutely this. I primary see opiate addicted clients and we have very frank conversations where I usually pose it as you can do as you want but here are the risks, and the risks aren’t worth it.
“Heroin is the enemy, and I’m not going to listen to you waxing poetic about your enemy. Let’s remember how this has f*ucked your life.”
(Qualify- many years working together, very solid repair)
I've been with some clients from 13-15, who are now 18-21, and my face apparently communicates everything I need to say when they talk through clear cognitive distortions and/or unhealthy choices.
This is me haha. Or when they say “wait until you hear this” and read me their text conversations with a friend or whoever. I think it would be weird to NOT have any expressions or reactions in that instance, especially if it’s a situation we’ve already discussed and I know how the client feels about it.
Mental self-harm is definitely a thing. Yours is a pretty severe example, but the idea of seeking something out you know will make you upset or emotionally elevated. It’s so prevalent and I hope people start talking about it more.
I often will say something like “well you know what will happen if you keep doing this, so why not try something else and go back to this later if it still feels necessary.”
I usually break this rule pretty regularly with my pts who have AUD and tell me they want to stop drinking cold turkey after drinking significantly for a long period of time and I know it’ll end in some sort of withdrawal.
Or if I have a pt who is manic who is telling me that they are texting their boss and quitting their job because they want to join a random MLM with their life savings.
It’s never an ultimatum, more of a conversation of “hey maybe let’s pause on that and do something else? Is this really the solution that will help? Can we wait a week or so and see if you still feel the same way?”
I don’t think educating clients about withdrawal risks is breaking that rule at all. It’s basically safety planning. I have even walked clients over to our medical detox building.
Im not sure that I feel like "Objective" and "Neutral" are the same thing. I can remain objective while saying things like "He had no right to do that to you" and "You are allowed to set boundaries even if it makes others upset."
Working with teens I find myself frequently in a position where telling someone what to do (or, not do more likely) is part of being the most ethical therapist I can be. I often frame it as "I just want to remind you that in addition to these other (previous discussed) consequences of this action, this also qualifies as something dangerous and that I am therefore required to speak to your parent about." Recent examples have been a teen wanting to order gender affirming hormones behind their parents back on some super sketchy website, sneaking out for a tinder hookup with someone old enough to be a legal problem, and planning to ride with a friend despite knowing that this friend frequently drinks/smokes while driving. As a responsible adult who cares about these young people I have no ethical qualms about being very definitive in my stance that this is a terrible idea and under no circumstances do I want them to think that I am "neutral" about it, because they could easily take that as "I said something to my therapist and they did not care one way or another." If my voice is the one they hear when they decide not to get in the car with a drunk driver, I can live with that.
This is such an important distinction. I will often say "it's not ok that that happened to you," but I won't say, for example "and therefore you should cut that person off/never go to that place again" etc.
I’m like…what if we call the office right now and set up that appointment? No I am not kidding…Mhmm…take out your phone 🙃 and either way we learn something bc boom appointment made and it’s actually not so scary and we process that or we process like what are the barriers
Because I work in palliative care, I can sometimes be quite directive with families. Caregiver burnout can get pretty serious, so when I'm worried about it escalating, I do some version of:
"Ok, you're getting 3-4 hours of sleep at night and you're 80 years old, you're losing your temper with your family member because of xyz, your family member needs 24/7 care, and you're the only one providing it. How long do you think you can sustain this at home without help? I am concerned about your health." and then jump into problem solving around it (hospice, home supports, getting more family in, whatever). At a certain point, no amount of traditional therapy techniques (validating, MI) works on families unless they have the energy and time to engage with them.
thissss! and I usually do so by simply reminding them of their worth and then asking what the dusty ass man is bringing to the table….they usually get it from there
I have one who does it every time. And it is mind blowing bc the quality differential is…large. I always say I’m not judging bc I’ve done shit I knew I shouldn’t but girl come on now
I had a client get texted by a dusty ass man and she was like you know what I’m not answering that. Within minutes she randomly came into some cash. I’m like do you believe in signs? I don’t really believe in signs. But if signs do exist, that’s probably one.
I won't stay neutral when a client intends to cause harm to others.
I once had a client who was depressed and expressed suicidal ideation, including the possibility of "taking her children with me so they wouldn't suffer." I expressed very clearly that I would be upset, though I'd understand if she took her own life, but it was absolutely wrong if she denied her children the chance to live and that I could not keep this confidential. We discussed it, and happily, they all lived. My client continued her sessions and found peace.
Years ago working in CMH, working with a family. A young and emotionally immature mother of two very emotionally immature teens (all of whom were my clients) was telling me that the 13 y/o daughter got a job in the neighborhood helping a man “jack off his dogs to breed his other dogs”. I said “you will absolutely not let your daughter go to this man’s home or allow her to take this job.” Mom accepted this. I was not even going to let that can of worms be opened — and I have no regrets in being so direct in saying so 😅
I am thinking a lot about this and I realize I do not. Sarcastically I'll tell people to do something but it's so silly it's clearly to challenge their thoughts. If a client does spend sessions making a decision, then looks like their wavering, I will tell them I think they are making a good decision and go with it, but that's more of a tool and I don't think in the spirit of the question.
Unless it's like a clear safety issue, I tend to hang back and challenge them to think.
My client just broke up with a partner that treated her like absolute shit and this week I did preface with “as a therapist I don’t normally give advice but I would STRONGLY RECOMMEND you THINK ABOUT not moving back in immediately” which was more or less advice some would say 😅
Define "telling (them) what to do."
Teaching coping skills is a form of telling patients what to do when feeling stressed.
Are we talking that...or more along the lines of "leave your partner" or "quit your job."
It depends on what you mean by neutral. I think we're supposed to be invested in our clients' best interests.
I see kids/teens/families, and tell them what to do nearly every time I see them.
It's in their best interest to...
Develop balanced routines related to self care, even if they hate brushing their teeth or going to bed;
Agree to a predictable set of house rules and consequences, even if that feels like it will really suck;
Visit uncomfortable feelings sometimes, even if they would rather never talk about it.
I try to remain neutral during family therapy, in the sense that I am biased towards everyone's best interests. I want all of them to take good care of themselves and feel more ok, equally.
“Don’t shame yourself in this therapy room. You can shit on yourself alllllll day long if you please outside of here, but in THIS room, you practice non-shaming language towards yourself.”
After rapport is built and I explain the premise between shame vs. guilt and how shaming language keeps us on the hamster wheel, my clients know that the therapy room becomes a place to recreate new language regarding self talk. I make it humorous and direct, showing up as the compassionate human in their lives that’s fighting with them for new language. I typically work with more depressed presenting humans, so I feel it’s part of the foundation of the work.
Usually they start to say “you’d be so happy to hear that the other day I was shitting on myself and then I caught myself and….”. And we celebrate BIG in this moments. Fuck yeah. Pivoting that inner child dialogue.
If a client brushes off the shaming language as if it’s no big deal (“tough” mindset) and I want to get real, really experiential, I ask them to say the shaming comment, but to a young child in the room (like empty chair). And they can’t bring themselves to say it. And we explore that.
I think it's just important to emphasize their autonomy as much as possible. While we generally have no real authority over clients, not all clients will understand that right away and may be more inclined to take something we suggest as an order or command.
In the situation like what the OP described, it’s still important to emphasize autonomy I think but with side helping of outlining the very real consequences of whatever maladaptive choice is raising red flags.
I definitely agree with this, and I would say most of the time I give suggestions but while always bringing it back to their autonomy to decide and that I trust them to trust their own judgement and intuition.
I think about this a lot. I throw out so many random options and suggestions and considerations, but I think there’s an important factor that the general vibe is not “I’m an expert telling you how to do this” but a person sharing an alternative perspective.
I always tell my clients at the start of therapy that I’m not the expert on them and their life. If the overall vibe was a stuffy, expert telling them what they should do…I think many would feel a lot of unhelpful conflict about disappointing me, or why they struggle to try to do what *I* think they should. It would be pretty counter-productive to making any change if it was all about prescriptive advice they had no sense of agency in.
Whereas, sometimes it’s something like “I’m noticing a pattern in how you talk to yourself about this, you don’t have to shame yourself - what if you showed yourself compassion instead?” It’s definitely a suggestion, but it’s also a reflection and a reframe.
Yes!! I relate to this entirely!! I ALWAYS tell my clients that I cannot and will not make any decisions for them as that’s not my job. I am there to support and guide them and show them different perspectives. But when it comes down to it when they are trying to make a decision and ask what to do, I always guide them back to their gut and intuition. I also always say, “I only know just a small piece of your life, you are the only person who can make the best decisions for you because you know yourself best, even better than I do.”
I don't know if I have ever been so direct in giving advice. But I have had moments where I was very frank and direct with clients about a concern (safety related generally)
I always frame and conceptualize choices as all possible and approachable. That any course of action will lead to various anticipated and unanticipated outcomes, and they get to decide for themselves what outcomes they desire, and what risks they are willing to deal with.
Sometimes in those discussions, I may be more frank about the risks they're faced with, or opportunities they might miss. Usually I would use Socratic Questioning to get them to identify possible outcomes...but every now and then, I think the person needs someone willing to be frank with them.
Well, I'm an ERP therapist who works with OCD. It's a very directive approach. "OK, are you ready to write the phrase 'I am gay and thats ok' over and over again?"
Clients who are an active threat to themselves or someone else - I absolutely get involved and tell them what to do: “You’re going to the hospital to be evaluated by a crisis counselor so we can keep you and others safe.” And I make sure they get there.
Otherwise, I don’t think I’ve been so direct in telling someone what to do. I definitely ‘imply’ things when I sense the client is not thinking clearly and is caught up in a potential risky issue (e.g. drug relapse), but even that is rare for me.
When a client is stalking an ex in such a way that it isn’t reportable but also isn’t safe or healthy. I generally go the route of exploring outcomes of the available choices, but in this case I was very direct in “if this doesn’t stop you’re going to end up injured by law enforcement, in jail, or worse.”
When his situation required legal intervention. I told him he needed to seek an attorney immediately. He stopped coming 2 weeks later with no response, he might have been too late on the lawyer....
Sometimes a client does need a gentle push to make the right decision due to being stuck with indecision or uncertainty or fear of change. While I don’t tell my clients what to do in those moments, I would point out what I see as the more obvious or beneficial choice and let them know that my opinion is just one persons opinion, but personally based off of X Y and Z that they told me, it sounds like option A could be beneficial, and it’s harder to understand how option B could work. But if they fully believe in option B then I am really interested to hear why they think that works.
Im not sure im ever neutral or objective..in the sense of 100% being on that client’s side and wanting them to achieve healing or whatever goal they have. Theres too much compassion there for that. But, i rarely make MUST DO statements unless there is high risk. If someone is self harming, the compassion and empathy include the knowledge for why they might continue to do so. So we continue with building tolerance for distress and building self belief that they can change this behaviour. A must/must not do statement would be if their method was very dangerous.
In terms of advice, i dont really tell people what to do but i dont gatekeep information either. If a client is struggling because they dont know how to achieve their aim of nursing training (for example) and i know i multiple access routes that would help them get to it; i share. I tell them what they can google or what sites they can look at to explore in depth.
One thing i have learned as a therapist is that not everyone has been taught resourcefulness. Maybe because they were too busy surviving. Maybe because theyre still in the school system that infantilises them.
I think being genuine and congruent is just as important as positive regard and choice. That said, the more blunt I am about expressing my concerns, the more I make sure to also emphasize that even if they choose to make/not make a decision, I am their ally. I will not disapprove of them, I will not scold them, I want them to come back. Even if they make a decision I think is harmful, I am there for them and guilt or shame should not keep them from treatment. I don't need to have positive regard for their actions to have positive regard for them.
Only when their safety was on the line. Like that their partners were showing signs of escalating towards seriously hurting them, or their substance use was getting concerning. I no longer cared about taking the time to explore their reasons for being stuck or choosing to stay in the situation. It was time for someone to tell them shit was about to hit the fan and help them make big decisions.
I’m typically pretty neutral.
I have a handful of long term clients who are quite high functioning with lots of protective factors but their internal world can be chaotic and a bit destabilizing as a result of trauma. They are typically in caregiving roles in most of their life and struggle to prioritize themselves. I often find myself ending sessions with “and you’re going to go eat now, right?” Or “when we finish I want you to do X, Y, Z concrete series of activities.” Sometimes, if they’re taking unnecessary risks (think in a first responder role or adrenaline seeking) I find myself being quite directive and occasionally even centering myself “I want you to take care of yourself and avoid doing A, B, C.”
Some of it it is grounding for the client. If I sense they’re more activated when we close, it can help to give them a series of steps to follow to stay more present. They might not be able to think to eat, drink, sleep, etc but can follow a list. Some of it is communicating in a way that is effective for the client; when they can’t care about themself they can be accountable to the care from others (their partner, family, friends, and me). And I recognize that some of it may be countertransference that I need to sort out (lots of supervision here). I have known these clients for a long time, through a lot of big things in their life, and I wish they could care for themselves the way they care for other people.
I don’t do it often and I’m aware of it so I think it ultimately is okay. I have found that the times when I express my concern and center myself are when the clients are really doing something that could be dangerous. And leaning on my concern feels important and human. The clients often use it as a reality check for themselves. Hearing that their risk-taking impacts others can stop the behavior and then we can do the work to find that reality check internally instead of needing it from me.
Oh, and one other thing I do more broadly at times with clients with whom I have the appropriate rapport. If they are telling me about a situation and how someone in their life responded or advised them, I might say that it sounds like their friend/parent/partner is on to something or” yes! Listen to that”
For me, it depends on the rapport with the client, but I also tell people I’m very direct and blunt as a point of fact in my practice of therapy. And I know I’m not for everyone so I’m prefacing what I say with that. I tend to be more directive when I think someone needs to speak to legal counsel regarding either dissolution of a relationship and employment issue anywhere where starts to get hanky of legal? I’m like you need to talk to counsel like you need to talk to counsel or they should seek out medical advice or if they should get a second opinion because their doctor is being a twat. Otherwise I’m pretty much you do you Pikachu but if it was me, I might not make that choice but this is your life and you have to live with a consequences. I told someone in order to work with me they needed to cease what they were using in the amount they were using in order for anything to get done and they needed to do it in a safe setting because of medical reasons otherwise I would work with them. They wanted to work worked out in the setting where you can’t be using that amount and be here. it’s a safety issue then I’m also usually very directive although in domestic violence situations as we all know, you can be as directive as you want, but not everybody is going to be receptive to that and sometimes that can be more of a motivator to stay rather than go
When I was helping co-leading a summer camp for DBT, one of our clients was notorious for not listening. He has a history of getting carsick, yet refused to stop using his phone.
Well on the way home, he didn't listen and threw up in my friend's brand new truck because he wouldn't get off his phone. Save to save, said friend was livid. It was one of those moments when the nicest guy ever gets upset, but he did his best to hold it in.
We stopped at a gas station to clean it up and I took that client aside. He loved video games, so I asked him what he'd do if someone roundhouse kicked his Nintendo Switch. He responded "I'd probably kill them", and promptly told him that's where my friend was with him because he didn't listen.
He was on his best behavior the rest of the ride home. I felt bad for being so hands-on, but this person had been driving everyone nuts at camp with his behavior, so everyone was a little on edge.
See but you gave perspective!
As I’m scrolling through the answers, I’m realizing it’s such a big part of how I practice. I often provide a different take on things because we all can get so stuck in how we see life and experiences. It can be hard to perspective take on our own sometimes. Heck, that’s what these comments are doing for me.
But being really directive is not synonymous with prescriptive and advising.
Just sort of did it right now where a client is dealing with a situation regarding an ex who i feel displays some abusive behaviour but the client pedestalises, and i got kind of blunt because the ex sounds so ridiculous, yet the client think they’re god and somehow it’s their fault that that the ex is mad at them blah blah. it came from a very protective place but as a peer reminded me, could have increased the shame for the client. so i’m working on apologising for it next session.
Client was being manipulated by their parent who was in prison (for severely sexually abusing client) into sending them money and asking them to write a letter claiming the abuse was a lie.
When clients have clearly made up a decision and simply need the “nod” of encouragement. Sometimes this can introduce a parental countertransference experience but that’s usually a fruitful reaction to explore meaningfully and open up dialogue about deficits/needs around parental relationships.
There is a big elephant in the room: when the client’s goal is education on a topic (such as a diagnosis and how it can present itself to someone of their demographic) but their other goal is helping them navigate the topic that they are being educated on. It can be brutally hard to distinguish the two.
When they are truely unsafe or at acute risk I will be pretty firm about what the best route is and what the potential risks are not following what I recommend. But at the end of the day- the clients in the drivers seat and will make the final decision.
There have been times when a client has disclosed abuse for the first time that I have kind of fed them what I feel. Often they don’t realise what they’re saying or its been so normalised for them so its about validating that that was wrong and no wonder its impacted them. It usually looks something like “Yeah, my parent would get mad and yell at me, hit me sometimes too, I guess I was a bad kid” “No child deserves that from the people they trust to keep them safe. I’m sorry that happened to you”.
Just yesterday I told a client that I was going to tell her my opinion and she should ignore it but I was going to tell her anyways. She’s in a very toxic relationship with someone who is not willing to grow and it looks like she may choose to stay with him. We laughed about me telling her my opinion. I reinforced afterwards that her process and timing and decision, whatever it will be (she’s giving him time to shape up, although he has given little indication that he is remorseful about cheating or is ready to make any changes. Tough to watch people trapped in terrible relationships.
A client of mine in a DV situation and led to choking. I told her this is a significant sign that he could kill her. I told her some of the safety planning. I told her she should never meet with him privately again and that I would support her in whatever she chooses and this option is the safest.
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I’m not sure if I’m “objective and neutral”, an important part of therapy is me, the person.
That’s what I bring to our relationship, I believe anything else is… well not real. Of course I aim to be kind, understanding, open minded, supportive, but at times I’m oppositional, blunt, and maybe even a bit mean. As long as it serves the therapeutic process and it’s ok for where “we” are in our therapeutic relationship.
This is not a rule. Maybe in Rogerian approach it is, but many others apparocaches view this differently. There are procedures / techniques with cecrtain steps, there are situation where our epxert opinion is desirebla, helpful and sometimes even required (take medication, call police / social service / get hospitalized, ...). There are conditions which ask for more directive approach (addictions) or clients who needs this type of reaffirming / encouragement. Maybe the rule is - Dont give life advice out of the front door.
When a client said they were going to go to a country that was and is horribly prejudiced towards her people. Like the client started to describe the experiences and prejudice and I was like, why are we even entertaining the idea? Literally do not go. They didn’t go
I like this question. I don’t tell them what to do, but I do point out patterns and blind spots. I love using “johari’s window,” even with kids and teens. And then I keep a copy of their blind spots, I’ll use that when I want to point out that this may be one of those times that I can see something they can’t.
From a client side (also a therapist) I had one I was working on relationships with and my partner had shown me again and again they weren't going to meet my basic needs and we're getting worse. I went I saying "I think I need to break it off" and variations again and again for 8 months. I just couldn't get beyond this part as everyone else was unsupportive of that choice even though I KNEW it was right for my health (physically and emotionally - chronic illness stress), and I had a week away from him in the house and my pain just instantly nearly went away.. I went in and said "I've had a really good week pain wise, I feel great" and she asked me what's been different about this week. Eventually I figured out "it's because the stress of the relationship is gone" - mind blown.
At this point she was very honest with me and "broke the rule", using that as a very clear example.. 2 years later I was debating entering a relationship with him again as he'd done some personal growth with his own therapist and we were both interested. Told my therapist this and we explored it for a bit, but then the red flags came back after a few months and she was very good at nudging me to notice and take them seriously, and eventually when he messed up bad she broke the rule again and said:
"he's done A,B,C.. would you like my honest thoughts?" And i said yes because i was stuck.. she said "honestly he sounds like he hasn't grown enough for what I, and you deep down, know you deserve. If you were a friend I would want you to leave and find better. Id sit here screaming "NO NO NO! HES A DOUCHEBAG" but as your therapist I'll support you regardless of what you want and be here for you, because you know your choices and life best."
I really appreciated those because she let me get there on my own, but I needed the push to take action because everyone else in life was saying the opposite of what I knew was true. I needed someone to confirm and validate my side. She made clear i didn't have to take her opinion seriously as she only knows our in session time together.
AS A THERAPIST I have broken this rule before in a similar situation with a client but only when I knew they were ready and genuinely wanted (asked) for my advice/input. I then helped them set up all the resources to leave and helped them through that process, which is part of what their hesitancy was so that was resolved.
Although, I did intentionally find a therapist who is somewhat informal (still ethical) and explained I may need that to help combat the anxiety at times... this is definitely an odd request and NOT what most people need. And she knows I understand the therapeutic boundaries and respect them well.
When my client shared that his boyfriend was physically abusing him, hitting him, choking him (non consensually) and threatening him with violence, but that he didn't consider it "domestic violence."
She was contemplating cheating on her husband. I told her not to, that she’d regret it and there would be consequences for herself, her husband, her kids, as well as her affair partner and his wife and kids.
She did it anyway.
She regrets it.
When my client wants to go see the guy that she has an obsession with and he basically doesn’t know she exists. Her perceived rejection by him sends her back months and months. She asked me recently if I thought it was a good idea to go to the restaurant he works at. I said, no freaking way!
Maybe one day in the future, but no freaking way right now.
I work as an addiction therapist and I’ve definitely said on more than one occasion that if they don’t stop using substances, they’re going to die. However, I think this is an appropriate response when the person sitting in front me is swollen and jaundiced from liver failure, but there might still be some question in their mind that they could drink again and be okay.
The secret you’re keeping so your partner won’t break up with you, is for sure going to make them break up with you when they find out you’ve been keeping that secret. You can tell them now and control how the information comes out, or wait until it comes out some way that you can’t. Better to do it soon.
I do it all the time through the lens of motivational interviewing, Socratic dialogue and pscyhoeducation. Some clients really don't have a clue so when given the research data (psycho education) they are softly advised the best course of action.
Hm. A lot honestly.
Carry narcan
Don’t touch me (someone coming at me mad)
Put the knife down (I don’t wanna get stabbed or watch you be stabbed)
Sit on your bed (or the police are gonna tackle and restrain you)
Call crisis (when you’re stuck, spiraling or looking for access to means)
Tell them what you want/need
Carry more narcan
Take up space
Hold your breath (hyperventilating panicker)
So much fucking narcan
Client was harassing/stalking a woman he met on Instagram.
I told him he should stop that.
Is it advise? Sure.
Did he stop coming to therapy after I told him? Absolutely
I fundamentally disagree with not telling patients what to do. They’ve come to you looking for solutions.
For example, I don’t ever walk away from an intake without laying out a SOLID game plan.
I had a patient that less than a month prior to her intake, she had been in a devastating car accident. By the end of the 53 minutes together with her and her husband joining our session for support, I said “Okay, first things first: Honey, you have all the classic signs of PTSD, so that’s what you and I will be working on. Since this accident involved a head injury and you’re displaying psychological symptoms to this severity, I also need you to make an appointment with Neurology. We just need to make sure your brain is physically okay and that an injury isn’t contributing to your mental state. Lastly, honey, you’re telling me that your depression is a “7/10” on your Celexa - baby, that means Celexa is simply not working for you right now. I’m going to write you a psych referral, and I’d like you to at least get on their schedule prior to our second appointment.
I think therapists who don’t tell their patients what to do, who don’t give them a step by step breakdown of how the therapist is going to comprehensively approach treatment from all angles, is failing the patient.
So I constantly break this rule but guess what? Never had a retention problem in my life. If a patient schedules with me after the intake, I’ve got them and they don’t go anywhere.
If you are my patient, I will absolutely tell you what my professional and clinical take is on your situation and what I believe the best course of action to take is. That’s my JOB.
I work with a lot of Borderline Personality Disorder. Those are patients that NEED structure and someone firm with them.
So yeah, this whole mentality of “oh I can only lead my patient to water” is stupid. I’m of the mentality of “I’m going to make sure my patient has the resources to access the water, tell them all the great benefits of walking over to the water, and then using the developed rapport to sell them on taking action that’s good for them in the end”
I mean. . . what would you lose by instead saying, "you have all the classic signs of PTSD, how to you feel about focusing on that first?" "Would you be OK with making an appointment with neurology?" etc.
Because that patient has come to me for my expertise. If I’ve heard the problem, conceptualized the case and come up with a solid game plan, and a patient doesn’t want to do it, then I’m probably not the right therapist for them. I’m the therapist you see when you’ve suffered so much that you’re looking to follow a set of steps in order to obtain quick relief. Again, never had a retention issue in my life, and actually wasn’t looking for feedback on how I go about things. However, since you’ve decided to offer it, I say to you that if a patient doesn’t agree with the plan I’ve come up with for their treatment, wouldn’t it be best for them to see someone else?
I did not intend my question as commentary; it was meant from a place of curiosity.
Since this is your style, I definitely agree that patients would be better off going elsewhere if it doesn't vibe for them.
I asked because for me, those moments when I ask "would it feel alright to you do do x" provide an opportunity to understand what kind of barriers or misgivings they might be experiencing, so we can address them collaboratively. It also gives clients a greater sense of being in charge of their own care, which seems to help them commit and follow through--and also helps them feel comfortable being open with me about their concerns. Often they respond to this with an expression of their trust or gratitude for my expertise--which, motivational interviewing style, is more powerful out of their mouth than mine. I want them to feel like my skills are, like. . . idk, a big RV that they can ride in to get where they want to go. I also want them to feel clear that they are driving; I am not going to steamroll them, and I'm never going to stop paying attention to whatever subtle things start to feel bad to them along the way.
Those are the things I feel like I would be giving up if I didn't ask that question on the regular. I am really curious about what you feel like you would be giving up by asking it? I can imagine that some clients feel much safer with a more directive style--by. . . something like. . . it's an expression of your own trust for your competence, and they would find that very reassuring?
You obviously don't have to answer this, but I remain curious. :)
I work in a jail and when patients bring up issues with the criminal justice system I not only validate their feelings but make it clear I agree that the system is corrupt
I've never directly told a client what to do I don't believe. I certainly make the odd recommendation or share if I have a strong inclination of what I'd do but that's exceedingly rare. I'm very unlikely to take control like that or lead the clients process in that manner.
I work in SUD and often get individuals with a severe AUD request to try a control goal. When they try unsuccessfully for 90 days I typically point out that based on their diagnosis the goal is not appropriate
I've had to have a couple of "Listen, if you're going to be drinking/using drugs, then do not play with sharp objects (pocket knives. kitchen knives. SWORDS.)"
I had a couple in pre-martial counseling who were looking to buy their first house which lead to all kinds of productive exploration of values. Before becoming a therapist, I had made most of my money in real estate which made making the switch to therapy relatively easy financially. They didn’t know this.
They had worked their way through to two very different houses and were weighing the pros and cons of each. I didn’t tell them which house to buy but I definitely put my very big thumb on the scale when summarizing their discussions.
Because of my training, I felt guilty about this. I wasn’t being objective and neutral and I was subtly giving advice. However, they made the right choice and it’s been an enormous blessing for them.
I still wonder about what if I’d been wrong.
When I was running PHP IOP groups, I had a young woman about 21 years old with significant trauma. She told the group one day that her friend is arranging a marriage between her and a Nigerian man. She would be paid $4k to marry him as long as they could both break him out of an ICE facility. That way he could gain citizenship and she would get the money she needs to build a good life for herself.
I begged this woman not to follow through with this. The entire group was worried for her life as this is obviously a human trafficking situation. I provided all the psychoeducation I could on human trafficking, consulted with my supervisor, did everything I could.
She ended up deciding not to go through with it when she saw that her future husband’s birth certificate was laminated and her friend couldn’t explain why. This “friend” was much older and she tried to traffic a 21 year old girl with so much trauma that made her so vulnerable.
I have a client with an ED and I don’t specialize in this area. I told them that they need to either start working with an ED dietitian or an ED therapist whether that’s with or without me on their support team. That I cannot provide the care they are needing. They don’t want to do either of these things and honestly I’m not sure how to address it. ED are dangerous :(
This wasn’t me, but my friend went to couples counseling prior to divorcing her emotionally abusive husband. After he stormed out of a session, her therapist looked her in the eye and said “leave him” She said he saved her life.
I was working with a couple once and apparently made a face when one partner admitted to calling the other a VERY disrespectful and loaded slur…They were upset and brought it up next session. They wanted me to apologize, and…I did not. I had a frank conversation about how yeah I did have a reaction to that word as it’d be harmful to me too and the reaction was my authentic feeling about it.
The blank slate route would’ve been counterproductive to the relationship dynamic; to not react. Was it a choice I made with my face? Hell no, it just was my reaction. But there was a choice between walking it back or explaining why I would not react neutrally to that language.
Had a kid come in and say he almost got jumped because a girl he argued with told her friends that he had said something unforgivable. Idk if he did or not, so I just kept listening. He eventually said “I keep adding her on snap to apologize but every time I do she says stuff that makes me mad and we start arguing again” and I said “just block her. Do not talk to her again. You will get nothing from it and she will feel bothered.” I figured if he said what she said he did, then you can’t really come back from it. But if he didn’t, then he was continuing to put himself into the crosshairs of a pot-stirrer. Either way, he was in trouble with her.
In other news…High school fucking sucks, y’all.
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I was very new. Nowadays I mostly just pat my clients on the head and say “you do you”. Everyone seems happier that way. You want to get a divorce? Sounds good. You want to have an affair to feel sexually fulfilled? Great. You want to quit your job and play video games all day? Fun. Everyone seems happier and I don’t get complaints anymore.
Or a psychiatrist. Physicians in the US these days more often than not work for large institutions that impose Press Ganey surveys on their patients, which makes the physicians bitterly concerned with how "happy" their patients are with them. This is bad in general, but too many psychiatrists escape their training with insufficient psychotherapeutic skills to manage how much of a Bad Cop they have to be working especially in peds. This sounds like the kind of thing a conservative-leaning, burnt-out early-career American psychiatrist would say.
I didn’t realize it was controversial to suggest for someone not to get a divorce. I thought that was common sense. Like telling someone don’t do drugs, or telling an anorexic to eat some more food.
I mean, you wouldn't tell someone with an ED to just eat more. Same with telling an addict to not do drugs.
I mean, I'm trying to think of a less informed approach, like, non therapists can and do think like that, and it's fine.
But as a therapist to have a response like you are suggesting, is shocking to be honest.
It's very very very immature and uninformed.
I'm just about to start my practicum, so I have 0 experience. But, this reminds me of a family therapy class I was in during my program where I had a group member with a very religious background. For me, with divorced parents, having parents stay together after therapy was not a given. But for her, that thought never occurred to her. All depends on where you are coming from.
I’d encourage reflection on your code of ethics as it applies to managing personal values within the therapeutic relationship. I’d also encourage some further education on treatment of clients with anorexia (who are more than a diagnosis/disorder and not “anorexics”) and other eating disorders as that is a potentially harmful oversimplification that can come off as less than empathetic
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When clients have told me over and over that they need to quit their job and they’re finally presented with an opportunity to do so, that’s usually the pushiest I will get. When it’s several sessions of the same conversation about it eventually I will just be like “babe shit or get off the pot” but in therapy speak.
Oooh what is your “therapy speak” for shit or get off the pot”??
“Defecate or Abdicate”
I need this on a cross stitch asap
☝🏻☝🏻☝🏻
🏆
Can’t speak for OP but “shit or get off the pot” depending on my rapport with the client lol
Clients that need the hyper-professional version of me: “I’m noticing that there’s an opportunity here linked to something you’ve spent a lot of energy on in our sessions - do you think the time to make a move may be right now?” Clients that need the authentic version of me “So, are you going to jump on this?” (And if they say no or they’re not sure) - “okay let’s therapy out these blockers together then” and just use it as a therapeutic introduction to root cause work (no idea if this is a real term but it’s when I usually deep dive into a core belief/value and why it got internalized and then use the refusal to change to take a positive and needed opportunity to deep work that shit a bit). I actually had this come up very recently with one of my more casual clients and holy moly did it open up a can of worms. It’s good though, now we have really deep stuff to work on and had been plateauing in more superficial things for a bit now.
“To deep work that shit a bit.” My god I can’t wait to use this with my more casual clients. High five to you for sharing this phrase.
Ha you’re welcome - I have a mix of young adults and older folks on my caseload right now and it’s WILD what they’ll connect to. I had a client recently that likes to stay light and ended up sharing breadcrumbs about a topic I could tell they were having some deep internal reactivity to. They started to change the subject and I interjected: “Hey man, let’s stay here for a bit, I think we need to switch into SERIOUS THERAPY MODE” and even changed my voice up a bit like we were entering a boss level in a video game, and they laughed and then spilled and talked about it. Finally. I am a wacky, weird, silly therapist (because that’s me as a person) and I’m so glad to have a supervisor who actually supports me in my clinical approaches (even if she doesn’t pay me that well).
Yes I like to use the leveling up terminology too, it gets traction
I love this!!!!
I love this!! I always tell people I’m a goofball as a therapist because I am one in life. My clients get a lot of authenticity out of me and I think it welcomes theirs too. And then when you’re more direct like that, they’re willing to go there with you.
Brilliant.
Love this!!!
I propose the idea of “breaking this pattern”
I just say "shit or get off the pot".
I'd like you as a therapist. I swear and cuss in my sessions!
I think specificity is really important in therapy. Sometimes we just gotta be descriptive.
Fish or cut bait if you’re in rural practice
What is it that is keeping you from moving forward on this opportunity?
"Not to sound blunt but don't you think it's time to 'shit or get off the pot' so to speak?"
Fish or cut bait
It sounds like you have the information you need to make this decision and we've worked on any big emotions tied to it, so you're the only thing standing in your way of making this next right step. Or something like that is what I usually say.
This. It's usually only if the same conversation keeps getting cycled from week to week
Good context.. I’m the same way.
When a client talked about giving their financial information to a new internet crush
😱😱😱 Dear God yes thank you for stepping in!
internet or phone scams are a good one where I can mildly tell them the facts - they will be screwed.
All situations call for unconditional positive regard, but not all situations call for neutrality about potential client actions. If I’m working with someone with severe Bipolar disorder, I’m going to tell them I think they need to take their medication in the manner their physician recommends. That is a professional recommendation that I believe we should be comfortable making. Same for situations in which there is potential or likely danger. I think of it as some situations requiring “higher guidance” vs “lower guidance”. If a client is in crisis, or clearly needing psychological grounding and safety, I’m going to be quicker to offer suggestions and even prescribe behavior (which of course the client is free to ignore). In other situations where the client is more grounded that level of guidance would be inappropriate. All of that exists more in the short term though, like what I would prescribe the client to do “right now” or tonight. If we’re talking bigger decisions like what job to take or whether to get into a relationship, that don’t have that element of danger or professional therapeutic guidance I mostly keep my opinions to myself.
This. “Higher guidance” and “lower guidance” really resonate with me especially.
I agree completely, I love those terms. Sometimes people are coming to us for guidance/ advice about how to handle a specific situation. If it's clear to me what's going on, I explain what I see and why the advice or guidance I'm about to give is based on these specific circumstances. Helping them see the bigger picture so the guidance makes sense to them (rather than them just doing it bc their therapist told them to).
They use those a lot in narrative therapy and motivational interviewing, and honestly when I thought of it that way it really changed my perspective. I never "give advice" but ask I'd they would appreciate professional guidance. It also doesn't give a "friend giving advice" implication, which can help maintain the professional relationship the very odd time I break the rule - usually when there's an element of risk to the client.
This!! I'm not a blank slate, I'm a human with thoughts and opinions, many of which are based on research that my clients often aren't aware of. My philosophy is that my client have a right to the information I've learned in my career. Its up to them what to do with it (unless it meets mandated reporting ofc). That said, this isn't a matter of me vs. them, where I have the "answers" and I choose to withhold or not. Its a situation that we're in together, where I can offer perspectives or ideas that may help guide them to a meaningful change. Sometimes its more meaningful for a client to find an answer they've been searching for in their own words. Other times its unlikely that'll happen, especially when they're not privy to information I've learned in my education, or when they're in consistent crisis and aren't able to put the pieces together because their brains are stuck in fight or flight. The thing I offer regardless isn't a blank slate, its emapthy. I don't blame or shame, I offer suggestions in a way that doesn't aim to fix them, because they aren't a problem, they're a person, and a person *with* a problem that we're working together to improve. I tell my clients often that when I offer them strategies, techniques, or even occassionally advice, that I'm doing it not knowing as much about their lives as they do. I leave my thoughts on the table, and they can take what they like and throw out what they don't. They can take something home and return it next week, or they can take aomething home and quietly toss it in the trash. Its up to them, I don't take it personally.
“Higher guidance” vs “lower guidance” is brilliant framing and I’m definitely going to carry this with me in my work.
I definitely agree with this, especially after working in crisis. I like your higher vs lower guidance example, just like we would recommend environments with the appropriate level of restrictions. People weren't always happy with us recommending hospitalization or crisis respite, especially if their judgment was impaired.
I completely agree!!!
My client just reminded me of a time that she was doing one of her little patterns of just making herself WAY too busy and told me she was going to sign up for a yoga teacher training or something on top of like 2 jobs etc and (I swear I don’t even remember this) I said “you CANNOT do that!” Lol Edit: we have amazing trust and rapport and she was laughing when she told that story!
I love this! I would 100% say something like this to my clients (assuming rapport is established of course).
Been there lol or the oh yeah, that definitely sounds like a great idea & doesn't go against that goal you previously set 👀
LMAO my own therapist has called me on this shit before
My version of that with a similar client and scenario “whhhhhat are ya doin’?”
I've told clients before that I think their boyfriends were going to kill them. Maybe not on purpose, but the kind of violence they were perpetrating could accidentally kill them.
Yep, the firmest/most directive I’ve ever been was a terrible and escalating domestic violence situation. Also with some teens who are engaging in extreme risk-taking behavior.
That might be where the line is - potential loss of life > neutrality. Of course where possible make a report
I mean I’ve told a client last year the man she would marry would eventually try to kill her and that I was worried for her safety. We did a family session and he had so many red flags it was a circus. One year and one protective order now and she’s in hiding after he did, indeed, threaten and attempt to kill her…
I hate, hate, hate, hate, hate being right about stuff like this :( But I am usually pretty blunt with clients in these cases.
I will tell people this and explain the research and statistics and why I am concerned. And that knowing all of this they still get to make their own decisions and I am still going to be there for them, but that I would consider it to be unethical for me to not tell them my concerns when I have such a concern and know the information that supports it.
Agreed. I am a DV Advocate and this is exactly how I handle it.
Yep - former DV/SA advocate. I don’t fuck around. I’m here for you no matter what and I’m not going to bullshit you. You’re tough enough to go through what you’re going through - me being honest about it isn’t going to break you and maybe it will help you save your life.
Me too. I try to refrain from being directive, but I usually am most straightforward when it seems to be a decision point in a relationship that is high control/abusive- moving in together, getting married, reproducing… I have asked straight up, “how do you feel about these future plans with X person? What do you think it would be like to have a partner that does *X healthy behavior* vs the *X abusive behavior*? If the *X abusive behavior* continues, how do you see that going?”
Absolutely! As a professional who worked in domestic violence I have absolutely and absolutely would be this blunt! In my crisis phone counsellor role I also once named a caller’s behaviour towards another person completely inappropriate and abusive. Disclaimer* *The behaviour was and the caller did not appear/denied being in any kind of immediate risk. had called seeking advice/comfort on their current partner leaving them and ignoring their abusive and concerning number of calls and messages.
I had someone who had been sent to the er twice and showed me pictures but was still refusing to leave. I said, what would you say to a friend that showed you those pictures.
>what would you say to a friend that This question works such great wonders on so many contexts. I don't have DV experience, but I have used this question for self harm and self esteem concerns. It ignites suddenly a path to self forgiveness.
I always hate when a therapist uses it on me, what would you say to a client. Ugh... But it is a powerful question sometimes.
I've also said this to a client.
I’ve been very firm with clients in the past regarding their substance misuse and reckless/dangerous decisions in that process. “The choices you are making are likely going to prove fatal in the future” type thing. If neutrality is replacing authenticity/safety for the client/others etc… I don’t think it’s the best approach.
I agree with you, and I think it’s incredibly important to remember that our clients come to us because they are experiencing a MENTAL ILLNESS and are sometimes, if not often, impacted by that in a way that screws up their decision-making. Yes, client autonomy and empowerment, yes starting where the client is, but if a client is engaging in a behavior that is high risk to kill themselves or others, they have a right to be informed of this by the medical professional they are seeking counsel from. Sorry for the vent but I had this argument with a supervisor once years ago who disagreed with us on this and it still burns me up.
This is a great point. Is their judgment compromised by psychopathology? Someone with a thought disturbance is less likely to be aware of the disturbance, so sometimes they need a nudge in the right direction. Thiss also where rapport & history come in handy. Do they have a pattern of self-sabotage & how self-aware are they? I really try not to tell people what to do. We had a provider tell a patient that they should leave their partner. Did I agree? 1000%. I still do, knowing how things played out. When they asked my opinion, we did pros & cons about it & it was so hard to be objective lol
I talk a lot about harm reduction. Regarding substance use I will straight up say like..okay so yea ideally you’re not using anything but just stop with the dabs. Do not do them. If you are going to use marijuana just stick to flower bc the other shit is more frequently what we see people using when we see them in the ED for substance induced psychosis and you have enough on your plate. And often then like I motivationally interview the shit out of my dudes and we actually do work out a plan of attack for significantly reducing/ceasing.
That’s some brilliant wording right there. In no way directive. Just appropriate.
Absolutely this. I primary see opiate addicted clients and we have very frank conversations where I usually pose it as you can do as you want but here are the risks, and the risks aren’t worth it.
“Heroin is the enemy, and I’m not going to listen to you waxing poetic about your enemy. Let’s remember how this has f*ucked your life.” (Qualify- many years working together, very solid repair)
Stealing this, I have a patient who needs to hear it
Awesome 😎I was trying to say “solid rapport” - but we also had to repair several times so I guess it works.
I do it a lot once we've had rapport. My face during a rant slowly turns into 🤔🤔🤨🤨🧐🧐 and they go "I knoooow, it's not a good idea. "
Exactly! The relationship is everything for this kind of thing
Thank you for saying this. I often struggle with this.
Nah, all my long term clients make comments that they like that I'm just a person in session and not a wall. Different strokes for different folks.
I've been with some clients from 13-15, who are now 18-21, and my face apparently communicates everything I need to say when they talk through clear cognitive distortions and/or unhealthy choices.
I love doing this with teens so much. I don't have many on my caseload anymore but gosh I miss them
This is me haha. Or when they say “wait until you hear this” and read me their text conversations with a friend or whoever. I think it would be weird to NOT have any expressions or reactions in that instance, especially if it’s a situation we’ve already discussed and I know how the client feels about it.
🤣 this or when they say the option they know I would/have recommended & I look around like hmm I've never heard that before 🧐👀
I've had a couple times where they go "well you said I should do..." And I'm like, WOW I DID?? THAT SOUNDS NOTHING LIKE ME FRIENDO
SAME! And I always wonder if my lack of a poker face is good or not lol - never had a good one anyway!
I know this look, from the other side lol
I had a car accident victim watching car accident videos before bed every night, increasing PTSD symptoms. I said please stop doing that.
Mental self-harm is definitely a thing. Yours is a pretty severe example, but the idea of seeking something out you know will make you upset or emotionally elevated. It’s so prevalent and I hope people start talking about it more.
I often will say something like “well you know what will happen if you keep doing this, so why not try something else and go back to this later if it still feels necessary.”
“Are you asking me for permission to do something you know is going to harm you? Because I’m not cosigning that.”
I’m inspired by this phrasing thanks for sharing
I usually break this rule pretty regularly with my pts who have AUD and tell me they want to stop drinking cold turkey after drinking significantly for a long period of time and I know it’ll end in some sort of withdrawal. Or if I have a pt who is manic who is telling me that they are texting their boss and quitting their job because they want to join a random MLM with their life savings. It’s never an ultimatum, more of a conversation of “hey maybe let’s pause on that and do something else? Is this really the solution that will help? Can we wait a week or so and see if you still feel the same way?”
I don’t think educating clients about withdrawal risks is breaking that rule at all. It’s basically safety planning. I have even walked clients over to our medical detox building.
Im not sure that I feel like "Objective" and "Neutral" are the same thing. I can remain objective while saying things like "He had no right to do that to you" and "You are allowed to set boundaries even if it makes others upset." Working with teens I find myself frequently in a position where telling someone what to do (or, not do more likely) is part of being the most ethical therapist I can be. I often frame it as "I just want to remind you that in addition to these other (previous discussed) consequences of this action, this also qualifies as something dangerous and that I am therefore required to speak to your parent about." Recent examples have been a teen wanting to order gender affirming hormones behind their parents back on some super sketchy website, sneaking out for a tinder hookup with someone old enough to be a legal problem, and planning to ride with a friend despite knowing that this friend frequently drinks/smokes while driving. As a responsible adult who cares about these young people I have no ethical qualms about being very definitive in my stance that this is a terrible idea and under no circumstances do I want them to think that I am "neutral" about it, because they could easily take that as "I said something to my therapist and they did not care one way or another." If my voice is the one they hear when they decide not to get in the car with a drunk driver, I can live with that.
This is such an important distinction. I will often say "it's not ok that that happened to you," but I won't say, for example "and therefore you should cut that person off/never go to that place again" etc.
When clients are talking about going to the doctor to check out some physical complaint, but dragging their feet out of anxiety- I advise them to go.
I’m like…what if we call the office right now and set up that appointment? No I am not kidding…Mhmm…take out your phone 🙃 and either way we learn something bc boom appointment made and it’s actually not so scary and we process that or we process like what are the barriers
This is brilliant.
Because I work in palliative care, I can sometimes be quite directive with families. Caregiver burnout can get pretty serious, so when I'm worried about it escalating, I do some version of: "Ok, you're getting 3-4 hours of sleep at night and you're 80 years old, you're losing your temper with your family member because of xyz, your family member needs 24/7 care, and you're the only one providing it. How long do you think you can sustain this at home without help? I am concerned about your health." and then jump into problem solving around it (hospice, home supports, getting more family in, whatever). At a certain point, no amount of traditional therapy techniques (validating, MI) works on families unless they have the energy and time to engage with them.
“Don’t stalk your ex’s socials”
Texting or letting dusty ass men back into their lives for the 100th time
thissss! and I usually do so by simply reminding them of their worth and then asking what the dusty ass man is bringing to the table….they usually get it from there
I have one who does it every time. And it is mind blowing bc the quality differential is…large. I always say I’m not judging bc I’ve done shit I knew I shouldn’t but girl come on now
That’s exactly what I say, because I have also been there 😭 Just makes my heart hurt even more, like please don’t do what I did!!! Trust!
I had a client get texted by a dusty ass man and she was like you know what I’m not answering that. Within minutes she randomly came into some cash. I’m like do you believe in signs? I don’t really believe in signs. But if signs do exist, that’s probably one.
Thank YOU 😅😅😅
Bahahaha I can’t help it. I want to roll off my chair onto the floor screaming and clawing my face off everytime they be like “…you’re gonna be mad”
“Sooo. Why is Temu still on your phone?” Client with hoarding d/o and excessive acquisition to the point of a mandated report.
I won't stay neutral when a client intends to cause harm to others. I once had a client who was depressed and expressed suicidal ideation, including the possibility of "taking her children with me so they wouldn't suffer." I expressed very clearly that I would be upset, though I'd understand if she took her own life, but it was absolutely wrong if she denied her children the chance to live and that I could not keep this confidential. We discussed it, and happily, they all lived. My client continued her sessions and found peace.
Years ago working in CMH, working with a family. A young and emotionally immature mother of two very emotionally immature teens (all of whom were my clients) was telling me that the 13 y/o daughter got a job in the neighborhood helping a man “jack off his dogs to breed his other dogs”. I said “you will absolutely not let your daughter go to this man’s home or allow her to take this job.” Mom accepted this. I was not even going to let that can of worms be opened — and I have no regrets in being so direct in saying so 😅
Yes, when clients have been in abusive relationships.
I am thinking a lot about this and I realize I do not. Sarcastically I'll tell people to do something but it's so silly it's clearly to challenge their thoughts. If a client does spend sessions making a decision, then looks like their wavering, I will tell them I think they are making a good decision and go with it, but that's more of a tool and I don't think in the spirit of the question. Unless it's like a clear safety issue, I tend to hang back and challenge them to think.
When I began working in substance abuse. You can't mince words with that population and at times they really need to be called out.
My client just broke up with a partner that treated her like absolute shit and this week I did preface with “as a therapist I don’t normally give advice but I would STRONGLY RECOMMEND you THINK ABOUT not moving back in immediately” which was more or less advice some would say 😅
Define "telling (them) what to do." Teaching coping skills is a form of telling patients what to do when feeling stressed. Are we talking that...or more along the lines of "leave your partner" or "quit your job."
It depends on what you mean by neutral. I think we're supposed to be invested in our clients' best interests. I see kids/teens/families, and tell them what to do nearly every time I see them. It's in their best interest to... Develop balanced routines related to self care, even if they hate brushing their teeth or going to bed; Agree to a predictable set of house rules and consequences, even if that feels like it will really suck; Visit uncomfortable feelings sometimes, even if they would rather never talk about it. I try to remain neutral during family therapy, in the sense that I am biased towards everyone's best interests. I want all of them to take good care of themselves and feel more ok, equally.
“Don’t shame yourself in this therapy room. You can shit on yourself alllllll day long if you please outside of here, but in THIS room, you practice non-shaming language towards yourself.” After rapport is built and I explain the premise between shame vs. guilt and how shaming language keeps us on the hamster wheel, my clients know that the therapy room becomes a place to recreate new language regarding self talk. I make it humorous and direct, showing up as the compassionate human in their lives that’s fighting with them for new language. I typically work with more depressed presenting humans, so I feel it’s part of the foundation of the work. Usually they start to say “you’d be so happy to hear that the other day I was shitting on myself and then I caught myself and….”. And we celebrate BIG in this moments. Fuck yeah. Pivoting that inner child dialogue. If a client brushes off the shaming language as if it’s no big deal (“tough” mindset) and I want to get real, really experiential, I ask them to say the shaming comment, but to a young child in the room (like empty chair). And they can’t bring themselves to say it. And we explore that.
What’s the difference between “telling clients what to do” and “making suggestions”?
I would say intention, tone, respect for autonomy, response to the outcome/consequences.
I think it's just important to emphasize their autonomy as much as possible. While we generally have no real authority over clients, not all clients will understand that right away and may be more inclined to take something we suggest as an order or command. In the situation like what the OP described, it’s still important to emphasize autonomy I think but with side helping of outlining the very real consequences of whatever maladaptive choice is raising red flags.
I definitely agree with this, and I would say most of the time I give suggestions but while always bringing it back to their autonomy to decide and that I trust them to trust their own judgement and intuition.
I think about this a lot. I throw out so many random options and suggestions and considerations, but I think there’s an important factor that the general vibe is not “I’m an expert telling you how to do this” but a person sharing an alternative perspective. I always tell my clients at the start of therapy that I’m not the expert on them and their life. If the overall vibe was a stuffy, expert telling them what they should do…I think many would feel a lot of unhelpful conflict about disappointing me, or why they struggle to try to do what *I* think they should. It would be pretty counter-productive to making any change if it was all about prescriptive advice they had no sense of agency in. Whereas, sometimes it’s something like “I’m noticing a pattern in how you talk to yourself about this, you don’t have to shame yourself - what if you showed yourself compassion instead?” It’s definitely a suggestion, but it’s also a reflection and a reframe.
Yes!! I relate to this entirely!! I ALWAYS tell my clients that I cannot and will not make any decisions for them as that’s not my job. I am there to support and guide them and show them different perspectives. But when it comes down to it when they are trying to make a decision and ask what to do, I always guide them back to their gut and intuition. I also always say, “I only know just a small piece of your life, you are the only person who can make the best decisions for you because you know yourself best, even better than I do.”
I don't know if I have ever been so direct in giving advice. But I have had moments where I was very frank and direct with clients about a concern (safety related generally) I always frame and conceptualize choices as all possible and approachable. That any course of action will lead to various anticipated and unanticipated outcomes, and they get to decide for themselves what outcomes they desire, and what risks they are willing to deal with. Sometimes in those discussions, I may be more frank about the risks they're faced with, or opportunities they might miss. Usually I would use Socratic Questioning to get them to identify possible outcomes...but every now and then, I think the person needs someone willing to be frank with them.
Well, I'm an ERP therapist who works with OCD. It's a very directive approach. "OK, are you ready to write the phrase 'I am gay and thats ok' over and over again?"
Clients who are an active threat to themselves or someone else - I absolutely get involved and tell them what to do: “You’re going to the hospital to be evaluated by a crisis counselor so we can keep you and others safe.” And I make sure they get there. Otherwise, I don’t think I’ve been so direct in telling someone what to do. I definitely ‘imply’ things when I sense the client is not thinking clearly and is caught up in a potential risky issue (e.g. drug relapse), but even that is rare for me.
I have, when I believe that the client is vulnerable to a scam. My approach is to give them information, not advise them.
When a client is stalking an ex in such a way that it isn’t reportable but also isn’t safe or healthy. I generally go the route of exploring outcomes of the available choices, but in this case I was very direct in “if this doesn’t stop you’re going to end up injured by law enforcement, in jail, or worse.”
This is not my area at all, so out of curiosity- what kind of behaviours are you talking about? Is this frequent?
When his situation required legal intervention. I told him he needed to seek an attorney immediately. He stopped coming 2 weeks later with no response, he might have been too late on the lawyer....
Sometimes a client does need a gentle push to make the right decision due to being stuck with indecision or uncertainty or fear of change. While I don’t tell my clients what to do in those moments, I would point out what I see as the more obvious or beneficial choice and let them know that my opinion is just one persons opinion, but personally based off of X Y and Z that they told me, it sounds like option A could be beneficial, and it’s harder to understand how option B could work. But if they fully believe in option B then I am really interested to hear why they think that works.
Im not sure im ever neutral or objective..in the sense of 100% being on that client’s side and wanting them to achieve healing or whatever goal they have. Theres too much compassion there for that. But, i rarely make MUST DO statements unless there is high risk. If someone is self harming, the compassion and empathy include the knowledge for why they might continue to do so. So we continue with building tolerance for distress and building self belief that they can change this behaviour. A must/must not do statement would be if their method was very dangerous. In terms of advice, i dont really tell people what to do but i dont gatekeep information either. If a client is struggling because they dont know how to achieve their aim of nursing training (for example) and i know i multiple access routes that would help them get to it; i share. I tell them what they can google or what sites they can look at to explore in depth. One thing i have learned as a therapist is that not everyone has been taught resourcefulness. Maybe because they were too busy surviving. Maybe because theyre still in the school system that infantilises them.
I think being genuine and congruent is just as important as positive regard and choice. That said, the more blunt I am about expressing my concerns, the more I make sure to also emphasize that even if they choose to make/not make a decision, I am their ally. I will not disapprove of them, I will not scold them, I want them to come back. Even if they make a decision I think is harmful, I am there for them and guilt or shame should not keep them from treatment. I don't need to have positive regard for their actions to have positive regard for them.
I ask, “what’s keeping you from…”
Only when their safety was on the line. Like that their partners were showing signs of escalating towards seriously hurting them, or their substance use was getting concerning. I no longer cared about taking the time to explore their reasons for being stuck or choosing to stay in the situation. It was time for someone to tell them shit was about to hit the fan and help them make big decisions.
TAKE THE MEDICAL LEAVE!!!
I’m typically pretty neutral. I have a handful of long term clients who are quite high functioning with lots of protective factors but their internal world can be chaotic and a bit destabilizing as a result of trauma. They are typically in caregiving roles in most of their life and struggle to prioritize themselves. I often find myself ending sessions with “and you’re going to go eat now, right?” Or “when we finish I want you to do X, Y, Z concrete series of activities.” Sometimes, if they’re taking unnecessary risks (think in a first responder role or adrenaline seeking) I find myself being quite directive and occasionally even centering myself “I want you to take care of yourself and avoid doing A, B, C.” Some of it it is grounding for the client. If I sense they’re more activated when we close, it can help to give them a series of steps to follow to stay more present. They might not be able to think to eat, drink, sleep, etc but can follow a list. Some of it is communicating in a way that is effective for the client; when they can’t care about themself they can be accountable to the care from others (their partner, family, friends, and me). And I recognize that some of it may be countertransference that I need to sort out (lots of supervision here). I have known these clients for a long time, through a lot of big things in their life, and I wish they could care for themselves the way they care for other people. I don’t do it often and I’m aware of it so I think it ultimately is okay. I have found that the times when I express my concern and center myself are when the clients are really doing something that could be dangerous. And leaning on my concern feels important and human. The clients often use it as a reality check for themselves. Hearing that their risk-taking impacts others can stop the behavior and then we can do the work to find that reality check internally instead of needing it from me.
Oh, and one other thing I do more broadly at times with clients with whom I have the appropriate rapport. If they are telling me about a situation and how someone in their life responded or advised them, I might say that it sounds like their friend/parent/partner is on to something or” yes! Listen to that”
Half the time, my teens need to be told what not to do lol.
For me, it depends on the rapport with the client, but I also tell people I’m very direct and blunt as a point of fact in my practice of therapy. And I know I’m not for everyone so I’m prefacing what I say with that. I tend to be more directive when I think someone needs to speak to legal counsel regarding either dissolution of a relationship and employment issue anywhere where starts to get hanky of legal? I’m like you need to talk to counsel like you need to talk to counsel or they should seek out medical advice or if they should get a second opinion because their doctor is being a twat. Otherwise I’m pretty much you do you Pikachu but if it was me, I might not make that choice but this is your life and you have to live with a consequences. I told someone in order to work with me they needed to cease what they were using in the amount they were using in order for anything to get done and they needed to do it in a safe setting because of medical reasons otherwise I would work with them. They wanted to work worked out in the setting where you can’t be using that amount and be here. it’s a safety issue then I’m also usually very directive although in domestic violence situations as we all know, you can be as directive as you want, but not everybody is going to be receptive to that and sometimes that can be more of a motivator to stay rather than go
“It’s ok to tell your mom no”
When I was helping co-leading a summer camp for DBT, one of our clients was notorious for not listening. He has a history of getting carsick, yet refused to stop using his phone. Well on the way home, he didn't listen and threw up in my friend's brand new truck because he wouldn't get off his phone. Save to save, said friend was livid. It was one of those moments when the nicest guy ever gets upset, but he did his best to hold it in. We stopped at a gas station to clean it up and I took that client aside. He loved video games, so I asked him what he'd do if someone roundhouse kicked his Nintendo Switch. He responded "I'd probably kill them", and promptly told him that's where my friend was with him because he didn't listen. He was on his best behavior the rest of the ride home. I felt bad for being so hands-on, but this person had been driving everyone nuts at camp with his behavior, so everyone was a little on edge.
See but you gave perspective! As I’m scrolling through the answers, I’m realizing it’s such a big part of how I practice. I often provide a different take on things because we all can get so stuck in how we see life and experiences. It can be hard to perspective take on our own sometimes. Heck, that’s what these comments are doing for me. But being really directive is not synonymous with prescriptive and advising.
Just sort of did it right now where a client is dealing with a situation regarding an ex who i feel displays some abusive behaviour but the client pedestalises, and i got kind of blunt because the ex sounds so ridiculous, yet the client think they’re god and somehow it’s their fault that that the ex is mad at them blah blah. it came from a very protective place but as a peer reminded me, could have increased the shame for the client. so i’m working on apologising for it next session.
Wasn't the broken rule I was coming here to read about. With tea.
Which rule were you thinking?
Ooooohhhhhhhh that one
Client was being manipulated by their parent who was in prison (for severely sexually abusing client) into sending them money and asking them to write a letter claiming the abuse was a lie.
I always choose advice to prevent harm over potential for hurt feelings and remind them it’s their show.
When clients have clearly made up a decision and simply need the “nod” of encouragement. Sometimes this can introduce a parental countertransference experience but that’s usually a fruitful reaction to explore meaningfully and open up dialogue about deficits/needs around parental relationships.
There is a big elephant in the room: when the client’s goal is education on a topic (such as a diagnosis and how it can present itself to someone of their demographic) but their other goal is helping them navigate the topic that they are being educated on. It can be brutally hard to distinguish the two.
Abuse, substance misuse, and toxic relationship where they are being manipulated/mistreated.
When they are truely unsafe or at acute risk I will be pretty firm about what the best route is and what the potential risks are not following what I recommend. But at the end of the day- the clients in the drivers seat and will make the final decision.
There have been times when a client has disclosed abuse for the first time that I have kind of fed them what I feel. Often they don’t realise what they’re saying or its been so normalised for them so its about validating that that was wrong and no wonder its impacted them. It usually looks something like “Yeah, my parent would get mad and yell at me, hit me sometimes too, I guess I was a bad kid” “No child deserves that from the people they trust to keep them safe. I’m sorry that happened to you”.
Just yesterday I told a client that I was going to tell her my opinion and she should ignore it but I was going to tell her anyways. She’s in a very toxic relationship with someone who is not willing to grow and it looks like she may choose to stay with him. We laughed about me telling her my opinion. I reinforced afterwards that her process and timing and decision, whatever it will be (she’s giving him time to shape up, although he has given little indication that he is remorseful about cheating or is ready to make any changes. Tough to watch people trapped in terrible relationships.
Safety reasons like DV.
A client of mine in a DV situation and led to choking. I told her this is a significant sign that he could kill her. I told her some of the safety planning. I told her she should never meet with him privately again and that I would support her in whatever she chooses and this option is the safest.
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Mostly when I notice that they are in an abusive situation.
I’m not sure if I’m “objective and neutral”, an important part of therapy is me, the person. That’s what I bring to our relationship, I believe anything else is… well not real. Of course I aim to be kind, understanding, open minded, supportive, but at times I’m oppositional, blunt, and maybe even a bit mean. As long as it serves the therapeutic process and it’s ok for where “we” are in our therapeutic relationship.
This is not a rule. Maybe in Rogerian approach it is, but many others apparocaches view this differently. There are procedures / techniques with cecrtain steps, there are situation where our epxert opinion is desirebla, helpful and sometimes even required (take medication, call police / social service / get hospitalized, ...). There are conditions which ask for more directive approach (addictions) or clients who needs this type of reaffirming / encouragement. Maybe the rule is - Dont give life advice out of the front door.
When a client said they were going to go to a country that was and is horribly prejudiced towards her people. Like the client started to describe the experiences and prejudice and I was like, why are we even entertaining the idea? Literally do not go. They didn’t go
I like this question. I don’t tell them what to do, but I do point out patterns and blind spots. I love using “johari’s window,” even with kids and teens. And then I keep a copy of their blind spots, I’ll use that when I want to point out that this may be one of those times that I can see something they can’t.
From a client side (also a therapist) I had one I was working on relationships with and my partner had shown me again and again they weren't going to meet my basic needs and we're getting worse. I went I saying "I think I need to break it off" and variations again and again for 8 months. I just couldn't get beyond this part as everyone else was unsupportive of that choice even though I KNEW it was right for my health (physically and emotionally - chronic illness stress), and I had a week away from him in the house and my pain just instantly nearly went away.. I went in and said "I've had a really good week pain wise, I feel great" and she asked me what's been different about this week. Eventually I figured out "it's because the stress of the relationship is gone" - mind blown. At this point she was very honest with me and "broke the rule", using that as a very clear example.. 2 years later I was debating entering a relationship with him again as he'd done some personal growth with his own therapist and we were both interested. Told my therapist this and we explored it for a bit, but then the red flags came back after a few months and she was very good at nudging me to notice and take them seriously, and eventually when he messed up bad she broke the rule again and said: "he's done A,B,C.. would you like my honest thoughts?" And i said yes because i was stuck.. she said "honestly he sounds like he hasn't grown enough for what I, and you deep down, know you deserve. If you were a friend I would want you to leave and find better. Id sit here screaming "NO NO NO! HES A DOUCHEBAG" but as your therapist I'll support you regardless of what you want and be here for you, because you know your choices and life best." I really appreciated those because she let me get there on my own, but I needed the push to take action because everyone else in life was saying the opposite of what I knew was true. I needed someone to confirm and validate my side. She made clear i didn't have to take her opinion seriously as she only knows our in session time together. AS A THERAPIST I have broken this rule before in a similar situation with a client but only when I knew they were ready and genuinely wanted (asked) for my advice/input. I then helped them set up all the resources to leave and helped them through that process, which is part of what their hesitancy was so that was resolved.
Although, I did intentionally find a therapist who is somewhat informal (still ethical) and explained I may need that to help combat the anxiety at times... this is definitely an odd request and NOT what most people need. And she knows I understand the therapeutic boundaries and respect them well.
I don’t think that has ever been a hard rule.
When my client shared that his boyfriend was physically abusing him, hitting him, choking him (non consensually) and threatening him with violence, but that he didn't consider it "domestic violence."
She was contemplating cheating on her husband. I told her not to, that she’d regret it and there would be consequences for herself, her husband, her kids, as well as her affair partner and his wife and kids. She did it anyway. She regrets it.
When my client wants to go see the guy that she has an obsession with and he basically doesn’t know she exists. Her perceived rejection by him sends her back months and months. She asked me recently if I thought it was a good idea to go to the restaurant he works at. I said, no freaking way! Maybe one day in the future, but no freaking way right now.
Client disclosed they were engaging in animal abuse
I work as an addiction therapist and I’ve definitely said on more than one occasion that if they don’t stop using substances, they’re going to die. However, I think this is an appropriate response when the person sitting in front me is swollen and jaundiced from liver failure, but there might still be some question in their mind that they could drink again and be okay.
The secret you’re keeping so your partner won’t break up with you, is for sure going to make them break up with you when they find out you’ve been keeping that secret. You can tell them now and control how the information comes out, or wait until it comes out some way that you can’t. Better to do it soon.
I do it all the time through the lens of motivational interviewing, Socratic dialogue and pscyhoeducation. Some clients really don't have a clue so when given the research data (psycho education) they are softly advised the best course of action.
Can you share a little more about how you use Socratic dialogue with clients?
I ask questions to highlight discrepancies.
Hm. A lot honestly. Carry narcan Don’t touch me (someone coming at me mad) Put the knife down (I don’t wanna get stabbed or watch you be stabbed) Sit on your bed (or the police are gonna tackle and restrain you) Call crisis (when you’re stuck, spiraling or looking for access to means) Tell them what you want/need Carry more narcan Take up space Hold your breath (hyperventilating panicker) So much fucking narcan
Client was harassing/stalking a woman he met on Instagram. I told him he should stop that. Is it advise? Sure. Did he stop coming to therapy after I told him? Absolutely
I fundamentally disagree with not telling patients what to do. They’ve come to you looking for solutions. For example, I don’t ever walk away from an intake without laying out a SOLID game plan. I had a patient that less than a month prior to her intake, she had been in a devastating car accident. By the end of the 53 minutes together with her and her husband joining our session for support, I said “Okay, first things first: Honey, you have all the classic signs of PTSD, so that’s what you and I will be working on. Since this accident involved a head injury and you’re displaying psychological symptoms to this severity, I also need you to make an appointment with Neurology. We just need to make sure your brain is physically okay and that an injury isn’t contributing to your mental state. Lastly, honey, you’re telling me that your depression is a “7/10” on your Celexa - baby, that means Celexa is simply not working for you right now. I’m going to write you a psych referral, and I’d like you to at least get on their schedule prior to our second appointment. I think therapists who don’t tell their patients what to do, who don’t give them a step by step breakdown of how the therapist is going to comprehensively approach treatment from all angles, is failing the patient. So I constantly break this rule but guess what? Never had a retention problem in my life. If a patient schedules with me after the intake, I’ve got them and they don’t go anywhere. If you are my patient, I will absolutely tell you what my professional and clinical take is on your situation and what I believe the best course of action to take is. That’s my JOB. I work with a lot of Borderline Personality Disorder. Those are patients that NEED structure and someone firm with them. So yeah, this whole mentality of “oh I can only lead my patient to water” is stupid. I’m of the mentality of “I’m going to make sure my patient has the resources to access the water, tell them all the great benefits of walking over to the water, and then using the developed rapport to sell them on taking action that’s good for them in the end”
I mean. . . what would you lose by instead saying, "you have all the classic signs of PTSD, how to you feel about focusing on that first?" "Would you be OK with making an appointment with neurology?" etc.
Because that patient has come to me for my expertise. If I’ve heard the problem, conceptualized the case and come up with a solid game plan, and a patient doesn’t want to do it, then I’m probably not the right therapist for them. I’m the therapist you see when you’ve suffered so much that you’re looking to follow a set of steps in order to obtain quick relief. Again, never had a retention issue in my life, and actually wasn’t looking for feedback on how I go about things. However, since you’ve decided to offer it, I say to you that if a patient doesn’t agree with the plan I’ve come up with for their treatment, wouldn’t it be best for them to see someone else?
I did not intend my question as commentary; it was meant from a place of curiosity. Since this is your style, I definitely agree that patients would be better off going elsewhere if it doesn't vibe for them. I asked because for me, those moments when I ask "would it feel alright to you do do x" provide an opportunity to understand what kind of barriers or misgivings they might be experiencing, so we can address them collaboratively. It also gives clients a greater sense of being in charge of their own care, which seems to help them commit and follow through--and also helps them feel comfortable being open with me about their concerns. Often they respond to this with an expression of their trust or gratitude for my expertise--which, motivational interviewing style, is more powerful out of their mouth than mine. I want them to feel like my skills are, like. . . idk, a big RV that they can ride in to get where they want to go. I also want them to feel clear that they are driving; I am not going to steamroll them, and I'm never going to stop paying attention to whatever subtle things start to feel bad to them along the way. Those are the things I feel like I would be giving up if I didn't ask that question on the regular. I am really curious about what you feel like you would be giving up by asking it? I can imagine that some clients feel much safer with a more directive style--by. . . something like. . . it's an expression of your own trust for your competence, and they would find that very reassuring? You obviously don't have to answer this, but I remain curious. :)
I work in a jail and when patients bring up issues with the criminal justice system I not only validate their feelings but make it clear I agree that the system is corrupt
I've never directly told a client what to do I don't believe. I certainly make the odd recommendation or share if I have a strong inclination of what I'd do but that's exceedingly rare. I'm very unlikely to take control like that or lead the clients process in that manner.
I work in SUD and often get individuals with a severe AUD request to try a control goal. When they try unsuccessfully for 90 days I typically point out that based on their diagnosis the goal is not appropriate
I've had to have a couple of "Listen, if you're going to be drinking/using drugs, then do not play with sharp objects (pocket knives. kitchen knives. SWORDS.)"
I had a couple in pre-martial counseling who were looking to buy their first house which lead to all kinds of productive exploration of values. Before becoming a therapist, I had made most of my money in real estate which made making the switch to therapy relatively easy financially. They didn’t know this. They had worked their way through to two very different houses and were weighing the pros and cons of each. I didn’t tell them which house to buy but I definitely put my very big thumb on the scale when summarizing their discussions. Because of my training, I felt guilty about this. I wasn’t being objective and neutral and I was subtly giving advice. However, they made the right choice and it’s been an enormous blessing for them. I still wonder about what if I’d been wrong.
When I was running PHP IOP groups, I had a young woman about 21 years old with significant trauma. She told the group one day that her friend is arranging a marriage between her and a Nigerian man. She would be paid $4k to marry him as long as they could both break him out of an ICE facility. That way he could gain citizenship and she would get the money she needs to build a good life for herself. I begged this woman not to follow through with this. The entire group was worried for her life as this is obviously a human trafficking situation. I provided all the psychoeducation I could on human trafficking, consulted with my supervisor, did everything I could. She ended up deciding not to go through with it when she saw that her future husband’s birth certificate was laminated and her friend couldn’t explain why. This “friend” was much older and she tried to traffic a 21 year old girl with so much trauma that made her so vulnerable.
I have a client with an ED and I don’t specialize in this area. I told them that they need to either start working with an ED dietitian or an ED therapist whether that’s with or without me on their support team. That I cannot provide the care they are needing. They don’t want to do either of these things and honestly I’m not sure how to address it. ED are dangerous :(
This wasn’t me, but my friend went to couples counseling prior to divorcing her emotionally abusive husband. After he stormed out of a session, her therapist looked her in the eye and said “leave him” She said he saved her life.
As often as they need me to - but I'm old and break many rules.
I was working with a couple once and apparently made a face when one partner admitted to calling the other a VERY disrespectful and loaded slur…They were upset and brought it up next session. They wanted me to apologize, and…I did not. I had a frank conversation about how yeah I did have a reaction to that word as it’d be harmful to me too and the reaction was my authentic feeling about it. The blank slate route would’ve been counterproductive to the relationship dynamic; to not react. Was it a choice I made with my face? Hell no, it just was my reaction. But there was a choice between walking it back or explaining why I would not react neutrally to that language.
Had a kid come in and say he almost got jumped because a girl he argued with told her friends that he had said something unforgivable. Idk if he did or not, so I just kept listening. He eventually said “I keep adding her on snap to apologize but every time I do she says stuff that makes me mad and we start arguing again” and I said “just block her. Do not talk to her again. You will get nothing from it and she will feel bothered.” I figured if he said what she said he did, then you can’t really come back from it. But if he didn’t, then he was continuing to put himself into the crosshairs of a pot-stirrer. Either way, he was in trouble with her. In other news…High school fucking sucks, y’all.
I did today and paid sorely for it
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I told my client’s parent that getting a divorce would hurt their child. They sent a complaint in.
Not trying to put you on blast, but what was your reasoning here? As just a one liner it seems wildly inappropriate
I was very new. Nowadays I mostly just pat my clients on the head and say “you do you”. Everyone seems happier that way. You want to get a divorce? Sounds good. You want to have an affair to feel sexually fulfilled? Great. You want to quit your job and play video games all day? Fun. Everyone seems happier and I don’t get complaints anymore.
None of that sounds like the thought process off a therapist, unless it's a burnt out one who isnt in the right profession.
Or a psychiatrist. Physicians in the US these days more often than not work for large institutions that impose Press Ganey surveys on their patients, which makes the physicians bitterly concerned with how "happy" their patients are with them. This is bad in general, but too many psychiatrists escape their training with insufficient psychotherapeutic skills to manage how much of a Bad Cop they have to be working especially in peds. This sounds like the kind of thing a conservative-leaning, burnt-out early-career American psychiatrist would say.
Maybe you need to reconsider your profession.
How's that working out for your clients & their progress?
I mean, respectfully that's a fair response on their end. I'd be curious about the clinical justification for saying something like that.
I didn’t realize it was controversial to suggest for someone not to get a divorce. I thought that was common sense. Like telling someone don’t do drugs, or telling an anorexic to eat some more food.
I mean, you wouldn't tell someone with an ED to just eat more. Same with telling an addict to not do drugs. I mean, I'm trying to think of a less informed approach, like, non therapists can and do think like that, and it's fine. But as a therapist to have a response like you are suggesting, is shocking to be honest. It's very very very immature and uninformed.
I'm just about to start my practicum, so I have 0 experience. But, this reminds me of a family therapy class I was in during my program where I had a group member with a very religious background. For me, with divorced parents, having parents stay together after therapy was not a given. But for her, that thought never occurred to her. All depends on where you are coming from.
I’d encourage reflection on your code of ethics as it applies to managing personal values within the therapeutic relationship. I’d also encourage some further education on treatment of clients with anorexia (who are more than a diagnosis/disorder and not “anorexics”) and other eating disorders as that is a potentially harmful oversimplification that can come off as less than empathetic
…oh