How to be a great therapist
Concepts on effectively treating trauma and relational dysfunction
Being a great therapist has little to do with our training, credentials and fancy techniques. It has more to do with how we engage and cultivate a relationship with, and in service of, our clients.
I choose to write this article from 3 combined perspectives:
1 A patient who has engaged in all kinds of therapy since age 18. I have had countless experiences where I felt misunderstood, belittled, quieted or gas-lit and shut down. (I have also had a couple of incredible experiences that really supported me through certain phases of recovery).
2 A therapist with a full practice and a line out the door. People come to me, not for my credentials. I am very young in therapist years! They come because within our relationship they access safety, hope, awareness and catalyzation.
3 A teacher and clinic director who sees some therapists making huge relational blunders and inserting themselves into the client’s process.
Integrating all these aspects of my experience, here are the key points I feel we need to be aware of in order to be effective facilitators for our clients’ journey of discovery, repair and reclamation.
1) Learn to Listen to the unsaid
Clients will often arrive at therapy with a verbal narrative, and a problem they want addressed. It is very rare that their initial expression has anything to do with the roots of their current issues. If it were that simple, we probably wouldn’t need therapy at all! As a therapist learning to be somewhat of a detective is really important to connecting to the true ‘point to work with’. And there may be many of them. We can learn to listen to various aspects of our client that will serve as a trail of breadcrumbs. Areas of listening include: Core emotions, beliefs and organizing principles, neurophysiological base line and threat responses, somatic bracing patterns and signals, current trigger patterns, relationship dynamics and family of origin and attachment dynamics. It is through understanding how all of these elements work together to form the client’s ‘why’, that will illuminate the path of recovery that you will help them explore.
When we fail to listen and illuminate this tapestry of self, processing will be disjointed and done in the dark. There will be no opportunity for integration into the whole self.
2) Follow the resistance
When working with the intention to repair and transform, there is going to be layer upon layer of resistance to work through. Most resistance rises from the blocker emotions of fear and shame. As therapists, we need to learn how to spot resistance, acknowledge it and gently challenge it. When resistance dissolves, there is a doorway into the elusive unconscious truth. If we continue to look for the resistance and safely hold the client in it, it will dissolve naturally, OR it will illuminate another thread that is essential to explore first. It may also trigger an experience of transference (which is a whole other topic). Resistance can show up as: a) the client changing the topic b) rushing through a story c) holding down tears d) deflecting to the therapist for answers e) disassociation f) fragmentation g) transference (usually in the form of anger). Along with resistance, there are often subtle changes in eye contact, body posture and bracing patterns.
Being confident enough to spot and work with resistance is fundamental to helping our client’s navigate what is too overwhelming for them to consciously connect to and process.
3) Create safe relationship with clear boundaries
This is by far the most important thing required for anything to truly integrate from the therapeutic process. For many, the roots of their distress exist in their attachment and family of origin narrative. It was the lack of safe relationship and healthy boundaries that led them to be the person they are now (in all their mess and glory). If we want to work effectively with relational dysfunction and trauma, we need to have a deep understanding of boundaries and the effects of both transference and counter-transference. In my opinion, working without this knowledge and the clear intention of creating safe relationship and acknowledging and repairing ruptures can be incredibly harmful. I have had many walk through my doors who have felt the deepest harm from their well-meaning (yet unaware) therapists and I have also seen many therapists working with no idea how they are inviting a re-living of the client’s harmful attachment dynamics. As a patient, I have also experienced this and felt so much harm. As a therapist, I have only learned how to engage this way over time, and am certainly guilty of not having good boundaries earlier in my career (I think if as therapists we have poor boundaries, it points to our own need for processing attachment wounds relating to codependency and receipt of love).
Clear boundaries with a client include:
a) Keeping the therapy to the booked time slot — if we become too flexible to meet the clients every need and emergency, they will see us as their lifeline and carer, which can only lead to eventual feelings of abandonment and rejection when we cannot meet their requests.
b) Concise communication between sessions — If we set up the dynamic where there can be extended conversation via other channels, we again reinforce the idea that we are the client’s lifeline and supporter. It fosters unhealthy attachment, desire for direction or approval. While we think we may be supporting the client, we may be inadvertently disempowering them, or inhibiting them form connecting to their own internal resources.
c) Saying no to endless emotional purging- Often when clients come into therapy, there is a need to purge their story and emotions. This is all well and good. However, for some this can be one of the patterns that need to be broken. If every session becomes nothing more than a download of distress, we are not really supporting change. It is our job to disrupt the loop of distress and find a focus for exploration. Oftentimes, ‘looping’ is connected to an early attachment narrative. In some way the client is trying to get their parent to hear them, respond differently and make it better. We need to feel into the emotional root behind the purging and explore its origins.
d) Set clear expectations at the outset of therapy — when a client knows what to expect from the relationship, the ‘rules of engagement’, they will be able to navigate them with more ease. Taking time to clearly express what they can expect from you and what they can’t at the beginning of treatment sets the tone for safe relationship as well as permission for both sides to respond to any possible ruptures. Us therapists are human too, and sometimes our own projection or counter-transference will rise, or boundaries will falter, so being able to have good conversations about this is imperative.
4) Maintain Separation & health empathy
As therapists we want to empathize with our clients and engage with compassion. Being able to remain separate and whole while doing this is paramount to our own well-being as well as ensuring we do not project our unhealed selves onto the client. Because we are so very human, it is inevitable that sometimes our own processing content will stir up during or after working with clients. Learning to notice our signals and making time to process between sessions is really important. If we fail to do our own work, it is inevitable that we will experience enmeshment with our clients. We can often mistake this for deep empathy and fall into the trap of calling ourselves ‘sensitive’ or ‘empath’. In fact, we are all sensitive and empathetic. This is about being able to define the boundary between self and other and this takes a lot of work! Some of the signals that you may be experiencing enmeshment or casting projections include: 1) having overwhelming experiences of emotion during or after a session 2) connecting to what you think the client may be experiencing and finding they do not resonate. (It is normal that this may occur from time to time, being able to spot it, sit with it, process, integrate and self-correct is vital).
In order to do this relational work with others, it is important to be constantly doing it for yourself with your own therapist and/or supervisor. Just as we provide an anchor to neutrality and a processing mirror for our clients, we need it for ourselves. If we don’t have this in place, we can lose touch with our place in the relational matrix.
5) Identify Dissociation & Avoidance
Clients will often approach therapy from a place of dissociation, or they may avoid the most difficult content that is essential to their recovery. If we try and process with a client in a state of disassociation, nothing will integrate and no transformation will take place. We need to ensure that they are present in their bodies before processing can commence. We also need to make sure that we are aware of where and what they are running from, because it is there that the transformation lies. Dissociation can present in many ways. The client not being able to feel or respond to their somatic signals is a clear sign. If a client is dissociated, some work may need to be done before any real processing can occur, to make it safe for them to engage in an authentic process.
As a therapist, in order to spot a client’s dissociation, we must first be firmly associated to our own bodies and aware of our relationship to the physical client. It is through our own embodied experience that we will learn to pick up clues of relational disconnection, that signal possible dissociation.
6) Manage activation levels
When we are working with difficult experiences, there is going to be activation and some experience of distress. We can make the mistake of thinking that high activation or emotional release/catharsis makes for a great session. This is so wrong! Navigating the relationship between safety and activation is the goal. We want to help the client a) increase their internal and relational safety b) access vulnerability, authenticity and expression (which includes activation) c) return to a felt sense of internal and relational safety. This nurtures resilience in the nervous system and the establishment of a new organizing principle: ‘It is safe for me to express my difficult experiences and truths in the presence of another’. We want to ensure that whatever we explore is not too overwhelming and that there is no experience of shame. If a client leaves in a state of distress or high activation, this can hinder their process of increasing internal and relational safety. As therapists, we need to learn to spot signs of activation or shame, and have a toolkit on hand to help swiftly support our client’s back to safety and self-acceptance. Learning how to orient a client to the present, the physical space and your relationship can go a long way to effectively managing activation levels and safe connection.
At the end of a session a client should feel safe in themselves and be able to walk out the room feeling calm, collected and safe in their internal and relational experience. This fosters the feeling ‘I am safe in me and I am safe with you’. This experience can shift their entire concept of life as they know it.
7) Curb your need to express or be the guru
When we find ourselves wanting or needing to express ourselves as therapists, we lose touch with the intention of therapy, which at its core is to hold space for the client, meet them where they are and help them explore and make sense of themselves. We may find ourselves talking about our techniques or various frameworks that we have trained in. We may place ourselves in the role of teacher or ‘one who knows’ or can ‘show them the way’. We may find we tell them what we sense or intuit in order to direct the line of processing or inquiry. Many of us get into this line of work as part of our own exploration of relational healing. When we unconsciously use the treatment or the client relationship as a place to express ourselves or be the teacher or healer, we are acting from a part of ourselves that requires love and approval, and/or power. This is something to check within ourselves again and again (it is often part of our archetype and not to be loathed, but rather loved and self-soothed). When we unconsciously demand love and respect from our clients or tell them what is the right way to heal, we are often triggering some murky repetition of their attachment dynamics. In fact, we are disempowering the client and inhibiting them from finding their own internal compass, ability to self-illuminate and express their truth.
As therapists, we need to ensure that we are there not for our own expression, but as a beacon of safety, neutrality and encouragement for the client’s own exploration. When we find ourselves needing to express ourselves, it indicates that we are not only holding space for them, but we are unconsciously asking the client to hold space for our own processing. And this is not what they signed up for.
8) Illuminate projection and transference to end victimization
If the client continues to blame others, or the world, they are projecting their victimization from early years. If they blame past therapists or us for not being able to help them, this is also a transference loop that requires illumination and exploration. As a therapist, it may feel counter intuitive to tell the client ‘no, the whole world is not a perpetrator’. However, this is part of working with boundaries, co-dependency and developing healthy relationship dynamics.
In order to be able to set this boundary and ‘burst the bubble of disillusionment’ we need to have first developed deep relational safety and trust. The ability to navigate a shift into a more objective experience of themselves can provide an incredible breakthrough.
9) Place a focus on integration and ‘making sense’
Therapy is a non-linear exploration of the self and the way we engage in the world. In each session, so much can be illuminated, felt and expressed. Taking time to integrate these experiences and make sense of them is required in order for the client to ‘live the change’ outside of the treatment room. Depending on your modality and approach to care, integration may occur in different ways.
By the end of a session, a client should be able to have clearly verbalized what was new for them. This signals a cognitive and left brain integration of what is often a very felt and right brain experience. Repairing left and right brain communication is a focus for recovery.
10) Empower your clients to self-care and relational repair
Real change does not occur in the treatment room or within the client-therapist relationship. It occurs outside in real life. We can consider that our sessions and our relationship are a safe place to practice being human. In order for our clients to go off and live healthy connected lives, they need to be equipped with the tools, relational skills and permission to go off and do it differently. Providing our clients with easily accessible self-care tools empowers them to go off and change their lives. Helping them find ways to identify their relational dysfunction, circuit-break them and respond differently empowers them to engage in self-expression and relational restructuring that will ultimately transform the way they engage with the world.
If as therapists, we fail to incorporate this piece into care, the bird will never leave the nest. It will be too safe and cozy, and the ability for vulnerability, authenticity and relational restructuring will never integrate for them. This often manifests as clients who are in therapy for years and rely on their therapy session as the only safe haven in their week. We want to help our clients move beyond treatment and into the dance of life.
In conclusion, being a great therapist is not about how trained or important we are. It is about how aware and intentional we are. We can approach care with these three pillars at the foundation: 1) How can I be embodied in my own humanness? 2) How can I engage for the client and not for my own expression? 3)How can I help make it safe for them to explore and express?
Humility is essential to the process.
Natalia Rachel is a somatic trauma therapist and the creator of ‘Trauma-informed Relational Somatics’ TIRS. If you’re interested to learn from her, you can sign up for her online foundation workshop ‘The Language of Touch’
https://somaclinic.mykajabi.com/language-of-touch
Or enquire for her comprehensive TIRS immersion training.
