“My therapy has come from paying attention to my life.” —Oprah Winfrey

It can be hard to know what is happening in therapy, by its very nature as an endeavor to explore the unknown. Without appropriate clarity, therapy can be mystifying and confusing especially when people are in greater need. Patients can be reluctant to bring up important issues when uncertain if they are “allowed” to, and even may not feel comfortable even asking about what is OK or not. Therapists may not return to important issues, often those raised in the first couple of meetings. Patients have a way of thinking about important issues outside of appointments, which somehow don’t come up during sessions.

Quite often, these kinds of issues are about the person of the therapist, or about the therapeutic relationship. They can also be more directly pragmatic, about office policies and procedures. Regardless, therapy depends on a level of open inquiry, and to a significant extent, that works both ways.

With these ideas in mind, I’ve touched on several different areas which people in therapy may need to cover with their therapists but often don’t get to discuss. Patients can bring difficult subjects up with therapists, and therapists can bring up some of the same issues, but also have to provide an environment which makes it as straightforward and safe as possible to discuss constructively subjects ordinarily off limits.

1. A willingness to discuss where the therapist is coming from.

Have you ever wondered about your therapist’s personal history? To what extent how a therapist works is related to training models, and how much is personal style? Or, more to the point, whether they have been through similar things as you? If so, where are they in their own progress, and what does that mean for your care? This conversation can go from superficial to deep, about more abstract considerations or about very personal experiences that therapists invariably bring into the room in some way, shape or form. Some therapists are more comfortable with “self-disclosure” and some therapeutic approaches normalize openness on the part of the therapist, but at the same time boundaries are important. Boundary crossings can often be used productively if they don’t happen very often, but boundary violations are always a red flag.

2. Changes in the therapist.

Therapists go through life changes. We age, we have families, we go through life’s challenges and have failures and successes, too. Is that relevant? I’ve found that my perspective has, of course, shifted on important issues over time. As I get older, I believe I both understand some things better and recognize other things I cannot understand until I go through them. My sense has been that, especially working with people for many years, often on the order of decades, the developmental paths of both therapist and patient become more entwined in certain ways (as they would with anyone, but in a therapeutic relationship). This is an important source of understanding, if discussed.

3. Competent handling of mistakes.

We want our caregivers always to be perfect and make the right decisions which lead to good outcomes, and handle difficult situations with poise and mastery. Yet we know that mistakes are made. It’s not comfortable to discuss, but errors do come up. Usually they do not lead to major adverse health consequences, though they can. But what happens if a therapist forgets to call us back or doesn’t give us an invoice for a couple of months? Or more directly in the therapy sphere, doesn’t seem to remember something important, or confuses my life with someone else’s, or says something off-base? Even tries to cover up things and act like they didn’t happen?

That’s not necessarily therapeutic, and may be about embarrassment and related reactions. How they handle it is of critical importance as a therapeutic action, but errors also render therapists more human than we’d often like, and can sting more sharply because they represent failure by a trusted caregiver, and may resonate with earlier experiences. If betrayal is part of the developmental history, failures by therapists take on heightened significance. Consistent issues like this can mean the therapist has a problem, either personally or with a particular client. Therapists have to be able to take responsibility in a way which acknowledges any missteps and attempts to rectify them, without using therapeutic utility as an excuse and while also taking advantage of therapeutic potential in relationship breaches when possible.

4. Good billing and claims support.

This one is more a business issue, and it’s notoriously difficult for therapists to stay on top of billing and insurance issues. The reputation is that therapists aren’t business-minded, and don’t want to deal with issues like this. There are exceptions, but management is not typically even in the caregiver training. Therapists often seem constitutionally inclined to be irritated by bureaucracy and anti-authoritarian, though this is variable. Practicing therapy is a very different way to spend time than filling in documents and making phone calls to insurance companies. Don’t hesitate to ask about billing and related issues, for example if a bill is chronically late or missing information, or if you have a payment due and no one is saying anything about it. More therapists use management services, which can be a useful compromise, but may be less desirable because it brings a third party into the working relationship.

5. Clear policies.

Financial, scheduling and related policies should be clear from the outset of officially starting therapy. Preferably, there is a written treatment agreement which is reviewed and signed by both parties. The treatment agreement should spell out the obligations of both the person seeking care as well as the clinician. Without knowing what we are getting into, we can’t fully consent to any form of clinical care. Written treatment agreements aren’t intended to be used as leverage if there is an issue, though that can happen, but work best when they serve to build and maintain a solid foundation for care, which requires a level of dialogue, mutuality, and sometimes compromise.

6. Recognition and basic human decency.

Therapeutic relationships can be viewed as being fundamentally lop-sided in many important regards. One person is seeking help with something; the other person is sought out as having helping expertise and typically receives payment for providing a service. Yet at the same time, in addition to essential professionalism therapists address basic human needs, and people seeking therapy regardless of their problems need respect and validation of subjective experiences. Recognition of the mutual validity of different points of view does not mean that patient and therapist have to be in agreement. However, a lot of therapeutic growth is allowed through the presence of shared space for exploration, which means that in important ways, therapy is a meeting of equals. Recognition may be viewed as a form of love, but do we need our therapists to love us?

7. Assessment of progress and discussion of treatment planning.

Therapy can be open-ended and without clear definition. This is more often the case with long-term psychodynamic and psychoanalytic therapy. While I am a big supporter (and practitioner) of psychoanalytic practice, I also understand that patients and therapist can get stuck in lengthy ruts which are ascribed to thorny and difficult-to-treat problems when actually something isn’t working well either in the therapeutic relationship, or in the kind of treatment being used. It’s one thing to realize that many of life’s problems, often forged during development and deeply ingrained on social and psychobiological levels after years of adolescent and adult life, do indeed take a long time to shift and require a deep and consistent therapeutic presence over spans of years. It’s another thing entirely to consider that the therapy isn’t working, and needs review.

Such discussion, while it doesn’t necessarily have to use structured outcome measures or treatment goals written in stone, is important to have on a rolling basis, and when issues arise. Whatever comes out of these discussion must be integrated into the care, whether it is with the same provider modifying the work, or involves collaborative care, referral, or additional evaluation. If a problem isn’t getting better, it is time to take a step back and ask why that is.

8. A full range of therapeutic experiences.

I’m mainly talking about more open-ended psychoanalytic approaches, but this applies to other forms of therapy as well. Without being able to fully explore all layers of the therapeutic relationship, including at times a discussion of the therapist’s contributions, therapy can be incomplete. A particular way this comes up is when patients are protecting their therapist, or perceive themselves as needing to do so. Exploring therapeutic process, and especially our experience with the person of the therapist, may uniquely shed light on our own ways of relating to others and biases in how we see the world

Patients can feel shy about bringing up sensitive issues with therapist who can be vulnerable, and/or can be perceived to be vulnerable. However, it is often those very areas of possibly excessive caution which lead into unexplored, and highly important, therapeutic territory. When therapists create an atmosphere of safety and curiosity, and are secure-enough in dealing with challenging inquiries and know when to share, patients have greater access to issues which are important to them which are guarded by parallel protective mechanisms. Part of the therapist’s job is to keep track of important issues and set the stage for addressing them—sooner or later.

Originally published in Psychology Today on January 26, 2018