What's my therapist thinking?

Like every blogger everywhere, I check my "stats" once in a while, curious to see what brought people to this particular corner of the interwebs. Often, some variation on "what is my therapist thinking?" Or "does my therapist like me?" pops up. And it makes all the sense in the world.

In therapy, one of the things you do as a client is to open yourself up, often to a greater degree than you would with a close friend. Of course you'd like to know how that's being received. Coupled with the therapist's duty to make the therapy session about the client, and not about the therapist, there's a knowledge gap there that can be uncomfortable to tolerate.

While I can't purport to know what every therapist is thinking in session (yikes! No thanks!), I can tell you a little bit about how that process works for me. And, if this is well-received, I may just take a flyer on a "does my therapist like me?" post somewhere down the road. MAYBE.

One of the things I dearly love about therapy work is that it is so engaging. I can truly say that there are very few times that I'm thinking about anything but my client when I'm in the middle of a session. Distractions outside the room abound - as hard as we try to eliminate them - but my focus is on my client. If I'm tired, stressed about something in my personal life, sick... those things really do tend to melt away in session. I'm in the midst of a flow state, when I'm doing it right.

So, I'm not thinking about things outside the room. What's going on inside the room that I'm focusing on? Therapy's complicated. A good therapist is tracking all kinds of meta-communication, like body language, vocal tone, eye contact - and parsing it all in the context of that client, the depth of the relationship (new client? Long-term?), cultural differences, etc. We look for changes in the meta-communication between sessions, and especially within session - if your eyes shift at a telling moment, if I see tears welling, if your smile isn't congruent with what you're saying, I'll point that out if the time is right. But, I have to think about whether the time is right.

We listen for content, but we try not to get too wrapped up in stories. If I'm trying too hard to remember who Uncle Bob is, and why Aunt Marge is mad at him, I'm likely to lose track of the emotional content of what's happening in the room at that moment.

Have you ever seen one of those shots of a TV control room, or a NASA launch center, with all the monitors displaying different content? Yeah. It's like that.

Another thing we're paying attention to is your safety, if that's been an issue for you. We assess for risk on a number of levels. We sometimes grimace a little, internally, when you tell us that you're going to do something that we both know is not good for you. I'm not your parent, though. Autonomy is important to me. And, if you say something that really resonates with me, that makes me remember something in my life, I have to make a very quick decision about whether or not to tell you about it. Self-disclosure isn't taboo for me, but there needs to be a reason for it.

For me, above all, therapy is about acceptance. If I can't find it within myself to truly accept you, and all that you bring each week, I can't do my job. For that reason, I really do believe that some people are able to be therapists, and some aren't. When I tell you that I'm not judging you, I mean it. The day that I'm not able to do that, I'll stop doing therapy. I love the challenge of being myself within the confines of the therapy relationship. That keeps every day, every session, worthwhile for me. Paperwork, getting to and from the office, relationships with coworkers, all of that can be difficult, but it can wait for when you've left my office.

The therapy relationship is a complicated one, but at its heart are some very simple things - respect, autonomy, acceptance - and as long as I stay there and try not to work too hard, I think I'm doing my job.

Why your last therapy session may be the best one of all

As you know if you've read this blog for any period of time, I work at a college counseling center. At this time of year, most students are bracing for finals, and for that trip home that some love, and some loathe. For some of my clients, though, it's time to graduate.

Graduation is a positive event for nearly everyone. All those years of attending classes, writing papers, taking tests... finally, it's time for a break. But as my clients get closer to the big day, they start to see the truth in one of the things I often say to the people with whom I work. For every loss, there are gains. And, for every gain, there are inevitably some losses. If we've been working together for a while, it can be hard for my client to accept that their graduation means that they'll have to stop seeing me for therapy.

In the therapy biz, this is called "termination." I've always disliked that term, as it conjures up images of Arnold Schwarzenegger dressed in black leather and smoking a rogue robot with a giant gun. Therapy termination is not as dramatic as that, but it can certainly feel just as final.

Termination happens in just about every therapy relationship, not just those at counseling centers. Eventually, therapy ends, whether through artificial means such as a graduation or someone moving out of town, or through organic means like the natural end of a successful therapy. And, for the client and the therapist, there are some ways to make sure that termination is a meaningful, mindful experience that can bring lasting benefits to both people.

Here are six ways that you and your therapist can make termination a positive, healthy experience.

1. Have a plan. A good therapist will pace the overall course of your therapy, just as he or she paces each individual session. Coming to the end of therapy is something that should be planned by you and your therapist. It's a good time to take a look at how your therapy has gone, what you've learned, and where you'd like to go from there. The last 2-3 sessions of therapy should look as though you are heading toward some kind of conclusion.

2. Stick to it. if you avoid things like this, tell your therapist so they can keep you on track. Therapists avoid goodbyes, too... they're human. Make sure they do their job, too. There should be an explicit conversation about how to tell when you (or your therapist) is avoiding doing the termination work, and about what to do if that happens.

3. Resist the urge to drop the bomb. Every therapist has a story or two about clients who save the last session for something earth-shattering. If there are things unresolved in your therapy, then maybe it's not time to terminate. If you're in an artificial termination (like graduation, or moving out of town), work with your therapist to set up the next step. Your therapist can offer a referral. Work with your therapist to plan your next step.

4. Let the emotions come. Work at acknowledging that this relationship is important, and give it the attention and emotion it deserves. Learning how to look someone in the eye and truly say goodbye is a lesson that many people never learn. It might help you as you say other goodbyes, which leads to number five...

5. Generalize your gains. Apply the lessons you've learned in mindful therapy termination to your other relationships. You will nearly always need to be the "grownup" out there in the real world, and take on the hard (but so satisfying) work of not letting yourself or others avoid goodbyes.

6. Remember that it's truly over. When a therapy relationship is over, it's OVER. While we can take the sting out of some endings with a "see you around," your therapist won't be in contact with you again. It's not ethical for your therapist to start a friendship with you after therapy is done, no matter how comfortable or natural that might seem. So, at the end of therapy, it's important to realize that the two of you won't be seeing each other again. This is the case in many goodbyes, but with this one, there's no question.

As a therapist, I think that learning how to terminate with clients is one of the lessons I've learned that has the most application to my "outside" life. It's just not something that anyone shows us how to do. It's also one of the places that some therapists bumble, and let their clients down. By being aware of how the process works, and willing to work with your therapist to do it right, you can use your therapy termination to make important gains right up until the very last moment.

Ask the Doc: How do I talk to my therapist about suicidal thoughts?

Sometimes I think it would be better for everyone if I wasn't around. I don't think I'd ever kill myself, but I'm worried that if I tell my therapist about it she'll have me committed to the hospital. Can she do that?

First, I'm sorry to hear that you're feeling that way. You'd probably be surprised at how many people share that feeling with you on any given day. One of the things that I've learned in my work as a therapist is that it is nowhere near uncommon to have suicidal thoughts once in a while. According to the American Foundation for Suicide Prevention, nearly a million people make a suicide attempt each year. For every one of those attempts, there are many more people in the situation you describe - not really wanting to die, but wondering how it would be to just not exist. We call this "abstract suicidal ideation" in psychology parlance, and it's a very uncomfortable thing to experience.

What you need to know is that your therapist is very willing to talk to you about what you're thinking, and unless you are unwilling to say that you'll keep yourself safe, she's not about to send you to the hospital. I've had clients who have had significant suicidal thoughts for months at a time, and the last thing I wanted to do was have them hospitalized. The fact is that, even though they were thinking about suicide and what it would mean, they were also continuing to function at work, at school, and in their relationships, and they were willing to keep themselves safe with a plan that we had worked on together.

Saying "I wonder what it would be like to kill myself" or "I've thought about suicide" are big flashing red warning signs for people around you, and I can certainly understand why you're keeping them to yourself around friends and family. Your therapist looks at things differently than your friends - that's why they're your therapist. Times like these are what we train for. We learn to ask questions about your level of intent, about whether you've got a specific plan, and about what you've got in your life that prevents you from acting on your thoughts. We learn to work with you to determine your level of risk, and to make a safety plan that fits your personality and your lifestyle.

If you truly don't feel as though you can keep yourself safe outside the hospital, that's another story. Don't keep that information from your therapist, because suicide is a permanent solution to what often turns out to be a set of temporary problems. But, if you know you're safe, and you need to pour your feelings out to someone without fear of overreaction, please talk to your therapist. Human life is a beautiful, valuable thing, and we're here to help you get the most out of it. To do so, we need to know what's going on with you. All of it.

One final note: if you're considering suicide, or just feel pretty awful, and you don't have a therapist, today is the day to start your search. As I said, life is beautiful. Consider this an opportunity to show yourself the love you'd show to a friend in the same situation, and get some help getting back on the path.

Best wishes, and thanks for reading!

*Thanks to reader Melinda F. for the suicide stat update!

Ask the Doc - Am I burning my therapist out?

Life has been a struggle for me lately. It seems like all I ever bring into my therapy sessions is an endless parade of bummers. Sometimes I worry that I'm too much for my therapist. Is that possible? Can too many bad events burn my therapist out?

The one thing I can tell you for sure is that you're not alone in your concern. It's easy to see your therapist as someone who is "paid to hear bad news." That feels pretty unbalanced. You certainly don't want a therapist who tells you all of their problems, but it can feel strange to just dump yours on someone.

I can't speak for every therapist, of course, but I've had conversations with plenty of clients who worry that they're bringing me down. Many colleagues deal with the same questions from clients, and we talk about what that means. Sometimes, concern about sharing things with your therapist can be a sophisticated defense against getting to what really bugs you. Sometimes you're just dealing with a social norm that doesn't apply to the therapy setting. Whatever the reason for it, undue concern for your therapist's well-being can definitely get in the way of getting your therapy work done.

I can honestly say that, while I think of my clients and their worries between sessions, I am infinitely more satisfied with the job I'm doing when a client "burdens" me than when they protect me. For many people, that act of "protecting" people is what has stood in the way of their ability to fully experience their emotions. And I firmly believe that until we can accept and experience our true emotions, we can't live a full and balanced life.

If you broke your finger, would you try and protect your physician's feelings by pretending that it didn't really hurt that much? Would you understate your pain so your doctor didn't go home and worry about you? Likely not. While it's okay to show physical pain in our culture, mental pain is a much more complicated subject. And as a therapist, it's my job to provide a comfortable and trusting environment with well-defined boundaries so you can fully experience your emotions without thinking that it's causing problems for me.

I'm much more tired after a day of trying to turn a casual conversation into something worth my clients' time than I am after a fully-connected, fully-disclosing session with someone who is really doing the therapy work. That's what I'm there to do. There's a lot of satisfaction that comes with feeling as though you have really helped someone by connecting with them.

This doesn't mean that your every visit to the therapist should include wailing, teeth-gnashing and the rending of garments. But, if you need to get there and you're worried that it will be too tough for your therapist, it's time to have an open and honest conversation about that very thing during your next session.

Ask the Doc: How much should I email my therapist?

In this day and age, I use email for as much as I can. Sometimes I've got a question for my therapist in between appointments. Should I email her?

Therapists, like pack mules or carrier pigeons, sometimes have more trouble than most when it comes to grappling with modern accoutrements like computers and smartphones. I'm not sure why that is - with 4 teenagers around the house I have had to stay caught up or perish - but it seems like the psychology profession lags a little in this area.

That being said, your therapist should have a well-defined email policy, just like all of her other policies. For me, I draw the line at scheduling via email, and here's why. Email, as you know if you've ever used it (ha!) can be a very tricky medium when it comes to understanding emotional intent and emphasis. My work is all about emotion, and my concern is that one of us will misinterpret something that's said in a letter. Also, establishing an expectation that email will be returned sets up the potential for further misunderstanding. As I've said in the past, it is important to me that I treat all clients the same, and that all my clients understand my therapeutic "frame."

I have had clients express dismay that I won't engage in long email conversations between sessions, because their previous therapist was available 24/7 for them. They'd write, the therapist would respond. Some even continue the conversation after they are no longer a client. This is dangerous ground to tread, given the artificial immediacy of electronic communication, and sets the therapist up for possible ethical violations. Once someone is your therapist, that's their role. Converting clients to friends or confidantes via email is a very slippery slope.

So, in short, scheduling = yes. All other communication, especially therapeutic or just "saying hi," = no.

And, if you have any questions about this post, feel free to drop me an email, because I'm not your therapist. :)

How much should my therapist talk about himself?

One of the joys of my job is helping to train new therapists. Every fall, our clinic hires doctoral students to work with us as trainees, and I have the pleasure of helping to supervise them. New therapists consistently ask questions about some of the things that we struggle with in our profession - "how do I deal with suicidal clients? "What do I do with a client who won't let me get a word in edgewise?" And, "how much should I tell my client about myself?"

We call this "self-disclosure" in therapist parlance, and it's an ongoing question for therapists. I've worked with clients who have told me of therapists they've had who couldn't shut up about themselves, griping about family issues, medical problems or just day-to-day crap. As you can imagine, their clients started to feel bad about bringing their problems to such "troubled" people.

A more common issue for trainees, and for all of us in the field, is whether to do any level of personal disclosure. As we hear about things our clients are experiencing, we're invariably reminded of our own lives. As we listen, we are weighing the costs and benefits of sharing that we've been through the same things. Will it help my client if I tell them that I, too, have lost a friend? Would they be dragged down or elevated by knowing that I've had similar problems?

For some therapists, depending on their theoretical orientation, self-disclosure is the antithesis of what they are in session to do. For some of my colleagues with a psychodynamic bent, their job is to remain enigmatic so their clients can project onto the therapist all the things in their subconscious (note: this is a drastically oversimplified depiction of a very complex process - work with me here!). And almost any therapist you see will limit what they say about themselves - it is, after all, your hour, not theirs.

When my trainees ask about self-disclosure, I start with my very simple rule of thumb - am I doing this for my client, or for myself? If my theoretical stance and my relationship with my client dictate that it would helpful for them to know that I've suffered similar tragedy, or that I have children, or whatever else, I'll carefully share. If I'm telling them that I saw their favorite band from front-row seats, does that do anything other than show them how cool I am? I'll hold that one back.

As I think about it, I apply that rule to everything I do in therapy. I filter my words based on whether they are about the client, or about me. One of our basic ethical principles is that of nonmaleficence, of doing no harm to the client. While it's a stretch to say that telling someone about my life while they are seeing me for therapy is harmful, it certainly isn't helpful. And, any time of theirs that I take to work out my own stuff is time that they could have spent working on theirs.

Next time your therapist makes a personal disclosure, think about that rule of thumb. If you find that you're working with someone who is disclosing to help themselves, maybe it's time to at least have a conversation about their habit. If that kind of self-disclosure persists, it may be time to move on.

7 things to do during your first therapy appointment

I have a friend who is returning to therapy after a long time away. She's understandably a little nervous about the whole thing - one of the things I always try and remember is that even though therapy is a comfortable situation for me, a first visit is often anything BUT for my clients. She asked for some ideas about what to do, and what to expect, on a first visit. Being the accommodating type, here they are!

1. Spend a little time preparing. Sit down with some paper and a pen (whoa! Old-fashioned! Keyboard, tablet or phone works just fine, as well) and do a 5-minute free-write about what is on your mind, and about what your therapy goals are. Or, make a thought map by writing random words with your non-dominant hand. Free-associate. Make a spreadsheet. Bake a cake and pipe your goals onto the icing. The point is, rather than just walking into the therapy room and going "oh, uh, what now?" just invest some time in thinking about what you want out of this therapy thing. It is ABOUT YOU. Let's repeat this - therapy is ABOUT YOU. One of the things that makes people nervous about therapy is wondering how to do it right, or how to please the therapist. This will result in less progress and more frustration. Quiz time: Therapy is about ___. Right!

2. Realize that your therapist has some basics that need to be covered. We all do it a little differently, but we all have some things we have to take care of. You'll go through a process that we call "informed consent." This is an ethical obligation of ours. You'll be told about your rights of confidentiality, and about times that your therapist might need to break confidentiality (short version - life-threatening emergency, imminent suicidal risk, some court-related things that most likely won't happen to you). Your therapist will hopefully explain his or her policies about attendance, cancellation, etc. At some point, they'll do a risk assessment, in case one of the reasons you're in therapy is due to suicidal thoughts or intentions. At this point, if you have questions, ask them. It's always so refreshing when someone asks questions after the informed consent process!

3. Get a feel for the relationship. This one is a little tougher to explain in words. As I've said a few times around here, and will say a lot more, the relationship is critical to getting good therapy work done. If you are uncomfortable, don't feel safe, or just don't feel that connection, you're really going to have to force the work, and that's not what you're paying for. Sometimes it is immediately apparent that your therapist is not the one for you - in that case it's absolutely fine to simply say "I don't think I'm going to return" at the end of the session. "We just don't click" is not a bad thing for us to hear. I'd so much rather hear that than struggle through a few sessions with a client who is obviously not feeling the connection. If you're into humor, tell a joke or see if your therapist tries to. Some people want a concerned mortician to talk to. None of my clients are those people. It might not be a night at the comedy club, or a conversation with your best friend, but you'll know if it feels right. If it doesn't, then one and done is fine.

4. Go ahead and trot out that "one thing." Yeah, easy for me to say! I have this theory that everyone has at least one thing that they're sure nobody can accept, or they've been conditioned to think that it's bad or wrong. At least one. I've gone months with people before they've told me that they spend the majority of their time off going to swing clubs and being bound and gagged, or that they're Republicans, or, you know, whatever. And after they tell me, things shift. They've gotten That One Thing out on the table, I've accepted it, and we've moved on. You don't have to spend the entire session talking about the fact that you've lost your last three jobs due to your obsession with Papa Smurf, but maybe just drop a hint. Your therapist will be okay. If your therapist is not okay, and gasps disapprovingly, GET OUT NOW. Really, don't even wait until the end of the session. Therapy is where That One Thing is something that can be talked about. That One Thing is a part of you. A good therapist values all of your parts.

5, Set some goals, but realize that things change. Sometimes one of my clients will express amazement at my lack of whiteboard, or the fact that I haven't made a goal list and set deadlines. Here's the thing: So many times, a client will tell me what they want to work on, or what their goals are, and when I go back at the end of our work together, those goals have been left far behind, abandoned for whatever has become more important to them. Figuring out how to survive your crazy boss suddenly becomes a non-issue when your boss gets hit by a meteorite (okay, no personal experience with that one). Lives change. Minds change. Superficial goals are replaced by the ones that you find when you start to find yourself. This is one of the most beautiful things about therapy work. Come in with your list, but be prepared to burn it ceremonially, or maybe just chuck it in the shredder.

6. Make sure your therapist checks in. A good therapist will check at the end of the session, and throughout your work together, to make sure you are feeling comfortable (or at least aware of why you are uncomfortable) and safe in session. They will assess in an ongoing basis how you are doing on your goals, whether you are making progress, and how you feel about the therapeutic relationship. If you finish your first session, and your therapist doesn't at least ask if the match seems okay, then listen for it at the beginning of your next session. If they skip past this, then ask them why. Some therapists, believe it or not, have a tough time with some of the necessary work of building the therapy relationship. Make sure that your therapist isn't one of those.

7. End with some adjustments. Screw up your courage and make a suggestion or two. "I'd be more comfortable if we could spend more time chatting at the beginning." "I noticed you checking your watch and wonder if that's necessary." "I realized that I don't really want to talk about my mom yet." Whatever you've got. Hopefully your therapist will do number six above, and give you some time to just relax and reflect on that first session. If the two of you can do that together, you're on your way to good work.

There are plenty more suggestions all over the internet, if you'd like to do some more reading. That counts as preparation! The bottom line is this - you should feel respected, listened to, and be in an environment that feels safe and non-judgmental. You are by far the best judge of what works for you. Stay open, breathe a little, and take that first step on your journey.

Is it really that easy to Just Do It?

Today's email brought news of another study about the impact of exercise on depression. This one was conducted by the University of Texas, seems very well-designed, and the upshot is that exercise works just as effectively as a second medication for folks with long-term depression. The trend among prescribers is to add something like Abilify to a current SSRI (Paxil, Prozac, etc.) for their patients who have depression that's not responding to just one med. This study shows that there is another way for many people to have the same result, without an extra med. Around half of the people who added regular exercise to their SSRI improved significantly.

So, you say, why don't I just tell all my clients to exercise?

The answer, as always, is that it's just not that simple. While I am keenly aware of the benefits of exercise, and try try try to add it into my lifestyle (No, really, I try!), it's not as easy as simply suggesting it to someone as though they've never heard that idea before. Can you imagine that there's someone left in the U.S. who hasn't dealt with a daily barrage of messages about their size, their laziness, their lack of motivation, their inability to look like people on TV? This is where my job gets complicated. Again.

The act of fostering change is one that we spend all our time in graduate school trying to figure out. And then we go into practice, and we learn a little more, and we keep trying. We get a dozen years of experience under our belts. And we are faced with a client who, for all we know, would make rapid improvement with exercise. And our years of experience sit there in our heads, mocking us.

While there are some who benefit from the boot camp approach, I'm guessing that many of them aren't overcoming serious depression, or a life of parental shaming, or a daily battle with body image. Screaming at my clients to "just do it" might benefit a couple of them, and damage my relationship with the rest. Mine is not really to urge, or cajole, but to join with my client in a process of discovery - how do I really feel when I resist exercise? What are some thoughts about my body that I might want to choose not to believe anymore? Is there a gentle experiment I can do, one without a failure component, that will let me try something new in a safe way?

Unlike the trainer at the gym, my job isn't to goad you into getting your workout done, no matter how positive the results may be. My job is to help you realize that no matter where you want to go, you've got to start just exactly where you are today. Judgment doesn't change that. Then I work with you to help you find about yourself, figure out what might be in the way, and to stand by and support you as you try out some new behaviors. If those behaviors don't "take," that's just as successful an experiment because we've learned more about the problem. I'm happy to help hold my clients accountable, if they want, by asking them to exercise, and I'm hoping that they'll have a few experiences that show them there's a better way.

There are therapists who will push, and goad, and you can find them by asking if they'll do that for you. In the long run, I've seen my way work more often than not. And, to me, that's reason enough to stick with it.

Why won't my therapist give me longer appointments?

One of the things I do when I come into work in the morning is pick up the messages from people who have called during the hours we're closed. This morning, there was just one - a plaintive request from a client of one of my colleagues, asking for longer sessions. The client said that she felt she could do more with more time.

This is not an uncommon request. My clients will ask from time to time if we can meet for two hours instead of one, or go 15 minutes over, or any stretch of extra time, because they feel that we're ending while they still have something to say. I understand that, and I think there's all kinds of merit to the desire to do more work in therapy.

Here's the problem, though, from your therapist's perspective. If I do that for a client, should I do that for all my clients? If one of my clients finds out what another one is doing (and, in my job in a college counseling center, many of my clients know each other) how will they feel? Of course, I can't talk to any of my clients about what any of my other clients are doing - but they'll know. And they'll wonder why someone is getting special treatment when they're not. And this will color our work together, at least for a while, and maybe distract from the other good stuff that we're getting done in session.

Incidentally, one of the hallmarks of therapists that are sliding towards an ethical violation is doing special favors for one client above all others. Keeping later hours when they'd usually be headed home. Coming in on a weekend. Allowing that client privileges that no one else is getting.

I'm very sensitive to this, and I work hard to keep the "therapeutic frame," that container that helps our work together feel safe and consistent. If I find myself favoring someone, or feel like I'm NOT doing something for someone that I'd do for someone else, it's time for me to sit with that and figure out what's going on.

For your therapist, the work continues after the clients are gone. We need to make sure that we're centered, available, and doing everything we can to clear out those hidden prejudices and acts of favoritism. From the outside, it might just look like 15 extra minutes. From my perspective, it feels like a lot more than that.

Not all therapists are with me on this one, and I know of some folks I very much respect who give extra time to some folks. I've done it myself, when the clinical need was strong, once or twice. Those instances have been few and far between, and I've had a good conversation with myself, and then my client, about the reasons behind the shift. As will all things involved in being authentic and human, sometimes the little things mean a lot more than we think.

Five tips for finding a therapist, from a therapist

According to Google, this is online article number 1,630,001 about finding a therapist. Rather than be daunted by that challenge, I'm going to choose to ignore the other 1.6 million and give you some tips that I hope will help you wade through the mass of information.

1. Take a deep breath and start NOW. Therapy goals are often long-term goals, and we're not so good with those in terms of self-reward. Looking for a car means you get a new car. Hunting for the best vacation spot means you get to go somewhere soon. Get comfortable with the idea that you're putting effort into a long-term investment, and put at least as much effort into your search as you would into looking for the best price on a new computer. The benefits of good therapy last far longer than anything you can buy.

2. Like shopping for pants, comfort of fit is everything. We've all bought pants a size too small, just knowing that we'll soon be able to fit into them. Therapist-shopping is like that - many people cut the uncomfortable search process short as soon as they find someone they think they can live with. Some "how to find a therapist" articles warn AGAINST comfort of fit, saying that if you're too comfortable, all you'll have with your therapist are chit-chat sessions. My clients will likely tell you that I'm a pretty comfortable guy to hang out with, but when it comes time to do the work, we don't hold back. Without that welcoming safety net underneath, nobody wants to go up on the high wire. Most people will do more work, more quickly with someone they are comfortable being around.

3. Good therapists are good at recommending good therapists. Ask your friends if they know a good therapist, or if they know someone who does. Get the list of therapists from your insurance company. Then ask your friend's therapist if they know someone on the list. Or, if your friend's therapist is so great, go to them! I work in a college counseling center, and many of my clients know other clients of mine. It has no impact at all on our work. Confidentiality rules and general common sense forbid me from even acknowledging that I see your friend, much less say a single word about our work.

4. Don't let location make up your mind about who to see. The college I work for is in the sticks, location-wise. Many of my clients tell me that they value the drive (or bus ride) there, because it gives them time to think about what they'd like to talk about. And the ride home gives them time to process what just happened. A therapist five minutes from you is convenient, but if you land one of those build some time into your schedule to process your session, right after your session. Trust me on this one. You'll consolidate your gains and make more progress that way.

5. Know the difference in degrees and licenses, but don't let that make up your mind for you. In Oregon, psychiatrists and psychiatric mental health nurse practitioners prescribe meds and do some therapy. Psychologists do testing and therapy. Licensed professional counselors, marriage and family therapists, and other master's-level counselors do therapy. And there are a raft of other practitioners. If you have questions about someone's credentials, ask. I know people with a year of therapy experience that I'd recommend over others with a dozen years (if I could). Some have it and some don't. Experience helps, but it is definitely not the only thing to look for.

5a. See number 2. Relationship is everything. Look until you find someone with whom you can be comfortable and open.

Okay, add that one to the pile of 1.6 million other resources out there. Keep up the search - the rewards are great. And if you think you've found someone and you find you just don't fit, see my post on firing your therapist. It happens all the time!

Defining "healthy."

I'm working with someone who is going through a pile of difficult stuff right now. She has a complicated trauma history, and has been abandoned more than once. She is convinced by trial and error that nothing will ever turn out well for her - the universe has shown its capricious hand with her over and over again, and she feels as though she has been taught the truth by life.

As is often the case with people who have fallen into a run of terrible luck, she is sure that she has done something wrong, navigated poorly, and that because of this things will never change. She is mired in a relationship right now, or the semblance of a relationship, and she feels as though she is being taken advantage of.

Today she told me that she thinks she should just drop this relationship, just never answer another text or call or email, and move on. She pointed to the example of a friend of hers who did this. It just seemed so healthy. This example "proved" that this is how to handle this situation.

I asked her to imagine her emotional reaction if she just walked away from this guy. If she dropped all communication and no longer had him to talk to. She told me that she'd feel lonely, broken and abandoned. She'd feel lost. She'd take a while to recover.

I asked her how healthy that sounded to her.

After a pause and some reflection she began to understand what I was getting at. I'm not sure I agree with the concept of "mental health" as prescribed by endless movies and tv shows. We see our friends' behavior from the outside, with no idea how it really feels on the inside. My client's concept of "healthy" is an impossible standard for her.

To me, healthy starts when you accept who you are, and what you need, whether or not it's ideal. And, trust me, it's rarely ideal. If you know who you are, and you're okay with what you need, you can start adjusting your environment accordingly. You're going to be a lot happier functioning as your true self in an environment that fits that self, rather than trying to force changes in yourself to fit an environment. I would, of course, never recommend that someone stay in a relationship that is abusive or degrading. At the same time, I would never judge them if they felt the need to pull away slowly. I can't look into them, or into their relationship. No one can. Luckily, my client is not in a damaging relationship like this.

As my client works towards independence, and self-worth, the last thing she needs is to pull the floor out from under herself. Less-than-ideal relationships, imperfect jobs, tentative engagement with the world - all can function as transitional objects as one finds out where one really belongs, and goes there.

Does my therapist think of me between visits?

I was sitting with a client a while ago. We were at the beginning of the session, a time that is sometimes less focused and more "social" than the rest of the session, a time when we're figuring out what is primary and what can be left until next time or left behind entirely. I mentioned that I'd seen a sign along the highway that reminded me of her.

She was stunned.

I couldn't untangle all the different emotions that played across her face, but the one I resonated with was the one that probably mimicked the look I had when I was a 3rd grader and I saw my teacher in the grocery store. In that moment it had dawned on me that my teacher was a human, a real person, not someone who sat in unknowing stasis in the classroom until we came back at 8:15. My teacher shopped! She probably peed, and ate, and knew real people in the world. She didn't sleep at school! Maybe she had kids!

It was a little hard to handle.

I think my client felt the same. In a flash, therapy changed for her. She suddenly realized that there was a human sitting across from her, someone incapable of unfeelingly compartmentalizing all the emotion and life that flows during our times together. She knew then that I wrestled with those questions away from the office. She discovered something that therapists do that clients often don't think about - we think about our clients and their lives and their emotions and their problems and their bright victories and jarring losses away from the confines of that rigid 50-minute office frame.

Studies from across the theoretical board show that if you want to get good therapy work done, it's all about the relationship. Therapists from all corners of the profession are in the business of making strong human bonds so they can do the rest of their work. If that bond didn't transcend the therapy hour, it wouldn't be real, it would be an invention meant to enable therapeutic progress. And it just doesn't work that way.

Your therapist, if she or he is doing the job in a competent way, is bound to you by far more than a pile of therapy notes and insurance bills. And I can virtually guarantee you that at some point, on some insomniac night or relaxed coffee-sipping morning, you've been thought of as much more than a client number.

Ask your therapist next time you see them, and see what sort of answer you get.

Harbinger

She sits across from me, drawn, gaunt, eyes red, and tells me that she can't sleep in her dorm room without her cat. When I ask her why, she tells me that it is only because of her cat that she can tell the difference between a night terror and something that she should really be afraid of. She sees ghosts. She is sensitive to the presence of things that should remain in other worlds. If her cat remains unaffected, the ghosts aren't real, and she can feel as safe as she is capable of feeling.

That afternoon I will write a letter asking that she be allowed to keep her cat with her. I won't explain exactly why.

In the early days of mining, men sent deep into the earth to hammer out coal would bring a caged canary with them. The canaries, prized for their delicate metabolism, would begin to sway uncertainly on their perch in the presence of trace amounts of methane or carbon monoxide, gases that presaged untimely death by suffocation or explosion. The sight of a dying canary sent the wary miners clawing for the surface. My client's hope was that her cat could keep her safe from fates even more horrible than a lack of oxygen or a cave-in triggered by an underground blast.

Many of my clients come to me bearing such cages. They scan the environment, hypersensitive to that clue that will remind them of just how unsafe their world is, the clue that will send them clawing for the surface, scurrying back to bed and under the covers and safe for another day. They miss classes and end relationships based on the swaying of a canary. They avoid the harsh glare of life, the seeped methane of distrust, the carbon dioxide of a poisonous memory. They live underground, their days dimly illuminated with the faltering beam of headlamps and dingy lanterns. There are days when I feel that to convince them to let the canary fly free is just too jolting and unkind, and I sit with them in the dark, and we watch the canary breathe, both of us mindful of the fragile respiratory rhythm of life.

There are those glorious days when we watch an unfettered flight, the canary soaring, striving to be more than a simple harbinger. I love those days, but I value them the same as the other days, as they are all part of the miner's life. The cage is never discarded, as there will be more descents into darkness. Canaries are easy to come by, a dime a dozen, and as often as they have failed to do their jobs they are still the closest thing to trustworthy that many will ever find.

And on some days, that's enough.