I was browsing an online psychology forum this week when I came across a post about seeking therapy while on internship. The writer stated that he was feeling overwhelmed by the demands of internship training and was looking for a way to address his difficulties effectively. He was considering therapy, but was concerned about the cost and time required, as well as the desire to maintain his confidentiality given that many local therapists were affiliated with his training site in some capacity.
In reading the post, I assumed that many of the responses would be similar to my own initial reaction: of course you should seek therapy. Taking care of yourself is incredibly important, particularly when you also have a professional responsibility to take care of others. As therapists ourselves, we know how effective therapeutic interventions can be – so why wouldn’t we take advantage of this resource when needed?
Unfortunately, this opinion was in the minority.
Instead, many responses were critical, suggesting that the author must be doing something wrong if he could not handle the rigors of internship without therapy.
I was struck by the tone of these responses. Not only were most unsupportive of the author’s struggles, but there seemed to be an underlying assumption that therapy is only appropriate for certain types of people. In this view, hardworking, intelligent, and successful individuals do not need therapy. Therapists should therefore never seek treatment themselves because our advanced degrees and professional achievements mean that we have our lives figured out. If only.
This attitude only serves to prevent us from engaging with our clients effectively. Most behavioral and cognitive therapies encourage us to act as guides for our clients, leading them toward behavioral change or helping them learn to challenge inaccurate cognitions from the perspective of someone who knows better, someone who can pick out the cognitive errors or understand the reinforcement principles maintaining negative behavior. However, this stance can also promote the belief that we do in fact know more than our clients, that we are in a superior position.
What is wrong with this belief? The main problem is that it can blind us to the client’s struggles. From a superior position, it is much easier to conclude that our client is not trying hard enough. After all, we understand that the thought “I’m a failure” is an exaggeration that doesn’t present a complete accounting of her worth. In this vertical approach to the relationship, the therapist is positioned above the client.
A vertical view of the therapist-client relationship promotes sympathy. Wow, that must be so difficult for you.
A horizontal view creates space for empathy. I have felt the sucking, sinking devastation of failure, and I know the pain of trying to convince yourself that this does not represent all that you have to offer this world.
A horizontal view of the therapeutic alliance, in which the therapist and client are considered to exist on the same level, requires so much vulnerability. It requires us to show up to the session prepared to react exactly as the people we are. If something the client shares reminds us of our own experience of sadness, we feel that sadness. If the client talks about the fear of being abandoned by others, we confront whatever permutation of that same fear exists within ourselves. We don’t get to hide behind the shiny armor of professionalism or wrap ourselves in the various diplomas we’ve nailed to the wall. Taking a horizontal view is like wearing that ratty t-shirt you’ve had since 2002 instead of your best suit. It incorporates the real you, the one who has also felt pain and been lost and not known what to do.
To be clear, employing a horizontal therapeutic approach does not mean making significant changes in your external behavior. In fact, it may not be particularly visible to your clients. The horizontal view is more about how you react internally to information presented in session – the emotions you allow yourself to feel, the personal experiences you allow to be touched by what is happening in the room, the way you think about your client in relation to yourself. This internal experience is likely to impact the quality of your interaction with the client – his or her felt sense of being understood, listened to, and validated in a truly compassionate way – but it is not a prescription for a specified set of behaviors. And the horizontal view absolutely does not mean that you are telling your client about arguments with your spouse or the time you were let go from a job. This is not a conversation between two friends. But it is a conversation between two equals. Two people who have both had difficulties. Two people who have both needed help at various points in their lives.
In Acceptance and Commitment Therapy (ACT), there is a metaphor called “two mountains” that illustrates this concept perfectly. The client who has come to us for therapy is scaling a mountain. And we, as therapists, are his guides. But we are also scaling our own mountains nearby. From our vantage point, we can see obstacles and pitfalls the client is not aware of yet. But that does not mean that our experience is free of obstacles of our own. After all, we each have our own mountain to climb.
This is the horizontal view. A space from which we can empathize and therefore connect more effectively. From this space, it is difficult for judgments about the client’s supposed lack of effort or “resistance” to completing homework to wiggle their way into our minds. Instead of the role of cognitive or behavioral expert, we assume the mantle of a compassionate investigator, a person on the same team as our clients (the human team), struggling to understand and cope with the universal difficulties of self-critical thoughts, difficult emotions, and less-than-ideal behaviors (five hours of Netflix, anyone?). It is a challenging place to be. But it is a place that can bestow great benefits for our clients, and ourselves, if we let it.
So what do you think? Where along the continuum between vertical and horizontal therapeutic relationships do you tend to fall ? How might you consider approaching one of your clients from a more horizontal stance? What would need to change?