I recently had a rough day of clinical work. Feeling frustrated after several no shows, I consulted with a colleague about my fears that these missed appointments indicated one or more of my clients might be on the verge of dropping out of therapy. I was particularly worried because several of these individuals were engaged in evidence-based, trauma-focused treatments.
If you have ever done trauma-focused therapy, you know that encouraging the client to stay in treatment and complete the protocol is one of the most important therapeutic tasks. As clinicians and consumers of research, we know the benefits of Cognitive Processing Therapy and Prolonged Exposure, but to our clients, being asking to think, write, and speak about past traumas can be extremely difficult. So difficult that clients sometimes choose to end therapy midway through the treatment rather than sticking it out through the end of the protocol.
I have always found this to be one of the most upsetting aspects of clinical work. I’m sure we can all think of cases where we truly believed that we could help the client to reach their goals, but the client elected to end therapy before we could reach that point. While I understand it from the perspective of the client (behavioral and cognitive therapies require a lot – a lot of time, emotional investment, money, cognitive resources, etc.), it can be heartbreaking as the therapist. Especially when you are working with clients who have struggled with their trauma for years. You know that if they could just stick with the therapy it is likely that some or even most of their symptoms will diminish. But sometimes the avoidance is too strong, and clients choose to terminate.
On this day, I was worried that this process had already been set into motion. What if my clients were finding the trauma-focused work to be too much? What if this was just not the right time for them to do the work required by this therapy? What if I hadn’t done enough to convince them that the therapy would be effective?
I sought input from a colleague, hoping for validation that the clients would return, that this day of multiple no shows was a fluke. As we talked, my colleague shared her perspective on no shows and the ease with which our therapists’ minds jump to conclusions about what a missed appointment might mean. Then, she said something that struck me. “Even if they end up dropping out, at least you know that you were nice to them.”
Hmm. I thought about that for a second. Clearly, my colleague was trying to validate my efforts as a therapist – even if clients leave before we’d like them to, we can feel confident that they have gotten to experience a positive relationship with a nice person.
But while I saw what she was getting at, the word “nice” didn’t sit very well with me. In truth, I hadn’t been very nice to my clients. They came to me for help moving beyond the painful memories of trauma and the associated emotional, behavioral, and cognitive sequelae of those memories. And what did I do? I made them remember. I encouraged them to think about, to retell, to engage with those memories, even when they hurt (especially when they hurt) as a way of habituating to them and disengaging the memories themselves from some of the emotional pain associated with them.
To me, this is not being nice. Being nice would mean never bringing up painful topics, never challenging easy assumptions. Family members can be nice. Friends can be nice. Therapists are not in a position of being nice, especially trauma therapists.
Therapists are not nice. But we should be warm.
What is the difference? To me, niceness implies that you are trying not to ruffle any feathers. You interpret the client’s social cues and you follow them. Your client becomes hesitant when talking about that experience? Fine. No problem. We’ll talk about something else. The client tears up when a particular family member is mentioned? Not a big deal. We don’t need to go there. Niceness means using your therapeutic skill of reading another person and assessing where they are at to make sure that you don’t upset them.
Warmth is something else entirely. A warm therapist moves toward emotional pain in the room and engages in this movement from a place of compassion and caring. Your client begins to cry when you talk about what is going on for her at work? Rather than shy away from it, let’s talk about what is happening that is feeling so upsetting for her. And let’s do it in a way that illustrates to the client that we are coming from a place of caring, of understanding how painful this is and of choosing to go there anyway in the service of the life the client really wants for herself.
Warmth is a series of behavioral choices made by the therapist.
Warmth goes beyond what we choose to talk about in the session, but encompasses how we talk about that subject. Warmth means conveying through tone of voice, body position, eye contact, and word choice that we are present with the client and care about what is happening for them.
Warmth means that the caring we have for that client is coming through in our voice. Our tone is not flat or merely inquisitive. Our tone illustrates the caring that we feel. We could be saying anything – even something very difficult for the client such as “I need you to continue with this exposure” – and our tone illustrates that we’re saying it with a client-focused purpose in mind.
Warmth is also conveyed in body position. If I am slumped back in my chair or (more commonly) sitting up straight as a board, the picture of professionalism, I may not be conveying warmth. What may be needed in the moment is orienting toward the client, even leaning in closer to them to illustrate that I am here for them, that I can see something important is happening and that I am with them in their pain. This shows that even while I am holding a firm line (this is painful and I’m not going to let you get out of talking about it regardless), I care. I’m attuned. This is a human interaction, not just the implementation of a protocol.
Eye contact, or lack thereof, can be a mechanism of warmth as well. Looking at the client when they are tearful shows that you are present – you aren’t scared of this emotion, which can help to normalize that experience for the client. In our daily lives, friends and family so often look away when we cry. Just allowing space for that pain, honoring it with your attention, can be a powerful intervention that shows how much you care. Lack of eye contact can also be a move toward warmth. Looking down to give the client a moment to him or herself can be meaningful, can show that you are willing to wait, that we don’t have to hurry up and move on from this emotion.
Regardless, the way that you utilize eye contact is important. Holding eye contact with empathy is different than looking at someone with panic (This is too much emotion – what do I say to the client next?!) or blank curiosity (Wow, why are you so upset? Is this really that big of a deal to you?) or boredom (I know I’m supposed to give clients a minute when they cry, so let’s get through this and move on.). Similarly, lack of eye contact can be interpreted differently depending on body position and other non-verbals that affect the feel of the experience in the room. For example, boredom (if your gaze is wandering all over the room or looking at the clock) versus engagement if you are looking down at a spot between you and the client, present but slightly removed, allowing them to have a moment to themselves. Spend some time with a mirror examining how your gaze appears. If possible, videotape yourself with clients (or with a friend for practice) to see how your non-verbal behavior comes across. It is not uncommon for there to be a disconnect between how you are feeling internally (caring) and what is coming across to the client (confusion, anxiety about what to say next, disinterest, boredom, professional detachment) based on your non-verbal behaviors.
Finally, word choice is, of course, critical. It is so important to validate pain. Again, nice means that we don’t talk about pain, we politely pretend that it is not there. Warmth means I will hold your feet to the fire, but I will do so in a way that acknowledges how difficult this is for you. “I know this is so hard to talk about, and I’m going to ask you to keep going.” If the client is having difficulty moving forward in talking about a painful topic, a mix of open-ended questions and commands can be helpful. “What is showing up for you right now?” “Tell me more about what happened.”
Warmth may feel like something that you either have or don’t, but it can absolutely be learned. What is important to remember is that, like so much of therapy, it is about much more than what is written in the protocol or being a generally nice or pleasant person. Warmth is about caring for your client and conveying that care through your verbal and non-verbal choices. Warmth is what kept the clients who did not show up for our therapy sessions on that recent rough day from dropping out entirely, despite the fact that trauma treatment (or any therapy for that matter) is not always nice.
How do you move toward warmth with your own clients? Do you agree that good behavioral and cognitive therapists can be warm without necessarily being nice all of the time? How might you think about experimenting with your non-verbal behavior in order to foster a feeling of warmth in the therapeutic relationship?