The Expanding Staircase

Square spiral staircase
Photo by Elena Kuchko on Unsplash

The following is a work of fiction, based on my experiences working with clients but not a reproduction of an actual session with a specific person.

My office, any given day:

— It just feels like I’m not making any progress. I mean, I know I’m making progress, but…it just doesn’t feel like it.

— Yeah. It’s hard to keep going when you can’t tell where you are.

— Yes, it’s like, I keep doing the things that are supposed to help—getting in to see you, getting in to see the psychiatrist, getting the referral for the assessment, starting the medication—but each step takes such a long time, and then that psychiatrist turned out to be unable to do the assessment, and then when I finally got the referral and scheduled it, it turned out they don’t even do those assessments either…

— Does it feel like those steps—for instance, getting in to see the psychiatrist or starting the medication—are getting you to where you want to go?

— Not really, because the psychiatrist couldn’t do the assessment, and the medication isn’t really helping so now I have to try another one.

— Right. It’s frustrating when the steps you take don’t seem to “count.”

— Exactly. Like, if the medication isn’t helping, did that step really take me anywhere?

— What does your gut tell you?

Continue reading “The Expanding Staircase”

The Expanding Staircase
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“But You’re a Therapist!”

It can be weird being open and vulnerable with others as a person who also happens to be a therapist. People are sometimes very surprised to hear that their therapist friends also, believe it or not, struggle to understand their partners, get petty or irritated, feel abandoned, lash out at people, avoid flossing or exercising or initiating difficult conversations, or feel judgmental. For example.

I’ve been hearing the refrain “But you’re a therapist!” since—actually—before I even technically became a therapist. (Back then it was, “But you’re going to be a therapist!” Yes, and? You’re apparently going to be a millionaire or a bestselling author one day, and yet.) I even see therapists themselves throwing this at other therapists in some of the Facebook groups I’m in. That, combined with actually becoming a therapist and hearing a lot about how other people think, has given me a lot of opportunities to reflect on what causes people to say this.

People seem to be of two minds about therapists. Either we are fully self-actualized human beings who float through the world with the gravity-defying force of our own impeccable coping skills and preternatural ability to sense others’ thoughts and intentions; or we’re all “crazy” and “broken” and got into this field either to wallow in our misery along with our clients, exploit those clients, or use them to somehow fix our own unusually severe mental issues.

Obviously, I highly dislike both of these stereotypes (though the latter is of course more offensive and ableist). The reality is that most people will experience some sort of significant mental distress at some point in their lives, therapists included, and experiencing it early in one’s life can be a motivating factor when it comes to choosing a career path.

But I think there’s more going on here than just stereotypes about particular professions, and I think it reflects a common misunderstanding of how therapy works. Continue reading ““But You’re a Therapist!””

“But You’re a Therapist!”

Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

This is a cross-post from my professional blog, where the most updated version of this will be.

The field of mental healthcare has its roots in medicine. The earliest mental health professionals were doctors—psychiatrists. Like medicine, psychiatry and clinical psychology are based on the process of assessing patients’ symptoms, performing some sort of test if needed, assigning a diagnosis, and creating a treatment plan based on that diagnosis.

This is a very sensible approach for most medical issues. If I appear at my primary care doctor’s office complaining of persistent headaches, she shouldn’t just treat the headache by prescribing a painkiller. She should refer me to someone who can figure out what’s causing the headache, and then treat that condition, whether it’s extreme stress, a head injury, a bacterial infection, a brain tumor, or some other problem.

Even though we’ve been treating mental health issues this way for at least a century, it’s not the best way to treat them. And many psychiatrists, therapists, and researchers are starting to realize that.

That’s why we’re finally starting to see approaches to assessment and treatment of mental illness that move away from the much-argued-about diagnoses in the DSM, and sometimes away from the concept of mental illness altogether. Psychologists such as David Barlow, Rochelle Frank, and Joan Davidson have been working on so-called transdiagnostic approaches[1]; the newest edition of the DSM includes a chapter about a proposed new way to diagnose personality disorders that’s based on specific personality traits rather than broad, stigmatized labels[2].

I’m looking forward to the day when the field as a whole has shifted to these types of approaches entirely. For now, I needed a tool I can use with clients to help them (and myself) understand what they’re dealing with and access helpful resources and support. So I created my own informal dimensional assessment.

Continue reading “Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness”

Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

Why I Told My Clients I Have Cancer

Self-disclosure–what to share about yourself with a client, and how–is a big topic of debate among therapists. Some old-school psychologists think that you should share as little as possible, and be a “blank slate” to avoid distracting the client from “the work.” Other therapists, especially those who operate within a feminist or relational lens, tend to believe that appropriate self-disclosure can strengthen the professional relationship and move the work along.

Most agree on a few things, though–don’t share personal medical details with your clients, and don’t share anything that you haven’t fully worked through already. It’s one thing to mention to a client that you went through a divorce years ago and that there’s no shame in it and that healing will come; it’s another to tell a client that you’re actually on your way to the attorney’s office after work.

I was, until recently, completely on board with these general guidelines. Then I got diagnosed with cancer, and suddenly they didn’t work for me anymore.

Almost immediately, I dreaded having to explain my absence to my clients somehow. I didn’t know anyone in my field who’s ever gone through anything like this. Neither of my supervisors at work did, either. Most of the time when something medical interferes with work, it’s rather more straightforward than cancer treatment–for instance, a surgery. You tell your clients, coworkers, and supervisors varying degrees of detail about the fact that you’ll be out for 6 weeks, and gently shut down any inappropriate questions.

I, however, was about to start chemo and I’d be working through it. I wasn’t sure how much, and I knew that might change as I went through treatment. As it turns out, it’s uniquely impossible to be vague or coy about cancer treatment. I knew right away that if I tried to spin some bullshit about how I’d be off a few days every other week for “my treatment” and then start showing up in wigs, I would come across like I’m either ashamed of it, or think my clients are children. People know what it means when you miss work every two weeks and lose your hair.

Unable to get any clear direction from professionals with more experience, I went next to Google. Here I found a number of articles by therapists who’d had cancer. They all told their clients that they’d be “leaving this position” and referred them to other therapists. I was confused. Were they not planning on returning to work? Would they have to just build up an entirely new client base? That sounds like a lot of fun on top of recovering from chemo.

One article described a therapist processing her imminent departure with her clients and having to pretend that she was moving on to another job, and reassure her clients that it wasn’t because of them and that she really valued working with them.

Later, she received an email about her own former therapist, who had terminated treatment with her the same way. He’d died of cancer.

Ultimately I decided that this level of deception and fakery not only goes against my ethical values, but would literally be impossible for me to manage. Telling my clients I had cancer was painful enough; I couldn’t imagine having to also pretend that the cancer was actually a cushy new job. Having to apologize to my clients for leaving our work unfinished as if it had been my decision, rather than a horrible thing that happened to me.

So I went for the opposite extreme. I told every single one of my clients that I’ve been diagnosed with breast cancer and would be undergoing chemo followed by surgery. I invited them to ask me any questions they wanted about it and reassured them that I wouldn’t answer anything I truly felt uncomfortable with. Some didn’t ask for any details at all. Most asked if I felt okay to be at work. (I did.) A few wanted to know more–what stage, what type of surgery, what chemo feels like, if cancer runs in my family.

Was it awkward? Sometimes. Did it distract from the client’s therapeutic needs? Maybe, in some ways. Is that ideal? No.

The problem, though, is that therapists are in fact human, and we have human bodies that fail in the same glorious ways as everyone else. I don’t believe I could’ve continued to do this work effectively throughout my chemotherapy while actively deceiving clients about what I’m going through. I also don’t think that would make me a very good role model.

A lot of surprising conversations came out of it. One client revealed his own battle with cancer, years ago. He’d never talked about it. A few mentioned that they really ought to be doing breast self-exams because it runs in their families; I told them where to get more information and explained that when caught early, breast cancer is extremely treatable. One client, surprisingly, brightened and smiled when I told her. She explained that a beloved relative is a survivor of breast cancer several times over and that this relative is her mentor and source of inspiration.

Another client said she was glad I told her. “I’ve been working on being more vulnerable and open with the people in my life,” she said. “If you’d tried to hide this, it would’ve sent the wrong message.”

That conversation was a reminder that while therapists often keep personal information from clients in order to “protect” them or to avoid distracting them, clients may interpret this secrecy as a product of shame, callousness, or both.

That’s not to say that my transparent approach hasn’t had its downsides. It does sometimes make my clients feel awkward about sharing their own problems; cancer tends to be that thing people remind themselves at least they haven’t got, so it can be weird to vent about your shitty job when someone’s just dropped cancer into the conversation. But I always reassure my clients that 1) I’m here because I want to be, and 2) I still see their problems as valid and important even though I have cancer now. The awkwardness usually doesn’t last.

It does sometimes make things harder for me, though. When I was first diagnosed and didn’t know the staging or prognosis, I could hear the unasked question on many of my clients’ minds. No, I didn’t know if I was going to survive or not. (Even now, with chemo going swimmingly, I can tell you that I’m pretty unlikely to die of cancer, but recurrence is a thing and it could happen anytime.) I could only tell my clients the same thing I could tell myself–that I had no reason to expect the worst, so therefore I’d hope for the best.

Sitting with uncertainty is one of the most difficult things in life, and probably the most difficult thing about cancer especially. Yet it’s also one of the most important skills to develop, for me and for my clients too.

As treatment went on, I often found myself having to be a bit performative when clients asked how I’m doing. It’s true that chemo isn’t too bad and that I feel okay most of the time. But some days are very hard. Yes, there were days when I wished I’d stayed home from work, but I didn’t because I wanted to be as consistent as possible with my schedule. (There were other days when I called off even though I’d planned to be there.)

Most days, I’m not my best self at work. I’m just not. It’s just impossible. The only other option would’ve been to take all four months of chemo off work entirely, but that would’ve been worse for my clients, worse for me, and ultimately impossible. I don’t have enough medical leave for that.

So although I don’t tell my clients many details about treatment, I continue to be transparent. I’ve told them that I feel tired a lot. I’ve mentioned that chemo sometimes leaves me with bone aches, which is why I stay home a few days after each treatment. I keep a positive attitude and tell them that many chemo side effects are very well-managed with medication and that chemo isn’t what it used to be. My hope is that if any of them end up being diagnosed with cancer, or having a loved one who is, they’ll remember that, and they’ll remember not to be afraid and to ask the doctor for help if they need it.

Disclosing this to my clients a week after diagnosis–telling 40 or so people that I have a potentially lethal illness and then taking care of them around that disclosure–is the most difficult challenge I’ve faced in my professional career so far. I found myself having to reassure people about something happening to me, something I found (as most people would) horrible and terrifying.

This situation turned the usual ring theory inside out. Normally the person at the center of a trauma or tragedy is the one who gets taken care of by everyone else. But as a therapist, it’s my job to take care of my clients. Which is probably why the conversations were sometimes so raw and awkward–my clients sensed that they “should” be the ones comforting and reassuring me, but they also understood that that’s not their role. And because of the strong therapeutic relationships we’ve already cultivated, we were able to talk about that directly.

I had my last chemo treatment this past Monday, so things are going to be more straightforward from here on out. But that doesn’t mean I’ll be able to stop having conversations about this with my clients. I have multiple surgeries and other procedures in my future and it could drag on for years. I may not be able to be at work as much as my clients (or I) would like, but I hope that by being open and honest I can reassure them that help is available even when I’m not there and make sure they know how much I wish I could be there with them.

Over the past four months, I’ve had to radically redefine what professionalism and appropriate self-disclosure mean to me. As it turns out, vulnerability isn’t just good for my friendships and partnerships; it’s good for my professional relationships too.


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Why I Told My Clients I Have Cancer

How to Get the Most Out of Therapy

Drawing of a therapy session in progress.
Credit: Guy Shennan

When you spend a lot of money on things, they usually come with an instruction manual to help you use them in the most effective possible way. Unfortunately, therapy doesn’t.

A common misconception about therapy held by many laypeople (and, unfortunately, some therapists) is that all you have to do as a client is show up and then…some vague hand-wavey magic stuff happens, and then the client gets better. Many people think of therapy like this:

  1. Go to therapy
  2. ???
  3. PROFIT

Really, though, it’s more like this:

  1. Go to therapy
  2. Establish some rapport with the therapist before you can delve into the serious stuff
  3. Sometimes be really uncomfortable
  4. Have a lot of meta-conversations with your therapist–that is, talk to the therapist about the process of talking to the therapist
  5. Do homework (in some types of therapy)
  6. Get called on your shit by the therapist
  7. Be uncomfortable again
  8. Make changes in your life outside of therapy
  9. PROFIT

As a therapist, it’s tempting to say that you should just show up and let the therapist do their job and you’ll feel better. Sometimes that’s exactly how it works. But ultimately, you can only get as much out of therapy as you put into it.

Continue reading “How to Get the Most Out of Therapy”

How to Get the Most Out of Therapy

Should Therapists Decline to Work With Clients They’re Bigoted Against?

armchairs

[CN: homophobia, thought experiment-ish discussion of bigotry]

The topic of therapists refusing to work with particular clients due to differences in values is one that came up often when I was in graduate school, and continues to come up often as therapists–many of whom come from traditional Christian backgrounds–confront the reality of practicing in diverse settings.

“Differences in values” usually refers to homophobic therapists not wanting to work with lesbian, gay, and bi/pan clients, but it can actually apply to tons of different marginalized identities: trans, poly, kinky, atheist, Muslim, and more. Differences in values can also impact therapeutic work with clients who are making decisions that the therapist strongly disagrees with for whatever reason, such as getting a divorce, getting an abortion, accusing someone of sexual assault, and so on.

Although it might seem counterintuitive, competent and ethical therapists occasionally choose not to work with particular clients for all sorts of reasons. They may feel that they lack sufficient knowledge or experience to help a client with a particular niche issue or disorder, and that they can’t make up for it with extra training quickly enough to avoid harming the client. They may be triggered by some aspect of the client–for instance, some therapists cannot work with convicted/admitted rapists, especially if pedophilia is involved. They may realize they’re too closely connected to the client within their community–for instance, the client is the parent of the therapist’s child’s best friend, or the client is dating a close friend of the therapist. (Although in these situations, openly discussing it with the client and setting some boundaries and expectations also goes a long way.)

Regardless, if a therapist chooses not to work with a client, it’s their ethical responsibility to refer the client to another professional who can work with them effectively. So it’s never just like, “Nope, can’t help ya, sorry.” And if you ever get that response while seeking therapy, know that you’re entitled to get some help finding someone else.

So choosing not to work with particular clients due to lack of knowledge/skill, personal triggers, and boundary issues is accepted in the field. How about choosing not to work with particular clients because you cannot accept their identities or lifestyle choices?

Continue reading “Should Therapists Decline to Work With Clients They’re Bigoted Against?”

Should Therapists Decline to Work With Clients They’re Bigoted Against?

A Good Critique of the Medical Model is Hard to Find

I was optimistic about reading this critique of the medical model of mental illness by professor of clinical psychology Peter Kinderman, in part because it is written by someone with experience in the field and in part because it is published on Scientific American, which I trust.

However, while the article makes a number of good points that I will discuss later, it starts off immediately with such a tired and oft-debunked misconception that I almost quit reading after that:

The idea that our more distressing emotions such as grief and anger can best be understood as symptoms of physical illnesses is pervasive and seductive. But in my view it is also a myth, and a harmful one.

I’ll say it again for the folks in the back: nobody* is trying to medicalize “distressing emotions such as grief and anger.” They are medicalizing mental patterns (which can include cognitions, emotions, and behaviors) that are not only very distressing, but also interfere with the person’s daily functioning. It’s kind of like how some stomachaches are minor annoyances that you wait out (or take a Tums), and some land you in the ER with appendicitis. Therapists and psychologists are not concerned with the mental equivalent of a mild cramp.

In general, people don’t end up in my office because they get pissed off when someone cuts them off in traffic; they end up in my office because they are so angry so often that they can’t stop physically attacking people. They don’t end up seeing the psychiatrist down the hall because they get jittery and uncomfortable before a job interview; they see the psychiatrist because they feel jittery and uncomfortable all the damn time, and they can’t stop, and they can’t sleep, even though they rationally know that they are safe and everything’s okay.

I understand that it’s more difficult to grok differences in degree as opposed to differences in kind, because Where Do You Draw The Line. Yes, it would be easier if mentally ill people had completely different emotions that had completely different names and that’s how we knew that they were Really Mentally Ill, as opposed to having emotions that look like more extreme or less bearable versions of everyone else’s. (Sometimes, from the outside, they even look the same. “But sometimes I don’t want to get out of bed either!” “But sometimes I feel sad for no reason either!” Okay, well, you might be depressed too. Or you might find that those things have no significant impact on your day-to-day life, whereas for a person with depression, they do.)

But it really doesn’t help when you’ve got mental health professionals obfuscating the issue in this manner.

As I said, Kinderman does go on to make some really good arguments, such as the fact that psychiatric diagnoses have poor validity and reliability. This means that they don’t seem to correspond that well with how symptoms actually look “on the ground,” and that different diagnosticians tend to give different diagnoses to the same cases. However, these are criticisms of the DSM, not of the medical model. I’ve felt for a while that we should move away from diagnostic labels and towards identifying specific symptoms and developing treatment plans for those symptoms, not for some amorphous “disorder.”

For instance, suppose I’m seeing a client, Bob. After getting to know each other for a few weeks, Bob and I determine together that there are a few issues he’s particularly struggling with: self-hatred and feelings of worthlessness, guilt, difficulty sleeping, lack of motivation to do anything, loss of interest in things he used to enjoy, and frequent, unbearable sadness. Traditionally, I’d diagnose Bob with major depression (pending a few other considerations/differential diagnosis stuff) and move on with treatment. But without these often-invalid and unreliable diagnostic labels, I just skip that step (although I might let Bob know that “depression” might be a useful word to Google if he’s looking for support and resources). Instead, Bob and I look at his actual symptoms and decide on treatments that might be helpful for those particular symptoms. Cognitive-behavioral therapy might help with Bob’s self-hatred, feelings of worthlessness, and guilt. Behavioral activation might help with his lack of motivation and interest. Certain dialectical behavior therapy modules, such as distress tolerance, might help him cope with sadness in the meantime. Antidepressants might very well help with all of them!

Because mental healthcare doesn’t treat disorders; it treats symptoms. Whether that mental healthcare is medication, therapy, or some combination, the ultimate goal is a reduction in symptoms.

I can see how the medical model makes this seem bad when it isn’t. In traditional healthcare, treating symptoms rather than getting to the root of the problem is downright dangerous. If someone has headaches and you give them painkillers without diagnosing their brain tumor, they’re in serious trouble.

However, we haven’t yet developed great ways of figuring out what “the root of the problem” is when it comes to mental symptoms, especially since there often isn’t one. It’s almost always some complicated tangle of genetics, early childhood stressors, interpersonal patterns learned from family, sociocultural factors, and so on. All of this affects the brain in fundamental biological ways, which further drives the symptoms.

Thankfully, that’s not as much of a problem as it would be with a physical health condition. If you only focus on symptoms and don’t treat the underlying cancer or diabetes or whatever, it will slowly kill you. But if you successfully treat the symptoms of mental illness, you will make the person’s life much better no matter what originally caused the symptoms. There won’t be anything silently killing them in the background, and good therapy teaches people the skills to avoid future relapses of their symptoms.

Sometimes the root cause of mental illness is, as Kinderman points out, a social problem. Poverty, social inequality, and other issues contribute heavily to mental illness. But since you can’t solve those issues from the inside of a counseling office, all you can do is help your client as much as possible. I do this every day, and believe me, it feels weird and gross at times. But what else can I do? Until our fucked-up society decides to come in and take a seat in my office, I can only work with my clients as individuals. (Otherwise I would have a very different job and it would not be therapy.)

Kinderman argues that treating mental illnesses as diseases is wrong because of these social factors that contribute to them. I understand his concern, because he (and many other people) treat “disease” as synonymous with “thing that is entirely biologically based.” So, the medical model feels like an erasure of the complex and valid social dynamics that contribute to what we call mental illness.

But I don’t think of disease that way at all, and I’m betting most doctors don’t either. Social factors contribute heavily to physical illnesses, too. People who are living in poverty or who are marginalized by the healthcare system in other ways are much more likely to have all sorts of physical health problems, and the results tend to be more severe for them. Stress, which includes the stress of poverty, racism, and other social problems, makes everyone more vulnerable to illness. Eating well and exercising enough, two very important factors when it comes to physical (and mental) health, are not equally accessible to everyone. Heart disease and diabetes may have biological origins, but they do not happen in isolation from societal factors, either. Just like mental illness.

You might argue that physical illnesses and mental illnesses differ in that physical illnesses are more heavily caused by biological factors and mental illnesses are more heavily caused by social factors, and I might agree. But again, that’s a difference in degree, not kind. Both types of illnesses affect us physically and mentally.

Another good argument that Kinderman presents is that the medical model may not help reduce stigma, and there’s research to back this up. Kinderman writes:

Traditionally, the idea that mental health problems are illnesses like any other and that therefore people should not be blamed or held responsible for their difficulties has been seen as a powerful tool to reduce stigma and discrimination.

Unfortunately, the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual. In contrast, a more genuinely empathic approach would be to understand how we all respond emotionally to life’s challenges.

So, that’s important and deserves highlighting.

However, I think the issue of how best to reduce stigma against mental illness is slightly separate from the issue of how best to help people with mental illnesses feel better. (There’s a school of thought in the disability community that disabilities [including mental illnesses)] “hurt” only because of the stigma and prejudice against people who have them, and I’m not particularly equipped to engage with that here except to say that it makes me angry in a way I can’t possibly explain. It completely invalidates how awful and wretched I felt because my symptoms hurt unbearably and not because of anything anyone else said or did to me as a result.)

When it comes to what people with mental illnesses actually find helpful, for some it’s the medical model and for some it isn’t. In her piece on mental “sick days,” Katie Klabusich writes about how freeing it actually was to see herself as “sick” when she needed to take a day off due to her mental illness:

I’d realized that not only is it alright for me to think of the dysthymia as the illness that it is, it’s necessary. If it were a south-of-the-neck illness, I wouldn’t have had the conflict about it. Yes, I’ve worked when I had a virus and shouldn’t have. (See the stats on service industry staff who work when they’re sick; we’ve all done it.) But my thought process would have been totally different. I certainly wouldn’t have needed the Ah ha! moment to know I had the flu. So why didn’t I realize I was sick?

Our culture impresses upon us that we SUCK IT UP and GIT ER DONE when our “issue” is “just mental.” Except . . .

MY BRAIN IS PART OF MY BODY.

It turns out that what happens in my head has a real—not imagined or exaggerated—physical affect on my other bodily functions. That list of symptoms from a dysthymia flare? They’re worse than the flu. Full-blown body aches and exhaustion alone are enough to make just sitting up nearly impossible. What work Idid do last week was all done from bed. Including writing this.

Others may not find that way of thinking helpful, in which case, they should absolutely abandon it in favor of whatever does help.

I want to end on a cautionary note about this whole idea of the medical model “pathologizing” “normal” emotions, because the alternatives I sometimes see offered to the medical model seem far, far worse about this. While Kinderman seems to argue sensibly for a more “psychosocial” approach to mental healthcare and a reduction in the use of medication (which I disagree with, but at least it’s sensible), others turn entirely away from scientifically validated treatments into “holistic” or “alternative” treatment. In many of these communities, “positive thinking” is seen as the only treatment you need, and anything that strays from the “positive” (like, you know, the negative emotions that are a normal part of almost any mental illness) is actively preventing you from recovering. There’s a very victim-blamey aspect to all of this: if you’re unhappy or sick,” it’s your own fault for not thinking positively enough.

I’ve had clients from these communities in counseling, and it’s very difficult to get any work done with them because they only ever want to share “positive” thoughts and feelings with me. As it turns out, medical model or no, they have completely pathologized any sort of negative emotion–including, in fact, the totally normal negative emotions that all of us experience all the time.

Yet it’s those evil psychiatrists who don’t want anybody to be sad or angry ever. Okay.

Some critiques of the medical model are quite valid and very useful. Others seem to rest less on evidence and more on a general sense of unease about the idea of thinking of mental symptoms as, well, symptoms. Kinderman even implies that it’s unethical. But “makes me uncomfortable” isn’t the same as “unethical,” as we all know. Unless I see evidence that this conceptualization is harmful overall, I see no reason to throw it out.

That said, if you’re a mental health provider and you have clients who are clearly uncomfortable with this model, maybe don’t use it to explain their conditions to them, since it’s unlikely to be helpful. All of these labels and diagnoses and explanations should serve the client, not the other way around.

And if you’re a person who experiences some significant amount of mental distress and you can’t stand thinking of it as an illness, then don’t! You don’t have to think of it in any way you don’t like. I hope you’re getting treatment of some sort that works for you, but at the end of the day, it’s actually none of my business.

~~~

*Yes, there are probably some bad psychiatrists out there who think that grieving at the loss of a loved one is literally a mental illness. There are also surgeons who leave crap inside of people’s bodies or amputate the wrong limb. I see these as roughly analogous.

~~~

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A Good Critique of the Medical Model is Hard to Find

Setting Boundaries With Your Therapist

It’s a rare relationship that doesn’t require any boundary setting, and the therapeutic relationship is no exception.

Setting boundaries is something many people find difficult for all sorts of reasons–fear of rejection, uncertainty over whether or not your desired boundaries are legitimate (spoiler alert: they are), a history of getting bad reactions from people when setting boundaries with them, and so on.

It’s especially difficult to set boundaries with people you perceive as having more power than you, whether they actually do or not. Therapists are often perceived as having power over their clients because of their expertise and authority, and because it can feel like your therapist is holding your mental wellbeing in their hands. Sometimes that power is more tangible–for instance, in cases where counseling is mandated or when the client needs their therapist to sign off on or approve something. And sometimes that power is compounded by structural factors, like when a client of color works with a white therapist or a queer client works with a straight therapist.

Although these power differentials are real and have consequences, it might be helpful to reframe the client-therapist relationship slightly. Namely: you, as a client, are employing your therapist. Your therapist works for you. Most likely, either you or your insurance company (or both) are paying this therapist, not the other way around. If your therapist isn’t helping you, or is doing something that you find harmful, you have a right to let them know and to expect them to fix the problem. You can fire a therapist who is failing to help you just as you can fire anyone else you hired for some task or service that wasn’t done to your satisfaction.

Some therapists may reject this framing because it feels too consumer-y, or because they worry that this will cause clients to leave them. But I would argue that we shouldn’t be using social norms to trap clients in therapeutic relationships that aren’t working for them, and also, this framing is directed more at clients than at therapists, because I think it will help them feel a greater sense of control over their therapy.

How to know when you need to set a boundary

Therapy can be uncomfortable sometimes. But it should be uncomfortable in ways that mesh with your goals. For instance, if your goal is to learn how to ride a motorcycle, but you’re scared of riding motorcycles, you’re going to be rather uncomfortable. That’s normal and okay. However, if your goal is to learn how to drive a car, and someone is pressuring you to ride a motorcycle instead, that’s not a normal and okay sort of discomfort.

If your goal is to form healthier, more stable relationships with others, you might be uncomfortable when your therapist notes that you seem to assume negative things about people without evidence. You may disagree with your therapist’s observation, at least at first. You may even be right. You may think, “How dare they tell me I assume the worst of people!” But that discomfort is part of the process. Even if your therapist’s observation turns out to be wrong, both of you have gained from this. You’ve gained greater understanding of you. But if your therapist’s observation turns out to be right, then you’ve especially gained.

On the other hand, if your goal is to form healthier, more stable relationships with others, and your therapist suggests that maybe it would help if you accepted Jesus into your life, the discomfort you may feel (at least if you don’t already believe in Jesus) is not part of the process. You and your therapist are at cross purposes. You have already decided that Jesus is not for you.

Not all examples of boundary-crossing are that obvious, however. Many people who go to therapy to deal with trauma report that therapists ask them invasive questions about the trauma, questions that they’re not ready to answer before more trust is built or before they work through things a little more. However, some therapists were trained that they should push for details about traumatic events because talking it all through in detail helps people heal. This theory has since been complicated quite a bit.

Even if sharing all the details of a traumatic event necessarily helped people heal, though, it is crucial that therapists understand that just because the therapy office should be a space where clients feel comfortable sharing anything, that doesn’t mean it automatically is. It can be triggering for survivors of trauma to reveal intimate details about what they went through to someone who is still basically a stranger to them. It’s perfectly legitimate for them to shut down certain avenues of questioning and to expect therapists to respect that boundary until they are ready to shift it.

Setting a boundary vs. firing

When do you ask a therapist to stop doing something that isn’t ok with you, and when do you simply stop seeing them? In most cases, the answer probably depends on what happens when you try to set a boundary. If your therapist refuses to respect your boundary or argues with it, it might be a good idea to find a different one.

(Note, though, that they might agree to respect your boundary but still ask you questions about the boundary itself. While this can feel uncomfortable, I think that’s usually that better kind of uncomfortable–your therapist needs to understand you and your boundaries in order to be able to help you, and it may also help you to process your reasons for needing the boundary.

For instance, when a client says that they can’t talk about something [yet], I won’t push them to talk about it. Instead, I might say, “How do you feel when you imagine telling me about this?” or “What happened last time you tried to talk about this with someone?” That yields a lot more information than “I really think you should tell me,” and is more compassionate.)

Another way to tell whether to boundary-set or leave is this: think about what it would take for this situation to be okay. For instance, suppose your therapist mentions that attending church might be a helpful way for you to cope with depression because that’s what helped the therapist. This makes you feel really uncomfortable and you don’t want to hear anything else about the supposed benefits of religious observance from your therapist. Imagine you say, “Please don’t mention religion to me anymore; I’m not religious and am absolutely not interested in attending church or hearing anything else about church.” Imagine your therapist responds, “Okay, absolutely. I won’t mention it again.” Does this feel okay to you? Are you okay continuing to open up to someone who might believe that you’d do better if you went to church (but doesn’t say so out loud), or are you still uncomfortable?

If you continue to feel uncomfortable no matter how well the therapist responds to your boundary-setting, then you might need to find a new therapist. The strength of the relationship between a client and therapist is the best predictor of the effectiveness of the therapy, so if you can’t trust or feel comfortable with your therapist, they’re unlikely to be able to help you.

Scripts for setting boundaries

In many ways, setting boundaries with a therapist doesn’t work much differently from setting boundaries with other people. Just as I might ask my friends not to talk about weight loss around me, I might ask my therapist not to mention weight loss in therapy. Just as I might ask a partner not to ask me about [topic], I might ask a therapist not to ask me about [topic].

One difference, though, is that it might be really useful in therapeutic boundary-setting to explain why you’re setting that boundary. With other people in our lives, that’s not always necessary and may be too scary/risky–I don’t want to disclose my history of disordered eating every time I ask someone not to talk about weight loss with me. Your boundaries are your boundaries whether your reason for them is one that others would consider “legitimate” or not. (All boundaries are legitimate.)

But a therapy situation, telling your therapist why you need this boundary gives them useful information that will allow them to help you better. If you say “please don’t mention weight loss because I have a history of harmful behaviors around that,” they might know what else not to mention, or what to ask for permission before mentioning. Knowing that you have a history of harmful weight loss behaviors helps them understand your psychological history and know what to look out for in the future.

Here are some specific examples of ways you can set boundaries with a therapist:

“Please do not ask me about my weight or dietary habits. It’s a trigger for me because of past issues with disordered eating.”

“Actually, I didn’t ask for advice. Please either ask me before you give advice, or wait for me to ask for it myself.”

“The issue I came here to work on was my depression, not my relationship with my parents. Let’s keep our discussion focused on my depression as it’s affecting me right now, because that’s what’s causing the most problems for me right now.”

“I’m not ready to talk about the stuff that happened with my brother when I was little. You can ask me again in a few weeks and I’ll let you know if I’m able to talk about it then.”

“My identity as an atheist is not the reason I’m struggling with depression. If you continue to suggest that my mental illness is caused by atheism, I won’t feel comfortable coming here anymore.”

“I do not believe in karma, Zodiac signs, or any other superstitions. Please stop bringing them up in our sessions and stick with what can be tested scientifically.”

“I need you to stop suggesting that it’s my fault that I’m being bullied. Even if there were some truth to that, it feels like you’re putting all the blame on me and it’s preventing me from opening up to you about things.”

It may feel somehow manipulative to tell a therapist that you won’t tell them things or come back to therapy if they don’t respect your boundaries, but it’s also true. You can’t effectively work with a therapist you can’t trust, and they need to know that.

Also, while I certainly don’t think you should be intentionally mean, don’t worry about the therapist’s feelings. It’s our job to worry about our feelings, and your job to be as direct and open with us as you can be.

When setting boundaries is a challenge

As I mentioned, most people find boundary-setting difficult, especially in situations where they feel that they have less power than the other person. If you’re finding it so difficult to set boundaries with a therapist that you’re unable to speak up about it at all, here are some suggestions:

  1. Practice first. You can practice in front of a mirror, alone in the dark, with a friend–whatever works for you. If you’re practicing with a friend, you can tell them a little about your therapist and what they’ve been doing that’s problematic so that they can roleplay as the therapist. Make sure to be clear with your friend about what you want them to do in the roleplay–for some people, roleplaying “worst case scenarios” (for instance, your therapist arguing with you and refusing to respect your boundary) can be useful because it allows them to prepare; for others, it might just be really anxiety-provoking.
  2. Write it down and bring it to session. If you don’t feel like you can come up with the right words on the spot, write them down and bring them to therapy with you so you can read them or at least refer to them. It might sound weird, but you won’t be the first person who’s done it. Many therapists actually encourage clients to do things like this, because anything that helps facilitate communication in therapy is probably a good thing.
  3. Write it down and email it. Although we often hear about the virtues of Real Face-To-Face Communication, I’d say two things here: 1) text-based communication is also a real and legitimate way to discuss difficult things, and 2) the perfect is the enemy of the good. If you are so uncomfortable bringing something up with your therapist in a session that you’re not going to bring it up at all, try doing the next best thing, which is emailing them. That way, you’ll have ample time to think about what to say and run it by trusted people if you want to. Know that your therapist may respond by asking you to bring this up with them in the next session, so you’ll probably still need to discuss it with them in person, but that initial email can help open the floodgates.
  4. Be transparent with your therapist. You can say something like, “Setting boundaries is really hard for me, so I’m having trouble finding the words for what I’m trying to say,” or “I’m really uncomfortable with something you said in the last session, but I’m scared of bringing it up.” A good therapist will know how to guide you through this and help you speak up.
  5. Don’t worry about bringing things up days or weeks after the fact. You don’t have to have a perfect, firm, concise boundary-setting comeback right away. It’s totally normal in therapy to bring up things that happened a few sessions back. It’s never too late to make sure that therapy is meeting your needs.

Conclusion

Sometimes all people need to hear to be able to set boundaries with their therapists is that they have the right to. Always remember that. Your therapist works for you. Your therapist has expertise, yes, but they are not the expert on you individually. You know way more about yourself and the boundaries you need than any therapist can ever know.

It is true that some of the boundaries you may set may delay your growth or recovery, or make it more difficult for your therapist to understand what’s going on with you. However, what delays your growth or recovery even more is feeling unable to trust your therapist or connect with them. A boundary isn’t a permanent brick wall. It’s a fence. Two people can stand and chat from opposite sides of a fence, and over time, you can choose to build a gate in the fence and open it up, or close it again.

~~~

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Setting Boundaries With Your Therapist

The Importance of Self-Awareness for People Who Want to Change the World

I gave this talk at Sunday Assembly NYC last weekend. A bunch of people have asked to see my notes and slides, so here they are! That’s why this isn’t really in blog-post format. Here are the slides.

[At the beginning, I asked how many people in the audience volunteer their time to a cause they care about, and/or donate money to a nonprofit organization. Not surprisingly, it was most people in the room.]

Why do people engage in altruistic acts like volunteering time or donating money? Here’s a partial list of reasons:

  • Community building: for instance, we might donate or volunteer when there’s an emergency in our community, or when someone in our social network is doing a crowdfunding campaign.
  • Social pressure: for instance, we might donate when a canvasser asks us to and we feel bad about saying no.
  • Religious or moral obligation: maybe not applicable to most people in this room, but some people do altruistic acts because they believe their religion obligates them to.
  • Social rewards: when we volunteer for reasons like resume building or making friends, those are social rewards
  • And, finally: because it feels good! This is the one I’ll mostly be talking about here.

Some people claim that altruism stems entirely from one’s values and ethics, and that emotions have nothing to do with it. They may also claim that doing good things because it makes you feel good makes those things less good, which makes it unpopular to admit that you like how it makes you feel when you act altruistically.

This view is more about the sacrifice made by the individual doing the altruistic act, and less about the actual positive consequences that that act has. It comes from the belief that anything that feels good is inherently suspicious, possibly morally bad, and a barrier to being a good person–a belief I’d associate more with religion (specifically, Christianity) than anything else.

But there’s nothing inherently bad about doing things because they feel good. In fact, we can harness this feature of human nature and use it to do more good! But in order to do that, we have to learn to be aware of our motivations, whether we like them or not.

Before I get into that, I also want to note a practical aspect to this: if we allow activism or charity work to make us feel bad rather than good, we’ll burn out, lose hope, and stop trying. It might be prudent to encourage each other and ourselves to feel good about altruistic acts. Of course, self-care is really important anyway, even when it means taking a break from activism or quitting it altogether. But that’s a topic for another talk.

Let’s look at some research on altruistic behavior. Keep in mind that these are just a few examples of a vast number of different studies and methods; studying altruism scientifically has become very popular.

Empathy, which is the ability to see things from someone else’s perspective and imagine how they might feel, is a predictor of altruistic behavior. However, as we always say in the social sciences, correlation is not causation. The fact that it’s a predictor doesn’t necessarily mean it causes it; maybe engaging in altruistic behavior also enhances our ability to empathize, or something else is impacting both variables. But it does seem that the two are related.

Relatedly, brief compassion training in a lab can increase altruistic behavior. Compassion training is basically just practicing feeling compassionate towards various targets, including people you know and people you don’t. Even after a short session of this, people were more likely to do altruistic things.

People who perform extraordinary acts of altruism, such as donating a kidney to a stranger that you’ll never see again, may have more activity in their amygdala, which is a brain region that (among other things) responds to fearful facial expressions. It’s difficult to say for sure what this means, but it could mean that altruism is driven in part by automatic neural responses to someone else’s fear.

People who volunteer for “selfish” reasons, such as improving their own self-esteem, tend to keep volunteering for the same organization for a longer period of time than those who say they volunteer more for purely ethical reasons. Keep in mind, though, that this doesn’t necessarily mean that the “selfish” volunteers volunteer more overall. It’s possible that the ethics-driven volunteers have less of a motivation to stay with the same organization–after all, many people and causes need help.

Unsurprisingly, spending money on others makes people feel happier, and the happier they feel as a result, the more likely they are to do it again, creating a feedback loop.

It works similarly with donations to charities, even when they involve a simple money transfer without much of a human element. Donating to charity activates brain regions linked to reward processing (usually associated more with getting money than giving it away!), and in turn predicts future giving.

What does all that mean?

Basically, seeing people suffer may make us more likely to engage in altruistic acts to try to help them. Seeing people suffer is painful for most people, and helping them is a way to ease those negative emotions. Doing nice things for people can make us happy, which can make us even more likely to do nice things for people again. The implication of brain structures such as the amygdala suggests that it’s not all about higher-order values and beliefs, but also basic, automatic brain processes that we can’t necessarily control. But of course, our values and beliefs can in turn influence our brain processes!

If we do altruism for “selfish” reasons, like having a sense of belonging or feeling good about ourselves, we may choose things that feel best rather than the ones that do the most good.

One example is voluntourism–when people travel for the purpose of volunteering to build houses, for instance. I have no doubt that many of these programs do a lot of good, but they have also been criticized, including by the communities they’re trying to help. For example, sometimes houses built by college students who have never done a day of manual labor in their lives aren’t necessarily very well-built. And often, these programs don’t actually empower the target communities to thrive on their own, leaving them dependent on charity. But these programs feel very rewarding to the volunteers: they’re intense, they build strong social bonds, they involve traveling to a cool place, and they make people work hard physically and get stronger. No wonder so many people love them.

Another example is in-kind donations. Again, sometimes very helpful, but often not. Organizations that do disaster relief often ask for money instead of goods, because then they can use it for whatever’s most urgently needed. They may desperately need medicine, but keep getting t-shirts instead. Giving them money rather than clothes allows them to buy what they need. Donated goods may also not be practical for the area in question–for instance, TOMS shoes, which is where you buy a pair of shoes and another gets sent to an impoverished child overseas, may not actually be very practical in communities where people walk miles each day over unpaved roads. While they’re very cute and comfortable, they may not last long. But, of course, organizing a clothing drive or buying a pair of shoes probably feels a lot more rewarding than sending a boring check.

Here’s one more study to help illustrate how this plays out. In this experiment, researchers showed one group of participants a story about a starving girl and asked them to donate to help her. Meanwhile, another group of participants saw the exact same story, but this time with accompanying statistics about the broader implications of starvation and how many human lives it takes. You might think that the latter group would give more money–after all, they have even more of a reason to donate.

Instead, they donated much less.

Why? From the NPR article:

The volunteers in his study wanted to help the little girl because it would make them feel good and give them a warm glow. But when you mix in the statistics, volunteers might think that there are so many millions starving, “nothing I can do will make a big difference.”

The participants in the second group, the ones who saw those dismal statistics, felt bad. They felt so bad that they no longer wanted to give money.

And likewise, we may choose forms of giving that feel best, which means “sexy” causes, issue affecting people emotionally or geographically close to us, and causes our friends are doing. We may not even realize that’s how we’re choosing. A little self-awareness can go a long way.

It’s difficult to hear criticism of one’s activism or charity work. It’s especially difficult when our motivations include social acceptance and self-esteem. This is especially important in social justice activism, where you may be working with or on behalf of people who are directly impacted by things you’re not.

I often get angry responses when I try to constructively criticize men who are involved in women’s rights activism. They’ll say things like, “How dare you tell me I’m being sexist, I’m totally an ally!” Their need to feel accepted makes it impossible for them to hear even kind, constructive criticism.

There are other, smaller-scale ways in which we help people all the time–listening to a friend who’s going through a hard time, giving advice, or, if you’re a counselor or therapist like me, doing actual counseling.

Sometimes, people–even therapists–do these things because they want to “fix” people. Seeing people in pain is hard and we want to make their pain go away–not just for their sake, but maybe for our own, too.

But if that’s our motivation and we’re not aware of it, we may give up in frustration when people don’t get “fixed” quickly enough. We may even get angry at them because it feels like they’re refusing to get fixed out of spite. As someone who’s struggled with depression for a long time, I’ve lost friends and partners this way.

As I mentioned, I’m also a therapist. Most therapists, especially at the beginning of their careers, have a supervisor. A supervisor isn’t just a boss or a manager–it’s a mentor we meet with regularly to process the feelings we’re having as we do our work, and to make sure that our motivations and automatic emotional responses don’t get in the way of that work.

Most of you aren’t therapists, but you can still learn from this practice. Supervision is therapy’s version of checking yourself before you wreck yourself. If you’re supporting someone through a difficult time, it might be helpful to talk through your own feelings with someone else.

[Here we did a small group exercise, though I also made sure to give people the option of just thinking about it by themselves if they don’t like discussing things with strangers. The exercise was to think/talk about these three prompts:

  • Think about a time when you volunteered, donated money, or did some other altruistic act, and found it very rewarding. What made it feel that way?
  • Think about another time when you did an altruistic act and didn’t find it very rewarding at all. Why not?
  • Think about a time when you were trying to do something altruistic, but your own emotions or personal issues got in the way. What was that like?

Afterwards, I asked for audience members to share their experiences with the larger group and we talked about how all of those experiences relate to the themes I’ve been talking about.]

In conclusion: Selfish motivations can inspire a lot of good actions. There’s nothing wrong with that! However, being aware of those motivations rather than denying their existence can help you avoid their potential pitfalls.

If we truly care about helping others, we should try to do so in the most effective and ethical way possible, and that means being willing to ask the tough questions about what we do and why.

~~~

Here’s the blog post this was partially inspired by.

The Importance of Self-Awareness for People Who Want to Change the World

"That totally happened to me, too!": The Urge to Relate

A lot of what happens in therapy should only happen in therapy. (I’m looking at you, folks who oppose trigger warnings because “exposure is very important for overcoming trauma.”) But a lot of other things that happen in therapy are very applicable to the rest of our relationships and interactions. One of those is the tension between normalizing someone’s experience and validating it.

Normalizing someone’s experience essentially means helping them feel that their experience is normal. Short of memorizing statistics, the easiest way to do that is to relate what they’re telling you to something that’s happened in your own life. This is a very common conversational move. Someone tells you about a bad breakup and you say, “Oh, I totally went through something similar recently. It can be really hard.” Someone tells you their NYC subway horror story and you respond with one of your own. (We all have an arsenal of those.)

Validating someone’s experience is a more complex conversational move. To validate means “to demonstrate or support the truth or value of.” In the context of therapy or supportive conversations between friends, validating someone’s experience means letting them know not only that you believe them when they say that it happened–which can be particularly important when someone discloses, say, sexual violence or mental illness–but also that you affirm this as an “okay” thing to talk about or think about. The opposite of validating is to say “That’s not that big of a deal.”

Obviously, you can both validate and normalize someone’s experience in the same conversation. Therapists frequently do both.

However, the way of normalizing that we most frequently use in casual settings–relating someone’s experience to our own lives and selves–can get in the way of that.

For instance, someone says, “I’m having such an awful time getting out of the house this winter.” If you immediately jump in to say, “Oh, me too, it’s so awful, I couldn’t even make myself go to my friend’s birthday party because it was so cold out,” you may succeed in helping them feel like it’s okay to be having this difficulty, but you may also miss an opportunity to affirm the fact that their own unique experience is legitimate and difficult for them.

I get this often with fatigue. I try not to talk about being tired very much because I don’t like “complaining,” but sometimes I do mention it, and people usually jump in immediately to talk about how tired they are and how they only slept four hours last night and so on. But the thing is…my tiredness is a little different. I sleep at least 8 hours almost every single night, and have been for years. If I let myself, I would sleep 10 or 11 or more hours. I don’t know what it means not to want to sleep. Every day I daydream about coming home and going to sleep.

Of course my friend’s experience is also legitimate, and it sucks to only get four hours of sleep and feel shitty. But for them, not feeling tired as often as simple as finding the time to sleep enough. For me, absolutely nothing I have been able to try without medical intervention has helped.

So when I mention being tired and people immediately jump in to relate, I feel like I can’t talk about how extensively awful it is for me, because everyone feels tired! Feeling tired is normal! That’s just how life is! (Deal with it!)

On the other hand, some things feel bad not just in and of themselves, but also because of the shame and isolation that surrounds them. Mental illnesses are often like this because few people know a lot of people who are open about it (though that may now be changing). When I was first diagnosed with depression, I didn’t know even one other person who was (openly) diagnosed with it. I thought everyone else had it together and I alone was a failure. I saw the statistics on how common depression is, but they did nothing for me. What helped was to start meeting other people who struggled with it. Depression still sucked, and still does, but I no longer had to carry the burden of Being The Only Person In The World Who Can’t Even Be Happy.

How can you tell what someone needs in a given moment? How do you know if it’ll be more helpful to normalize their experiences, or to validate them?

Often there isn’t really a way to tell. In sessions with clients, I rely a lot on intuition and previous experience. But there are some things that people say that can serve as hints as to what they might need from you.

For instance, when people say things like, “I can’t believe I’m having trouble with something so simple,” or “I’m such a failure; I can’t even find a job,” or “Nobody else has all these problems,” that can be a sign that normalizing might be helpful. It can reassure them to know that other people do have trouble with these supposedly simple things, or that other people do actually struggle a lot with finding a job, or that other people do have these same problems. Sometimes what the person is dealing with really is shitty, but it feels a lot shittier than it has to because they think they’re the only one who’s so pathetic and incompetent as to have that problem.

On the other hand, when people say things like, “I know it shouldn’t even be a big deal, but–” or “Everybody probably deals with this but–“, pay attention to those but‘s. The part after the but is the part they have trouble accepting as valid. Everybody deals with it! It’s not a big deal! Therefore, what right do I have to even complain about it?

When someone says things like this, sharing your own experience and relating to them might not be as helpful. What they really need to hear at that moment is that their unique version of that probably-common problem is worthy of paying attention to and talking about. They might know perfectly well that other people have similar problems, but it still feels bad and that’s the part they want to hear acknowledged. Yes, everybody hates winter, but here’s how it sucks for me. Yes, everyone is tired, but I almost passed out after climbing a few stairs. Yes, I know you probably miss your family too, but I just really really miss mine today.

“Common” problems are easy to relate to. Most of us have had bad breakups or manipulative family members or really exhausting days. But rushing to relate your own experience closes off the possibility of learning more about their life. When you feel an urge to share your own experience, instead, try asking more about theirs and seeing if your experience is still as relevant as you thought.

With certain types of issues, relating your own experiences can also easily come across as one-upping even when you don’t mean it to–although, to be real, sometimes that’s exactly how people mean it. Please don’t one-up people. There’s no need. There is not a limited quantity of sympathy in the world, so there is no need to compete for it.

You might also accidentally relate to only a very small part of what they actually said, leaving them feeling misunderstood or unheard. For instance, if I share a story about a classmate saying something very hurtful and ignorant about queer people, and you share a story about a classmate saying something very inaccurate about cell biology, you may have missed the fact that the relevant part of my story wasn’t “a classmate said something silly” but rather “a classmate made a homophobic comment in class that impacted me personally.”

The urge to relate to someone’s experiences comes from a lot of places, I think. It’s a common way of trying to show someone that you understand. Showing someone that you understand them is a common way of earning their trust, respect, and affection. It indicates that you have things in common.

In therapy, of course, things are different in that the focus should always be on the client and their needs. But therapists do sometimes share stories from their own lives, and the purpose is slightly similar to how it works in casual conversations between friends–it’s a way for therapists to signal understanding of their clients, and also to let them know that they are not alone in some of their experiences. Sharing a personal story can be more powerful than simply saying something like “You’re not alone in that,” because it gives something more than a reassurance: it gives evidence. (Anecdotal, but still.)

Yet both in therapy and in life, sharing one’s own experiences can get in the way of fostering a better, deeper understanding of another person. It can also make it difficult for them to tell you more about their experience, because you’ve now turned the conversation back to yourself. It can seem very disingenuous if it’s clear to the person that you don’t actually understand very well at all.

And while we often tell ourselves that we relate to others in order to make them feel better, there sometimes is some selfishness in it. We want to prove to others that we “get it” so that we feel better about ourselves and our ability to understand and connect with people. A natural impulse, but that doesn’t make it necessarily helpful or productive all of the time.

I see this often in conversations about injustice. A marginalized person shares an experience they have had with discrimination or prejudice, and a person who is categorically unable to have the same experience nevertheless tries to relate something from their own life. Sometimes they relate an experience of being treated badly in a way that has nothing to do with their societal position, and sometimes they relate an experience that has to do with another dimension of identity.

There are definitely some important similarities in the ways in which many different marginalized groups are treated, but that doesn’t necessarily always mean that we can relate. The presumption of understanding can easily get in the way of actual understanding when a white woman assumes that her gender helps her understand someone’s experience of racism, or when a gay man assumes that his sexual identity helps him understand a trans woman’s marginalization. I mean, maybe it does, in a few limited ways. But we should always strive to learn more before assuming we “get it.”

I think a lot of people experience the urge to relate. I’ve definitely felt it. For instance, once a friend of mine who is Black was sharing some experiences of racism they had had, and I suddenly noticed a little gear turning in my brain trying to generate similar experiences from my own life that I could share. I thought, wait a minute, I never told my brain to do that! That wouldn’t be helpful right now. How could I listen fully if part of my brain was so busy trying to connect my friend’s experience to my own? How could I even come close to understanding their experience if I was already biasing that understanding by thinking of my own interpretations of my own experiences, which had nothing to do with racism?

This, I think, is what drives a lot of the confusion and miscommunication that happens around issues like race and gender. For instance, suppose a Black woman is telling me about how her coworkers and supervisors always assume she is angry and hostile when she isn’t. I start thinking about times when I have been assumed to be angry and hostile, and how that hurt, and how I dealt with them. Maybe I dealt with them by adopting a more friendly and cheery approach, and that helped. Awesome! I’m going to tell my friend about My Experiences and What Worked For Me!

Except that What Worked For Me is very unlikely to work for someone who is not white. As a white woman, I am not automatically assumed to be angry and hostile no matter what I do, generally speaking. So adjusting my demeanor, even though I felt that I was behaving appropriately before, might help change others’ perceptions of me in a substantially helpful way. A Black woman can be as painfully polite and deferential as she possibly can and yet she’s still likely to face that sort of stereotyping. Maybe if I’d listened rather than spent all that brainpower thinking about my own life experiences, I would’ve understood that.

(See also: Lean In by Sheryl Sandberg.)

Likewise, when I talk about feeling threatened by a man in public and men jump in to tell me that I should’ve Just Punched Him or Just Told Him To Fuck Off, they are thinking of their own experiences and how they might’ve reacted in that situation (for better or worse). A man who decides to Just Punch a man who is being offensive to him may end up getting hurt in a fistfight, but the consequences would be much more severe for me if I tried the same thing.

(See also: “Just call the police!”)

So, what do you do when someone shares an unpleasant experience and you have no idea whether or not relating something from your own life might be useful?

Here are some scripts:

  • “Do you think it might help to hear about something similar I’ve dealt with?”
  • “I’ve gone through something that sounds a lot like that. Feel free to ask me more about it if you want, or to just talk about your own stuff.”
  • “I know this may not necessarily fix the problem, but something that helped me with that was _____.”
  • “That sounds really hard, but you’re not alone in dealing with that.”

Alternatively, it’s almost always a good idea to ask them more questions (with the caveat that they don’t have to talk about it more if they don’t want to) so that you can understand what they’re going through better.

In social work school, we learn a lot about the importance of being very aware of what’s going on in our own heads as we’re trying to help others. That’s useful for any sort of interpersonal situation. It’s a good idea to go into these types of serious conversations with an awareness of what you’re bringing to the table, including your own needs and desires and biases. Many of us want to feel competent when it comes to understanding and helping our friends. That’s commendable, but it too easily turns into a search for affirmation from people who are busy trying to share their own troubles.

Don’t let your need to demonstrate your understanding get in the way of actually understanding.

"That totally happened to me, too!": The Urge to Relate