Patients frequently question their mental health professionals as to what action they should take in any given circumstance.  Most want advice about marriage, children, jobs and coworkers, while others have concerns about other relationships.  One of the most complicated of these, which can cause the most angst, and possible detriment, is the therapeutic relationship. 

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Miri is an 18-year-old girl who began to see a therapist after several teachers voiced concerns about her irritable and sad demeanor. She was agreeable to start a low dosage of an antidepressant, and to begin therapy. Although she soon showed definite improvement, she continued to complain about headaches and tension. During our next session, she approached me, “Doctor, I asked my therapist what she knows about CST, and she appeared offended. She asked what this was, and could you believe I had to explain Craniosacral Therapy… to my own therapist????...I explained what it was and asked if she could show it to me.  She said, no, and asked me to find a different therapist. We have not spoken or had an appointment since”.

In the above example, there are several points to consider. Clearly, Miri interpreted this lapse as ignorance on the part of her therapist.  However, is this fair or valid? While many therapists do have an area of expertise, or conduct a particular type of therapy, not all do. Additionally, not all specialty therapies should be used on all clients. Another point to consider, is that therapists are people, too, who can become ashamed, frustrated, or embarrassed.  Thus, we cannot interpret her therapist’s actions, nor advise if the therapeutic relationship should or should not continue, if Miri is not willing to continue the dialogue with her therapist, or give consent for her MD to intervene on her behalf. 

After further discussion, Miri was able to describe the positive aspects of her sessions with her therapist, as she felt that she had been helpful in improving her mood overall. Although she did not want her MD to approach her therapist, she was willing to have a discussion, and consider staying the course. Unfortunately, her therapist denied having any memory of the prior conversation when Miri brought it up again, which further fragmented Miri’s trust, leading to her termination of treatment with her therapist.

Although Miri was upset with the outcome of the treatment, she was proud that she was able to have a difficult discussion, which took courage for her to be able to re-open the dialogue. With guidance, she was able to discuss her interest in cranio-sacral therapy at the onset of treatment with her new therapist, whom she chose specifically due to her knowledge of that modality. 

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Rachel is 28-years-old and has been married for 6 years.  She has been trying to have children, but has been struggling with infertility. This has caused her a great deal of anxiety, and has precipitated panic attacks, which have interfered with her daily functioning.  Although she has been in therapy with a therapist she adores, she has been finding herself reluctant to schedule a new appointment after her current therapist’s latest maternity leave.  She wonders whether to find a new therapist.

After discussion, Rachel was able to articulate her reluctance to see her therapist after maternity leave, as she felt that this was a reminder of her own perceived inadequacies and struggles. She had been feeling, for some months, that her therapist did not understand her emotions, having never been faced with similar circumstances. However, her conflict centered around her positive transference towards her therapist whom she perceived as a motherly figure.  

With encouragement and support, she was able to schedule an appointment with her therapist and have an open and honest discussion about her feelings.  Her therapist was able to validate her concerns, and referred her to a support group, and an individual therapist affiliated with her fertility center. 

This therapist showed maturity and was able to understand what her client needed in order to progress.  Although Rachel’s treatment ultimately needed to be transferred, she felt validated and understood, which, in itself, was considered a positive outcome of therapy.

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Malky is a 46-year-old woman who is married with several children. She had been seeing a therapist for three years, but had not been making much progress, as she was reluctant to speak of any past experiences. Instead, she only focused on seemingly trivial minutiae happening in the present or recent past. When confronted about this, she was slowly able to disclose that she had a history of trauma, but was reluctant to divulge the details. Due to her burgeoning trust, she slowly began feeling happier and calmer.  However, one day, she attended a family simcha, and randomly spotted her therapist across the room.  Since then, she has been having nightmares and has become preoccupied with thoughts of her therapist gossiping about their confidential sessions. 

Malky appears to be guarded by nature, and is slow to confide in others.  However, it appears that her therapist showed skill and compassion in allowing her to go at her own pace, as she gained confidence in the therapeutic relationship. When she saw her therapist in a social situation, her anxiety increased, and she became consumed with doubt and fear, which caused her trust to diminish.  However, objectively, there was no reason to believe that any boundary had been breached. 

Malky was able to speak with her therapist about her concerns at their next appointment. Her therapist was able to reassure her and validate her concerns.  Further, they were able to have a discussion about how both should react if they meet in a social situation, as they live in adjoining communities. Due to these circumstances, Malky continued to make progress over the next few years, eventually graduating from therapy.  She was happy that she had stayed the course, and became an advocate within her social circle, about the importance of addressing one’s mental health needs. 

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Yossi is a 24-year-old young man, who is dorming in yeshiva.  One day, he entered his therapist’s office disheveled and smelling of smoke. He excused his appearance, explaining a night of drinking and smoking marijuana.  He did not appear ashamed, nor repentant, later bragging to MD about how his therapist joined him in smoking weed outside his office after a session. 

This was a clear example of a broken boundary, and possible exploitation of the patient. However, Yossi was very enamored with his therapist, and felt that his substance use was validated, leading to an acceleration of his cannabis usage.  Unfortunately, Yossi continued in his therapy sessions, until the following week a DUI brought the circumstances to light, and he entered into substance abuse treatment, albeit reluctantly.  (Whether this therapist should have been reported to an official agency is outside the scope of this article).  This example illustrates the immense influence therapists have over their clients, which should be used for positivity and not destruction. 

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Meir is a 10-year-old boy who was brought to therapy after refusing to attend school for several weeks.  After a guarded and hostile start, he began to disclose a history of trauma.  Despite this breakthrough, he began to refuse to awaken from his bed, and started to avoid his sessions. His parents wondered if he should find another therapist. 

Due to these circumstances, my involvement initially involved collateral sessions with his parents. During those sessions, I was able to explain the therapeutic process, as well as discuss goals for the treatment.  Often, when traumatic memories are uncovered, the patient will feel worse before feeling better. In actuality, the fact that he was able to trust in his therapist was a huge factor in his recovery.  His parents agreed to stay the course, and he benefited greatly from his treatment.

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All mental health providers are different, as are all patients. In addition to their physical characteristics, as well as age, gender, and ethnicity, all therapists have their own personality and therapeutic style. How patients relate to their therapist usually involves the “chemistry” present in all interpersonal relationships.  There is no “one size fits all”. When difficulties arise, it is common for clients to become confused as to expectations and how to resolve conflicts. Thus, patients often reach out to their other health care providers for guidance.  

When faced with these dilemmas, I usually reassure patients that in most circumstances there is no right or wrong, only different paths that one can take.  I will almost always encourage them to discuss their feelings and concerns with their therapists.  This will resolve most conflicts, and usually opens up honest and productive dialogues, elucidates expectations, and solidifies relationships. In the event that termination occurs, it provides a sense of closure for both parties. In the rare event that continuation of the treatment would be detrimental to the patient, the other health care professional may need to intervene to smooth the process. In therapy, as well as in life, often the best option is to stay the course, which can lead to a more comfortable and brighter future. 

Pamela P. Siller, MD, is a Board-Certified Child, Adolescent and Adult Psychiatrist who provides medication management as well as individual and family therapy to children and adults. She maintains a private practice in Great Neck, New York. Dr. Siller is also the Director of Child and Adolescent Psychiatry at the Interborough Developmental and Consultation Center in Brooklyn, and an Assistant Professor of Psychiatry at New York Medical College. Dr. Siller can be reached at 917-841-0663.

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