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A Crash Course in Psychotherapy: Moving through Anxiety and Self-Doubt
Filed Under: Beginning Therapists
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"There is a way out," I couldn't help telling myself as I imagined the door to the small clinic office behind me. The room held nothing but two mismatched office chairs, a window with half-retreated, yellowing blinds, and the heavy smell of sweat, carpet cleaner and someone's lunch. My stomach was tied in knots, and air flowed in and out of my nose surprisingly easily, the way it always seemed to when my heart picked up its pace and my sinuses cleared in response.
There was no room in that cramped office for a break: no way Sam* and I could stretch our legs, distract ourselves by staring at titles on a bookcase, or recline in our chairs and close our eyes. There were just two feet of space between us, and I cringed at the thought of moving and accidentally having our knees bump. It was just us—his regretful disclosure, and my words that brought no comfort—that I had to be with, unless I bolted out that door.
I remember the simple instruction that was given to us psychotherapy interns during orientation week: Always sit in the chair closest to the door so you have a way out if your client places you in danger. This was a surprising prospect for me, a 25-year-old first-year therapist still in graduate school, who chose to work at an outpatient LGBT community mental health clinic. I pictured myself with clients struggling to come out to family and friends, coping with the loss of a loved one, or needing to heal from childhood trauma. This was, in fact, the case. But it was also the case that I would see clients who suffered paranoia, borderline personality disorder and severe post-traumatic stress disorder.
This is the way it works in the mental health field—the least experienced get assigned the most severely disordered and challenging clients
This is the way it works in the mental health field—the least experienced get assigned the most severely disordered and challenging clients, whereas the seasoned therapists get to pick their client load, and more often than not, it seemed, stick to young women with relationship problems.
I stayed in that clinic office with Sam, because if I didn't, what was I proving to myself? What was I proving to my client? I could make it through this. He could make it through this. There was no physical danger, only a danger that I sensed we both felt coming from inside ourselves, screaming to us through our blood and pounding down on our chests. But this danger felt more difficult to conquer, because the perpetrator was all around and nowhere at once.
Two months after I started my internship, my clinical supervisor and I did an intake with Sam, who I was scheduled to see weekly for psychotherapy. In Sam's intake, he volunteered very little about himself. The soft lines around his eyes and mouth told me he was in his mid-30s, and he wore jeans and a flannel shirt. He didn't look at all like the gay men who worked at the clinic, with their pressed button-down shirts and neatly gelled hair, or the preppy Castro-neighborhood dwellers wearing pastel shirts with the collars up, tight designer jeans and Ray-Ban sunglasses. Sam came in carrying a skateboard and a messenger bag. His narrow, stubble-covered face was topped with a mess of light brown hair, and his Levi's seemed to almost fall off his scrawny body.
Sam refused to give us his last name, and the stiffness in his body turned to agitation when my supervisor and I asked him about his family history. "I don't understand why you need to know this," he told us, his eyes shifting around the room and his arms crossed tightly in front of his chest. We told him he didn't have to tell us anything he didn't want to—something I would find myself saying to him many times throughout our six months working together. I discovered later that day that he had disclosed more on the intake form than the interview.
The three fractured sentences he wrote under the History section spoke volumes: "Sexually abused as a kid. A lot. Don't know how many times."
The three fractured sentences he wrote under the History section spoke volumes: "Sexually abused as a kid. A lot. Don't know how many times."
I already knew from his intake that Sam would be a challenge to work with. But when Sam told my clinical supervisor that he wanted to have her as his therapist instead of me, I knew I would be in for a rocky ride, and I would have to prove to Sam, despite my inexperience, that I had the clinical expertise to help him. I thought it would be easier to talk to Sam with my supervisor out of the room, and hoped he would feel safer that way since it would be just one—not two—therapists to contend with.
We spent the first therapy sessions with me mostly asking questions and him answering. Moments of silence brought his body to shift in his chair and his eyes to stare wide at the door, so I kept the conversation going any way I could. He told me about his boyfriend and the problems they were having. He recalled fits of anger toward his boyfriend that seemed to come from nowhere, and anxiety attacks at bars and parties. But I could see that something much darker and scarier lurked under Sam's surface and controlled his life. He continued to refuse discussion about his family and childhood, and even benign-sounding questions like "Where were you born?" would lead Sam to erect a wall of fear and anxiety between us. "I don't want to talk about it," he would say, his face turning white, his expression cold and serious. "Okay," I nodded, keeping my tone calm and even, and moved the conversation back to the present.
The truth is I wasn't calm. I dreaded every session with Sam. I felt inadequate to deal with what lurked under the surface, and felt responsible for the tenseness between us. I had received basic clinical training on working with trauma survivors in school. I knew it was important to move slowly with Sam and not let too much be revealed at once, because the memories of his past could overwhelm him. But I felt like the therapy was moving too slowly, and that I wasn't reaching him at all.
Like a lot of new therapists, I was hard on myself. I pushed myself to be the kind of therapist Sam wanted and needed. His case consumed my thoughts:
I fantasized about having a breakthrough moment with him, where he would finally relax into our sessions and open up to me, and I would guide him through reclaiming his painful past with perfect expertise and confidence.
I fantasized about having a breakthrough moment with him, where he would finally relax into our sessions and open up to me, and I would guide him through reclaiming his painful past with perfect expertise and confidence. I often spent my entire supervision hour consulting on his case and brought what I had learned into our sessions. I taught Sam practical techniques to get a handle on his anxiety, and new ways to open up discussions with his boyfriend. I was doing the best job I could as his therapist. But the problem was, neither Sam nor I could see this.
About a month into his treatment, Sam came into session frustrated and anxious. He and his boyfriend had been fighting all week and were considering breaking up. When my empathic words like, "That sounds really painful," fell short of what he wanted, he turned the conversation to discuss me. He explained to me all the reasons why I was not a good enough psychotherapist: I was too young. I was inexperienced. I didn't look like what therapists are supposed to look like. I had no clinical specialty in trauma. I had no list of degrees. I wasn't a gay man.
I didn't know what to do other than take in all that he was saying about me. My face and body remained calm as I mentally halted the oncoming surge of panic, heat and tears about to erupt from my gut. I told him he was entitled to his feelings and opinions. I couldn't refute his accusations because they were, in fact, all true.
After he left the clinic, I grabbed my own belongings and sped through the clinic doors as fast as I could. I needed air and it felt as if the clinic itself were choking me. As soon as a cool San Francisco December breeze hit my face, my skin began to crawl and my stomach, arms and legs, and even my blood all felt suddenly, completely wrong.
I felt like there was a monster inside of me, and that I would soon be exposed for who I really was.
I felt like there was a monster inside of me, and that I would soon be exposed for who I really was. I needed to hide, and as I hurried home through the streets of the Mission District, I envisioned myself as a snake, searching for a rock to slither under.
Being in this state made me recall something I was currently learning about in my Severe Psychopathology class: the psychoanalytic defense mechanism called projective identification. I thought about how Sam couldn't tolerate his feelings of shame, fear, and disgust, and so was unconsciously transferring them to me. I learned that, ideally, the therapist is supposed to process these emotions to a tolerable state and return them to the patient. But I didn't know what to do with all these feelings; I didn't know how to process them and return them to him. The concept of projective identification gave me a framework to understand what was going on between Sam and me, but did not help me move through this impasse between us. I felt stuck and overwhelmed with his feelings, and unfortunately my defense mechanism of choice—analyzing, diagnosing and intellectualizing the problem—did not bring me peace of mind.
During the next few days my behaviors began to resemble the serious psychopathology of Sam and some of my other clients. I was hyper-aware of my surroundings all the time and hated leaving my home. When a friend coaxed me to go with her to a holiday party, I entered the house to find a kitchen full of acquaintances staring at me.
I was convinced they all knew Sam, and Sam had told them about what a terrible therapist I was. My dirty secret was out.
I was convinced they all knew Sam, and Sam had told them about what a terrible therapist I was. My dirty secret was out.
When I peeked down the hallway I saw that the living room was full of more people lounging on couches, leaning against walls and chatting. I heard a mix of voices muddled together and I strained to pull Sam's out of it. I was convinced he was in that room talking to people I knew, even though as far as I was aware, we had no friends in common. It felt wrong for me to be at this party. I feared I would be called out: how dare I go somewhere Sam might be and put him in that terribly awkward position of seeing his therapist—his bad therapist—in public! I gave my friend who brought me there a quick goodbye, slid out of the house without anyone noticing, and hurried back home.
Sam couldn't tell me about his past, and about the horrible things that had happened to him. These feelings that were now overwhelming me were all I had to go on, and were the only hints about what he might be struggling with everyday.
It would be three weeks before I saw Sam again. He and I both left town for the holidays, and it was definitely a welcome break. When our next session approached, I began to panic. "I don't want to see him anymore. We're not a good match. I need another week. I'm not ready!" I told my supervisor in long, desperate attempts to cancel the session. I wanted someone, anyone, to tell me I could end the therapy with him. I wanted to be told that he was abusing me, that I shouldn't take it, and that I was unsafe.
My supervisor, professors and colleagues all empathized, but pushed me to continue seeing Sam. "You need to go back in that clinic room with him for you, not him," they told me. "You need to prove to yourself that you aren't going to let him run you down." I cried. I protested, and I fought it to the very end. But ultimately, I knew they were right. And so it brought me to this moment with him, locked in struggle, a wound exposed, and only myself to hold onto.
Sam arrived fifteen minutes late to the session, which wasn't unusual for him. I was somewhat surprised he showed at all and wondered, If he thinks I am such a bad therapist, why is he still coming to the sessions? His expression was cold and he refused to make eye contact. He began speaking almost immediately, and recounted a recent sexual experience he had with his boyfriend the night prior. As the story went on, it became quite graphic and disturbing. Sam described feeling pressured into doing something sexual he didn't want to do. He described freezing and not being able to stop it as it was happening. He was crying and I was startled by the sexual details I was hearing. There was something in me that knew that what he was doing—confessing this painful experience to me—was too sudden. My gut, along with words from the textbook on trauma lodged in my brain, were telling me the same thing: this could overload him. But at the same time, another part of me felt relieved that he was opening up to me and trusting me with the story. Was this the breakthrough moment I had been waiting for?
Everything moved quickly. Then, before I fully knew what was happening, he turned his face to me. His crying slowed to sniffles, and he squinted as if to focus and find something deep in my eyes.
His chin wrinkled and quivered as he said, "Now I feel like garbage—what are you going to do about it?"
His chin wrinkled and quivered as he said, "Now I feel like garbage—what are you going to do about it?"
There was no rock for me to climb under. I had to stay there in that moment. And I had to respond.
"I wish there were something I could do to make the pain go away, but there isn't. I'm sorry that happened to you, and all I can do is be here with you through it."
"Sorry? You're sorry? That's bullshit!" he said, shifting back and forth in his seat, grabbing his hair with one hand and grinding the other one into the arm of the chair. "How can you just sit there and let me feel this way? How can you make me tell you that—make me feel so disgusting—then not do anything about it?"
Everything in the room came into micro-focus, and I felt pressed up against it all, like I was trying to push time forward more quickly to get out of the nightmare erupting around me. I thought about the door. I thought about what everyone told me—that I needed to get through this for me. I knew I couldn't make him feel better. I couldn't erase what had happened to him 30 years ago or the night before. I couldn't take away the pain he felt because of it. I couldn't soothe him—he wouldn't have let me even if I tried.
As his anger and accusations continued to fill the room, I repeated the only honest words I knew: "I'm sorry, there's nothing I can say to you right now that's going to make you feel better."
As his anger and accusations continued to fill the room, I repeated the only honest words I knew: "I'm sorry, there's nothing I can say to you right now that's going to make you feel better."
As our 50-minute time slot came to a close, he became silent for a few moments, exhausted, with nothing else to say. Then, as if he had been watching the clock for when the second hand hit the mark, he hastily grabbed his bag, wiped his face and left the office. I didn't want to move, because moving would stir all the feelings inside me that I knew would soon erupt. I felt like I had been run over by a truck—flattened and broken. But I was alive; I could see and feel that much.
Finally I had to get up and leave the office because another therapist had reserved the next time slot. I went downstairs to the intern room. June, an intern in her sixties, was there doing paperwork. She read the destruction on my face immediately. "Are you okay?" she asked softly. I exploded into tears, and she wheeled her chair toward me and hugged me. I cried on her shoulder like a child who had just been beat up by a bully, crying to her mother.
"What's happening? What's going on?" Her eyebrows lowered, and her tone remained soft and calm, but concerned. June already knew about Sam, and had heard me process my sessions with him in group supervision, so she wasn't surprised when I told her everything that happened in the session, including what Sam said and all my responses to him.
"You said that? You said those things?" June perked up.
"Yes," I said, expecting criticism. But instead a smile broke across her face.
"It sounds like you did the right thing."
"I did?" I said, coming out of my sniffles, feeling somewhat pessimistic but more hopeful.
"Yeah, I don't know what I would have said . . . I mean, what else could you have said?"
"I don't know, but . . ." I trailed off, not knowing the end of my thought.
"Seriously," she repeated, "what else could you have done?"
I wanted to give her an answer that provided hard evidence against me: an analysis of the conversation that showed where I'd messed up and what I could have said and done differently that would have left Sam, and me, in a better place. I wanted to prove to her that I was not the right woman for the job.
"Not be his therapist?" I finally responded, hearing the desperation and uncertainty of my words, and realizing for the first time that I could not stay in this place any longer—needing other people to show me the way, trying to find a way out, and wanting to be someone else.
June laughed, threw up her arms and gave me another hug. "You'll be okay," she said. I began to laugh with her, because she was right: I was okay. In that session with Sam, I hadn't tried to escape. I'd stayed with myself, as scary as it was, and it hadn't destroyed me.
Something shifted in me after that. I felt like I'd won a battle, and I was proud of myself. I was tired of the fear and the self-criticism. I began to see the fruits of my labor with my other clients as they all made progress in their therapy, and I realized that I could be and was a good therapist. I began to see that
being a good therapist was not about being a punching bag or taking on my clients' pain, but about making my clients responsible for their feelings and behaviors.
being a good therapist was not about being a punching bag or taking on my clients' pain, but about making my clients responsible for their feelings and behaviors. I was not there to save anyone; I was there to help people help themselves, and even then, only if they would let me.
Something changed in Sam, as well. The next week when he came in for his session, he kept his head turned down and looked up at me with wide eyes, half smiling, searching my face again for something, but this time it was approval.
"Hey, I'm sorry for the way I acted last week," he said. "I guess I was pretty mean, huh."
"Thanks for your apology. I think last week was a challenge for both of us." I paused at this and he continued to look at me with wide eyes, now a little nervous. So I continued, "I have to be honest with you—you have definitely been a challenge for me to work with. I've spent a lot of time thinking about our sessions, and received a lot of guidance from my supervisor, and I think I've done the best I can."
"I think so, too . . . but the thing is . . ." I could see Sam searching for his words carefully as his eyes didn't move from one spot on the wall, "I guess I just can't trust you."
"Because of my age, level of experience, and stuff?" I replied easily, now feeling confident and relaxed.
"Yeah. To me, you're just not who my therapist is supposed to be."
"If that's the case, why do you keep coming back to see me?"
Sam paused at this and looked at the floor, rubbing the back of his head with his hand. "I don't know. I guess I didn't think I had a choice."
"You do have a choice, Sam."
"What is it? What's my choice?"
"You can continue to see me at this agency, or you can find a different therapist at a different agency."
"Like where?"
"If you decide that's what you want, I can give you some resources."
"Can you call them for me? Or can we call them together?" His leg shook as he spoke.
"No, you'll need to set it up yourself. I can't do the work for you."
At this he seemed satisfied. He made the decision to find a different therapist, and I followed through on giving him some resources. I realized that, had I been more seasoned and further along in my career as a therapist, things might have turned out differently. Perhaps I would have questioned his assumptions of who his therapist was "supposed to" be, and urged him to stick through it with me. But
as a new therapist, I looked truthfully at my limitations with a dose of self-empathy.
as a new therapist, I looked truthfully at my limitations with a dose of self-empathy. I also relished the huge wave of relief that washed over me after Sam made his decision. And so I felt satisfied with his decision, as well. I was helping him take responsibility for his care, as well as his feelings.
Within just a couple of weeks, Sam set up his therapy at an agency that specialized in trauma work. Despite the fact that he had already completed his intake and was about to start seeing a therapist weekly, he told me he wanted to continue our sessions, as well. I told him this wasn't going to be possible, since it is counter-productive to see two individual therapists at the same time. I was also curious about his desire to continue to see me, after all that he had said about me not being able to help him. So I asked him about it:
"Sam, why would you want to continue therapy with me since you say you can't trust me, and you have another therapist that you think you will be able to trust more?"
"Well . . ." he said, "you have been helpful in some ways."
"In what ways?"
"Well, like I learned how to be able to notice what happens to me before I have a panic attack, so I can stop them from happening…"
I nodded.
"And I learned how to talk to my boyfriend when I'm upset instead of letting it build up into an explosion." He looked at me matter-of-factly, like it was not new information, and not strange or surprising for me to hear that I had, in fact, helped him.
A part of me was tempted to bring this contradiction to his attention and say something like, "So, who's the inadequate therapist, now?" But I held my tongue. I didn't need to prove myself to him or any other client any longer.
Instead I smiled and said, "I'm glad I could help."
My six-month therapy with Sam, as difficult and painful as it was at times, turned out to be a crash course on becoming a therapist.
My six-month therapy with Sam, as difficult and painful as it was at times, turned out to be a crash course on becoming a therapist. It taught me profound lessons about what my role as the therapist was, and how to sit with some of the most difficult material and still hold onto myself.
A year later, I saw how I had grown as a therapist from this experience. During a clinical internship in the counseling department of a Bay Area high school, I met with a student, Linda, who was in the acute phase of post-traumatic stress disorder. A few months prior, Linda had been kidnapped and raped on her way home from school. I passionately wanted to help Linda and my heart brimmed with empathy.
However, like Sam, Linda rejected my empathy. When I asked her questions, any questions, she would immediately tear and tense up.
"Please don't ask me about what happened. Please don't make me talk about it," she sobbed and quivered. Her body folded in on itself as she brought her knees and arms to her chest in the small plastic chair. I immediately thought of Sam.
"No one is going to make you talk about it. You can talk about whatever you want."
These words, and any other words from me, didn't calm her. In fact, it was clear that, from week to week, her anxiety in my office was getting worse. One week, her fear turned to anger:
"You're making me come here and talk to you, and I hate it! I don't want to talk to you! Stop making me talk to you!" Her body shook with fear and her eyes pierced me. I felt her anger come toward me, but I also recognized the fear that encased her body, so I didn't absorb the blame from her accusations.
"Linda, no one is making you do anything. You don't have to come to these meetings. It's your choice. I know you are very scared right now and I want to help you."
Linda continued to sob, and then, with her eyes to the floor, said in a very soft voice, "I don't want to come here anymore."
Linda was not ready to face the horrible demons terrorizing her. I didn't blame myself for this, nor did I take her demons on for her. I refused to cooperate with Linda's projection of me as the bad guy and helped empower her to take responsibility for what she was feeling.
I also knew how badly she needed help. So I asked her for one final request: could I speak to her and her mother together? Linda agreed, and I set up a meeting. Her mother poured her heart out to me about how sad she felt for her daughter, and the two of them cried and held each other together in my office. I explained to them both the symptoms and ramifications of PTSD. While Linda's eyes shifted around the room as if her mind was somewhere else, her mother listened closely to my urge to get her daughter help.
I left it up to Linda to contact me if she wanted to see me again, with or without her mother. I knew this would be the only way she would feel an ounce of safety in my office. However, I never heard from her again.
This time I knew that even the most skilled therapist in the world can't help someone if they don't want to be helped.
This time I knew that even the most skilled therapist in the world can't help someone if they don't want to be helped. And I felt peace of mind knowing that I did all I could do: reach a safe, confident and competent hand out to Linda.
Nothing I learned in any of my graduate classes could have prepared me for the emotional experience of being a new therapist. As they say, it is one of those things a person has to learn the hard way. Many of the difficult emotions I felt were due to a complex combination of my clients' and my own personal experiences in the world. But the self-doubt and fear were universal and part of the first developmental phase of becoming a therapist. True confidence comes with time and experience, and will only come when we dare to test ourselves and allow our clients to move us in profound ways.
*All names and identifying information of the clients and psychotherapists have been changed to protect confidentiality.
Copyright © 2009 Psychotherapy.net. All rights reserved.
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- Discuss how the depicted therapist addressed their fears of inadequacy
- Apply these insights into your own therapeutic work
Charlotte Dailey is an Oakland, CA–based writer who enjoyed a career as a psychotherapist before leaving the field to pursue her writing full-time. She has a Master's degree in Clinical Psychology.
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Learning Objectives:
- Discuss how the depicted therapist addressed their fears of inadequacy
- Apply these insights into your own therapeutic work
Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here
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