Reflection of a Therapist 31.8.26
I recently started to work with a new client who wants to focus on themes around regret, guilt and shame. The first session was mainly focused on establishing a therapeutic relationship and clarity about how we will work together.
The client communicated how pleasantly surprised they were that they felt so energised after the first session. And noticed a number of their physical symptoms had disappeared including their ongoing mind fog for a good 48 hours or so. They came to the second session understandably with expectation and anticipation. Within the second session we focused on the theme they wanted to expose being regret. Within the session we did a number of reflective activities including the regret timeline. They shared 2 big events that they felt regret and shame around.
A few days later they emailed me saying it had left them feeling very wobbly. And they were thinking of cancelling the next session and having a break. I messaged them explaining how what they felt was normal at the early stages having attended 2 sessions. I also reflected we may have gone into a big event too much too soon. And we would continue to monitor and be more aware of the pace.
This then left me reflecting on what was potentially happening for the client and their process. In addition, I took this to my supervisor to consider the approach and activities my client and I had explored. Including what I may do differently on reflection for future learning. And to think about how I continue to work with this individual and the content they were bringing.
My initial reflection in my supervision was that my initial response to the client had been clinically sensible. I had validated their reaction and communicated that increased distress was no evidence the therapy had gone wrong. In addition, I acknowledged that the work may have gone too deep/too quickly. So, I also considered that I may slow the pace down.
As a Therapist I am aware there are several useful theoretical lenses for understanding why my client may have been feeling worse before they began to feel better. This is particularly the case when working with shame and significant life events. I discussed these with my supervisor and the following are five of the theory frameworks we explored.
1. Therapy can temporarily increase emotional activation.
One explanation is that my client had brought material which until this point had been relatively contained, avoided, compartmentalised, or kept at a distance into active awareness. As they had begun to process shame and a major life event, dismantling their defence mechanisms may have naturally triggered some psychological and physiological reactions.
2. The "window of tolerance".
A second explanation we explored is called the ‘window of tolerance’. This is probably one of the most useful frameworks that I can also share with my client.
The basic idea is that we have a zone in which we can think, reflect, feel and remain sufficiently regulated.
Outside it, someone may move towards:
Hyperarousal: anxiety * agitation *racing thoughts *intrusive memories *emotional flooding *difficulty sleeping *feeling overwhelmed
or:
Hyperarousal: numbness *withdrawal *exhaustion *disconnection *feeling flat *wanting to avoid everything
I also considered that ‘The regret timeline’ may have taken my client outside their optimal window. And it may be useful to rephrase the word ‘normal’. I wondered if saying what they felt” is normal” may have inadvertently communicated:
“This is what therapy does, so you just have to put up with it.”
And it may be better framed using the words ‘makes sense’.
“Your response makes sense, and it gives us information about how we should work together.”
I also reflected that I may need to introduce more scaffolding and preparation for my client about what they had experienced. “I think we may have discovered that this material carries more emotional weight than we realised. Sometimes when we open up something significant, our emotional response can be bigger than we expected. That doesn't mean we've done something wrong. It tells us something about how carefully we need to approach this material.”
3. Shame can be particularly destabilising
I think moving forward it would be useful to pay more attention to the fact that my client described shame as well as regret.
Regret tends to have the quality:
“I did something I wish I hadn't done.”
Shame can become:
“I did something bad, therefore there is something bad about me.”
That distinction is clinically significant.
A person can revisit an event cognitively without becoming destabilised. But when the memory is connected to identity, worth, morality or how they believe other people see them, it can become much more threatening. I discussed in my supervision ways of opening the conversation up to help differentiate the distinction. For example:
“When you remember that event, what do you believe it says about you?”
“Is the painful part what happened, or what you believe it means about you?”
“What do you fear I might think of you when you tell me this?”
“Is there a difference between I did something I regret, and I am someone who should feel ashamed?”
That last distinction can become a substantial piece of the work.
4. The therapeutic relationship itself may become part of the same experience
After disclosing something shameful to a therapist, the client can experience a kind of post-disclosure vulnerability.
During the session: “I've finally told someone.”
Afterwards: “What did I just tell them?” “What do they think of me?” “Why did I say that?”
“Perhaps I shouldn't have talked about it.” “I've exposed myself.”
And then possibly: “I don't want to go back.”
The desire to cancel the next session can therefore sometimes be understood not simply as avoidance of the topic, but as an attempt to escape the vulnerability of having been seen. This made sense to me as I know I had experienced this process a number of times with my own Therapist at different points.
On reflection with my supervisor I considered I may ask at our next session:
“After you left our session and had some time to think about what you'd shared, what did you imagine I might be thinking about you?”
This is a different question from asking my client to revisit the event itself.
5. Avoidance can temporarily make people feel better
From a behavioural perspective this can become: Remember event → distress → avoid thinking about it / cancel therapy → distress decreases
The brain learns: Avoidance = safety.
This is why avoidance can become self-reinforcing.
On sharing with my supervisor, we agreed the language I used when communicating this with my client was key. So, to not say: “You shouldn't cancel because that's avoidance.” As this could recreate the very dynamic, I am trying to avoid.
Instead: “You have a choice to cancel and initially this may leave you feeling safer. We want to make sure we can help you build this sense of safety both in and out of the session. Let’s explore more of what we need to create in our sessions and Therapy Agreement. What does safety look like? Sound like? Feel like?”
I want my client to experience: “I can approach difficult material and move away from it when I need to.”
rather than: “Once I've opened this door, I'm trapped and have to keep going.”
This sense of agency is particularly important early in therapy. My biggest reflections overall with this client is to combine more psychoeducation and strategies to manage the somatic emotional regulation.
If you need any further support, please contact me at mandy@knowlimitscoach.com
And my poem ‘Next Chapter’ can be found @mandygutsell5940
I offer supportive strategies to honour the past, accept the present and look to the future with peace of mind.
If you need any further support, please contact me at mandy@knowlimitscoach.com
And my poem ‘Next Chapter’ can be found @mandygutsell5940
I offer supportive strategies to honour the past, accept the present and look to the future with peace of mind.
Click Here to head over to our YouTube reading of this Poem.