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I wasn\\u2019t feeling so hot yesterday so took a time-out day and watched "Shrinking", the Apple TV series that has a superb cast and follows the lives of three therapists and their friends and families. It\\u2019s full of expletives, especially the f bomb. Which is fine by me but there\\u2019s wasn\\u2019t one person in the cast who didn\\u2019t explore its complete usage\\u2026 It\\u2019s also very moving. And I was relieved to see that except for some entertaining but weirdly unethical behavior, the therapists are painted as caring and trying hard to help. But also having HUGE struggles in their own lives.

I get it. There have been times when my struggles have been larger than others. And yet it\\u2019s still my job to be there for my clients \\u2013 the way they\\u2019ve come to expect me being there. \\xa0Because I\\u2019m a shrink.

So, I thought today we could talk about what those expectations \\u2013 at least the basic ones \\u2013 the stuff that both behind the scenes and front and center can be the building blocks of trust and safety in therapy. \\xa0an episode on creating emotional safety in therapy. That\\u2019ll be in your show notes. Today, we\\u2019re focusing on basics.

The listener email today is from a listener in Bermuda who\\u2019s tried several therapists but not found one that has helped her \\u2013 what she calls \\u201cmanage\\u2019 her depression as its recurrent. And do I know any international treatment options? \\u2018I\\u2019ll do my best to answer her.

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Vital Links

An episode on creating emotional safety in therapy.

You can hear more about this and many other topics by listening to my podcast, The Selfwork Podcast. \\xa0Subscribe\\xa0to my website and receive my weekly newsletter including a blog post and podcast! If you\\u2019d like to join my FaceBook closed group, then click here and answer the membership questions! Welcome!

My book entitled Perfectly Hidden Depression is available\\xa0here! Its message is specifically for those with a struggle with strong perfectionism which acts to mask underlying emotional pain. But the many self-help techniques described can be used by everyone who chooses to begin to address emotions long hidden away that are clouding and sabotaging your current life. And it\'s available in paperback, eBook or as an audiobook!

And there\'s another way to send me a message! You can record by clicking below and ask your question or make a comment. You\\u2019ll have 90 seconds to do so and that time goes quickly. By recording, you\\u2019re giving SelfWork (and me) permission to use your voice on the podcast. I\\u2019ll look forward to hearing from you!

\\xa0

Episode Transcript

350 SelfWork: Being A Shrink and What You Can Expect from Yours

I wasn\\u2019t feeling so hot yesterday so too a time-out day and watched \\u201cShrinking\\u201d the Apple TV series that has a superb cast and follow the lives of three therapists and their friends and families. It\\u2019s full of expletives, especially the f bomb. Which is fine by me but there\\u2019s wasn\\u2019t one person in the cast who didn\\u2019t explore its complete usage\\u2026 It\\u2019s also very moving. And I was relieved to see that except for some entertaining but weirdly unethical behavior, the therapists are painted as caring and trying hard to help. But also having HUGE struggles in their own lives.

I get it. There have been times when my struggles have been larger than others. And yet it\\u2019s still my job to be there for my clients \\u2013 the way they\\u2019ve come to expect me being there. \\xa0Because I\\u2019m a shrink.

So, I thought today we could talk about what those expectations \\u2013 at least the basic ones \\u2013 are. There are skads of different approaches and schools \\u2013 that we\\u2019ll leave for another episode. But I\\u2019m talking basic stuff here \\u2013 the stuff that both behind the scenes and front and center \\u2013 can be the building blocks of trust and safety in therapy. I\\u2019d already published an episode on creating emotional safety in therapy. That\\u2019ll be in your show notes. Today, we\\u2019re focusing on basics.

The listener email today is from a listener in Bermuda who\\u2019s tried several therapists but not found one that has helped her \\u2013 what she calls \\u201cmanage\\u2019 her depression as its recurrent. And do I know any international treatment options? \\u2018I\\u2019ll do my best to answer her \\u2013 have done several episodes on emotional regulation or managing emotions so I\\u2019d start by having her search for managing depression or managing emotions on my website at drmargaretrutherford.com to help locate things I\\u2019ve already mentioned could be helpful.

Before we go on, let\\u2019s hear from BetterHelp \\u2013 rated the \\u201cbest\\u201d online therapy service\\u2026

Yesterday I woke up in a bad mood.

I\\u2019m usually quite cheerful in the morning, a trait others might love or might need me to tone down a bit, depending on their own morning ritual.

But yesterday, several things cropped up. We\'d eaten at a place that we hadn\'t been to in a long time for dinner the night before. And my stomach didn\'t particularly care for what it had been offered. And my gut is usually like iron, so I haven\'t built many skills for handling that discomfort.

And I was tired. I\'d been going pretty strong for several weeks with no break - and like every other time I do that, the same thing happens. Overwork and overbusy brings bad mood - a little feeling of self-pity or entitlement that I can act less nicely to my spouse - just because I\'m in a bad mood. That choice only makes my mood worse however, because I know what I\'m doing - giving myself permission to be a jerk - when the little part of me that\'s watching what\'s going on is saying, "What in the hell are you doing and why did you talk to him like that?\'

But I rode in sullen silence to our usual Saturday breakfast diner. (which might\'ve been a relief for said spouse...). And when we got there, they\'d put in new lighting that was flickering every few seconds, a glitch that needed fixing. As I was already feeling kinda yuck, then I felt like I might be thrown back into vertigo which I\'d experienced for the first and hopefully last time a few months back. So, I was staring down at the table, trying to decide what I could eat, trying to be nice to the waitress, when my husband made me laugh, making fun of the plethora of physical complaints expressed by the two of us since rising.

Thank God for laughter.

It didn\'t help my stomach - but my bad mood lifted almost instantly.

Not that that happens every time. Sometimes, like everyone else, I can hold onto worry or feeling sorry for myself - whatever\'s constituting my "mood..." until... I get to the office. And I become\\xa0your\\xa0therapist. My mood needs to change - and it\'s my job to know how to do that. To get out of my head as much as possible - and tune into you. Not that where I am isn\'t going to affect that. But I need to try as much as possible to take my little bruised ego and put it on the shelf (fancy word here.. compartmentalized) until I have the time and space to look at what might be causing it. And that time is AFTER I\'ve seen you.

Interestingly, what I\'ve noticed is that when this happens, or when I\'m actually sad about something in my life, I focus differently. Maybe better in some way, because I\'m coming from a quieter place? That\'s at least what I\'ve thought.

So when I also finished watching the first season of "Shrinking" yesterday, I had to stop and consider - once again - how others may see their therapists, what they expect on both an intangible but also a very tangible, pragmatic level. \\xa0The series is filled to the brim with f... this and f... that and there\'s a lot of sex being had, drugs being taken, and sarcasm being passed out. But all in all, at least the therapists are portrayed as really caring and wanting to help, although ethical boundaries are entertainingly (but not realistically) loose. Not since 1991\\u2019s "What About Bob" - which if you haven\'t seen it and you\'re in therapy, you definitely should see - has there been more dual or triple relationships between therapist and patient.

But back to how you see your therapist... I was always curious about mine. I was relieved when one very helpful but more soft-spoken therapist told me she\'d thrown a plate at her husband when she got mad one time\\xa0 - after the hundredth time of me shaming myself in her office for the way I\'d acted when angry. It\'s not that my choices didn\'t need to change. But her joining me in living with regret was helpful.

Now, we\\u2019re going to turn to talking about these basic intangibles and tangibles in the therapeutic process. I do want to announce this \\u2013 I took a lot of this from my very first SelfWork episode! The one I created \\u201cin class\\u201d \\u2013 I was so very nervous\\u2026 So I used the ebook I\\u2019d created for subscribers to my website as my \\u201cstructure.\\u201d It was funny \\u2013 when I pulled out that book today to see if I could use any of the material, I realized that most of it is still very good. And hits the basics. What I need to add to that today is so much more about online therapy and changes in HIPAA due to that. Also, the rise of life coaches \\u2013 a career that\\u2019s been around quite a while but within the last five or more years, has exponentially grown. And even more techniques to choose from \\u2013 which is wonderful but also confusing.

So let\\u2019s first talk about the intangibles.. there are seven of them.

• Have a strong therapeutic alliance: feel that the two of you are working together well.

What does this mean? One my FB group members commented \\u2013 when I told them I was writing this post and what might they want to add\\u2026 said the \\u201cpower differential\\u201d was difficult for her. Meaning that her life was the focus of the relationship as well as her vulnerability being exposed\\u2026 and that was one of the most difficult things for her.

To me, this may mean the therapeutic alliance isn\\u2019t strong enough. She may want a more collaborative kind of therapy \\u2013 one where there\\u2019s a little more ease \\u2013 even though again, the work is hers to do. But you want to feel as if your therapist understands you \\u2013 and is working toward helping you in the way you understand and want.

• Know how you\\u2019re moving toward positive change; be able to say how you\\u2019re getting better in a tangible way.

This may be harder with some approaches than others \\u2013 and honestly, probably reflects my own bias toward a more collaborative approach. So, I\\u2019m admitting my bias. I think it fits our lives today \\u2013 and with both of you knowing what you\\u2019re aiming for, the changes that when they happen, you\\u2019ll both be able to know you\\u2019ve done \\u201cthe work\\u201d \\u2013 that\\u2019s vital to me. That doesn\\u2019t need to mean the change itself isn\\u2019t in the emotional or mental realm. But knowing you got there \\u2013 and how you got there \\u2013 is important.

• Have a therapist that is attentive in session.

Believe it or not, I have heard stories of therapists going to sleep. Or forgetting major things that you\\u2019ve told them. This is a pragmatic thing but it has huge relational components. If you feel I am really listening to you, really seeing you, and helping you see yourself \\u2013 then trust is built. I have a fairly new patient right now \\u2013 a fairly young guy \\u2013 who says he loves therapy because of this very thing. His family situation was tough in some ways \\u2013 and being seen means the world to him.

• Believe your therapist knows what they\\u2019re doing. And you know their basic treatment strategy.

What do I mean by this? Well, let\\u2019s say for the first four to six sessions, I tell you we\\u2019re going to start connecting your past with your present because, after hearing you tell your story in the first session, I think there would be some helpful connections to make \\u2013 due to how you\\u2019re reacting to the present. Maybe things are making you so sad you can\\u2019t stand it. Or way too mad. Maybe if you understand how you\\u2019re getting triggered, then you can have more control over those emotions. And you agree to that.

But in the third session, I say, \\u201cI think we need to start couples work.\\u201d That\\u2019s never been mentioned \\u2013 I just decide. You can see how that can be unsettling \\u2013 now if I have a really good reason to change course, okay. Let\\u2019s talk about it. But out of the blue? Not helpful.

• Expect reasonable business practices.

Okay\\u2026 the fact is that what can make someone a good therapist may not be what helps them be a good business person. But if not, that\\u2019s not your responsibility. You need to understand the business aspect of your relationship and that needs to be solid and secure. We\\u2019ll talk more about that.

6 and 7. I realize six and seven are very integrated \\u2013 they\\u2019re about the therapist gaining your trust with your information \\u2013 not only written information, but you knowing and trusting that confidentiality is being highly respected. And that their business is operating in a way that their staff only has limited access to your information. And also vital \\u2013 that personal physical and sexual boundaries are being respected as well. There is absolutely no reason why a therapist should engage in any kind of physical touching without your express consent or your request for it. Obviously if my patient suggested something sexual, then I\\u2019d need to establish a boundary there and that would become a therapeutic focus.

So those are the intangibles. What are the pragmatics? We\\u2019ll hear those right after this message from AG1.

So, here\\u2019s the quick and dirty list of what you can and should expect pragmatically from a therapist.

1. You should sign a well-written statement concerning your consent to treatment and a confidentiality agreement. That agreement should include information on what the therapist charges and what occurs if you miss an appointment without calling within an appropriate amount of time.
2. HIPAA documents should be made available to you. Or a form that states you have seen the document. Online therapy has its own HIPAA requiremends and you can ask questions about how confidentiality is being kept when and if online therapy is occurring.
3. You should know about how insurance or payment is being handled. Many therapists do not file insurance at all. Some do. You should know whether or not your insurance is through "managed care" or not. That means whether or not your therapist is free to make all clinical judgements or whether your treatment might be modified by your insurance company. This information is available through your insurance company.
4. There is huge variety about the way therapists deal with financial matters. Some will reduce their fee. Some will not. You can ask questions about these topics as you are contacting mental health professionals as a potential therapist or certainly in an initial session. Also, bills should come regularly and as stated initially and costs should not change unless you\\u2019re notified well ahead of time.
5. Confidentiality in the case of treatment of children, adolescents and in marital work should be outlined. The boundaries of that confidentiality should be understood by all.
6. Your therapist should be very clear with you about whether or not they provide emergency or after hours coverage. You need to know that going into the relationship. You and your provider need to have a plan on what you should do in case of emergency.
7. There are several different mental health degrees that allow people to practice as "therapists." The training is very different between them. Psychiatrists are medical doctors. They prescribe and sometimes offer therapy. \\xa0The rest are psychologists, social workers, licensed professional counselors, marriage and family therapists. Perhaps even other designations. When choosing to educate yourself about the training in the different professions so that you can choose well for your particular condition. Feel free to ask how much experience he or she has in working with patients with your particular issue. Ask what specific techniques they will use to help you get better!
8. The profession of life coaching has greatly increased. But it should be made clear that a life coach is not a licensed mental health professional. It\\u2019s my understanding that there are certifications you can obtain by going through courses offered by life coaching platforms. But please realize the two professions are very different. That doesn\\u2019t mean better or less than. It means different. I\\u2019ve referred a few patients to qualified life coaches I know and it can be very helpful \\u2013 as they help the patient deal more with pragmatic things.
9. If you do not feel you are improving, look elsewhere! Ask a medical doctor for other referrals. Frequently, family physicians, pastors or gynecologists have a referral list of mental health professionals. Remember, the "fit" is extremely important!

Listener email

Hello and good afternoon ,Dr Rutherford,

Hope you are well.
I am a huge fan of your podcast and listen to it regularly on my walks! I have gained a lot from it, \\xa0but was also interested in one to one therapy! I am based in Bermuda, and understand from your website that you wouldn\\u2019t be able to help with potential clients outside of Arkansas; I just wanted to get in touch to ask if there is anyone globally that you would recommend that can provide therapy remotely? I have tried various therapists all over the world and none have seemed to work for me. I have suffered from recurring depression since a young age, but instead of accepting that and living with it, I would love to finally learn how to manage it.

I am very grateful for any guidance or recommendation you are able to share.

Kind regards,

My response:

Hello and thank you for being a listener. I wish I could help with the one-on-one part of what you\\u2019re seeking. Maybe a way I can help is to write a podcast episode about what \\u201cmanaging\\u201d depression actually means. I\\u2019d like to research that a bit myself because I can certainly think of clients of mine who do just that. But I\\u2019m sure you\\u2019re not the only person who doesn\\u2019t exactly know what that might look like. To me, it means asking yourself what\\u2019s happening or what are you doing or experiencing when you don\\u2019t feel depressed - and try to add those kinds of things more into your life. And then when you do feel more depressed, what do you do when you\\u2019re in it?

I hope that perhaps that might help. I\\u2019ll write myself a note so I don\\u2019t forget!

Basically, managing depression \\u2013 especially recurrent depression \\u2013 is managing triggers. Knowing what may cause a \\u201cflare-up\\u201d of emotions that can easily cycle into depression \\u2013 and either avoiding those triggers if you can \\u2013 or at the least, being aware of what they are. The most obvious example I can think of right now -.. let\\u2019s say a wife had an affair or several on business trips out of town. So they work really hard together and things are going well. Then the wife goes out of town without there being any safety or trust plan. Guess what? Something happens and al hell breaks loose. Trust is lost again \\u2013 perhaps not due to any distrustful behavior, but because the couple hadn\\u2019t planned on how to stay in touch in order to AVOID a problem. I call that walking into a mine field, knowing it\\u2019s a mine field, but thinking you can do that unscathed. Being aware \\u2013 even listing \\u2013 what is likely to trigger me? Very helpful.

\\xa0