An Empathic Therapist, Please Help Rupert

[Never_falter2]

A discussion in one of the other threads made me think about the qualities of an good and empathic therapist.
A topic I am very much interested in is how a therapist should act towards the sufferer who is unemotional, trying to keep up the appearances and not willing to open up.

I'd like to start a little story and hope you continue it and we can discuss the therapist and the sufferers behaviour.

I write about a sufferer who does not openly say he has ptsd or what his trauma is and the therapist now has to find out if he can help him and how.

Setting: Dr. Miller's office. Dr. Miller is a therapist, specializing in ptsd
Dr. Miller enters his office: A man around thirty is sitting on a chair but jumps up, when Dr. Miller enters and gives a broad smile. He is wearing a crisp white shirt, a freshly ironed trouser. His short hair is neatly cut and his shoes freshly polished.
Dr. Miller: "Good morning, Sir. My name is Dr. Miller. How might I help you"
Rupert (the sufferer: "Good morning, Sir Doctor. My name is Rupert Smith." He smiles broadly again.
Dr. Miller: "Wouldn't you like to take a seat, Mr. Smith"
Rupert places himself on the edge of the seat like he wants to jump up any minute.
Dr. Miller: "How can I help you, Mr. Smith?"
Rupert: "You, know. I am working for banking company. I work in capital city, but I live in Smallville. I did not want to live in capital city. I don't like public transport. I really, really do not like it, but know problem because I have a car. So I drive there. No problem... but now... there is a construction site and that stresses me. So my wife, you know how they always are. She tells me I need to talk to somebody. Just how women are, you know?"


Please help me continue the story.

 

[Justmehere]

Are you asking us to help you write a fictional story?


<undeleted for thread continuity>

 

[Never_falter2]

Yes, a story, but it will only serve the purpose of discussing the qualities of a good therapist.

No, I am not asking you to help you write a story I want to sell that was your question. Does this have any whatsoever literary qualities??? Well, thanks a lot... but not it was not my intent to write a book.

I would like to have a discussion or maybe tips some for the aspiring therapist because I know there are some on this board.

 

[Never_falter2]

My last post is an answer to a post that was deleted.

 

[Leighlee87]

Hmmm....I'm not sure how to answer that. I'm not sure it is any one thing that the therapist says. I know that for myself, I was very closed off/guarded, unemotional, numb, all of the above. I played the part the best I could. My therapist was and is very empathetic. I'm not going to go with any quotes, things said, etc. but instead I will describe tactics used.

Closed off/ guarded comes down over time. Questions are asked, life and family history is asked about. With this information, it gives the therapist areas to start worming his or her way in. The client can insist that it doesn't hurt, but likely it does. Keep pushing those areas, not too hard, but enough. Eventually the client will open up about issues that are there.

Unemotional/numb. Honestly, for me, I was completely detached and numb to the trauma. It had just occurred, it was extensive, but I felt nothing when I talked about it. Honestly, I didn't feel any emotions at all, ever. I was completely detached and didn't know how to change any of it. It was a sign of depression, ptsd, dissociation,etc. It's also a huge protective defense and ties back into the closed off/ guarded side. There were questions that hurt so I refused to talk. Sometimes my therapist realized I was getting overwhelmed. She had struck a chord, I wasn't going to show it in front of her, but somewhere inside it was hurting. So she would give it some space and move onto a more neutral topic. Other times, we started going in a direction I didn't like so I would intentionally stop cooperating, wouldn't answer, change the topic, etc., and in these situations she would get rather stern with me. She would repeat the question, stare at me and quietly wait for the response. If she didn't get the answer she would say my name, and look at me once more. If I tried to change the topic, she would remind me that, that wasn't what she had asked and would repeat her question once again. But this was only when she knew for a fact that I could handle the material, I was just being stubborn and obstinate.

Over a year into trauma therapy, I have never cried in therapy. I've come close. Everytime she sees that struggle, she gives me space to pull it together. She understands the pride and the fear behind showing weakness in front of someone. It's not something she has pushed just yet. She has watched me feel incredibly vulnerable though, and it took a long time for me to be okay with her seeing me as anything but strong. This one, I think takes a really, really long time, and there may very well be a history behind it.

Empathy looked more like this for me, especially on the outset. When discussing something difficult, it was "It makes total sense why you would have felt that way." or statements such as that. It was more just sitting there, on par with the other person.

When it came to answering painful questions I didn't want to, or her seeing a vulnerable side of me, most often her response is to stay quiet for just a brief second, say "good", and then calmly move into the next question. This affirmation, gives you a sense that this is what you are SUPPOSED to be doing. Instead of hiding, instead of staying strong, instead of protecting yourself, you are being strong and doing something right and empowering by making yourself vulnerable even though it is frightening.

The hardest part in a situation where a client comes in closed off like that and only because the wife wants him there, is to convince the client that he should stay, especially when those bandaids start coming off and everything starts to hurt.

 

[Justmehere]

I deleted my first post before I saw your follow up posts. Sorry about that. From time to time, there are people who post seeking info in order to assist them in writing fictional stories or novels for publication. That is why I asked. Thanks for explaining the purpose of the thread.

I don't think there is any particular one script a therapist could follow to show empathy.

In the US, most initial therapy sessions would start off with a pile of paperwork... and that would be a launching pad into what brings the person in. From there, some of the ways a therapist would help a client open up could be very culturally based.

Using the example given to start the thread, I think a therapist would ask more questions about symptoms, history, and listen to not only what the client says but how they say it.

Listening involves noticing body language and etc.

A good therapist would explain the therapeutic techniques that use along the way and after asking some questions to see about history and to better understand what brings the client in, they may use a variety of techniques to help the client manage the anxiety and perhaps over time develop a therapeutic relationship and a sense of safe place that encourages the client to share more.

My therapists sometime show empathy with silence. Spmetimes when I cry, they don't say much in order to let the tears come, and other times, they do talk or encourage me to keep talking.

Sometimes it's their body language that helps me share, sometimes it is stories and examples they give, and sometimes they actually show empathy through the way they challenge me to think better of myself.

I was closed off and shut down when starting therapy, but I was also desperate and hurting. The first time a therapist said I had PTSD, it was 3 months after they figured it out and 6 months into therapy with them. I had not spoken a word of any trauma to them. They suspected it by the way I acted and the lighter examples I gave of my life. I was shocked when they told me. We were playing a simple board game when they told me. We would do that while talking because I was that shut down and couldn't talk without the distraction of the game. They saw my cues and gently told me things would be ok, I wasn't damaged just grew up in a war zone and was traumatized.

In another therapeutic setting where I was shut down, a therapist with a very different style knew I could handle some kind confrontation about it and asked if I was really there to engage in small talk. That helped me open up.

Some of the skills therapists use to show empathy are taught in school, but many are not. Some are just things they already do or learn over time. To some degree, some of it is part of their personalities and styles.

Think about the ways non-therapists show empathy. Non-judgemental presence is one very good way.

The most important advice I could give to the aspiring therapist is to
1.) get training in various trauma techniques, in addition to a robust general training.
2.) do your own therapeutic work -- this is essential.
3.) be willing to get outside help and supervision while in practice
4.) become very good at self care.

Those three things will go far to help a trauma therapist to have the emotional capacity, skills, and space to help someone else work through their own trauma.

 

[joeylittle]

Please help me continue the story.

It's impossible without knowing why the client is there, in that office, in the first place. You say the therapist specializes in PTSD. The client is presenting with some level of anxiety and a life stressor problem.

Why are they there?

 

[Never_falter2]

@Leighlee87: What kind of therapy was that? It does not sound like CBT, does it?

@Justmehere: How did they manage to figure without you talking about the trauma?

@joelittle: Okay, in that case I am going to give him a backstory. Rupert had a traumatic experience. The construction site and the public transport are some of his triggers. His fear is far worse than what he presents the therapist. His is basically unable to get to work now, because he cannot use public transport and cannot drive past the construction site.
His wife noticed he has changed. He started drinking and spends a lot of time away from her in a bar. He picks fights. He isolates. She has tried to make him see a therapist before and now because his problem with the construction site he finally agrees. It is the first time he is seeing a therapist.

 

[Never_falter2]

Sorry @joeylittle, misspelled your name.

 

[Suzetig]

Empathy isn't a skill you pick up though, it's a way of being, so the way I might offer empathy will be different to the way someone else shows empathy. There are so many ways to communicate that you're right alongside someone, seeing their world as they do (which is what's meant by empathic).

I suppose for my part it's not about trying to gather a list of symptoms, or get a history or any of that stuff - in the very early stages it's about making connections and building a relationship.

In the early days if my own therapy, my T communicated that she understood my depth of feeling and that x, y, z issues held a lot of power for me without even trying to understand why that might be - right from the start she fully accepted me and my world view and was right in it with me.

So, for me, I'd want to reflect my sense that Rupert was having an awful time and invite him to talk about it. And then I'd listen. A lot.

 

[MisterCatLady]

I was very very guarded when I started therapy. The therapist I am with now is very patient with me. I recently started opening up. It just takes time. Some take more time than others. I have seen my current therapist for 10 months. I saw other therapists for a year prior to finding her.

 

[Leighlee87]

Therapists tend to use more than one theoretical approach. They don't use use just one theorist. They tend to pick a couple different theoretical approaches and blend them in a way that they find best suits them in a therapy setting. My therapist and I have worked extensively with CBT, gone through EMDR, etc. It's worth looking at different theorists and approaches, to get a more well-rounded professional character.
That said, CBT is a large part of what we do, however, my case is complicated. I grew up in a situation that very closely mirrored a cult, have a lifetime of abuse to sort through, and the trauma/grief of losing my entire family because I couldn't endure it anymore. So, there is a lot for me to sort through. Questioning one thing, leads to a firestorm of painful realizations and completely pulls the rug out from under me. It happens time and time again. There are a lot of flawed thoughts, things I was taught to believe were my fault or my responsibility. Things I was taught I should allow to happen or be done to me, etc. It's been complex. CBT, is about finding dysfunctional thinking, well....I grew up in a world that doesn't fit with this "other" world I now live in. A lot of my beliefs were flawed, but the pain in acknowledging those flaws is worse than blaming myself. The war goes back and forth.

But with your character, CBT shouldn't look much like what I'm going through at the moment. However some of what I said in the previous post can easily be used in any therapy setting where the client needs that reaction/behavior from the therapist. There isn't a one size fits all. Sometimes, it's a matter of what that person needs in that moment. Honestly, I think in your situation, CBT along with EMDR and possibly exposure therapy might work really well.