Therapy isn’t just tough for clients. It’s also tough for therapists, especially when they have to deliver difficult feedback to their clients. For instance, clinicians might need to challenge their clients’ denial or self-destructive habits. They might need to tell them things they don’t want to hear.
But while challenging, this is vital work. “I believe some of our most powerful work as therapists occurs through the ability to tolerate very uncomfortable or difficult news, moments or feelings and continue to stay present and empathically connected to the client,” said Joyce Marter, LCPC, a therapist and owner of the counseling practice Urban Balance.
Difficult feedback comes in many forms. For instance, Marter had to help a client realize that her husband, who admitted to an “emotional affair” with a colleague, was still hiding a big skeleton about the relationship. According to Marter:
I certainly didn’t know the truth of the matter, but as therapists, we can tell when stories don’t make sense and there is missing information. I asked several questions to try and get a more complete picture.
When my nagging suspicions remained, I said to her, “Have you considered the possibility that his story is not the full truth?”
She was quiet and visibly displeased and we sat in some discomfort for a few moments. I had to tolerate the discomfort and not sweep it all back under the rug again.
I felt worried that I pushed her too far, but she came back the next session and said she confronted her husband and learned he had been sleeping with that woman for many years. Our conversation was a difficult but necessary part of her growth and recovery, and she is doing fabulously without him!
Another time Marter had to tell a self-conscious client that his lack of luck with women stemmed from his grooming habits. Not wanting to hurt his feelings, Marter skirted around the issue for several weeks. But, ultimately, she decided to be straightforward. (He started a relationship three months after this session.)
This kind of candor helps clients become more self-aware and encourages growth. Plus, it fosters the relationship between client and therapist.
“Being honest and direct with clients is a very genuine, authentic, intimate experience. The initial discomfort of the tough feedback will pass, the client will see that you are invested in them and care enough to be real, and the therapeutic relationship will deepen,” Marter said.
Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression, had to deliver difficult feedback in the form of a diagnosis. She vividly remembers having to tell a young couple, who was in deep denial, that their son has autism.
There was a great deal of heartache at the moment of the diagnostic disclosure. Their grief, confusion and shock shifted them into a true crisis state. Though I felt great sadness delivering this news, I also felt hopeful and confident that early detection and early intervention would offer significant help for this little boy. It’s never easy for a psychologist to deliver a diagnosis – nor is it ever easy for a parent to receive it.
John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens, regularly shares difficult feedback with parents. Recently he talked with a couple about whether the high school they chose for their son was really in his best interest.
“They were both alums of this prestigious private school, but he was, for many reasons, clearly better suited for the local high school. They were not pleased with the feedback, to be honest, but they did understand.”
He also gives tough feedback to his teen clients. He described a recent example:
I told a boy that he could not blame his academic lapses on his parents’ recent separation. He so wanted to hold that as his excuse, and I knew he was hiding from the reality of his own accountability.
In fact, experience told me that were it not the separation, he would have blamed some other external facet of his life. So, I had to tell him his D’s and F’s were on him. That was the bad news.
The accompanying good news was that he had the power to do something about them as well. There is almost always some good news underlying the bad.
Duffy used to feel anxious about giving this kind of feedback. But he doesn’t anymore. “This is part of the job, and the reason that people entrust us with their well-being. Holding back will only protect you the therapist, not your client.”
Marter agreed. “As therapists, there are times we need to say the things that other people have not been able to say to our clients. Not saying anything is a form of colluding, enabling or even neglect.”
The inherent nature of therapy can spark difficult discussions. “It’s always difficult to let clients know that the issues they want to overcome may take some time,” said Ryan Howes, Ph.D, a clinical psychologist and author of the blog “In Therapy.” Their concerns “will take months or more to understand, treat, and (hopefully) resolve.”
But time isn’t the only tough topic. When clients start to delve into their stories, they often realize that instead of one issue, they have three. Around the fourth or fifth session, Howes said, clients start to feel overwhelmed and wonder why they’re coming to therapy in the first place.
Consequently, he helps his clients understand that it’ll “get worse before it gets better.”
I try to reassure them that this is a common experience and that they’re not facing this alone; we’re working to understand and resolve the issues together. As we develop a treatment plan and begin to see tangible progress, the overwhelmed feelings change into a sense of control and hope.
When working with clients who have depression, Jeffrey Sumber, M.A., a psychotherapist, author and teacher, often tackles a difficult theme: Depression may serve his clients in some way. He frankly asks: “How is your depression serving you?”
While many people have depression because of biological and genetic vulnerabilities, Sumber finds that “many others find a home in depression as a reaction to pain, disappointment, fear, anxiety, etc.”
Sumber can relate to feeling “right at home in the warm womb of deep sadness.” He struggled with depression in his early 20s. After much inner work, he realized that “depression was in essence a defense mechanism that I used readily.”
According to Sumber:
When working with these folks, it can be a very difficult moment in treatment when I must confront the component of melancholy that is voluntary; however, I find that relying on my own history and path to recovery has been instrumental in supporting people in trusting that I am not discounting their experience but rather, expanding it.
Delivering difficult feedback can be a challenge for therapists. And it’s certainly rough on clients, too. But, ultimately, these kinds of discussions encourage positive growth and change.
Tips for Readers: Delivering Tough News
Do you have to communicate a difficult message or news to someone else? Marter shared several tips for doing so constructively. First, she recommended reflecting on this quote from Shirdi Sai Baba: “Before you speak, ask yourself: Is it kind, is it necessary, it is true, does it improve upon the silence?”
If the answer is “yes,” then speak “simply, honestly and directly, with compassion and respect.”
She also suggested delivering hard news in person (not text or email) and giving the person your undivided attention (no technology use). “Choose a time and space that is quiet and confidential and free of interruptions.”
Separate your own response from the other person’s, she said. “You may each have different feelings about the news and that is OK. Allow the person to have their own response, and demonstrate empathy.”