Our “Therapists Spill” series takes a behind-the-scenes look at clinicians’ personal and professional lives. Therapists have spilled everything from their life mottos to why they love their jobs to the best advice they’ve received on conducting therapy and leading a meaningful life.

This month we asked clinicians to share the hardest part about therapy. Five therapists reveal a range of challenges.

The hardest part of therapy for Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression, is watching clients work through their issues. Therapy is highly effective. But it requires effort and hard work. And it requires traversing potentially painful territory. She said:

For me [the hardest part is] knowing that talk therapy doesn’t always make you feel better. Making a breakthrough in therapy is exciting and meaningful for both myself and my client. However, achieving awareness sometimes requires you to be brave and fearless. Recalling memories and experiences, or changing a behavioral style, can be trying, upsetting—even overwhelming.

Being in therapy will reduce your symptoms and help you feel better, but it’s beneficial to know that the journey can sometimes be bumpy. It’s hard for me to witness my clients moving through such pain, even though I know the experience will yield important results.

Clients must get past their problematic patterns, which are tough to detach from. For John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens, helping clients separate from these profoundly entrenched patterns is the biggest challenge. He said:

I love the process of therapy, especially when it is oriented around growth and strength. I find the toughest part for me, and perhaps my clients as well, is creating movement among long held, maladaptive patterns of thoughts and beliefs. We create our deeply held thought patterns at a young age, and undoubtedly they serve a purpose for quite a while, sometimes years, even decades.

But they are so difficult to let go of when they no longer serve our needs, or they inhibit our growth. It takes strength, resolve, hope, and a bit of a leap of faith in the process to let go. When that finally happens for a client, it is most rewarding.

It’s also challenging to maintain a happy medium between letting clients rinse and repeat these unhealthy patterns and pushing positive change. According to Joyce Marter, LCPC, a psychotherapist and owner of Urban Balance:

One of the most challenging aspects of conducting therapy is finessing the balance between meeting clients where they are at and also encouraging them to grow. I believe we all unconsciously recreate patterns in our life that are familiar to us as a way of working through our issues.

When a client presents for therapy, I will honor their emotional experience and reflect empathy as a way for them to express and release feelings that may be preventing them from moving forward. I will gently but directly encourage them to identify themes and patterns in their life that are no longer working for them.

When clients are ready to make positive change[s] in their lives, they will learn from these insights and empower themselves to choose roles and relationships that promote wellness, happiness and success in their lives.

However, sometimes we need to repeat these patterns over and over until we are ready to look within ourselves and make the changes. It is difficult when clients focus on others (who they cannot control) and continue to cycle in a way that is self-limiting.

It is at these times that I need to practice healthy detachment with love–the ability to unplug from my clients’ stuff and understand that they are exactly where they should be in their journey and they will make positive changes only when they are ready.

I often refer to the Serenity Prayer, which is, “God, grant me the serenity to accept the things I cannot change, the courage to change the things that I can and the wisdom to know the difference.” This reminds me that I should focus on everything that is within my power as a therapist, such as providing empathy, compassion, insight, interpretations, coaching on how to change self-talk and perspective, and increase copings skills and awareness through psycho-education.

I need to continually remind myself to let go of that which I cannot control, such as the clients’ responses, behaviors, progress, etc. I remember when I was in graduate school, a beloved professor of mine said, “Joyce, you are very good at being empathic and breathing people’s stuff in. You need to remember to breathe it out.” Her words were very wise and I reflect on them daily as I continue to grow as a clinician.

Creating positive change is taxing on clients. And, naturally, it’s also emotionally draining for clinicians. Christina G. Hibbert, PsyD, a clinical psychologist and postpartum mental health expert, tries her best to prevent emotional overwhelm.

For me, the toughest part about doing therapy with a client is ensuring I do not get consumed with the emotional drain. I strive to be fully present with my clients, to listen carefully and feel what they are feeling. Empathy and connection in the therapeutic relationship is key to helping the client make change, and it is rewarding to get to know these wonderful people in such a deep and intimate way.

However, it can also be very draining. I used to work longer days and I would come home depleted, with little left for my family’s needs. But now I work shorter days, which helps keep my energy levels up.

I also prepare myself before sessions through deep breathing and visualization techniques that help me feel prepared to be with my clients, to empathize and feel with them while they’re there with me, but to also leave it all in my office when I go home.

I don’t let the emotional experiences “stick” to me like I used to, and that makes doing therapy so much healthier for me, which makes me a better psychologist for my clients.

Adding another person — or party — to the therapy process also can get tricky for therapists. Ryan Howes, Ph.D, a clinical psychologist in Pasadena, California, said that “triangles” can be especially trying for him.

I feel great about working directly with clients, but when a third entity enters therapy the work becomes much more difficult. That third entity could be an insurance company that limits our sessions, a spouse or loved one who undermines our work, or intangible factors like finances or schedule conflicts that make our regular meetings more difficult to attend.

Working directly and intensely with a client is empowering, but dealing with an intrusive third entity distracts us and could stunt our work. I know some of these third objects are necessary and at times quite helpful (insurance and family, for example), so I try to face them with as much acceptance and assertion as I can muster, but at their worst, they are my biggest challenge.