The Benefits and the Boundaries
as published in The Psychotherapy Networker Magazine July/August 2018
Imagine you’re learning to ride a bike and you’ve asked two people to help: a therapist and a coach. The therapist might stand off to the side, closely observing your attempt to stay upright. She’d be empathic, compassionate when you fall, and give you useful insights about why you’re a little unstable and wobbly. She’d help you express your feelings or frustration about your struggle to move forward on two wheels, and maybe explore why you waited so long to try. Over time, your riding skills would improve as you developed more confidence, armed with new insight and awareness.
The coach, however, would climb on the seat right behind you and ask, “Where do you want to go today?”
This is an exaggeration, of course, but the difference in role is clear. Having a coach right behind you, an ally guiding you and the bike as you both pedal along together, is an example of coaching collaboration. The coach and client work together through intense partnership. Rather than observing from a neutral distance, a coach is at your back, keeping you motivated to continue riding until you can do it on your own, like a pro. You’re in the steering position, and her only agenda is to get you where you wish to go, in the fastest, most focused manner possible.
At its best, this collaborative position can reduce the friction of hierarchy and promote faster behavioral change. You may have experienced it with a fitness coach who’s run alongside you as you’ve jogged around a track. Or perhaps you had a tutor who sat right next to you, shoulder to shoulder, sharing calculations, as you tried to work through an algebra problem. Having a coach at your side, or at your back, can help you go faster and try harder than if you’re being observed by a distant expert. I learned what this collaboration felt like when I hired a life coach to resolve a problem that was beyond my grasp.
I Get Coached
In 1998, I was working full-time as a therapist in a busy private practice. I’d just completed a two-year coach training program and, because I had a business background, had begun coaching a few clients I called reluctant entrepreneurs—people who’d ended up in business but had never studied business basics. Unsurprisingly, this included many of my fellow therapists in private practice. Eventually, I decided to turn the manual I wrote for them into a book, one that would help therapists master the business of therapy. But when an interested publisher asked to see the manuscript, I found I couldn’t move forward with actually writing it. One month went by, and then another and another, with no change in my writing output. It was clear that I needed to hire a coach for myself. So I sought out Pam, a former therapist, now a life coach.
During our first call, Pam asked what I thought was important about writing this book. Although it was supposed to help other therapists, my answer mostly involved all the ways I thought publishing it would build my own career. Pam took a moment to think about this. “Lynn, I’m listening to your reasons for writing and, sweetie (I learned later that Pam called all her coaching clients affectionate names), I just don’t think that you have a big enough vision to get you over the writer’s block. I request that you find a bigger, better reason, other than your personal career agenda, for this book to exist.”
“Honey, that’s what I’m asking you! I can’t find your answer, but I do believe it’s inside you. If I was thinking about this for myself, I might start with my values. Think about this over the week, and let’s talk more on our next call.”
For Pam, the best way to shift perception when someone was stuck was to get them to think bigger. So I took long walks and thought about what a book with this topic might accomplish for others. It occurred to me that if I could help therapists be more successful, it might keep the therapy profession alive in the world, maybe help it grow. I believed deeply in the importance of therapy and thought about all the therapists I knew toiling in private practice—smart, generous, caring people—who deserved to earn a good living. I began to get the spirit and motivation I needed to start writing in earnest.
Pam was a cheerleader in this endeavor, but she also brought in her other expertise, knowledge of the publishing field. When I’d completed four chapters, she outlined the next step—how to write a book proposal—and when I’d done that, she gave me the name of a copywriter to perfect it. As a coach, Pam modeled a partnership position: she sat behind me on the bike.
I felt that my goals became her goals. Her interest in my success seemed real and helped me move forward faster and more easily than if I’d been on my own. But when I tried to describe my relationship with her to my friends, who were also therapists, I got stuck. Pam was kind of an advisor, but she worked with me, as one therapist would say, “close in”—like a longtime buddy. She had immediate, real reactions. She was flexible and made jokes. She cared a lot about my goal. Certainly, no therapist had ever called me “sweetie” and “honey.”
But she wasn’t really a friend, or even a colleague. We talked by phone. I never met her face-to-face. And while I paid her—as I would a therapist—she was transparent and self-disclosed tidbits about her own life and work to help me stay motivated. She’d “break the frame” to email me between our sessions to find out how I was doing and if I was making progress on a specific action. She made suggestions freely and openly. She introduced me to her publishing resources and shared her network of assistants. When my book got published, she bowed out gracefully, allowing me to take all the credit. This stood as a good example for me of the effectiveness of collaboration and the partnership position, delivered through coaching.
Partnership within Therapy
When I began to develop the Therapy with a Coaching Edge model, I found that some coaching elements fit into therapy easily, while others challenged therapeutic norms and needed modification. So I spent a few years defining a set of distinctly adapted coaching skills for use within therapy sessions, then I thought hard about who was “coachable” within therapy.
Bringing in a coaching style required identifying the therapy clients who could accept and benefit from a directive, action-oriented, short-term method, versus vulnerable clients who’d find this approach too exacting. For clients who seemed to be a fit for this approach, I experimented with formatting sessions to make them more strategic, with a distinct beginning, middle, and end that ensured there was time to both set goals and consolidate gains.
The coaching strategy of commenting openly on progress as it occurs translated well into therapy. I slowed down and paused a session to highlight client results—a new insight, cognition, expression of affect, demonstrated strength, or moment of honest self-reflection. Rather than merely observing signs of their development, I prompted clients to give their session takeaways, and if they came up blank, I asked if I could share what I’d be putting in my notes. Soon clients began to recognize and verbalize their own markers of forward movement in therapy, session by session.
Yet the success of these strategies hinged on incorporating the coaching element of collaborative partnership, which also presented the biggest complication. Therapy is traditionally hierarchical for many good reasons. Could the power of a nonhierarchical partnership—being on the back seat of the bike—be adapted for a therapeutic relationship without compromising its integrity? Would working more transparently and directly with a client help or hurt the goal of therapy?
The more I considered it, the more I saw how a reduction in hierarchy and working “close in” could grease the wheels of motivation. I longed to replicate some of that leverage or ability to boost action within therapy, but wondered how to translate partnership ethically for therapy professionals. Was it possible? I concluded that with enough careful attention to respecting the distinctive boundaries of a therapeutic relationship, enhancing collaboration between client and therapist can add an important dimension to the therapy. In many cases, I saw that it could result in helping clients take action faster, with more behavioral compliance.
Taking the Lead
Therapists have been shifting their conception of their role since the field began. Of course, their behavior and the nature of their relationship to clients need to be congruent with their underlying model of bringing about change. A Freudian analyst who’s neutral, blank, and silent acts that way for a reason. She wants the client to forget her presence and focus inward, without her interference. In contrast, a therapist who makes eye contact, shakes hands, and shows warmth and emotion does this to create rapport as a primary healing element.
Steven Johnson, author of several classic books about psychotherapy, notes the development of what he calls postmodern therapy, and observes that as methods have changed, so have therapists, becoming more natural vs. neutral, proactive vs. nondirective, supportive vs. diagnostic, responsive vs. deflecting, questioning vs. interpreting, and leading vs. following.
Therapy with a Coaching Edge echoes Johnson’s postmodern progression. To further the coaching elements of partnership, action, and possibility, the therapist must relate in a proactive way that signals authenticity. This requires being a presence in the room, not a neutral, blank slate. It requires being real—talking normally, rather than with stilted or carefully worded interpretations. To be seen as both an expert and a person, you need to let yourself be expressive, communicate curiosity, show real interest, and have a sense of humor. The last point in Johnson’s list is also an important skill: knowing how and when to go from following to leading.
In my early training as a psychodynamic therapist and a social worker, I was taught that my primary role was to follow, not lead. I let the client begin a session. That meant I’d start a session in silence, so as not to influence or bias the client in any way. My client could talk or not talk; I wouldn’t influence or interrupt. I let a client take the lead and watched as the session unfolded, sometimes in confusion if a client wasn’t sure how therapy worked or what to do.
Unlike the blank demeanor that I was taught, Therapy with a Coaching Edge encourages therapists to take some leadership, at certain times, as a way to offer collaboration. Don’t stay neutral and force a client to flounder. Help out the process; ensure that it goes well. Use skills to shape a session agenda, to give it structure and a dynamic flow that promotes more results. Rather than allow a client to devolve into long narratives off topic, help them follow a plan. Ask effective, pointed, even powerful questions when it would help to pick up the pace. Take responsibility to keep the session organized and relevant.
For example, I used leadership with my client Angela to keep her focused on making a necessary change after she arrived in my office one day and told me she needed to talk about something important. “You know that my husband works for the military and we move a lot. We’ve lived in six states in four years. I’m not complaining about that, but I have a young son, and most of my time is spent taking care of him. I work a little part-time, and I’m into yoga.” I nodded my head to show that I remember her telling me this before. “But I think I’m bored or just uneasy,” she continued, “and when I get like this, I tend to get in trouble.”
“What kind of trouble?” I asked.
“Well,” she admitted, “I start to look for a man to flirt with. In fact, I’ve started to think about getting a little friendly with my neighbor. He’s cute and single, and I’m home a lot by myself.”
Angela looked at me for my response. I realized I had a choice to make about my therapy persona. I could stay silent, and just nod as many therapists do, or I could respond more authentically, using a collaborative stance. I choose the latter.
“Yikes,” I said. “You sure do know how to make trouble.” I smiled slightly.
Angela sat back in her chair to indicate her surprise and barked out a laugh. “I didn’t think you’d say that! It sounds bad when I hear you say that out loud, but you’re right. My husband really got mad the last time it happened. He said if I didn’t get help, I shouldn’t follow him to the next posting. It’s a great posting, to a city I absolutely love.” She proceeded to chat about everything she loves about the place, and the session started to devolve into a guided tour of sorts.
I decided to take the lead, to interrupt, and in doing so, redirect her. “I’m really curious. Are you in therapy right now so you can follow him to the next posting and live in the city you love, or are you here to save your marriage?”
There was a long pause. Angela stared at me. “That’s a good question. A really good question. I guess I don’t know why I’m really here. Or what I really want,” she said.
“Thank you for stating this so honestly. I appreciate that you don’t know what you really want. If you’d like to use our therapy sessions to figure out why you’re here and what you do want, I could absolutely stand behind that goal.”
“I’d certainly like to figure out what I really want,” she said. “That would probably change my life.”
Defusing Negative Transference
In an earlier session, Angela had explained that her husband reminded her of her father, a stern authoritarian; she’d rebelled as a teenager to establish her individuality. She now does this to her husband. Transference is a normal aspect of relationships. Most of us operate with some degree of idealization or demonization of those in our current lives, based on unconscious bias and family history.
But when transference, especially negative transference, is focused and projected onto the therapist by a client, the pace of a session needs to slow down. It takes time to process negative transference, which requires a neutral, nonreactive response from a therapist so the client can have open space and sufficient time, even multiple sessions, to work through the layers of complicated feelings and thoughts being projected onto the therapist. Obviously, this interferes with a shorter-term method of therapy that uses a coaching approach.
Negative, erotic, or idealized transference inhibits action, thinking about possibilities, and constructive partnership. So I stay cognizant of the normal occurrences of transference and countertransference in therapy and address them transparently and quickly, to lessen their intensity and get back to the topic at hand. When hints of a negative transference emerge, I try to observe and talk about them calmly, without reactivity or judgment. Transference is a form of client communication. I communicate back, not dodging the issue, but not trying to expand its occurrence, all with the aim of staying collaborative and focusing on achievable goals.
With Angela, I had to defuse a bit of negative transference when she was late getting to a session. She’d encountered a traffic jam on her way to my office and came in flustered, asking immediately if she’d be charged for the entire session or if I’d prorate it and charge her only for the time we actually talked. I told her that I’d need to charge her for the full session, regardless of her being late.
“It’s not my fault that I’m late. I can’t control traffic,” she said, irritated. “I don’t see why you can’t be more flexible and work with me on this. This therapy is very expensive, and I’m not getting my full session. Why can’t you make an exception?”
Let’s bracket Angela’s question for a moment to explore a traditional therapeutic response to this situation, so you can understand why I responded to Angela the way that I did. In my earlier career, using a psychodynamic model, I was trained to handle a complaint like this by doing nothing to soften the client’s negative transference. Instead, I’d turn the question back on her to ask, “How would you feel about me if I did make an exception?” After the client responded, I’d follow up by asking, “How would you feel about me if I didn’t?” and then process the responses at length to help her develop more insight about the idealized or negative feelings and thoughts, and what aspect of her history or psyche it related to. All the while, I’d screen my own thoughts and feelings behind a neutral persona. Nothing would show on my face as I’d explore the client’s unconscious resistance to therapy, the potential lack of organization in her life. I’d mention her statement about the expense of therapy, her feelings and thoughts about having to pay for treatment, and any and all anger or upset directed toward me.
Therapy with a Coaching Edge has a different purpose. I’m not promoting insight and affect or expression of feelings to the degree I do when using a psychodynamic approach. Instead, I’m focused on action and a prospective, future-forward direction of problem solving. So I need to defuse negative transference in service of the goals of a coaching approach. First, to maintain rapport, I validated Angela’s upset.
“It makes sense to me that you’re frustrated and upset. I know that some of what made you late was out of your control. This is costly, not just in terms of money, but also the stress you feel, trying to get here on time,” I said.
Next, I chose to be transparent, to be authentic, and to allow her to see me as more than her projection. “I was a bit upset, too. I was waiting and worried about you. I’m really glad that it was only traffic that delayed you.”
Angela looked at me carefully. “It never occurred to me that you’d be worried or wondering if I was all right.”
“I was, and while I waited, I did some thinking about you,” I responded. “I reviewed our notes from our last session. I thought about how we could focus our conversation today, to try to make sure you got what you needed, even if we had less time. Can I share my idea of where I think we should start?”
Here I collaborate to make the session successful, if possible. I take responsibility to provide value in my role as the therapist: not just paid for waiting, but paid for working. I had a plan, given a reduced amount of time, so that she could leave the session with some results.
Angela looked relieved and said, “Yes, that’s good, thanks. I’m ready.”
We were able to have a productive session. At the end, she listed the things she’d take away from our time together, including what her action steps could be. At the door, she turned and thanked me for helping everything work out so well.
By opting for collaboration, I intentionally defused her negative projection, not to let myself off the hook of her anger, or to defend my boundaries, but to shield the model of therapy. I wanted to stay focused and make the session useful. I also used this experience as a therapeutically teachable moment—how to find ways to make things go better by accessing resources (in this case, the resource of me, as her collaborator, using the time to review notes and think of a plan). And I could remind her of our shared goal of staying connected to each other, even when trying circumstances, like lateness, interfered.
Increasing Use of Self
Throughout my training to become a social worker, I heard teachers employ the term use of self. Use of self, I came to understand, meant that who you are—the combination of both your professional and personal life experience—is perhaps the most important tool you can bring into any therapeutic situation.
Therapy, at its essence, is based on a relationship. The therapist and the client sit in an otherwise empty room, without props or tools. Experienced therapists recognize the power of a use of self; they’re comfortable being themselves and relying on their presence as the main healing element they have to offer. For newer therapists, the need to depend on oneself is often fraught with anxiety. Newer therapists worry, “Have I said too little or too much? What if I don’t know enough to be the expert on this issue? What can I say to help a client? How might I relate better?”
I remember an old cartoon that showed a doctor sitting at his desk talking on the phone with a patient. Unseen by the patient was the fact that the doctor was smoking cigarettes, had a bottle of Scotch opened and a drink poured, and was seriously overweight. The advice he was giving the patient belied the scene. “As your doctor, I’m telling you to get healthy! Immediately stop smoking, stop drinking, and drop some pounds.”
The old medical mantra of “do as I say, not as I do” won’t work for a therapist using a partnership position. With reduced hierarchy and less transference, clients will look to you as a model of your services. You’ll need to represent what you provide. For example, if your therapy practice specializes in addictions, you need to be on a solid path of sobriety. If you specialize in wellness, you need to have optimized your own healthy choices. Your ability to make use of yourself, to stand as an example of the clinical results you promote, helps forge an authentic relationship with clients. You need to develop a strong therapeutic sense of self, so that you demonstrate a balanced, real adult in your clinical role.
One way to heighten a use of self is with appropriate self-disclosure. Studies have shown that clients experience greater warmth and relatedness with a therapist who occasionally self-discloses. Showing real concern or apologizing helps repair the therapist–client alliance when it’s broken. Of course, when you use self-disclosure, do it with intention, caution, and care. Assess whether sharing something personal about yourself would benefit or burden a client, and do it only when you feel confident that it will further the treatment goals.
In one session with Angela, who had a lifelong struggle with her sense of self-worth, she said, “You probably never had this problem, Lynn. You’re very self-confident, but I’m not smart enough or strong enough to say what I think in the moment. Then afterward, I can barely stand myself, because I missed my chance.”
I asked Angela if she thought that speaking up was a skill that could be learned, but she looked doubtful. “Either you’re born with this ability or you aren’t,” she said.
I could’ve challenged this belief system by explaining that many people have overcome shyness or inability to speak up, but given her idealization of me (“you’re very self-confident”), I decided to use myself as a role model. I wanted to demonstrate, not the end result of my being assertive, but the process of its development.
“Can I share a story from my own life?” I asked. She nodded. “I remember my first job, when I tried to ask my boss for a raise,” I said. “I thought I’d pass out from anxiety. I literally had to sit down to catch my breath after I got a few words out. My boss asked if I was going to be ill. You can imagine how that ended. No raise. And I never got up the courage to try it with him again.”
Angela laughed. “You were scared? How did you get to be the way you are now?”
I paused before answering. I knew that Angela was an amateur musician, so I framed my answer as a lighthearted question, one I knew she could answer. “What do they say about getting to Carnegie Hall?” I asked.
“Practice, practice, practice,” she said immediately, and we laughed together.
Now I offered support. “We could practice together in a therapy session, perhaps use a role-playing scenario.”
“That would be great, especially if we can make my part easy to start, like playing scales before attempting a concerto.”
Angela grabbed onto the metaphor of Carnegie Hall as a way to understand how to move toward this goal of assertiveness. “Scales first” became her favorite mantra during her remaining time in therapy, one that helped her take small but important steps to achieve other meaningful actions.
Shifting to a less hierarchical, more collaborative relationship as a therapist might worry those who’ve been trained in models that are intentionally neutral to protect therapeutic and ethical boundaries. I’ve sat through many ethics workshops during 30 years of practice as a clinical social worker, and I respect the rationale for keeping clear boundaries between therapist and client. But discussions of boundaries aren’t always black and white, or exacting in their application. If you want to adopt a coaching approach and a partnership position but don’t find it natural to the way you currently work, it’s important to proceed slowly and, of course, adhere to all the ethical requirements of your licensure.
To better understand the shades of gray in situational ethics, when applying a new persona to your practice, I like the distinction psychologist Ofer Zur makes between boundary crossings—clinically effective interventions such as self-disclosure, home visits, client touch in the form of handshakes, or a nonsexual pat on the back—and boundary violations—when therapists cross the line of decency, violate or exploit their clients sexually, financially, or in other unethical ways, including misusing dual relationships.
The issue of dual relationships is one that can be confusing at times for a client, especially a client of a therapist who works using a coaching style. Indeed, we therapists can get confused about what’s therapy and what’s coaching in a way that can set up possible boundary issues. I faced such a situation toward the end of my work with Angela, who’d decided to recommit to her marriage and was ready to go to the next posting with her husband. Once they moved, she wanted to start a small business teaching yoga classes at the military base. Knowing that I worked as both a therapist and business coach, she asked if I could become her business coach and work with her via phone or Skype. “Since we’ve worked well together and our therapy has had a coaching style, and it feels like coaching a lot of the time, can I hire you as my business coach? Would that be okay?” she asked.
Some therapists wonder whether the two roles—that of therapist and coach—can be combined with a single client. Is it possible to switch roles and be a client’s therapist and then, later on, her coach? If it’s sequential, or there’s a break between the contracts, is it permitted? I’m of the firm belief that the roles of therapist and coach for a client are distinct and need to be kept separate. Even though I use a model of therapy with adapted coaching skills, when I practice as a therapist, I stay in that role.
I could understand that from Angela’s perspective, this boundary wasn’t clear. For her, therapy and coaching seemed to be very similar. But I knew better. What I understood from my position, which would be hard to explain to Angela, was the concept of a dual relationship. When I work as a business coach, I explain to clients that I’m part coach, part consultant. I become involved in strategies regarding their finances and debt, marketing and business planning, promotions and goals. It’s essential my business clients have the ability to analyze rationally what I suggest, and then freely reject my ideas. They need to rely on their knowledge and instincts to do what’s best for themselves and their businesses. We contract with this in mind, to balance my influence and equalize the power differential.
As Angela’s therapist, I couldn’t erase our prior therapeutic relationship to have a clean slate for coaching. Even though I’d tried to minimize the transference and idealization, I knew I’d been privy to her pain, defenselessness, and deepest feelings about herself and her marriage. This would give me an unfair advantage in any coaching or consulting engagement; my words and ideas would carry extra weight, a hidden influence. That wouldn’t be fair to Angela, and would affect the balance of a coaching relationship, which requires that we have a level playing field.
Thus, my policy, whenever I’m asked to switch roles, is to say no, hold the boundary of the existing contact, and if desired, make a referral. But I do this with some care, to preserve the sense of partnership and collaboration. After Angela made her request, I took a moment and then responded, “I’m so appreciative that you’d consider me for the role of your business coach. I like all you’re planning for yourself and wish I could be a part of your circle of support. But unfortunately, I’m not able to switch roles. Since I started as your therapist, I need to stay in my role as your therapist.”
“I thought this would make sense and we could still work together. I hate to leave,” Angela said.
“I, too, have feelings about ending and have enjoyed our work together. Let’s spend time today talking about the sadness of ending. I can also offer a way to help you end therapy well and consolidate all the gains you’ve made. When you move, whenever you’re ready to hire a business coach, I’d be happy to see if I can suggest a few referrals. I’d be glad to support you in that way, if possible.”
Angela took three sessions to complete her therapy. She reviewed the progress we’d made, identified next steps to maintain her new behaviors, and used time to express her thoughts and feelings about her results and our positive therapeutic relationship. She called this a good ending, an experience of having a supportive relationship end on a positive note.
For me, it was an opportunity to more sharply clarify the difference between coaching and therapeutic work. Both have the potential to be profoundly helpful to different kinds of clients with different issues, at different stages in their journey. But professionals with training in both modalities must be aware of the strengths and limitations of each and not imagine that it’s possible to seamlessly shift back and forth between defining themselves as a coach or a therapist without confusing their clients and giving into the illusion that they can be all things to all people who come to them for help.
Adapted from Therapy with a Coaching Edge: Partnership, Action and Possibility in Every Session by Lynn Grodzki. Copyright © 2018. Available from W.W. Norton & Company, Inc.
Lynn Grodzki, LCSW, MCC, is a psychotherapist, a master certified coach, and the author of Therapy with a Coaching Edge and Building Your Ideal Private Practice: 2nd Edition.