NOTE: To protect patient privacy, all names, ages, and peculiarities have been changed. The general storyline, however, remains unchanged. 

Brent is a 36 year old husband and father of two who presented to my office for initial psychiatric consultation. He presents at the request of his wife, Jennifer, who recently moved out of their family home because she “just couldn’t take it anymore.” My first meeting with Brent went something like this:

Therapist: Hi Brent, what brings you in today?

Brent: Didn’t you read over my file before this? You should know the answer to that already. I’ve seen enough therapists to know how this is supposed to go.

Therapist: Can you help me understand what you mean by that?

Brent: What do you need help understanding? It’s pretty simple. I’m supposed to come here, tell you my problems, and you’re supposed to listen and say things that make me feel better. Aren’t you a therapist?

Therapist: Hmm, has this been your experience with therapy in the past?

Brent: Yep. I mean let’s be real, therapists don’t actually care. They just pretend to care so they can take my money. It’s such a scam.

Therapist: Wow, I am sorry this has been your experience. It sounds like you haven’t had very positive experiences with therapy in the past. It makes sense that you would be skeptical about our time together. How can I be most supportive?

Brent: I don’t even know. My life is falling apart. I am not sure there is anything you can do at this point.

Therapist: Sounds like life has been really difficult. I am wondering what you mean when you say your life is falling apart. 

Brent: Well, my wife left me, my kids don’t want to see me, and I might lose my job. I just don’t understand what I’m doing wrong. [Brent becomes tearful]

Therapist: [I remain silent but attentive to encourage Brent to continue]

Brent: I’m sure you’re rolling your eyes inside, ‘here we go, another drama queen.’

Therapist: What makes you say that?

Brent: I can just tell. You must get so tired of listening to people like me.

Therapist: [I make note of Brent’s assumption because it could provide insight into how he feels about sharing his emotions with important people in his life. However, I don’t immediately reply with an overly validating remark that might stymie the therapeutic dialog]. Sharing our emotions can be really scary sometimes. Can you tell me a little more what you mean by ‘people like me?’

Brent: I can’t tell you how many times I’ve been told I’m too sensitive or overly dramatic or that I read into things too much.

Therapist: How does it feel when others say those things?

Brent: [Brent becomes tearful again]. It hurts so much. No one gets it. I care so much but that just ends up biting me in the ass. It would be so much easier if I just didn’t give a shit about anyone.

Therapist: [I remain silent and refrain from offering an automatic reassuring remark but I use body language to show Brent that I am attentive and concerned].

Brent: When I love someone, I love them with all my heart. I go out of my way to make sure people feel special. That’s just who I am. But what about me? What about my needs?

Therapist: [I nod]

[Brent’s body language communicates to me that he is angry and unsatisfied.]

Brent: This is stupid, you just sit there and nod like you know what I’m going through. How dare you pretend to care! I came here because I needed help. Just sitting there staring at me and nodding isn’t helping, it is making things worse! I knew I should have stayed home!

Therapist: [I begin to feel frustrated by my inability to meet Brent’s expectations and I feel insulted and disrespected by his comments. At the same time I begin to feel anxious, ashamed, and insecure as I start to believe Brent is right.] I am sorry you feel that way. Nodding is my way of showing attentiveness and interest in what you’re sharing with me. 

Brent: [Looks away and shakes his head]

Therapist: [I begin to question by abilities. Maybe I’m not good enough to be a therapist. Maybe Brent is right. I decide to share my feelings with Brent.] I’m frustrated with my inability to help you. It hurts me when I see others suffering. [I share with Brent how this situation is affecting me and I validate his emotions by letting him know I can see he is in pain. I show compassion by remaining calm and concerned so Brent doesn’t feel I am abandoning him]. 

Brent: [Brent becomes tearful.] I am in so much pain. I get so angry because I feel like no one cares about me. [Brent begins to shift his anger away from me. His defenses begin to lift now that he feels validated and unabandoned. He opens up a little more as the session continues].

How To Support Someone Like Brent

Validation, Validation, Validation. If you’re a compassionate human being, it is normal to feel uncomfortable when someone you care about is suffering emotionally. Imagine a close relative expressing the following sentiment:

“I am such a loser. No one will ever understand me.”

Our gut reaction might be to offer reassurance by saying something like:

“That’s not true!”

While this might be well intentioned, it is rarely effective. Reassurance is usually not the way to go because it isn’t as supportive as validating the emotion. It is easy to get caught up in the content and forget about the underlying emotion. Has a close friend or relative ever said something like:

“You don’t even care about me!”

We might become defensive and push back with “yes I do!” But again, this is probably not helpful. Instead, try validating the underlying emotion. Consider the following alternative response:

“It hurts me to hear that. I can’t imagine how painful it must be to feel that way.”

We all know our thoughts can be irrational and untrue sometimes, but our emotions are ALWAYS real regardless of whether we believe they are justified. By validating the emotion, we avoid getting caught up trying to “convince” someone like Brent that his thoughts are irrational (which is not validating at all and will ultimately lead to frustration and anger for everyone involved). 

Set Strict Boundaries. This cannot be overstated. It is vital to set boundaries for yourself. When a difficult patient, loved one, close friend, or colleague begins attacking with hurtful comments, it is easy to become immediately defensive and then insecure later on. We might begin questioning our abilities and our intentions.

It is easy to mistakenly internalize emotions that aren’t ours and this is when we become vulnerable to manipulation. It is important to set limits and boundaries for yourself. Your needs matter as well. It’s when we begin losing our sense of self that we become resentful, angry, and lost.

Don’t fall into the trap of believing we can’t be compassionate and supportive unless we allow others to walk all over us. This way of thinking is very unhealthy for everyone involved.

It is important to let Brent’s problems remain his problems. 

Stay Consistent. If you say 11:30am, be sure you are ready at 11:30am. Try to be consistent in how you respond. If one day you respond one way and then another day you respond differently, someone like Brent will never learn from the responses. It is the consistency in response that promotes learning. Someone like Brent will begin to learn that his behavior must change if he seeks a particular outcome. 

Don’t Be Afraid To Share Your Feelings. If we hide our feelings, it is impossible for others to know how we feel. This is particularly important for supporting someone like Brent. When Brent says something hurtful, make it known. Tell him. Allowing yourself to be emotionally vulnerable and share exactly how you feel does two things–it validates your own feelings so you don’t neglect yourself and it provides important feedback to someone like Brent. Sometimes it can even de-escalate the situation. 

Seek Reassurance From a Colleague or Friend When Needed. It is normal to question yourself. But when you begin believing the irrational accusations others make, it is important to keep yourself grounded in reality and run things by people you trust and respect. This is ESSENTIAL.

(Learn all about Projective Identification here)!

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