As therapists, we care deeply about our clients. But is it helpful to be nice?
I remember a particularly tough day of clinical work that I experienced several years ago. I was completing my clinical psychology internship at the Palo Alto VA, with the goal of gaining greater experience in evidence-based treatments for trauma and related conditions. While I love working with clients with a history of trauma, I was feeling demoralized after several clients in a row didn't show up for their scheduled appointments. One of the most rewarding things about working with clients with trauma is that they can see so much improvement through a relatively short course of therapy. However, one of the most challenging aspects of this work is the fear that they won't be able to engage in the treatment to actually receive these benefits - the desire to avoid any reminders of their trauma might simply be too powerful. My biggest concern on this day was that the string of missed appointments suggested one or more of my clients was considering dropping out.
I have always found unanticipated terminations to be one of the most challenging aspects of clinical work, especially in the case of clients with trauma. I’m sure we can all think of cases where we truly believed that we could help the client to reach their goals, but the client decided to end therapy before we could reach that point. When clients have been struggling with trauma for years, all I want to do is help them find greater peace around these terrible experiences. If they can just stick through the early, difficult sessions when the urge to avoid is high, they can receive so much benefit from therapy. But sometimes the avoidance is too strong, and clients choose to terminate before getting much benefit out of therapy.
On this day, I was worried that this process had already been set into motion. What if my clients were finding the trauma-focused work to be too much? What if this was not the right time for them to do the work required by this therapy? What if I hadn’t done enough to convince them that treatment would be effective?
I sought input from a colleague, hoping for reassurance that my clients would return and the multiple no shows were an unfortunate coincidence. As we talked, my colleague shared her perspective on missed appointments and the ease with which our minds can jump to conclusions about what a no show might mean. Then, she said something that struck me. “Even if they end up dropping out, at least you know that you were nice to them.”
Hmm. I thought about that for a second. Clearly, my colleague was trying to validate my efforts as a therapist – even if clients leave before we’d like them to, we can feel confident that they have gotten to experience a positive relationship with a nice person.
But while I saw what she was getting at, the word “nice” didn’t sit very well with me. In truth, I hadn’t been very nice to my clients. They came to me for help moving beyond the painful memories of trauma and the associated emotional, behavioral, and cognitive struggles brought on by those memories. And what did I do? I made them remember. I encouraged them to think about, to retell, to engage with those memories, even when they hurt (especially when they hurt) as a way of finding new ways of holding these traumatic experiences and disengaging the memories themselves from some of the emotional pain associated with them. Through exposure exercises and exploration of the caustic thoughts and beliefs that had arose from those traumatic experiences, I asked my clients to confront the most painful parts of their life every week in therapy.
To me, this is not being nice. Being nice would mean avoiding painful topics, not challenging easy assumptions. Family members can be nice. Friends can be nice. Therapists are not always in a position to be nice.
This is especially true when we are working with clients presenting with situations or emotions in which the desire to avoid painful content is particularly strong, such as trauma, anxiety, or shame. In these cases, behavioral therapies such as CPT, Prolonged Exposure, CBT, DBT, and ACT ask us to help clients show up to those painful emotions, repeatedly.
Therapists are often not very nice. But we should be warm.
What's the difference between being nice and being warm? To me, niceness implies that you are trying not to ruffle any feathers. You interpret the client’s social cues and you follow them. Your client becomes hesitant when talking about that experience? Fine. No problem. We’ll talk about something else. The client tears up when a particular family member is mentioned? Not a big deal. We don’t need to go there. Niceness means using your therapeutic skill of reading another person and assessing what's showing up for them internally to make sure that you don’t upset them.
Warmth is something else entirely. A warm therapist moves toward emotional pain in the room and engages in this movement from a place of compassion and caring. Your client begins to cry when talking about what is going on for him at work? Rather than shy away from it, let’s talk about what is happening that is feeling so distressing. And let’s do it in a way that illustrates to the client that we are coming from a place of caring, of understanding how painful this is and of choosing to go there anyway. Here, we are discussing difficult content in the service of the life the client really wants to be living, even when that process is incredibly painful.
Warmth goes beyond what we choose to talk about in the session (the content) and instead reflects how we talk about that subject (the process). Warmth means conveying through tone of voice, body position, eye contact, and word choice that we are present with the client and care deeply about what is happening for them.
Warmth means that our care for the client is coming through in our voice. Rather than a flat or merely inquisitive tone of voice, our tone illustrates our caring stance. We could be saying anything, even something very difficult for the client such as “I need you to continue with this exposure even though you really want to stop.” And yet, our tone illustrates that we’re saying it with a client-focused intention in mind.
I have seen clients literally beg to stop an exposure, particularly in a trauma-focused treatment like Prolonged Exposure. Remembering the details of their trauma is so incredibly painful. And yet, if they are willing to keep going, they will get so much more out of treatment than if they continue avoiding. And so, sometimes with tears in my eyes, I encourage them to continue, even though it hurts. In some circumstances my firm but warm request means they are able to continue, while in other circumstances they choose to stop. However, both of us know that the path toward healing is ultimately through the pain rather than around it.
Warmth is also conveyed in body position. If I am slumped back in my chair or sitting straight as a board, I may be conveying disinterest or professionalism rather than warmth. What may be needed in moments of particular pain is orienting toward the client, leaning in closer to them to illustrate that I am present, that I can see something important is happening and that I am with them in their difficulty. In moments in which I need to hold a firm line, such as asking the client to talk about or do something that they want to avoid, physically orienting my body toward them and leaning in shows that I care. I’m attuned. We are having a human interaction, and I am not immune to the pain within this experience, even though I am the one encouraging the client to do something so painful.
Eye contact, or lack thereof, can be a mechanism of warmth as well. Looking at the client when they are tearful shows that you are present and are not scared of this emotion, which can help to normalize the experience of showing up to painful feelings. In our daily lives, friends and family so often look away when we cry. Just allowing space for that pain, honoring it with your attention, can be a powerful intervention that shows how much you care. The way that you utilize eye contact is also important. Holding eye contact with empathy is different than looking at someone with panic ("this is too much emotion – what do I say to the client next?!"), blank curiosity ("why are you so upset? Is this really that big of a deal to you?"), or boredom ("I know I’m supposed to give clients a minute when they cry, so let’s get through this and move on").
Lack of eye contact can also potentially be a move toward warmth, although it can be interpreted differently depending on body position and other nonverbals that affect the feeling in the room. Looking down to give the client a moment to themselves can be meaningful, showing that you are willing to wait and that we don’t have to hurry up and move on from this emotion. However, lack of eye contact could also convey boredom if your gaze is wandering all over the room or glancing at the clock.
Spend some time with a mirror examining how your gaze appears. If possible, videotape yourself with clients or with a friend (always with their consent!) to see how your nonverbal behavior comes across. It is not uncommon for there to be a disconnect between how you are feeling internally (e.g., caring) and what is coming across to the client (e.g., confusion, anxiety about what to say next, disinterest, boredom, professional detachment, intellectualization of their pain) based on your nonverbal behaviors. Work on finding ways to show your internal experiences on your face and through your body position.
Finally, word choice is, of course, critical. It is so important to validate pain. Again, nice means that we don’t talk about pain, we politely pretend that it is not there. Warmth means I will hold your feet to the fire, but I will do so in a way that acknowledges how difficult this is for you. E.g., “I know this is so hard to talk about, and I’m going to ask you to keep going.” If the client is having difficulty moving forward in talking about a painful topic, a mix of open-ended questions and gentle commands can be helpful. For example, “What is showing up for you right now?” and “Tell me more about what happened after that.”
Warmth may feel like something that you either have or don’t, but it can absolutely be learned. It's important to remember that, like so much of therapy, this process is about much more than what is written in the protocol or being a generally nice or pleasant person. Warmth is about caring for your client and conveying that care through your verbal and nonverbal choices. Warmth is what kept my clients who did not show up for therapy on that tough internship day from dropping out entirely, despite the fact that trauma treatment (or any therapy) is not always nice.
Consider ways that you can increase warmth in your work, particularly when dealing with painful or challenging topics where the client's urge to avoid is likely to be particularly strong. Examine moments when you may feel the desire to be nice instead ("it's totally okay that you haven't been doing your homework," "I can see how tough this is, so let's not talk about it today and see if you're up for it next week"), and try to explore the function of your nice behavior. If it's about rescuing the client or yourself from discomfort, this might be a moment when you could turn up the warmth while still holding firm to effective therapeutic behaviors. Encouraging clients to complete challenging homework or fully engage in painful exposure exercises rarely feels nice, but is often the most caring thing we can do for people who are struggling. Lean into warmth in these moments.
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