Out of Session Support

I would like to here everyone's opinion regarding out of session support. I frequently suffered what I will call "session fallout" following a therapy session. Sometimes when this occurs I send my T a letter or email expressing what I'm feeling or experiencing. We have discussed my doing this and she is OK with it. However, I have some problems with MY actions.

I am simply curious what others think. Should we as patients expect our T's to provide out of session support in the form of answering emails, phone calls, etc? I welcome all perspectives.

I wrote my T for 6-7 years between sessions and when she was away, actual letters mailed to her office. We didn't discuss very much about them, often didn't even acknowledge they'd been received by her. In 18 years I think I only called her on the phone 3-4 times for out-of-session contact.

I think it all depends on your and your T's relationship. What they are comfortable with, what you're comfortable with and what "works" to help you.

I decided to stop writing my T myself, to keep contact to only the session in about my 7th of 9 years. It was very frightening and difficult but I was able to "contain" myself and not spill over into writing my T. I was very proud and my T was pleased also. Our sessions became more personal and intense because that was the only time we "saw" each other.

I agree that whatever works for you and your t is good. My t encourages me to e-mail between sessions, especially if there's something we're working intensely with. She recognizes that not everything happens in that one hour a week and that for me, it's really helpful to have support and feedback between times. It's also a way of strengthening our connection and building trust, for me at least. We usually talk about the content of the e-mails during sessions, however. I also use them to bring up things that I want to bring up in session but are afraid of hiding. In that case, she'll bring them up right away to see where we want to take them. For me, it makes talking face to face easier, but I know that for some people it becomes a way to hide.

I think if a T is worth their weight, they will realise that in the beginning we will most proberbly need a certain amount of support between sessions, and that with time if they are good at what they do, this will lessen. I equate to having a baby, for a while we have to walk the floor at night until the baby can go through the night, as we know as time goes on this happens., If a client 5yrs down the road is still wanting constant phone or email contact then I think that needs to be looked at too.

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mckell13 said:
However, I have some problems with MY actions.

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I don't have any problems with your actions :-) What problems do you have, maybe we can help you think them through? Expose yourself, McKell, get down and vulnerable

Mouse,

I like the baby analogy :-)

I think what sparked my question is that although my T has said it is OK for me to email/ write her. It is ME who seems to have a real problem with it. So,... if I have a problem with communicating with her outside the session--WHY DO I CONTINUE TO DO IT?

Keep in mind that my T does not respond to the emails or letters I send outside of the session. So my sending her the communications requires very little extra workload on her part. I have never requested a reply so this is OK with me. I'm also confident she would reply if I requested one.

I'm wondering..what is really going on with me?....what's the big deal???

I know everyone has different needs/wants, pathologies, life circumstances, etc. I'm just curious about how others view this issue and how much you vacillate about it. I personally spend a lot of time shifting back and forth between Send ----Don't Send.

For those (like me) who waste valuable cognitive effort with the Send ---Don't Send decision, what do you think about?

Honestly, WAY too many things go through my head for such a minor issue like this.

I guess I started this thread as a way of exploring reasons for 1) sending messages in the first place and 2) why engage in self loathing afterwards?

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Perna said,
Expose yourself, McKell, get down and vulnerable

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Al rightly then...

Why do I want to send a letter or email?
1. Because my head started to explode with stuff that surfaced after the session and just journaling about it didn't relieve the pressure.

2. I want my T to know something that I was unwilling to physically say/discuss in a face to face meeting. (To admit this one is a big step for me, mainly because until recently I was in denial about wanting anyone to know anything about me.)

3. Because the inner me never seems to be able to surface and connect directly with my T in a live session.

4. Because the inner me wants to learn how to express and share my feelings with other, but hasn't been able to figure out how to get past the outer me. I'm hoping that expressing myself in written form will some how magically eventually lead to being able to express myself extemporaneously. (Not sure there is any evidence to support this approach. It has been a purely trial and error activity on my part.

Why do I choose to beat myself up about it afterwards:
1. I feel like I should be able to deal with session fallout on my own with disclosing stuff that many be irrelevant.

2. I feel like out of session communication should be limited to emergency situations (i.e. to prevent suicide, self harm, drug/physical abuse, etc). None of which I am currently experiencing.

3. I am worried that through my writings my T knows way too much about me and this is going to eventually come back and bit me in the *&&.

4. I feel like I'm being a baby, whining about stuff that only I can fix.

5. I feel like I am expressing stuff that should normally be kept to ones self. We all have feelings, thoughts, fears, etc that should be acknowledged and dealt with privately. I'm having confusion over what should be shared and what shouldn't be share in normal relationships.

Very good! I'm with you 100% there.

But think of it as an extension, only in your head, of the therapy session. As you noted the therapist doesn't have to do much, for all we know they say, "Ah, another long-assed post from McKell" and give it to file 13 with the other junk mail :-) They don't, you ought to talk about just that with your T, it will bring you closer. So, you think about therapy when you're not there and here you're actually doing something concrete to make that true! That's very creative and useful to you. Being useful is good. Nevermind the names your inner critic calls you, just combat them with "But it's useful!" and it won't have an argument for that, it just has name calling skills.

I like your #4. I found it to be true for me. Think about all you have learned here writing stuff out at PC? It is the exact same thing but in a more personal, relationship, situation when you're writing your T about things you have mentioned or think important. Wanting your T to know things and sharing them in writing is the beginning of opening up and having a relationship and it's still with T, like a session, so it's "safe" in the same way. So, you get to practice saying personal things you can't actually say in person yet. Eventually you will say some things in person, because this writing thing will go well and give you courage to take the chance.

Your #2 beat up self reason makes me curious. Where did you learn such an idea? My stepmother wasn't big on complaints. When I was sick, I had to have a fever to stay home, couldn't just not feel well or have a cold or something, had to "prove" I was sick by throwing up or having a fever. When I complained about something, was too cold or hot or hungry (mind you I was 5-7 years old) I was told, "Everyone else is just as tired as you are" (or cold, hot, hungry, etc.) usually said when we'd walked a million miles shopping and I was expected to keep up with her adult legs and quick stride. So, I don't complain and if I'm not paying attention, I give people who do complain a hard time about it. One is not allowed to have one's own outlook, the situation defines itself and everybody responds accordingly. So, who taught you to only bother them when you needed to borrow their phone to dial 911, that a simple, warm conversation wasn't a good enough reason to get in touch?

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anneke06 said:
She recognizes that not everything happens in that one hour a week...

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My T has mentioned this too. That her job is just to focus my attention in certain general directions. What happens then its up to me. In a fantasy kind of way I would really like support and feedback at 3 AM when I am writing a letter. But realistically, I would respond to this type of support the same way I do the 1 hour face to face session. I'd waste it being defensive.

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It's also a way of strengthening our connection and building trust, for me at least.

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I've been hoping that my written expressions would eventually transition to more relaxed verbal communication. This may be happening some, but I'm not sure.

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We usually talk about the content of the e-mails during sessions

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We do too. And much to my dismay last session I learned that if I send it, SHE WILL RAISE IT. Even if I request otherwise.

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For me, it makes talking face to face easier, but I know that for some people it becomes a way to hide.

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Hmmm.... easier... not feeling that. Hiding...dunno, maybe...

[Perna said,
So, who taught you to only bother them when you needed to borrow their phone to dial 911, that a simple, warm conversation wasn't a good enough reason to get in touch?

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Damn Pern! I honestly have no freak'n idea who taught me this!!!!!!

But it is a concept that I seem to take to the extreme in MANY ways.

I was recently banned, LOL, true story, from emailing AND phoning my T (unless the call was stating that I needed to be hospitalized). We were going through a tough spot, I had stopped idealizing him, and I knew that he was not going to be here for me forever. I was angry. I sent him quite a few angry emails and also some good ones. However, I can be obsessive, and sent him more than the one allotted email a week (ooooops). So, I also have a problem with MY actions.

When he told me that I could no longer email or call him, I started bawling. He asked, "What are you thinking?" I told him that I felt like I was being punished for being who I am (needy) and for having what I have (OCD).

I renogotiated these terms, though. I have never, ever abused the phone privilege. I always fight myself not to call him because (LOL) I don't want him to think I'm needy! (I'm sure he has no clue). He agreed and I am back to the normal as far as the phone goes. Meaning, I haven't called him once. Anyway . . .

My opinion? I think that they should get paid for it. I think that it should be individualized and contracted based on the baseline data/needs of the patient. For example, if someone generally calls twice in between sessions, the T and patient should make a contract that the patient can call two times in between sessions (the T can specify the times exactly, can tell the patient she can call between __ and ___, or whatever). Then, maybe the T can allow one call a month that is not at the specified times if needed.

I also think that this should reduce the number of hours that T can see other patients. Yes, this would mean that he wouldn't have as many hours to devote to other patients (less competition, fewer assprints LOL). These calls should be treated as sessions, the T will be paid a set amount for the phone sessions, insurance should cover this, so the T can't take your call while he is in session with someone else. He should devote all of himself to you during that time (and should think about you all other times.

What a good question! What do you think?

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mckell13 said:
Should we as patients expect our T's to provide out of session support in the form of answering emails, phone calls, etc? I welcome all perspectives.

</div></font></blockquote><font class="post">I don't think there are blanket expectations that can be applied to all therapeutic pairs. I think what is most important is that the T communicate clearly, at the outset of therapy, what his policy is on out of session calls and emails. It seems that often it is the uncertainty that is hard for people to deal with. If I email him, will he respond? If I do email him, should it be for only brief, procedural reasons or can I do online therapy with him? If I phone him, will he call back? If we do talk on the phone, how long is permitted? Are there extra charges for these services? I think the policy should be stated in the consent form you sign on the first day of therapy. As time passes, if your T wants to modify his policy based on your special needs, then I think that is OK. But hopefully they will be aware that changing their policy too many times could be confusing or upsetting to the client.

The point is on one hand: they don't get paid for it. Now I know most patients think but it's only for me... but yet, they might have a full case load... and that might mean 20 patients a week. A T doesn't (at least we hope they don't) just walk in to meet you without any forethought or plan for therapy. You need to add up to 2 hours a week for each patient on average, without phone calls and emails etc. And the main point: they need a personal life or they will burn out and be useless to everyone.

I'm sorry that you feel punished. Try and think of it this way: T is helping you discipline yourself for your own best interest.

During those times when you would normally email or call T, write stuff anyway. Then, perhaps find other ways of expressing your emotions...through some type of art. Then move on to distracting ourself from those feelings.

Some Ts suggest that you don't do any therapy between sessions, but leave it for the guided session. Try to get through your life, make notes, distract yourself, and then come prepared to share how tough it was (and also your victories) when in session.

(((hugs))))

Its interesting reading about others' arrangements with their therapists. I came here today because I'm very much "missing" my therapist, I saw her yesterday and this part of the week is hard because it seems it is such a looong 6 days until I get to see her again. And, I'm pretty uncomfortable with how attached I am to her already. I know its fairly normal and even good to be attached. I'm also a very stay within the boundaries type of person and I feel that if I'm not paying her for her time, I should not contact her at all between our sessions unless I am in dire straits. I have had some excellent therapists over the years and while they said it was of course fine to call if I was in danger, they did not welcome contact between sessions.

I e-mail my T every once in awhile just to say the things I couldnt say in session.....she doesnt mind....and if i need to call her its not a problem...she told me in 13 years of being a therapist, she only had to tell one client not to call her anymore ....every T is different...my first T didnt give out any personal information....e-mail/cell phone.....he was strictly a "session" T.....

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Now I know most patients think but it's only for me

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Sky, while I respect your opinion I have to disagree. I don't think MOST patients think but it's only me. I think when patients call their Ts they may be thinking about harming themselves, killing themselves, obsessing over things that have been said, or many other reasons.

Above, I advocated for T being paid for the calls and extra time and I mean that. I'm not anti-T. I fully believe that they should be paid for their work AND that they should be there for the patient. Therapy is flat out painful and at times close to unbearable. You can't resolve emotional strife by rationalizations, it just doesn't work. Textbook solutions to our issues aren't always the answer.

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I'm sorry that you feel punished. Try and think of it this way: T is helping you discipline yourself for your own best interest.

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If one feels punished, as I have, I don't think the answer is that you are undisciplined and need someone to discipline you for your best interest. Actually, the feeling likely comes from the past and is one that has been reinforced over the years. I know intellectually that my feelings don't match what is going on, but they still are my feelings. And they still are intense.

There has to be a way that our in between session anxiety can be reduced/alleviated AND the therapist can be paid for his work. I gave an example of how in my response above. Yes, the object is not to be reliant on your therapist. However, if the therapist is skilled, he should know how to gradually reduce this behavior in a way that builds the self-esteem of the patient.

We need to start a peaceful revolution that will better therapy for both the therapist and the patient. All of the issues on both sides need to be addressed and dealt with. I really think this is possible. So, where do we start? DocJohn, any suggestions? Anybody?

I'm sorry my words weren't understood in the spirit I sent them. Let me try again.

My referring to the "but it's only for me" means that the patient is so heavily invested in their own problems, they don't realize that if a T opens emails up to one, they need to for everyone. What you said is in agreement to that thought about the patient only thinking of herself, indeed, they are unable to focus on much but their own pain and suffering. I'm not saying this is bad, no, just that it happens. The T must think and consider all his/her patients.

I am sorry that you feel punished, but you aren't being punished, you haven't done anything "wrong" in my eyes, but need help to hold those parameters that every patient fights against. T has to hold them for all patients, until they are strong enough emotionally to do so also. It's a terrible feeling, I know. What your T will show you, I hope and am pretty sure of, is that these parameters though they feel like something bad from your past, are not from the past but from now and that your T is showing you the good side of it all, and how healing can come from this.

I am sure your T understands that you didn't call and that it was very hard for you not to do so. You don't have to tell T everything, some things are "given." I'm proud that you are able to still call when in dire need.

The place to start on needing payment/coverage for all a T gives... wow... I think there is no ONE place, but a revolution like you said. However, there are so many ppl needing basic coverage and yet the insurance companies win... It needs to beging, legally, with our our State Senators and Congress, I think. I think again we agreed but with different statements on this.

TC! (((hugs)))

I have after session reactions that are improving, lessening in intensity and frequency.

She asked me soon after we started working together how I would feel about being able to call as often as I needed, to leave messages and that she would return a call to me *if I ask* (hard for me). I welcomed her offer and I do call, often in meltdown after session.(Last week twice on the way home from session! lol) When we do talk together on the phone it is just for a minute or two, agreeing that we will talk in session about what I'm distressed about. It is relieving and calming at a time I cant' do that for myself.

This last week she called and said to remember that there is no rush. I was upset that I didn't get to some things in session and I beat myself up too about how I "do" in session.

My opinion is that I need this and it's helpful. I don't worry about the boundaries around it too much because that's up to her. Recently after the holiday break she announced that 'phone calls will be brief'. She needs that for her she said. I'm glad she takes good care of herself. (That announcement felt punitive to me at ifrst but we talked about it several times and got it worked out)

I really wish I could email but she doesn't do that. I have taken writings and she's read them, but prefers to hear it in my voice. So, I journal to her and that helps me get from session to session too.

I think out of session support depends on so many things: what kind of therapy is being done, what's going on the the patient's life, where the patient is emotionally, if the between-session contact is in any way taking away from the in-session work or experience, as well as the practical things like the therapist's need for time away from their work and to nurture their own personal and professional lives.

I have worried about my actions. I have called her in such distress I could hardly speak. We have talked about that, where it comes from and she assures me it is okay (and she is not mad at me for calling so many times) and it will get better. I leave a lot in her hands now. It feels so good when I can do that.

I can so relate to your list!

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Soliaree said:
I was recently banned, LOL, true story, from emailing AND phoning...

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Sol you crack me up. I think I'm afraid of being a pain in the butt. Even though, my emails or letters don't require her to do anything other than, print and file them, I still feel this way. I think she does actually read them, but I don't think she studies or analyzes them. I also keep things as short as possible 1-2 pages max.

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My opinion? I think that they should get paid for it. I think that it should be individualized and contracted based on the baseline data/needs of the patient.

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I think this is a good point. When I first started therapy I had no idea what to expect. I could barely call to make the appointment. So asking at that point what her rules were if I want to communicate with her outside of a session didn't even occur to me. I think in my first email to her, I think I started with...Feel free to charge me some "clinical reading fee" or something. When I came to the next session, she actually chuckled at that and said she doesn't charge patients for letters they write.

Here is an issue I have. If my therapist said to me: 'Hey, I accepted your letters in the beginning because you were having trouble. But now, you need to stop sending this crap.' I would be OK with that. I'd simply try to find some other solution for my session fallout. I might even be brave enough to ask some "what if" type questions and negotiate the rules.

However, my T is choosing not to set a boundary and is leaving the choice to write or not totally up to me. Now, many people would welcome this freedom, but for me... I don't like that! My brain goes wild trying to figure out what is appropriate, how would a "normal" person deal with this freedom, what is she learning about me based on the boundaries I set for myself????? Maybe she truly doesn't give a crap what I do, but "I" care.

I know I am a freak

Sky,
I am sorry - I didn't mean to sound so abrupt and rude. I am a teacher and totally understand the extra time put in for those that choose the helping professions. I absolutely believe that Ts should be paid for all of their work. I felt punished at the time, but that is lessening now. I don't think I could ever express how much pain I am in at times, I guess the pain of abandonment. It is unbelievable and at those times I do anything and everything to ease the pain, including contact my T. I am learning, albeit slowly, to do it myself but am not even close to where I would like to be. I agree about the insurance companies, they need a total overhaul!

Take care.

Sunrise,
Excellent! What you suggested is kind of like a Therapy Handbook for new patients. Why don't T's do that? It would have reduced so much of my anxiety about therapy. When I arrived at the.. 'Hey, this feeling YOU helped me dig up really sucks! I want to talk to you now.' point, I could have simply referred to my Therapy Handbook to find out what the rules were on Out of Session Communication. :-)

((((soliaree))) Part of what your T is modeling for you is that though you feel punished and abandoned, T will still be there. What you are experiencing is part and parcel of therapy...and it's tough work. Going slowly sometimes is faster... wanting to rush through things is normal, as it's thought it will lessen the time of the pain.

Please know that Ts fully understand the emotional pain of therapy. It's still ok for you to remind them that you need to hear it from them, that they understand.

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_Sky said:
Now I know most patients think but it's only for me... but yet, they might have a full case load... and that might mean 20 patients a week.

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Sky I hear ya, that is probably why I'm feeling needy. I totally get my T's workload and need to protect her personal life. I also am very much interested in disciplining myself and learning to deal with my inability to express myself and effectively utilize my therapist's time. However, it is obvious that my desire to communicate at times strong enough to click the send button.

I think my awareness of potential workload is one reason I am struggling and feeling guilty about my actions. Then again, clicking the print button and tossing my letter in my file doesn't seem too unreasonable. Maybe there is more to it.

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I think in my first email to her, I think I started with...Feel free to charge me some "clinical reading fee" or something

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I also told my T that he should somehow charge me for reading my emails (Pre-ban era). He said that if they became cumbersome that he would think about it.

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If my therapist said to me: 'Hey, I accepted your letters in the beginning because you were having trouble. But now, you need to stop sending this crap. I would be OK with that'

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Yeah, you're a better person than I. I bawled on the couch when he said, "You can no longer send me emails and any phone calls have to be calls in which you need to go to the hospital". I always wondered also if he thought my emails were helpful. Now I've heard my answer loud and clear, LOL!

No, you're not a freak! I'm not sure, but I think it has something to do with how you act around others. For example, do you do what you want to do if given the chance or do you base your actions on other people's expectations? A few things you said of interest were "how would a "normal" person deal with this freedom", "what is she learning about me based on the boundaries I set for myself?????", and "Maybe she truly doesn't give a crap what I do". Maybe instead of writing when and what you want you want her to set boundaries so you feel comfortable? I may be way off base. However, I am exactly like that.

Take care,
Soliaree

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SoSadMom said:
I'm pretty uncomfortable with how attached I am to her already.

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I am NOT attached to my T!....
This is a new admission for me. I like my T too and I am very uncomfortable with this realization. The only thing that makes it tolerable is that I've also realized some of the benefits to sharing stuff with others. My relationship with kids and friends have improved a lot. These benefits make it worth it at this point.