Is it OK for therapists to cry?

Patients aren’t the only ones to tear up during therapy — sometimes therapists do, too.

You are leading a therapy session when your patient reveals she was horribly abused as a child. Your patient starts to sob — and tears fill your eyes as well.

Is this an appropriate response? Should you fight your tears, hide them or let them fall? And if you do cry, how will this affect your patient?

Many graduate programs don't address tears in therapy, either in the classroom or during supervision. As a result, students may be led to believe that therapists must remain strong and neutral, and that tears are unprofessional and undermine a therapist's strictly defined role.

Yet tears are common for many therapists, research suggests. A 2013 study in Psychotherapy by Amy C. Blume-Marcovici, PhD, Ronald A. Stolberg, PhD, and Mojgan Khademi, PsyD, of Alliant International University, for example, found that 72 percent of psychologists and trainees had cried at some point with patients, with 30 percent having shed tears in the previous four weeks.

So how should you approach the possibility that you may find yourself in tears during a session? What role do therapist tears play in therapy? Here's some advice.

A sign of humanity

When she was in training, crying with patients was not talked about, says Nadine Kaslow, PhD.

"There was an implicit message that you shouldn't do it, that it somehow showed boundary problems," says Kaslow, professor and chief psychologist at the Emory University School of Medicine. Female therapists especially were led to believe that if they cried, tears showed "you weren't strong enough to do the work."

These messages haven't changed much, Kaslow says. Yet she believes restrained tears — not full-on sobbing — can be a positive and natural element in a therapeutic relationship.

"Many of us who are sensitive and compassionate and feel our emotions do get choked up or tearful on occasion with a patient," she says. "And that's a normal human and interpersonal reaction.

While all psychologists work with emotional issues, some are more prone to hear stories that trigger tears. Among them is Sarah E. Dunn, PhD, clinical director and supervisor at the Grady Nia Project at Grady Hospital in Atlanta, which serves African-American women who are survivors of domestic violence.

Dunn says her trainees sometimes find themselves choked up by the emotionally powerful histories their clients share — "almost like vicarious traumatization." This has caused several of her students to come to her with concerns about their tears.

"They feel panicky: Should they leave the room? Go to the bathroom and pull it together? Or is it OK to show to their patients?" Dunn says

Over the years, she's come to realize that "seeing the therapist as a person and having the therapist show emotion helps [patients] to open up a little more."

What do patients think?

Research asking patients what they think about their therapists' tears is scant.

In a 2015 study in Psychotherapy, researchers Ashley Treat, MD, Jonathan Kelly, and Glenn Waller, PhD, surveyed 188 patients with eating disorders and found that about 57 percent had experienced their therapists crying. Most of these patients saw their therapist's tears in a positive light, but this wasn't automatic: It depended on how they viewed their therapist, researchers found.

If patients saw their therapists as having a "positive demeanor" (defined by researchers as showing happiness, firmness or consistency), they were more likely to view the tears positively and to want to continue therapy. But if they felt their therapists had a "negative demeanor" (characterized by anxiety, boredom or anger), they felt less positive about the tears and their therapy.

The type of tears mattered, too. Most described their therapists as looking or sounding close to tears. Some described therapists crying openly but still carrying on with the session. Much less frequent were open tears that caused a session to be paused or ended. These types of more extreme tears were rated negatively by patients.

"Therapists' crying cannot be assumed to be an almost universally positive or neutral event — it depends on how patients see the therapist as a person," the researchers concluded.

In an as-yet unpublished dissertation, University of East London student Alice Watson researched patient responses to therapist tears. She was inspired to study the topic after she experienced therapists crying as a patient — and had two very different reactions. One incident left her feeling closer to the therapist, while the other had the opposite effect, marking the end of an already rocky therapeutic relationship.

For her research project, Watson interviewed eight people, ages 25 to 56, in the United Kingdom who reported seeing their therapists cry during a session. The qualitative study examined what worked and what didn't, finding that patient expectations about therapy and therapists made a difference in their perceptions. Some reacted negatively, viewing tears as a diminution of the therapist in their eyes and an uncomfortable blurring of roles and boundaries. Others found their therapists' tears to be a welcome affirmation of their pain.

Whether they viewed them positively or negatively, says Watson, all the participants felt the therapist tears were "a big moment that mattered and influenced how things went in the relationship."

What should you say if you cry?

If you've shed tears in front of a patient, should you acknowledge the moment? Or move on as if nothing has happened?

Kaslow says it depends on the situation and the relationship. Sometimes it's better to say nothing.

"Shared tears in the face of a sad situation may not require an explanation," she says.

But if the patient responds by trying to take care of the therapist, "that might need to be addressed."

If only the therapist cries, but not the patient, Kaslow recommends saying something along the lines of: "I think I may be crying because ..." or "What is your response to my shedding some tears?" This could be brought up immediately or later in the session or even at the next session.
When tears are inappropriate

Crying can mean anything from eyes that glisten to a gentle tear streaking down a cheek to loud wailing. Therapists usually feel more regret about "more intense crying or more frequent tears or tears that are related to their own situation," says Blume-Marcovici.

Another red flag: crying every time you see someone with a particular problem.

If you start to cry whenever a patient discusses a particular issue, "it's really about your not having dealt with that issue yourself," says Kaslow. If this happens, you need to get help for yourself and should discuss this with your supervisor, she says.

Common triggers for therapist tears are grief and loss or trauma, says Blume-Marcovici. Therapists who have suffered recent losses or major life stresses may return to work too soon — and then may find themselves crying when counseling patients who have had similar experiences.

Therapists need to know how to assess their own readiness to return to work, she says.

Of course, it can be hard to know exactly when — or if — tears will fall. But therapists need to be aware that this very human reaction may occur and have some idea what to do if it does happen, rather than be blindsided during a session. Ideally, say Kaslow and Blume-Marcovici, psychology training programs will help provide these answers.

By Lorna Collier, via APA
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