If I had a friend who began every sentence with an apology, I might eventually point it out and ask her to knock it off. If a colleague told the same anecdote three times over the course of one lunch hour, I might tell him to quit repeating himself, or else intervene and change the subject.
But what if these things happened with my patients? What's the difference between conversations with friends and conversations with patients?
The difference is that with patients, everything I say or do should be in the service of the patient. With the friend and colleague in the examples above, I'd speak up to save myself from boredom and crankiness; with patients, my personal feelings are expressed if and only to the extent that expressing them would be helpful to the patient.
Example: Say I had a self-effacing patient who was driving me crazy by beginning every sentence with an apology. By the end of a session, I might want to snap "Quit apologizing!" but that would be a mistake. A better intervention would be to gently say something like "I've noticed that you frequently begin your sentences with an apology." Whereas the former comment expresses personal irritation, the latter is a simple and therapeutically relevant observation; the latter comment also allows for follow-up questions such as "Is apologizing something you also do with other people?" "How do you think your habit impacts your conversations?" and "How might you perceive someone who apologized all the time?" If later the patient and I were hypothesizing about how other people might perceive his constant apologizing, I could ask him for ideas (e.g. "People might think I have low confidence; they might think I'm being fake"), and then maybe add something like "Some people might find it endearing; others might find it frustrating." But my personal impatience would not be relevant.
Second example: Recently, I recently expressed frustration with a friend who kept repeating herself. She was struggling with the decision to move her elderly mother into residential care; despite my validation of the struggle and the decision, my friend continued to repeat just how much she loved and respected her mother, what a good parent her mother had been, etc. Finally I lost my patience and exclaimed "I get it, already--you love your mom!" This wasn't very helpful for my friend; a more helpful response would have been something like "Yes, you've mentioned that a few times. It must be really important for you to make that point clear."
With a patient, this kind of neutral comment is even more important, and often elicits useful information such as "I didn't know if you heard me the first time I said it because you just nodded but didn't say anything" or "I guess I feel guilty, like I'm just getting rid of my mom now that she's become a nuisance, or worried you'll think I'm a bad daughter" or "Really? I already said that?" With patients, these answers can prompt valuable conversations about validation, guilt, and social skills, respectively.
In therapy, comments like "Quit apologizing!" and "I get it!" are not appropriate because they imply a responsibility of the patient toward the therapist (e.g., to not be boring, to not waste my time), and because they express therapist feelings in a way that isn't relevant or helpful. But are there occasions when a therapist should express her true feelings? The answer is yes, but the same rule applies: only in the service of the patient.
Example: A depressed patient tells me he's bad at communicating and I respond that I've noticed that he's actually quite forthcoming and articulate in our sessions.
Example: A panic disorder patient tells me that he felt silly jogging on the spot in my office to try to induce panic symptoms for an exposure exercise, and I tell him that I was just thinking how brave he was to engage in an exercise designed to bring on symptoms that terrify him.
Example: A socially anxious patient reaches over in the middle of our session to pluck a stray hair off the arm of my sweater and then immediately asks, "Was that weird? Should I not have done that?" and I respond that her act didn't seem out of the realm of normal social behaviour, but that the timing was surprising and the gesture had taken me a bit off guard.
In each of these example, my comment is authentic and is designed to validate, bolster, and/or reflect reality to patients whose perspective may be unhelpfully distorted.