American Board of Psychological Specialties

10 Miles. 1 Hour. Therapy on Two Wheels.
Life often presents us with challenges, opportunities, and lessons. I recently experienced first hand how life can tell us what therapy might be like for our clients in a way I never imagined.
The Tour de Nick is an annual 10- and 25-mile bicycle ride through Northfield, MN, coordinated by Bill Metz to honor and remember his cycling friend Nick. Nick died by suicide, and this ride helps raise awareness of both suicide and mental illness. I drove to the bike shop where the race was to begin. I was filled with both anticipation and apprehension as I hadn’t been on a bike in nearly 25 years. Would I be able to keep up? Could I ride 10 miles?  How much pain would I be in the next day? Would I embarrass myself, and if so, how much?  After all, the other riders were all avid cyclists like Bill.

I arrived to a sea of what looked like the Tour de France (rather than the Tour de Nick). Men, women, and some children of all ages were dressed in shiny, silk, endorsed cycling gear. I heard clicking sounds everywhere from spikes in special shoes. I was told the shoes are worn by racing cyclists, and the shoes fit into bike pedals so they wouldn’t slip out. I, on the other hand, was dressed in blue-jean shorts, heavy tennis shoes, and a polo-type shirt. Everyone was wearing aerodynamic helmets that looked like something from an outer-space movie and special watches that tracked “split times” and “elapsed time.” Embarrassed and feeling vulnerable, I clearly stood out in the crowd as different. All of the bikes were very expensive, very light, and had at least one if not two water bottles attached to them with turned down handle bars. As I looked around, my anticipation left me, while apprehension increased. New-found anxiety appeared as I was in such unfamiliar surroundings.
I was fitted on a rental bike with upright handlebars, no water bottles, and 5 gears, not at all like the other racing bicycles I was looking at. I did not know what I would do with 5 gears, but I was pretty excited to have them, only until I found out the other bikes had 15 or more. “Who cares, I am going to do this!” I told myself. Next I was given a helmet, which I didn’t want to wear, but I figured it best since it would protect me from what I was about to embark on.  
Standing next to Bill, a 5’2”, thin, athletically built managed care professional, we spoke to the crowd about the race and the reason we were all there. I told them that 90% of those who die by suicide had a diagnosable mental illness or substance abuse problem at the time of their death. I shared data about suicide being the third-leading cause of death for 15–24 year olds in our country, but that with proper medications and psychotherapy many suicides can be prevented. It was now time to leave, and Bill told everyone that as we left, it was customary for the first mile to be ridden in silence and for us all to ride together as a pack. At the 3-mile mark, the 25-mile riders would go left, and the rest of us would go right. Bill said that we should probably hang back and leave last. After the first mile we could catch up, and I would “benefit from catching the draft,” whatever that meant. At this point, my goal was to ride out of the parking lot. Sure I wanted to finish, but I couldn’t imagine getting very far, so leaving last seemed smart to me. I didn’t know what to expect. I told myself to trust my guide, and I’d be fine.
”Take a right out of the lot and ride down a small hill, then take a left at the first light. Head straight through the first mile and it’s pretty even, shouldn’t be a problem for you Dan,” Bill said. With no reason not to trust him, off I went in silence. As I coasted down the hill I thought it was going to be easy, but I can also remember telling myself not to get too cocky. We had a long way to go.

Following his instructions, I turned left at the light. By then, a ¼ mile was over, and I felt great. As we pedaled in silence, I thought about how great it was that so many turned out to honor a fellow rider. I felt good about the community, the team spirit, and the camaraderie among the group. A quarter mile later, from out of nowhere, I began to feel a burning sensation in both of my legs. What was this and why was it happening? Was I not paying close enough attention? Had I done something wrong? Because we were still riding in silence I knew we couldn’t have finished one mile, yet my legs were in pain. Worse, the pain was getting more and more intense as I was pedaling. I began to get scared, and the pain grew worse. My heart started to beat faster, and it was now getting warm I thought to myself as I began to sweat. Fear and self-doubt ran through my mind. I thought, “I cannot do this. I will not make it. I have to stop. What if I don’t? If I push through this, will I damage anything? This is not good. You must keep going! Dan, you are pathetic! What’s the matter with you? Keep going!”
Trying to stay as focused as I could to conserve my already depleted energy, I noticed that Bill was riding next to me, pedaling much slower than what he normally would be. I felt badly about this, but at the same time I was comforted to know he was there. He turned to me and asked, “You doing okay?” I wanted so much to say no, but too embarrassed to be honest I politely lied and said, “Yeah, I’m okay, this is great.” I was stunned as he congratulated me, “You made it through the first mile, nice job.” A deep breath was quickly exhaled noting my accomplishment, and then I realized that this meant I had 9 more miles to go and no confidence that there was any way I could or would make it. “Keep going,” he said. “You’ll be fine. We can stop any time you want, just say the word.” Panting but trying to cover it up, I felt reassured, but unconvinced this was going to be a good thing for me.
“So tell me what’s going on with you. How’s work? Your life outside of work? Have you been busy lately?” Bill wanted to talk to me? Are you kidding?! I could barely breathe, and he wanted to have a conversation. Is he serious? Maybe he was pushing me more than I could handle or maybe he could see my distress and was trying to distract me so I didn’t keep thinking about the current situation, feelings, or worse, what was yet to come. It didn’t matter really. I told him only what I thought he needed to hear, but enough so that he believed we were communicating. I had to keep doing this and was determined, eve despite my negative thoughts and feelings of pain and suffering.
By the end of the second mile I was thankful my legs were not burning any more. I was still breathing pretty hard, and it felt like I was riding through Niagara Falls with the sweat dripping down my face. I had renewed hope that I could do this, and I began to talk more. For the first time I could enjoy the environment around me. Just then I realized that “the pack” was gone. I asked Bill where everyone had gone. “Oh they took off. They’re now in race mode. We’ll see them at the end of the day. They’re doing 25 miles, so they’ll turn off to the left up there.” “We’ve only gone 3 miles? Are you kidding me,” I asked seriously. Why was I starting to hurt again? Was I that big of a failure? For the first time, Bill no longer seemed to be the comfort he once was. For the first time, I realized that this was about me.
Bill gently prepared me for the hill that was ahead. “It’s a long, slow incline, but a big one,” he told me. Why was he doing this to me? Wasn’t there any other way? Was there another route? I was exhausted, and he wanted me to go up a huge hill. “Don’t worry,” he said. “You’ll do fine. Remember, we’ll go at your pace.” As I turned the bend, I saw the hill up ahead. He was right. He was so right. From afar it didn’t look too bad. It wasn’t steep, but it was long, and we were headed right for it. I began to mentally prepare myself. “Think about your former patients. Think of the pain they went through in therapy and in their lives. Think about the three patients you lost to suicide and the agony they suffered for so long.” Think, think, think. No, wait—why am I feeling? I didn’t like this, and I was not feeling good. I didn’t like these feelings. Stupid. Insecure. Humiliated. Ashamed. Frustrated. Angry. Incompetent. Out of shape. Couldn’t I just keep thinking and not feeling?  Was I really going to have to do this alone? I didn’t think that I could. The battle in my head was waging, and the hill was getting closer and closer.  
At the bottom of the hill, I began the long trek up. It was going pretty well until about halfway up. I can’t do this, I thought. I can’t. I have to stop. I can’t take the pain. I feel every muscle in my body, every joint ache, every bead of sweat. My lungs burn, my heart is racing, and it is all just agonizing pain. I kept telling myself that I couldn’t stop pedaling and I couldn’t stop living, however I was now pedaling so slow that I was not sure I could stay up on the bike. Pushing down hard on every turn of the pedals and trying hard to hold the handle bars straight was almost unbearable. This was NOT going well. I needed help. I needed help but I wasn’t going to ask. I’m not good about asking for help and worse at accepting it. Clearly, I was in trouble. Just as I was about to give up and give into the pain, Bill rode up along my left side. With the last bit of energy I had, defeated I gave up my focus on the top of the hill and turned to look at him. Surprised but happy to see him next to me, he said, “Don’t worry. We’ll do this together.” At that moment I felt his hand on my back. Pedaling in unison, one foot over the other, I was now extending my head and neck toward the top of the hill as if it would somehow help me get there sooner. The next thing I knew, Bill had helped me to the top of the hill. I had made it!
Thrilled to be at the top and feeling as though I had just conquered my biggest obstacle, the joy was short lived. A flat road for about another mile left me feeling like the “thrill of victory” wasn’t quite worth “the agony of defeat.” What I didn’t know was what was left in front of me on the last half of my journey.
Not far ahead was another bend in the road and another hint from my guide. “You’ll be going downhill, so get ready to enjoy the breeze.” This was exciting and gave me the energy to continue on. Still breathing hard but focused and determined to finish, I put it into third gear and headed for the downhill glide. As I approached the bototm, I felt myself pedaling harder and faster. “Please God, get me there,” I said to myself. I needed a rest and to glide along for just a while. A few moments later, I was there. My tired, exhausted legs stopped their spasms and their pedaling almost instantaneously. Looking back I’m not even quite sure how they knew they could take a rest, but they did. I felt a sense of relief like none other so far, even greater than topping the hill and passing the halfway mark. The wind was cool and helped dry my drenched body and hair. I was able to take in the scenery around me and notice how beautiful it was: trees, clouds, blue sky, fields, birds, and calm serenity; it was perfect.
What I didn’t realize was that there were just under 4 miles left for me to bike, and there was still more for me to learn. We had one last hill to climb. “Are you joking with me?” I asked but this time out loud. “No,” Bill said, but he also assured me that this hill wasn’t going to be anything like the last hill and that I would make it. He told me it was a short hill, “like a small speed bump compared to the last hill,” and he’d help me like before if I needed it. That was comforting, but not really. How did he know what this was like for me? He wasn’t inside of me feeling what I was feeling. I didn’t want him to have to help me, not again. I wanted to be able to do this on my own now, but I was still afraid. Filled with mixed feelings of comfort and trust in him, anger and resentment that he could do this and I couldn’t, I pedaled on. My self-talk was different now than it was a few miles ago. At first it was all negative, but now I had some positive thoughts too. I was so angry at myself for agreeing to do this and at Bill for what seemed like everything. Yet, I was also too far along to go back, and there was no way I was going to be able to just stop and sit where I was, so forging ahead was my only option. Determined to succeed, I now had some positive thoughts and a few moments of developing self-worth.
Just then, I approached the hill. I knew and I felt that I couldn’t make it up to the top without stopping. Unfortunately for my already battered body and self-esteem, there just wasn’t going to be any way around this. The old feelings of anger, fear, humiliation, shame, doubt, etc. were back. Feelings I wasn’t expecting on this 10-mile ride were once again right in front of me. I thought to myself, “Think of all the clients you have had before. Remember their pain, how much they struggled and how much they hurt inside.” I thanked myself for reminding myself of such a clever thought. This was the answer: feel their pain in my body and pedal on, pedal hard. For every pulled muscle, for my over-worked lungs, for my pounding heart, all I needed to do was think of them and it would get me to the top.
My great insight worked for a while, but then stopped. I tried desperately to remember various sessions with clients who sobbed in pain. I recalled clients whose painful histories ruled their lives so greatly that they were constantly defeated and hopeless. I remembered stories of people trying desperately to work through past traumas, troubled relationships, and fears, but facing defenses so extreme that they agonized week after week with no resolve or success. When I couldn’t think of any more, it was clear that everything was again just about me. The focus was on me and myself. Could I battle this hard enough, long enough? I knew I couldn’t do this alone, and yet I didn’t want any more help. Ultimately, the answer was no. About halfway up the hill, I had to stop. I had had enough. There was simply too much. Too much battling of my own thoughts. Too much emotional energy drained out of me. Fearing he would see me as a failure, I yelled up to Bill and told him I needed to rest. He turned his bike back from the top of the hill where he already had reached and headed down to where I was and reassured me that it was just fine. He rode to where I was, stopped, handed me his water bottle, and said, “It’s good to know your limits.”  
After 5 or 6 minutes and now more determined than ever before to finish, I stepped back on the bike and began pedaling toward the top of this final hill. Fast, shallow breaths, wobbling unsteadily on my bike, pedaling to the top without his hand on my back, I went on. I was finally doing this on my own but still thankful that Bill was near enough for me to see him. What I didn’t know, but of course he did, was that awaiting me at the top was some of the most beautiful landscape. Below a river valley, there was a small town, and off in the distance was the end of the ride. What I also didn’t know was that I had a long downhill ride in front of me that allowed me to drift, coast, and feel like I was floating through the air like I was part of the world again but without the pain and pressures I left behind. As I came close to the bottom of the hill, I was about 2 miles from the finish. In my anticipation and excitement, I peddled harder and faster and felt a renewed sense of success, self-worth, and accomplishment. I finally put my bike into 5th gear for the first time!  
We rode through the town and much to my amazement, no one cared and no one was paying any attention to us. We were merely part of what was happening that day, nothing more and nothing less. I realized how much our clients must feel this almost ironic sense as they come to therapy. Inside our safe four walls is one world, and the rest of the world goes on outside those walls while we talk to them. At the end of each hour, they leave and walk right back into the world that hasn’t stopped, not even for a second. On the one hand, how can we expect to truly help them when we don’t know their world outside of our office? On the other hand, it’s something in that world that has brought them to us. Riding through the town, I was again part of the real world and felt like it too. I was almost back.
Less than a mile to go, it was a flat ride to the finish. Interestingly enough, it was right where I had started. How could that be, I thought? How can I be back in the same place, yet feel so different? Riding next to me, Bill told me I rode an average of 10.2 miles an hour. He gave me one final word of encouragement and then told me up ahead he would be turning left as I turned right. I was to go around one more corner, and up a block, I would see where it all began. I was ready now and felt confident that I could do this on my own.  Not only could I finish, but I could go beyond and do this again, and I could see things differently than I had just one hour ago.  
When I arrived back at the bike shop and got off the two wheels that had carried me so carefully over the last 10 miles, I felt a bit of sadness about leaving what had helped me much along the route. I was ambivalent about leaving what I had become one with and yet I knew I needed to leave it behind. I parked the bike, took off my helmet, and walked ever so slowly (and I’m certain, awkwardly) to my car. Each step reminded me of a mile, and a patient, and when I sat down in my car, turned on the air conditioning and radio, I knew it had all been worth it! I had gone 10 miles in 1 hour on two wheels and had learned 10 important lessons.
Lessons Learned
Just as I had apprehension and anticipation, both positive and negative, so do our patients before that come to see us. Just as every one of the cyclists got on a bike for the first time as I had that day, starting therapy can have the same first-time effect and feelings for everyone.
The more negative self-talk I had, the more I was fighting myself. It is good to remember that our clients don’t really fight us, they fight the things that brought them to us.
As therapy begins, it is easy. As it continues, you don’t ever know exactly where it will go or what will be coming next. Having a (treatment) plan with clear goals is helpful for you and your clients to monitor along the way.  
When your patients have the first sensations of pain, discomfort, and desire to stop therapy, that is the time to remind them that you are there to help and guide them and that getting through it will help.
It is always good to be a few steps in front of your client and to let them know you know where you are headed. It’s also important to remember that your clients may not always like you, and that is okay.
In therapy and in life, no one does it alone. There are just some times when we have to ask for and/or accept help. Doing so does NOT diminish our success.    
At times the therapeutic process, like life, is just too much. Taking a break can allow you time to re-group, re-focus, and find the strength to continue on. A therapist who knows their client’s limits is key.
When the light bulb goes on, and you can see it, is a beautiful thing!
Always remember that your client comes to you, and you are secluded by four walls for an hour each week. However, their world continues on all day and every day, and they must be part of that when they leave your office. Be cognizant of this in what you ask, say, and suggest to your clients.
Clients come to us alone, and they leave alone. We share the ride with them only for a short while, and we take part in different ways along that journey. If you do it right, they leave you with increased awareness, strength, humility, and gratitude.