Postmodern Play Therapy: Helping a Child Overcome their “Trouble Energy”

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When I was deeply entrenched in research, writing, and play therapy practice that incorporated superheroes, I learned about the importance of the origin story — the backstory narrative. It is no different in the context of this article, which is about what I call “postmodern play,” a term I use to describe play-based interventions rooted in Narrative Therapy. As a brief but related aside, I had just finished a book on the use of superheroes in counseling and play therapy when I was contacted by MSNBC to come on air to discuss what they, NOT I, called Superhero Therapy. When I sat excitedly in front of my television that night to watch myself, I noticed a chyron beneath my image that said, “The APA does not endorse Superhero Therapy.” Fifteen minutes of infamy, I guess.

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Ironically, I had never used the term, “Superhero Therapy” in my writing, nor did I profess my clinical work with superheroes to be evidence based. And so, it is here! The APA will never endorse postmodern play, nor will it ever attain evidenced-based status. And I aspire to neither.

But, as Irvin Yalom suggested in his Gift of Therapy, nonvalidated therapies are not (necessarily) invalidated therapies. So it has been for me, and postmodern play. In my child therapy work, particularly involving play, I have noticed that positive changes in the child’s world, both inside and outside of the therapy space, could often be explained by some of the core principles of Narrative Therapy, one of the postmodern approaches to therapy — which also includes Brief Solution-Focused Therapy. These core principles included a(n):

  • Strength-based orientation rather than one based on deficiency
  • Focus on the child as an agent of change
  • Externalization of the problem
  • Collaborative orientation to treatment that includes parents and teachers
  • Author-editor relationship between therapist and child
  • Future orientation that draws upon past successes
  • Articulation of preferred identity through storying
  • Personalization of outcome measures
  • Understanding that children have islands of competence

Channeling Trouble Energy in Play Therapy

As an example, I recall 8-year-old Liam, who came with his parents for help with “his” problems of stealing food, his mother’s jewelry, and temper tantrums — exclusively at home when he was confronted with his misdeeds. Born in Asia, Liam was adopted in early infancy and seemed to be progressing nicely through his developmental journey. But something was happening that was giving rise to this relatively new spate of behavioral problems. During the intake, the parents and I wondered together if the racial/cultural difference between him and his parents was contributing to an emergent and distressing sense of “otherness” — they rarely, if ever, discussed the adoption, Liam’s origin story. We wondered if he was trying to process the loss inherent in the adoptive process, stealing as a way of filling a gap. We wondered if the marital tension between them was creating a bed of unrest and insecurity for Liam. We wondered!

When Liam came to my office the following week, I was met by a very poised, articulate, and interesting child whose vigorously shaking leg suggested that deeper currents of emotions ran just below the surface of this very seemingly contained boy. Drawn in by that current, I wondered aloud about the “energy” in his leg, and asked in what other parts of his body does he sometimes feel such energy. He played right along and said how sometimes that energy goes to his stomach, and sometimes arms, and together, we called it “body energy.” We explored this body energy when it started and whether he liked it, whether it got in the way sometimes and what he typically did with it once it appeared.

From there we launched into a conversation of other possible types of energy that he had, and as I asked him to describe some of his interests, which included history and origami, I asked him if he could label that energy, to which he responded, “art energy and learning energy.” A bit later in the conversation, when our conversation turned to the concerns his parents had around his stealing and angry outbursts, he quite spontaneously came up with the notion of “trouble energy.” I asked him to pick a colored piece of Play-Doh and show me how big trouble energy could be in his life, and he offered an apple-sized ball of Play-Doh in his little hands. That was the sum total of our intake and treatment plan.

The clinical work in the following weeks consisted of:

  • Play therapy with Liam using the sandtray to act out play out scenes of family separations and reunions
  • Playful conversations about trouble energy in his life, and what he wanted to do with it and its influence
  • Liam sharing his vast knowledge of world history and “trying” to teach me origami
  • Discussing simple behavioral methods for the parents to use when Liam expressed anger and took things
  • Collaboration with his teacher around additional sensitivity to his needs, and
  • Occasional family drawing time during which Liam and his parents expressed themselves freely.
  • Referral of Liam’s parents to a marital counselor which they happily agreed to.

I never doubted that Liam was content with allowing trouble energy to rule his life, and I always had confidence that his parents and teacher could and would work together to support him and bring out the best in him. As a tip of my hat to readers who might be wondering, “well, what was your outcome measure(s),” I offer the following which is Liam’s depiction of trouble energy at the time of our last session at right, in contrast to trouble energy at the beginning of our work, at left.

I also offer the words of David Nylund, speaking at the Pan Pacific Brief Therapy Conference in Japan in 2001, regarding outcome measures in a postmodern, narrative play therapy context. He said, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person is able to reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”

***

My work with Liam and his family was complete, satisfactory to all involved. His tantrums subsided, the family re-visited and openly discussed the story of his adoption, and his feelings about it, and the stealing ended. I trust that my description of the work adequately captures the core principles and methods of what I call postmodern play therapy. Chyrons not withstanding!

Questions for Reflection and Discussion

What are your impressions of this author’s work with Liam?

In what ways have you found narrative therapy to be helpful?

What about this approach do you find interesting? Helpful?

Psychodynamic Therapies: How Did We Get Here & Where Are We Going?

Posted on by Psychotherapy.net Team

I just finished reading Our Time Is Up, a wonderful combination of novel and memoir authored by the talented psychoanalyst and writer, Roberta Satow. Dr. Satow has created the most vivid description I’ve ever read of what real psychotherapy actually feels like — from the very different perspectives of the patient, the therapist, the supervisor, and the trainee. Most books on psychotherapy either miss its elusive magic or overplay its drama — this one has perfect pitch and puts you right there in the room.

Throughout my career, doing psychodynamic psychotherapy was always the part of my week I most enjoyed. Satow’s book both recalled many fond memories and inspired me to pull together what will likely be my final thoughts on what is wonderful about dynamic psychotherapy, and what are its limitations.

Psychodynamic Therapy’s Checkered Past

I’ll start with the checkered past — especially paying tribute to Sandor Ferenczi, the master clinician who was the underappreciated father of psychodynamic therapies. Next, I’ll evaluate the much reduced, but still crucial, role of dynamic techniques among the current chaotic and bewildering array of therapies. Finally, I’ll try to predict the future — what is the best-case final fate of psychodynamic therapies?

[Full disclosure] I graduated from Columbia University’s Psychoanalytic Center and taught its Freud course for 10 years. But I never was much of a fan of 4/5 times a week, on the couch, traditional, regressive psychoanalysis — regarding it as unnecessary and impractical for almost all patients and wasteful of resources better allocated to once a week, sitting up, long- or short-term dynamic therapies. While best at psychodynamic therapy, I also learned and integrated cognitive, behavioral, interpersonal, and family approaches. I think Freud was greatly overvalued in his own time and is greatly undervalued in ours — and I equally oppose blind Freud worshipers and blind Freud haters.

Freud: Great Model Builder, Lousy Clinician

Having invented psychoanalysis (in collaboration with his mentor, Joseph Breuer, and their shared patient, Berthe Pappenheim), Freud divided it into three separate endeavors: 1) research tool; 2) model of the mind; 3) clinical treatment.

Psychoanalysis as a research tool was at the outset enormously exciting — uncovering basic aspects of human nature that informed not only psychology, but also the study of myth, anthropology, sociology, art, and literature. But most new insights into the unconscious were made early on, and nothing really novel has emerged from the couch since Freud’s death.

Much more enduring has been the psychoanalytic model of the mind. Here Freud sat on Darwin’s shoulders — applying Darwin’s revolutionary, but generalized, discoveries in evolutionary psychology to the specifics of human behavior and symptom generation.

Freud borrowed from Darwin three crucial insights: 1) human mental functioning is just as derivative from our primate ancestors as is our bodily morphology; 2) much of our behavior derives from inborn motivations that reside outside our conscious awareness; and 3) these have been shaped by natural and sexual selection.

Freud filled in Darwin’s general outline with exquisitely detailed and specific analyses of the form and content of the unconscious and how one’s past experiences powerfully influence current hehavior. Freud’s model of the mind contained some bad (but then plausible) guesses which are the source of current ridicule — but the main concepts hold up extremely well and remain important in understanding people and treating them.

Freud never claimed to be a great therapist, or even to having much interest in psychoanalysis as a clinical art. He saw himself much more as an adventurer using psychoanalysis as a research tool in the scientific exploration of how the human mind works — awake and in dreams. Descriptions by Freud’s patients describe him as highly intellectual and patriarchic in his approach, using the therapeutic encounter to formulate and test his theories of how the unconscious works.

Ferenczi: Master Clinician

Sandor Ferenczi, Freud’s student & analysand, was the great clinician of early psychoanalysis and by far the most powerful influence in how psychodynamic therapies have since evolved and are practiced today. He was responsible for defining its healing qualities, introducing many major innovations, and adapting esoteric psychoanalytic theory to real world practice.

Here’s a summary of Ferenczi’s clinical contributions:

Therapeutic Alliance: Ferenczi emphasized the importance of negotiating a strong collaborative relationship with the patient, established on more equal terms, characterized by shared goals, and with mutually agreed upon roles and division of labor.

Interpersonal/Relational Therapy: Ferenczi was much more alive than Freud to the power of the healing relationship and the importance of establishing a strong affective bond with the patient. As his student, Sandor Rado, put it, “Insight never cured anything but ignorance.” The relationship is more curative than specific interpretations, however brilliant or accurate they may be.

Empathy: Ferenczi regarded therapist empathy as an essential tool in promoting change. Sharing feelings and feeling understood facilitates change as much as does gaining specific insights.

Here-and-Now: Freud mainly used psychoanalysis as a research tool to determine how past experiences shaped the unconscious and influenced current behavior. Ferenczi did this too, but also brought more focus to the triggers of present problems and how best to solve them.

Therapist Activity: Freud aspired to (but never really achieved) being a passive “blank screen” upon which patients could project their fantasies. Ferenczi was much more active and real in the sessions.

Patient Activity: Patients don’t get better just through free association and the insights gained in the therapy sessions — they must also widen their experiences and get out of repeated behavioral ruts. What happens between sessions is at least as important as what happens within sessions.

Corrective Emotional Experience: This was best stated by Ferenczi’s student, Franz Alexander, who said, “The patient, to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.”

Psychodynamic Therapy: Regressive psychoanalysis was originally a great research tool but has never been a practical treatment — it is way too resource wasteful, suitable only for pretty healthy patients, and risks creating excessive dependence and hiding in the treatment. Ferenczi’s innovations allowed psychodynamic theory and technique to be flexibly applied in less intensive, but very effective, sitting-up psychodynamic therapies occurring usually once a week.

Time-limited Focused Therapy: Ferenczi and Rank realized that long-term therapies were too intense and inefficient to treat the many people who needed help. They developed a remarkably useful brief dynamic therapy (currently much underutilized) that focuses only on understanding and changing the most pressing presenting conflict.

Self- Disclosure: Ferenczi was not shy about revealing information about himself if this would further the relationship or provide a useful model for the patient.

Role of Childhood Traumas: Freud’s first theory of neurosis attributed it exclusively to early childhood sexual traumas. But he abruptly and completely abandoned this causal theory in the early 1890s because such childhood sexual experiences were so commonly reported by his patients. Freud then assumed the reported experiences existed only in fantasy, rather than having actually occurred in reality. Ferenczi had the more balanced view that real childhood traumas do sometimes play a contributory, but not exclusive, role in producing adult symptoms and that they are not exclusively sexual.

Treating More Difficult Patients: Many classic psychoanalysts were often so picky about selecting patients that only the people who didn’t really need treatment would qualify for it. Ferenczi adapted psychodynamic understanding and techniques so that they could be usefully applied to the more severely ill.

In summary, Ferenczi, not Freud, was the clinical father of psychodynamic psychotherapy and his innovations shaped how it is still practiced today.

Psychodynamic Therapy’s Current Status

My previous essay; Psychotherapy Status Report offered a report card on the current status of psychotherapy. It nicely provided context for the more specific question of where psychodynamic therapies fit in. The short answer is that all psychotherapy practice is fragmented and chaotic — and that psychodynamic training and practice add to the confusion.

There is little integration among the more than 50 different named forms of psychotherapy. These are often seen as competing; most trainees receive instruction in just one narrowly focused method and many practicing clinicians identify with just one form of therapy. “CBT” is the most popular brand name, followed by “psychodynamic,” and “trauma-informed” which is becoming increasingly popular. There is also an age and gender disparity. Older therapists are more likely to identify with psychodynamic; younger with CBT; women with trauma-informed.

Training in psychodynamic psychotherapy is also chaotic. There are hundreds of different programs varying greatly in theoretical model, prerequisites, intensity, techniques, and accreditation. At one extreme are the traditional psychoanalytic institutes which are more selective, require many years of intense didactic and clinical training, often still use of the couch, and require personal analysis. At the other extreme, there are now psychodynamic training programs that are open to all and, remarkably enough, completely online.

There is very little research on psychodynamic psychotherapy because it does not conform easily to standardized clinical trial research designs and only a handful of its practitioners are research trained. The few scattered research studies suggest that psychodynamic therapies are equal in efficacy to better studied psychotherapies.

Dynamic therapy is gradually declining in influence. Most psychiatric residency programs now provide little or no training in psychodynamic therapies — even though such training is still often desired and sought after by some residents. Young therapists in other disciplines are less and less likely to be trained in dynamic techniques. And insurance companies are less likely to fund dynamic as opposed to other techniques that are less intense and better studied. The average age of dynamic therapists is rising, and its cultural relevance is diminishing. The future does not seem bright.

Future Directions

Will Psychodynamic Therapy Continue as a Separate Profession?

I hope not. Psychodynamic therapy was always my favorite technique, but only if combined with cognitive behavioral, interpersonal, and family techniques. Similarly, the training programs I created were based on the integration of psychotherapies, not their separation into separate silos.

I have long felt that psychoanalysis is too important to be left to the psychoanalysts. They have maintained an unfortunate rigidity in technique and teaching; have been resistant to innovation; and missed opportunities to expand their purview and influence. Their biggest mistake was rejecting Aaron Beck’s CBT. Beck was a trained analyst who originally conceptualized his innovations as an expansion of psychodynamic techniques, not a replacement. Had the psychoanalysts been wise, they would have embraced CBT as an extension, rather than rejecting it as a competitor. I don’t think that psychodynamic therapies should be taught in institutes that specialize in it. Similarly, I don’t think that “CBT” or “DBT” or any of the other 50 alphabet denoted therapies should be taught or practiced as a separate discipline distinct from other psychotherapies.

Instead, I think psychotherapy should be considered a unified therapy which includes within it a wide variety of techniques. And training programs should no longer brand themselves narrowly. Narrowly trained therapists become hammers looking for nails, rather than flexibly responding to patient need. Psychodynamic techniques should be highly valued because they are very valuable- but they should be valued as a component of psychotherapy, not as a separate specialty.

Will Psychodynamic Therapists Be Replaced by Computers?

I’ve written an entire blog on the history of computers delivering psychotherapy: their current role and their future potential. Bottom Line — there is nothing humans do that computers won’t eventually do better.

One small consolation is that computers will have more trouble and take longer replacing psychodynamic therapists than almost any other type of professional. More than most human endeavors, uncovering someone’s unconscious motivations and facilitating corrective emotional experiences are intuitive and inferential processes that don’t easily lend themselves to the number-crunching powers of machine learning. But given enough data and enough time, even these most human of skills may be mastered by artificial intelligence.

Should this pessimistic prediction discourage people from entering the field? I think not at all. First off, psychodynamic psychotherapy is a better hedge against computer replacement than almost any other career choice. But more important, doing psychodynamic psychotherapy is one of the most rewarding ways of spending one’s time on earth. You have the immense satisfaction of understanding and helping others, with the valuable added bonus of learning from your patients how to become a better person.

***

Which brings us back to where we started. Roberta Satow’s book is a great introduction for new psychotherapists and a great refresher for experienced ones. No manual of psychotherapy, and no textbook, can ever capture the special healing ambiance of the therapist/patient relationship. Only the lived experience of someone who has been a patient, been a therapist, been a supervisor, been a trainee — and can write really well — can bring therapy alive in a way that inspires and educates.

Questions for Thought and Discussion

In what ways do you concur or disagree with the author’s assessment of dynamic psychotherapy?

Would you consider training in psychodynamic therapy?

What kind of client would you refer to an analytic therapist and why?

Ink Therapy: Harnessing the Power of Vintage Self-Help Books

Posted on by Psychotherapy.net Team

My dad was an avid reader, visiting the library weekly as well as purchasing new and used books. As a teenager, I spied a vintage copy of a 1957 work titled How to Live with a Neurotic: At Home and Work and snuck it into my tiny bedroom.

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A Very Brief History of Self-Help Literature

I couldn’t attain complete privacy in my room, shared with my brother, due to the 6-foot barbell we stored under the bed preventing the door from closing fully. But seriously, for the most part who needs privacy when you have weightlifting to focus on?

I discovered the book was written by Albert Ellis, a New York clinical psychologist, and I thought his ideas were monumental. I made up my mind right then and there that one day I would write my own book and interview Ellis. Indeed, many years later, when Ellis was 89 years young, I did, and the interview was much more intriguing than I ever could have imagined. But I digress. 

As a graduate student, I came across his name again, only this time he had teamed up with another clinical psychologist, Robert A. Harper, to pen a 1975 edition of A New Guide to Rational Living. The word “new” was added to the title since the original version was released in 1961. The book outlined how to use Albert Ellis’ Rational Emotive Therapy or RET (now Rational Emotive Behavior Therapy or REBT) to enhance happiness in everyday life. 

Simply put, I thought it was hands-down the best self-help work I had ever read. It turned out I was not alone in my opinion. The head of the publishing company, Melvin Powers, a lay hypnotist and self-made millionaire, whose picture graced the book cover along with his wife, agreed. Powers, one of the premier publishers of paperback self-help literature, said in the foreword, “it may well prove the best psychotherapy book for layman ever written.” Powers ended the foreword with, “You have my best wishes in reading a book that I think will remain the standard for years to come.” (Don’t you love it when others concur with your opinion?)

If the book had an Achilles heel, it was that the text might have been a little too complex for the average person to understand. But an answer was right around the corner.

Enter Wayne Dyer, a counselor educator at St. John’s University, who, after studying Ellis, created an easier-to-comprehend and much more popular book titled, Your Erroneous Zones in 1976. According to some estimates, 100 million copies have been sold! Behind the scenes, a controversy brewed with Ellis claiming Dyer stole his ideas and gave him no credit in Erroneous Zones. Dyer became one of the most popular lecturers and a guest on thousands of television and radio talk shows worldwide.  

The bottom line is that these classic 60s and 70s bibliotherapeutic works are still a goldmine for clients in 2024 and beyond. As I often quip, “Good counseling and self-help never goes out of style.” I have often heard therapists assert that the 1960s and 1970s were the golden age of self-help.

Self-Help Guidance for the Next Generation of Therapists

A few other gems from the era you could suggest as bibliotherapy to assist your current clients could include:

The blockbuster and often provocative 1964 transactional analysis (TA) text Games People Play by the founder of the theory, former psychoanalyst Eric Berne. Or another TA flagship work, I’m OK – You’re Okay, by psychiatrist Thomas A. Harris in 1971.

Taking this theme a bit further, Muriel James and Dorothy Jongeward wrote Born to Win: Transactional Analysis and Gestalt Experiments in 1971, integrating the work of Fritz Perls into the equation. TA made psychotherapy and self-help fun using words like Parent, Adult, and Child, in place of analogous and confusing Freudian terms such as Super-ego, Ego, and Id.

As a final example, clients who wish to blend psychology with spirituality could benefit from M. Scott Peck’s 1978 The Road Less Traveled.  

One unique feature of the books from the era is seemingly that they crossed the invisible line between textbooks/professional literature, and self-help or so-called pop psychology. To put it another way, these works, and many others like them, were as at home in a graduate counseling, psychology, or social work class as they were in the hands of people outside of the mental health field struggling with marital issues, addiction, depression, anxiety over public speaking, or many other challenges of everyday life.

In embracing the timeless wisdom of vintage literature, our current clients can unlock a treasure chest of insight from the past. It’s not just about self-help, it’s about tapping into a reservoir of wisdom that transcends time, offering guidance and solace to all who seek it.

Questions for Reflection and Discussion

How have you used self-help books with your own clients?

Which of the author's favorites have you used either personally or professionally?

What other newer self-help books have you found useful in your practice  

Losing the Atmosphere, A Memoir: A Baffling Disorder, a Search for Help, and the Therapist Who Understood

Posted on by Psychotherapy.net Team

[Editor’s Note: The following article begins with an excerpt from the author’s book, Losing the Atmosphere, A Memoir: A Baffling Disorder, a Search for Help, and the Therapist Who Understood, followed by a portion of the Afterword by her therapist, Jeffery Smith.]

The Saddest Present

“Do you got anything to tell me?” Wendy asked, her custom at the start of a session. It was late October, 1998. I looked at Jeffery trustingly, expecting his usual No.

“Yes,” he said softly, reluctantly.

“What is it?” Not Wendy’s confident voice, but someone’s who felt she was about to be dropped.

“I’m going to be away from December sixteenth to January fifth.”

Three weeks. A long moment of silence. Then Wendy again. “You know dose doll-babies I cut up with scissors a few years ago? I need to see them.”  

Jeffery lifted the couch seat and rummaged through the storage chest beneath. That was where he kept my blanket and pillow, crayons, and drawing pad, what made his office my special place for four hours — two double sessions — each week. I looked away, not wanting to see what else he stored there.

Hearing the lid close, I faced him. He handed me a small paper bag. I turned it upside down and tiny plastic body parts fell to the floor.

AlmostVivian had bought the dolls several years before, when I was still seeing both Sarah and Jeffery. It was during the time the babies on the bottom level were coming out often in sessions, alternately moaning and screaming. I listened and was amazed because I didn’t feel any torment. Sometimes, I tried to stop the sounds by choking the babies in me, putting my hands around my neck and squeezing so tightly I coughed. Jeffery would pry my hands off so I could breathe, telling me to let the sounds happen, that even though I didn’t know what they were about, someone in me did, and eventually I would, too.

But outside of session, I felt their neediness coursing through my veins, a hunger and yearning that could never be satisfied. I was sure that monster neediness would repel Sarah and Jeffery and I would lose them forever. I hated the babies and wanted to bash them out of me. I needed Sarah and Jeffery to know about the hate. It was too big for me to handle alone. On the walk home from work one evening, AlmostVivian got the idea of using dolls instead. She stopped at a toy store and bought their entire stock of miniature plastic babies, 12 of them. Each was about four inches tall, sealed in its own cellophane package, with dimples and blue eyes.

In my next session, which was with Sarah, I took the dolls and a pair of sharp scissors from my backpack. Laughing diabolically, I held the closed blades like a dagger and plunged them into a doll’s stomach. “I’m going to kill you!” I said, as I began cutting through the waist. It was a voice like that of TheOneWhoCursesCars but raging at the Inside babies instead of Outside people. The plastic was hard, and the scissor loops dug into my fingers. I kept cutting. When the doll’s body was severed, I pulled on her head. It came off with a popping sound. I tossed the three pieces aside and attacked the next doll.

At the same time that one part of me was gleefully plunging scissors into the guts of the dolls, another part was aware of Sarah, sitting silently on the floor with me. As if I were in her head, I knew she was uncomfortable. I also knew it troubled her to be uncomfortable, because she felt that as a therapist, she should understand and accept what I was doing. I didn’t want her to be uncomfortable. I needed her to talk in her gentle Mommy voice and look at me with the soft eyes that were ordinarily filled with love for me. I needed her to understand the desperation behind my lunatic laughter. But the more I butchered the dolls, the more uncomfortable she seemed.

Suddenly I felt dirty. Unacceptable. Sarah was good and pure. She believed in God and went to church. I stopped cutting, threw everything back into the paper bag — the three dolls I had mutilated, the nine still sealed in cellophane, the scissors — and stuffed the bag into my backpack. For a minute I looked at Sarah, not saying anything, trying to win her back with my eyes. She regarded me dubiously.

I felt my face get soft and my body relax. Then I heard Emily’s whisper. Young, trusting, shy. “Sarah?”

Sarah cocked her head and looked at me from a different angle.

“Sarah?” I whispered again.

The warmth came back into her eyes. “Emily?”

I slid my hand toward her along the floor. She took it in hers, and we locked eyes. “Hi, Sarah,” I said.

“Hi, Emily.” She smiled kindly at me. All was well again.

The next day, in my session with Jeffery, I continued the massacre.

“Somebody’s really angry at the babies,” he said.

Once I saw I didn’t repulse him, I let go, stabbing and cutting. “Now you’re going to die!" I growled.

Theoretically, I knew this killing spree wouldn’t free me from the babies. I also knew I was supposed to embrace and care for them, because they were part of me and needed to heal. But I didn’t want them to be part of me. Shrieking and giggling, I dismembered all but one, then stopped. If I destroyed the whole lot, how would I get them back when I was ready for them to heal? I tossed the last cellophane-wrapped doll to safety on the other side of the room, then snatched one of the severed heads off the floor and cut it into tiny slivers.

Several years had passed since then. The bottom level was less dominant, and I less needy. I had forgotten about the dolls until now, with Jeffery’s three-week absence looming. Looking at the body parts on the floor, I knew I had to fix the most broken baby — the one with her head in slivers — before he left, so I could take her home and care for her myself while he was away.

“Do you got any glue?” Wendy asked.

So began our routine for the next few weeks. At the beginning, middle, and end of each session, I glued one sliver of the baby’s face in place, allowing time for it to set, all the while joking about my pediatric trauma unit. It was painstaking work. I wouldn’t let Jeffery help but was glad he was there, watching each piece make the baby more whole.

I also asked questions.

“Are you going to be in another time zone?”

“Yes.”

“What airline are you taking?”

“I think it’s Tower.”

I had been expecting something like United or American. Those flew to many places in the United States. Tower went mostly across the Atlantic Ocean. Best not to ask where. “Make sure you’re careful.”

“I’ll be very careful.”

Things could happen even if he was careful. Dr. Welch died while he was on vacation in Europe. “Are you going to come back?”

“Yes.”

In our last session, before Jeffery left, I worried that I wouldn’t be able to hold onto the reality of his existence for three weeks. He said some of us knew he existed when I couldn’t see him. Others didn’t. “You need to set up a bucket brigade, so the ones of you who do know can pass the information to the ones who don’t.”

I liked that idea and sprawled on my stomach, crayons in hand, to draw 21 tiny buckets. I cut them out, wrote one date on each, and heaped them, like a pile of multicolored confetti, on top of the mended baby. She had scars on her face that would never go away, but she was whole.

Jeffery drew me a coupon: two stick figures, big and little, him and me, holding hands. There was a dotted line connecting their hearts, and a border around the whole picture.

“Is dat border because you and me are in the same world together, even if you can’t see me and I can’t see you?”

“That’s exactly right.”

“And even if you’re in a different place, you’re still the same person?”

“That’s exactly right. I’m me, and I never change on the inside even if I wear different clothes, or my voice sounds different, or I’m in a different place.”

When it was time to leave, I put everything into my backpack: mended baby, paper buckets, coupon. As I stood in the doorway, I realized Jeffery’s office would be empty for three weeks. That was scary. I hoped he wouldn’t die.

Atmosphere people never died. People in bodies did.

“Be very careful,” I whispered.

He nodded and waved.

We said goodbye three times and I backed out, holding him with my eyes until I closed the door.

For the first time since Jeffery started becoming more of a flesh-and-blood person than an Atmosphere person, all of us believed he existed, even though he was away. Every few days, we mailed a letter to his office, along with the cutout paper buckets for the days that had passed since the previous letter.

On the day he was scheduled to fly back — three days before my session — I visualized him in his body. He orders a drink when the flight attendant comes down the aisle. He rests it on his tray table while he reads a magazine. He gets in line for the bathroom. All day, I listened to the radio — for plane crashes. I worried that he wouldn’t be able to land because of the snow, even though most of it was in the Midwest.   

The phone rang late that evening.

“Hi, Vivian. It’s Jeffery. I’m back.” We had prearranged that he would call.

“Thank you for telling me,” I said, and we hung up.

I played his words over and over in my head. Was his voice different? Was he the same person?

Tuesday came at last. To avoid seeing the patient before me leave, I walked through the waiting room to hide in the kitchen, as had long been my custom. Soon I heard the first in the usual sequence of sounds. The door to his office. Next, the hall door. He or she was gone. Now the noise of the sliding-door closet in the waiting room. I peeked out. He was standing in front of the closet. In a body-shape; Jeffery, yet not Jeffery. He took off his shoes and put on another pair. So that’s where he hid the new ones that upset me. I knew I should step back, because he would pass the kitchen door on his way to the next sound: the bathroom. But I ran into the waiting room.

“I saw you!” I laughed, jumping up and down. “I saw you go into the closet and change your shoes.”

Jeffery looked momentarily surprised. Then he smiled, a wide smile that deepened the crinkles in the corners of his eyes “Hi, Vivian.”

“Are you really back?”

“Yup. It’s me.” His smile got bigger.

He’s obviously happy to see me. I’m glad he’s happy. I’m devastated he’s happy. His happiness is proof that he wasn’t with me in the atmosphere all along. I hate him. I love him. I hate him. I punched him in the arm.

Still, he smiled.

“So, how are you?” I said, a little girl trying out sophisticated talk. It sounded funny. I giggled and tried another phrase. “Nice to see you.” Oh my god. That’s what you say to someone who has been away. The scary words kept tumbling out of me. “How was your trip? It’s been a long time.” He smiled. I wanted to cry. I punched him again and giggled some more.  

I tried to frame him in a familiar context, but nothing fit. He wasn’t the Atmosphere Jeffery because he didn’t know everything I thought and felt and did while he was gone. Yet he connected eyes with me in the old way. But he was in a physical body and his body had probably been across an ocean. Could the Jeffery who smiled at me now be continuous with the Jeffery who had waved goodbye three weeks ago?

I spent the entire session trying to merge the before and after Jefferys; I looked for the mole he used to have on his forehead. It was still there. Most of all, I kept checking his voice and eyes. The old Jeffery was in both. Yet I couldn’t settle and never got to tell him all the things I had saved up. I left feeling empty and cheated.

When I got home, I wrote a letter that I mailed the following day.

You think you came back, but you didn’t. Your smile came back, but not your insides to our insides… You can’t expect to take up from where we left off….  

Over the next few months, as Jeffery’s presence in the Atmosphere continued to fade, the entire Atmosphere began to lose potency. Though Sarah and Marybeth were still in it, their essences were weak, not enough to sustain me. There were major upsets over minor events. Jeffery forgot to call when he said he would, or he remembered to call but his voice was ever-so-slightly hurried; either way, I was sure he hated me, and I had lost him forever. Jeffery wore a new sweater; this evidence that he went to a store or received a gift meant he was gone from the Atmosphere, and I had lost him forever. Jeffery changed my session from Fridays to Thursdays so his weekends could begin earlier; it was clear I was a burden to him and had lost him forever.

With each incident, I felt betrayed anew. “I HATE YOU!” the angry ones screamed. The hurt ones whined. “You said you would call, and you forgot. You shouldn’t say something if you can’t do it.” The abandoned ones became paralyzed and mute. Each time, Jeffery reassured me that I hadn’t lost him, and he hadn’t changed. Only my perception of him had changed. Each time, I would feel better. Until the next time.    

The more Jeffery became real as a flesh-and-blood person, the more self-conscious I was about the nonsense syllables and noises that had seemed natural and acceptable before. But I was unable to talk about Inside concerns in regular English words, so I filled long stretches of my sessions with prattle about Outside happenings: my boss was being fired; the traffic on the way to his office had been horrendous. All the while, Inside yearned for the kind of connection I used to have with the old Jeffery.

I brought a computer to a session and found I could type what I couldn’t say out loud. Jeffery answered either by typing back or talking, depending on what I indicated I wanted. This became our new method of communication. Often, I didn’t know what I was going to say until I saw the words appear on the screen. It was as if they flowed from my fingertips, bypassing my brain.

One day I wrote about what I considered Jeffery’s shortcomings as a skin-container person, and how much I missed his Atmosphere version. I finished typing and handed him the computer. When he lowered his eyes to the screen to read, I took the opportunity to scrutinize his body. Who was this person trying so hard to reach me? I looked for things that would make him real and found them in comforting imperfections: a small hole in his sock, one unruly gray hair sticking out of his thick black eyebrows, an ink spot on his shirt pocket. He typed something, then held out the computer to me.

I’m a skin person, but I’m a lot more like an atmosphere person than what you think of as a skin person. Because you think of a skin person as somebody who drops you. Somebody who breaks the connection with you. I’m not the kind of skin person who does that.   

I looked up to see a sincere face that matched the words. His eyes met mine and held them, and I felt a tiny bit of the connection I used to feel with the Atmosphere-like Jeffery. At the same time, I was aware that he was not in the Atmosphere. The eyebrow hair was still sticking out.

Only Wendy could report in out loud words about anything that mattered to Inside. Before I had this new conception of Jeffery, she used to appear just at the beginning of sessions, a scout checking for potentially dangerous skin-world manifestations in the otherwise Atmosphere-like Jeffery. But with Jeffery rarely in the Atmosphere anymore, Wendy now stayed out for most of the session, a lone soldier on the front line, and no one else got a chance to be with him. At first, because Wendy was perky and chatted freely, Jeffery thought I was adapting well to my new perception of him.

“Wanna hear a joke I heard on the radio?” Wendy asked one day in her saucy little-girl voice.

“Sure,” Jeffery said.

“What’s the difference between an HMO and the PLO?”

“I give up.”

“You can negotiate with the PLO.”

Wendy was delighted when Jeffery laughed.

“I know a joke, too,” he said.

Jeffery had never told us a joke before. Atmosphere people didn’t joke. “What is it?” she asked, trying to maintain a cheerful voice

“How can you recognize a happy motorcyclist?”

“I give up.”

“He’s the one with dead bugs on his teeth.”

Wendy managed the required giggle, but there was an earthquake Inside. Jeffery had violated a boundary, crossed further into skin territory than Wendy could protect us against. Her giggle stopped abruptly, and she punched him in the arm. “You’re not supposed to tell jokes,” she said angrily. “Only we’re allowed to tell jokes.”  

His face turned serious. “I’m sorry. I won’t do it again.”

“And don’t smile! Don’t act glad to see us when you first come in.” She punched him in the other arm. “That’s just to make it even,” she said in a more gentle voice, “so your arms will be balanced.”

We had had the conversation about smiles many times. Jeffery knew we saw his smile as proof that he was seeing us for the first time after a break. If he had been in the Atmosphere, there wouldn’t have been any breaks. “It’s good to remind me,” he said.

I did keep reminding him — about his smile, his tone of voice, his mannerisms — in an attempt to preserve what little remained of the Atmosphere. I still needed it for time-outs from the real world, though it wasn’t as soothing as it used to be.

Atmosphere people were no longer pure essences, so completely mingled with mine that I never felt self-conscious about anything I did. Now they were separate, looking down on me from someplace near the ceiling, where they hovered in invisible bodies. “Alone” in my apartment, I was embarrassed when I pulled my pants down to sit on the toilet, because they could see me. Once, when I was cooking fish, I opened the window to get rid of the smell — not for me, but for them. I felt foolish whenever I did things like that, yet I kept doing them.

The only times I felt satisfyingly connected to Jeffery were when we had toast, my ultimate comfort food. He let me keep supplies in his kitchen: a toaster on the counter, a loaf of artisanal white bread and a stick of butter in the refrigerator. We developed a ritual of having toast at the beginning and end of each session “Breaking bread together,” Wendy called it. She was usually the one who ate with him, chatting, using big words, playfully comparing the designs his bites and hers made in our slices. Jeffery and I may have been separate people, but we were having the same sensations of taste, smell, and crunch.

Four months after his Tower Air Christmas vacation, in the last week of April 1999, Jeffery and I were sitting on the floor in the kitchen at the start of a session.

“Do you got anything to tell me?” Wendy asked.

“Yes.”

I stiffened and waited.

“I won’t be here next Thursday.”

I felt a stab. “Did you forget it was my birthday Friday?” We had planned to celebrate during our Thursday session. The stab went so deep, I couldn’t even punch him. I inched backward until I felt the wall behind me, then slumped forward, head between my knees.

“I’m sorry,” Jeffery said.

He did sound sorry. I looked up to see him sitting cross-legged on the mat.

“I hate you!” screamed an angry voice. “You forgot my birthday,” whispered a devastated one. I punched his arm several times. He pressed his arms into his sides but didn’t flinch.

It suddenly struck me that all this was ridiculous. My body would be 57 next week and I was carrying on like a three-year-old having a tantrum. Jeffery wasn’t an Atmosphere that had deserted me. He was an ordinary human being, the kind you might see in the supermarket, but a very wonderful human being. It was rare that he missed a session. He must have something he really needed to do, and I was making it so difficult. Part of me was still upset. Another part felt a surge of love for him.

While one voice was whining, “It was gonna be my birthday,” another voice, grownup and calm, interrupted with, “Wait. I think it’s time to give you a present.”   

Jeffery looked at me quizzically. I reached for my computer and began typing.

…When you are a baby, you would never think of giving your mother a present, because your mother just IS. She is part of you, and you are part of her. But when you get a little bigger, you realize your mommy is a separate person, and she can get glad at you, and she can get mad at you. That is very scary. Now you have to do things to make her like you, or you will use her up. When you realize, you are supposed to buy your mother a present for Mother’s Day, you cross into a whole different dimension. You lost something you will never get back.

I passed the computer to Jeffery. He read. But before he could type an answer, I took it again and continued writing.

We never thought of you as someone we needed to give a present to. But last weekend, something made us know that now we did. We remembered when you used to say you needed to be seen. And we knew you would be seen if we gave you a present. So, we walked up and down the booths of the Columbus Avenue crafts fair, and then we saw a very special puzzle box with a secret compartment… When we were packing up the shopping bag to come here tonight, we put the box in, and we were very depressed about it. Then we forgot it was there — until we just got so upset when you asked us to change the session next week when it is our birthday. We realized we were right. It’s time to give you a present. It’s the saddest present we ever gave. But it’s also a very nice present.

I handed the computer to Jeffery. This time, when he finished reading, I reached inside the shopping bag and passed him a small package wrapped in white tissue paper. Jeffery held it in his hand and looked at me, as if he didn’t know what to do.

“Open it!” I commanded.

Rigid with anticipation, I watched him unwrap the layers of tissue. When at last he held the round box in his hand, he still didn’t say anything. He just turned it over slowly examining the top, the bottom, the side. But I saw that he was admiring the graceful streaks of dark brown grain running through the blonde wood, polished as smooth as satin.

“Take it apart,” I instructed. “The side piece first.”

He fingered the side, then slid it up. It came off in the shape of a crescent moon. He slid the top off sideways to reveal another cutout piece underneath. I watched his face and was thrilled to see his appreciation deepen as he lifted the last piece and discovered the hidden compartment, lined with dark brown felt. It was a truly magical box, small enough to fit in the palm of your hand, large enough to hold a secret.

“Thank you,” he said, looking up. “It’s a very beautiful box.”

I felt powerful — and grownup. I had given Jeffery a present that made him happy. I had let him know I saw him. But underneath, a deep sadness started to roll over me. Before it completely engulfed me, Wendy, always close to the surface, popped out. “I think it’s time to have some toast,” she said gaily.

“Good idea,” Jeffery agreed.

Retracing the Human Journey of Attachment

from the Afterword by Jeffery Smith, MD- Vivian's Therapist   

Losing the Atmosphere is more than an account of living with multiple personalities. In telling her story, Vivian opens a window into the drama of early attachment: how, during our first three years, we become connected to our caregivers and, through those connections, gain awareness of ourselves and begin to forge the capacity to cope with strong emotions.  

The best way I have of understanding Vivian’s Atmosphere is to think about the experience of birth. After existing in the insulated, warm, muffled environment of the womb, humans are suddenly ejected into a world with loud sounds, sharp sensations on the skin, and cold air. The shock must be enormous. Now imagine a protected childlike Vivian facing the emotional equivalent of birth. The Atmosphere was ever-present, existing in the form of molecules intermingled with hers, so there was total, immersive contact. This womblike protection kept her from ever experiencing aloneness. Any fear was met with a reassuring presence; emotional pain was instantly understood and thus barely felt. After years of being surrounded by this protective Atmosphere of benevolent beings with no needs of their own, constantly attuned to the feelings of one small girl, she is suddenly subjected to the harshness of raw emotions.

Losing the Atmosphere is about encountering, for the first time, fear, pain, and separateness. We have all gone through these very experiences but so long ago that they lie beyond the reach of memory. Because Vivian’s self was split into separate parts, and because some parts were shielded from these universal experiences until adulthood, she is able to give a firsthand account of a journey we all make on the way to becoming attached and emerging as social beings.   

This material is excerpted from Losing the Atmosphere, A Memoir: A Baffling Disorder, a Search for Help, and the Therapist Who Understood, by Vivian Conan, and re-printed here with explicit permission of the publisher, Greenpoint Press.  

Teaching Prisoners to Lead Grief Support Groups

Posted on by Psychotherapy.net Team

A Novel Prison Hospice Program

Most people are unaware that many prisons in the United States have hospice programs. What makes them unique is that they utilize select inmate volunteers to serve as caretakers for the dying. The prisoners go through extensive vetting with the hospice staff, current volunteers, and the prison wardens. Once chosen, they become a part of the care team along with the doctors, nurses, and clergy. Most recently, four psychiatry residents from Tulane Medical School were part of a new program that trained 31 caregiver-inmates at four different prisons in Louisiana to facilitate in-house grief groups.

Prior to the grief support project, I had not worked directly with the incarcerated population. Thus, my knowledge of this kind of working was abstract and superficial. It was mostly two extremes, the horrible gruesome details of the crimes that had been committed, or the stories of those who had been wrongfully committed and their civil rights stripped from them for years. I (HC) was intrigued when my therapy supervisor, Dr. Marilyn Mendoza, spoke with me about her experience with Angola’s hospice project and her visits to other facilities. I wasn’t sure what to expect when she connected me with Mr. Jamey Boudreaux, the director of Louisiana Mississippi Hospice and Palliative Care Organization, to talk about the project.

The goal of our grief support project was to teach a select group of incarcerated individuals to lead grief support groups for their peers. In the state of Louisiana, whenever an incarcerated individual meets with a mental health professional, a document is generated which goes into his or her file. These documents are available for the Department of Justice to review. As you can imagine, there is significant stigma that mental health notes will negatively impact the decisions of the Pardon and Parole Board. Thus, by having trained incarcerated individuals provide bereavement support to their community, the dreaded mental health documentation can be bypassed. In addition, having peers with shared experiences lead groups allows participants to feel more comfortable in sharing their stories.

The project involved six participants selected by the corrections facility as individuals that had qualities that made for a good peer support facilitator. Depending on the number of participants, there could be up to 15 weekly meetings. The first three weeks were focused on introductions, outline of the project, and didactics of grief and groups. Weeks four to nine was a six-week adult grief support group led by a facilitator (in our case, psychiatry residents). The weeks contained different topics of introducing their deceased loved ones, sharing a photograph, sharing an item, writing a letter, planning for a special day, and reflecting on the experience. Weeks 10 to 15 repeat the same format but with the participants assigned a week to facilitate.

A Clinician Embraces a New Challenge

Although the outline and the project seemed straightforward, I was worried. I had no prior experience in working with therapeutic groups. Was the setting going to be conducive to groups? Would I be able to establish rapport with the participants? Would I be able to relate to the participants? Would I feel safe where the groups were being conducted? Would the participants be comfortable sharing sensitive information with me?

As I prepared the didactic material, the day for the first visit came. I was grateful that Mr. Boudreaux, who was familiar with the corrections facilities, accompanied me to Elayn Hunt Correctional Center located in St. Gabriel, LA. On the drive, he shared the history and changes that have occurred in Louisiana’s corrections facility. The security process included confirming our identity, searching our vehicle, confirming our identity again, and a complete body scan.

As we walked down a long walkway between chain-link fences, I pondered on all the different possible crimes that people may have committed to bring them to this facility. I had the list of names of the participants that would be joining me. Through public records, I could easily look up the details of their charges, convictions, and sentences. I decided not to as it was unnecessary to know for our work together. In hindsight, I like to think it would not have changed my perspective of the men I worked with, though I will never know for certain. Mr. Boudreaux also mentioned on our drive that it was a faux pas to ask incarcerated individuals why they are behind bars and for how long.

As I prepared, I wondered if I would have difficulty in getting the men to discuss their feelings. I felt that perhaps being in a cold, rigid setting would have made it difficult for them to be vulnerable in sharing their emotions. Would I have any credibility as a “free person” who had no idea what life was like in prison? Being a soft-spoken Asian woman, would I be able to redirect the group if discussion derails into a heated conversation?

As we continued towards the Skilled Nursing building, a few casually dressed men greeted us and I was unsure if they were incarcerated individuals or staff members. The Skilled Nursing building provided the highest level of medical care for the sickest residents. I instantly felt at home as the inside looked, sounded, and even smelled like the regular hospital units I was accustomed to. The eight participants were waiting in a room surrounded by windows facing directly at the nursing station. The men politely shook our hands and introduced themselves.

Mr. Boudreaux had been working with them on improving the education and resources available for the men providing end of life care. As I listened to them reflect on their work, I was struck by how passionately they spoke of their work and their patient advocacy. When I gave them the general outline, multiple participants asked thoughtful questions and seemed very eager to learn. They shared that the experience providing hospice care has been very difficult yet rewarding. I learned that these men are given the option of learning a trade or receiving more education. Hospice was neither and it was completely voluntary. Despite being a thankless job, this core group of volunteers devoted their time to helping others as it gave them a sense of purpose.

The first three meetings were lectures based with PowerPoint slides printed on physical paper. Each person came prepared with writing utensils and jotted down notes as I talked. They were engaged and asked insightful questions. They were interested in topics from the neuroscience behind grief to the spiritual aspects of grief and loss. They even made a point of asking if I could bring the articles or books I listed on the reference page at the end of the packet. There was a genuine curiosity to learn as much as they could.

A Surprising Place for Compassion

Week four was our first official session using the peer-support model. Having never led groups prior to that time, I was a bit anxious. We started the session by discussing ground rules of respectful listening and confidentiality. They shared how important confidentiality was in a setting where at times what you say can be used against you. Each person shared how he slept at night (“like a baby” can mean two totally different things), how he felt, and introduced the person whom they were grieving. They were all immediate family members, some that had passed years ago and some only months ago. As the sessions progressed, I became more comfortable.

Something the men have told me multiple times was that the course gave them the opportunity to learn skills that were not only helpful in facilitating grief groups, but also supporting their own family in the free world. I was inspired by their motivation and passion for helping others and often found myself lost in thought on the long drive home. I reflected on what it was that made this experience something I looked forward to weekly. Working in outpatient psychiatry, I sometimes feel drained by patients coming to me for a quick solution. It was refreshing that these men were looking within themselves for the answer. I was grateful that they felt comfortable in being vulnerable. There were lots of laughs and some tears shed.

When the second half of the lessons started, where the participants were each assigned to facilitate group, it did not feel repetitive as the men created new topics to focus on. Though each participant had their own style in facilitating, they all possessed great leadership skills. Many of them were trusted mentors and already possessed counseling skills. They created a therapeutic environment for sharing. I felt that in comparison to the sessions that I led, which might have been separated by a sense of power differential, they were building onto the conversation.

They chose interesting topics such as reflecting on their favorite memories, sharing where they keep photos and why, and what items from their loved ones they would like to have. There were times when the men disagreed with each other and respectfully brought up their own perspectives. They also provided comfort for each other. We frequently discussed how their loved ones continue to live through them and how spirituality and their culture affects the way they grieve. At the end of every session, they expressed gratitude for having a space to share.

Although our primary focus was on grief, it was only natural that we also discussed other sensitive topics. There was a lot of discussion about trauma and “the hand you were delt.” They described past life decisions as choosing between a series of what consisted of only bad options. Psychosocial factors made it very easy to choose a life of crime and drug use. It also made it difficult to trust others. It was after incarceration that some were compelled to take the arduous, personal journey of searching for purpose. Religion and spirituality were often sources of comfort and guidance.

During our discussions about grief, I reflected on how although it was such a personal journey for everyone, the universal stages of grief were ever-present. Some men spoke of their loss in superficially lighthearted manner as to not disrupt the complex, darker emotions lying underneath the surface. Some shared their experiences of shifting between the various stages of grief. Some shared how they grew from the experience. In some ways, being isolated from the outside world made it easier to stay in denial for longer. It was difficult to have a sense of closure, there was limited opportunity in attending funerals or, especially during the pandemic, to share the grief in-person with another family member.

As hospice volunteers, they have all experienced grief from losing patients. They each took shifts keeping vigil at the bedside of their fellow dying inmate, ensuring that their last moments would not be alone. After a patient died, they felt that it was only appropriate to push the emotions to the side to attend to the many other duties. They described a sense of relief in then having a gathering dedicated to sharing complex emotions. We felt less alone. I say we because the men included me into their groups. This was a foreign experience to me as I have mostly limited self-disclosure in my practice. Each person was a successful facilitator, I felt heard and supported.

Our last session was bittersweet. I felt proud of all the work the participants did and was confident that they would be able to lead grief groups successfully. Echoing my initial concerns, some of the men wondered if others would be able to share their feelings and personal details of their lives. Throughout the weeks, I gave them supplemental material regarding compassion, reflective listening, exploring feelings, and managing strong emotions. I could see that they studied the additional resources, sometimes quoting them or utilizing specific skills. The last session, I gave them a handout on termination. They quickly read the title and declared that they didn’t like that word termination because it sounded too definite. I like to think that the things we have learned from each other will continue to positively impact our lives.

***

The award ceremony was a bustling event with some unfamiliar faces of important people at the facility. I brought some snacks that were required to be repackaged in clear containers. One of the men made two different homemade cakes that tasted professionally done. Compared to our usual intimate group, it felt a bit foreign as I called each participant by his legal name to obtain his certificate. I have come to know them each by their nicknames, their unique personalities, and the stories they have shared with me. The car ride home felt a lot like being let out for summer break after graduation from college. There’s a sense of uncertainty about whether I will be able to reconnect with these wonderful, caring people I have met or if this was truly the last time I will see them.

This has been one of the most meaningful experiences that I have had in my career. During times I feel exhausted and drained from clinic, I think of my time at Elayn Hunt. The men reminded me of the fulfillment and joy that comes with being able to help others. Their passion for learning is truly infectious.  

Advice for Young Therapists: A Long View

Posted on by Psychotherapy.net Team

I am in my 70’s and still working full time as a psychotherapist. Psychotherapy has been my career, and never simply a job. It represents who I am and has never simply been a way of making money.

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The world in general is always confounding, and the field of psychotherapy can be perplexing as well. There are so many schools of thought, treatment approaches, new ways of practicing therapy, and the potential of radically new types of intervention on the cultural horizon. I have become increasingly interested in how beginning clinicians feel that they fit in, and where and how they develop their personal and professional skills.

A Veteran Therapists Offers Wisdom to a New Generation

As I approach the late phase of my career, I feel a desire to share viewpoints and learned lessons with beginning therapists, regardless of their age. As a veteran therapist, I think it is important to pass the baton, and share key concepts that might clear some of the potentially confusing path forward.

As a therapist, I have strived to help my clients strengthen and broaden the range and the quality of their personal relationships and their active involvement in the world. Too often in therapy, the arrow of attention points inward on the individual, assisting them to forge their own way through the challenges of life. While that is often a right and necessary focus, it is not a complete view of the role, or the potential, of therapy.

I have learned to help clients focus that arrow outward towards relationships, skill acquisition, the assuming of roles, and building up the clients’ productivity and sense of purpose. It has never been solely important for me to help the client be better within, but also better with others, and better able to effectively contribute themselves to the wider world.

In writing this, I hope that early-career therapists participate in the development of psychotherapy, not simply in their own practice. Learning new techniques along the way is certainly important, but I have always valued the importance of filtering their value through tried-and-true perspectives and approaches.

I can’t overstate the important contributions of three particular therapists. Carl Rogers (On Becoming a Person: A Therapists’ View of Psychotherapy), Viktor Frankl (Man’s Search for Meaning), and Erik Erikson (Life Cycle Completed) have provided me with a firm foundation for a therapy career, and a yardstick against which to measure the value of newly emerging ideas.

Carl Jung suggested the therapist should learn everything, then forget it when they sit down with the client, but that learning should not be limited to the theories and history and techniques of psychotherapy. I have come to appreciate the importance of mythology, religions, folklore, theater, poetry, and literature — each of which have become resources in my personal and professional development. Absorbing the wider context of art and culture through history has helped me to view the client and their relationships in new ways. Yes, the dynamics of the psyche are important, but so too is the client’s (and therapist’s) place in the dynamics of a long and vibrant history of human culture and creativity.

The great 13th century Italian poet Dante, wrote the three-volume masterpiece “The Divine Comedy: Inferno, Purgatorio, and Paradiso.” At the beginning of the first volume, Dante becomes lost in a dark wood, midway through life’s journey. He was guided and tutored in his subsequent trek by the ancient Roman poet, Virgil, who is said to have represented human reason.

Lost in a dark wood during one’s journey. Talk about a universal experience! Life can be so complex, and so difficult at times — both client and clinician can find themselves lost on their respective journeys. Many of my clients have come to me for guidance and tutoring in their journey through the thicket of their hardships.

I have come to seek wisdom in my work as a therapist, as someone able to blend art and reason in my effort to accompany others through the descents and ascents of life. As a psychotherapist, I aim to guide and educate others through their darkest troubles, and towards recovery, and/or attainment of their fullest capacity for love and a purposeful place in this wide world.

Questions for Thought and Discussion

What impact does this author's words have on you as a person and as a clinician?

What have you learned thus far in your professional journey that you might want to pass on to others?

In looking back, what life's lessons have you brought into the therapy space?  

Avoiding Burnout Traps: Managing the Conflict between Empathy and Exhaustion

Posted on by Psychotherapy.net Team

“The best people possess a feeling for beauty, the courage to take risks, the discipline to tell the truth, the capacity for sacrifice. Ironically, their virtues make them vulnerable; they are often wounded, sometimes destroyed.” – Ernest Hemmingway

As a beginning therapist, my first five years were spent in uncomfortable places. Maximum security facilities, county crisis centers, and emergency rooms. In these environments, I could feel stress in the air like it was coastal humidity, and chaos was the rule rather than the exception. I seemed to meet two types of therapists in these places. There were those at the beginning of their careers and those who were nearing their end. The clinicians in their middle chapters of their work had often left for administrative roles and private practices.

I found the new and veteran therapists to be different in some noticeable ways. The new therapists were often energetic and inspired. They were personally invested, and despite their lack of experience, they seemed to help clients make significant improvements. They didn’t make much money, but they didn’t mind having roommates or driving economical cars. They had a cause and that was more than enough.

The veteran therapists were less excitable. They were wise and calm, and they had witnessed how idealism can lead to painful lessons in therapy. Sometimes they were rough around the edges, but because they had the benefit of making a therapist’s salary for many decades, they drove slightly newer economical cars. Their vehicles had fewer miles, powertrain, and bumper to bumper warranties. The big leagues.

I had only been a therapist for a few years, but I quickly found myself losing my passion. I wasn’t sure I would grow into a seasoned therapist because I wasn’t sure I would remain a therapist for much longer. To manage my exhaustion and stress, my days became bookended between caffeine in the morning and alcohol at night. My sense of humor darkened, my wife worried, and my friends pulled me aside to express their concerns. I was changing, and those around me were whispering about it.

What I believed about therapy was changing, too. I started to believe that my clients who improved would have done so without my help. With my clients who didn’t make improvements, I started believing they simply couldn’t change. I was once a true believer, but I was becoming a skeptic. I was losing my faith in therapy.

I didn’t notice I was changing while it was happening. The process was gradual, and it didn’t have an obvious turning point. It felt like a current had pulled me down the shoreline and I lost track of my towel which was further up the beach. I had become someone different, and it wasn’t someone I wanted to be. I spent months asking myself how this transformation occurred, and eventually, I came back with my answers.

The Empathic Personality

In graduate school, I was taught that empathy was a vital part of therapy. I was told to pack my bags, leave myself behind, and join my clients behind their eyes. To be a therapist was to commute to the deepest feelings and perceptions of another. Empathy was interpersonal travel, and to be a therapist meant holding a passport that permitted me into deeply private conversations. It got me through customs.

At that time, I thought about empathy in the way I thought about kindness. I wanted to exhibit more empathy and kindness for the people in my life. Clients or not! These virtues seemed pure and uncomplicated, and it was hard to imagine an overabundance of either. But eventually, I started thinking about empathy as something more complicated than kindness. This tendency to be aware of others and to travel into their worlds wasn’t simply a virtue, but it was a temperamental characteristic. Unlike kindness, this personal characteristic came with risks.

It was this new understanding of empathy’s risks that unlocked the answers about what happened to me. It helped me understand why I transformed from an energetic therapist into a calloused one. It helped me understand why I hated my economical car.

I think that empathy can be separated into two different categories: there’s unmanaged empathy and managed empathy. Here’s how I think about the difference. When my empathy is unmanaged, I can join into the pain of others, but I can’t disconnect from it. This type of empathy has one step and so becoming glued to the suffering of others becomes inevitable. Alternatively, when my empathy is managed, I can join in the pain of others and then uncouple from it. Managing my empathy has been a two-step process.

My therapeutic training only focused on joining into suffering, but I was never taught how to uncouple from it. I never made the distinction between unmanaged and managed empathy. To be fair to my counseling educators, it’s not realistic to expect a seminar entitled, “Uncoupling from the Suffering of your Clients.” But because I didn’t learn to separate from suffering effectively, I relied on my unmanaged empathy. Joining into the pain of others had always come intuitively, and so I simply did with clients what I had always done in my personal life. This unmanaged empathy flowed by the gallon, but it eventually became a stream, and then it dripped and dried bare.

The Interpersonal Dynamics of Burnout

When my classmates and I studied to become counselors, we shared universal experiences. Nighttime classes, unrelated daytime jobs, and increased coffee consumption. At some point, my classmates and I purchased our first therapist uniforms. Horn-rimmed glasses for some and shawls for others. Some bought cardigans. It was Carl Rogers couture.

During this time, those in my personal life expressed an interest in what I was learning. I was asked for my perspective more often and I eventually became more comfortable giving it. People changed towards me, and I changed towards them. I gradually became a therapist in my own mind and in the minds of others. These changes in my social world weren’t always positive. I answered late-night phone calls when help was needed. I was cornered into awkward conversations at parties. During an argument with a friend, I was told, “You should know better — you’re a therapist.” I wasn’t yet, but fine. Checkmate.

After I finished my graduate program, I found my first clinical job. My empathic temperament had previously led me to help those in my personal life, but I was suddenly assisting clients, too. While it was once possible to have a private life filled with people I hoped to help, the new empathic demands of therapy led to working with suffering on all sides. There was no place to separate from suffering and I became a 360-degree giver. This was the first trap that led to unmanaged empathy and subsequent exhaustion. Mother Theresa could do it, but I couldn’t turn my life into Calcutta.

To practice managed empathy, I could no longer remain in the helper-role in my personal relationships. While my relationships with clients were characterized by one-way assistance, my personal relationships couldn’t remain this way. Most of the time, a simple conversation changed my one-sided relationships into two-sided ones, but occasionally more was required. Sometimes I had to use dials and levers. This was how I disconnected from the suffering of others, practiced managed empathy, and escaped this unmanaged empathy trap.

Restructuring the Interpersonal Dynamics of Burnout

I’ve never liked the word boundaries. The word has always seemed forceful and rigid, and to “set boundaries,” always sounded formal and severe. For me, this made the prospect of establishing limits less approachable. But the space between myself and others did need to be refereed, because it had become flooded with unrealistic and demanding people. It seemed that like nature, dysfunction abhorred a vacuum.

Rather than “setting boundaries,” I started thinking about using dials and levers. Here’s how this worked. When a relationship was one-sided, but the relationship was too important for me to end, I set the relationship on a dial. I reduced my involvement in the relationship by lengthening my distance in degrees. I took steps backward until I reached a comfortable interval. Putting a one-sided relationship at a greater distance made these relationships more sustainable. I could help when I was around, but I wasn’t around too much. But other relationships exhausted me regardless of the distance that I created. When I attempted to leave the helper role behind, some people didn’t go without a fight. Pro bono therapy was a hell of a drug. In these situations, I used levers to end the relationships entirely. I moved the lever from the “on” position to the “off” position. While the dials worked in degrees, the levers worked in absolutes.

I found distance by degrees to be preferable to absolutes, and eventually I was able to regain some measure of control in my relationships. When I changed my one-sided relationships into reciprocal ones, I could step back from being a 360-degree giver. Once I implemented dials and levers, this created newfound open space in my personal relationships, and in this space, I could practice the second step of managed empathy. I could uncouple from suffering there.

The Intrapersonal Dynamics of Burnout

My public roles and my private values have always been an important part of understanding myself. Part of my sense of self comes from being a spouse, father, brother, and the professional role that I play. The other part of my selfhood comes from the values that I’ve privately held dear. But problems emerged for me when there was a poor balance between the public roles I played and the private values I held, and this was a setup for the second unmanaged empathy trap.

In my earlier stages of counselor development, I viewed becoming a therapist as too central to who I was. I over-identified with my therapeutic role, and I lost part of myself. To understand how this occurred, I started noticing professionals who went through similar transformations. I also noticed the professionals who didn’t.

What I learned is when a public role elicits some amount of societal reinforcement, there’s a tendency to over-identify with it. Take the surgeon, for example. Most surgeons don’t think being a surgeon is something they simply do for work, but instead, being a surgeon is a central component of their identity. This is also true for professional athletes, executives, politicians, and lawyers. But it’s not true for those who stock vending machines or drive garbage trucks. These jobs don’t come with societal applause. When talking about their work, these folks often say things like, “It pays the bills.” The job serves a purpose, but it’s not the most important thing about them. They leave it off the dating profile.

While being a therapist doesn’t elicit the same societal reinforcement as being a surgeon, I think it comes with similar risks. It was often difficult to leave my therapeutic identity in the chair. I was a therapist when I drove into work, and I was a therapist when I left.

I think I underwent a charismatic therapeutic conversion. My identity had become consumed by my new public role, and my transformation into the therapeutic persona was too thorough. I became a therapist in every area. I read books about therapy and talked about therapy with my therapist friends. I attended therapy conferences and built my community around therapy. I even started talking in a therapeutic dialect: “reframe” this and “normalize” that. I became a born-again clinician. It wasn’t a good look for me.

When I allowed myself to be overtaken by my therapeutic role, I stepped into this second unmanaged empathy trap. I was always a therapist behind my eyes, and so I was never without clients. This meant there were fewer places in my life to separate from suffering. Luckily, there was a way out. I didn’t need to accept that my personal identity would be consumed by my public role, but instead I could learn to do something requiring just a bit less personal investment.

Restructuring the Intrapersonal Dynamics of Burnout

It was those who worked less emapthically-demanding jobs who taught me how to escape this trap. Like them, I learned to create space between my professional and personal identity by prioritizing my private life. The person who drove into work became different from the person who drove away.

This meant treating therapy more like functional work and less like a totalizing identity. To develop a sustainable therapeutic career, I needed to nurture and protect my non-therapeutic self. I needed to cultivate an identity that rested more upon my private values and not entirely upon my vocational role.

In order to do this, I adopted new endeavors that weren’t remotely connected to therapy. I also reconnected with old friends. These old relationships helped me remember who I was before I was a therapist. I didn’t use words like “schema” or “metacognition” back then. But in order to avoid the second unmanaged empathy trap, I had to avoid the charismatic therapeutic conversion. I had to cultivate a private life where my non-therapeutic self was expressed. It was when I allowed the part of myself that was disconnected from my therapy to engage the world around me that I could separate from suffering more easily. I could practice managed empathy there.

The Attachment Dynamics of Burnout

It seems that within human relationships there’s a spectrum of give and take. On one side of the spectrum, I’ve met the habitual givers. These folks are highly empathic and accommodating. As moons orbit planets, they orbit the lives of others. Orbiters rotate around the people in their lives and keenly discern and meet their needs. They’re natural satellites.

On the other side of the spectrum, I’ve met the habitual takers. It seems that these folks expect to be accommodated. They’re unaware or disinterested in the feelings of others. They often find it upsetting when others don’t adjust to them. They expect to be orbited. And of course, most of the people I’ve known fall somewhere in between these two extremes.

This spectrum became relevant to my eventual exhaustion because, like most therapists, I found myself closer to the cooperative patterns within the orbiters. The ability to assess and meet the needs of others had always come naturally, and so becoming a therapist was a perfect fit. Perhaps without knowing it, it was my cooperative predisposition that guided my professional direction.

Eventually, problems emerged because of this strong cooperative urge. When decisions were made, I often found myself deferring to the preferences of others. Instead of imagining what I might enjoy, I would comply to connect. When people asked about where to go for dinner, I might say, “Wherever, I’m easy.” When asked if I needed anything from the store, I would respond reassuringly, “No, I’m okay with whatever you pick up.” I was engaged in need-mirroring. I think of need-mirroring as the reflexive matching of the preferences of others, and while it increases cooperation in relationships, it also leads to a life that’s directed by others.

With my interactions often characterized by deference, I lost track of my own desires. My difficulties with a self-directed life became even more concerning when I tried to listen inward for my own preferences, but no inner voice responded. I could no longer locate what I sincerely wanted. It seemed that desire itself worked like a muscle, and because I hadn’t listened to myself for an extended period, this muscle eroded. I had undergone appetite atrophy.

Becoming locked into this orbiting orientation was the third unmanaged empathy trap that led to my exhaustion. It became difficult to separate from suffering when I was overly attuned to the perceptions and desires of others. While rotating around my clients was essential to my therapeutic work, when I orbited those in my personal life, it became difficult to know what I needed. But like the first two traps, there was a solution that helped me practice managed empathy. This strategy helped me restrengthen the muscle of desire, it separated me from the needs of others, and I became able to listen to myself once again.

Restructuring the Attachment Dynamics of Burnout

The path to overcome my orbiting style was to express my needs more regularly within my relationships. Prioritizing myself more allowed me to move closer towards the middle of the spectrum of give and take, and this restored the balance within my interactions.

There were problems at first. I had practiced need-mirroring for too long, and when I tried to track down my desires, I couldn’t find them. So, I tried something simple. Instead of searching for my needs, I invented them. I practiced having a preference. When I got it right, it sounded something like this:

Them: “Where do you want to go to dinner?”
Me: “Eh. I don’t care, – you know what, I feel like Mexican food.”  

When I was halfway through need-mirroring, I tried to express an invented preference, instead:

Them: “I’m headed to the store. Do you need something?”
Me: “I’m good, thanks. On second thought, can you pick up some gum?”  

My objective wasn’t to detect and convey my deepest desires, but to practice expressing any preference at all. This was effective because the strength of my cooperative impulse had anesthetized my desires, and to lift the anesthesia, I needed to increase my comfort with being less cooperative. When I practiced expressing an invented need, I was creating a moment where I stood apart from the desires of others. I was practicing a small act of non-cooperation. Slowly, as my comfort within this non-cooperative space grew, my desires eventually reawakened, and I was able to express these desires within my relationships.

It’s a strength to orbit clients in therapy because this can help me perceive unspoken needs and adjust on their behalf. Yet when this tendency ran free in my personal life, I lost the ability to direct myself, and my exhaustion knocked at the door. But when I practiced having a preference and become more comfortable standing apart from the needs of others, my desires could be once again detected. This created separation from the suffering of others and a return to managed empathy.

***

While I once thought that empathy was an uncomplicated force for good, my exhaustion led me to conclude otherwise. Empathy is something that’s effective when guided, but it’s harmful when it’s not. Empathy is like water. It’s beautiful in the river, but not in the flood. However, if the traps that lead to unmanaged empathy can be understood and managed, the wisdom of the seasoned therapist can be cultivated without losing the spirit of the new one. That has and will forever be my goal.

The Elder in Exile: Psychotherapy with Older Adults

Posted on by Psychotherapy.net Team

A frustrated and depressed nursing home resident recently described the facility as “a place where unwanted elders can be exiled.” Through our therapy conversation in that session, he came to acknowledge that he did have problems with his memory and his health, and that his facility residence was reasonable — even though unwanted — and was not a rejection by his son. “I know he’s only doing what he thinks is right for me.”

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The Emotional Plight of the Nursing Home Resident

Many residents of nursing homes view their predicament as a rejection, or an exile, or an imprisonment. Many blame family members for the situation and try to pull the heart strings of loved ones in efforts to get them “to take me home.”

Many adult children weep as they speak with me about the conflicts they feel over the placement of their mother or father in the facility. Daily care at home with family is desired by all, yet available to only a few.

The older person living in the nursing home may feel a loss of home, family, their former roles, and too often, their sense of the value of their life. Some older people feel not only cast out by others, but inadequate due to the infirmities of their advanced age and their medical problems.

As I speak with seniors in psychotherapy at nursing homes, I discuss the specific aspects of their situation and seek to place some of their experience in a broader cultural and societal context. For example, I talk of ways that “the Elder” has traditionally been venerated in human societies.

Whether sitting around a fire in the cave, or in a small tribe, or a simple village, it has been the Elder who others looked to for history, stories, and advice. The younger members of the tribe or clan or family came to the Elder to learn the lore and lessons of their people. Others listened to and memorized the stories told by the Elder, and those stories they passed along when they, in turn, became an Elder.

The older nursing home resident might feel adrift from their family and their former life, but the value and the lessons of their life endures, and the sharing of their personal stories — whether in life-review therapy, with family, or with others at the facility, is a key part of reclaiming and affirming the value of their experience.

I encourage residents to share their stories with me and others in their life. I point out and affirm the dignity and value of the person’s journey through a long life. I speak to seniors of ways the society has changed, and how elders might not socially be held in the respect that their lives deserve and have earned.

Some people have suggested that nursing homes ought to have daycare programs attached to them, for the mutual benefit of old and young. But I think that it might be more productive, and developmentally appropriate, to have programs for troubled teens associated with nursing homes. Then, a teenager might share her problems about a relationship, her parents, school, or a career choice, and the senior might be able to understand and share suggestions, relate anecdotes, and offer guidance that might be helpful and in line with the long history of ways younger persons have been helped and guided by the wisdom of the Elder.

“Okay, but I don’t know if I really am wise, and I have all kinds of problems,” an elderly lady said as we discussed these ideas one day. I point out that throughout the long history of human life, the Elder who others looked to and venerated, likely also experienced problems with balance, and with short-term memory, and with urinary incontinence; but that did not erase the value of what they could contribute to younger generations.

It is important to share the stories of one’s life. As we age, we might become less active, and we might forget some of the recent events, but we might retain long-term recall of long past events and situations and relationships — and the sharing of those stories can enrich the understanding and the development of the younger person.

A nursing home sponsored a program a few years ago in which all the staff wore a round metal pin labeled “I’m a Future Senior Citizen.” That program enhanced the awareness of younger workers about the aging process. We each may now be, or may later be, senior citizens. Aging does not invalidate the adventures and lessons of a full life. A key task for the elderly person is to share their tales, and that is as it ever has been, and should be. And one of the most valuable tasks a therapist can undertake with the elderly is to give them the opportunity to share their story. 

Psychotherapy Status Report: Past Achievements/Current Failures/Future Disruptions

Posted on by Psychotherapy.net Team

A Very Brief History of Psychotherapy

Depending upon how you look at it, psychotherapy is among the oldest of professions — or one of the newest. Lacking effective active treatments, doctors always got by with some combination of supportive psychotherapy, magic, and placebo effect.

The Shaman in prehistoric times was the first psychotherapist — diagnosing and treating the mental and physical ills of tribal members by negotiating with the spirits on their behalf. In settled agricultural societies, priests assumed the same role, though the negotiation was with gods, not spirits. Then came the philosophers.

All the basic principles of CBT were laid out by the Epicurean and Stoic philosophers in ancient Greece and Rome. The Arab world, one thousand years ago, was the first to have a separate profession of psychiatry, whose practitioners developed techniques of psychotherapy quite similar to how we practice today. And Pinel substituted psychotherapy for chains in caring for the mentally ill in Paris 225 years ago.

Modern psychotherapy began with the few practitioners of psychoanalysis in Vienna 140 years ago — but psychotherapy quickly became a growth industry, both in the number of practitioners and in the wide variety of techniques they used in their practice.

One hundred years ago, there were very few people who would label themselves psychotherapists; now there are almost 200,000 in the US. About 60% hold a master’s degree, 40% are PhD’s; 70% are female; and average age is 45. Seventy percent of therapists provide mostly individual therapy; 30% also work with couples and/or families. Therapists in private practice usually see 20-25 patients a week; charge anywhere between $75-$200 for sessions that last 50 minutes; and on average, see patients for anywhere between1 and 12 sessions. The average wait time for a first appointment is several weeks.   

CBT is the most popular form of treatment followed by psychodynamic approaches. Two thirds of therapists feel deep satisfaction in their work, but half report having felt burned out at times during their careers. The US Bureau of Labor Statistics estimates that the number of therapists will increase by about 20% by 2030. You can find many more interesting statistics characterizing therapists and therapies here: 

My purpose in writing this piece is to provide my personal, and admittedly biased, view of the major achievements and major failures of our psychotherapy enterprise — and to provide some guesses of what likely future directions will be.

Five Major Achievements in Psychotherapy

The Therapeutic Relationship

The greatest paper in the history of psychotherapy was among the first — Saul Rosenzweig’s 1936 “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” Rosenzweig correctly predicted that the most robust finding in all the later extensive psychotherapy research would be that “everybody has won, and all must have prizes.” His “Dodo Bird verdict” (borrowed from Carroll’s “Alice in Wonderland”) asserted that most comparisons of the efficacy of various forms of psychotherapy result in tie scores. Although therapies may differ greatly in theory and technique, the greatest contributors to good outcomes are the factors all have in common; the therapeutic relationship, patient and therapist positive expectations, healing rituals, catharsis, and regression to the mean with the passage of time. The success of any given form of therapy is not proof of its specific theories or practice, because so much of the variance comes from what is shared across therapies, not what is particular to each. This is not to deny that specific techniques have specific value for specific indications, but it does focus therapist attention on getting right the more general factors that cut across therapies. Rosenzweig guessed the Dodo Verdict without the benefit of any controlled studies, but many thousands of subsequent well-controlled, randomized comparison studies have proven him remarkably prescient.

Documenting The Efficacy of Psychotherapy

The most important thing I’ve ever done in my career was serving on the NIMH committee that funded the early studies of CBT and DBT during the 1980s. These were the early days in systematic psychotherapy research applying the model of clinical trials — the controlled, randomized comparison method that had already revolutionized medical research and efficacy studies of psychiatric medications. 

The few million dollars that supported research documenting the efficacy of CBT and DBT have since benefited millions of patients worldwide. In contrast, NIMH has since spent many tens of billions of dollars on brain and gene research that has provided little to no benefit to patients. The research success of CBT and DBT legitimized psychotherapy and led to their widespread acceptance as reimbursable treatments worldwide. Tens of thousands of therapists have subsequently received systematic training in CBT and DBT — and both have generated extensive professional literatures and also books aimed at patient education and self-help materials, virtual and written. Psychotherapy would not be nearly so widely accepted today if it lacked this demonstration of efficacy.

Expanding The Scope of Psychotherapy and Its Specificity

Modern psychotherapy began with Freudian psychoanalysis, usually conducted several times a week, with the patient lying on a couch and free associating. Within decades, innovative pioneers developed less regressive short and long-term psychodynamically-based therapies that eventually largely replaced the original model. Almost simultaneously, behavior therapy had its origin in Pavlov’s dog conditioning experiments and was brought into clinical practice through innovations introduced by John Watson, B. F. Skinner, and Joseph Wolpe.

Cognitive therapies developed independently by Albert Ellis and Aaron Beck became popular in the 1970s and dialectical behavior therapy was developed at about the same time. In subsequent decades, at least 50 different psychotherapies have been named and defined. This profusion of different therapies is not an unmixed blessing (as we shall soon see), but it has vastly augmented the toolkit of modern therapists and increased the specificity of psychotherapy techniques for depression, panic attacks, generalized anxiety, phobias, anorexia, bulimia, addictions, sexual, and many other disorders. 

Research Comparing Psychotherapy with Psychiatric Medications

The ultimate test of psychotherapies is not how they do against one another (because such comparisons routinely result in tie scores (actually, CBT is usually found to be more effective than others), but rather how they do against medications (when either might be indicated) and how they do against no specific treatment (when meds are not indicated). The evidence of hundreds of studies across different therapies, different medications, and different disorders is that psychotherapy and meds are about equally effective when both might be indicated and that the combination of both may be more effective than either alone. Meds work quicker (not entirely true); psychotherapy has more enduring effects. 
A useful rule of thumb is that psychotherapy alone may be indicated for most milder psychiatric problems; psychotherapy or meds, alone or in combination for moderately severe symptoms, and meds plus supportive therapy for more severe and enduring symptoms. Very mild and transient symptoms do well with watchful waiting (or, as prescribed in the UK, self-help materials or self-help groups).

Reducing Stigma

Mental illness had been more easily accepted before the urbanization that followed the industrial revolution. And in some cultures, the mentally ill had even been revered as a source of spiritual power and insight. But stigma increased dramatically when individuals with mental illness became inconvenient denizens of crowded cities. The typical expectation was that the mentally ill were all badly out of touch with reality; useless; in the way; untreatable; likely to deteriorate and become dangerous; and worthy only of warehousing in badly overcrowded, dingy, smelly, neglectful inpatient snake pits. This stigmatization of mental illness has been much dissipated with the expansion of disorder definitions according to the DSM; the inclusion in the DSM of much less severely impaired individuals; and the widespread experience of psychotherapy in the general population. Many people, especially in cities, have been in therapy or know someone who has.   

Five Major Failures

Lack Of Access

In the US, most people needing psychotherapy can’t get it or wait months on waiting lists. Some of this is due to a shortage of trained therapists. Some is due to lack of parity in insurance coverage and tricky ways insurance companies have of avoiding responsibility for reimbursement. Some is due to geographical distribution of therapists — people with psychiatric symptoms live everywhere, but almost all psychotherapists live in cities.

But economic inequality is by far the greatest culprit in depriving needed psychotherapy for the very people who are experiencing the greatest psychosocial stresses. Add to this that most therapists are white, come from middle class backgrounds, and have little experience with or empathy for (or deep understanding of) people of color, with diverse cultural experiences and values, and with the economically disadvantaged. It is a great failure of public funding in rich nations that the needs of the vulnerable, most in need, are so often neglected. 

Lack of access is exacerbated by the fact that most psychotherapists focus on doing the most possible for each individual patient, rather than having the public health ethos of striving to do the greatest good for the greatest number. Many psychotherapists exclusively conduct long term therapies with very ambitious goals, resulting in long waiting lists or no treatment at all for those frozen out of the system. Most patients want and need only brief treatments aimed at symptom relief. Long term therapy is valuable, but it should be the exception, not the usual first reflex.

Community mental health centers, often vastly understaffed and with therapists with less training, are expected to treat a crushing number of patients per week. And then there has been the emptying of psychiatric hospitals without needed therapeutic services, housing, and vocational support

Lack of Integration

There has been a tension during the past 50 years between the psychotherapy splitters (those who create an ever-expanding list of new psychotherapies) and the psychotherapy lumpers (those seeking to integrate psychotherapy into one coherent whole). Despite the best efforts of the lumpers (count me in here), the splitters are winning out. At last count, there are more than 50 named psychotherapies — a veritable alphabet soup. Most therapists are narrowly trained in one type of therapy and remain tribally loyal to it — applying the same techniques to all their patients rather than developing sound conceptualizations and treatment plans for each individual, integrating and flexibly applying the specific techniques most appropriate for that individual.

Most training programs are narrow in focus — locked into the techniques developed and taught by their founders, rather than teaching a wide array of the best techniques from across all models. Cognitive therapies are now by far the most prominent in the world because they have been by far the most flexible — over the past 40 years incorporating behavioral, psychodynamic, experiential, and recovery techniques and applying them flexibly to a widening range of symptoms within their theoretical framework

Losing The Battle with Drug Companies

Psych meds are essential for those with severe psych symptoms, and often necessary for those with moderate symptoms. Even though most people with milder symptoms would do better with psychotherapy or watchful waiting, a startling 20% of the general population are instead regularly taking a very often unnecessary psych medication.  

There are three causes of this overuse of psych meds and accompanying/underuse of psychotherapy; 1) drug companies spent billions of dollars promoting meds; virtually nothing has been spent promoting psychotherapy; 2) 80% of psych meds are prescribed by primary care doctors with little training and great eagerness to get a satisfied patient quickly out of the office; and 3) psychotherapists are so hard to access in most communities. This overuse of meds and underuse of therapy is bad for patients, bad for therapists, bad for society — it is good only for drug companies.

Underemphasizing Supportive Therapy

The flourishing of specific techniques of therapy has obscured the fact that supportive psychotherapy is valuable and should be part of every patient encounter, whether in a medical or a psych setting. With the exception of some psychiatric residency programs, there are few training programs teaching how to do supportive therapy, and few books and papers describing it. This, despite the facts that supportive therapy is the only helpful tool most doctors have had during most of the history of medicine, that psychotherapeutic support creates hope, reverses demoralization, and counters isolation, and that supportive psychotherapy requires more skill and empathy than the use of specific techniques.  

Failing To Include Evolutionary Perspectives

Darwin was the greatest psychologist who ever lived. He had three seminal insights that should vitally inform modern psychotherapy: 1) we have inherited many of our emotions and behaviors from our animal ancestors in the same way we inherited our bodily morphology; 2) we are unaware of the underlying motivations of our behaviors; and 3) many of our now maladaptive behaviors are relics of a time when they were much more adaptive.

An evolutionary perspective helps patients normalize their symptoms by better understanding where they come from and why they have them. It is normal to grieve as the price of love. It is normal to feel sad when we fail as a motivator to do better in the future. It is normal to have anxiety and phobias in response to dangers, to feel paranoid when confronted by potential enemies, to be dependent when in need of help, to overeat when delicious food is available, and so on.

Normal feelings and behaviors become problematic symptoms only when they are severe, prolonged, stereotyped, and not adapted to the current environmental contingencies. Understanding the normal roots of symptoms reduces the patient’s feeling of being uniquely damned and points the way to more adaptive responses. The valuable application of an evolutionary perspective toward psych symptoms has been described for 30 years — but most psychotherapists are woefully ignorant about it. Notably, one of Aaron Beck’s last papers did include an evolutionary perspective on depression. 

Five Future Trends

Teletherapy

Telemedicine has been around for 60 years, particularly for providing services in rural areas and particularly in psychiatry. But all this was on a small scale until Covid isolation protocols temporarily made telethetherapy the predominant way for psychotherapists and patients to communicate and for young psychotherapists to be trained. States temporarily relaxed licensing restrictions that had prevented therapists from extending their reach across state jurisdictions. The results were remarkable — many therapists (and patients) preferred zoom to in-person sessions because they afforded greater scheduling convenience, eliminated travel, allowed access to a greater range of therapists, reduced waiting time for first sessions, reduced therapist overhead, and achieved surprisingly high rates of patient and therapist satisfaction.

The lifting of Covid restrictions has made teletherapy something of a geographical jumble. Different states now have very different licensing requirements, some welcoming teletherapists from other states, some tightly restricting, and many in between. But the trend is clear — more and more, psychotherapy (like so many other aspects of life) will be done remotely via screens, rather than in person.

Text Therapy

Covid isolation also resulted in the explosive growth, increasing acceptance, and commercialization of text-based therapy. The convenience and advantages of easy and expanded access, flexible scheduling, efficiency, and low cost are clear. But texting as a psychotherapy modality also has some real advantages over in-person meetings. Patients are often more open in texts than face to face, and less likely to ignore or reject therapist’s comments. Writing gives them the opportunity to think through their problems, and texts can be read and reread and considered in a way not possible with fleeting verbal communication. One exception may be CBT, where clients are encouraged to take good notes of the most important points of the session.

The disadvantages of texting are also obvious — the lack of visual appraisal and non-verbal cues can lead to incomplete evaluations and miscommunication. We can’t really trust the few generally positive studies on texting as they may be biased, but my guess is that it will play an increasing role with the advent of a new generation of patients and therapists, who have grown up using texting as one of their major forms of relatedness.

Competition From Coaching

Life coaching is a fast-growing profession with over 70,000 coaches practicing worldwide. Theoretically, coaching and psychotherapy have different goals, practitioners, and consumers. Therapists receive more extensive training, require more formal licensure, and treat psychological symptoms that are diagnosed, coded, and compensated as “mental illness.” Coaches receive much less training, have much looser licensure requirements, and provide wellness training to improve business, interpersonal, organizational, or sports performance and to enhance life satisfaction. People with more severe problems need psychotherapists; those who are generally doing well but want to do better may seek coaching. Coaching has the advantage of less stigma (no DSM disorder required); but the disadvantage of not being reimbursed by medical insurance. As coaching becomes more available and well known, it will doubtless draw many people who would otherwise have seen therapists.

Corporatization

Psychotherapy began as mostly an individual endeavor — one practitioner contracting with one patient who paid out of pocket. Soon however, and particularly after World War II, psychotherapists increasingly began working in institutional settings — hospitals, outpatient departments, community mental health clinics, the military, and VA facilities. Especially beginning with managed care in the 1990s, psychotherapists have increasingly worked as employees of increasingly larger and larger private, for-profit groups.

Teletherapy has recently exponentially speeded up the concentration of psychotherapist — one company has accumulated a network including tens of thousands. This has the possible advantages of improving patient access and quality control but drains money from the system and risks creating inappropriate uniformity and decreased quality.  

Artificial Intelligence

I have previously written on the very real risk that computers will replace psychotherapists.  

Conclusion

It is the best of times and the worst of times for psychotherapy. Best because we have so many therapists and effective therapies. We can help most patients more than medication can and no profession is more interesting or fulfilling. I am a much better person than I otherwise would have been because my patients taught me so much. Worst because the field is so unnecessarily fragmented, so poorly compensated, and so at risk of being controlled by corporate interests and/or reduced by coaching or replaced by artificial intelligence.  

The best hope for the future, both for patients and practitioners, is to do our job well. We must integrate the hodgepodge alphabet soup of existing therapies by combining what works best from each within the context of a sound conceptualization. Therapists should no longer be trained in, and express fealty to, just one school of therapy. We should discuss, but rather feel comfortable applying techniques across all relevant schools, flexibly meeting the specific needs of each patient.

Psychotherapists have, since the dawn of time, provided comfort and solace to mankind. Labels change — shaman, priest, minister, doctor, psychiatrist, psychologist, social worker, counselor, nurse, occupational therapist, coach, and many more. But the essential function of explaining and healing human suffering has always, and likely always will be part of the human condition.  

The Benefits of Making Metaphors Meaningful in Psychotherapy

Posted on by Psychotherapy.net Team

“Nature cocks the hammer and experience pulls the trigger,” said the presenter. Everyone nodded, in seeming understanding, that in the context of the presentation, eating disorders, too, are more complicated than learned behavior. Grinning at this clever metaphor, I slipped it into my back pocket for when the nature-nurture discussion would invariably arise in my abnormal psychology class.

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Metaphors, as figures of speech, have various conversational and literary roles. They also offer powerful therapeutic opportunities for clients that, in my experience, have ringed unconscious bells and helped them to make connections and draw important conclusions. I have always enjoyed using them in treatment, particularly those moments when a well-chosen metaphor has breathed new life into a therapeutic relationship.

Fred: Testing Therapeutic Waters

Fred was a 25-year-old graduate school student studying earth sciences. He sought therapy because, according to his girlfriend, Heather, he was “in a funk again.” Heather, who accompanied Fred to his first session, also pointed out that he never spoke to her about how he was feeling during these “funks,” which strained their relationship. Overall, the couple had a lovely relationship, but periodically, particularly when school and work stress billowed, Fred lapsed into one of these brooding episodes, which could last days.

“Fred,” I began, “I see you just listening in over there. What do you say?”

“Why should I let my crap bother other people? It’s hard to explain when that happens, anyway. I’ll deal with it,” explained Fred, providing common “logic” often exposed in couples’ work.

“God! You think keeping your stuff to yourself is protecting me somehow,” cried Heather. “I don’t know what’s going on with you when that happens, and it hurts that you’re unwilling to let me in or at least try to talk to me. Now we’re in a therapist’s office. It doesn’t help me to see you suffer.”

To test the waters, I asked Fred what it was like listening to Heather say that. He leaned on the arm of the couch with his forehead in his hand, remaining reticent. Clearly there was room for improved communication, and I had to figure out how to provide Fred with a new perspective to help the couple gain momentum.

During a subsequent session, Fred looked particularly tired and noted that he “felt like deadwood” that afternoon. Noting his “dead” reference, a metaphor that took advantage of Fred’s interest in earth sciences took shape that might illustrate the benefits of communicating emotions.

As the session took shape, I awaited an opportunity to capitalize. The metaphor goddesses were with me, for Fred commented that his classes were draining him.

“Surely,” I began, “you’ve had a class studying the world’s great bodies of water,” getting Fred’s attention.

I continued, “You know, the Dead Sea and the Red Sea are both fed by rivers teeming with life, but nothing survives in the Dead Sea. Do you know what makes the difference?” Fred sat quietly, considering the query, and shrugged. “The Dead Sea has no outlet,” I finished.

Looking up, Fred, nodding, reflected, “It isn’t flushed out, so stuff stagnates and dies.”

The bell was rung, and the message was clear. He was periodically stagnating like the Dead Sea because he was not expressing his emotions and dealing with his conflicts, contributing to his “deadwood” feelings. In the rest of the session, Fred was able to start reframing the consequences of his internalized emotions and why communicating them was important.

Beth: Metaphors to Guide Diagnostic Conversation

While I have found metaphors to be therapeutically useful in guiding patients to new understandings, sometimes patients have used a metaphor to help me understand their experience. While I would never diagnose someone based on a metaphor, I have used them to guide diagnostic conversations.

Beth was a 31-year-old professional who sought therapy because she had been feeling increasingly moody and exhausted over the preceding few months. After being checked for Lyme, low iron, thyroid complications, and other medical causes, her physician suggested Beth meet with a therapist.

“I feel like I’ve been living on an emotional rollercoaster” she described in our first meeting. While more of an analogy than metaphor, I thought there might be a way to capitalize on this poignant description.

In my clinical experience, “emotional rollercoaster” is a common way that clients, or those in close relationship with them, have described the experience of bipolar disorders or borderline personality disorders. I have had to be cautious; however, not to jump to conclusions in instances like these. Afterall, jumping from a roller coaster can be hazardous to clinical health (I couldn’t resist). “Beth,” I replied, keeping with her description, “I don’t spend much time in amusement parks, but I know there are all different sizes and intensities of coasters. If your emotional experiences were actually a roller coaster, how would you describe the one you’re on?”

Chuckling at the idea of trying to guide me along, she explained, “It’s not fast with steep hills and loops,” she began, “but sometimes I feel totally unbalanced and like I’ll fall off, like my head’s just not on straight.”

“Tell me more about that ‘head not on straight’ description.” Beth shared that she frequently just couldn’t gather her thoughts and focus well, as if “nothing wants to germinate in my mind.” It took extra time to think things through, especially at work where critical thought was involved. Beth added that, at home, she felt lazy and zoned out much of the time, even if she might want to do something. “It’s exhausting,” she signed.

“That doesn’t sound like much motion; a roller coaster moves,” I observed. “What’s the emotional ‘ride’ you initially mentioned?

Beth continued, “Well, most of the time, I feel unenthused and tired, but I get irritated so quickly and can stew on something. It could be how I hate feeling like this. It might be at a friend I’m on the phone with and they don’t silence their dog in the background. It’s so annoying and rude! I’m just mad, and that irritates me more because it doesn’t feel good, and then I’m exhausted again.” Beth detailed that it often happened daily or just a couple times per week.

It seemed her mood changes were generally reactive and short-lived, superimposed on withdrawal and malaise. After more interviewing, she failed to describe anything indicative of the moodiness ever spiking into hypomania/mania or having psychotic symptoms. The fatigue, slow cognition, lack of enthusiasm and dysphoric mood that Beth described was indicative of someone who had been depressed for months. And there it was!

***

I have come to appreciate that planting a good metaphor is like cultivating the flower instead of pulling out all the weeds.