Now, this would also focus on concerns about climate change; although, I think in the ‘90s, climate change was not the pressing crisis that it is now. Ecopsychology kind of came about like a lot of movements — outside of academia and outside of the mainstream schools of psychotherapy. In some ways, it was a reaction to them in the sense of the lack of obvious presence or mention of nature, the natural world, and other species in classic psychotherapy, which, in the lingo, we’d consider more anthropocentric, more human-centric. These folks were more eco-centric; they were thinking more in terms of ecology. And so, once you start to think more ecologically, it does bring all this stuff up. All these ideas in ecopsychology are pretty understandable now and actually have gotten well into the mainstream.
It’s about people thinking of their ideas — their identity — in the sense of their connection with nature, and the value of, as you know, being out in nature for our mental health. A lot of the research has caught up with these ideas as well. There’s a very robust body of research on nature connections and mental, as well as physical health. And so, yeah, ecopsychology, at least up to recently, has kind of existed on the outside, as a commentary.
When I was teaching, I would distinguish between environmental psychology, which is a subfield of psychology, and was started by researchers that were studying how people interacted with places and with buildings, and with architecture and landscape design. Issues such as why certain landscapes are more pleasing or easy to navigate, studying things like noise and crowding.
And then, environmental psychology, in the late ‘60s and early ‘70s became more environmental in terms of thinking about environmental problems, the design of recycling programs and things like that. It’s also separate from clinical practice. It’s not a therapeutic or clinical field; it’s an academic research field. But with ecopsychology, and with my work, and with what’s going on now, these things are kind of coming together.
If you draw a box that’s labeled psychology, we can put all kinds of things in that box and study all kinds of things from a psychological perspective. You know, we can study relationships; we can study human development; we can study pathology. We can also study our relationships with the environment from a psychological perspective. But it’s a different endeavor to create a box that’s called ecology, and then put a smaller box in there called psychology. Then we’re actually practicing psychology from a different base.
It helps us realize that “wow, I didn’t realize that traditional psychology had such a human focus which is really tied in with the enlightenment and the idea of human superiority over nature. I like that idea of thinking of ecology as a larger sphere, and then the question would become, “What could or should psychology look like if it focused instead on people, not apart from or above nature, but as natural beings on the planet?” It’s pretty interesting philosophically. And then, unfortunately, the press and distress of environmental issues broadly, and climate change more specifically and in the short term, have really put a lot of pressure on people to start thinking about this, essentially whether they like it or not.
Therapists might have to learn about a new disorder, a new form of treatment, or a social phenomenon like different gender presentations. But the therapists themselves might not personally be experiencing any of these things. But with climate, with the climate crisis, therapists, like everyone else, are experiencing disasters: smoke, heat, flooding, storms. They’re going through it right alongside everyone else. So, there's a double urgency here. And then, what happens is that as people get involved in this, they begin to realize, “Oh, I didn't know there was ecopsychology and environmental psychology, and that people have been writing books and thinking about this for a long time.” So, they’re kind of rediscovering these things for a new generation.
And we have our lowercase “i” issues, which is our stuff: our own personalities, our own strengths and weaknesses, our vulnerabilities, our losses, our traumas, our neuroses. So, when I'm working with people, I'm trying to hold both of those things in conversation; people obviously resonate with larger social issues that have some relevance for them personally, and then that could be an obvious undoing process from their own background or work, dealing with their own traumas in a classic sense. Or it just resonates with their values, or they’re seeing it playing out in their communities. So, all that intrapsychic stuff is relevant.
So, what exactly is healthy, and what is the role of psychotherapy in promoting it? What has been in the shadows and largely ignored in therapy like spirituality, has turned out to be quite important? I think it is the same with environmental issues. I work with a lot of therapists that are seeking to be climate-conscious. They're either wanting to get some basic skills or they’re even wanting to specialize in this area. And part of how you specialize in any area is that you advertise your specialty.
People wouldn’t seek you out for any problem unless they somehow got a signal that you worked in that area. There’s a permission giving. There’s a permission giving to say, “Yes, I'm open to talking about these kinds of things.” unlike in past years, just mentioning LGBT somewhere on your webpage to acknowledge that you work with people of different sexual orientations is common now. It gives permission for clients to know that you deal with spirituality or trauma or workplace concerns or substance abuse. You get the idea! And so, it’s like an experiment and I’ll even encourage readers to think about this. Just add ‘environmental concerns and/or climate concern’ to your list of services and you'll be surprised.
I think we have an ethical responsibility to talk about climate and environmental issues because they are the biggest public health threat that the world has ever faced. And it is only going to get worse. We know very well from science that more climate-related weather problems and disasters are going to occur all over the US and all over the world, and people are going to be affected by these. To not talk about the greatest public health threat in history seems odd to me. So, I think psychologists and therapists have a responsibility to learn a bit about this.
But the rub is that it’s politicized, so it’s not a clean topic, and that’s another part of the climate elephant. I use this metaphor of the elephant in different ways with climate change. It’s the elephant in the room, obviously. It’s something that’s not acknowledged for a number of reasons. Partly, it’s an inconvenient truth, as Al Gore says. It affects our entire economic and political system to talk about these things. I think it’s ethically responsible to know a little bit about it and to let the public know that you’re open to talk about this if people want to.
People can take it further if they want. A number of therapists I know are personally interested in this for themselves and find that it’s something they want to get more deeply into. Because of my background doing the Ecopsychology Journal, I’ve had to learn a lot about this stuff. These are like extra degrees that I’ve picked up over the years. And so, there’s just a wealth of information out there. It can easily be a specialty or even just a personal exploration for someone’s own identity and health. There are a couple of different ways to approach it.
Essentially, bringing environmental issues into the therapy room would be a form of ecotherapy, as would taking the therapy process either outside in terms of walking sessions, or sessions that are done in an outdoor space where the actual natural environment is more a part of the process. So, it can go in different directions, but there's generally some sort of intent there to recognize nature and the natural world and our ecological connections.
Many therapists don't necessarily think of themselves as ecotherapists, but they’ve integrated outdoor and walking since COVID. I find walking therapy quite interesting because it’s kind of its own thing. It’s a technique, but some people think of themselves as walking therapists; it becomes kind of an orientation. I was just meeting with a therapy group this morning with people from around the US, Italy, and India. We were talking about walking therapy, and if you Google walking therapy, even in the last year, you’ll see how it’s exploded. Walking therapy doesn’t automatically have the deeper ecological thinking component of ecopsychology, though it can be practiced that way. What it shares with ecotherapy is a different view of the container of therapy, and also adds a movement and experiential component. It doesn’t have the environmental-political angle of ecotherapy, which tends to be environmental, in terms of environmental politics. But walking therapy is quite fascinating.
As a tangent, just think of the explosion of psychedelic therapies in the last couple of years. I was just at the American Association for Behavioral and Cognitive Therapy Conference here because it met nearby. I was speaking on a panel on some of these environmental issues there. But it surprised me to see all the psychedelic therapy work there at this behavioral therapy conference. Things change rapidly; walking therapy is more accepted, psychedelic therapy, more accepted. Ecotherapy is more accepted as well for all the reasons we’ve been talking about.
When I help therapists think about walking therapy, it’s actually quite interesting. I haven’t really thought about it directly in existential terms, but it is because we think about our existence as a being in relation to other beings and in time and in weather: it’s inherently transpersonal in the sense that it takes us out of ourselves. So, we can think of walking therapy as transpersonal. We can think of it as existential. I tend to think of it as an embodied approach because when I am walking and moving, my body, my brain works slightly differently than when I’m sitting in a room. And so, I think of it as a brain-based approach because it activates things similar to EMDR; it’s activating the brain in bilateral ways.
You might experiment with reflecting on something in a room in a stationary setting, and then reflecting on the same content while you’re walking. It’s hard to describe, but it feels different, and it’s more empowering. There was a great story in Outside Magazine this writer Erica Berry interviewed me about. We did walking sessions, and she wrote about it. She had a great quote. She said, “It was hard to feel powerless when you were reminded with every step of your power.” As we were walking, she shared feeling empowered. So, I totally agree with what you’re saying is that this modality does add all kinds of things. It’s quite healthy, and it’s more therapy-friendly than you think in terms of all the different orientations that are likely to come into play.
And so, it does exacerbate people’s natural tendencies to be anxious, and with someone who already has trauma or other anxieties, or have experienced earlier disasters in their life, then new ones can really tip things over. Young moms, postpartum moms who are already highly protective of their young ones, are going to be hyperactivated by smoke and heat because it is literally dangerous to babies. So, you’ve got all that to cope with. And then, of course, people feel natural concern and loss about issues like extinction and lack of places, especially when certain iconic places are destroyed, like Lahaina in Hawaii, or from the fires in California. The Hawaii fires were catastrophic, not only locally, but many people had emotional connections with that place, these places they had visited, Maui and Lahaina. And so, it touched a lot of people.
So that grief and loss is right under the surface. It’s a chronic issue when I talk to people. When you get people to open up, these issues come up. I don’t think I’ve ever met anyone who doesn’t have some of this going on. So yes, it’s important. Erica later said, “As we continued up the hill, I tried to recall where my train of thought had stopped, but it no longer felt important,” because we had seen a bird, and we were listening to the bird. And she said, “I had been talking about suppressing climate sadness because I didn’t want to sound like an evangelist or bum my loved ones out. But now, I was thinking about the bird, and wasn’t that the opposite of doom brain, tuning into all that lived around me.”
She added, “This sort of reflection certainly wouldn’t happen in a therapy office, but it wasn’t a bad thing. You know, the bird had, for a moment, airlifted me out of my anxiety.” So that idea of being present in nature and walking gives us this expanded scope, and you can think about these things and contain them, but you’re also living. You’re also in the moment in a way that’s just quite different. So, there is a tie-in between eco-anxiety and some of these modalities. People do seek out therapists that can help them with eco-grief or anxiety, either because the person’s highly connected with nature, or they’re an environmental professional or a climate scientist, or they’ve dealt with a disaster; or it’s just a developmental stage for them.
There’s a concept called the “Waking Up Syndrome,” where people just become aware — they have an ecological awakening of some sort. Many people have this in school, when they’re in college or graduate school, or when they’re studying things, they realize, “Wow, everything is connected, and there’s a system here, and I just didn’t realize, and I never realized the scope of some of these things.” So, there’s a natural developmental experience that most every adult can speak to where they kind of woke up to the world. They woke up to the state of the world. They became adults. They became aware of the systems, and of justice and injustice and identity and all these kinds of things. And sometimes we have a container to hold that and someplace to process that—a mentor or parent or counselor. Many people don’t. It’s like a rite of passage.
Countertransference is unconscious, right. And so, it’s really that kind of conspiracy of, “I’m not going to bring this up because I don’t know how to handle it. “I don’t want to expose either of us to something that we can’t cope with,” right? I think that therapists are coming to grips with this. They’re people, and they have their own environmental identity, right? You were hinting at this in your earlier comments. So, we have a sense of our environmental identity, our sense of connection, our sense of ourselves as a human in relation and nature in the natural world.
It’s implicit for everyone until we talk about it, just like any other form of identity: our gender identity, sexual identity, cultural identity; we have all the values and beliefs in action, but unless we’re taught to think and have a metacognition about them, we can’t necessarily elucidate it. It is similar to environmental identity. When therapists start to understand their own environmental identity and feel comfortable with it, they can better understand how, when, and when not to bring it into therapy.
We’re not perfect. We’re flawed people. Everyone wants to do more. We’re in a tough system. Most people are constrained. We’re hostages to a system that’s quite unsustainable. We don’t control it. Once we learn to forgive ourselves and to be comfortable with our own environmental story, then we can sit comfortably with other people’s stories, right? And then we don’t have to solve climate change. You don’t have to solve climate change to cope with it.
We don’t have all the answers to our clients’ problems. That’s not our job. Our job is to support our clients while they’re seeking the answers. But to get to that level of comfort with the material in the room and let go of it so it can just be there, that’s where the developmental task is for the therapist. Some issues are so difficult, we’re never fully comfortable with them. But we learn to have the capacity to contain them and be with them. A lot of the challenge with doing ecotherapy is developing the capacity to sit with ecological issues in the therapy room, knowing that we cannot solve these things, and we may not solve them in our lifetime, but we do have values, and existentially, we do what we can and be our best self.
So, yes, I do think, for many, many reasons that understanding our unique connection with nature and the natural world, the outdoors, is just generally an essential life task. We’ve forgotten that we’ve evolved on a planet. We are creatures. We are animals. We didn’t come from a machine. We’ve forgotten all these things. Some people would laugh and say, “Well, of course, we forgot. How could we not?” But this speaks to our society and our culture not our essential selves. So yes, I do think it’s part of self-actualization. I think of Maslow a lot, too — all parts of his pyramid a
The Disconnection of Depression: How to Restore Attachment Using Cognitive Interventions
“Despair is an ultimate or ‘boundary-line’ situation. One cannot go beyond it.” – Paul Tillich
“I don’t want to be a burden,” she told me. It’s a phrase that I’d heard many times, and it often came from my aging or depressed clients. Her words came from a selfless place. She didn’t want to hurt others with her pain. She didn’t notice that withholding her suffering meant she was introducing disconnection within her relationships. Or maybe she did. As she pulled away from the people in her life, her silent march towards death’s absolute disconnection had begun. It was an incremental, self-inflicted dying.
In the last entry, I shared how clients can experience the moral dimension of suicide. It’s important for me to notice when my clients feel like a burden, because suicide can appear like a strategy to protect others from themselves. In this context, I wanted to explore what my clients have taught me about how to avoid this trap, and how they were able to eventually reconnect to those they desired to protect.
Blended Truths: A Cognitive Intervention
When my clients have talked with me about being a burden, they usually point to a mountain of supporting evidence. They tell me they’re no longer able to work, that their spouse is earning the only income, and the kids are visibly confused. To make matters worse, they aren’t helping around the house. They tried to vacuum, but “the chord got tangled.” Then they tried to cook dinner, but they became “overwhelmed by the existential absurdity of shredding carrots.” So, back to bed they go. In their absence, their loved ones are suddenly forced to do it all, and they’re sure it’s their fault.
When clients present this way, I try to help by asking them to reconsider this belief. At first glance, the conviction that they’re a burden appears to have some merit. The people in their life are struggling to compensate for the consequences of their depression. That’s usually true. But one of the hidden mechanisms found within depressed thinking is the presence of blended truths.
Blended truths are thoughts that contain some amount of truth, but they also contain some amount of falsehood. Facts and fiction co-mingle. The problem with these blended truths is because they hold some amount of merit, they initially seem persuasive. Unable to argue with the apparent validities, clients are simultaneously baited into swallowing their inconspicuous falsehoods. The good goes down with the bad. Blended truths operate like a worm-hidden hook — or an Almond Joy.
But it’s true that their loved ones are affected by their depression. That’s the first part of the blended truth that’s factual. This is an unavoidable part of being a social animal, and it’s the cost of admission when we’re meaningfully connected to each other. But I’ve noticed that my clients believe something more than this. If they simply believed their loved ones were having trouble, this would create feelings of worry, but it wouldn’t create feelings of guilt. So where does the guilt come from? It comes from the second part of the blended truth. It comes from the belief that it’s their fault. This is the hidden falsehood within the blended truth. It’s the sharp hook. Or the chalky almond. This is where I try to help clients address their sense of burdenhood, and if I’m having a good day, it might sound something like this:
Therapist: You mentioned feeling like a burden, can you tell me more about that?
Client: Well, everyone is working to pick up my slack. My wife is exhausted. She’s working and doing the parenting while I watch reruns and avoid phone calls. I hate what I’m doing, but I can’t seem to get myself right.
Therapist: You hate that your family is affected by the depression. I mean, how could you not? It sounds like everybody is really struggling. I’m sorry to hear things have been so difficult.
My first step to untangle a blended truth is to validate the part that’s true. In the past I tried to reassure my clients that their loved ones couldn’t be struggling too badly. That was a mistake. It was a mistake because my clients knew I didn’t know their loved one’s experience, and when I feigned that I could, this made me less credible. My false consolations had led to lost credibility, and my lost credibility led to damaged rapport. What was intended to be a supportive sentiment, ended in a damaged therapeutic relationship. But despite the punishing grind and slothful speed that is my learning curve, I eventually learned that if I could acknowledge the part of my client’s blended truth that was true, I could earn credibility and tighten our rapport. Then with the relationship standing on firmer ground, I could initiate the second step of addressing these blended truths. I could invalidate the part that’s false:
Client: Yeah, so that’s what I mean by being a burden.
Therapist: I gotcha. Would you mind if I picked a friendly fight?
Client: Go for it.
Therapist: So, I don’t doubt that your family is struggling. That sounds undeniable. You make a difference in your family, and so your absence is going to be felt by them. But I’m not sure considering yourself a burden is completely fair.
Client: Well, it’s my fault that they’re struggling and so that’s what I mean by being a burden.
Therapist: Hm, that’s hard. Would you mind if I keep pushing?
Client: Fine.
Therapist: I think worrying about your family makes sense because it sounds like they’re having a hard time. There’s no getting around that. But the second part of what you’re saying — that it’s your fault – this sounds to me like it could be depression talking. So, with the risk of sounding obtuse, let me ask you directly. Are you choosing to be depressed?
Client: What? No, I’m not.
Therapist: Of course not. If you were choosing to be depressed, you could simply choose not to be. But that’s not exactly the nature of what we’re dealing with, is it?
There are a couple things I try to make happen in these moments. The first is I ask to pick a friendly fight. If I can characterize the impending disagreement as friendly, I can emphasize that challenging my client will occur between the cushions of our existing rapport. If I can get their permission to proceed, I can then introduce the idea that part of their thinking might be depression-inspired (“this sounds to me like it could be the depression talking”). This invites the client to depersonalize their thinking about being at fault, and if they can separate their authentic thoughts from the depressed ones, this can make challenging their depressed thinking more realistic. In whatever form it takes, “Is this really you, or is this the depression?” is a question I can’t do without.
This second step of invalidating what’s false is concluded by plainly asking the client if they’re choosing to be depressed. This is a ridiculous question. It’s like asking, “How many inches is the temperature outside?” But the ridiculousness is the point. This makes the implicit falsehood within the blended truth explicit, and it invites the client to sign on depression’s dotted line. When the falsehood within the blended truth is no longer hidden, my clients have a better chance to avoid digesting it.
Divide By Two: A Behavioral Intervention
Untangling blended truths is one way to explore the mental dimensions of the depression, but in some cases, I’ve found that the cognitive strategies don’t work. Sometimes my clients are overcome by their despair, and they lose any interest in thinking abstractly. In these cases, I think it’s better to start with the behavioral interventions.
I’ve found it can be useful to begin by identifying the behavior that’s connected to the client’s belief that they’re a burden. I’ll call this burden-behavior. Burden-behavior seems to present similarly across differing cases. Clients withdraw from their life in order to protect their loved ones from themselves. They hide out in bedrooms, run the fans on high, and bundle themselves in blankets. The judgmental Netflix algorithm keeps prompting them, “Are you still watching?” (What does it take to get some unconditional-positive-regard algorithms around here?)
But as each day passes, life becomes more difficult to reenter. When these determined clients make the choice to re-enter their lives, they quickly run into problems. They plan to go for a walk, but the front door appears miles away. They schedule time to meet with friends, but they immediately find reasons to cancel. As quickly as plans are made, they’re unmade, and their return to isolation occurs. Reentering life feels more like mountain climbing, and each attempt upward is followed by a slide back to the bottom.
In these situations, I try to show my clients that their plans are divisible. When they determine their plans are too difficult, instead of returning to the bedroom, they can learn to divide their plans. My aim is to interrupt the status quo of complete inactivity and to encourage them to find the outer rim of what they can handle. Then eventually, they can widen the circumference of their experience. To provide a sense of how this can work, and to show how much division can be done, here’s an example of how Divide by Two can sound:
Client: So, I tried to go for a walk around the neighborhood, but honestly my body just felt incredibly heavy, and I stayed home.
Therapist: That’s sound really uncomfortable. What did you do, instead?
Client: I just stayed in bed. I’ve been watching reruns of Cupcake Wars.
Therapist: Cupcake Wars? Yeesh. Things are worse than I thought.
Client: Tell me about it.
Therapist: On a serious note, it’s really difficult to feel cemented the way you do. Would you be open to a suggestion that might not apply?
Client: Sure.
Therapist: In these situations, I often suggest dividing by two. Here’s what I mean. If you plan to take a walk, but it becomes too difficult — divide by two — try going to the mailbox. This way you won’t find yourself trapped behind your bedroom door, beating yourself up for the plans you didn’t implement.
Client: This is going to sound pathetic, but the mailbox feels pretty far away, too.
Therapist: I bet it does. I’m glad you said that. The useful thing about this technique is that it’s flexible. You can always divide by two again. If the mailbox is too far away, determine if you can make it to the living room. If that’s too far, divide by two again, discover if you can make it to the nearest bathroom.
Client: If the bathroom is too far?
Therapist: It might be. Depression can be that way sometimes. But the trick is to do more division. Determine if you can put your feet next to your bed. If that’s too much, you guessed it — divide by two — practice a progressive muscle relaxation exercise while in bed. Too much? Start thinking about what it might be like to practice progressive muscle relaxation. The idea is to divide your plans until you find the outer range of what you can handle. Anyway, I’m sorry for preaching. Tell me about where this might not fit your situation.
With this behavioral intervention, I can invite my client to consider how to reenter their life after forfeiting their plans, and this can prevent them from sliding back to the base of the mountain. Instead of returning to complete inactivity, they can ask themselves what half-measures they can handle, and this can boomerang them back to the outer edge of engagement in their life.
The Five G’s: An Affective Intervention
Exploring the cognitive and behavioral parts of my client’s experience of being a burden is important, but so is discussing their emotional experience. This means exploring the emotion of guilt. Guilt has always carried a negative connotation for me. It makes me think about childhood religious guilt or being prompted to donate to sick puppies at the grocery store register. No thanks. Those puppies had it coming. I’m too familiar with the internal wincing that’s created by guilt. It’s an emotion that pinches the heart.
But my clients have taught me how to help them with their guilt. And in order to explore guilt’s excesses, I had to learn about its purposes. There’s a version of guilt that’s deeply important to wellbeing, and once I understood this, guilt’s surpluses became clear. What I learned is that guilt is an emotion that requires training. It’s an unbroken colt teeming with raw force. Nature doesn’t provide guilt with a safe level of calibration.
Without the right technique, it’s dangerous to the rider. This is the reason my perspective on guilt had previously been negative. I experienced guilt’s force, and it led to injury. The only colt that I had ever known had bucked me to the ground, and from the dirt I cussed and condemned it. I didn’t know it needed to be trained. I didn’t understand that before guilt could teach me anything, it needed to be taught by me. More on this in a moment.
I also used to think that guilt was an emotion that was only relevant to my past behavior. When I behaved in ways that were misaligned with my values, my guilt pain came after. Then I’d get stuck there. I’ve since come to understand that this fixation with the past is characteristic of untrained guilt. It can lead to injury. But when guilt is well-trained, it’s not only an emotion related to past regret, but it protects me from future regret, too.
The purpose of guilt isn’t to create suffering for the mistakes I made yesterday, but to prevent more suffering in my tomorrows. This guilt might take a moment to evaluate my mistakes in the past, but its additional purpose is to create fulfillment in the future. It seems that when guilt is well-trained, it’s equal parts retrospective and prospective.
This also seemed true with my clients. When my clients held unbroken eye contact with their past, they lost the ability to move forward. Focusing on their mistakes this way could lead to self-hatred, and this self-hatred would foment the conviction that others must be protected from themselves. When the retrospective was dominant and the prospective was absent, these clients would become convinced they were a force for harm in the world. But in order to join them in these difficult moments, I will try to introduce the 5 G’s. With it bit of luck, it can sound something like this:
Client: I don’t know, I’m just the worst.
Therapist: That seems harsh, and only one of us has that opinion of you, but what brings that forward?
Client: Same stuff. I just feel awful that I can’t get back to work. I tried to contact HR to figure out the process, but I started crying while I was drafting the email. My wife deserves better.
Therapist: It sounds like there’s a lot of guilt going on in there.
Client: Yeah, and I deserve it.
Therapist: Can we explore this guilt a little more? I have a few ideas.
Clients: That’s fine.
Therapist: I don’t believe guilt is harmful in every case, but in this one, I’m not so sure. Can I share a strategy to help you determine whether your guilt is useful or not?
Client: Go for it.
Therapist: So, I think we can assess guilt by using the 5 G’s. This stands for Good Guilt Gives Good Guidance. Yes, the alliteration is excessive but here’s what it means. When guilt teaches us something about how to succeed in the future, then I think it can be helpful. But when guilt doesn’t provide guidance, or if the guidance that it provides isn’t particularly wise, then the guilt is working in service to the depression. It creates an emotional environment where the depression can make itself more comfortable. But tell me what I might be overlooking.
Client: Well, I hate myself for being stuck, but my guilt is also telling me to go back to work. How is that not good guidance?
Therapist: Right. I think you’re close to identifying what your guilt is saying, but I think you might be missing two words. Tell me where this doesn’t fit, but is it possible your guilt is telling you to return to work right now?
Client: Okay, right.
Therapist: I’m wondering if you think that’s good guidance. What do you imagine would happen if you returned to work after lunch today?
Client: It would be a nightmare.
Therapist: We can probably agree it wouldn’t go so well. So, how might we update this guidance to make it more useful to you?
Client: I don’t know. Maybe I should tell myself to return to work eventually? But that doesn’t feel urgent enough.
Therapist: Hm. I can see how that might feel too open-ended. Can I submit a rough draft for your editing?
Client: Go for it.
Therapist: What about something like, “Do everything that’s possible to feel better today, because this will get me back to work as quickly as possible.” But take out your red pen, where should we make edits?”
This framework can help me to extract the wisdom within my client’s guilt. If I can ask them to evaluate their guilt along the lines of its guidance, this can nudge them away from looking backward and towards looking ahead. The client can travel towards their feeling of guilt, but for the purpose of returning with a new direction. This can bring the retrospective to the prospective, the colt to its bridle, and the feeling of guilt to its belated resolution. Once it’s well-trained, their guilt is a guide.
***
Working with clients who consider themselves a burden has been rewarding work. These clients have taught me that when they unravel their Blended Truths, Divide-by-Two, and implement the 5 G’s, they can release themselves from this conviction. Once their sense of being a burden is broken apart, disconnection from others can be incrementally reduced, and attachment to those they wanted to protect can occur once again.
[Editor’s Note: In the next and final installment in this five-part series, the author will address the challenges of balancing empathy and burnout]
Finding Ways to Communicate with Clients About Their Symptoms
Some nursing homes tend to have few, if any, residents with major mental illnesses. There are other facilities that have many residents with a mental illness, and those are the nursing homes where I prefer to work.
A 50-year-old lady with a diagnosis of anxiety, described her symptoms as “sweats, shaking, very nervous, and feeling pulled away from things.” A 72-year-old lady movingly described depression as “a heavy something that weighs on your brains, and you can’t think beyond that feeling — until someone helps bring you out of it.”
Asking someone to describe the symptoms of a mental health condition can be a helpful way to begin the process of deepening and clarifying their self-understanding. It can also be helpful to use some of the language and concepts of the client as a starting point, while avoiding sole reliance on technical jargon about mental illness. I’ve found that many clients have developed a defensive deafness to such language, anyway.
Helping Clients Understand their Symptoms
One way that I approach conversations with clients about their conditions and symptoms is through an exploratory series of questions:How do you know when you are experiencing depression, (anxiety, bipolar symptoms, difficulty telling the difference between things real and unreal)?
How do others know when you are feeling depressed (anxious)?
Do you sometimes feel depressed, anxious, or have mood changes, or have maybe unreal experiences and others don’t notice?
What might others need to pick up on to recognize when you feel depressed, anxious, or afraid?
In general, individuals experiencing anxiety and/or depression may be interested in and receptive to education and discussion about their symptoms.
Yet many persons with a schizophrenic illness might deny the condition and rationalize the symptoms — due to stigma and shame, and due to limited capacity for logical reasoning. “I don’t have schizophrenia, I’m psychic; I get psychic attacks,” suggested Martha, who, nonetheless, is sometimes willing in therapy to directly acknowledge her schizophrenia, and her peculiar experiences as being symptoms.
Therapeutically educating a client about symptoms of schizophrenia might start with distinguishing things that are subjectively real from those that are objectively real. We might discuss inner perceptions and beliefs that may be real subjectively but may not be objectively real. Some already feel as though they live in a separate and inward world, somewhat apart from others.
Recently, I have begun experimenting with using a Venn diagram of three overlapping circles to illustrate differences between subjective and objective experiences. The first circle, on the right, is labeled as the client’s inner, or subjective world. In that circle are listed several of the specific symptomatic experiences already discussed in therapy, that the person might confuse as being real. The second circle, on the left, is labeled as the outer, or objective world. The overlapping middle circle represents the client and me in therapy, looking into each world to make connections and distinctions. Here is a compilation of some selected items from the right-hand circle for five clients: psychic attacks, mind-boggling thoughts, curses and accusations made by voices, paranoid thinking, anger, depression, anxiety, my make-believe world, messages received from the TV or radio or unseen persons. The list in the left-hand circle would include the facility, medical and psychiatric diagnoses, and related care and treatments.
I draw arrows to show, for example, how the experiences in the inner world circle are symptoms of the psychiatric diagnosis in the outer world circle, and how medications and psychotherapy from the outer world circle are intended to address the symptoms. Clients have shared poignant responses to lessons learned from this approach.
Cameron said, “This helps me understand mental illness. I feel relieved when we talk like this. I get it mentally, about what’s going on.”
Betty said that “Nobody ever told me this. It makes me understand what’s going on in my head better.”
“That means we’re on the same page, I appreciate that,” suggested Martha. “You understand what it’s like for me.”
Richard said, “Sometimes I think it’s real, and sometimes I don’t; it’s hard to tell. It relieves my mind when we talk about it.”
Donald said that “I’ve gotten a lot more mature and rehabilitated talking to you, Tom. I just don’t know what to say sometimes. It’s a big thing for me to get up to this level of reality. It’s your words that make me feel I’ve turned.”
For multiple reasons, it can be difficult to educate people with schizophrenia about the psychiatric nature of their subjective experiences. I had the impulse to try the Venn diagram with one client, and his response encouraged me to try it with a few others, as well.
***
I don’t use this approach with all clients, as some may be too delusional at the time to experience benefit. The people I have tried this with each showed some willingness to question the validity of their unusual subjective perceptions and beliefs. So far, I have only tried this approach with these five clients, and I have been pleasantly surprised, and touched, by their responses. Other therapists may wish to experiment, as well, with this simple, yet promising technique.Questions for Thought and Discussion
What is your reaction to this therapist’s approach to explaining symptoms to clients?
What methods have you used to help clients understand their psychiatric symptomatology
With which clients might this approach be effective? With which others might it not?
The Wisdom of Therapist Uncertainty
“Uncertainty is your space for growth.” – Angela, psychologist
Work hours for many are unpredictable. Political divisions, pandemics, and extreme weather add further unknowns to daily life. In an era that challenges mental health, it’s easy to assume that therapists should be pillars of all-knowing sureness.
One Fear to Rule them All
But growing evidence suggests that practitioners can benefit from leaning into their uncertainty in times of flux. Skillfully accepting and even embracing not-knowing is linked to better mental well-being and improved decision-making in both clinicians and their patients. “We need to help psychologists view uncertainty not as a horrible thing you need to minimize, but as an opportunity to learn and grow,” says Elly Quinlan, a senior lecturer in psychology at the University of Tasmania and a leader in the study of uncertainty in clinical practice.
How humans contend with the unknown is a topic attracting attention in clinical psychology. This critical capacity is measured by gauging people’s “intolerance for uncertainty,” or the degree to which they view unknowns and the unsureness they spark as threatening or merely challenging. (Sample assessment component: “Unforeseen events upset me greatly.”) (1) Importantly, being intolerant of uncertainty is now recognized as a transdiagnostic vulnerability factor for a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. (2) As Canadian researcher Nicholas Carleton writes, this trait (and state) may be the “one fear to rule them all.” (3)
As a result, leading psychologists are targeting uncertainty intolerance as a promising new way to treat many mental disorders. By taking on more unknowns in daily life, patients gain skill at meeting life’s twists with a curious, open mind, rather than fearfully racing to eliminate uncertainty through denial or snap judgment. During one intervention, young adults tried answering their phones without caller ID. (4) An adult learning uncertainty tolerance in therapy challenged himself to delegate more at work. (5) Results are encouraging: in one recent study focused on bolstering uncertainty tolerance, worry and anxiety in people with generalized anxiety disorder fell after treatment to levels experienced by the general population. (6)
Now Quinlan and others increasingly see uncertainty tolerance as a needed skill for psychologists themselves to practice. Psychologists interviewed for a small quantitative study led by Quinlan reported primarily negative responses to situations filled with unknowns, such as an ethical dilemma or the challenge of selecting treatment for a high-risk patient. (7) The psychologists, who had diverse levels of experience, reported anxiety, feeling inadequate, frustration, and anger. Some avoided complex, ambiguous cases or left a client in order to escape uncertainty. “I actually could not resolve that uncertainty, so I shifted the client to another clinician,” said one.
Such markers of an inability to manage uncertainty are associated with both anxiety and with burnout, conditions that undermine well-being and decision-making skill. In one study of 252 psychologists, their uncertainty intolerance in client care and in daily life predicted burnout (8), a form of exhaustion that up to 40 percent of mental health providers experience today. (9) Uncertainty intolerance is also linked to overtesting, according to studies in primary care medicine. (10)
The Importance of Uncertainty Tolerance
In contrast, psychologists who accept the intrinsic uncertainty of their work and see not-knowing as an opportunity for learning, as discomfiting as that may be, tend to have higher mental well-being. Angela, a psychologist who participated in another of Quinlan’s qualitative studies, advises younger peers to “treasure the darkness a bit. Uncertainty is your space for growth.” (11) Uncertainty-agile clinicians ask, “What is this ambiguity or my uncertainty telling me?” instead of rushing to bury or eradicate the unknown, says Quinlan, whose research has inspired her to assure her trainees that it's okay, and even helpful, to not know.
By recognizing uncertainty as a path to wisdom, providers gain time and space to consider nuance and alternative perspectives. In a speed-driven world where experts are expected to be all-knowing and ultra-decisive, psychologists often “long for the magic wand” of the quick, clear answers, observes educational psychologist Daniela Mercieca of the University of Dundee. But “it is only by allowing ourselves to be uncertain that we are open to shock and surprise … and complexity.” (12)
How can psychologists learn to recognize unsureness as an opportunity? Efforts to map uncertainty tolerance are so new that interventions to teach this skill set to practitioners are sparse in both psychology and in general medicine. One intervention found that training in non-judgmental mindfulness helped trainee psychologists become less stressed by uncertainty. (13) Other studies have shown that exposure to the visual arts or the humanities can boost uncertainty tolerance in medical students. (14) Quinlan plans to begin formally testing uncertainty-tolerance strategies for trainee psychologists in a few years.
There may come a day when healthcare practitioners will be routinely taught to manage uncertainty as a way to improve their well-being and their efficacy. But until that time, perhaps clinicians can learn from the peers and patients around them who find wisdom in accepting life’s inherent unpredictability and in realizing that at any one moment they might not know.
Recently, two young practitioners found that openly admitting uncertainty in their practice felt unexpectedly liberating. The opportunity arose in 2020 as cognitive behavioral therapist Layla Mofrad and psychologist Ashley Tiplady worked with Mark Freeston of the University of Newcastle to develop a group intervention to teach uncertainty tolerance to patients just starting to receive care for a range of disorders. (15) To model the intervention’s content, they explicitly talked to one another and to patients about the program’s unknowns, ranging from outcomes of this novel treatment to how a tech outage might affect the day’s schedule.
Most patients who completed the “Making Friends with Uncertainty” intervention showed significant improvements in their anxiety and depression and nearly half became more tolerant of uncertainty. Moreover, the facilitators themselves found that working with, not hiding from, uncertainty improved group solidarity and their own ability to be partners in care. “It’s easy as a therapist to jump into trying to make things feel more certain … we tried to hold back from that,” says Mofrad, adding that this approach returns therapy to its ideals. “The best therapy will always have an uncertain element, and the best therapists are those who will ask questions, be curious, and not stick to a rigid framework.”
Note: All quotes are from interviews with the author unless otherwise noted. Due to an editing error the references below have been updated as of 4/24/2024
Questions for Thought and Discussion
1. What were your impressions of the author’s premise about certainty and uncertainty?
2. How comfortable are you with uncertainty both professionally and personally?
3. In what ways might you carry forward the author’s research in your own clinical work?
References
(1) Carleton, R. N.; Norton, P. J., & Asmundson, G. J. G. Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.
(2, 15) Mofrad, L., Tiplady, A., Payne, D., & Freeston, M. (2020). Making friends with uncertainty: Experiences of developing a transdiagnostic group intervention targeting intolerance of uncertainty in IAPT: Feasibility, acceptability, and implications. The Cognitive Behaviour Therapist, 13 (49), 1-14.
(3) Carleton, R. N. (2016). Fear of the unknown: One fear to rule them all. Journal of Anxiety Disorders, 41, 5-21.
(4) Unpublished material shared with the author by Stephanie Gorka and Nicholas Allan of Ohio State University’s College of Medicine.
(5) Keith Bredemeier Assistant Professor at the University of Pennsylvania Perelman School of Medicine Center for the Treatment and Study of Anxiety, in discussion with the author, September, 2023.
(6) Michel Dugas et al. (2022). Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults with Generalized Anxiety Disorder. Behavior Therapy, 53 (6), 1147-1160.
(7) Quinlan, E., Schilder, S., & Deane, F. P. (2021). `This wasn’t in the manual’: A qualitative exploration of tolerance of uncertainty in the practicing psychology context. Australian Psychologist, 56 (2), 154-167.
(8) Malouf, P., Quinlan, P., & Mohi, S. Predicting burnout in Australian mental health professionals: Uncertainty tolerance, impostorism, and psychological inflexibility. Clinical Psychologist, 27 (2), 186-195.
(9) O’Connor, K., Muller Neff, D., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74-99.
(10) Korenstein, D., Scherer, L. D., Foy, A…Morgan, D. J. (2022). Clinician attitudes and beliefs associated with more aggressive diagnostic testing. American Journal of Medicine, 135 (7); also Lam, J. H., Pickles, K., Stanaway, F. F., & Bell, K. J. L. (2020). Why clinicians overtest: development of a thematic framework. BMC Health Services Research, 20 (1011),
(11) Fewings, E., & Quinlan, E. (2023). ‘It hasn’t gone away after 30 years.’: Late-career Australian psychologists’ experience of uncertainty throughout their career. Professional Psychology: Research and Practice, 54 (3), 221-230.
(12) Mercieca, D. (2009). Working with uncertainty: Reflections of an educational psychologist on working with children. Ethics and Social Welfare, 3 (2), 170-180.
(13) Pickard, J. A., Deane, F. P., & Gonsalvez, C. J. (2024). Effects of a brief mindfulness intervention program: Changes in mindfulness and self-compassion predict increased tolerance of uncertainty in trainee psychologists. Training and Education in Professional Psychology, 18 (1), 69-77.
(14) Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56 (12), 1163-1173.
Terminally Ill Pediatric Patients and the Grieving Therapist
When asked about the favorite aspect of my (dream) job, I could talk for hours. I feel passionate about working in a pediatric hospital setting with chronically ill children and their families. Each day brings new challenges. I enjoy inpatient and outpatient sessions, parent consultations, family work, collaboration, and advocating for this population any chance I get.
On the contrary, when asked about the least favorite aspect of my job, my response is far less glowing and enthusiastic. I work with children from various departments within the medical center, including oncology, cardiology, trauma, and solid organ transplant. It is inevitable that I encounter children who are terminally ill. I will never understand why children die. Experiencing the death of a child is the most painful part of my job, and it will never make sense to me although logically, I know this happens. On the other hand, I feel honored to be a small part of the most vulnerable time in a family’s life, and to walk alongside them in their journey of grief and loss. Helping a family and their child during end-of-life care is arduous work. It has been impossible for me to not be deeply impacted working in this arena.
I will never forget the first patient with whom I worked that received a terminal diagnosis. I was an intern completing my graduate work. Because I speak Spanish, I was privileged” to work with more challenging cases. I remember sobbing to my mentor at the time, not understanding how a child could die. In response, my mentor neither chastised nor criticized me. She agreed with me and mourned with me. She supported me through that experience and reminds me even to this day that we are human. That support has stuck with me as I continue to mourn the deaths of children with whom I work.
When I was first asked to write a post related to working with terminally ill children and their families, I hesitated, perhaps not wanting to open old wounds and visit the pain that comes with this kind of work. But as I’ve experienced more child deaths over the years, I wanted to share my thoughts and feelings and am humbled to share my stories.
The Dying Child
The dying child has a variety of emotional, physical, and spiritual needs. They have questions and often want information about what is happening to them. The child who is terminal often feels unsafe and understandably anxious. One word I’ve frequently heard, particularly from the parent, is “brave.” In my experience, many parents of terminally ill children find inner strength in the strength of their own children. I remember one child who was aware of her prognosis comforting her parents, reassuring them that she would be “okay.” She arose each morning and worked hard to remain connected with her parents, family, and friends. I also try to remember, even in the face of their strength, that these children are scared. As I have discussed with many families, fear and bravery can, and often do co-exist. For me, bravery is moving forward even in the face of fear.
To Tell or Not to Tell
A glaring ethical question is whether a child should be told they are terminally ill and that they will die. In my experience, many medical providers and members of the psychosocial team believe a child should be informed of the severity of the diagnosis; whereas parents often do not wish for their child to know. Many parents believe children will “give up” if they are aware of the prognosis. To the one, children often know something is very different or not right. They may be confused and desire open communication to understand what is happening within their own bodies. It is my job to provide caregivers with this information and connect them to the Child Life department if they would like guidance regarding how to tell their child. It is not my job, however, to advise them on what to do or impose my own beliefs. The decision is ultimately up to the parents.
The Dying Child’s Family
The families with whom I’ve worked represent a wide range of cultures, faiths, religions, abilities, and beliefs. It has been imperative for me to work with them through a very focused lens of acceptance and understanding of end-of-life issues so that I can be as useful as possible. When learning about a family’s culture, it has been important to know and appreciate the family’s beliefs about the afterlife as this has guided me when discussing their child. Faith can be an important coping skill and protective factor when a family receives news of a terminal diagnosis for their child. However, challenges may arise because of a family’s faith. I have met with Christian caregivers who struggle with the balance of faith and science. Many worry that preparing for end-of-life care, such as transitioning to hospice, considering a DNR, or planning the funeral indicates they are not “good Christians.” Connecting families to spiritual care has been crucial when the family’s faith is important to them.
Families are often faced with challenging decisions regarding end-of-life care. Many parents process these decisions with the child’s therapist. Some parents worry that focusing on the child’s quality of life and reducing seemingly futile treatments will be perceived as “giving up.” I have often worked with caregivers who struggle with the continuation of treatments that are painful, and sometimes even agonizing, for their child. While they want what is best for their child, the decision to extend that child’s life can be tortuous.
Complex and anticipatory grief can make the adjustment to a terminal diagnosis that much more difficult. It is challenging for caregivers to be fully present while still grieving the impending loss of their child. In addition, siblings are often overlooked as a necessity for the dying child’s care. I recall the family of a dying child with whom I facilitated sibling play therapy. My goals during sessions were to connect with each child and help them connect to each other. During those sessions, the child with the terminal illness often felt ill and lethargic. The sibling first requested that the patient play with her in many ways. However, as sessions progressed, the sibling learned to allow her sister to lead. For example, instead of two chefs working at a restaurant, the sibling was the chef who served the tired patron a meal. The ability for families and siblings to find strength to cope always amazes me.
Hope vs. Denial
It is not uncommon for me to receive proclamations from the child’s medical teams that the family is in denial about their child’s diagnosis. I will never forget sitting down with a particular mother to discuss her child and family. She said, “I know what the team thinks. They think I don’t understand what is happening. I understand. I am just choosing to have hope. Hope in a higher power. I know my child’s doctors do not have the last say. I have hope that God will heal my child.” Hope is not denial. Hope is an adaptive and positive coping skill that bolsters a child and family during outstanding hardship.
The Challenges of Working with Dying Children
I was fortunate to be surrounded by deeply empathetic people during my internship, when I first experienced the death of a child patient. Since that time, I have met many medical providers who have been able to build an emotional tolerance for this kind of work out of necessity to care for their patients. I have always been thankful for their skill at addressing the physical and medical needs of these children and their families.
As a therapist, however, my role is to attend to the emotional needs of the family — their strengths and fears along with, of course, their presenting concerns. I have learned the importance of allowing space for all feelings, including my own, when a child’s death is imminent or has occurred. I used to believe I was not able to grieve the loss of a patient. My grief meant nothing compared to the limitless grief of the family, friends, community, and bedside staff. However, I quickly and poignantly came to see the disingenuousness of this belief. I have learned that the only way I can be fully present for the child and their family is by remaining firmly anchored in my own humanity and vulnerability.
I have certainly heard words like compassion fatigue, secondary trauma, contagious emotions, and empathy trauma bandied about, and how any of these experiences can lead to burnout. One extreme challenge I’ve experienced when meeting with a terminally ill child and/or their parents has been the pressure of meeting with a healthier patient immediately afterward. I will never forget receiving news a patient with whom I had worked for years died two minutes before a session with another patient. I still question whether I was able to offer unconditionally positive regard to that second patient as I struggled under the weight of what had happened moments before. Shifting those emotional gears was a challenge.
Over this and related experiences, I have had to learn ways of grieving to avoid burnout. Showing my own humanity and vulnerability within the boundaries of safe relationships and work friendships has made me a better therapist and afforded me an outlet for my own emotions. I remember working with a chronically ill child for over a year who received a terminal diagnosis. As her illness progressed, I transitioned to working with her parents. I learned to never schedule a session with another family or patient directly following these interventions. After these emotionally dense and intense sessions, I would schedule five minutes to cry. I would shut my office door and have a few minutes to allow myself to experience these heavy feelings and an emotional release. I have learned that by allowing myself to grieve, experience, and understand my own humanity, I have become a more empathic person. This has, in turn, allowed me to continue to work with this population and alongside grieving families.
Guilt and Perspective
There are several challenges and, not surprisingly for me, blessings when working with this population. One glaring emotion I often experience is guilt. When leaving the hospital for a vacation or holiday, I must inform the families of newly admitted patients that I will be gone for a few days. Many families say, “Have fun!” or “Merry Christmas!” The typical “you too” does not suffice in this scenario. The extreme guilt I felt as a young therapist was overwhelming. Then, with two healthy pregnancies and subsequent maternity leaves, and now, with two healthy children, I am often surprised by waves of guilt. Over the years, these waves have decreased in size and duration. I know I have a role to fill to support these patients and families, which will be impossible if I continue to focus on the guilt I feel.
On the other hand, I feel deeply grateful to work with these patients and families. Their strength and steadfastness are astounding. In addition, this job fills me with immense amounts of perspective. I recall a mother saying to me, “I don’t know how you do this — choose to come to work with these sick kids every day.” I replied, “I don’t know how you do this — show up for your family every day with vulnerability, strength, and support.”? Small arguments at home or my childrens’ typical tantrums seem so manageable when compared to the hardships families I work with endure. This often leads me back to guilt. It has taken me years to focus on the perspective and honor I feel instead of allowing guilt to overcome me. I realize this helps me be a better therapist for the children and families with whom I work.
Countertransference
Another challenge I’ve encountered when working with this population is countertransference. Loss prompts memories of past losses, with each new one potentially amplifying the pain of those that have come before. This has been extremely challenging for me when working with dying children, especially when I think of my own children. I recall working with a family whose child was nearing the end of her life. The parents and family wanted to make new memories by visiting Disney World, Six Flags, Disney on Ice, and birthday parties. I found myself planning with the parents during parent consultations ways to motivate their child to want to attend these events.
The child wanted none of these outings, instead choosing to remain home and stay close to her parents and siblings. In looking back on that episode, embarrassingly, I wondered if the child was exhibiting depressive symptoms. I naively believed that it would be to everyone’s benefit if she did those things with her family. During a subsequent parent consultation, I suddenly realized I was pushing my own agenda. I mentioned this to parents and that this was not what their dying child wanted. In that moment, I realized the potential power and influence of countertransference when working with dying children and their families. Therapy and supervision are key in instances such as that one.
Boundaries and Self-Care
I’ve always valued the importance and recognized the challenges of maintaining boundaries when working with this population. Our mission at Children’s Health is “making life better for children,” and I genuinely strive for this every day. However, I have encountered specific ethical dilemmas necessitating clear boundary setting. These have included coming in on a weekend or evening when a child is not doing well or nearing the end of their life, wanting to buy gifts or necessities for families who are struggling, attending funerals, crying in front of families, or sharing information with others outside of work. While buying gifts and sharing information outside of work lie within strict ethical parameters, attending funerals, coming to work when not scheduled, and crying with families lie more in the ethics shadows. Attending patient funerals is a particularly challenging ethical domain. Many providers simply do not attend funerals, while just as many others do. It has been important for me to determine if harm might befall the family if I attended their child’s funeral.
Showing emotions to family members is also a sticky issue. Many therapists have been told “don’t cry in front of families!” I have openly teared up with several families.
Therapist as Advocate
Over the years, I have discovered the importance of advocacy. If the patient expresses certain wishes, such as knowing details of their medical/health status or having friends nearby, I share these with the family and medical team when appropriate and after discussing this with the child. My role as advocate has also included helping the caregivers understand their child’s desires. As with the example of the client and her family mentioned above, I helped parents see their child’s perspective and, in turn, meet her needs during the end of her life. We were able to focus on the goal of togetherness and provide her with feelings of safety and connection the way she wanted. This was a difficult shift to focus not only on what the family wants but want the child desired. Legacy building through memory making is yet another form of advocacy, which can be built into the (play) therapy.
Postscript
Working with children who are dying has been emotionally strenuous yet deeply gratifying work for me. Staying present in my feelings while being fully present for the child and family has been particularly challenging. Utilizing rituals to remember and honor a child has been a helpful tool. Our hospital hosts a memorial service each year for employees to grieve patients who have died. Others plant a seed or add a bead to a bracelet for each child who passes. I choose to keep mementos given to me by patients and consider how each child impacted my life and changed me as a clinician. Moving forward is one of the hardest challenges for me as both a clinician and person. I have learned the absolute importance of surrounding myself with others who understand my experiences working with this population.
Avoiding the Adverse Impact of Electronic Communication in Couples Therapy
Although it is nearly impossible to break communication habits in the Internet age, I have had numerous therapeutic instances where clients only dig themselves deeper relational holes by attempting to resolve interpersonal issues by texting and messaging their partners. The nuances of tone, emotional body cues, facial expressions, and the imperfections of language that are a normal part of face-to-face interaction, are lost through these digital mediums. The result is often an exacerbation of ongoing communication difficulties. Through my informed voluntary consent at the outset of therapy, I make my position about texting and messaging outside of the therapy hour very clear. Because clients frequently do this, my informed consent includes these statements for reasons that will become clear in the cases below, but also because SMS creates the expectation of an instant response, which I am only prepared to provide in an emergency. I also encourage clients to deal with emotional issues with each other in person, or at least by phone. In this way, the nuances of non-verbal communication and precise language can be more readily perceived, clarified, and addressed.
Case Examples of Electronic Communication Gone Wrong
Brian and Samantha, a couple in their forties who had lived together for two years, presented the problem of frequent arguments over both trivial and deeper issues. These tensions regularly escalated into withdrawal, name-calling, and impulsive criticism, with old resentments resurfacing. I worked with the couple on the basics of communication, problem-solving, and behavior exchange, and explained the role of lingering resentments. They did well with practicing and understanding these issues, but resentments still lingered, and comments flared up.
After six sessions of rocky and frustrating, ungratifying conjoint therapy, I received copies of text exchanges between them. They each sent me the copies they received without their partner’s knowledge in hopes of proving to me the other’s abusiveness — ignoring my informed consent provision. In one thread, Brian apologized for commenting at dinner that a glass was dirty, saying that he was merely making an observation, not a criticism. Samantha replied, “If you don’t appreciate all I do for you, when you never do anything around the house, you can do it all yourself!” Brian then attempted to clarify his intent, to no avail.
I replied to Brian by text, indicating that my informed consent stated that I do not use the internet for emotional content such as this, and we could discuss it further in our next conjoint session. In their next “post-text debacle” session, Brian did not bring it up out of embarrassment. They continued for six sessions, working on the resentments that surfaced and terminated with improved overall skills; I never found out whether they were able to resolve past resentments.
In another case, I worked with a disgruntled individual client, Belinda, who was in a severely dysfunctional marriage with her wife, Lucy. Her goal was to obtain recommendations for dealing with the anger she felt for several reasons. I explored them cognitively and emotionally, having her align her values with her behaviors. Belinda sent me pages of exchanges going back eight years in which Lucy had historically berated her for everything she resented. Seemingly, Belinda wanted me to agree that she had indeed been emotionally abused.
When Belinda directly expressed outrage at home, Lucy said she “didn’t really mean all that,” to which Belinda told her she could not take it back and they should consider divorcing. In the next session, we explored her situation, and I told her that moving forward, I could not take an additional hour to go over all the comments her wife made in those electronic exchanges but could instead help her to consider some resolution of the contempt and disconnect she felt. I advised that they see a couple therapist, either myself for a 1-2 session consultation, or another therapist. She seemed to have a better understanding of her resentment and how to control it.
***
In looking back on these two cases, I understand the widespread use of texting and messaging in today’s electronic world. Although I discourage clients from using it to discuss emotional issues, I cannot prevent them from doing it, either interpersonally or with me. I believe it’s important for therapists to set an example — and boundaries — by not using electronic media for intimate communication.Coming Full Circle: Helping a Young Couple Through Their Grief
A Matter of Death in Life
After seeing my last patient out, the sun in the back-office windows faded into twilight, darkly illuminating the autumn leaves. I began to feel weekend-ish, looking forward to a long, relaxed walk with Charley in the park, and the single gin and tonic with two limes, which I allowed myself on Friday evenings. As I put the day’s session notes on the desk, I saw the light blinking on the answering machine. One of my grad school colleagues and friend, Ben, sounded mildly upset.
“Hey Liz, I don’t know if you could see someone over the weekend, but a friend of mine just lost a baby to what they think is SIDS. They have a three-year-old son. They’re in shock and want to talk to someone about how to handle it with the kid. I thought of you immediately. It’s kind of urgent. Call me back.”
I sat quietly, letting this request wash over me. Was this a little too close to home, me aged 3 with the dead brother? But this felt urgent to me, as it was my story. Then with certainty and a whole-body-resolve, I thought, I could be of help. I dialed my colleague back.
“Liz? Hey, thanks for calling back.”
“Sure. Give me some details.”
“Upper-middle-class family. Lives on the west side. Dad seriously Type A. Mom too, but she has an arty vibe. The dad, Mark, left early for work this morning and when mom got up later, she thought it was strange her one-year-old daughter Bonny hadn’t woken her up. Claire, the mom, found the baby blue and not breathing in the crib and called 911. Claire tried not to panic, because Angus, the three-year-old, was up. Angus saw the cops and the medics and watched as the baby was taken out of the apartment. I think Claire was really freaking out too. Mark called me — he is a friend of my brother’s — after the baby was pronounced dead at the hospital. He is worried about his wife and his son.”
“I can see them tomorrow morning before yoga. Nine?”
“Sure.”
“Did the father describe the three-year-old’s reaction at all?”
“I think he is usually pretty rambunctious but after it all went down, apparently the kid has refused to talk and is very subdued.”
“Got it. Why don’t you just call them back with the time and give them my name, the office address, and my cell number in case by morning they change their minds. I assume they can afford a full fee?”
“Definitely,” Ben responded. “Great, I knew you were the person for this.”
“Thanks.” I hesitated and then said, “I think I am too.”
Ben was a good guy. We had bonded over leukemia; Ben got sick with it in adolescence and had been able to tell me about that experience. This helped me to know what it may have been like for my brother. Sometimes the universe is a sticky web. We get stuck in with those we need to know.
As I hung up, I realized I was somewhat daunted by the intensity of this referral, but felt it was necessary I take it on. What will I learn by touching the rawest parental grief over a lost child? Would I learn something about what my parents really went through when Jim died, or what I went through then too?
The weekend feeling vanished, but I was still up to mixing my gin and tonic.
The next morning, I knew I needed to be centered and calm. Before my shower, I breathed in the roses on the terrace and then gave Charley’s belly some extra rubbing. As Charley and I walked to the office, I kept my awareness on what I could take in through my senses: the silver-grey concrete, the smell of traffic, the feeling of my foot hitting the pavement, and the cool morning air. I would have to steady my own feelings, so my own ancient grief did not disrupt what the family needed to bring to me. I had been known to get tears in my eyes when my patients were in pain.
At the office, Charley snoozed under my desk, and I settled into my buttery soft leather shrink chair. I kept working to find the right emotional space to work from — calm, steady, receptive. I didn’t get to stay put long when the outer doorbell rang. Game on.
A Sense of Helpless Defeat
I tried to softly smile as I greeted them. “Hi, I’m Liz Tingley. Please do come in.”
The father shoved out his hand and said, “Mark McNitt. This is my wife, Claire Holm.” They were in their late twenties, both tall, the woman quite thin. She was blond and the man’s hair had a reddish tint. They wore jeans, he with a jacket and button-down shirt. She had on a light-colored linen sweater, her long blond hair held back from her face in a ponytail. Their expressions were somber. Neither looked like they had slept.
I studied her face, pressed lips, red, swollen dull eyes. This plummeted me back to my own mother’s dark hole eyes the morning after my brother died, the look that made me back away so as to not get sucked all the way into her blackness. I felt a muscle in my neck tighten.
Stay in the present, Lizzie.
“Please come in,” I repeated, gesturing toward the adult patient chairs on one side of the room. Mark took his wife by the hand, almost depositing her in the first seat.
Type A alright, but protective too. She needs that now. That memory of my father pulling my mother to him, as we left the hospital where they learned Jim would die, reverberated in my head.
“Ben only told me a bit of what’s happened to you,” I said as I sat back. I made eye contact with each of them slowly, lingering a bit with Claire, her eyes tearing as she met my gaze. “Just tell me where you are.”
Mark reached over to hold Claire’s hand. He spoke first. “In shock, really.” Claire nodded.
“Yes. And it will take a while for that to wear off,” I said softly and paused. “Do you want to tell me about it?”
Claire nodded. “It was a usual morning, except that we had been out late to friends for dinner with both kids the night before. We put the two of them down for bed about an hour or so later than usual. So, in the morning, when I didn’t hear Bonny stirring, I didn’t think anything of it.” She broke down, sobbing. Mark put his arm around her.
She must be feeling guilty, like if she had checked right away, the child might have lived.
“You had no reason to think it wasn’t normal for her to sleep in a little.”
Claire nodded as she sobbed. She pulled herself together. “Angus was playing in his room. I could hear him. So, I put the coffee on first and then went into Bonny’s room. She was lying on her side, with her head in an odd position. When I touched her, I knew something was wrong. She was blue. I screamed, grabbed her up, and called 911. They had me try to clear her airway and do mouth to mouth. When the paramedics got there, they took over. They took her away and I called Mark to meet them at the ER.” She looked down, her voice tapering off to a whisper and then she stopped.
Mark finished the story. “She was already dead,” he said. “The EMTs told me that at the hospital.” In a monotone, he continued, “They let me see her.” He teared up too but bravely went on. “They told me it was an unexplained death and they had to investigate. They called the Agency for Children’s Services and the cops. They’ve kind of been at the house since.”
Claire continued, “They said it’s a ‘SIDS-like’ death, but she was too old for SIDS.” She was trying to hold onto her tears but couldn’t. “She was nearly a month premature, but she had caught up at her one-year check-up. She seemed so healthy.”
“Yeah,” I said, trying to match my tone to hers, this inexplicable crazy fact of her dead baby.
“And Angus,” Claire again began to cry, with a panicked tone.
“That is why we are here, Dr. Tingley, to figure out what to do for him.” Mark sat up straight in his chair, ready for instructions.
Inwardly I groaned. They couldn’t fix this for their son, or for themselves any time soon, and I could see that at least Mark wanted a solution now. They were going to have to live in grief with him and themselves for a long while.
“Yes, let’s do talk about Angus. But let’s not go too fast to him. Before I can share what might help you with him, I want to know more about how you are experiencing today and yesterday. What has this been like for you?”
Claire sat back in her chair, with an air of defeat. “Devastated. And I feel a cascade of things. Exhaustion.”
That’s it, the sense of helpless defeat when you can’t protect your child. Though no one’s fault, it feels like a parental failure. I decided this was not the moment to elaborate this. What agency they had left they needed to carry them through the next few days.
Mark too leaned back in his chair, looked at his wife, and then made piercing eye contact with me. I held his gaze, to reflect the pain I saw on his face. Mark added slowly, “I didn’t know something could feel this bad.”
“Those feelings for you aren’t going away for a long time. And there is a lot to get through,” I replied.
“I know they just have to do their job, but I feel like both the cops and the social workers are very suspicious of us,” Claire reported.
I nodded.
Mark jumped in. “We know we didn’t do anything to cause this. The autopsy will show that. They just have to follow up.” Claire hung her head.
“You want to know how I am?” Mark continued, his tone now angry. “I am so mad. Not at the cops, but this is so unfair. Cosmically unjust. And Angus is suffering.”
Ah, he is trying to protect his son, because he “failed” to protect his daughter.
“It is,” I said with emphasis, “Completely unfair.”
Mark met my eyes again and a tiny sliver of real connection seemed present, but he was rushing to solve the problem at hand, his son’s trauma from this abrupt death of his sister. “So, what can we do to help Angus?”
I decided to work with his wish for some answers. “What has been his reaction so far?”
Claire grimaced. “I’m not sure what he was doing when I found her, and I was screaming and trying to breathe life into her. He came out into the living room when the EMTs arrived. He looked spooked. And my son is usually a little bit of a tough kid.” Here she smiled just a bit.
Mark added, “He is usually a little bit oblivious and is very active, in his own world.”
Claire went on, “After they took Bonny away, he started to cry and asked where she was going. I feel like I came to my senses then and told him she was sick and going in the ambulance to the hospital and that Daddy would meet her there. He seemed to take that in. I said Sandy, his babysitter, was coming while I went to the hospital too. He asked me to stay with him but then I left him with Sandy. She was reading to him when I went out. We didn’t know what to say when we came back, with Bonny dead.” Claire started to sob uncontrollably.
I sat, looking at them both, trying to generate warmth, allowing her strong affect to flow and for me to receive it. Mark went over to hold Claire, his eyes wet too. Finally, Claire’s sobs receded, and she sat up, grabbed a tissue from the table next to her.
“How does it feel to let it out?” I asked.
She smiled faintly. “It’s not like regular crying. It doesn’t get any better if you let it out or hold it in.”
“Yes, the grief is intense, and it won’t go away altogether, ever. It may, with time, be less intense.”
She nodded, then continued her description of Angus’s reaction to the chaos. “When we got back, Angus was not himself. He clearly knew that something was terribly wrong. He won’t talk now, not a word. And he is not his usual bundle of energy. He kind of just sits there.” Claire paused. “What should we say?”
“It’s hard to know how to explain this to him when you can’t explain it to yourselves,” I replied. Both parents looked so utterly sad, helpless, and young. “I don’t know what you should say exactly, but we can think about it together. It has to be honest. You have to say that she is dead, that her heart and brain stopped working, and that she is never coming back. Do you have any religious views that you want to give him about death?”
They glanced at each other and then said, “No, not really,” simultaneously. That was a good sign; they were attuned to each other. That could go a long way to help them get through this.
“Has he ever stopped talking before?” I asked.
Mark shook his head. “He did have some pronunciation problems and he’s had some speech therapy but no, he’s never stopped talking before. Though he is an action kind of kid usually.”
“How old is he exactly?”
“Three and a half.”
That gave me an idea of how he thought. Concretely. And with probably slightly underdeveloped narrative skills given what else they were saying about his language. It might be hard for him to participate in creating a coherent story about this.
“Okay. Basically, what I said before goes to the main point, to let him know that Bonny is dead.” I watched to see how they would react to this clear statement of the reality. Mark minimally flinched but I went on. “Angus will not understand death at his age. I always recommend the book The Dead Bird by the lady who wrote Goodnight Moon. It is simple and direct. You can read it to him over and over if he wants, to help him understand.”
Mark took out his phone and made a note of the book. “I will order it when we leave.”
I continued, “And even though you tell him once that Bonny is dead, he will likely need to hear it more than once, because he will understand it differently than you think he does. I mean, cartoons make sense to kids; when the guy gets run over and then he pops back up. Permanence doesn’t mean the same thing to preschoolers as it does to us.”
Both parents nodded.
“Don’t force him to talk but keep talking to him. Empathize with his state of shock. Label his feelings, including confusion. Children often regress under stress. His language sounds a little vulnerable. It’s not surprising that he might lose that. He might regress in other ways too, toileting for instance, or not being able to sleep alone.”
Mark almost chuckled. “Claire had him in our bed last night, and he had been in his own room for more than a year.”
“I had to be sure he would make it through the night, Mark,” Claire said, distressed.
“I understand completely,” I replied. “And it was wise. He needs your physical presence more than anything, and to the extent that you can, your emotional presence as well. Children are most reassured by their parents. You need to help him feel safe. Mark, can you be okay with that for now?”
“Of course. Claire, I didn’t mean…” She nodded at him.
Different Ways of Grieving
“One part of this, as you try to manage what Angus needs, is to allow each other to need things that might be different. There is a lot of research suggesting men and women often grieve differently.”
Claire asked, “What do you mean?”
“Let me ask Mark. When are you going back to work?”
“Oh, I’ll want to get back in a couple of days. I can’t imagine sitting around like this for very long.” Claire looked horrified.
“That is what I mean. To feel useful and in the routine can often feel like healing to men. Often, women find they just need more time together. And that conflict can be misunderstood by both. I wonder, Mark, if you really will want to get back to work so soon, and if you will be able to meet your need to do that and balance what Claire and Angus might need.”
Mark looked at his wife. “We can talk about it, of course.” She smiled for the first time.
“When we have the funeral, should Angus be there?” Claire asked.
“Yes, unless there is some compelling reason elsewise. But you need a back-up plan, in case he is disruptive or very upset, or you feel you can’t grieve as you need to with him there. Someone who could take him out and could bring him back. It has to be someone he knows and trusts. Though he won’t understand all the nuances, he will be a part of saying good-bye to his sister, with you and family and friends. That’s what matters,” I said.
I could have cried right then. I had succeeded in pushing my past out during most of the session, but something felt very big, pressing down inside of me, my own emotional exhaustion at trying to hold them and me at the same time. They were hurting and it hurt to see that, to feel the hurt with them, as I suggested what they do for Angus. Why couldn’t someone have said these things to my parents? Why? But I had to push that question away for the moment. I still had work to do.
“This is, not to sound clichéd, a process,” I continued. “It is going to take time. The goal with Angus is to help him have a story to tell himself about this time and about his lost sister, a story that will become part of his life story, that helps him feel that it is coherent and hangs together. To do that, you are also going to have to be willing to be with him over time and to talk about your own sadness and grief and confusion — of course in a modulated way when you can — so that he feels you all together.”
Mark let out a big sigh. “That fits with so much of my gut instinct, but already I can see that Claire’s mother wants to take him out to her house in Westchester, so we have time to cope and make arrangements. But I want him with us. Don’t you Claire?”
“I’m not letting him out of my sight for more than five minutes,” she answered forcefully.
“Is he close to his grandmother?” I asked.
“Well, yes and no. She travels a lot, but when she is around, she is super fun with him.”
Grandparent as playmate. Not what this kid needs right now.
“Some of that will be fine, but more as time goes on. You will deserve breaks sometimes, but now he needs you. As best you can, give him that,” I said softly. Both were quiet for a moment, and I saw Mark disconnect and return to some state of shock.
“I think this is enough for now,” Mark said. “You have given us the start, a preliminary road map. Claire?”
Claire nodded, tearing up slightly, and said, “Thank you Dr. Tingley. I feel like I have some better ideas about helping Angus.”
“I’m glad it feels helpful. It’s going to be a tough row to hoe, but I think you have what it takes to get it done. And remember, like always with parenting, taking care of yourselves is also a way to take care of Angus.” I made full-on eye contact, first with Claire and then Mark. “And remember I am here. Call if you need more.”
Claire bowed her head at me as they stood. Mark shook my hand.
When I returned to my chair, I let the tension of holding myself together through the session evaporate. Silently, I still felt all the same terror, confusion, sadness, helplessness, and anger as Mark and Claire, but I knew I had done decent work with them. I also thought, as Ben had said, that I was the perfect person for this — on many levels. It wasn’t just my 40-plus years in the field, working in childcare with toddlers, where I lived with children’s everyday tears and frustrations, or the career in academic developmental psychology where I learned the research that supported work with young children, or even my time as clinical psychologist, where I found a theoretical frame and the tools to connect with and manage pain and growth. It was all of that combined with my own experience of early loss, that brought me here to be able to do this job, this day. That felt satisfying.
There was another feeling, too. Gratitude. These two grieving people had come to me, trusted me, taken in my empathy and knowledge. I was honored they had let me in at such a time in their lives.
A circle was complete. My career began because I wanted people to take the emotional experience of young children seriously, as my parents had not. I had just done exactly this for Angus. This small child, whom I’d never even meet, allowed me to finish what I started, unconsciously, so very long ago, saving myself, and all the children I had touched in my career, from the denial of their young children’s grief and pain and the aftermath.
A quite different sensation took hold: I am done. I will not be compelled to do this work anymore. My mission is complete. I could work, but I didn’t have to, the compulsion gone. I slumped down, exhausted, and exhilarated. Was there time to get to yoga?
Postscript: I did not see the family again but heard from my colleague that they had relocated to Vermont and had another child. I also did not give up the practice of psychotherapy but now see many more adolescents and adults in my practice.
Using Play Therapy (and Movies) to Heal Attachment Wounds in a Young Child
A Troubled and Troubling History
Peter was four. He had just started Head Start programing when his mother announced she was pregnant. It seemed almost immediately after that Peter became non-compliant with any authority. He experienced a disturbance in sleep and appetite, withdrew socially, refused to wear a seatbelt in the car, and misbehaved in public until his mother had to bring him home. Peter hit, bit, threw things, broke toys, and screamed to get his way, and developed an excessive need to be in control.
More alarmingly, Peter engaged in harmful behaviors, riding his bike across the street in front of traffic, running over a two-year-old with his bicycle, putting a pillow over his mother’s head telling her to die, and deliberately putting toys on the floor to make his grandmother fall.
Peter’s mother reported that at eight months of age, he had rolled out of the bed, resulting in an ER visit and a report of suspected child abuse. During that ER visit, Peter’s grandmother was asked to help restrain him while they took X-rays, which revealed a broken knee cap. DCFS took custody of Peter and charged the mother with neglect. He spent two days in the hospital and one night in a foster home before being returned to his mother.
I concluded that Peter’s school referral and his mother’s pregnancy had triggered the medical trauma, separation, and attachment issues that were contributing to his behavioral and emotional difficulties. In that assessment, I identified several issues for treatment, including (1) intense fear and anger at separation from attachment figures, (2) inconsistency in setting limits/boundaries and consequences for misbehavior, and (3) the use of behavior, rather than words to express himself. At the time of developing Peter’s treatment plan, I noted that his favorite act of defiance was to run outside in his birthday suit (naked). Our first task in behavior management was to have him put on his underwear before his appointment began!
Growth and Understanding through Play
Peter’s mother and grandmother were nurturing and invested in his growth and development, as well as my support team during our home play therapy visits. Books, toys, and movies were abundant in the home. Working with children, I had come to understand that they find comfort and a sense of security in the predictability in movies. Peter was no exception and movies were frequently playing when I arrived.Using a client centered approach that incorporated themes from movies his parents had allowed him to watch like, Honey I Shrunk the Kids, Titanic, and Jaws, Peter was able to process his experience and communicate very aptly the chaos he felt both internally and externally. He would play these movies, or parts of the movie during appointments, while he built his creations, including his parents and myself with his toys, and then act out the scenes. I saw the parallels between the movies and his life experiences.
He built an elaborate shrinking machine in the living room which, I believe, reflected his feelings of being totally overwhelmed with his world and the multiple changes he was experiencing. As he adjusted to school and the birth of his sister, his shrinking machine became smaller and disappeared.
Titanic reflected the family’s chaos during the time his mother worked away from home, which took her away for extended periods, and other times resulting in her return home after Peter was in bed. The grandmother was left to assume all parenting and childcare responsibilities. Peter would rewind and replay the moment the ship would break in half and sink into the ocean in a perfect parallel to the absence of his mother. He wore out the tape! His mother quit the job.
The presence of Peter’s grandmother in his classroom as an aide helped to heal the attachment wounds that had occurred during his early infancy. She took him to school, remained in the classroom and brought him home. As Peter adjusted to the structure and routine of school and gained confidence in the return home, he became challenged by the learning process and his desire to learn took precedence over his misbehavior. Both parental figures read to him and the social stories of The Bernstein Bears, and his ability to understand and apply what he heard helped him adjust to new and changing social situations.
Peter became able to verbally express his dislike for his sister but never intentionally attempted to hurt her. He would simply pick her up and move her, even when she would unintentionally destroy one of his play creations. One of my repetitive phrases during appointments was “Use your words!” Feelings of resentment disappeared when he was able to use his words and tell his mother and grandmother he did not like his sister because she was messing up his creations. They in turn made more conscious efforts to keep her away from his projects, and to listen when he used his words.
In his play around the themes from the movie, Jaws, Peter was the captain of an imaginary boat in shark infested waters. He brought all the people and things important to him into the boat, his mother, grandmother, sister, and me to protect us. He acted out the shark attack addressing his fears about his safety and nurturing needs. He would replay this scene many times. As the boat became bigger and bigger, the shark infested waters grew smaller and ultimately disappeared. So did his disruptive and aggressive behavior.
***
Peter was phased out of treatment. His mother and grandmother were learning that withholding his movies could quickly bring misbehavior under control, while their nurturance, consistency, and attention to his safety and security needs helped to strengthen and support his positive and social behaviors. Peter was able to play with new friends and enjoy all of the experiences of school.How a Missed Therapy Session and Self-Disclosure Led to Therapeutic Gains
Placing Therapist Needs First
They have always been uneasy feelings for me, ones that I’ve experienced over the years, mostly leading up to the major holiday break. Rarely, if ever, did they arise when I was a beginning therapist. I must admit now, that after having been a clinician for more than two decades, I find myself really looking forward to time to myself and engagement with family and friends over the holiday period — more than seeing patients. I also look forward in some instances to not seeing particular patients. Let me be clear though, that these feelings or desires are in no way a reflection on how I feel generally about working therapeutically or with my patients in general.
These feelings, I should add, typically arise in anticipation of a holiday break, and very rarely during the “normal” working periods during the year. In spite of my rationalizations, I still feel a measure of shame in making this admission. However, I believe that it is better to acknowledge my feelings and have the freedom to explore them without undue censure. I believe that this minimizes the chances of acting them out, although it is hardly a guarantee. My historic silence around this issue probably reflects an internalized taboo against choosing personal time over professional time, especially when clients’ wellbeing lies in the balance. I have chosen to break this silence here in hopes that doing so will benefit colleagues who struggle in similar ways.
I’ve learned that the cost to the client for repressing these feelings is enactment, in the form of forgetting appointments, double booking patients, or last-minute cancellations. While other periods leading up to non-major holidays may also be potential triggers for me, the end of the year is a seemingly more potent stimulus for these specific types of clinical acting out.
Case Illustration
I practice out of a large shopping centre, a setting that offers a combination of a relaxed atmosphere and buzzing intensity — a truly curious blend for me. Having a cup of coffee in the morning before seeing a patient is one of my favourite activities, part of my commitment to caring for myself in a rather small way. This particular day, I was especially excited in anticipation of treating myself to a Jamaican blended dark roast latte with foam. Its exquisite taste and heady aroma came hurtling to the forefront of my consciousness well before I arrived at my local coffee shop, assaulting my senses with feelings of anticipation.
I was nearly a week away from my upcoming year-end holiday and was looking forward to the well-deserved break. I was scheduled to see my first patient at nine o’clock — I refuse to do any earlier sessions because, in essence, I am not much of a morning person. Since I seemed to have plenty of time, “seemed” being the key word, I decided to indulge myself further, choosing to take my latte as a sit down in the coffee shop instead of the usual take-away. I sat at a table and settled in, motioned to the waiter, who took my order rather cheerfully as I made a brief nod to the barista, someone who I had become fast friends with over the past few months.
I made a mental note to stop and check in with him on the way out. He knew exactly how I liked my latte, so I felt I was in good hands. As I sat alone, sipping my delicious “nectar,” my thoughts drifted to the upcoming break. Spending long days at the beach whilst being unencumbered by work sounded heavenly at this point. As I was enjoying this moment of pure self-indulgence, I couldn’t help but reflect on a vague, yet growing recent feeling of not wanting to see patients. And those feelings did not reflect on my work with any particular one. The thoughts revolved around secretly hoping that patients wouldn’t arrive for their sessions (which indeed some did not). I hated the feeling even though I experienced it only dimly at times during this period. I tried to chase it from my mind so that I could continue with my sensory immersion of the moment. But it continued to nag at me.
The Rupture
Suddenly my attention was drawn to the time. It was 9:10 and I realized that my patient had been waiting for a full ten minutes for me. Panic ensued as I tried to unlock my phone. I had a missed call at 9:05 from the patient. I had “accidently” left the phone on vibrate and therefore didn’t hear it ring or pulsate. A rare lapse for me, but a lapse no less. I hastily returned the call hoping that the patient was still in my office, only to discover that they had gone. I detected no hint of anger in her voice, but I was not convinced when she said that I could talk tomorrow about setting up another session.
I apologized, but she rapidly talked me off the phone saying she had to go. I was dismayed, a sinking feeling of guilt and shame wrapped itself around me like a cloak, which I felt everyone could see. I hurriedly raced from the coffee shop in utter shame, upwards towards my rooms. Once there, I tried with profound difficulty to wipe from my mind the feelings of shame and guilt whilst I prepared for my next patient. But Jane drifted into my mind, and it became clear that as hard as I tried, it would not be so easy to forget what had happened. Jane had been a perfect patient in many ways, almost always on time, rarely cancelling a session, and paying on time for her sessions without any reminders. In many ways, she was one of my favourite patients (yes therapists do seem to have favourites, I’m afraid!).
Jane
Jane’s history made my infraction feel all the weightier. Jane and I had worked well together, after all, she took risks in her sessions and tried to be as open as possible. The one element that struck me was her reserve around expressing any criticism of me. Jane had grown up in a household where her parents seemed to discourage any form of criticism towards them. By all accounts, there was little to criticise in terms of their behaviour, but no parent is perfect, and when Jane tried to offer them any negative feedback on behaviour which she found less than desirable, she was immediately made to feel exceptionally guilty for doing so with words such as, “Was our behaviour towards you really so deserving of so much anger?”
After leaving her parents’ home, Jane had remained in an unsatisfactory marriage out of fear of hurting her husband if she expressed dissatisfaction with his frequent, less-than-pleasant behaviour. When she did eventually muster the courage to complain, he reacted predictably; in a manner which she experienced as defensive and counter-critical. The marriage ended during our therapy, after many sessions spent examining in detail why she remained. I listened patiently and attentively, intervening in as neutral a manner as I could tolerate. I am almost certain that some of my disapproval of her staying in the marriage must have leaked out.
About a week following the “incident” of running late, I left a voice message for Jane saying again that I was sorry for the error, and wondered when she would like to come in again. I offered her a free session as I had wasted her time by not being there for her. I knew deep down that the offer of a free session was meant in part to assuage my own sense of guilt and shame over missing the session, although I hoped it might go some way in making amends for my “transgression.” Another two weeks passed without any word from Jane, and I resigned myself to never hearing from her again. To my surprise, she called up one day almost four weeks after the missed session and apologised. She had gotten my messages but had become very busy with a work project and therefore hadn’t had the time to call me. She asked if I could schedule a next session, which I promptly affirmed for the following week at her usual time.
A Therapeutic Moment of Truth
Prior to that next session with Jane, I thought deeply about how I wanted to address the issue of missing her session. While I typically follow the dictum that the patient is responsible for initiating the session, I felt that this was one of the rare instances where I would take the lead. It was an opportunity for me to understand what my error had meant to Jane, to assist her in exploring any thoughts and feelings she had towards me for having committed this error and giving her an opportunity to decide whether she would like to continue seeing me. A hint of reservation regarding this pre-planned intervention did waft through my mind just before seeing Jane, but I ignored it completed (perhaps therapeutic instinct should not be so easily dismissed by us) and decided to proceed regardless. As soon as Jane entered the room, and even before I could speak, she immediately began speaking about her difficulties.
I decided to interrupt her, thinking that the error I committed was plaguing her as it was me. In retrospect, that was just a tad narcissistic of me. I began, “I know I missed our session three weeks ago and I noticed you didn’t bring that up. I realize that you’re having challenges at work currently and that the work issue is at the forefront of your mind, but please indulge me for a moment. We can certainly return to your workplace concerns before the end of the session.” “What are your feelings towards me for missing your session?” A long silence ensued from Jane which was not her typical manner of responding to me. Something was wrong. “Jane, I am aware that you have been quiet for some time after I asked you for your feelings towards me for not arriving for your session.” Again, Jane looked away and continued in her silences. Finally, she said, “There’s no feelings, I am sure it was an honest mistake. You’re making a mountain out of a mole hill.”
Usually, I would let it go at this point, but not that day. I pressed ahead. Perhaps Jane was again refusing to complain, reprising both her marital and childhood roles. Was she passing up an opportunity to do important work? I persisted, “But Jane, I noticed that you didn’t respond to my initial communications with you and even today there appears to be something off in your manner of speaking to me. This isn’t the Jane I know.” I continued, “Please try to look inside for a moment, Jane, and tell me what’s happening between us right now.”
Jane hesitated momentarily but then as if in a fit of fury, the likes of which I had never seen from her before, she spat out, “You could have at least simply apologized to me face to face instead of trying to analyse my feelings!” I was shocked, Jane had never spoken to me so directly and with such anger. I took a second or two for me to gather myself as she pierced me with her gaze. I retorted, “Jane, you’re absolutely right. I haven’t offered much of an apology to you in the flesh. Thank you for me telling me that now. Indeed, my focus on your feelings must have come across as self-serving. I can see that now. I am deeply sorry for having missed our session and I do regret my error; please can you say more about it?”
To my amazement, Jane immediately settled down, looked me straight in the eye and said, “I thought you missed our session because you forgot about me, perhaps I wasn’t as important to you as I thought I was.” I knew that this had something to do with Jane’s early history, after all, she had little experience of being taken seriously if she complained. But I choose instead to focus on the here-and-now between us.
I was not about to waste this golden opportunity to self-disclose, repair the rupture, and help Jane, all at the same time. I replied, “Jane you’re misreading the situation. The fact that I missed our session has nothing to do with you, in fact, it has something to do with me.” I paused and noticed that Jane was now concentrating intently on my words. I continued, “In fact, it had everything to do with me. I missed the session because I was caught up in my own imagination and enjoying some personal time just prior to our session, which caused me to lose track of the time. You see, I was distracted with rather pleasurable thoughts of my upcoming holiday break, and this was the reason for me losing track of the time. In fact, I always look forward to our sessions, however at that point in the year I am susceptible to thinking about my break.”
I anticipated a wave of criticism from Jane, clearly a moment of countertransference, but the opposite occurred. For the first time in our work together, Jane shared her feelings of not being good enough and her feelings of competitiveness with my other patients. In truth, I had no real way of knowing exactly how my self-disclosure would impact Jane, but if I expect honesty and self-revelation from my patients, then I too must take a calculated risk in sessions as much as I expect them too.
***
I’ve learned that self-disclosure does not always facilitate the therapeutic process. It remains a high-risk/high-gain intervention. I may have succeeded in this instance, as I banked on my clinical judgement that my disclosure would be more effective than merely exploring her fantasies about whether she was important to me or not. My disclosure provided concrete evidence to Jane that she was indeed likeable, and while we did work on her need for approval in future sessions, this disclosure on my part led to her feeling more confident in asserting herself both inside and outside sessions and in taking such incidents less personally.
Questions for Reflection and Discussion
What are your thoughts and feelings about the therapist’s experience following the missed session?
How do you balance the demands of clinical practice and your personal life?
How might you have conducted that follow-up session with Jane?
How do you know when you’ve reached your limit on seeing patients and how do you address that clinically and personally?
How to Use Narrative Therapy to Help Clients Locate Alternate Stories
As a practicing psychotherapist, I hear a lot of stories. These stories are, without fail, complex, nuanced, and multidimensional. But, often, clients come to therapy with a singular focus on only one element of their larger story. In narrative therapy, the term is “problem-saturated” story. Part of my work as a therapist is to guide clients to widen their lens beyond this problem story and recognize that many of their stories are actually a story within a story (within a story). The act of locating these missing story parts and creating an alternate narrative is a way to alter the problem-saturated story and to clear the way for a new, more accurate, and helpful story to emerge. I enjoy little more than when a therapeutic opportunity presents itself — it feels like a gift. So, when John, a 76-year-old gay man, shared his story with me, it came with a giant bow on it: here was a perfect opportunity for a narrative therapy approach. John’s story began like this. It felt as if he had spent his entire life being “sneaky,” and feeling remorseful for what he described as his “untrustworthy ways.” As he began to share his life story, however, a very different story presented itself.