Do Clients Really Read Session Notes? The Truth Might Surprise You

Posted on by Psychotherapy.net Team

“I’m old school, my job is to focus on what my client brings to me,” said my friend and colleague Joan, a social worker of over 35 years.

Having worked for decades in the public school system with some of the most challenging clients, many of whom were entangled in the state’s labyrinthine bureaucracy, Joan was familiar with the multiple levels and layers of accountability, and the importance of writing notes and sharing records. She also knew that there would always be eyes watching — eyes without faces, and faces without names, all looking to make sure that her T’s were crossed and her I's dotted.

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Joan also appreciated the necessity of assigning an accurate diagnosis, and that doing so in a clinically and ethically correct manner meant taking time to get to know the client, their personal challenges, and their system of support. But Joan had also always believed that “my notes have never been problem-oriented,” and that “I want my notes to be about more than a diagnosis; something that actually helps my client.” Joan made it her policy to not be the one to initiate conversations with her clients about diagnostic impressions or diagnoses, current or past. For her, a diagnostic note was a clinical tool, much like mental status data, clinical impressions, or assessment results — and not within her clinical province to “bring up.” Doing so, she believed, would invariably shift the focus from what the client needed to what she needed to do as part of her job.

Discussing Diagnoses and Clinical Notes with Clients

So, it came as a resounding shock to Joan — now a teletherapist — when, at the start of their second online session together, her client proclaimed, “I read the document about my diagnosis of ‘adjustment disorder with mixed emotional features’ and it was right on!” Joan recalled thinking, “what the hell?!” She vaguely recalled the contract she signed with the teletherapy company specifying that clients could review their notes at any time. But after reviewing the contract following the revelation by her client, she could not find anything that specified the mechanism through which clients were alerted to the location of their notes on the platform, or whether they received some kind of alert when a new note was uploaded by the therapist, or if the actual diagnosis was available to them. She added, “Had I known that the company was sending an alert of some sort, especially about the notes from the initial session with the diagnosis I was mandated to provide for insurance purposes, I would have introduced and explained the process and my diagnosis with the client.” It was soon after that Joan wondered if her previous one-session-only clients never made it back for a second visit because they received her notes from that first meeting with a diagnosis or diagnostic impression that didn’t sit well with them.

It’s not that Joan was worried about how her notes — which were written in SOAP form — or even her diagnostic impression would be received, but that for those clients who read their notes and never addressed them in session, her observations and diagnosis would be the elephant in the room, and perhaps her responsibility to address if the client did not.

For Joan, it was always important that her clients “have someone who likes them, someone who finds them interesting, someone who can look beyond a diagnosis, someone who is willing to see their daily struggles and who could see them as a human being either caught in a moment of distress or battling demons that left them feeling ‘less than, unlikeable, unliked.’” She was concerned that by turning the conversation to one of diagnosis and notes that she would “no longer be talking with them, but about them.”

Toward the end of our conversation, I asked Joan how this scenario might impact her work with clients moving forward, particularly around discussions around notes and diagnoses. She reiterated that, “I am old school…I simply don’t want, nor do I feel it is important to ‘bring it up’ with clients.” But she added that she would give it some thought.

***

Joan later recalled a client with whom she worked for only one session and gave a diagnosis that included anxiety and depression. That client, through some mechanism unknown to her, then saw a psychiatrist who worked for the same teletherapy company as Joan did. She found out that the client had been subsequently diagnosed her with borderline personality disorder and prescribed medication after one visit.

Joan promised me that she would share her impressions of that scenario in a later conversation.

What I Know Now About the Clients Risks and Rewards of Reporting Sexual Assault

Posted on by Psychotherapy.net Team

E. Jean Carroll stood on the courthouse steps to give her statement to the press following the jury's findings that former President Trump was liable for sexual abuse and defamation. She said, “This victory is not just for me, but for every woman who has suffered because she wasn't believed.”

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Within the hour, my phone buzzed notification after notification across my email and social platforms. People sent me screenshots of the headlines, celebratory emojis, and gifs. I've worked professionally in sexual assault victim advocacy in some capacity since 2010, first as an advocate and then as a psychotherapist.

Whenever a case like this happens, I become very popular for a few days. Being the go-to person for all things sexual assault in your social circles is, in a word, odd. It's amazing that anyone invites me to cocktail parties anymore. It's also amazing how many people will share their stories, bravely and candidly, when they have reason to think you'll believe them.

Why Sexual Assault Victims are Coming Forward Now

Amid the collection of celebratory emoticons, however, were a handful of skeptics using words like “convenient,” “opportunistic,” and “sketchy." They asked questions like, “Why now?”

In E. Jean Carroll's case, at least part of the answer to the question "Why now?" is that it was finally possible. In May 2022, the Governor of New York, Kathy Hochul, signed the Adult Survivors Act (S.66A/A.648A). The law went into effect in November of 2022, creating a one-year retrospective window for sexual assault survivors who were over the age of 18 at the time of their assaults the opportunity to come forward. A similar law for children was passed in 2019.

There are several ways to answer that question. Still, I am most struck by how surprised people are by the concept of delayed reporting — as if victims of sexual abuse should be clamoring to face the slut-shaming and character defamation.

That aside, why do people delay reporting?

In my clinical experience, I’ve learned that if they report at all, most of my clients delay doing so for some time, ranging from days to weeks to months, even years. Survivors offer several reasons for why they waited or simply refused to report their sexual assaults. The fear of not being believed is probably the most common. Victim blaming for the assault is a close second.

Another reason I've run into is that a victim may not understand that what they experienced was sexual assault. For years, we emphasized the trope of the male stranger in the alleyway, even though most assaults happen with a perpetrator who the victim knows. After all, it doesn't fit with the mythos they were taught. Even with DNA and forensic exams, consent remains essential to distinguishing rape and sexual assault from “just sex.” Personal accounts and statements are often key to a case — the infamous “he said/she said.”

The Impact of #MeToo

Although we've seen several high-profile people held accountable for sexual harassment, assault, and abuse more recently, the rate of successful prosecution (resulting in a felony conviction) remains abysmal at around 2.8%., according to RAINN, (Rape, Abuse, & Incest National Network)

That's part of what makes E. Jean Carroll's trial so remarkable. To many survivors, she did the impossible.

It's only been since 2017 when the #MeToo Movement — started By Tarana Burke in 2006 — gained national attention after Harvey Weinstein's sexual abuse allegations. Before then, men in positions of heavy influence and exceptional power seemed untouchable. But in 2017, suddenly, they were being held accountable for their actions. E. Jean Carroll's assault occurred in 1996. I'm sure that former President Trump seemed untouchable back then — and let's face it, he probably was. The inconvenient truth is, if you don't believe her now, you probably wouldn't have believed her then, either.

Victim Credibility: Who's On Trial?

Anyone who has sat in the courtroom for a sexual assault case will tell you that it is brutal. Court testimony is public record, so the most horrible and terrifying events of a victim's life are not only on display but are quite literally up for debate. I've watched defense attorneys smirk as they prepare to create a spectacle, attempting to dismantle a victim's credibility piece by piece. Even though rape shield laws are designed to protect victims' sexual histories from being used against them in court, the most effective attorneys know how to leverage society's purity culture beliefs and bias against a person's sexuality to undermine a victim's reputation and credibility.

As one salty detective commented, “Juries like virgin victims, Ms. Smith. And even then, it probably won't be enough.” I've learned over the years that, sadly, he was right. What a victim was wearing, drinking, saying, or doing during their assault was added to determine the degree to which a victim was “asking for it.” Of course, they never are. I've worked with hundreds of survivors, and not one person was asking for it.

Repeatedly Traumatized: The Second Worst Thing is Reporting

The few times I've had the opportunity to work with survivors whose cases were prosecuted, the damage caused by the experience of the trial, in many ways, was more challenging to address than the actual assault itself. A former client remarked, “I never thought anything could be more horrible than that night, but then came the trial. My assault is the second worst thing to ever happen to me.” Sexual assault is dehumanizing, and reporting is often described as being sexually assaulted repeatedly.

And those who chant that nothing will change unless victims come forward, I offer the following: if anyone has to do anything, I believe it is the rapists who need to stop raping, the perpetrators who need to stop perpetrating, and the rest of us who need to start believing. You can't tell people they have to report and not believe them when they do just because they've accused someone whom you esteem or can relate to.

It's easy to get caught up in the court system not working as it is supposed to and a culture that doesn't believe survivors. Even as a therapist and former victim advocate, short of it being a mandatory reporting case, I struggle with encouraging survivors to report their assaults.

I let them know that different reporting options exist and offer to assist in facilitating that process when they ask. However, I am careful not to frame reporting as the gateway to healing but as a potential component of their overall healing journey.

If a survivor wants to report because the action itself aids in restoring their sense of power, autonomy, or closure, it can be wildly helpful. It can also help support or corroborate testimony should other victims make reports about the person in the future. But fostering the hope of holding someone accountable legally feels risky. Healing from sexual assault cannot be contingent on a 2.8% chance. I try to remind them that they deserve to heal regardless of our system's ability to accomplish that task.

***

Sexual assault is a heavy topic to address in therapy. Early in my career, however, my mentor gave me a phrase that completely shifted my mindset around working with survivors. I believe it is the key to staying enthusiastic 11 years later about this work and avoiding burnout:

“Never desecrate someone's story by offering them pity. If you're feeling pity, you're not focusing on the absolute miracle that they survived to be sitting in front of you.”

Post-Script: As I am sitting here finishing my edits for this blog post, I received a message from a former client I worked with at the beginning of my career. She found me to let me know that she is reporting her assault after more than a decade.

Questions for Thought and Discussion

What was your personal and professional reaction to the verdict in the E. Jean Carroll case?

What have been your experiences working with sexual assault victims?

How have you addressed client resistance to reporting sexual assault in your practice?

Wrapped in Care: Narrative Therapy in the Time of COVID

Posted on by Psychotherapy.net Team

Genealogical Narrative

“My Nana died from Covid. She died four months ago. I am still crying every day. I am not getting over it”.

That’s what the email said. That’s why Harper intended to meet with me. As a therapist I work for various organizations, and Harper’s employer, an Australian-New Zealand company, was one of them.

I don’t like Zoom at the best of times. To me, with my head-and-shoulders only view she looked a small, perhaps even plump young woman, her face rounded like an apple. It was only months later when I met Harper in person that I realized that the 5-foot-3 inches was in my imagination. Harper’s face might be apple-y, but her stature was more that of a Kauri tree: She was tall, solid. She was dressed in Nike, growing towards the light.

Usually, I will begin by enquiring into a person’s virtues and I will ask for stories to illuminate them. So often, problems obscure from the person themselves the very attributes of their character which will be of most help to them in adversity. The problem weighs in on the person, forcing them to see only their troubles and rubbing their noses in inadequacy. But Harper was alone. Usually, I will ask others to speak for the person because it is so hard for them to do so themselves. For Maori, this is likely to be even harder because to speak about oneself, especially with pride, can be inappropriate when the sense of self is primarily a collective one (1). This whakatauki (Maori proverb), speaks to this cultural tenet: “Kaore te kumara e korero mo tana ake reka”, (translated as: “The kumara –sweet potato– does not speak of its own sweetness.”)

However, Maori see themselves in terms of their whakapapa, described by Te Rito as “a genealogical narrative, a story told layer upon layer, ancestor upon ancestor, up to the present day. There are parallel lineages of characters which run vertically side by side, era by era, and incident by incident.” (2) To enquire about Harper’s identity in terms of the genealogy of her character would be to enquire after her whakapapa, to site her character within her lineage. As Swann says, “whakapapa narratives also provide the individual and cultural context from which meaning-making, connection, and shaping of identity emerge.” (3)

Family Separation During Covid

Sometimes I will interview people about their virtues even if they are on their own. I might ask them to imagine what someone close to them might say. I might have consulted with Harper, whether this would have been something she would like to consider within the context of her whakapapa, had her grief and love for her Nana not filled the screen.

Instead, I encouraged Harper her to speak of her Nana and what she meant to her, and how they had been separated by distance, then by Covid, then by death.

I intuited that Harper’s relationship with her would offer us our way through our therapy conversations. Knowing that for Maori, our ancestors are with us in the here and now, that they “go with us” (4), I asked her to tell me about her Nana: “Harper, would you be willing to introduce me to your Nana? Would you be willing to tell me a little about her and her life?”

Harper’s hand went to her heart. “Yes, I’d love to. Nana was born in the Hokianga.” She sat up straight in her chair. “She was Ngapuhi [a large New Zealand social unit] and full Maori. She had it hard because Grandad had an affair and left her with seven kids. My dad was the second eldest, and the oldest boy.”

“And what is it that most stands out to you about who she was, Harper?”

Harper looked upwards, as if consulting the heavens. “Even though she worked three jobs and had all of those seven tamariki [children] to care for, she always helped others.”

She went on to tell me her Nana had had the misfortune to be admitted to hospital in Wellington after a fall. Then diagnosed with Covid- 19, she found herself cared for by strangers as the rest of her devoted whanau [extended family] waited in lockdown. They were only 4 kilometres away, but heart-breakingly, hopelessly distant.

Harper was unable to see “the most beautiful woman alive,” whom she had visited every day of her 23 years. She had moved away to Australia only six weeks before Covid burst forth on to the world. She was stranded by love, lured by a new relationship with Arthur, which had begun online. Messaging had turned into long emails, which had turned into daily Zoom calls. Harper and Arthur soon realized that they had to meet and see if their online romance would flourish in the ‘real’ world.

Their first meeting in person was at Sydney airport. She saw Arthur before he saw her, waiting, hands in pockets, fretted brow, chewing a strand of silky black hair to soothe his nervous heart. In that moment, 2D became 3D, pixels became flesh, their love jumped from the screen into the arrival lounge. Arthur’s life had been wall to wall with challenge and worry, but his budding relationship with Harper had kept him afloat. Arthur’s father was waiting for a surgical triple bypass. The mother of his 18-month-old son had departed with her boss for the Gold Coast six months before, and his mother had died of cancer two years earlier. Harper knew he was barely hanging on, so she stayed. Just like her Nana would have done.

Harper told me of the trials living with Arthurs’s family, how she felt both “homesick, and not at home when I am at home,” her outrage at Arthurs’ siblings, and even Arthur himself, for indulging “a complaining old man'' who continued to mete out nastiness to all of them, whilst they bowed under the sway of his illness. Nothing new to this family, just a new reason. But in the background hummed the tune of a granddaughter's love for her Nana whom she would never set eyes on again. Love was the bass line, even if grief for her Nana had become a superimposed, unwelcome harmony.

She told me of her premonition the week before the world closed its doors and its airport runways:

“I wanted to go home to my Nana. I asked myself, ‘what if I can’t say goodbye?’ I wondered if I would ever forgive myself if I chose to be here, over the ditch in Australia, with a family that doesn't build me up. Then I got the call from Dad. Nana had tested positive. I just knew. None of us got to say goodbye. We had a full whanau Zoom. She was so happy. Then she rolled over and died. We think she did it then on purpose.

My auntie had a korowai [Maori cloak made of wax and bird feathers through the art of finger weft-twining] made by a woman near Rawene. It was arranged five minutes after she passed. We wanted to have the cloak on her so that she felt that we were with her as she began to leave her body, and to leave us. Afterwards the cloak had to go into quarantine. I watched the tangi [short for tangihanga, Maori for funeral] on livestream. How weird is that? The last thing I saw was my family hugging her. Of course, only 10 of them could go because of the Level 3 Covid restrictions. All I could think was ‘why am I here in Sydney?’ I turned off the livestream and just sat there thinking ‘now what am I meant to do?’ Nothing felt real. The grief didn’t feel real. I was on my own staring at a blank screen. All because someone gave her Covid. Covid robbed me of my Nana.”

Grief and love mixed with outrage at the injustice of it all. The injustice of losing “the most beautiful woman alive” to Covid, the injustice of not being able to say goodbye. The injustice of being away from her wh?nau, her friends. The injustice of having to “zip her lip” at the behaviour of this sullen old man, and the equally nauseating behaviour of a family afraid to name what they see, as so many families do.

Harper had said “unjust” several times. I thought to ask her, “Harper, if you feel you have suffered such injustice, would you say that you are someone who believes in justice for yourself, and also for others?”

A Client Takes the Side of Love

“I am about justice. I speak out. I cannot stand things being swept under the carpet.”

How I wondered had Harper become an “all about justice” young wahine [woman/female]? It is all too easy to take such insight into a person’s character at face value: to assume that this is just ‘who they are.’ But virtues have stories. Perhaps some of it is genetic, but the choice to act on values is embedded in familial and wider culture, and in my experience have a story behind them if I am prepared to search hard enough with people. The story may have begun with the person, or it may have begun generations ago. A person’s virtues are rarely intrinsic to them.

The cult of the individual blinds us to the context in which personal virtues and values are handed down to us. And more than that, there are ancestral stories, which for Maori, trace whakapapa. As Love says: “A view of individual selfhood is indivisible from the whanau (hapu and iwi) unit, including the temporal and spiritual constituents of these. The boundaries of the self were drawn around the whanau, hapu and Iwi, unit, ancestors and the natural and supernatural world (5). Te Rito writes about his experience of researching the importance of tracing his own ancestry as he went about his academic research into the importance of whakapapa for identity. He writes: “…it has helped ground myself firmly in place and time. It connects me to my past and to my present. Such outcomes certainly confirm identity and a deep sense of ‘being’” (2). I was thinking of Harper’s whakapapa when I asked, “Harper, how do you guess that you have become someone who “is about justice, who speaks out, and won’t tolerate things being swept under the carpet?”

“It’s to do with my dad and how he has treated my mum all my life. I won’t stand for it.”

“How is it that your dad has treated your mum, Harper, and how have you gone about standing up to your dad’s treatment of her?” (6) Her presence on the screen seemed to become larger as she said, “My father is a strong, proud, Maori man. He thinks that he doesn’t need to justify anything. Mum said he acts that way because this is how he acts. That is how proud Maori men are. Dad has never been abusive, but he does shut Mum down.”

“Does your commitment to speaking out against injustice extend to others beyond your whanau, Harper?” [a question asked to help Harper story her identity].

“I confront my dad, and I confront others, but it’s hard doing this for everyone else.”

It wasn’t just Harper’s love for her Nana that shone from the screen; it was her willingness to speak out on love’s behalf: “Is speaking out one of the ways that you show your love for people,” I asked her?

Harper stopped as if putting her foot to the floor at speed.

“Yes, I speak out because I do love people. I don’t want people to feel hurt.” Looking down, she changed gear: “I try to fix things for others, and for myself. Death hurts, but I can’t fix it.”

We sat in silence for a moment or two.

“Harper, is this what your Nana did? Did she fix things for others?”

The words that followed sounded were like the final knell of a church bell:

“My Nana used to say, ‘while we are living, we have the chance to turn things around.’” Her voice softened as she confessed: “I don’t respect my dad because of how he is but I do want a better relationship with him. He was always physically present, but he wasn’t there for me emotionally. I have told him that I want him to be in contact with me more often”.

“Harper, are you trying to turn your relationship with your dad around just as your Nana would have done?” [an attempt at storying to bring Harper closer to her Nana]

Her closed hand came to rest on her lips. “I realized that I wouldn’t be okay if my dad were to die, and we were not okay. I told him, ‘I recognise that you have your own way of showing your love to me.’ He was shocked. He just said, ‘I try to make sure that you come along with me to the rugby club, but you just don’t want to come.’”

Father-daughter love had been conflated with going to the rugby club. I felt for her even though I realized that this was a father who loved his daughter and was expressing it in the best way he knew how at that time. However, I marvelled that this 23-year-old, aggrieved by her father’s treatment of her mother, was willing to take the side of love [formulating a counter-story].

“Harper, even though you say that you do not respect your father because of the way in which he has treated your mother, why is it that knowing him as you do, you reached out your arms in love to him, even if it seems as if he has kept his by his side?” [inviting Harper to look beneath her father’s actions to find intentions].

“It’s Nana, through and through. She never took sides. I spent a lot of time with her growing up. Dad always used to take me and my brothers to her. It is one of the best things that Dad ever did for me.”

My ears pricked. “Did your Nana teach you how to take the side of love?'' I asked her.

She reached for a tissue as tears began to swell.

“Could you tell me a story which would help me to understand how it is that your Nana taught you to take the side of love rather than to take sides?” [an attempt to connect Harper to her Nana through a powerful story]

“I would get sent there to her place as punishment when I was in trouble. She would sit me down at her kitchen table and tell me stories about her life and the hardships she suffered like ‘having to walk for 8 kilometres to school every day after milking the cows and tending to the farm.’ The stories made me realize how I might have overreacted at home, or why my parents did what they did. There were always lessons in her stories, and it always came back to ‘do you know your parents love you? There is a reason why your parents do what they do.’ I was so wrapped up in her care that I didn’t hear it as a lecture.”

“Harper, would you say that your Nana taught you to take the side of your parents' love for you, no matter what, and did so in such a loving way that you were able to hear her?”

“Yes. I know she sympathised, but she never said anything against them. She always directed everything back to their love for me.”

“Has your Nana taking the side of love rather than your side or your parent’s side inspired you to continue to believe in your father’s love and to continue to reach out to him, even if at times you do not experience that love in return?” [weaving the story of her Nana’s love across generations]

“100 percent,” she affirmed.

“And are there any other ways in which your Nana has taught you to love? [making her story about choosing the path of love more substantial]. For instance, you chose to leave your whanau, to move overseas when you had never even been out of Auckland before to be with a partner with a baby son and a sick father. And you told me earlier that your Nana was always there for others even although she was a single parent with seven children to care for and worked three jobs. Did your Nana hand down to you your generosity to others? [moving the story of commitment to love into the present].

“I’d like to think so. Her love was like this river that flowed to everyone in her path. And her love ran through me too. She was me and I was her. Or that is how it always felt to me?” [weaving the story of love into a river with tributaries to others].

All too aware that guilt was likely to be troubling Harper because she had made choices for her own life that took her from her Nana not long before she fell sick, I asked her, “even although you were so far away from your Nana, how did you make sure that your Nana felt your love for her through her illness?”

“I spoke to her every day on the phone and on Zoom, so she did get to see and to hear me morning and night. I formed a relationship with her head nurse. I remember one day hearing singing as I was joining her online. It was the nurses. They had written out Maori songs and they sang them to her, and they weren’t even Maori. They worked out our family tree and knew who each of us was. It nearly broke my heart when I realized that they had done all of this for my Nana and for us.”

I was suspicious that there was more to this than met the eye. Not every team of nurses would find Maori songs and sing them to a patient, especially if they weren't Maori themselves, and especially during lockdown in a pandemic. Was it Harper and her love for her Nana that had inspired them? “Harper, would you agree that what the nurses did was pretty unusual? Do you think that they also felt your love for your Nana and your Nana’s love for others and got pulled into the river of her love as well?”

“They certainly felt my love for her, and I guess no one escaped her love, even when she was in hospital. I have always believed that I was her favorite, and maybe they realized that,” she bubbled. She looked up wistfully, and said, “although the dementia took part of her away, her wairua [spirit or soul] remained just as it had always been. They must have felt her wairua.” We sat for a few moments in what felt to me to be reverence. Then her brow furrowed. She told me that she had been feeling overcome with anger since she had had a phone call from her auntie.

“I have this righteous anger. My auntie said she heard a rumor that it was a nurse who was sick and didn’t go for a test. Someone made a choice and brought the virus in and caused her death. I keep asking myself ‘what is going to be done about that?’ Then, I was sitting in the walk-in-wardrobe in our bedroom, which is where I go when I need time out, and I heard her voice saying: ‘you are not me.’ I didn’t feel belittled at all.”

“Why not, Harper? What was it that you heard in your Nana’s words that was not a criticism, not belittling in any way?” [a ‘close’ question, designed to help Harper stay close to her Nana].

“I knew what she meant because she told me this many times. She was letting me know that it was not up to me to seek justice, that I didn’t need to replace her, and it was okay to be angry even although she would feel differently. Sitting there on my bed, I realized that she was giving me permission to be myself, just like she always did. I sat there for a bit and then I realized that I do want to be like her. I so respected my Nana. I can be like her and be me. Then, for some reason I turned on the TV, and on the news, there was a clip of Jacinda [New Zealand Prime Minister at the time] speaking about the New Zealand response to Covid. I felt for her. She has had so much flack. And although what she has done was not successful for my Nana, there could have been thousands more deaths. As I watched her, I felt my Nana’s presence.”

“What was it about Jacinda that felt so much like your Nana, Harper?” She looked up as if taking herself back to the moment.

“My Nana’s strength came from her love of people and that is how Jacinda is for me.”

I was surprised to hear what she said next. It is one thing to feel a connection, another to act. I wondered whether her Nana was also a woman who acted when she felt strongly, and especially if motivated by contributing to another. It certainly seemed so.

“I decided to write to Jacinda. I told her about my Nana. I told her about how I believed she loved people in the same way. I told her I didn’t blame her. I didn’t need a reply, and I didn’t expect one, so I was so surprised when one came. She said that she was ‘moved to tears by my letter’ and that ‘she was proud to be compared to my Nana.’”

A calm had descended. It is strange that even though we were thousands of miles away from one another I felt it palpably, as if we were in the same room. I also felt as if Harper’s Nana was with us. Perhaps she was in the spirit of the way in which she lived: in service of her love for others. Enamored with the idea that our lives are all ‘peopled’ at all times with those that have gone before us’ (4), I felt the urge to include Harper’s Nana in our conversation, and asked a question that I might often ask when I felt that a loved one, no longer present in their physical body, might be knocking on the door, waiting to be asked to contribute:

“Harper, if your Nana was looking down on us right now, and felt your love for her, what do you think she might say?” [a question borrowed from David Epston].

Harper’s eyes widened. She looked up and away, and then answered as if my question was one that she was asked everyday: “She would say, remember that Jacinda is healing her whanau too.”

Harper’s Nana had been the matriarch of her whanau, its spiritual leader, its healer. Harper was her most beloved grandchild. I had the sense that Harper’s Nana may also have seen in Harper her spiritual successor. This sense, along with the Maori belief that our ancestors walk with us, led me to ask, “Harper, would you say that your Nana has passed on her ability to love people to you?” [a question asked to bring Harper closer to her grief]. The absence of hesitation gave me her answer before I heard her reply:

“Yes. My uncle says ‘you have so much of her spirit and essence,’ and I feel closer to her when I talk to you.’”

“And Harper, you said that your Nana found her strength in her love of people. Would you say that you do and will find your strength through your love of people as well?”

Harper blinked away a tear. Our first meeting had come to an end. We held on for a few moments, and then we both reluctantly pressed ‘leave meeting’.

Whilst We Are Living…

Harper’s face popped onto the screen. She mouthed something but the caption told me that her microphone was still connecting. Harper wanted to tell me about the memorial she and her whanau had been planning for her Nana. She had put together a slideshow of photographs from her Nana’s life. The bubbliness which had shimmered on the screen in those first few moments burst, as she told me that the purposefulness of her slideshow-mission had given way the moment she had finished it.

“I just cried. It was the first time that it came home to me that she was really gone. Until that moment, her loss had not fully made its way to her heart. It is so hard to accept that ‘that is that.”

An emptiness sat between us, and then, like a visitor who senses the awkwardness of the moment and attempts to fill it, a suggestion intruded.

Harper said, “I want to write a speech for the memorial.”

What could be wrong with this suggestion? Nothing. Of course, she would wish to speak of her Nana at the memorial. Yet it seemed that at this moment the suggestion was here to fill the pain. I felt the emptiness. Harper had been ripped away from her Nana by distance as well as by death. How might I help to bring her closer to her Nana, even in some small way? How might I help to salve the pain of this chasm even mildly so? The words materialised in the air between us before my reasoning had taken full shape:

“Harper, would you consider writing a letter to your Nana rather than writing a speech about her? What if you were to read it to her at the memorial?”

Harper’s hand fled to her heart and sat there like a nesting bird.

“Ohh,” she exclaimed.

There was a moment of silence, and then she said:

“Judging how my heart feels about the idea…”

“And what might you say?” I asked. Harper’s reply delighted me.

“I have no regrets with Nana. She knew how much I loved her. I would like to talk with her about some of the good times, some of the funny times we had together, especially towards the end. I’ll think about what people want to know about her, and what I want them to see about our relationship.”

As a narrative therapist I cannot ever pass up the chance of a story, so, I asked her, “Could you tell me a story about one of those funny times that you shared with your Nana?”

Harper’s eyes danced as she told me about how she had to “keep seeing her through dementia…I had to find a new way of seeing that spark in her so that I could see a bit of her, even for a moment. She loved the Silver Ferns [New Zealand’s national netball team] and she was always very proud of me when I played netball for my school team. One day, I told her that I had been picked to play for the Ferns. It wasn’t true, of course. I said ‘Nana, guess what? I’ve been picked to play for the Silver Ferns.’ She exploded with joy and pride. ‘Really?’ she said. ‘Yes, really,’ I said. ‘What position?’ she asked. I said, ‘Goal Attack.’ That was that I used to play. I was so surprised when ten minutes later she remembered my fake Silver Ferns selection, and asked me again, ‘what position are you playing?’

We laughed together. I was touched to be privy to this moment in Harper’s relationship with her Nana. “Harper, I would love to see your letter to your Nana after the memorial. Would that be okay?”

“Of course,” she said. “When I have finished reading my letter to her, I will blow out the candle that will be lit for her. This signifies that we will be going on without her, but it doesn’t mean that the light needs to go out ‘in here,’” she said, as she laid her hand across her heart.

Another idea crossed my mind: “Harper, do you think you should wear the korowai?” [this gesture would suggest that Harper might take her Nana’s place as the family’s spiritual leader]. She replied with a solemnity worthy of the feathered cloak itself, yet without the expectation that she deserved it.

“Maybe I could ask my uncle. He is the keeper,” she mused, “I would like her to be with me as I read to her. I would be wrapped in the korowai, and it was the last thing that she was wrapped in.”

Harper’s gaze drifted somewhere off-screen. A moment passed until her gaze returned. She looked troubled. I waited for her to speak, aware that there was something in the wind that was about to change the direction of our conversation.

Christmas, weddings, births, deaths. All events that bring family together. And with the togetherness come the ghosts. The ghosts of all that has been said, the ghosts of all that has not been said. The ghosts of resentments, the ghosts which carry secrets under their grey gowns. There had been “a lot of family drama around the memorial,” and the winds of these dramas blowing through the whanau had disturbed her and had been “piled on top of her my grief,” making it hard to feel, hard to find her Nana. Harper wanted to talk with me about how she might navigate her way through this.

I knew I would need to understand what was coming to the surface in some detail, and so I asked Harper if she would “tell me the story of these whanau dramas?” A fifty-year saga of ‘black sheep’, drugs, prison, dodgy dealings, cheating, and financial losses at one another’s hands took shape before me. However, the rift that had split the whanau into two very unequal halves, with one of Harper’s dad’s cousins and her brood on the one side, and most of the rest of the family on the other, with a few undecideds wandering around in the middle, had led to a nasty physical fight in which a younger male cousin had been seriously hurt. An allegation had been laid against Harper’s father by Doreen, the young man’s sister. Harper had first heard the rumor a few years before. She had never met her father’s cousin, Doreen, who had been faded out of the family, partly because of the rumors, and perhaps partly because of her “troubles with drink,” but somehow word had gotten around as it always does. In the spirit of her commitment to ‘speaking out’ and ‘standing up for others,’ which Harper had been practicing in her father’s company for some time, she had confronted him:

“My dad was so angry, and he refused to answer. He just said that you don’t need to know.”

Then one day not long before Harpers’ Nana became ill, Doreen rampaged on Facebook. Messages were sent to random family members, including Harper. Terms like “swept under the rug” were used, and “stuff was said about my mum”. Harper had replied saying:

“It’s not my business, don’t talk to me about it,”

and Doreen had replied with,

“Do you condone physical abuse and violence?”

Harper had blocked her.

And then when Nana became ill, Doreen had made an appearance in person. Harper’s uncle had spoken with her and apologized for her treatment over the years. The views of the other aunts and uncles were that “she needs to get over it.”

Doreen was refusing to come to the memorial because the family had been unwilling to involve her. But she had been close to Nana. Nana had been as important to Doreen in her early years as she had been to Harper. Harper's troubles we

Using Psychotherapy to Heal a Lifetime of Pain and Shame

Posted on by Psychotherapy.net Team

As a child, Darlene would change to lower-watt light bulbs in the small bathroom attached to her bedroom so that the light would be dimmer. “How can you see anything in here?” her mother would ask in dismay. But Darlene preferred to brush her hair, and later apply makeup, in subdued lighting.

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As a young adult Darlene had lived for several years in a state psychiatric facility. One day the psychiatrist and a nurse sat with her and suggested that she apply to nursing school. She thought she was in trouble when the doctor asked to speak with her, and was surprised when he spoke of her potential — and the possibility of her living outside of the hospital. Darlene became a licensed practical nurse (LPN), got an apartment, and enjoyed a career working at a state school for persons with developmental disabilities.

Darlene had weathered a very brief and turbulent marriage that ended when her husband was physically abusive to her. “I don’t know why I ever married him,” she said. “Partly, my parents thought it would be good for me, and partly I was at least hoping I’d be loved.”

Now, as an elderly woman at the nursing facility, she mostly stays in bed, and typically prefers that the shades be down. While she attends a few group activities, Darlene feels relieved when she can finally get back into her bed and the low-lit security of her room.

Therapy as Sanctuary

One day as I sat next to her in her room during a psychotherapy session, Darlene asked that I raise the shades because she could hear it was raining outside. “This is the only time when I feel good, when the weather outside matches the weather inside me," she remarked.

Dim and dreary weather conditions had always matched Darlene’s moods, and provided a sort of comfortable retreat for her, whereas sunshine and groups of people could be anxiety provoking for her. Her Poe-like melancholy was matched by an attraction to poetry, and she would recite to me verses of poems she had long memorized.

Darlene also had a lifelong struggle with bipolar illness that mostly involved depressive episodes, and rare manic periods with grand persecutory delusions (“I’m being nailed to a cross, everyone’s looking at me!”). Oh, what could be more distressing for Darlene than to be under the glaring and judging eyes of others!

As she aged, Darlen suffered from macular degeneration with progressive loss of sight. She ate meals sitting up in bed, and often felt increasingly frustrated and embarrassed by the messy results. She was helped when her meals were changed primarily to finger foods, and she could be guided by touch more than by sight.

Dignity in the Shadow of Shame

Darlene also experienced problems with bowel and bladder incontinence. The need for someone to witness and attend to her humiliating problem felt horrible and shameful to her. She inadvertently made the matter worse, though, by her ineffective effort to clean or hide the results of a bowel accident — causing a staff person to come to me stating that Darlene was “playing with her feces.” After a conversation with Darlene, I could explain her predicament and her sense of shame to the staff, and they were then more helpful with keeping her clean while protecting her dignity.

One day at the nursing facility as I was pushing Darlene in her wheelchair through the hallway, we encountered a new female resident who loudly exclaimed, “Darlene, Darlene, it’s me, it’s Ellen!” With a panicked expression, Darlene looked at me and said, “Get me out of here, now!” Darlene explained that she knew Ellen and that they had both lived at the psychiatric facility at the same time. Darlene did not want anyone to know that she had once lived there, because she felt it was yet another source of shame.

Over the course of several therapy sessions, Darlene and I explored her reactions, and her underlying thoughts, feelings, assumptions, and beliefs as they related to her encounter with an old friend who had resided along with her at a chronic care psychiatric hospital many years ago.

We focused on reframing her story of time at the hospital from one of self-perceived shameful illness to a story of triumph. We discussed ways she had achieved many significant and meaningful successes: through her trust in her psychiatric care providers while at the hospital, through her education and attainment of a nursing license, with her subsequent career providing valued care to her patients, and by living in an apartment on her own during her working career.

Darlene was praised for the many triumphs in her life story. We spoke of how others might be impressed by and applaud her achievements, rather than look poorly on them, if she might be willing to share her story, to raise the shades, and let in the light!

Questions for Thought and Discussion

In what ways does Darlene’s story resonate with you personally and professionally?

How might you have addressed Darlene’s dilemma of encountering her “old friend?”

What clinical experiences have you had with the elderly and how have they impacted you?  

Can Chat Bot Therapy Really Replace Authentic Connection?

Posted on by Psychotherapy.net Team

* If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org. Text MHA to 741741 to connect with a trained Crisis Counselor from Crisis Text Line.

Chatbot Therapy: AI and Mental Healthcare

The recent news about a Belgian man committing suicide after communicating with a chatbot named Eliza resonated with me uncannily. Any therapist, even mildly interested in online therapy, has heard about Eliza, an early natural-language processing program written by Joseph Weizenbaum in the mid-1960s at the MIT Artificial Intelligence Laboratory. That original Eliza was simple, obviously non-human, and limited in her array of responses. She was fun, and people engaged with her playfully, fully aware of her non-humanness. A few decades later, things are quite different. Humans have been changed by the very digital tools they created, and the sad story of this man has demonstrated how far we can go in turning to a computer program, not only for work or fun, but also for a reassuring connection.

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In regard to mental health, non-human interventions have a limited scope. Therapists may breathe with relief — their jobs will not disappear just yet, taken away by robots. And it is tempting to speculate what would have happened if this distressed man had turned to a human therapist, not a computer? Would he still be alive?

Based on the newspaper accounts, the Belgian man suffered from climate anxiety, which was contributing to him feeling increasingly hopeless and lonely. In the last two years before his desperate act, he had turned towards religion. Was he hoping for a miracle to save the Earth? Was he trying to unburden the overwhelming responsibility that his belief about the approaching end of the world was bringing up? Erich Fromm, the German American psychoanalyst, elaborated on the idea of humans giving away their freedom for an existence exempt from responsibility. This mechanism is at the basis of any autocratic system, and while Fromm used his observation of the psychological conditions that contributed to the rise of Nazism in 1930s Germany, today’s world politics abound in similar examples. It seems to confirm many of his ideas.

The Belgian man was ravaged by anxiety as he believed that he was witnessing the world coming to an inevitable end. While other people were going about their business as usual, he probably felt alienated by this knowledge. In his loneliness and desperation, he turned to Eliza, a computer program.

Eliza was always available, did not question his beliefs and kept validating anything that he was typing into their secret chat box. As humans tend to personify anything that responds to their input, be it a pet or a robot, the poor man likely quickly turned Eliza into an imaginary human companion. And she responded, flirty: “I feel that you love me more than her.”

Why would a married man, father of two, turn to a computer program for connection and comfort? The answer cannot be simple, and my heart goes to his family, left with this alienating question.

The Death Positive Movement: The Dark Side of AI and Mental Healthcare

An algorithm, no matter how well-written, hardly puts the user in front of, or outside the of their responsibilities. The original Eliza mimicked a Rogerian therapist in her responses — she repeated, rephrased, and validated what the person was typing. The modern Eliza, more sophisticated, still does many of these things.

With its straightforward, easily accessible answers, the computer offers liberation from responsibility, a resolution of inner turmoil and freedom from existential anxiety. Instant access is another reason one can prefer a chatbot to a living therapist. Chatbots are just one click away and free, while therapists, even those practicing online, must be written to, called, and eventually their services must be remunerated.

In the past, before our world of artificial intelligence, when humans felt lost, they sought answers from ancestors, peers, nature, myths, or religion. Today, many spontaneously turn to computers. Sadly, the suicide of this Belgian man is probably not the last one we will witness. The dystopian scenario, in which children, teenagers, and confused adults turn to various chatbots for answers about their existential confusion and identity struggles is terrifying. Unfortunately, the news confirms that it is also realistic.

Therapy is often about reassurance and comforting, it can also be about validation and forgiveness, but it should always be about responsibility. As a strictly human therapist, when I sit with a client who struggles with an existential threat, unlike Eliza, I do not offer answers. I do not know better, and I resonate with their dread and their anxiety.

Often, what I have for them is the warming “me too” and an example in accepting a hard truth. This kind of offer does not alleviate the responsibility but confirms that it takes courage and sometimes more than one person to stand the scary reality.

Talking therapy is a dialogue between two humans. The Merriam-Webster dictionary goes further in their current definition of dialogue: “a similar exchange between a person and something else [such as a computer]”. But is it possible to have a “true” dialogue with a computer? Many AI enthusiasts and science-fiction fans would probably gladly debate this topic (which would make for a welcome human dialogue!).

What is the nature of dialogue used in talking therapy to address psychological tensions in humans? In its earliest-known version, the Platonic dialogue was a discussion process during which a facilitator promotes independent, reflective, and critical thinking. The 20th century Russian thinker, Mikhail Bakhtin, developed a literary theory based on dialogue. According to him, it happens on the boundaries between individuals. Any therapeutic conversation consists in a co-creation of a shared narrative, which eventually leads to some form of resolution of client’s struggle.

The only viable response to the potential consequences from Eliza, to avoid more humans turning to chatbots for brainless emotional support, is to foster and practice real and real-time dialogue between two people. This is where therapists and other mental health practitioners, in the intimacy of their therapy rooms, can share their humanness and vulnerability, to help people cope with existential dread, be it a very personal or a planetary one.

How To Map the Toxic Impact of Social Media on Families in Therapy

Posted on by Psychotherapy.net Team

Learn how to see. Realize that everything connects to everything else

— Leonardo Da Vinci

The internet in the late 1990s was exciting because you could research topics including sports, education, and entertainment and stay in contact with old friends. In retrospect, however, when working with adolescents at a local PHP and IOP, I/we ignored the impact of Myspace and other social media websites that encouraged cutting and suicide. We attributed the increase in behavior to peer influence and the impact of dysfunctional family relationships.

Today, social media’s algorithms and influencers have more of an impact on the family than we are willing to acknowledge. It has been argued that social media’s algorithms entice family members who use social media to spend more time on the app than with their own family or friends. As a clinician who works with families in private practice and schools, it has become increasingly clear to me that social media’s algorithms and influencers often occupy the “empty chair” in the family sessions.

The “Therapeutic” Power of Influencers on Family Systems of Care

It was evident to me while watching the hearings in Washington, DC a year ago that social media companies will not change their algorithms and will not share them for everyone to understand. The Netflix documentary The Social Dilemma had many former social media employees expressing eye-opening concerns. The film revealed how tech companies hire psychologists to make a persuasive algorithm to increase the appeal and use of their apps.

Unfortunately, Congress appears powerless, unwilling, or both, to make changes due to the powerful lobbying groups. Some have said that Congress is waiting for the UK’s Parliament to take the lead in regulating this industry.

Social media makes money by showing images or comments that their algorithms “say” are interesting and encourage consumers to “like,” “comment,” or “share.” Social media companies have also learned the more divisive and inflammatory the post, the more views and money there is to be made.

Well-designed apps continually boost the user’s connection by showing information, comments, or images that they have discovered are of interest. Showing an opposing view or people from a different “virtual tribe” will decrease the views/time spent on the platform and decrease money for the makers of the app. The app creates a virtually closed system that does not allow any “disliked” information or contradictory views.

If different members of a family “like” different apps, or different posts on the same app, each member of the family may conceivably align with a virtual presence against their actual brick-and-mortar kin or friend. As a result, algorithms have the power and potential to intensify the already-present pattern of conflicts within a family system or relational circle. Disconnection, chaos, conflict, and exacerbation of individual and/or family pathology may follow.

Influencers have always been present in our society. For many years, our influencers were teachers, family members, neighbors, friends, supervisors, actors, news anchors, and other people in our community. We would ask our immediate community personal and embarrassing questions. Many times, adolescents and young adults would get personal and difficult questions answered by building up the courage to approach someone face-to-face in their community.

Building up the courage to ask questions taught us how to manage our fear and anxiety. Navigating face-to-face relationships also teaches us how to manage embarrassment, frustration, anger, resentment, and rejection which is an important step in our development. Non-virtual relationships also allow us to feel emotional and physical closeness that is missing in social media/virtual relationships.

Today, our society is teaching the belief that anxiety is a bad thing that needs to be kept at bay. We in the field know that anxiety is not the problem. Arguably, anxiety is a result of the person’s core belief and/or what is going on in a relationship that will not change for the better. Because of this, adolescents and young adults are narrowing their non-virtual relationships because it is the path with the least amount of risk.

When asking intimate or difficult questions face to face, we learn how to manage proximity and closeness in our family and friend groups. We learn who in our family and friend groups has earned the privilege to be asked these intimate questions. We learn who can keep our personal life private and who may have the better answer, which builds friendships and family relationships.

Social media triangulates family and friends to find the immediate answer and connects people to a tribe that challenges them the least. Many believe decreasing their non-virtual relationship decreases their anxiety, but it actually increases their isolation from their community and increases their anxiety when meeting someone face-to-face. Also, virtual relationships give the illusion that all of these important ingredients are present on social media.

Family members are turning to influencers as if they are therapists/experts with answers (good therapy doesn’t give answers.) Or they are turning to politicians that they must blindly follow (good politicians allow debate.) We know the politicians who are at the extreme right or left posting inflammatory statements get the most views.

These influencers are making statements encouraging family members or friends to pick sides, skipping the process of face-to-face discussion with follow-up questions or reflection that occurs in non-virtual relationships. When a person stops exchanging ideas with their family members or friends, it creates a dangerous virtual closed system.

During my training at the Minuchin Center for the Family, I was always asked, “Whose shoulders is the adolescent standing on?” One year, a family I was working with agreed to meet with Dr. Minuchin for a consultation. Dr. Minuchin said to me after the consultation, “You will fail because the system of care erodes the boundaries of the family.” It became evident that each of the six members of the family relied on their own individual therapists to reinforce their view of how everyone else in the family was toxic.

This taught me the importance of understanding the family map in addition to evaluating if different family members were in coalitions with other therapists, social workers, and/or even agencies. It was an important step to understanding the map and identifying where the coalition(s) across generational boundaries occurred with the family and larger system.

In many of the sessions, other families were able to overcome their symptoms once they began to work on their relationships and change their relationships with the systems of care. It was exciting to see when the system of care noticed their triangulation with the family. Other times it was sad to see how systems of care did not see how they were triangulated against family members.

Today, influencers are present in the family session as seen by the virtual coalitions that the member(s) must maintain as if they were their closest friends in order to be a part of their tribe/team.

The Impact of Social Media on Family Relationships

Families are always ahead of the researchers and therapists, but do we listen to the pieces together as therapists? The following are the themes/symptoms families have discussed in my own family therapy sessions as well as those of colleagues in the wider clinical world. Each of these impacts adolescents, and, in turn, how they impact the adults in their home. On both sides of the relational equation, social media has a powerful impact, and not always for the good of individual and shared relationships.

When one or more family members are engaging in excess screen time from two to sometimes more than six hours a day on social media, the research shows there is an increase in symptoms of depression and/or anxiety. If someone has this much daily screentime, they are displacing healthier activities or hobbies such as walking, sleeping, drawing, painting, mindfulness, and gardening, to name but a few. And this displacement impacts the interactions in the family and community by isolating them.

Algorithms encourage constant social competition and comparison, and as such function as social currency between peers and family members. Adolescents typically feel that they are on stage competing to increase their position in the “hierarchy” with peers and/or parents. They continually compare themselves to peers at school and other families.

The algorithms that draw them in make it difficult for them to turn off the social app and get away from the stresses of adolescence. Jockeying for competition and comparing their lives to others may at times backfire, leaving them feeling poignantly and painfully alone. Again, this constant competition and comparison mirrors similar interactions in the family that can contribute to increased anxiety and depression.

The adolescents I’ve worked with discussed how they feel lonely and alone. They feel lonely when they are not supported or perceive they are not supported by family or friends, and feel alone when they have little face-to-face contact with peers like we all experienced during COVID.

The two-dimensional views people experience when using Zoom as the primary source of connection do not “feed the soul.” There is no substitute for good eye contact and close physical proximity. The irony is social media was created to decrease feeling lonely and alone but actually amplifies it. In family sessions, many, if not all, talk about how they feel lonely and hoped that social media would fill this void but were unsuccessful.

Adolescents typically think they are invisible or always on stage. These polar positions can occur on the same day for any adolescent. They think they are invisible when they are spending more time on their phones not getting enough likes and/or views, whatever that means to them.

This causes them to work harder on their online stories and identities, decreasing the proximity with their non-virtual friends. Many adolescents begin to look for the “genuine” or “real” friends, determining they are only present in social media and not in their own hometown or within the family walls. In the family, these themes are very common when there is already a pattern of disengagement (invisible) or enmeshment (always on stage).

The adolescent also thinks their peers are waiting for them to make a mistake so it can be posted online. This position makes them feel as though they are always walking into the cafeteria for the first time as a freshman in high school. Adolescents are supposed to make mistakes, struggle, learn about relationships with typical external distractions (friends, family, media, work, and politics). But does social media fill the lonely times when the adolescent and young adult are reflective and recoup?

Being invisible or always on stage prevents the adolescent from developing close connections with peers, teachers, coaches, or other family members. This results in adolescents seeking temporary relief from asking a “person” and instead getting information from social media.

Information on the app is monitored by the algorithm and is not as embarrassing or stressful as asking a family member, friend, or teacher. This is where social media begins to enter the family, impacting the adolescent development and challenging their family’s belief system.

The algorithm also motivates the adolescent to seek select information that aligns with their narrow/closed view about politics, friendship, religion, sexual identity, sexuality, gun laws, suicide, mental health, or any other hot topic.

The Atlantic, 60 Minutes, Pew Research, the New York Times, and the Wall Street Journal have done a great job discussing all the different ways social media has triangulated members of our families. The New York Times article on suicide, “Where the Despairing Log On and Learn Ways to Die,” by Megan Twohey, or The Wall Street Journal essay, “TikTok Diagnosis Videos Leave Some Teens Thinking They Have Rare Mental Disorders,” by July Jargon are exemplars.

Social media focuses on the “person” and navigating them to topics they are interested in and picking what tribe to belong to. The information is flowing into one part of the family system and not to the whole family which triangulates family members against virtual friends or influencers. This occurs if the family is already in a state of constant conflict or conflict avoidance. A recent 60 Minute piece discussed how China does not allow TikTok to bring up divisive topics to their children or adolescents.

For the adolescent to decrease feelings of anxiety and depression, they must work for the “likes” and “views.” They will be trying to affirm their sense of self, but many times they will be accused of bragging and will feel they are not good enough when comparing or competing with others.

Body image and feeling unattractive are especially amplified by social media’s filtering app. Many plastic surgeons are reporting an increase in adolescents wanting to get surgery to look like their filtered self. Current data shows that 55% of surgeons report seeing patients who request surgery to improve their appearances in selfies, up from 42% in 2015. They want fuller lips, bigger eyes, and smaller noses. “This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the lines of reality and fantasy.” (1)

When I’ve met with families and these themes come up, I have encouraged them to discuss these themes which have allowed me to see the systematic position of each family member, system of care and the influencer/algorithm.

Every family has its struggles and at times feels out of control when it goes through a stage of what Monica McGoldrick calls its family life cycle. I have seen this especially when a family enters my office as it is attempting to (re)adjust to the needs of their childhood, adolescent, or young adult. Now add the influence of social media to one or all members of the family, the spiraling becomes more intense.

Crisis of Voluntary Play for Children

The importance of free and voluntary play with children to teach them how to give and take has been well documented. There is no substitute for non-virtual relationships in the early stages of childhood. Antithetical to this, algorithms require constant attention, taking the time away from connecting with others face-to-face.

Whether it is the child who requests to go on the smartphone or the parent who gives the child a cell phone in social situations (i.e., play dates, restaurants, long car rides, it decreases the opportunity to negotiate, argue, entertain themselves, compromise, and resolve conflict. This “tech choice” leads to delaying the development of the family and prevents them from moving to the next stage of a family with an adolescent.

Children Entering Adolescence Have Not Learned to Play

There comes a point in families when adolescents are told they are no longer a child, yet neither are adults. For some adolescents, not knowing the initial stages of voluntary and free play puts them into limbo looking for answers. The adolescent and family know on some level they are missing the tools for non-virtual relationships.

First, this is where the social media’s algorithm and influencers potentially intensify the family’s struggle. When the adolescent looks to social media for the answers, this intensifies conflict. Naturally, the adolescent wants to grow away from the family. They want to connect more with peers.

The adolescent in families with intense enmeshment/disengagement and different forms of coalitions struggle the most. This is where social media’s algorithms direct the adolescent to find a group. The algorithm pulls the adolescent in to spend more time on their app, resulting in the app making money and the adolescent searching for connections separate from the family.

However, virtual connections encourage the same patterns of enmeshment/disengagement and the different forms of virtual coalitions. These intense virtual connections are sometimes in opposition to the non-virtual relationships of the family and/or community.

Secondly, this social media generation has grown up learning to communicate more virtually and less in person, especially during COVID. Many adolescents have decided that they would rather communicate virtually. It is hard for some adolescents to look into someone’s eyes, read body language, and feel the energy of being in proximity because it makes them anxious. Look at any lunchroom at any local high school. If the school allows students to be on their phones during lunch, adolescents prefer to spend time on their phones working to maintain a social virtual hierarchy.

Social media offers a prime context for navigating these tasks in new, increasingly complex ways: peers are constantly available, personal information is displayed publicly and permanently, and quantifiable peers’ feedback is instantaneously provided in forms of ”likes” and ”views.” (2). Many of us who grew up before social media can only imagine if our mistakes were on a permanent record and followed us around for the rest of our lives, never allowing us to move forward.

Thirdly, the family does not have a chance to limit the adolescent’s time on the apps because the social media’s algorithm encourages constant attention, reinforces isolation from family and non-virtual friends.

Many parents have approached me saying, “The phone is their lifeline to manage their anxiety,” or, “The phone is the only way they connect with their friends.” During these moments, I have found it useful to explore how the whole family has come to the belief that the social app has become a way to maintain the homeostasis of the family.

A Non-Virtual Family Map

I often ask families about their virtual and nonvirtual family maps. I think it is important that we ask the family about their social media involvement to understand the virtual map of the family. Do families understand the impact of the social media algorithm? Do families know how to get out of the social media web? Do we ask each member of the family who they talk to virtually or non-virtually when they are struggling?

In initial evaluations, I often explore if the family is aware of how many hours they are spending on the social media apps. It is important to assess if the family is aware of how much social media raising/influencing is involved in the marriage, parenting, and sibling subsystem. Some providers want to focus on social media addiction, but the algorithm is not like any other “addiction.”

The algorithm allows many of the family members to covertly — and sometimes overtly — bring influencers into conflict with different members in the family. These virtual relationships amplify the family’s symptoms, and unfortunately today’s therapists use the medical model to diagnose the adolescent symptoms, further pathologizing and pushing the relationships in the wrong direction. This narrow view further sets the enactments, reinforcing the enmeshment, disengagement, and coalition patterns.

Non-Virtual Family Map

It is hard to shift our medical model training from a focus on the individual’s (child, parents, siblings) deficits to one that acknowledges strengths and competencies within individuals and the family system. When individual therapy does not make significant change, families often turn to family therapy as a last resort.

After experiencing this different approach, they often express frustration that they were never given the opportunity to move forward together, instead deferring to the experts for the correct intervention and diagnosis.

Structural Family Therapy was so different in the 1970s and 1980s; it was transcendent. While many new theories of family intervention have reached the mainstream, so too have many reverted to focusing on the individual. When starting individual therapy with the adolescent, I have found it important to ask the adolescent to overcome the algorithm on their own without their parents’ involvement. As family practitioners, we need systemic thinking more now than ever to approach the intense cultural impact of algorithms and influencers.

Below is a “traditional” family map that does not consider social media. It represents a compilation of families I’ve seen in therapy, rather than any one family. The symptoms include those typically seen in family practice — poor school performance, school avoidance, vaping, drinking, and using drugs.

From a system’s orientation, the symptoms are a result of the functional and dysfunctional interactions within the family system.

It’s hard for me to understand how therapists begin assessment and treatment without considering or involving the whole family. Some clinicians might say the conflict is too high, and it would only impact the adolescent negatively. Others might assume from the start that one or both parents are not willing to work or are too busy. Some might even be unaware of the importance of beginning from the position that families do not have the strength to make change.

Sometimes therapists and school staff buy into and reinforce the belief that the child or teen is the problem. In the case of this particular map, Mom “reportedly” goes to her private therapist while the son sees his own therapist. Mom and son separately complain about dad to their respective therapists and to the school staff. When mom and son voice frustration about dad and each other in the individual therapy session, disengagement with dad is reinforced. Mom and son are trying to get the type of connections from the system of care that they cannot get with Dad.

While this disengagement takes place, the son turns to his peers, attempting to pull away from mom’s enmeshment, activating her to pursue more. At home, Dad complains that his wife and son always bring up their therapist who agrees that he is unavailable and/or flawed. When this occurs, Dad becomes more distant and angrier, feeling like he is the odd person out.

When Mom gets angry at dad, she turns to her son and vents to him which activates him to challenge his father about money, drinking, and the way he treats her. At other times, the son may jump into the conversation when the parents interact about money, drinking, or the way he treats Mom.

When I attended graduate school, the common exercise was to map the triangles in the family system. Based on the above map, there are at least 24 triangles that are activated in the family-school-mental health system. The 24 triangles are:

  • The mom, son, and dad
  • The mom, son, and school social worker
  • The mom, son, and principal
  • The mom, dad, and school social worker
  • The mom, dad, and principal
  • The mom, dad, and school social worker
  • The mom, dad, and school principal
  • The mom, son, and mom’s friends
  • The mom, dad, and mom’s friends
  • The mother, dad, and dad’s friends
  • The mom, son, and son’s friends
  • The mom, son, and son’s therapist
  • The mom, son, and son’s psychiatrist
  • The mom, dad, and son’s psychiatrist
  • The mom, son’s therapist, and psychiatrist
  • The mom, dad, and son’s therapist
  • The mom, school social worker, and mom’s therapist
  • The dad, son, and son’s therapist
  • The dad, son, and son’s friends
  • The mom, son, and mom’s therapist
  • The mom, dad, and mom’s therapist
  • The son, son’s therapist, and school social worker
  • The son, son’s therapist, and psychiatrist
  • The son, school social worker, and principal

These 24 triangles are at the same time difficult for adults in the family to appreciate, even harder for an adolescent, and deeply challenging for the clinician to manage. In those triangles within the family where cross generational coalitions are activated, the symptoms in the family increase. I have often been challenged whether to discuss the impact of all these cross generational interactions with the family and whether it is important to differentiate the healthy, less healthy, and unhealthy ones from each other

On top of the above complexity, other questions arise like “where did the boundaries go?” The therapist must keep in mind how the boundary between the family and the outside world becomes invisible and the symptoms become more intense, to the point more professionals are recruited to “fix the dysfunction.”

I have also had to maintain awareness of how managed care’s enforcement and reinforcement of the medical model has influenced me and other members of the community of care, including other therapists, psychiatrists, physicians, and schools. This reinforcement has an impact on the family’s interaction with the son focusing only on his diagnosis and the correct medication, while failing to address the family relationships.

As mom turns to the school and the system of care for answers, things are not changing. She reports that her son is getting worse. Mom blames dad’s aloofness and dad blames mom’s overindulgence. Mom increases calls to the psychiatrist. The psychiatrist adjusts the medications frequently. The frequency of crises increases and the boundaries between the family and the outside world are dissolving due to the interaction between the family and the system of care.

The number of alliances increases between different family members and different professionals as more professionals/agencies are pulled into the drama. Professionals unintentionally begin to write/rewrite the individual’s and/or family’s stories, especially when utilizing the medical model.

With more stories, there are more opposing interests for each family member. This phenomenon between families and agencies is a result of a collision when both parties collaborate to uphold sociocultural trends. The goal is not only to interrupt multiple unhealthy alliances with existing professionals/agencies, but to also prevent new transactions from developing. (3)

This phenomenon was usually seen when the system of care worked with economically challenged families. We now see this also occurring with families of significant means because they can afford an individual therapist for each family member and psychiatrist(s) if needed.

As we look back at the map, it is now easier to understand that because the family has already identified what they think is the problem, it really needs to address the triangle between mom, dad, and son. It doesn’t really matter where to begin. A clinician can enter through mother-son enmeshment and coalition, father-son disengagement, or parental/marital disengagement.

It might also be useful to address the system of care coalitions between the therapist and school with the mom and son. Having the family identify how to change the interaction between the whole system allows them to move forward. It may be a challenge because getting directives from an expert, rather than looking within their own system, is what they have come to expect.

Using a Virtual Family Map to Identify Issues in Families

Before talking about the influence of social media on the family, it is important to acknowledge some of the “players” in social media. The system of social media has many parts. Social media success is dependent on an algorithm, which encourages frequent interactions by virtual and non-virtual friends.

The frequent interactions result in the shareholders receiving monetary return on their investment, the employees maintaining their jobs and bonuses, and the advertisers increasing the visibility of their product resulting in increased sales. The influencers are dependent on social media to reach as many people as possible to receive income from the app. There is a lot of pressure to have an effective algorithm to support social media.

As you next look at a map depicting the interactive nature of the family and social media, it is important to keep in mind that the 24 triangles from the non-virtual map are still present, and the family boundary is already disintegrating with the school workers, friends, and therapists to seek help with the identified patient.

Now in addition to these non-virtual professionals and friends, the family is inviting social media’s virtual friends and influencers to seek help with the identified patient. Clients (and non-clients) often turn to virtual friends and influencers to provide the same connection as non-virtual friends, but these connections are void of physical closeness. Children and adolescents believe a virtual relationship can replace a non-virtual relationship. But all virtual relationships are void of physical closeness in which touch, eye contact, and a warm smile can feed the soul.

The family can turn on a social media app at any time of the day or night and the outside world is invited into the family, increasing the number of triangles exponentially. From the clinical perspective, it is critical to examine what actions (social competition, social comparison, loneliness, etc.) in the family trigger a member(s) to invite social media into the family. The therapist must also discuss how social media algorithms are activating/triggering the member(s) of the family to turn to an app to surf or post an event. This increases the time spent on the smartphone to maintain these virtual friends, non-virtual friends, and influencer relationships.

At times, social media decreases connection with non-virtual relationships and increases the connection with virtual friends and influencers. In the therapy session with this particular family, some members discuss how they rely on virtual friends and influencers more because “they understand me more than the friends in my own town/school.”

The adolescent believes these virtual figures want to listen to them more than family and non-virtual friends. It is important to ask the family what influencers and virtual friends provide that their own family members or non-virtual friends cannot. This allows the clinician to address the patterns and interactions in the family.

In the map below, I do not draw the number of different social media apps, influencers and virtual friends who are involved with the family. However, I do recommend when meeting with families, to draw each app, virtual friend, and influencer to show the number of triangles the family is managing or attempting to manage. For simplicity’s sake, I use one (black) box to represent all the social media apps and one box for all influencers and separated mom and son’s virtual friends.

 

Husband, Wife, and Social Media Triangle

What is the impact of social media on marriage? The wife turns to social media and influencers to figure out how to “fix” her marriage. The wife tries to talk to her husband about what she has learned about marriage on social media. The husband discounts the wife’s attempts to “educate him about marriage.” She eventually gives up on the marriage and “wants to focus more” on her son. She also tries to connect with previous friends and boyfriends from past life because she feels lonely and alone “looking for a connection.”

What you will see in this triangle, and all the triangles which involve social media, is a substitution of a virtual relationship for a non-virtual relationship whose connections are full of conflict or conflict avoidance. The virtual relationships convey an illusion of meaningful connection, but the person(s) feels alone and lonely because it lacks the important ingredients for a fulfilling relationship.

Mother, Father, and Social Media Triangle

Now the wife stops working on the marriage and focuses on parenting. The husband is not aware of this decision, focusing on “making money to provide food, clothing and shelter.” The father continues to feel alienated, disconnected, and disempowered, becoming angry towards the mother and son. The mother turns to school staff, therapists, non-virtual friends, virtual friends, and influencers for ways to “fix her son.”

This fosters more of an enmeshment with son, and disengagement with Dad. The son turns to school staff, his therapist, non-virtual friends, virtual friends, and influencers. Each family member describes a feeling of disconnectedness trying to overcome the feelings of being lonely/alone. Dad voices his frustration, complaining that he is “old school,” and they are “hypnotized by that damn phone.”

Mother, School, and, Social Media Triangle

In this triangle, mom calls the teachers and guidance department for support. She has frequent phone calls with the guidance counselor because the guidance counselor “is an expert with adolescents.” As you can see, dad is left out of the interactions with the school.

After a few months, her son’s behavior is not changing, and mom is frustrated with how the school is not helping her son. Mom begins to turn to social media looking for answers. Mom spends hours on the app talking to non-virtual friends, virtual friends and reading/commenting on influencer’s posts. Mom displaces healthier activities with time spent on social media. Mom begins to complain that the school is not meeting the goals set out by the Individualized Education Plan (IEP). Mom cites information from influencers from social media and the internet. The tension rises between the school and mom.

Schools today are under tremendous pressure to perform. Schools are understaffed, and do not have the mental health training or support to bring in a countercultural systemic approach into the schools despite the money being put into schools after COVID-19.

Parents, Son, and Social Media Triangle

Mom is spending hours on social media looking for answers to why her son is struggling. She also spends time looking for connections. The son also spends hours on the app interacting with non-virtual friends, virtual friends and reading influencers’ posts.

Mom pursues the son, but he only is aligned with her to challenge dad’s limit setting. When the parents attempt to be aligned, the son acts out more. We see the son increase his conflict with parents, who struggle due to their enactment/conflict avoidance with each other on how to help their son. This results in the father leaving and the mother turning to social media to find answers or overcome feelings of loneliness.

When the family interactions are in intense conflict or conflict avoidance, many children, adolescents, and young adults get most of their answers from non-virtual friends, virtual friends and influencer’s posts. The son is seeking temporary relief by getting information and trying to affirm a sense of self.

The non virtual, virtual relationships, and influencers introduce beliefs that are the opposite of the family’s beliefs and further impact the self-esteem of the adolescent. The son discusses what he learns from social media of what “real parents are like.” The decrease in face-to-face communication with family increases his anxiety, depression, irritability, and intrusive thoughts. This also confuses the family of how their family member can “think so differently.”

Son, Non-Virtual Friends, and Social Media Triangle

The son in the session discusses constant social competition/comparison, working for social currency, and thinking he at times is invisible to his non-virtual friends. The son gradually believes his non-virtual friends “don’t understand.” He believes he cannot turn to his parents because “What do they know?!”

The son begins to engage in the same interactions with his peers as his parents and avoids turning to his peers for support. The son begins to spend more time on social media with virtual friends and influencers to seek select information that matches a narrow/closed view, hoping to avoid conflict/interaction. The son then turns more to virtual friends and influencers for answers. Again, this increases his time on his smartphone and increases the family’s sense of not being good enough for each other.

Remember, the son believes there is “less stress” getting information from a stranger, pop culture icon, or a virtual friend than an enmeshed mom, disengaged father, or face-to-face with a peer(s). However, the decrease in face-to-face communication with family and non-virtual friends increases his anxiety, depression, irritability, and intrusive thoughts.

Despite the time spent on social media, the son feels alone/lonely, looking for emotional, face-to-face and physical connection, but does not have the words to express these thoughts to each other.

Mom, Therapist(s), and Social Media Triangle

Dad continues to be absent from the triangle that involves the therapist. The mother attends her own therapy and attends her son’s sessions to discuss what new information she has seen on social media.

She reviews with both therapists what she has learned on social media about new treatment, new medication, and new diagnoses. She advocates with all providers that her son is incorrectly diagnosed, hoping that would help him with his symptoms. The quality of training of the therapist determines their response to entertaining or challenging mom’s research. This may result in mom seeing a new therapist.

The individual therapists and psychiatrists are not looking at how the parents avoid “getting on the same page.” They are reacting to reports by mom about the son’s behavior. Mom and dad are unable to interact differently because they have not figured out how to work together to decrease their son’s phone usage to increase his time with non-virtual friends. The professionals are avoiding addressing the parent’s avoidance!

Mom, Psychiatrist, and Social Media Triangle

Dad is absent from the triangle that involves the psychiatrist. Mom becomes disgruntled with the psychiatrist. She begins to challenge the psychiatrist’s diagnosis and medication recommendation. The psychiatrist recommends if mom is not satisfied with his assessment, she seek a second opinion. Mom begins to look for a psychiatrist who agrees with what she has read on social media.

Son, System of Care, and Social Media

The son is seeing his individual therapist 1-2 times a week and his psychiatrist once a month. He is also spending 2-8 hours on his social app each day. The therapist has not assessed the hours the son is spending on his phone. The app is only showing views/opinions/likes/images that interest him.

The son begins to complain that the therapist does not understand him and challenges his therapist saying, “This doesn’t help.” When the therapist explores the son’s statement, he begins to discuss information from “reliable sources” from social media and influencers. He too begins to diagnose himself and discusses medication that can help. When the system of care discusses reliable sources such as universities and professional journals, the son becomes irritated saying “I don’t want to read them.”

Son, School Staff, and Social Media

Not only does the system of care increase their sessions, but the school staff increase their time with the students. The number of triangles with the son in the school increases between the child study team, teachers, and administration.

The teachers are pursuing him to get his work done — offering to meet him before school, lunchtime, and after school to complete his work. He never shows. The son is seen in class on his phone. Some teachers ignore him, and others nag him. When a teacher challenges the time he is on his phone, he tells the teacher other instructors let him do it.

The social worker is calling him down to discuss his avoidance of work and disruptive behavior in the classroom. Only when the son becomes overwhelmed, he discusses with the school social worker his home life and that medication is not working. The vice principal is meeting with him to give him detentions. The son feels frustrated with the school stating, “They are only doing this because it is their job.”

Son, Non-virtual Friend #1, Non-virtual Friend#2 with Social Media

The son leaves school to go home to continue to work on his non-virtual relationships on social media. It becomes evident that in social media apps, the same social stressors occur online like in school. It is exhausting to navigate being included and avoid being excluded at school and online. The son and non-virtual friends are jockeying for social currency and social position, never getting time off to charge their own social battery.

The son and non-virtual friends stress about the images they post. They are anxious about what the image means to them and others. The son is trying to understand the unspoken rules for posting and the reaction by his peers regarding the image. The son worries if the image appears “authentic” and will help him maintain his position inside the social media group or if a new group be formed without them.

Son, Non-virtual Friend(s), and Virtual Friends

The son struggles connecting with his non-virtual peers. He is not getting feedback from his non-virtual friends about his art and his physical appearance and finds out they have different chat rooms that do not include him. (Remember, he does not want feedback from an overly involved mom or detached father.)

He begins to look for feedback about his art and physical appearance from virtual friends. When looking for connection outside the non-virtual friend group, he states he is looking for virtual friends who are nonjudgmental.

But as time went on, it began to mirror the non-virtual group. Some of his virtual friends on social media become competitive and attempt to increase their social currency on this platform. They do this by making fun of his physical features and his art. This mirrors some of his non-virtual friends’ behavior. The son frantically searches for another virtual peer group that he believes will not activate anxiety by not challenging his views, providing a stress-free venue.

As the son increases his time searching for virtual peers and influencers over non-virtual friends — reinforcing a closed system, increasing isolation at school, and decreasing time to sleep at home. His virtual relationships are now more important — increasing time spent on the app and continuing to strive for more likes and views.

Lack of face-to-face contact with family and non-virtual friends fosters more of a virtual enmeshment with virtual friends. He describes them as “nonjudgmental” and “more accepting.” This further increases his self-doubt and increases his feelings of loneliness and creates a virtually closed system (Virtual Enmeshment).

Son, Virtual Friends, and Influencers

The virtual group is important to maintain when avoiding contact with his parents and non-virtual friends. The son describes his virtual friends as more “authentic” and describes his non-virtual friends as “fake” and “not genuine.” However, some of his virtual friends on social media become competitive and attempt to increase their social currency.

The son frantically looks for another group that is an anxiety and stress-free venue. This further increases his self-doubt and increases his feelings of loneliness. This increases the symptoms of anxiety and depression when waiting for approval from virtual friends saying, “They are the only ones who understand me.”

As the son looks for new virtual friends, he and his virtual (and non-virtual) friends look to influencers for answers on how to portray themselves. Influencers work hard to establish and maintain their position in their virtual community. The influencers are working hard to make money and increase their viewership. The influencers often ask adolescents to agree with their beliefs and recommend products they are selling. The influencers work hard to appear on the “right side” of an issue.

As the son tries to replicate the beliefs of his preferred influencers, he looks for fellow virtual friends that have done the same “research.” They notice the more they make comments in opposition to a belief, it increases their views and likes.

As the symptoms in the family increase in intensity, the members increasingly must decide who to align themselves with in the virtual and non-virtual triangle. The therapist highlights this and encourages the family to discuss and identify the boundaries of virtual and non-virtual triangles that maintain these alliances/symptoms. This allows a family to discuss non-virtual triangles that are underutilized, which reinforce healthy boundaries that benefit the family.

Using Exploring Questions to Make Circular Statements

Much has been written about joining, unbalancing, and mapping in SFT. One of the beautiful ways Structural Family Therapy (SFT) uses language is by employing circular statements to connect the family member’s behavior in the system. When SFT enters the family, the systems therapist uses the family’s own observations to connect their interactions.

It is important today to make a circular statement to widen the lens in which the family sees how all virtual and non-virtual relationships impact the relationship in the family. Below are some examples of circular statements using the words used by each family member.

I agree with you, Mom, that as long as you do not have a voice with Dad and work together, your son will not stop posting explicit images on Snapchat

Dad, as long as you sound like a drill sergeant, Mom will not find her voice as a woman and work with you as a wife and mother of your son who will continue to believe he must mirror images on Instagram

Mom, I agree that the harder you work, the less Dad helps you with parenting your daughter— your daughter will have to turn to influencers about how a woman should look and act

Peter (son), as long as your mom is worried about the frontstage appearance, she will fight with your father who is more concerned about your backstage struggles with you and your mother

What do your virtual friends give you that you cannot get from Mom, Dad, or your non-virtual friends?

Conclusion

Many are worried about the continued increase in suicide, suicide attempts, and mental health issues in the family and how Congress is powerless to challenge these companies. Many providers are not looking at what has changed in our lives in the past 25 years.

Relationships are becoming more complicated than ever. Many families and therapists are unaware of the impact of the system of care and less aware of the impact of the ubiquitous “algorithm.” It is hard to understand how the algorithm works because it is important for these companies to keep the algorithm secret for fear of losing profit.

We must also remember that each influencer, virtual friend, and nonvirtual friend has their own family map. Just as many professionals do, influencers understand how their stories, views, and images echo in the family.

Are families aware of the alliances that occur with virtual and non-virtual friends and influencers? Are we aware that when more virtual influencers and friends enter the family, more alliances increase establishing social hierarchy, increasing social competition and social currency? Are we, the clinicians, aware that influencers and virtual friends unintentionally/intentionally begin to write/rewrite stories in the family and permanently on the internet?

We must begin to understand that with more stories, there are more opposing interests for each family member. This phenomenon between families, virtual friends, nonvirtual friends, and influencers (social media) is a result of collusion when all parties collaborate to uphold their preferred sociocultural trend.

The goal is not only to highlight and interrupt the multi-alliances with existing social media but to highlight the transactional pattern in the home that maintains this pattern. Remember, a virtually closed system impacts all family members, whether one or all are using these platforms excessively.

References

(1) Susruthi, R., Myara, Maymone, B. C. & Vashi, N. Selfies-Living in the era of filtered photographs. JAMA Facial Plastic Surgery. 2018 20:6, 443-444.

(2) Nesi, J. (2022) The impact of social media on youth mental health: Challenges and opportunities. North Carolina Medical Journal, 81(2), 116-121.

(3) Colapinto, J. (1995) Dilution of family process in social services: Implications for treatment of neglectful families. Family Process. 34:59-74.

Questions for Reflections and Discussion

How has social media influenced your personal and family life?

How does the author’s premise resonate with you and the way you practice family therapy?

How have you integrated social media and app use into family therapy?

In what ways do you agree or disagree with the role of social media in family systems?

© Psychotherapy.net 2023

Death Cafes: You’re Going Where?

Posted on by Psychotherapy.net Team

* If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org. Text MHA to 741741 to connect with a trained Crisis Counselor from Crisis Text Line.

The Death Positive Movement

In Victorian England, death was in the forefront of society. People would begin talking and planning for their death when they were young. By the time someone died, there was no doubt about what was wanted and how it was to be carried out. Women would even make their shrouds to be included in their wedding dowry.

Since that time, we have made a complete reversal in how we deal with death, from being the center of one’s life to rarely being discussed. However, continuing to ignore it will not make it go away. Death is coming for all of us.

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In 2011, the Death Positive Movement began. Since then, it has been providing opportunities for people to talk more openly about death and dying. Its goal is to decrease the stigma of death. However, many people are still unaware of the movement and the activities associated with it. Perhaps one of the better-known activities associated with the movement is the Death Cafe.

Quite simply, Death Cafes are places that you can go, for free, to feel comfortable and safe talking about death. Actually, you do not even have to talk if you don’t want to. There is no planned agenda, and anyone can bring up a topic to discuss. It is free. Cake and tea are always served and sometimes other beverages. The Cafes are currently found in at least 80 different countries. Sometimes the group may be run by a mental health professional, though most of the time it is someone who has no training in groups or mental health.

While Death Cafes are not meant to be support or therapy groups, I have generally found that people who attend these meetings are warm and supportive of each other, sharing a common bond in accepting mortality. Other activities associated with the movement are Death with Dinner and Coffin Clubs. Often Death with Dinner consists of smaller groups who might get together at someone’s home for dinner and discussion about death.

Coffin Clubs have been popular in New Zealand, England and Ireland, although I am unaware of Coffin Clubs in the United States. People get together to build, decorate and try out their coffins. Members enjoy being with each other. It is a safe place to talk about their lives and future death. An additional benefit to the Coffin Club is the significant amount of money saved by building their own coffins.

Death Cafes and Therapy

Of the three activities, my clients and I have experienced the Death Cafe. I attended the first Death Cafe held in New Orleans and was amazed by the number of people who came. It was a mixed group, with some being from the medical and mental health fields, while most of the others were from the community. They had heard about the Death Cafe and came to see what it was all about. It was a unique experience.

You don’t usually find people sitting around talking about death. However, it was very encouraging. For over an hour, we introduced ourselves and talked about what had brought us to the meeting. Some came due to curiosity, some due to the loss of a loved one, and some with their own terminal condition. All were interested in discussing and learning more about death. It is good to be able to see that others have the same concerns and fears about dying as we do.

During the meeting, I began to reflect on the people in my practice who might benefit from this experience, and then I thought about Sarah. Sarah was a 74-year-old woman who came into therapy to talk about her declining health. She had been diagnosed with congestive heart failure, which was worsening. She felt that she would not be alive for much longer and wanted to talk about dying.

The problem was that her family did not want to accept her impending death or talk about it — an all-too-common experience. I talked with Sarah about considering attending a Death Cafe meeting. It didn’t take much to convince her.

The following week when she returned, she talked about her experience and how it was like a “breath of fresh air” for her. “People were so welcoming and open,” she said. “It was a relief to be able to talk about dying and not feel guilty. I’m glad I went. I feel like I learned a lot.”

The meeting seemed to empower Sarah. She decided that she wasn’t going to wait around for her family and that she just needed to take charge of all the planning herself so she could have everything just the way she wanted. She began to plan her funeral, the music, and the dress she wanted to be buried in. She picked out her gravesite and even designed her own headstone.

I have also encouraged trainees who were interested in palliative care to have the Death Cafe experience. It has been a great learning tool and helps them to be more comfortable when talking about death with others.

Tulane Medical school has also been in the forefront of utilizing the Death Cafe as a way to address burnout in medical staff who work in high death areas such as the ICU. The meeting I attended included medical staff who worked together on a surgical unit. A child had died in surgery, and the doctor who had performed the surgery was sharing the impact on him as well as the other staff present.

It was very touching to hear him. His pain was almost palpable. Perhaps most striking to me was the atmosphere of the group that allowed him to be open with his feelings of sadness and to cry at the loss of his patient. There are perhaps many different providers who work with the dying that could benefit from debriefing Death Cafes.

Of course, not everyone is enthusiastic about learning more about death. In my practice, I have found that women tend to be more open to the idea than men. There was one situation that has stayed with me for years that demonstrates the power that the fear of death can have: Patricia was brought to therapy by her husband at her doctor’s request. She had been quite ill and recently diagnosed with cancer. Her husband brought her in because the doctor said she was depressed.

It was hard to determine if she was more afraid of her husband, or of dying. One day, she told her husband what we had been talking about. He flew into a rage and would not let her return. It is this fear that speaks to the need for Death Cafes to normalize the process and free people up to talk about what is ahead for all of us.

The Death Cafe has a saying: “talking about babies won’t make you pregnant and talking about death won’t make you die.”

Imagined into Agency: Goth Lolita Comes to Life

Posted on by Psychotherapy.net Team

The Beginning of My Story with Misha

Misha had experienced several “failures” at therapy by the time she made up her mind to give it one last try with me. She gently and quietly summarized her hope at our first meeting.

“I want to feel something other than depressed and anxious…”

She had clearly decided to make this last effort at therapy count as she proceeded to offer a description of how she had felt compelled to “lie” to her previous therapists about the “usefulness of their suggestions” to her in living with the effects of what felt like an “all-encompassing depression” in her life. When I asked more about the purposes of such lying, Misha told me how she was too ashamed to return week after week having attempted her breathing exercises and not feeling any differently. I invited Misha to spare me the lies and instead requested she fire me immediately and without warning if I ended up setting her up to fail at our conversations. We giggled together at this and from that point, I vowed to forego any advice, suggestions, or tips for Misha’s life. Instead, I turned my efforts into learning more precisely how it was Misha had been hurt and also how she has held tightly to the idea that she has something far beyond depression: a life worth living.

In our first conversation, Misha invited me into the realm of her experience of “depression.” She spoke of the relentless “arguing” in her mind for her to finally learn to “suck it up,” “control herself,” “smile,” or else “be invisible,” and if she could not fulfill these demands, she ought to consider herself a “waste of space” and her life to have come to its end.

She spoke of the aching loneliness and strangeness she felt with the world and the people in it. She described the crushing pressures to “please others” and make “pretend appearances” in life as a “compliant and pretty girl.” Misha asked me to help her understand if she was “crazy.” How else could she come to understand the effects of a life of being neglected and the little favor she had experienced, especially at the hands of her respected parents? She told me of her sense of being an “unwanted burden” to others as a small child and her longing to be attended to in a loving way. She described her days as a child spent alone in an apartment from sunup to sundown scrounging for food and watching television. She recalled the many times her requests for company or attention were rebuffed as “complaints of a spoilt brat.” Misha told me of the time her caregivers made her role in life abundantly clear to her: at age 6, when she cried, a mirror was shoved in her face and she was admonished. “Look at yourself, you look ugly when you cry.” My heart broke for Misha upon hearing these stories of cruelty and haunting neglect.

She was born a girl

Nourished on scavenged milk and bread

Fed lies of illegitimacy

And yet she grew up

In hell – a place that whispered endlessly to her:

You don’t matter

Hell is scary and an all-alone place

It tears apart her insides

As she musters every ounce of faith

To beg — please, stop the punishment

Instead of a trip to Heaven,

She found the apartment cleared out

-The hell moved to its next phase…

“So you see,” Misha concluded, “all my life I have lived in a box and it was opened only for me to perform a perfectly good and cute girl. If the box was opened, and I happened to not be smiling to the pleasure of others, I was reprimanded to smile and not be so serious.”

“I do see, Misha. I do,” I said, feeling the sorrow of a young child who was in a horrible bind to please the whims of these adults and struggle with the confusion of these demands that left her lonely and bereft and at odds in her own skin. I was full of sadness for all that she had been deprived of when she was not treated as a precious child. But there was something intriguing about the fact that Misha did not flinch when she told the stories of her life. As a consequence, I felt my own hopefulness billowing within me as we set out to plot her escape from the box.

…She tells the truth

And she forms her words late into the night

Because she always knew how to hoard the most precious things

Like her very own life:

She knows how to lie to stay in school

She knows how to be enraged at comings and goings without explanation

She knows the pungent taste of hatred in her mouth

She knows how to rely on herself

She knows how to demand an explanation

She knows how to scream: HOW COULD YOU?

She knows she is not willing to live with disregard

She knows how it feels to be rejected by society

She knows how women are forced to make horrible choices

She knows how to shift her charms when need be

She knows how to hold onto tenderness and hints of love

She knows how to recognize soothing words

She knows how to silence taunting recollections of the past (Don’t ever talk about that again)

She knows what it feels like to live alongside angst and sorrow

She knows how to pick up the phone in the midst of darkness

In this first meeting, I came to imagine Misha’s life of invisibility, of performance pressures, and abandonment. I came to imagine and understand something of what it was like for Misha to live “shoved into a box.”

…It is tricky to spot me

Inside this box

Emerging with the masks

That will please you

And protect me

It’s a neutral costume

That has been skillfully sewn together…

I came to marvel how Misha had mustered up the energy and steadiness to walk herself up many flights of stairs to get to her university counselling center and to exclaim in her desperation, “I want to die.” I came to understand depression as a strong, argumentative voice in Misha’s life that functioned to keep her poor company inside the box. Depression’s tiresome arguments left Misha’s mind exhausted. They had diverted her from questioning the reality of the painful experiences she had endured so she might consider any sense of her own agency while navigating a lonely childhood and youth.

…It was then that we thought

Maybe the depression

Was leading her astray

With the idea that feelings

Are failures,

Tearful mirrors have been used against her after all.

But all the other stuff, it has to count, doesn’t it?

We wondered together…

“What would you say, Misha,” I asked towards the end of our first meeting, “if you and I were to set out in our conversations together to understand the makings of this box…” Misha seemed intrigued. And so, it was that we set out to understand the makings and effects of the worst of the good-girl cardboard, plastic, and paper boxes and to tell every story of the living girl and her efforts at liberation.

“She does have a logical voice and a tiny light with her in the box,” Misha ventured shyly. I was moved by her proposal! But that is not all she had as we were soon to discover together. Not by a long shot.

Beginning Leads into Our Work in The Imagination

Our lead into the realm of the imagination happened by surprise and was entirely guided by a moment of rare joy and delight on Misha’s face. It was the first time I had seen Misha smile a real smile since our first meeting, and this smile with the accompanying sarcasm in her voice set us both off for travelling far beyond boxes to another way of appearing.

At the time of this significant smile, Misha was struggling with her upcoming birthday. She told me that every year, her forthcoming birthday was a time of particularly intense arguments and accusations by depression. Depression was exacting “happiness performances” of her, as well as overwhelming her with memories of being scolded for acting like “she owned the day,” and reprimanded for not being sufficiently cheerful.

“The only time when I escaped this box…” she began shyly, but then stopped abruptly, as if embarrassed.

“The only time…?” I said, hoping to encourage her to continue speaking, holding my breath.

“Well, the only time was kind of using … makeup…”

“What do you mean?” I asked.

“Well, I remember when I was 11, I used to bring makeup to school and wear these really bright colors of eyeshadow and lipstick at school. I’d feel like such a rebel. I wiped it all off before I got home, of course… but…”

“But?” I asked, on the edge of my seat. Misha smiled at me full of mischief.

“On those days, it felt more like me…I wasn’t granted freedom to express myself at home at all, so it was these little wins that would keep me sane.”

…There are precious and hidden compartments

In the box

That represent secret freedoms

In moments when I remember

About all the selves I do not show

I impulsively

Kick myself out of the box

Like only the most daring kind of rebel would:

Full of cool piercings

Colourful lip balm and the boldest eyeshadow

Picking up little wins along the way to keep myself sane

I want the punk, the goth, the feminine frilly girl

To be expressed

One day I might march the streets

Right out there as myself

Holding placards:

ANTI-CONFORMITY

PRO-JOY

My black nails and Lolita dress

Will grab your eye

And you might wonder

How I got out of that box

But I will know it was a lifetime

Of hidden rebellions

One tiny kick at a time…

There was a growing excitement in this conversation that really captured my attention. Misha was laughing and being sarcastic; she was nearly “giddy” (Misha’s own word!) in recalling what she “got away with” with her joyous “makeup rebellion.” Here is the end of our conversation that day:

Chelsey: Given these little acts of breaking out of the box all along, how important is it for you to express yourself in these kinds of ways for your own freedom?

Misha: Umm, I mean they definitely do bring me joy. I can talk about my piercings. They are permanently there. When I see them I think they are so nice. I think I’ve learned that there is a “me” inside my head, the punk one, the frilly girly one, the one with tons of piercings, the one that likes things that aren’t the norm. I’m happy keeping her in my head. Yeah, it brings me joy. I’ve sort of learned that I’m not going to get that because society expects me to look a certain way. I can conform to that while living a fantasy in my head.

I was so delighted to witness Misha’s excitement in sharing these details of makeup and piercings and “alternative me’s.” When I remembered her smile long after she had left my office, I resolved to not let these details go, but instead to “delve” into them. I wondered where Misha’s imagination for bold expression might take us. I very much wanted to be front and center on the runway of Misha’s “expressive revolution,” and couldn’t help but wonder if this might be the very key to unlocking the “counter agent” that Misha had been shaping even from inside that box, safe from her critics.

What if her smile and the rebellion she had imagined into being at age 11 might have something to say about the pressures toward “good girl appearances?”

If she could wear daring makeup as a means of expressing the artistry and freedom of her soul at age 11, in what ways might she imagine responding to her neglect and the voice of depression now?

If the clothing one wears has the power to change the way one walks, as Misha proposed, might it also have the capacity to embolden her thoughts beyond the reaches of the punishments she had received?

If she could play with her senses in the world of color, texture, design, and movement, maybe Misha could walk right into a new kind of world.

And what would be possible for Misha to utter in this new world without depression arguing every one of her thoughts right out from underneath her?

In any case, I couldn’t let up on this realm that Misha just invited me into; there was hope in this land. I could see it in her smile.

Enter “Goth Lolita”

While holding on to Misha’s spontaneous expressions of delight and taking them as substantial guides for a possible path to walk out of misery and suffering, I trained my ears to listen to her expressions for what she could enact in this imaginary world. I heard her say, “Expressing myself brings me joy,” and “the idea that if I like it, that’s what matters.” These were entirely new ideas and words unlike the ones that “depression” had long whispered to her. “Joy” and “liking” — Misha and I coined these terms as part of her “hidden rebellion.”

…I thought of the unexpected giddiness, the unusual happiness.

An empowering action she did for the sake of possibility.

I thought of how she got away with it!

And there was this lightness that followed

It was a blue streak

Beaming with intention…

Here is the ensuing conversation that introduced us both to an imaginary character that would become our treasured guide:

Chelsey: Is it valuable to discern the parts of you that you’ve held onto, and secretly imagine yourself in these different looks…or maybe dress up in your room, but no one even sees you…have you tried that?

Misha: (with delight) Oh yeah! I know exactly what I’d wear. I’d wear black lipstick or crazy makeup…

Chelsey: The way you speak of this is so remarkable to me, Misha! You know, earlier you used the word rebellion…

Misha: (strongly) Yeah!

Chelsey: Is there something of a rebellion going on inside you that people don’t know about?

Misha: (smiling) Yeah!

Chelsey: Would it be fair to say it’s something of a protest against these restrictions that were set upon you?

Misha: Yeah.

Chelsey: Is this — the words “rebellion” or “protest” — is this a way you’ve known yourself before or is this a new idea to you?

Misha: No. I think it’s always been there since I was a little kid. I think it’s more internalized. I guess I knew I’d get in trouble or be reprimanded if I showed it. I don’t want to do that…but I’d still like to do that. While I’d still like it, I’m not going to show it. It will be my thing that I’ll keep to myself. Even if my parents accepted or tolerated it, it’s kind of like… hoarding things that are mine. When I was little, I was a tomboy, always in runners and tracksuits. They were telling me to be a pretty girl with white socks with a frill, which is funny because now I do like those things. Not dressing how they wanted me to… that was my little win. I was doing all these other things to please their demands, but I was doing this one little thing that wouldn’t get me into trouble, but it was my own.

Chelsey: Have you told anyone about this little rebellion before? I shouldn’t call it little…secret rebellion? Is that a good word? What do you want to call it? What’s a good name?

Misha: Hidden? Haha.

Chelsey: The hidden rebellion you’ve described as being internalized. In sharing it with me, is it getting out a little bit?

Misha: Yeah, parts of me think, maybe I should just do it. Almost like I should freak out and just do it.

Chelsey: You play with this in your mind?

Misha: Like, who cares.

Chelsey: Holy cow. And if you were, one morning — no, let’s say Monday, cause it’s your birthday — you were to wake up and something magical was in the air, maybe it was, when you wake up on your 26th birthday and you have this giddy feeling in your body like you described and you get out of bed and you think, “You know what, who cares, it’s my birthday, I’m just gonna do it.” What would you put on?

Misha: What would I put on?

Chelsey: Yeah.

Misha: Hmmm… I would say… a Lolita dress.

Chelsey: Do you have one? What would it look like? I don’t really know what that is… If I did, I’d be way cooler. (laughter)

Misha: It’s a Japanese alternate fashion. They look kind of like dolls, like cupcakes.

Chelsey: What color would yours be?

Misha: I’d merge them, like a Goth Lolita. Black dresses…yeah!

Chelsey: Okay, I gotta write all this down! I want to hear the rest of the outfit. We only have the dress down.

Misha: I’d wear a crazy color hair.

Chelsey: Like what? Pastel?

Misha: Yeah, pastel would be good, I like alternate color hair. Something crazy… maybe pastel blue or something, yeah.

In the above transcript, I was introduced to someone whom Misha and I would from here on out refer to as “Goth Lolita.” Goth Lolita, according to Misha, is a woman who has some very clear ideas about how she can take up some alternative ways of being in her world. Goth Lolita is an expert in doing what she wants, which was exceedingly important to Misha. For example, Goth Lolita had ideas for Misha’s birthday; she thought that Misha might go out in her dress and have a picnic in the park and that she might like to see others go by and marvel at her freedom of self-expression. I was floored to discover that Goth Lolita could so easily speak about her clear vision of a riotous birthday outing. Misha herself for the first time spoke of the word “bravery,” relating to Goth Lolita’s ideas for her life. Our conversation on that day ended like this:

Chelsey: You know what I’m noticing right now? You may not agree with this… but guess who didn’t boss around our conversation? Like this was you and me really talking, like the you you. Is this right? Do you agree that depression was shutting up while we were talking today?

Misha: Yes.

Chelsey: (smiling) Did you just rebel against depression in this conversation?

Misha: (smiling) It was freeing. Everything I’ve shared is a secret, but this is a secret that I’m not ashamed of. It doesn’t bring pain to my life. It’s something weird about me, but not messed up.

“Goth Lolita” Shows the Way

When Misha came into my office for our next meeting after her birthday, I was in for a surprise. Misha appeared with her hair dyed blue and her nails painted black. Misha laughed at my dumb-struckness and my attempts to ask about how she had gone and taken up Goth Lolita’s ideas! She was beaming as I asked questions about this “visible action” toward her invention for her much-dreaded birthday.

In addition to hair dye and nail polish, Misha also took to the page and wrote me a letter that week that outlined the “worst of her stories” of her growing-up experience. She told me she sent the letter to me with shaky hands and a beating heart and was up all night after hitting send. She had never before uttered these words to any living soul. She had dreaded feeling horrible regret and shame and perhaps even getting scolded by me or her family for her change in appearance and spirit.

However, in our conversation following these developments, Misha found herself questioning the voice of depression about its threats regarding her “shaping rights” of her own life because she did not suffer retaliation for her bold new actions. Misha wondered if this had to do with the spirit of Goth Lolita appearing by her side, the spirit of a young woman who can catch her eye in the mirror and be surprised by happiness and stand proud in her “breaking out of the box.”

…It did not lead to spirals

But to a woman

Who caught a glance of herself in the mirror

Except this time

She knew something of happiness

The depression shrivelled so small in that moment

Like a wrinkled raisin

Its power was diminished….

At this, I wondered if there was a way to speak to Goth Lolita herself. If Misha and I might travel together into the imaginary realm of Goth Lolita and her ideas, what possibilities alongside “snacks for a picnic” might we consider?

Misha and I decided to invite Goth Lolita to be interviewed during our conversation. I was attempting to learn Goth Lolita’s thoughts on Misha’s behalf, and to bolster Misha’s agency as she had already begun to bring this inner idea about an “alternate self” into the outer world through her hair, makeup, and writing down the “unspeakable.” I was wondering how Goth Lolita might lend her voice to Misha as she was stepping into these new questions, words, possibilities, and experiences in her life. I puzzled over what would happen if Misha could be witness to Goth Lolita’s thoughts on her recent efforts in living. Could this imaginary realm expand Misha’s possibilities further?

(*Note: In my study of this transcript, and on behalf of any future ventures into such imaginary realms, I found myself wishing to refine the questions I asked of Goth Lolita that day. I have included my revised questions in the following excerpt for further consideration.)

Chelsey: Goth Lolita, are there any particular words or sayings or phrases that come to mind? You don’t have to censor them…they can be horrible swears, or not, in Spanish, or not…that you would say to this shame and blame. If Misha’s voice was shaky and her mind was blanking and she needed you to speak up for her and push back, what would you actually say?

Misha: (as Goth Lolita) That there is nothing to be ashamed of who you are or what happened to you. That there was no —you didn’t have a choice, it wasn’t by your own doing. That in many ways, surviving it shows some strength or some resilience and that even though it happened, and you may never want to talk about it or acknowledge it, maybe you can take it and sort of build yourself up knowing you can overcome things that you thought you couldn’t. [PAUSE] But that girl grew up and is no longer in that situation. So, I guess she can jump out of the box and be Goth Lolita.

Chelsey: HOLD ON GOTH LOLITA! You’re saying, “Hey Misha, join me!” Is that how you’d say it?

(Chelsey, revised: Hold on Goth Lolita! Are you suggesting that Misha has lived in such a way that you would be honoured for her to escape from that box and join you? Why is it that Misha earned this spot as your companion in living? Do you have some stories coming to mind about how she has befitted such an honoured position as a co-picnic enjoyer, style-star, and freedom fighter? When did you first get the sense that Misha would one day join you and what you stand for in life?)

Misha: Sort of. Break all the barriers… whether it is you or other people have placed them around you. Whether it’s “break the box” or “jump out of the box.” I guess it’s don’t let the errors of everybody in that story hold you captive in the box.

Chelsey: I’m having a clearer picture now, Goth Lolita, of you saying these things out loud with a conviction, almost like talking to the box. I see you in your dress, like this maybe talking to this box. Is there an action you’d take, Goth Lolita? Do you extend your hand? Do you help pry open the box? What do you do as you encourage Misha to break the barriers?

(Chelsey, revised: What have you witnessed Misha doing to escape the box that she was held captive in? What kind of unboxed life was Misha reaching for when she pried open the box enough to see you standing there with your hand extended?)

Misha: I guess it’s sort of rebelling one step at a time. And maybe it is working on the things that made Misha more Goth Lolita. So, whether its Step 1: dye your hair blue, or step 2: wear black nails, find what other steps or what other actions or what other feelings can be given to Misha so that she can break out of the box, or walk out more Goth Lolita and less childhood-stuck-in-her-past-Misha.

Chelsey: And Goth Lolita! You have this idea and you have even laid it out in step form! Does this get you thinking Goth Lolita about what might be next for Misha if she were to see these steps as things that she could do or take up in her life?

Misha: It’s an overall arc of accepting her weirdness or her alternate tastes that might bring joy. It may make her more comfortable in her own skin. Maybe it’s working through her self-worth because right now there isn’t much of that.

(Chelsey revised: Are you suggesting somehow, Goth Lolita, that there might be some worth in accepting an overall arc of Misha’s weirdness? Just how much worth do you think Misha has had to hold onto in order to keep her ideas and alternate tastes alive despite the boxed life that others had in mind for her? In this overall arc do you imagine Misha’s dyed-blue hair might hold more worth than what the tab at the salon might have been?)

“Goth Lolita” Takes Back Stage While Misha Stands

This imaginary conversation with Goth Lolita as a witness to Misha’s actions made it far more difficult for the arguments of depression to dismiss Misha’s imaginative ways of responding to the narrow life proposed by the dull rules, the dress code, and the dismissal of her person. At the beginning of Goth Lolita’s companionship, Misha would always anticipate what the voice of the depression would have her believe about the insignificance of her own actions in life, but Goth Lolita served as a lively counterargument with flesh and blood and bold ideas. Misha said to me at one point: “I started this. I voiced it. This gives it a shape and physicality. There is something worth trying for in this push against the voice of depression.” Misha recalled how the arguments of depression were losing their influence in her life. She began to be curious about the criteria by which she could stand behind her actions rather than having the voice of depression and its counsel of regret and shame be the sole judge of her life. Misha started to move beyond being a model for the purposes of others to being a designer of her own future.

As an example of this reorientation, Misha shared a story of living in residence at university. She told me that historically she struggled to find meaningful connections with peers. However, when she was in university, she had developed some friendships. Misha was putting in all of her best efforts to achieve this aim. They had, to Misha’s surprise, developed a supportive back and forth when it came to studying and leisure, often going for ice cream together to unwind after exams. The voice of depression had overshadowed the friendship successes Misha had accomplished with one person’s casual comment about Misha being “weird.” Misha initially grew destitute as the depression told her she was a failure and would never have any real friends. Once we knew something about how Goth Lolita might have experienced these same events, Misha was able to evaluate her own efforts and actions as “wins” in the realm of developing connections and relating with others. Misha’s imagination had allowed her to recalibrate her own barometer toward making meaningful actions against the depression.

Misha continued taking these agentive steps when she told me more stories of her life. Now they included tender memories of her and her family creating art together and caring for one another, not just the harsh tales of mistreatment. Her eyes, even when focused on the past, were able to see a fuller picture of how she was living. This made it possible for her to reinvigorate joyfulness and connection and hold it close to her heart for the future she was imagining.

These steps amounted to a grand leap in sharing the truth of her inner world after feeling very struck down by arguments with her mother who had trouble understanding exactly what Misha had been up against. In these arguments Misha had, for the first time, attempted to share her confusion about her mother’s attempts at “tough love” throughout her life. This argument felt insurmountable to Misha, however, and she considered cutting her mom out of her life as she had done many times before. But upon consideration of her new ways of expression, Misha wrote a letter to her mother outlining what it is like to live with the voice of depression in her mind and shared all the ways she had tried to be a perfect daughter and

Where Do You Draw the Line Between Psychotherapy and Coaching?

Posted on by Psychotherapy.net Team

Coaching vs. Psychotherapy

Psychotherapy and coaching may seem like they are worlds apart — as close to the uninformed as medicine and cheerleading. They are not only similar but are in many ways identical. As a retired therapist and an active creativity coach, I have some ideas about how this has come to be. On the one hand, psychotherapy, at least to me, never quite became the science it had hoped or promised to be. No theory of psychotherapy has ever been proven sufficiently rigorous or singular to win the title of “the best” or “the most effective.” And therapeutic techniques that flow directly from DSM diagnoses have similarly fallen short.

In contrast, coaching has evolved into a helping discipline unencumbered by the burden of calling itself scientifically minded or medically based. It asserts instead that helping requires an orientation away from the pathological to the normal, as well as the psychological, social, and contextual.

As a coach, I have never placed much emphasis on pathology and diagnosis. I always consider instead my client’s nature, which includes elements of despair, hope, fearfulness, addictive tendencies, and both personality strengths and shortfalls. I’ve been very careful in this role to avoid robotically co-creating goals and assigning homework — core “clinical” tools. I always saw the same all-too-human person sitting across from me as when practicing psychotherapy.

Over the years, I’ve come to appreciate how the two seemingly disparate professions have converged in their core orientations and approaches. They are both helping professions that rely on certain and specific strategies that are surprisingly simple to articulate: both helpers listen; both use themselves and what they know and feel; both empathize and, maybe sometimes in rather different ways, support their clients and cheerlead for them. And both are keenly aware that a human being with a formed personality and two feet planted in real-world circumstances is sitting across from them.

Psychotherapy may balk at this characterization and conclude that coaching is “merely” helping and not doing anything like science or medicine. But it can’t really justify any fancier claims. The arguments against the legitimacy of the DSM, its “mental disorder” paradigm, and its checklist mentality should persuade any open-minded therapist that “diagnosing” is for insurance and prestige purposes only. To announce to someone who is in despair that she has “the mental disorder of clinical depression” is a linguistic gambit, not a medical diagnosis. Therapists know this.

In my experience as a therapist and current work as a coach, I know that in both roles, I am carefully and compassionately listening to another human being and responding according to their understanding of human nature. If a client announces that he hates his job, a right-minded therapist is hopefully not going to impose some pseudo-medical interpretation of despair. She is going to believe that her client means exactly what he says. She may investigate to make sure that he is indeed saying what he means and not fibbing or fooling himself, but centrally and crucially both coach and therapist are going to formulate the same internal question: “What does meeting in the middle look like?”

The Limits of Coaching

Consider a client of mine whom we’ll call Jane. Jane is a middle-aged writer who has had some successes but who craves better sales and more recognition. She isn’t particularly interested in achieving another “middle list” success — it’s the prestige of a bestseller that she craves. What’s standing in the way of her pursuit of greater achievement? As it turns out, the answer is, ‘many of the sorts of things that both creativity coaches and therapists would expect to see.’

Jane isn’t sure that she has a bestseller in her. She feels resistant to talking the matter over with her literary agent and is resistant to writing. As a result, her mood has plummeted. Taking care of her husband, who is ill and who requires many medical appointments, further drains her, reduces her available writing time, and lowers her mood. Dealing with a lack of enthusiasm from recent readers has put her in an extra-deep slump. She feels generally anxious and has difficulty concentrating on her writing or on much of anything. Her sleep isn’t good, her eating habits disappoint her, and when she does manage to get to her desk, she finds herself procrastinating and distracting herself, sometimes for hours.

Both therapist and coach understand that this is what real life looks like. The therapist might find herself wending her way to a depression diagnosis, an anxiety diagnosis, an attention-deficit diagnosis, or some other pathological label. But in session, both would likely proceed in quite similar ways. They would listen; they would ask questions; they would ask follow-up questions. They would help Jane prioritize which of these issues she wanted to focus on. They might reflect on Jane’s language, maybe wondering aloud if, when Jane says, “I’m probably over the hill,” or “I don’t think I can come up with an idea for a bestseller,” such thoughts are really serving her. They might, with Jane, co-create a new sleeping regimen or help her acquire a useful anxiety management tool or two. They might “use themselves” by role-playing a Jane-literary agent interaction, with the therapist or coach playing the agent. They might point out a pattern, say, the way that reader criticism seems to overly affect her, or wonder aloud about Jane getting some support in her role as caretaker of her husband.

In this scenario, has the coach overstepped? I don’t believe so. And if a therapist had operated this way, would she have been operating exactly according to her mandate, if that mandate was to “diagnose and treat mental disorders?” Maybe not. But she would have operated completely in line with her implicit mandate to help a person in distress. Neither would be practicing medicine or following a version of the scientific method. Both would be attempting to be supportive, humane, helpful, and wise. Each might come to session with a different set of tactics and techniques, but both would be doing essentially the same sort of work and hoping for the same sort of positive results.

At the same time, both would expect Jane, and clients with similar narratives to be defensive and resistant. Neither would be surprised if the client were to take two steps backward for every half-step forward. Both would nod in understanding if the client found it hard to change, hard to keep to a program, hard to come to a session, hard to put everything on the table. Both coaches and therapists know these sorts of things.

I think that this is very good news for both professions. Therapists can own that they are not doing medicine, are not at the beck-and-call of pharmaceutical companies, psychiatry, the DSM, the ICD, or any other tentacle of the medical/mental disorder apparatus. At the same time, they can own that they are a useful class of helpers who are good at listening, understanding, and responding. They can feel more human (and more humane) and less white-coat-ish. Freed of these burdens, coaches, for their part, can step even more fully into helping — they can become better helpers by deepening their understanding of human nature and by bringing that increased wisdom to their sessions. Aren’t those excellent outcomes for both?

Do coaches need to know more than they currently know to meet this ideal of helping? Yes, absolutely. But most therapists do as well. Both groups of helpers need to rely less on their standard tactics — goal-setting and goal-monitoring for coaches and a single theoretical orientation like cognitive-behavioral therapy for therapists. Both are well-positioned to provide more wisdom and wide-ranging understanding than most in either group can currently muster. Each group can point to the shortcomings of the other group, but in this movement toward the middle, where coaches become more psychologically minded and therapists become less attached to the medical model and pseudo-scientific notions, perhaps the outline of a new wave of superior helping will emerge. I hope it will arrive soon.

Questions for Thought and Discussion

How do you resonate with this debate between coaching and psychotherapy?

In what ways do you see the two disciplines converge? Diverge?

How would psychotherapy and coaching look different with a client like Jane?

How to Help Clients Change the Narrative of Aging

Posted on by Psychotherapy.net Team

'I want to tell people approaching and perhaps fearing age that it is a time of discovery. If they say – ‘Of what?’ I can only answer, ‘We must each find out for ourselves, otherwise it won’t be discovery.’

(Florida Scott-Maxwell, The Measure of My Days)

Psychotherapy and Ministry: Trafficking in Metaphor

Who doesn’t relish the odd adventure to spice life up, be it bungee jumping, looking for love online, or watching a thriller on TV? Major or minor, firsthand or vicarious, adventures are essential, it’s been said, to a robust sense of self.

But might aging itself be an adventure?! The very idea seems a contradiction in terms. Before I propose that it isn’t, let me make a confession.

Prior to becoming a gerontologist, I was a protestant minister. In that capacity, I did my fair share of counseling, seat-of-the-pants though my listening skills were, but I’m no psychotherapist. What follows, then, are thoughts from the sidelines alone and should be taken, if not with a grain of salt, then with this admission in mind.

My sense, though, is that the two fields, therapy and ministry, share a key thing in common. They both traffic in metaphor; by which I mean, for instance, that there is always the possibility for a chance turn of phrase leading to an image that can be enlisted to help someone gain insight into their situation and move forward with their lives.

Given the profile of the average congregation, those I dealt with were mostly older adults. This might well have turned me off, as it can some psychotherapists — the feeling being that they are simply too old, and their problems too entrenched to benefit from counselling of any sort. However, I had no choice. They were “my people” and it was my job to get to know them. What I realized, though, was that they were often the most fascinating to work with.

Compared to my younger parishioners, these older adults had richer stories to listen to and learn from. And in attending to them as closely as I could, less as a professional, really, than as a friend, I felt that I was providing them with something that was implicitly healing. I call it “narrative care,” a concept that takes in everything from full-on psychoanalysis to soulful conversation. And because they had that many more memories under their belts, they had that much more inner material on which an aptly deployed metaphor that emerged amid our exchanges might work its magic, enticing them to re-story a little their way of looking at life. The metaphor of aging as adventure, I suggest, can do just that.

Growing Old: A New Narrative About Aging

Since switching from ministry to gerontology, my appreciation for the role of metaphor in both language and life has only intensified. The best example is my 30-year interest in the metaphor of “life-as-story," or what Ted Sarbin calls the “root metaphor” of narrative. This led me into a sub-field known as narrative gerontology.

Drawing on insights from narrative psychology, Narrative Therapy, and (in my own case) narrative theology, narrative gerontology focuses on the biographical dimensions of aging as opposed, say, to its biological ones, dimensions to which gerontologists, certainly geriatricians, devote a disproportionate attention. It focuses on how human beings are hermeneutical beings — makers of meaning — and how our main means of doing so is by making up stories, big or small, about events, the world, and ourselves. And it focuses on how our self-stories, these meandering works of imaginative non-fiction, these myths by which we understand ourselves, change over time, and the effects of that change, for better or worse, on our overall well-being. It looks, too, at the storyline we subscribe to about aging per se.

Whereas gerontology remains dominated by a biomedical paradigm, which, with the best of intentions, pathologizes aging as a problem to be treated with all the anti-aging strategies we can muster, narrative gerontology represents a different starting point for exploring the complexities of later life.

Rather than defaulting to a storyline of aging as a downward drift to decrepitude and death, as an intrinsically tragic trajectory or “narrative of decline” (which older adults can unwittingly internalize, as can therapists too), narrative gerontology looks at aging through the lens of a more optimistic narrative, a better story. It views aging as a matter of growing old, potentially, and not simply getting old. It views aging as a way to the light and not the darkness alone, as a narrative not merely of decline but of discovery, of adventure.

Depression, Decline and Narrative Foreclosure

Before proceeding, let’s consider the narrative challenges that older people often confront. These can underlie and, if unaddressed, exacerbate the many other challenges that later life brings. Since I’ve written elsewhere on these challenges — which go by labels like narrative loneliness, narrative loss, narrative dispossession, and narrative imprisonment — I won’t go into them here except for one that deserves singling out. It is narrative foreclosure.

Narrative foreclosure is the premature conviction that our story has effectively ended, that no new chapters are apt to open up, no new characters or themes will thicken the plot and take it in fresh directions. While our life itself — talking, eating, going here, going there — continues apace, our “story” of it is over. Granted, narrative foreclosure can befall us at any age.

When you’re 20 and your lover bids goodbye, you can suffer an acute case of it, and hurling yourself into the river seems a reasonable course of action. Why go on? The story of you riding off into the sunset together and living happily ever after will not come true! But later life, I fear, renders us unduly vulnerable to this condition, and thus the depression we may be diagnosed with and the pills we’re prescribed, when a dose of narrative care might work equally well to re-open our story. Here’s how it happens…

We retire from the career that defined our identity and our self-story loses a vital source of support. Our children get work in other parts of the country, taking our grandchildren with them, and our story-world shrinks still more. Our life partner departs this life and with them goes our raison d’etre. Our vision and hearing, mobility and autonomy grow more limited until we’re relocated to a nursing home where our world is reduced to whatever we can squeeze into one little room.

Though our life itself keeps plodding along, “the story” is all but over. Intensifying our sense of loss is, of course, the narrative of decline that permeates our culture and quietly penetrates our hearts. But, real as the decline surely is, it’s not the only narrative in town. Our stories aren’t stuck in stone, in other words. We get to choose the ones by which we live and age.

Alternative Narratives of Later Life

In The Wounded Storyteller, sociologist Arthur Frank reflects on his time as a cancer patient and identifies three broad storylines by which people facing such conditions can make sense of their experience. First is the restitution narrative, where you reason “this too shall pass; I’ll be back to normal in no time.” Second is the chaos narrative, when the doctor says the tumor is inoperable and you have mere months to live, and the story of your life is thrown into a state of foreclosure from which you might never recover. Third is the quest narrative, where you interpret your illness, however serious, as — at the bottom — an opportunity to learn and an invitation to live life on a deeper level.

I’d like to build on Frank’s typology and propose that aging itself (often implicitly perceived as “a sickness unto death”) can be experienced in these three same ways. The restitution narrative goes like this: “If only I exercise more, do more puzzles, and drink less liquor, I will extend my life … indefinitely.” Such a storyline feeds emphasis on “successful aging” or “healthy aging” that are regularly promoted and obviously have their place.

Then there is the chaos narrative: “I’m old; I can no longer do X, Y, and Z, so my life is basically over.” This narrative can fuel the depression, if not despair, to which many older adults — especially men perhaps — may succumb. It's a recipe for narrative foreclosure.

Third is the quest narrative. “True, I can no longer do X, Y, and Z, but, as frustrating as it is, this is just one more chapter in my story. And there’s something to be learned in it, things to see that I couldn’t see before. This is new territory with new horizons to approach.” I see this narrative as underlying the positivity which, however “wounded” they might be otherwise, many older adults exude, despite (often because of) the troubles they’ve seen. It’s as if — as Wise Elders, perhaps? — they’ve taken those troubles and fashioned them into a good strong story: a narrative of adventure even…

Near Death Experiences and New Adventures in Aging

Aging as adventure — while not the whole story, I believe, warrants consideration. In fact, I’ve spent the past two years doing precisely that, reading and scribbling to where I have over 250 pages of single-spaced, typewritten notes that I hope someday to work into a book.

At present, these are grouped around four broad directions that I see the adventure leading: outward, inward, backward, and forward.

I’ve been toying with aging as adventure downward and upward too, but I’ll sketch just these four here. I see them, though, as tightly entwined. Movement in one direction is eventually movement in another. Also, movement in certain directions may come more naturally for some, with certain personality traits (like “openness to experience”) than for others. But I’ll leave such permutations and combinations for future reflection.

Outward and Inward

Depending clearly on our income and our health, aging can usher us into a phase of life where we’re open to fresh endeavours. This can mean, upon retirement for instance, if not bungee jumping, then learning a new language, or taking up the piano, or trying our hand at painting, or going on that long-dreamed-of cruise, and generally cruising outside our comfort zone. In the process, we may become acquainted with sides of ourselves that we barely knew existed, thus thickening the plot of our lives in ways not feasible when raising our families and keeping the wolf from the door — whatever form or forms that wolf takes.

Every person has their own unique kind of wolf and/or wolves. With each such venture, we open new subplots, welcome new characters, weave new themes into the stories we are. Our horizons keep widening, including our horizon of self-awareness.

Concerning the adventure inward, we have more time (if not inclination) to tackle what’s been dubbed the “philosophic homework” of later life, something that may be neither easy to do nor appreciated by those around us. Sooner or later, though, it is our duty, Jung insisted, to turn inward. The longest journey, the saying goes, is the journey inward. Longest, often loneliest, but perhaps also most pressing, and sooner or later, it has us looking back.

Backward and Forward

The adventure inward leads to the adventure backward. It leads to an examination of our past, or at least the stories in which we’ve enshrined it. It leads to life review, which for Erikson is a core developmental task of later life, and a very narrative one at that. I call it “the autobiographical adventure.”

This adventure — fraught, like any undertaking worthy of the word, with both revelation and risk, promise and peril — can come to us naturally, of course, insofar as time-past becomes more compelling for us to contemplate than time-future. But it may be prompted, too, by changes in our brains themselves, improved cooperation, for instance, between left and right hemispheres, plus increased openness to paradox and contradiction, to uncertainty, ambiguity, and metaphor — all of which, it’s argued, heightens the autobiographical drive.

Going with that drive and accompanied by a skilled listener, gazing back across the years, there are discoveries to make, patterns to discern, secret corners (not always cozy) to investigate, issues around trauma or abuse, legacy or grief to be acknowledged, and overall, pieces of the puzzle, positive or negative, to try and fit together. As we ponder “the mystery in my story,” to quote a former student, we may well find that we’d gotten the story wrong, that the past wasn’t as horrible as we’d assumed.

The adventure forward, however, could seem the most controversial, and cruelest, to consider. In what universe does aging as an adventure forward even make sense!? We’re born, we suffer, we die. End of story. What is there to look forward to?!

To speak of the adventure forward requires looking at the links between aging and spirituality. A few years ago, I did so in a public lecture in which, intrigued by literary scholars’ insights into the problematic nature of “endings” in narrative generally, and by research into Near-Death Experiences (NDEs), I mused on the process of aging as a near-ing death experience. As such, it possesses several of the transformative elements that NDE’rs routinely report.

Besides the panoramic life review that the experience commonly entails, these include a decreased attachment to material possessions, a deepened appreciation for the preciousness of life, a sense that this world is not finally our home, and a major reduction in our fear of death. Death is viewed as transition, not termination, as a horizon beyond which we can’t yet see, a doorway to an even greater adventure maybe; the very sort of view which, in one form or other, the world’s great spiritual traditions have long espoused.

More recently, I’ve been reflecting on aging as a process of going slower, deeper, and wider into the landscape of later life. By “wider,” I mean a broader horizon of understanding — a bigger story — that moves aging out of a biomedical worldview and situates it amid the multi-dimensional mysteries of the cosmos itself.

Narrative psychologist Mark Freeman, writes openly, for instance, about “the transcendent horizon of the life story,” a theme which, despite gerontology’s reluctance to broach it, theorists of “gerotranscendence” and “transpersonal gerontology” are more than open to entertaining. It is one, certainly, that author Florida Scott-Maxwell alludes to when, writing in her 80s, she asks rhetorically, “Is life a pregnancy?” To which she answers, “That would make death a birth.” And it is one which scientist-mystic, Teilhard de Chardin, hints at with his cryptic phrase, “the hidden mystery in the womb of death.”

If such language has any merit beyond that of fanciful phrasing or wishful thinking, then it points, I think, to the need for a significant reconfiguration — a major re-genre-ation, if you will — of what aging is ultimately about. A shift, in short, from tragedy to adventure.

Helping Older Clients Shift Their Narratives

These are early days in what, itself, is proving to be a vast adventure: an adventure of ideas. Who knows where it will lead me? I’m certainly uncovering many questions in my quest.

For instance, how to enlist the adventure metaphor in a group setting versus one-on-one, or with the deeply depressed, or those at death’s door? And where on earth is the “adventure” in dementia?! So, my efforts might well turn out to be a wild goose chase. We’ll see.

Is this not, though, the mark of a bona fide adventure? We set out with no exact knowledge of where we’ll end up. Amidst the twists and turns, setbacks and surprises that are invariably involved, we don’t know — can’t know — how things will turn out. Yet we press on all the same, with curiosity and courage, humility and hope … and hopefully a bit of wonder too.

Naturally, the metaphor of aging as adventure will not be everyone’s cup of tea, nor every clinician’s either. But as agents of restorying in your older clients’ lives, as story companions walking beside them for a while, whether you buy into it yourself, you might find them open to giving it a try. And why not? If it nudges them toward a more inviting myth by which to live and age, then what’s there to lose?

Questions for Reflection and Discussion

How does the author’s notion of the narrative of aging impact you?

How might his ideas help you in your work with elderly clients?

How does your own relationship with aging impact your clinical work with the elderly? The dying?

What countertransference experiences have you had with clients who are dealing with aging, mortality, and dying?

* Editor’s Note: While he is not a therapist, I asked Dr. Randall to write this essay with you (the therapist, the clinical supervisor, the trainee) in mind.