Building on Family Strengths to Solve the Puzzle of Child Protection Work

Posted on by Psychotherapy.net Team

Information is a difference that makes a difference.
                                               — Gregory Bateson

In nature, it is said that whenever there is a poisonous plant, there can be another nearby which contains its antidote. When it comes to helping families, the same is true that for every problem identified, the resources for resolution can be present somewhere in the family’s ecology.]

Unfortunately, especially for underserved families, competition among divergent treatment philosophies, practices, and limited resources create an unintended conspiracy within the mental health and social service delivery systems — perhaps a benevolent one, but one which nonetheless curtails the identification of systemic homeopaths. The unfortunate consequence of this inability to use potential “antitoxins” naturally present within the client’s ecosystem is inefficiency for the service delivery system, stressed-out workers, high turnover, burnout, and a spiral of reduced possibility in which hope’s grasp is tentative at best, and non-existent at worst.

Mental health and social service clinicians working within the childcare system must search for strengths and solutions that are present, though perhaps hidden, in clients’ ecosystems. The approach is based on systems thinking and the idea gleaned from the practice of Structural Family Therapy (SFT) that change in any system, whether it be a family system or a social services agency, is best affected by the lived experience of doing.

Crossword puzzles as a paradigm stresses thinking and doing as an “out of the box” means to a problem-solving end. This practice mines the strength-based belief of creating a “virtuous circle” — one which recognizes clinicians’ and supervisors’ capacities and creativity, like those of the families they serve.

In resource-poor environments, when the goal of training is the enhanced ability to search for strength, this is not simply a training “add-on.” Rather, it is a foundational principle that requires the same persistence and consistency that Minuchin and other family therapists demonstrated was present in the natural environment in which clients and their families are embedded. The naturally occurring strengths in clients’ ecosystems can be uncovered by robust “doing,” which is an optimistic and energetic search for resources and resilience within both the family and the larger ecosystem of change.

Collaborative Case Planning

Like the proverbial butterfly catcher with net in hand, human service organizations have long been involved in a quest to capture the elusive chrysalis of change. What distinguishes efforts at reform and the ability to succeed is an ecological, “whole systems” approach. Children, families, problems, and possibilities are viewed in toto — economics, social, political, educational, gender, vocational, racial, location, class, and psychological elements are all in play. It acknowledges the margins and builds accountability.

The human and fiscal expense of doing otherwise speaks to the futility of programs that do not account for the organic and sometimes chaotic environment that families attempt to survive and thrive in.
As the 19th century Prussian Field Marshal Helmuth Carl Bernard Von Moltke reminded us, “No plan survives contact with the enemy.” In this instance, the enemy of high-quality service delivery is the tendency to replicate the existing system rather than undergo the reformation needed to absorb the family’s own healing powers.

Another systemically inspired practice that infuses underserved families with greater choice, and ultimately health, is collaborative case planning. This time-honored intervention gets all the major players to the table — including the family — and in the process, becomes a kind of exercise in agency topography that borrows from the tradition of Hartman and her colleagues, who pioneered ecomapping of family systems for adoptive placements.

By using the wide-angle lens of mapping families in all their contexts, resources and potential pressure points can emerge for their potential effect on the child and family. From the agency perspective, efficiency and collaboration are increased with an ecomap; everyone can see who is doing what and when and how it is being done. As a form of “observational therapy,” an ecomap can have the same heliotropic potential. However, as business has learned, outcomes can be improved, but not always for the reasons one might think.

Unfortunately, the promise of systemic work and its healing potential as envisioned by therapists who worked in the family trenches is not always realized in the battles to transform larger systems. For clinicians in the human services, or for those who train them, the pitch of a systemic perspective too often mirrors the president throwing out the first ball of baseball season — well intended, lots of hoopla, but doesn’t reach the plate. Without a clear picture of where they fit in the larger service-delivery system or a sense that they can make a difference, workers can feel overwhelmed, disempowered, and disheartened.

The financial cost to the system in turnover and lost productivity can be measured. The loss of wisdom, the discontinuity of care, and the loss of hope, however, are beyond calculation. In that regard, the experiences of child welfare clinicians mirror the isolation that can permeate the system within which they work and the families that they treat.

It is for this reason that systems of care were re-designed to “wrap” services around families and to minimize the dilution of family processes that occur as a by-product of traditional service delivery. In a sense, “wrapping” can enrich underserved families with a wider net of resources in the way families of higher classes can choose their providers and supports more selectively.

Capitalizing on Strengths

In tracing the strands of effective, systemically inspired service delivery, there is one constant thread: strengths. Thank goodness! But just as it was found that a rising economic tide does not raise all boats, so too can the tidal waters of strength not elevate the all-too-often porous vessels of bureaucracy.

What is amazing is how far a little strength can go, even in conditions that are wanting. There are, after all, some quite beautiful plants that flourish in the shade. Sadly, however, in the wrong bureaucratic hands, even strengths-based practice can invite the agency equivalent of Frankenstein picking flowers with the little girl — it’s a nice idea, but eventually the monster kills it.

How, then, to help clinicians to see that “It’s the difference that makes a difference”? Is there a way to aerate the sometimes root-bound tangle of the childcare bureaucracy so that its ability to heal can be given the room to breathe and prosper? How to give clinicians — especially those just out of school — the understanding and confidence to “trust the process” of searching for strengths, both within disrupted families and the systems designed to serve them? Moreover, are there ways to create a culture of caring and learning transfer so that clinicians see themselves as “action agents” within the larger bureaucratic tangle?

Part of the answer lies in family therapy’s history and co-development with cybernetics — the study of how systems developed the concepts of circularity, non-linearity, recursion, the process of self-correction, and the ways family and organizational systems maintain stability/homeostasis while balancing that with change and transformation. Gregory Bateson and his colleagues at the Mental Research Institute (MRI) in California, along with other early adapters, were the pioneers in this new way of thinking that set the stage for family therapy as we know it today.

Using a notion central to Structural Family Therapy (SFT) about strength and extending it to conceptualizing strength as a verb can be unintentionally overlooked when children and families in dire need get lost within the morass of bureaucracy. The SFT concept of healing is more about thinking of strength as a verb. It’s not so much a matter of finding strengths within the family’s ecosystem as it is strengthening the resources that are hiding in the weeds, so to speak. In that regard, it is more of a leap of faith — that whatever challenges a case presents, health can prevail.

Businesses and non-profits share a challenge: getting their message through environmental “clutter,” or the glut of choices that compete for our attention. How, then, can human service organizations solve the multiple staff training dilemmas they face?

The skills and belief set needed are interwoven and important: ensure the safety of the child and family, reduce decision clutter, increase the active search for strengths, attend to and nurture family connections, expand the problem-solving lens to include extended family, community and idiosyncratic, home-grown resources, and get paperwork in on time. One path on the way toward answering this organizational koan is this: increase experiential capital by linking the worker and their day-to-day decisions with the larger mission of the organization.

Thinking Outside the Therapeutic Box

Bridging the gap between what we know and what we do, however, is no small feat. In Why Didn’t You Say that in the First Place: How to Be Understood at Work, Richard Heyman unravels this knotty problem with a question and a refreshing answer: “Why is it that ‘a picture is worth a thousand words?’ The picture is not talking about something — it is the thing the talk is about.”

From this perspective, to truly “get” the uber-goal of searching for strength and translating that into action, workers must experience the “felt sense” of search and discovery —finding something where apparently nothing exists. This experience is analogous to an “enactment” in SFT, in which the family is guided by the therapist in an interactive experience between members that is designed to offer them new opportunities to use underutilized strengths.

Many consider enactments to be the heart of Structural Family Therapy. The value of enactments is two-fold. First, as a “real-time” assessment tool, and second, for their change-producing potential, both of which scaffold nicely for training in human services.

Enactments between family members during therapy can principally occur in two ways, either spontaneously or through the therapist’s direction, and they are used in two ways, to assess family patterns and to promote change. Spontaneous enactments are readily available ways of interacting that might be thought of as familial “tells” (like the poker player whose nervous smile foretells the bluff), showing habits of relating in which relational organization is embedded. While some might consider these patterns to be so deep as to be unconscious, another way to think of them is as learned ways to relate and survive in the world.

The persistence of patterns can transcend the pull of context. Habituated behaviors tend to reveal themselves in multiple settings— a therapist’s office, a restaurant, school, work, or home. The persistence of these patterns can be linked to the tendency to reduce anxiety through prediction and habit. As the pioneer family therapist, Virginia Satir notably said, “Most people would prefer the misery of certainty over the misery of uncertainty.”

Like an artist who steps back from the picture they are painting, clinicians have the capacity to use themselves differentially, moving in and out of the family system to gain perspective. Minuchin described this as “use of self,” in which the therapist positions themself with the family from “proximate, median or distant” perspectives.

Harry Aponte has written about how therapists can make use of their own personalities, family of origin, and life experiences to guide clients during enactments in the “then and there” of limiting patterns so that they experience themselves and one another with increased possibility and hope.

Like a music student first learning scales as a prelude to improvisation, experiential training can evolve into a more responsive, “whole systems, both-and” approach in which requirements and innovation can co-occur. For example, when supervisors at one county office of a state child welfare agency were asked about their staff’s training needs, their response was, “To be able to think on their own/to think outside of the box.”

Their request comes from the experience of guiding their workers through the complicated bureaucratic and interpersonal seas of child protection. As Mumma wrote in his insightful piece about his agency training in systems work, “Taking these concepts (ways of thinking) and making them work in a particular agency setting is the real work of training.” The analogy of crossword puzzles can make that work a bit easier.

Finding Best Clinical Practices

Just thinking about all the aspects of a case — its who’s, what’s, and how’s — can be a bit overwhelming. Cases in the investigative and early treatment stages, particularly for newer clinicians and social workers, may seem all forest and trees, abounding with unanswered questions.
Over the years, agencies have found genograms, ecomaps, and structural maps to create a set of “blueprints” that graphically represent families and agencies in a way that quickly sorts out relationships and priorities. These tools have been essential in widening the practice/thinking lens to include others who may have clues to potential resources.

The rise in “manualized” treatment and the emphasis on evidence-based treatments has helped to sort through these difficult choices and prescribe “best practices.” While this is a necessary step in the right direction — much like learning scales is in music — it can be insufficient to encompass the unpredictable nature of cases. There needs to be a “both-and” approach that brackets safety, consistency, and growth with improvisation. Thinking in terms of crosswords can do just that.

In its own way, a blank crossword puzzle graphically resembles a complex clinical and, in this case, social services-related case — lots of questions, some inter-related, some not, and just to make it interesting, a few black boxes. As President Clinton said in the crosswords-based movie, Wordplay:

Sometimes you have to go at a problem the way I go at a complicated crossword puzzle. You start where you know the answer and you build on it and eventually you unravel the whole puzzle. And so, I rarely work a puzzle with any difficulty, one across and one down all the way to the end in a totally logical fashion. A lot of difficult, complex problems are like that. You must find some aspect of it you understand and build on it until you can unravel the mystery you are trying to understand and then you build on it and eventually you unravel the whole puzzle.

When one acts as if the answers are there, though perhaps hidden, the puzzle’s resolution moves from the shakier, contingent ground of “if” it will be resolved, to the more possibilistic ground of “how.”

Crossword Puzzles as Metaphor in Child Protection Work

Do you think I know what I am doing?

That for one breath or half-breath I belong to myself?

As much as a pen knows what it is writing,

Or the ball can guess where it’s going next.

Rumi

When a case opens in child protection, the most compelling, sometimes unanswerable question is “Who will keep this child safe?”
If an injury has occurred in the home, the prima facie answer may seem obvious: “no one.” In this instance, unless resources are surfaced, the child will need to be placed outside of the home, “in the system.”

Starting the exploration of strengths from a crossword paradigm assumes that like the printed puzzle, all the answers may not be initially apparent, but once safety is established, one can begin to answer the eternal risk-safety dilemma: Can the person(s) who caused or permitted harm now be responsible for safety? If one only looks at the alleged abuser, then the likelihood is that the answer to the question will be “no.” If more contextual factors are also considered, so, too, are possibilities.

The work becomes both retrospective and prospective, invoking Einstein’s dictum, “You can never solve a problem on the level at which it was created.” The “who” and “when” questions are now also answered by “how.”

The “how” to find and fill those potential strength-based empty boxes begins with questions like “Who else watches the kids when you go out?” or, “When you are having a rough day, who do you talk to?” or, “Who are some of the people you count on?” These ground-level questions are more than a set of techniques, they are the personal implementation of a larger policy that has the capacity to both be safe and value the child’s primary connection.

Enacting Possibility to Help Families in Crisis

Like the Zoysia grass, the grass/weed whose initial plugs merge over time into a uniform carpet, training from a Crosswords perspective can grow the seeds of organizational interpersonal attachment. One way to underscore the marriage of mission and method is to give training participants a felt sense of difference.

The enactment of possibility begins when participants fill out a blank crossword on their own. After five minutes of working alone in silence, the trainer helps the participants process their “silent” experience at multiple levels: What did you notice? Did you fill in the boxes you knew first, or did you have a system? What did it feel like? Did any of you get stuck? How did you get out of that — what did you do? Typically, people report a range of answering strategies — some very methodical, “I do every ‘across' first, then I start with the ‘downs,’” others more radiant, “I just see which ones I know and then go from there.”

Next, the trainer asks the participants what it felt like to do the puzzle. What did they notice about their mental/emotional and physical states? “It was quiet.” “I kind of got into it.” “It was frustrating.” “I felt tense.” “I was worried other people would see how much I didn’t know.” “I kind of enjoyed it.” “It’s like Solitaire or Wordle, I just got lost in it.” All their answers provide abundant raw material to talk about their work, their stresses, successes, and the strategies they use to problem solve. And it sets the stage for helping them think “out of the box” by using the other boxes.

To widen the lens, the trainer may provide another enactment. This time, they can ask participants to form small groups of six or fewer, telling them that they have another five minutes to work on their puzzles, but this time, together. People begin to talk, share their answers, laugh, and fill in the blanks as they see how quickly they can solve the new crossword together as a team.

When the time is up, the group is asked to process their experience and compare it with doing the puzzle alone. Inevitably, they notice the energy level, productivity, speed of producing answers, and their own internal experience of connecting while connecting the dots. In future puzzling cases, this brainstorming model can supply added, shared resource clues to support and, most importantly, help the clinician in their search for resources within the family and larger system.

Materials Needed: Copies of a Crossword Puzzle

Total Amount of time: 10–20 minutes

Lessons Learned: Start with strengths within and around the family, fill in the answers you know to discover the answers you don’t.

One does not need to know all the answers to get all the answers.

A “wrong” answer is eventually corrected by the context of right answers.

Just like a case, one does not know all the answers when starting — answers emerge over time often from unexpected sources.

Persistence pays off — but so does taking a break and getting help.

A Family Crossword Comes Together

The first time I (LPM) met Kyla and her mother, Teresa, was across a cold table in an institutional room. Kyla had been in the residential treatment facility for almost ten months following a series of escalating behavioral incidents in her previous foster home. I thought back to my meeting with the family’s caseworker, who told me that Teresa and her partner Linda’s relationship was volatile and created an unsafe environment in the home. Kyla’s father, according to the caseworker, was out of the picture.

During my first several months working with the family, I felt as if very little progress had been made. Each week, I’d pick Teresa up and drive her to the residential facility for family sessions. Dutifully, I went to family court, holding space for an equally enraged and devastated Teresa on the way home each time reunification was pushed back. I consistently showed up for the family, and despite good rapport with both mother and daughter, Kyla’s behavior remained a challenge and our family sessions felt focused on the crisis of the week, as opposed to addressing underlying family dynamics and struggles.

One day, Teresa unannouncedly brought her partner Linda to session. From that point, treatment changed almost immediately, as both Kyla and Teresa seemed more engaged and open during family therapy, and we began to focus less on minor incidents and more on boundaries and communication within the family system.

Still, somehow, it felt like a piece of the family puzzle was missing. I could sense that Teresa and Linda were holding something back, particularly when we discussed their co-parenting practices. This final piece fell into place one day when I went to pick up Teresa and Linda and Robert, Kyla’s father, eagerly and unexpectedly hopped into the van. It quickly became clear that Robert had been actively involved with the family all along.

I finally could see the full picture of the family structure and their dynamic. Teresa, Linda, and Robert were in a polyamorous relationship. Robert had been understandably hesitant to engage with the child welfare system out of concern that the polyamorous relationship would be condemned, and reunification denied.

The case that had “simply” been presented to me as an unreliable mother with a violent partner unable to meet the emotional needs of her unstable daughter was actually one where a child had three caring adults who wanted to support her. With all the pieces in place and the entire family finally engaged in treatment, meaningful therapeutic work ensued, Kyla’s behavior improved, and she came home.

Conclusion

“The solution to pollution is dilution.”

Using crossword puzzles as a conceptual framework and training method opens workers and the organization to both the learned and the lived experience of complexity, strength, possibility, and the importance of connective relationships when working in child protection. We know that systems can mirror the systems that they treat. For instance, In Child Welfare, the insidious nature of poverty is such that it can quietly, but inexorably, leach into the soil of good intentions in such a way that the attachments between worker and family, workers and other agencies, worker and supervisor, and workers themselves, can suffer the pollution of despair.

This is not to say that using crossword puzzles will wall off the effects of these potential systemic toxins. It is to say, however, that healthy, connected relationships can be grown and nurtured and, over time, create “the difference that makes a difference.”

***

The author would like to thank my friends and colleagues who helped me fill in the blanks, both across as well as up and down. A special thanks go to Lauren McCarthy (LM) for providing the case of Kyla.

Social Media Monitoring Tips for Successful Psychotherapy with Teens

Posted on by Psychotherapy.net Team

Therapeutic Encounters with Two Teens

Courtney was the kind of 10th grade-client that I completely enjoyed. She was cute, clever, and motivated. So, when she began to have an issue that ballooned into a crisis, I was a bit surprised. Her parent found out that she had shared a nude selfie with a boy she knew, who then shared it with the whole school. While Courtney’s mother was a nurse who well understood the ups and downs of being a single parent and the importance of being present for her daughter, she didn’t see this looming crisis coming and was unable to comfort her daughter.

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My clinical work with Courtney centered around understanding her own boundaries — that being a people-pleaser is not always what’s required — and giving voice to her past losses (including the tragic death of her Father), all of which were held inside too long. Throughout our work, and hopefully beyond, DBT for frustration tolerance and CBT to calm the inner critic were supportive anchors. I also made myself available for extra sessions until she stabilized. In addition, I helped her do some damage control at her school by speaking directly with the guidance counselor.

Nevertheless, Courtney landed in the hospital from sheer humiliation. And because she was so emotionally fragile, she needed time to be safe, without her devices, to regroup, process, and consolidate her experiences. While Courtney was scarred by her mistake, blamed and mortified for what another kid didn’t yet understand about privacy, she was, thankfully, able to benefit from the immediate help.

Another college-age client, who I will call Sasha, had insomnia and relied on her smartphone to fall asleep — much like scores of others her age do. Parents, Sasha’s included, often say things like, “You can take away all her devices but it won’t help.” Sasha, as it turned out, was reliving a traumatic memory that replayed in her head, and she often woke up screaming. Although I am not a sleep expert, I realized that she was in trouble because she hadn’t attended school in over a week.

My initial work with Sasha focused on the immediate presenting problem of sleep. For me, this is always an important discussion with teens. Then we moved slowly to her past trauma using breath and yoga to help her self-regulate. The incident she was reliving every night was painful, but it didn’t have to follow her into adulthood.

Adolescent Struggles with Self-Regulation

As I reflect on these two cases, which share certain digital/social media-related elements, I also appreciate their differences. Courtney was simply burnt out from the social media backlash and ongoing shame, humiliation, and guilt she felt knowing that everyone with a smart device could see her nude picture. She needed a reset.

Sasha, having had an entirely different kind of traumatic experience, was not quite as resilient as Courtney. Her body, as Bessel van der Kolk reminds us, kept the score and intruded on her sleep despite her best efforts to use a digital remedy. In the two instances, it was important for me to differentiate between depression, trauma, and anxiety, the symptoms of which often converge. Both, however, had difficulty coping with their respective crises because of their reliance, or perhaps over-reliance, on social media and digital devices.

In the cases of Courtney and Sasha, as I do with most teens with whom I work, I included the family. I offered suggestions around self-regulation for the teen, and to the parents for helping their child regulate the use of social media and digital devices. Interestingly, and perhaps not unexpectedly, because of their overreliance on their digital devices for connection during COVID, I had an uptick in patients who were convinced they were dissociating. Perhaps they were. One client said people were watching her from within the walls of her room.

Sasha accepted a few of my suggestions for learning how to re-regulate herself, but she never quite connected the dots that “the body keeps the score.” Instead, she insisted on staying online because without her friends, there was “no score at all.”

Helping Teen Clients Find Balance

While working with families like those of Sasha and Courtney, I simultaneously model calmness, generate a decision tree of steps for addressing the crisis, and calculate the practical and emotional cost of decisions they have or are thinking of making. At the same time, I try to comfort the teen that “this too shall pass,” and to provide the needed perspective they can’t yet take. The black-and-white thinking, a hallmark of adolescence, keeps them feeling there’s no way out when there usually is.

The teen’s default and refrain often remains: what will people think of me? But with time and support, their inner voice may shift to one of more self-compassion. I often say, “What would you tell a friend?” The hyper-fixation on self-image that is also the cornerstone of adolescent thinking, amplified by the social isolation of COVID and the endless resulting on-screen hours, was the perfect storm and seedbed for some of the angst and depression we have seen among adolescents. We cannot necessarily prevent social media, but we can still protect them from its potentially harmful effects.

I worked for early internet start-ups in the health and wellness space for some time, so I cannot readily cast away the benefits of the Internet or social media. Like many teen girls with whom I’ve worked, their virtual world is their true and only world. What others see of them is all that matters.

So, in Courtney’s case, the destruction of her carefully curated online image was shattering and felt like the death of part of herself. Do we now blame social media for what happened to Courtney or for Sasha’s experience? Unfortunately, we can barely ban guns, let alone phones. Schools are trying to take phones during instruction. That’s a good idea. I don’t think my daughter ever read a book in high school. There was no attention span left by the time she reached 10th grade. Joining with the teen on her journey lets her know that at least one grown-up in the world is on her team — her teen brain doesn’t have to define her.

It is so convenient for friends, family, therapists, teachers, and parents to say “social media be damned,” especially after an episode like Courtney’s. I agree with what they’re saying; after all, it’s legitimate to protect your children (and clients) from porn, abuse, catfishing, danger, and predators. My biggest parenting regret was not removing the phones from my own children’s possession by 10:00 PM like many parents do. Sleep is critical during adolescence, but too many kids simply cannot resist the allure of talking to their friends all night.

If my patient is on social media all day and night, what would be more appropriate: to scold her and instruct the parents to remove all screens, or perhaps teach her that rest is critical to development, as is exercise, diet, spirituality, creativity, and every possible other form of self-care? I often beg clients to get a hobby.

Social Media and the Benefits of Connection

One of my current clients is doing an online degree program in a special kind of painting that she posts weekly on Instagram. Because she has a significant trauma history, her present situation doesn’t allow her to visit museums or lectures or art studio classes. But she can paint and post and maybe one day sell those paintings online.

What gives her hope is the freedom to expose her work to the world without having to leave her room or open herself to bullying, intimidation, or abuse. And then there are clients who are either ill or live in a rural setting who can talk to their BFFs (and me) without having to drive. These are the many ways a young, isolated person may reframe the online world as an adaptation to her struggles, rather than the enemy.

I am not suggesting that my clients continue mind-numbing and wasteful activities like stalking their ex, trolling through others’ emails, engaging in illegal/aggressive or shameful bullying, or worse. What I say to my colleagues who work with young people is this; save your judgment and let’s figure out what the pitfalls and potential are in each situation, then help our clients to filter in what is meaningful, useful, and practical for them within their virtual (and “real”) communities and filter out what doesn’t serve them. I love working with young people because once they “get it,” they’re usually good to go.    

How to Watch Master Therapists in Session and Build Clinical Competence

Posted on by Psychotherapy.net Team

Taking Stock of Professional Development

Later life, as gerontological researcher William Randall writes, is a time for looking inward and outward as well as forward and backward. And as much as I don’t always like to acknowledge it, I am in later life. Having mysteriously and involuntarily arrived at that juncture, I find myself simultaneously shedding and accumulating; material possessions in the case of the former, and wisdom in the case of the latter. I am indeed looking forward, perhaps not yet as enthusiastically as I would like, but certainly looking backward to assess what about who I am both personally and professionally I would like to carry with me on this next leg.

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I’ll save the “personal” for a future essay and will focus here on the professional — specifically, my evolution as a psychotherapist. Having recently retired from my full-time position as a clinical educator, I am still in the classroom, and as I wrote in a previous blog, still training future therapists. And a significant portion of that classroom work has revolved around the use of clinical training videos that we (Psychotherapy.net) produce. As a caveat, I want you to know that I used these videos long before I signed on as the Editor six years ago.

Over the years as a psychotherapist, I have had face-to-face clinical supervision, read my share of clinical books, have “performed” in front of the one-way mirror, consulted with peers on case management, and even written for the therapy audience. But it has always been clinical videos that have not only rounded out but deepened my clinical skills. So, I thought it might be useful to share some of my favorites, those on whose production I have been involved, and those whose entry into our vast collection predated my arrival on the shores of Psychotherapy.net.

Watching Experts Work with Clients

I will shamelessly (mis)appropriate the famous movie line by saying, “You had me at Irvin Yalom.” Aside from the incredible trove of his clinical writings, Yalom has shared his many individual and group therapy skills in front of the camera. His insightful work and clinical acumen have been for me and my trainees — although I suspect for many others — what the likes of Carl Rogers’ work has been for current and past generations of clinicians.

I have done a fair amount of clinical interviewing and assessment over the years in a wide range of venues with a broad range of clients: prisons, hospitals, psychiatric facilities, private practice, and in the forensic arena. As we would likely all agree, good interviewing requires both art and skill, and I have thoroughly enjoyed and learned from the diagnostic interviews of Jason Buckles, who has deepened my understanding of the kind of questions that must be asked to differentiate among many and often overlapping and conflicting diagnoses — substance abuse, personality disorder, and mood disturbance to name a few.

Good assessment, however, requires not only diagnostic facility, but a foundation in interpersonal and interviewing skills that transcend specific pathologies. And to enhance my own interviewing skills, I often turned to the work of John and Rita Sommers Flannagan, who have reminded me how to incorporate mental status, biopsychosocial, and clinical questioning into the interview process. I have also continuously relied on John’s work around suicide assessment and intervention with clients ranging in age, ethnicity, and life circumstance.

As my own clinical practice has evolved over the years, I have been exposed to — or perhaps I should say, I have exposed myself to — clients whose circumstances, culture, and values have differed widely from my own. I have embraced the personal and professional awakening that comes with looking beyond my own relatively small sphere of experience so that I could appreciate the lives of others whose paths have been so different from my own.

Watching Sue Johnson wield her velvet EFT (Emotionally Focused Therapy) sword to cut through the resistance and defenses of couples has given me the confidence to work with couples. But our EFT Masterclass, a four-volume series in which EFT is demonstrated by a team of EFT experts, has been especially enlightening. It has helped build my confidence and courage to venture into challenging couples counseling arenas like pornography addiction, grief and loss, and sexual issues.

***


Certainly, I could go on extolling the virtues of our clinical training videos, but what has been useful to me as a clinician may not be so for you. You may not be drawn to the work of these particular clinicians. But certainly, there are enough training videos in our collection to satisfy all tastes. And there are many ways to learn. You may learn best by reading or doing. Some of you may hold to the belief that 10,000 hours of doing makes for expertise. But if you have the space and desire to invite the masters along on your clinical journey and enjoy watching them at work, grab a front-row seat and tune in.


 

Questions for Thought and Discussion

How do you resonate with the premise of this essay?

What training videos have you found useful in your own professional development?

What challenges have you experienced in using clinical training videos?   

The Upside of Loss: Helping Grieving Clients in Therapy

Posted on by Psychotherapy.net Team

The funny thing about grief, aside from the fact that it lasts forever, is that it has a life of its own. My wife died in September of 2021 after a three-year-long battle with cancer. She and I considered ourselves extremely fortunate that this happened in her eighth decade of life and not sooner, that she was minimally symptomatic and pain-free until the very end, and that the original six-month prognosis turned out to be three quality years. The love and support from family and friends throughout this period was, and still is, a major component of our, and later my, well-being. I believe the nature and quality of my own grief experience had a great deal to do with the quality of care that my loved ones and I were able to provide for my wife. My satisfaction with that care sustains me. That I have no regrets about her care means everything. I need no help in continually realizing how much I have lost after a glorious thirty-five-year love story. When I hear family, friends, and countless others describe how much my wife meant to them and their feelings about losing her, my own loss feels that much greater. Not surprisingly, those moments are emotionally mixed. When the sadness and sense of loss is intensified, it provides an opportunity to savor the gift of her presence in my life for all those wonderful years together. For me, that is grief at its best.

Of Magical Thinking

Joan Didion, in her book, The Year of Magical Thinking, spoke of her experience after the sudden death of her husband after 40 years of marriage. One of her reported observations is something that I have experienced countless times. The frequent wish to share information with a departed loved one is ongoing and serves as another reminder of the loss. Didion writes, “I could not count the times during the average day when something would come up that I needed to tell him. This impulse did not end with his death. What ended was the possibility of response.” For me, this form of verbal intimacy is one of the greatest losses of all. Most recently, this was manifested by the birth of our grandson, born four months after my wife died. He is the first child for our son and the first male grandchild after four granddaughters. Fortunately, my wife knew about the pregnancy, but not the gender. The impulse to discuss this great event with her occurs frequently, and probably always will. A common fear among the bereaved — me included — is what I call “memory fading,” as well as other “fades,” like the sound of her voice and her laugh, and the way she looked and sounded upon hearing stunning news of any kind. Of course, pictures are wonderful, and videos are even better, but the details of the interactions of everyday life for over thirty-five years are sometimes difficult to retain. J.W. Worden, in his excellent 1991 book, Grief Counseling & Grief Therapy, described mourning — the adaptation to loss — as involving four basic tasks:
  • To accept the reality of loss, which can be extremely difficult when it is sudden, unexpected, and tragic, like the deaths on 9/11
  • To work through the pain of grief, as opposed to denying the need to grieve
  • To adjust to an environment in which the deceased is missing
  • To emotionally relocate the deceased and move on with life
Worden’s four tasks suggest an action orientation that I have always found to be useful when working with grieving clients in my psychotherapy practice, as opposed to the more well-known stage or phase schema for bereavement which tend to imply passivity and a lack of action as the mourner passes along a continuum. Worden’s approach, which is more consistent with Freud’s concept of grief work, encourages activity and implies that the process can be influenced by outside intervention, such as a participating clinician. Following the attacks on the World Trade Center on September 11, 2001, I conducted a bereavement group for eight widows. The group was scheduled to last 16 weeks, but they remained together for over three years. That is when they felt their grief work had advanced to the point where the group was no longer necessary, while recognizing that their grief was not over — because it never would be. Clearly, bereavement is not a process that progresses in a sequential manner marked by a gradual and identifiable reduction in grief and other indications of a return to normalcy. In many cases, indicators of “progress” are not reassuringly evident. The mourner may appear to be getting worse as months go by, causing needless worry among friends and family. In fact, feeling “worse” is not necessarily a bad sign. It may be an indication that the painful work of grieving is proceeding as it unavoidably must, in fits and starts. The bereavement process may take weeks, months, or years. It is not a path to “recovery,” insofar as that means a return to pre-bereavement baselines. Instead, the process leads to the mourner’s increased ability to change, adapt, and alter his or her self-image and role to fit a new status.

Grief is Not a Disorder

Grief is sometimes seen as a disorder — like depression — and treated by some clinicians with medication only. This tends to cause grievers to believe that there is something the matter with them, something they must get over as quickly as possible. The potential self-esteem consequences of this belief are worrisome, especially when well-meaning others encourage “recovery” or “moving on” as essential. When Emily, a 32-year-old mother of three whose husband was killed in the World Trade Center attacks came to see me three weeks later, she was already on anti-depressant medication and claimed to be feeling sick. The advice she was given by friends, family, and, unfortunately, her psychopharmacologist, was that she had to “wait for this to pass” and to “protect” her children, ages 10, 7, and 5, by minimizing the loss and acting “normal.” “You must try to stop feeling so sad” was the comment she recalled being most upsetting. Worden’s tasks described earlier provided an excellent road map for the grief work ahead. She was receptive to the idea that grief was something you do, not something you have. She could influence the process rather than remain feeling passive, helpless, and anxious, and her grief was normal and necessary, not an illness from which she had to recover. My assessment of Emily’s mental status suggested that she was someone who was not likely to be retraumatized by interventive strategies designed to help her acknowledge and “handle” her feelings, as sometimes occurs with those suffering a loss, especially one so sudden and tragic. I also assessed the quality of her marital relationship to see if it was positive, ambivalent, or troubled, and to determine if specific interventions to address related issues might be in order. We normalized her grief and understood together that as an organic process, it needed to “breathe” and not be inhibited or minimized. We role-played instances where well-wishers offering unhelpful or hurtful advice needed a response from Emily. A self-described introvert, conflict-avoider, and people pleaser, Emily needed self-advocacy skills and “finding my voice” to help others help her. My work with grieving clients like Emily has, not surprisingly, often triggered my own grief responses. It requires effort to stay fully with them and not be distracted by my own sense of sadness and loss. Work with Emily preceded the loss of my wife but working with her and many others certainly activated old memory networks regarding earlier losses in my life, like the death of my father when I was eight years old. My ability to be empathically attuned, I believe, has been significantly enhanced by my own past and ongoing grief journeys.

Looking Back, Moving Forward

Months before she died, my wife urged me to consider the possibility of a new romantic relationship after she was gone. She knew of my unwillingness to even consider such an idea based on two things: one, my high tolerance for independent living, and two, my belief that I had the love of my life for 35 years and could not imagine a second experience with a new “leading lady.” Thanks to a recent serendipitous encounter, I came to realize that perhaps another romantic adventure at this stage of my life was not entirely out of the question. I had conflicting feelings about the fact that this chance meeting — where the mutual attraction was immediately clear — occurred only two months after the death of my wife. Initially, I considered not acting on my desire for more contact. However, I also appreciated that I could not ask someone to wait until I achieved the arbitrary one-year milestone that widows and widowers are “supposed to” allow before it is socially acceptable to consider a new partner. Like grief, the heart does not operate in accordance with the calendar. Thirteen months later, I am glad I seized the opportunity to explore a new relationship however earlier than expected —especially since this was never expected at all! The important insight for me is that mourning a lost love and embracing a new love were not at all incompatible. The new relationship has served to ease the transition from a memorable 35-year marriage to a new partnership that is similarly meaningful, valuable, and life-enhancing. Questions for Thought and Discussion What about this article resonated with you personally? Professionally? How have you incorporated your own personal grief work into your practice with grieving clients? What are some of the inner challenges you have when working with clients who have experienced loss?

Effective Nursing Home Psychotherapy: Blending Skill And Heart

Posted on by Psychotherapy.net Team

“My mother literally made gin in the bathtub; it was part of how she made money. She also had men ‘guests’ in the apartment, and unfortunately, she didn’t always protect me from them.” Daphne remarked as she spoke of her childhood in Brooklyn, New York.

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Daphne was now 84 and resided in a nursing facility. She used a wheelchair, and spoke in a raspy voice due to polyps on her vocal cords. As a result, she would not sing one note, since she knew it would never again sound like it had when she was younger. But she would laugh, and she would share her stories, and she was always curiously asking about the stories of other people, even mine.

On Her Own Terms

We often sat for psychotherapy in a small TV room in her unit. The room was about 8 feet wide by 10 feet long; just space for a loveseat, one chair, her wide wheelchair, a small TV on the wall, and a window looking out at the woods behind the facility.

During one session Daphne was speaking about the ironic balance of shyness and confidence of a performer. “How about you, you seem calm, but do you feel shy or do you feel confident?” she asked. I explained that when I was younger, I went to acting school, partly because someone wrongly suggested to me that taking up acting was a way to overcome shyness. Daphne laughed, and asked, “Well, so how did that work out, anyway?”

Daphne had a regal quality, along with her charmingly refreshing genuineness. Her issues in therapy were related to acceptance of aging and reduced functional independence, tolerance of the loss of her singing voice, and easing of suffering due to abuses experienced in her childhood. Daphne was intolerant of anything phony. She’d seen too much in her life, and seen through the disguises of so many persons. I could not have “played the part of a therapist” with Daphne — hiding behind a veneer of neutrality — my choice was to meet her on the terms she expected of authentic sharing, or nothing.

She roared with laughter as I told of the nausea and fear I’d experienced before a stage performance, and my delighted excitement during the performance. That pattern continued with each show — dread in anticipation, and elation while acting — and no, I certainly never got over being shy, I explained, as she threw her head back and laughed.

“So, why did you give it up?” she asked. I did not think it would be a successful, or tolerable, career — I could hardly tolerate putting myself through those ups and downs, so I went back to school to get a master’s degree to practice psychotherapy. “Well, didn’t you still have those same ups and downs in your new career?” she asked with her bright and penetrating gaze.

Actually, I would sometimes give talks or make presentations at professional conferences, and would experience the same nauseating apprehension, and then the same enthusiastic enjoyment while at the podium. ”Of course, I knew it!” she laughingly stated. “Let me explain to you why that happens,” she said.

Personality and Talent

“That’s the difference between personality and talent. Your shyness and your anxiety about putting yourself in the spotlight, that’s personality. But the joy and enthusiasm you felt when performing, in one way or the other, is talent. Talent and personality are not the same thing, but so many performers harm themselves because they never understand the difference.” Daphne wisely explained.

Daphne used examples of famous performers who confused their personality with their talent, and who got caught up in the projections of fans who thought that their personality ought to match their talent, and who developed problems because they could not, and should not, blend the two things that were categorically different.

Sometimes in psychotherapy, my clients are vulnerable and in need of guidance, strict boundaries, and a straightforward application of therapeutic techniques. In nursing facilities, I sometimes work with residents who have diagnosed mental disorders, and who need formal and conventional psychotherapy. Yet sometimes the residents I see in therapy don’t have a psychiatric disorder, but may instead wrestle with real-life problems such as illness or loss, and who may benefit from a less formal educational and supportive approach.

Daphne was of the latter; wise and resilient, she lived vibrantly, even when she was less able to function on her own. Her wisdom, her humor, and her curiosity about the lives of others were key strengths, and they found a place in our therapeutic conversations.  

How To Keep Students Engaged Using Psychotherapy Training Videos

Posted on by Psychotherapy.net Team

Challenges of Finding Engaging Counseling Videos for Students

Who among us, and by “us,” I refer to clinicians, clinical supervisors and trainees, and counselor educators, have not seen “Three Approaches to Psychotherapy?” Remember that timeless 1960s series of clinical demonstrations between that candid and brave 30-something Gloria and three giants of the world of psychotherapy — Fritz Perls, Albert Ellis, and Carl Rogers?

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My guess is that some of you fondly remember watching the series with a sense of wonder and admiration, asking yourself questions like, “Will I ever become a therapist who can work as effortlessly and masterfully as these giants?” I certainly did (and sometimes, still do.) Others among you may have watched them, stored them, and discarded them long ago as you went on to develop your own therapeutic voice.

And then perhaps there are those among you who are more recent arrivals at the shores of psychotherapy, who watch these and say, “Geez, can’t they find examples of therapy sessions that are a little more current, or relevant, or interesting — it is 2023 after all!” From my own firsthand experience in the classroom as a clinical educator, I hear a collective groan when I fire up the LED projector: “OMG, not more clinical demonstrations from the crypt!”

Whether I am teaching a didactic or internship/practicum class, or supervising clinicians, I try to “read the room” by presenting videos of clinical demonstrations that will interest, challenge, and entertain the graduate students and clinical trainees with whom I work. Not always an easy feat in the digital era of YouTube, TikTok, and Facebook, where clinical snippets abound. So, I try to offset that by sharing psychotherapy training videos that break this pernicious pattern.

Make no mistake, however, I love the Gloria tapes — they are foundational! But foundations shift, and so have client (and therapist) demographics, societal challenges, and their associated psychosocial impacts. As Psychotherapy.net’s Editor, I have a particular fondness for our offerings, but this long pre-dates my association with the company.

Our videos have contributed to my own professional skill development, and in the context of this discussion, my efficacy in the clinical classroom where students want to see masterfully executed psychotherapy in action. So, since we are in award season, I thought I’d share a few of my top picks.

The Psychotherapy Training Videos I Use in the Classroom

Carl Rogers’ stature in the field of psychotherapy is IMHO the stuff of clinical legend, and certainly, we have plenty of great videos featuring Rogers at work. But I have found other creative ways to highlight core person-centered skills to my trainees and students by showing Sam Steen in session with a pre-adolescent girl who is struggling with issues related to the intersectionality of racial and sexual identity.

And, by harnessing empathy, unconditional regard, and congruence, Darrick Tovar Murray creates a safe space and meaningful connection with three African American men trying to heal from the transgenerational scars of racism.

Albert Ellis was one-of-a-kind — a clinician, innovator, and showman, who inspired generations of clinicians to consider thinking about thinking as they attempted to subdue their cognitive demons. My students appreciate the theoretical clarity of REBT, and the seemingly easy ABCDE method of identifying, challenging, and modifying self-defeating thoughts and other REBT techniques.

Class role plays are usually energized, especially when I show them Dr. Janet Wolf using REBT techniques with a single parent, on whom she turns the tables by demonstrating the client’s own irrational voices. Quite surprised, the client finally gets to see just how counterproductive these voices are in attempts to parent her children. And then there are Drs. Ed Jacobs and Christine Schimmel, who integrate REBT techniques into their group therapy with eight women.

And who can forget that classic clinical provocateur, Fritz Perls, who, with cigarette in hand, confronted Gloria in every possible way on her road to self-awareness. Interestingly, she felt that Dr. Perls was the most helpful to her out of the three clinicians.

One of my favorites from our collection is the work of the legendary Violet Oaklander, who so effortlessly and compassionately showed us how Gestalt therapy techniques work with children in play. My students are usually awed by the Gestalt therapist at work. They also enjoy watching the work of Erving Polster as he uses Gestalt therapy to help Gerald, an unmotivated and resistant client.

***

There are so many more incredible demonstrations in Psychotherapy.net’s collection. However, these are the ones that have resonated with my students and trainees when highlighting the theories and techniques of person-centered psychotherapy, REBT, and Gestalt therapy. The demographic breadth of featured clients and range of their real-life issues provide offerings with which most of my clinical students and trainees can identify. As their clinical educator, I see clearly how my students learn, grow, and feel more effective after watching brilliant examples of therapy sessions on video.   

Is Private Equity Coming for Your Therapy Practice? An Interview with Joe Bavonese

Posted on by rezendevknowfully.com

In Search of Golden Geese

Lawrence Rubin: You are a practicing psychotherapist, owner of a large group practice, and consultant to other practitioners around practice development — including selling those practices. You have also mentioned to me that you twice went through the full process of selling your own practice to private equity firms but changed your mind in each instance. What exactly is a private equity firm, and why the seeming current high level of interest in psychotherapy practices? 
Joe Bavonese:
private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years
Private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years, hopefully making a profit. In the last five years, they’ve figured out that mental health practices can be a very profitable company to purchase in lieu of trying to make a profit. So, we’ve seen this influx of these large national companies that are heavily funded who have either started their own practice — like BetterHelp — or are simply purchasing practices with the goal that “We’re going to buy maybe 5 or 10 practices and then in 3 years we’ll sell them all to a bigger fish and we’ll make 50 percent profit.”  
LR: If the sole purpose behind private equity firms buying practices is flipping and profiting from the sale, does it really benefit the owner of the practice beyond whatever remuneration they receive? Or perhaps what I’m asking is if there is any fidelity to the practice of psychotherapy involved in these purchases. 
JB: Well, that’s been the big controversy, Lawrence, because in the last few years, it seems like the larger the private equity firm and the more money they have, the less concerned they seem to be about patient care and/or how the staff is treated. So, that’s one of the ethical issues that I think a lot of practice owners are experiencing. You know, “Do I want to sell my practice to a company where the care of the clients may deteriorate, the staff may be unhappy, and I’ve nurtured this baby from day one as my legacy, and it’s all going to get trashed?” So, that’s definitely one of the big problems. 
LR: They say that you never really lose money buying real estate or gold, but why do these equity firms think that psychotherapy practices are golden geese, so to speak?  
JB:
what’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment
What’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment. The demand for mental health, especially since COVID, is through the roof. Then what they typically do is buy a practice that only has psychotherapists and immediately hire several psychiatrists which adds tremendously to the revenue and the profit margin. They’ll do things like this just to eke out as much profit as they can, but it’s really a volume game. In other words, they are really looking for large practices where there are 30, 40, or 50 therapists and then they can really show a higher profit margin on volume. 
LR: Is that common? Are there that many group practices of that size in this country to be bought? 
JB: Oh, yes. There are. I can talk in terms of revenue over size of the practice, but there are quite a few group practices that have revenue of at least $2 million. I know quite a few that are between $4 and $6 million gross revenue, and then the profit of that ranges from 15 to 25 percent. So, if you have a $5 million practice and you make a 20 percent profit, that’s a $1 million profit a year. That’s not chump change. 
LR: No. That’s not chump change at all. Is there a difference between a venture capital organization and a private equity firm when it comes to buying and selling psychotherapy practices? 
JB: I’ve not heard of a venture capital company wanting to buy a psychotherapy practice. You hear about how they seem to go after tech start-ups and things that really have a chance to scale tremendously. Psychotherapy doesn’t scale tremendously like a Facebook or Amazon.  
LR: What does scalability mean when it comes to selling and buying a private practice? 
JB:
over the last two years hiring has been very difficult
Scalability means you can grow exponentially. So, a typical experience would be that of a practice owner who has three therapists who says, “Wow, this is great. I’m making $1,000 profit a month for doing nothing.” Then suddenly, they have 6, 9, 12, 15, and 20 therapists, and they’re making $200,000/year profit, and it just grows rapidly exponentially. Almost everybody I know who has a large group practice never thought they’d get as big as they are. They’re always like, “Well, I thought I might get 5 or 10 therapists and have a nice little cushy cash flow on the side.” But once it takes off it’s almost like it just gathers momentum and more people hear about it. Now, having said that, over the last two years hiring has been very difficult. I think the pace of scalability and growth exponentially has slowed down for many practices. 

Winds of Change

LR: What factors contributed to the financial attractiveness and scalability of psychotherapy practices?  
JB: I started my group practice in 2000 and there was very little competition. So, it was relatively easy to find competent therapists who didn’t want to deal with their own office, didn’t want to deal with billing if they used insurance, didn’t want to deal with marketing or advertising. They just wanted to show up, do their work, and go home and not worry about anything else. That model worked for a lot of people, so I began coaching group practice owners. 

I designed a course called “Creating Group Practice” in 2009. Back then, almost everybody did very well. The harder thing was getting clients. Getting therapists seemed easier. During COVID, there were two things that kind of juxtaposed. There was COVID, and then there was the influx of private equity. So, we now have companies like BetterHelp that are — you’ve probably got these things in the mail — you know, a $500 signing bonus to do teletherapy.

There are more and more group practices. On Facebook, there’s a page called “The Group Practice Exchange.” It has like 3,000 members. There are more people who have realized that just having a solo practice may not provide enough money to live the lifestyle that they desire. That was certainly my motivation. I thought when I got out of grad school, “Oh, I just need to fill out my practice, my wife’s a therapist and there’s two of us, and we’ll be fine.” Well, life is expensive when you have kids, a retirement, college savings, and all that, and a lot of us realized it’s not enough money.  
LR: So, there was an exponential increase in group practices. Did COVID impact the scalability of practices and their value? 
JB:
as the interest rates have gone up along with fears of a recession the valuations that private equity firms have given group practice owners have gone down significantly
The peak valuations group practice owners were getting was around 2020. However, as the interest rates have gone up along with fears of a recession, the valuations that private equity firms have given group practice owners have gone down significantly. But in terms of your question, during COVID I think the virtual therapy businesses like Talkspace and BetterHelp, who had massive backup funding from Wall Street, just poured millions of dollars into hiring and advertising. So, that created a real problem. The other thing I’ve been hearing in the last six months from several group practice owners is that some of these companies are poaching their therapists. So, yes. It’s just created a whole different climate. Now, referrals are plentiful, although that seems to be slowing down a little lately. But finding therapists is much more difficult. 
LR: So, these trends are making private practices less attractive to equity firms right now, or more attractive? 
JB: Less. They’re willing to pay a lot less than they were just two years ago. The other trend I should mention, Lawrence, is that it’s never been easier for a therapist to go out on their own. I’ve heard so many cases over the last two years during COVID of good therapists leaving group practices saying, “I’m going to sit at home and do what we’re doing right now on Zoom or on some other platform, and I’m going to make 100 percent of the money, and I don’t need to pay for an office.”  
LR: So, there was a massive increase in interest in group practices, followed by decreased valuation related to COVID? 
JB: Yes, because the people that were able to hire during COVID did very well. I have several colleagues and friends who put a massive amount of money into hiring and retention. They hired recruiters and did all sorts of things. Many of them expanded tremendously during COVID because the referrals were plentiful, and it was just a matter of finding bodies and you could fill them up instantly with referrals. 
LR: Then that slowed down? 
JB: Yes. Group practice owners' ability to hire has been a problem. I was just talking to someone yesterday in Oregon. He has a large group practice and said, “The problem is that therapists are leaving to go on their own just to do teletherapy. No office payment. Plenty of referrals if they’re just on Psychology Today. And they’ve been able to keep 100 percent of the money.” 
LR:
but with COVID and the exodus into teletherapy these same therapists figured I don’t need to pay overhead anymore I can work in my pajamas out of my basement
So, the group therapy practices were a haven for therapists who didn’t want to run their own practices, but with COVID and the exodus into teletherapy, these same therapists figured, “I don’t need to pay overhead anymore. I can work in my pajamas out of my basement.” So, there’s been a retreat from group practices and the group practices became less profitable, scalable, and thus less interesting to private equity firms? 
JB: Yes. They’re still interested. It just seems like they are willing to pay less. There’s a concept when you value a practice called EBITDA, which stands for “earnings before interest, taxes, depreciation, and amortization.” But what it really means, to simplify it for our discussion today, is the profit of your business plus whatever you pay yourself that a buyer wouldn’t have to pay. So, for example, let’s say your practice value is $200,000 a year, but you pay yourself $50,000 a year for salary and you pay yourself $50,000 a year for healthcare and other miscellaneous personal expenses. Well, the new owner isn’t going to have to pay for either of those, so you add that to the $200,000 and now your valuation is suddenly $300,000. Then they give you a multiple of that as the ultimate value they’re willing to pay for the practice. Two years ago, people were getting multiples of 10 or 12 times their EBITDA. So, again, if it was $300,000, that could translate into a $3 million value. Now, in the last few months, I’m hearing 4 to 6 is typical, with occasionally an 8. So, the value you could get two years ago could be double what you get today. 

The Business of Practice Ownership

LR: It sounds like owning a group practice, or even a private practice, requires a certain degree of entrepreneurial skill. My understanding and my experience are that psychotherapists who are there to help others are not necessarily entrepreneurs. Do you find that that’s the case?  
JB:
one of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money
Yes, absolutely. I’ve been coaching therapists since 2005. One of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money. A lot of therapists tell me they feel guilty if they promote themselves. A lot of therapists are not good at numbers and keeping track of all the metrics. What I would say is the group practice owners who have succeeded at a high level are all entrepreneurial, have all studied business in various ways, and have figured out how to be a business owner as well as a clinician. 
LR: That makes sense. You certainly seem business savvy, so what was your experience like each time you went through the process of selling your practice but then pulled back? 
JB: It’s interesting. The first time I went through the process was in 2018. Valuations were still pretty low back then. But the process was that you got a letter saying, “This is what we’re willing to pay for your practice,” and then you have a 60-day period of due diligence where the company that wants to buy your practice wants to look at all your metrics to make sure that what you told them was accurate, which makes sense. So, if you said your revenue was $2 million and it was really $1 million, they would want to know that. So, you had to give them a slew of things like years of tax returns, profit and loss statements, and a lot of just busy work. A lot of spreadsheets, PDFs, and things like that.  

The part I found uncomfortable was that they basically try to prove that you’re lying to them. And you’re pretty much talking to a bean counter. You’re not talking to a therapist. So, their job is to prove that the numbers are valid and accurate. But my experience was they did it in a fairly demeaning way, which was uncomfortable. Like I said, “I gave you all these tax returns, all these bank statements, and you think I’m lying or hiding? What could I be hiding?” So, that was part of the process. Then what happens is that you start out with an offer and then their job is to whittle it down by saying fairly trivial things just to keep lowering the number, which can’t go up from the original number — but it can certainly go down. 
LR: Like car dealers. Just it’s not a car, it’s a practice. So, it was demeaning, it was patronizing, it was nickel and diming, and that sort of took the wind out of your sails? 
JB: Yes. Ultimately, we ended up with a number that I didn’t think was worth it because one of the things you think about is, well, how much profit do I make in a year? And if I could make up in two or three years what they were going to pay me in one lump sum, well, that seemed kind of stupid. I figured I could make a lot more money in 5 or 10 years than getting out now and just having this one lump sum. 
LR: It seems that the group practice owner contemplating a sale must consider not only financial issues, but lifestyle issues, existential issues, family issues. It’s not just a matter of how much money, but it’s what’s left for me professionally and financially if and when I do sell. 
JB: Yes, exactly. Because if I said to you, “I’m going to give you $3 million,” well, that sounds like a good chunk of money. 
LR: But? 
JB:
if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning
But you’re going to pay taxes, you’re going to pay broker fees, you’re going to pay attorney fees. So, you usually end up with about two-thirds of that, and then is that enough money to live on for the rest of your life? In most cases, not. So, part of it is, do I have enough money to do this, or do I want to stay on and keep working like a lot of people do? I wasn’t interested in that when I was doing it, but a lot of people stay on once they sell and take an annual salary.

I’ve seen $125 to $250,000 a year, and that of course makes it easier to see if the money will last. But then you have the other issue of, “Now, I have a boss when I haven’t had a boss in years and I’m part of a large organization with politics and other things.” But you use the word existential. The meaning question I think is one of the significant ones because if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning, and I don’t believe one that’s easily replaced. 
LR: What types of psychotherapy practices seem most attractive to private equity firms? 
JB: What they’re looking for is consistent growth over the last three years — 20 to 30 percent per year. They want to see an expansion in staff. They want to see diversification of services. They’d rather have a company that’s the one-stop-shop that deals with anxiety, depression, couples, and trauma rather than just somebody who has one specialty. They’re also interested to know if medication is prescribed by a nurse practitioner or psychiatrist, which is a huge bonus because it’s a cash cow for them. They’re also interested in geography — they want to enter a territory and start you as the hub of that territory. Or if they already have practices in your location, they may want to add you as one of the spokes around the hub. Those are some of the main factors that they’re looking for. Also, a healthy profit margin. If your profit margin is 8 percent instead of 20, well, you’re not going to get as much money because there’s an inefficiency there that they’re going to uncover. 
LR: Have sellers of group practices ever been held liable by these equity firms for unmet financial promises? “ 
JB: This is what happens. Usually, they structure the deal where they’ll say something like, “This is the price I’m willing to pay, but it’s contingent on a certain percentage of therapists staying,” because a certain percentage of therapists will typically leave after a sale. So, for example, what they’ll often do is they’ll say, “I’m going to pay you $1 million for the practice, but only $500,000 today, and then depending on the size of the staff in 6 or 12 months, I may only pay you $200,000 more because you’ve lost 20 percent of your staff.” So, it’s incumbent on the owner to be the cheerleader to encourage all the staff to stay on. Typically, they have better benefits than they had previously, so there are some incentives to stay on. But again, if the quality of the client care and the staff care decreases significantly, a lot of people are going to leave. 
LR: When a group practice owner is planning a sale, do they ask or have their therapists sign an “I will not leave” contract to protect themselves against that?  
JB:
almost every mental health stock in the last 2 years has gone down 70 or 80 percent
No. The company buying the practice will have a contract everybody must sign. They typically don’t tell them until the ninth inning. It might be two weeks before they close. So, all the therapists will usually meet with the group practice owner as well as somebody representing the buying company, and they’ll present them with a contract. Then they’ll say, “You have two weeks to sign this contract,” and if a significant number don’t sign it then the deal is off. So, that’s the tense part. I have known some deals where they didn’t have a thing like that. The other thing I should mention, Lawrence, is often the companies that are buying prefer that some of the compensation be in the form of stock options instead of cash. So, I might say to you, “Okay, I’m going to pay you $2 million, but $500,000 of that is going to be in stock options.” Then they’ll tout the potential of the stock. However, almost every mental health stock in the last 2 years has gone down 70 or 80 percent, so if you were one of the ones who were banking for a big payday because of your stock options you may have lost quite a bit of what you thought you were getting. 
LR: Stock options? 
JB: Yes. In other words, I’m a big company that’s on the stock exchange and I have shares that I will give you. I’m going to give you so many thousands of shares. But you can’t sell them right away. You’ve got to have two or three years before you can sell them. But remember, in the last two years, almost every mental health stock has gone down like the rest of the market. 
LR: So, when you’re saying mental health stock, you’re not talking mental health stock. You’re talking about the stocks and the shares in the private equity firms or the firms that own the firms? 
JB: Yes. 

Ethical Concerns and Red Flags

LR: You said one of the positives to the therapists who stay in the group practice are benefits. Maybe life insurance, certainly continued coverage of overhead. Are there any other benefits that the therapists who stay on reap as opposed to any disadvantages that accrue to the remaining therapists?  
JB:
the therapists who stay on are at the mercy of this rather large national company
The benefits usually include health insurance and retirement. Sometimes it includes stock options for the therapist. That’s another thing. The healthcare and the retirement stuff is generally better than what they had, but in terms of a downside to staying, it's that they’re suddenly part of a huge company instead of a tiny company with 30 or 40 employees, so the policies and procedures are often quite different. They have to learn how to use a new electronic medical record program. They might have to participate in more meetings. They have less say in changing anything, which they might have had at a group practice where they were able to meet with the owner and change something. Now, the therapists who stay on are at the mercy of this rather large national company. 

Sometimes what we’ve seen is that some of these large national companies really don’t have anybody who’s ever run a group practice at the higher levels. So, some of the things that they do don’t work very well. I’ll give you an example. A large national company may, for example, have five practices around Tampa and only one regional call center. A potential client can’t walk into the actual practice and make an appointment. They can’t walk into the office where their therapist works to speak with that therapist or check on their bill. They have to call this regional center that has no idea who they are. The feedback I hear is it’s been awful because people are used to getting answers right away with a friendly face in the office. There might be an office manager they can talk to. Suddenly, there’s this impersonal regional center that answers the calls and a lot of people don’t like that. 
LR: Along these lines, you mentioned that you’ve had serious concerns about the ethical issues of selling. This is obviously one of them — the stakeholder, the client getting lost in a large corporate machine. What other ethical concerns have arisen from this for both practitioners and clients? 
JB:
i think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated
The other one is how the staff is treated. Again, when you run a group practice, you usually have a dedicated admin staff who have grown with you. It feels like your family. They’ve gone through all the tough times with you and the good times, so they’re very loyal. So, the idea of throwing these people to the wolves is part of the ethical issue. I think most group practice owners worry less about the therapists because there’s so many opportunities nowadays for them to land on their feet or go on their own. But I think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated. For example, an owner may sell their practice in 2022, and the purchasing company says, “Yes, in 2025, we hope to sell out to another company and then all the policies and procedures are going to change again.” So, there’s this unknown. What am I subjecting my staff to? It’s just impossible to know. 
LR: Aside from the impersonal nature of practices that are regionally managed, are there other downsides? 
JB: In addition to feeling like things have gotten more impersonal and colder, there may be changes in insurance. There may be changes in therapists’ availability. There may be changes in non-competes. They may feel more locked into a schedule. Those are mostly the things that I think the clients or patients feel. 
LR: Are there any red or green flags when a group practice owner is sent a letter of interest by one of these national equity firms? 
JB:
in retrospect, I’m grateful I didn’t sell because I had no idea what I was doing
The group practice owner must do their own due diligence. In the last couple of years, most group practice owners of a significant size have gotten two to five letters like that in the mail. So, usually, they just want to talk to you on the phone initially and give you the sales pitch about why you should consider this. But I think the red flags would be you really need to be part of a support group of other group practice owners. I run or co-facilitate four different group practice online groups of various sizes and we share resources. Somebody said, “Oh, I’ve got a new one. I just got a letter today. Has anybody heard of this one?” So, it really helps, because when I first did this in 2018, I didn’t know anybody back then who had been approached or tried to sell so I was really shooting in the dark. In retrospect, I’m grateful I didn’t sell because I had no idea what I was doing. 
LR: What about when a single therapist gets a letter about joining a group practice that has been purchased? Any red flags there? Because I get several of these a week. 
JB: Again, you just have to do due diligence and see what they’re really offering and ask if it’s really any better than what you’re doing right now. You’re definitely going to lose some freedom. It may make certain aspects of your practice easier. But you really have to research. The companies are so different. Some of them seem very focused on clinical care, and with others it just seems like an afterthought, just as an example. 
LR: Have there been reports to the Better Business Bureau or to the APA, or are there similar places where someone while doing their due diligence could go to see if these private equity firms have not met their promise or been abusive? 
JB: As simple as this sounds, Lawrence, the best thing is often to go on Google and just type in the name of the company with the word reviews and it reveals quite a bit. Some of the companies are listed in the Better Business Bureau, though not all of them, and you can get some feedback there. But I’m just finding that the word of mouth through the community probably gives the best information. But I’m surprised by just how much you can get just from a simple Google search. 

A Short List of Tips

LR: Is there a short list of tips and guidance you could offer a practitioner who is approached by or seeks out a private equity firm?  
JB:
some of these equity firms not all are just ruthlessly focused on growth and all they care about is bigger bigger and bigger
Well, like I said, do your due diligence. Get as much information about the company as you can. Especially ask, “Why are you interested in my practice now? What is your goal for the next few years? What is your philosophy about how you treat the staff and the clients?” Because, like I said, some of these equity firms, not all, are just ruthlessly focused on growth and all they care about is bigger, bigger, and bigger, and it comes through clearly when you talk to them. Others will slow it down and talk about their philosophy. But you really want to zero in on how much do you really care about clinical care? How much do you care about the competence of the staff, or is it just a numbers game to you? So, those are some of the things you want to find out. 
LR: So, theoretically, a private equity firm could come in and just fire the whole staff? 
JB: Well, they wouldn’t do that because hiring even for them is still difficult these days. Really the only value of the whole enterprise is the staff and the client, so if you fired them, you’d lose the whole revenue. 
LR: In insurance companies there’s usually a psychologist who oversees claims and answers difficult questions. In your experience, has there been a clinical point person in these equity firms? 
JB: Yes. Usually, they have a clinical director, a regional clinical director, or a national one that you’ll talk to who will make everything sound sweet and rosy. But during that 60-day due diligence, that person is pretty absent and you’re mostly just talking to the accountants or the attorneys. 
LR: Boy, you’ve really got to be sharp and on your game. 
JB: Yes. That’s what I should mention. There’s no way as a licensed psychotherapist to do this on your own. You have to get a broker or some financial person to help you through it. It’s just too much stuff that you have no idea about. You need somebody who understands the lingo and can help you avoid the obvious traps. 
LR: Have private equity firms favored white-owned, white-serving practices? Is there a racial/cultural line? 
JB:
i would say the percentage of black owned group practices is lower than the percentage of Blacks in the population
That’s a good question. I would say the percentage of Black-owned group practices is lower than the percentage of Blacks in the population. Like I said, I’ve talked to probably 80 to 120 group practices in the last 5 years. It’s not an exhaustive search, but it probably gives me a fairly decent survey of who is out there. I haven’t heard of that. I think they’re more focused on the numbers and whether the location fits into their long-term strategy, but I really don’t have any data on that. 
LR: Of those 80-120 practices you’ve spoken with over the last 5 years, have you found that there’s a consensus around the right time to sell, or is it more idiosyncratic? 
JB: Well, it is idiosyncratic, but there are some categories I think people fall into. One category is that “I’m so burned out and sick of this, I’ve got to get out,” which unfortunately I know a fair number of people like that where they are constantly stressed out by their group practices, constantly stressed out, and physically and emotionally exhausted by the demands of dealing with the staff. For those people, I think if they can afford the deal financially, it is probably best to get out because they’re not happy. They’re really not enjoying the ride. Then the other thing is the category of people that just want to say, “I don’t want to ever have to work again if I can get a good enough deal, and if I like the philosophy of the company buying me, then that’s good and I’m happy to do it.” But again, it depends on your age, the age of your kids, all those financial things, and your lifestyle. So, I’m thinking the most common thing is that the motivation is financial, clearly. A good friend of mine recently said, “I’m looking for a new challenge. I’ve been doing this for 10 years. It works well, I know how to do it, but it’s getting kind of boring. And a lot of the private equity firms are saying, ‘I want to buy your practice and then I want you to spearhead the project of adding eight more locations around the area of your practice.’” 
LR: And they don’t want to do that. They just want the hell out. 
JB: Yes. But if they want to stay on to keep a salary coming, that’s basically what they’re going to be doing for a while. It’s just, “Okay, what do you think of this one?” More than likely, the parent company will fund it. One of the nice things people have told me is not having to worry about the price of furniture or computers — it’s sort of like a blank check. Whatever you need in terms of a new location, we’ll provide it. 
LR: So, the group practice owner who is ambivalent or who is not quite at the stage of life where they should make the decision probably needs to be coached? And that’s where you come in with your consulting service. 
JB:
i do one on one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people
Yes. There are a lot of people who are interested in it, but they don’t know some of the things we’re talking about today. They don’t know the realities. Or somebody promised them something on the phone that turned out to be false in the long run. So, I do one-on-one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people. 
LR: Joe, to turn the tables; if you were me interviewing you, is there anything I’ve missed? Any questions I could’ve asked that would deepen our readers’ understanding of the issues? 
JB: JB: I just think the existential issue gets minimalized by people. I really don’t think people realize how hard it is to replace meaning in their life because it’s not like most entrepreneurial-minded people who are successful at a group practice do not do well with free time. One of the phenomena I’ve seen which is interesting is that as people get bigger and more successful, they stop seeing clients totally and then they delegate more and more stuff, and suddenly they might only be working 10 or 20 hours a week. You would think on the surface that would be great, but what I hear is, “What do I do with my time?” So, it’s like having gaps in their schedule after working crazy hours for years to build this thing up is often difficult. It sounds funny, but it’s a real issue that I think people minimize when they go into this process. 
LR: So, I would imagine you often coach these folks around the existential issue, almost like doing therapy?  
JB:
one of the things that I did was to ask myself what were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued
Yes. It becomes more therapy than business coaching at that point because everybody’s sense of meaning is different. But I guess it’s no different than retirement coaching other than they’re still working to some degree. But yes, it becomes more like therapy to kind of tease out, “Well, what are the most meaningful things?”

One of the things that I did was to ask myself, “What were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued?” Then I made a list and that’s what I’m doing now, so it works out nicely. But I still think a lot of people have never thought about it. “Well, it’ll just be an endless vacation, or I’ll just play golf.”   
LR: Or climb mountains or go to baseball games. 
JB: That’s right. 
LR: Thanks so much for sharing your expertise and experience with me today, Joe. This area is so new to me, and I think it’s going to be equally new and hopefully helpful to many of our readers, some of whom may be contemplating joining a group practice or building a group practice or selling their group practice.  
JB: Well, good. I’m glad to hear that, thanks. 

A Powerful Therapeutic Tool for Defeating Negative Self-Talk

Posted on by Psychotherapy.net Team

A client of mine, let’s call her “Jill,” got nervous for business meetings no matter what they were about. She often worried, daydreamed, and lost sleep the night before meetings. Afterward, she typically acknowledged something to the extent of, “It wasn’t as bad as I thought.”

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This was an exhausting strategy. Jill was convinced that her stream of hyperactive self-talk was preparing her for what was to come, but the amount of bandwidth chewed up by worry undercut her ability to plan well, if at all. On the day of the meeting, Jill presented as anxious, at least at first, until she realized that all was well. Fear of the moment was worse than the moment itself.

Sound familiar? Many of our clients experience similar struggles with anxiety and negative self-talk.

Eventually, Jill enlisted a strategy called WBL. Instead of steering her away from negative thinking (which would have felt precipitously close to telling her ‘How to feel’), we tapped into her brain’s natural predisposition to predict and created some parameters around it. It proved to be a powerful tool in our work.

A Cognitive Behavioral Intervention: The WBL Strategy

I adapted the WBL model from core CBT principles and have found it useful while working with clients like Jill. At the beginning of our work together, Jill and I defined the specifics of situations that aroused her anxiety. Often when anxious a set of varied concerns coalesced and appeared as one item. We combatted this generalized anxiety through a process called “unbraiding,” wherein we specified one particular concern from among the many. When her concerns appeared tangled, we pulled at only one thread.

Despite her competence and high level of achievement, Jill had grappled with imposter syndrome in the past, and at each new meeting, was inclined to “prove” her professional value.

After identifying the concern, we began the WBL process. The W stands for Worst. Jill was asked to imagine the worst possible scenario, with two limits: 1) take notes; and 2) keep time. We did this with pen and paper handy. The task was to write the ideas down and, importantly, to be honest. This was an important phase for multiple reasons.

First, we honored the inclination of her mind at that moment. In a recent incident, Jill was afraid of being shouted at. She said she did not want to feel powerless. She recounted her journey to achieve her position in the company and was terrified of losing that status. Once this worst-case scenario had been named, we were able to create space for it and distance from it. By talking through the W, we determined that it was not the business meeting that was bothering her, but the fear of feeling inadequate.

Together we agreed not to focus on the W for too long. We set a timer for five minutes and stuck to it. Importantly, Jill was the one who physically set the timer on her phone. She owned the duration; she set a barrier around the time we were allowed to spend considering the W. Before we started this process, Jill spent too much time contemplating the worst possible outcome.

The longer she sat in that hypothetical, negative situation, the more she colored her mind with negativity. Prior to beginning the WBL process, she would enter business meetings in that hyper-negative state, and as soon as she sensed that the meeting felt “off,” she would interpret it as a confirmation.

Therefore, the immediate next step, B, asked her to consider the Best possible outcome of the situation. Entertain the idea that the meeting will be full of praise, ending in a big promotion. What would that look like? Would it come with more free time? More money? More travel? It took considerable effort for Jill to allow herself to consider such a positive outcome. This phase of our work was not about considering what was “pretty good,” but instead, what the best could look like.

Jill had trouble getting to this place. She was hesitant to think big. She had no trouble going to the W but believed that the wonderful reaches of the B were not likely, so she talked herself out of them. Over time, we worked together to understand that the best was, by definition, just as likely as the worst — they were two ends of a hypothetical spectrum that she created.

Once we identified those two poles, we found a spot in between (it can be helpful to draw out the continuum on a piece of paper). In the L phase, which stands for Likeliest, we took a moment to be truly sensible. The outcome of Jill’s upcoming meeting was not likely to be at the worst pole, and, unfortunately, not likely to be at the best pole.

So where was it most likely to be? At this point, she tended to lean back toward the W side of the spectrum. It was important that she catch herself leaning into that negative default and do the work to stay centered. I encouraged her to, if anything, lean toward the B and let her mind be colored by positive thoughts, as they would have an impact on her interactions.

Once we did the work of naming the concern, then working through the WBL model, we put it all together. She had the power to influence the direction of the meeting through the energy she would bring to it.

Cognitive Strategies Lead to Successful Outcomes

Cognitive strategies like CBT did not rid Jill’s professional life of challenge but improved her approach to challenges. Jill was successful and driven. She was accomplished and continued to move in a positive direction. She credited taking control of her self-talk as an important step in the future she imagined for herself.

Deliberately cultivating Jill’s mindset was not a soft, feel-good skill (though it did feel good). It positively impacted outcomes. We call those positive outcomes feedback. The more positive feedback she received, the more confidence was built, and the less likely she would default the next time around toward a worst-case scenario. The more we repeated this process, the more we shifted the default positions away from the worst and toward the best.

The brain is, first and foremost, a prediction machine. The WBL tool helped us get behind the wheel of that machine and steer it. The difficult journey for Jill turned out to be well worth the effort.

In the Shadow of COVID, It’s Play Therapy to the Rescue

Posted on by Psychotherapy.net Team

Kevin’s Worried Parents

In March of 2021, families were emerging from almost a year of isolation due to the COVID pandemic. As a Licensed Professional Counselor Supervisor and Registered Play Therapist Supervisor in private practice specializing in children, I was flooded with requests for services.

During one particular intake interview, the parents of a four-year-old boy I’ll call Kevin asked me a fair question. “How will our son’s development and mental health be impacted by this year of isolation?” I immediately reflected their feelings with, “You are really worried about the long-term impact on your son.”

Their worry was understandable given the emerging research showing increases in children’s anxiety and depression since COVID began. Yet, multiple factors of genetics, parents’ behavior, peer interaction, and available resources contribute to children’s developmental and mental health trajectory after a crisis. To respond to their fair question, I needed more information from them.

I asked, “What is concerning you the most?” Both parents had college degrees and were well read so they had valid concerns in mind. “Our son has not seen, much less interacted with, another child for over a year. He is our only child. Even though we took him to the public playground, as soon as another child got within 20 feet of us, we would leave quickly.” I thought to myself, risk factor one — no peer interaction during a critical developmental period.

Preschool is when children learn to tune into peer facial cues, scaffold their own physical and cognitive learning by watching other children, negotiate sharing, and so on. I needed to provide some hope to the worried parents, so I tried to normalize the fact that most of his peers had a similar experience. I replied, “Some children’s social, physical, and cognitive development may be a bit delayed during COVID. Fortunately, children are resilient and can learn together, starting from where they left off.” They nodded with seeming understanding.

Then Kevin’s parents said, “Our son could tell we were stressed when we were working from home and paying bills with less money. We tried to play with him, but we had many conference calls. He didn’t understand and thought that we were ignoring him. He became clingy and we became irritated, occasionally speaking to him more harshly than we desired.”

I thought to myself, risk factor two — parent behavior that was interpreted by the son as anger, resulting in increased anxiety. Being a parent myself of an only child who also has ADHD, I empathized and normalized with a compassionate groan. “I get it. I experienced something similar with my child.

We can feel so disheartened, trying our best to juggle it all, and losing our temper more than we want. We are human, not superheroes. We need self-compassion. That’s why I go by the 80-80 rule of parenting. About 80 percent of the time, I try to do about 80% of what I know to be helpful. But during COVID, I lowered my standard to 70-70 because that is passing.” They laughed!

The parents added with a heavier tone, “We are also concerned about his anxiety because we both suffered with anxiety during our childhoods.” I thought to myself, risk factor three — genetics. Research shows a strong genetic influence on the development of childhood anxiety disorders. Again, the parents needed some hope. I reflected, “You both know the pain and struggle as a child with anxiety. You love your son so much that you want to intervene as early as possible. You are wise to do so. I can help with that. Research shows that play therapy can decrease children’s anxiety. Together, we can work to build those limbic system neural networks toward calmness rather than fight or flight.”

Yes, the risk factors for this child were compounded during COVID. He had no peer interaction for a year, stressed and distracted parents, and a genetic predisposition toward anxiety. Yet, he also had the biggest protective factor we could hope for — caring and proactive parents. This plus mental health treatment, interventions of parent guidance, twelve sessions of Child-Centered Play Therapy (CCPT), and psychoeducation could shift this boy’s development and mental health toward a more positive path.

Prior to beginning my work with Kevin and his parents, and to gauge the level of his behavioral and emotional difficulties, I sent his parents a link for the web-based child version of Achenbach’s System of Empirically Based Assessment (ASEBA) Child Behavior Checklist for ages one and a half to five. The results revealed a pattern of emotional reactivity, anxious and depressive symptoms, and sleep problems. While Kevin’s scores on the DSM-related scales for Autism and ADHD were in the normal ranges, his other scores were consistent with DSM anxiety and depressive symptomatology. These results corroborated his parents’ concerns.

The parents’ main goal was to decrease Kevin’s anxiety so that he could calmly engage with others without clinging to his parents. Their prior attempts to reassure him through reason were ineffective. Using Daniel Siegal’s Hand Model of the Brain, I explained strategies to calm the lower regions of the brain through deep breathing, rocking, and soft voice rather than trying to reason with his prefrontal cortex, which was “offline” during his anxious times.

To reinforce these concepts, I asked Kevin’s parents to watch a parenting video by Tina Payne Bryson called 10 Brain-Based Strategies: Help Children Handle Their Emotions, and to read Siegal and Payne Bryson’s No Drama Discipline. These two resources helped them improve their ability to calm their own anxieties so their son would co-regulate with their calmness. To deal specifically with anxiety, I also recommended Calming Your Anxious Child: Words to Say and Things to Do by Kathleen Trainor to guide them in the step-by-step process of systematically desensitizing his fears.

A World Opens

In the waiting room prior to his first play therapy session, I greeted Kevin, commented on his red tennis shoes and matching shirt, and said, “It is time to go to the playroom. Your mom will be waiting right here.”

I smiled with friendly confidence, moving toward the door, and gestured for him to follow me. “We have lots of toys there.” His curiosity was stronger than his anxiety, so, he followed me. Kevin’s eyes opened wide seeing my play therapy room filled with carefully selected toys for nurturing (dolls, doctor’s kit), creativity (puppets, paints and easel, dress-up clothes), real-life mastery (kitchen, tool bench), and aggressive release (swords, bop bag, army men). As we entered, I said, “In here you can play with all the toys in most of the ways you like.”

Kevin was hesitant and stood near me, asking questions. “What do I do first?” Given his anxiety, this was not surprising. “In here you can decide.” He moved his eyes but not his body. I view this as a “freeze” state, a survival response for people perceiving threat and feeling overwhelmed. The threat was not necessarily coming from the playroom but from being separated from his parents or close family members for the first time in over a year. I reflected his feeling with reassurance, “You are a little scared being in a new place,” and role modeled taking a deep breath. I waited patiently so he could sense my calmness and confidence, thereby communicating this was a safe place.

Kevin moved toward some small cars on the shelf and pushed them along the floor. This action with familiar toys gave him a sense of security and mastery. I reflected his feelings by saying, “You enjoy seeing how far you can push those cars.” My statement reassured him that he really was welcome to play and built his confidence. He said, “Yes, I have a blue and red one at home that I like to race.” I gave him credit for his skills, “You are an experienced car racer!” He smiled and pushed the cars toward the four-foot red bop bag, named “Bobo.” Kevin lightly pushed on it to see how quickly it moved. “What’s this for?”, he asked. I returned responsibility to him with “You are curious what you can do with that. In here, you can play with it in most of the ways you like.”

Little by little, he courageously experimented with different actions from punching it, sitting on it, hitting it with a sword, and shooting at it with a dart gun. With each step, his sense of power grew. Toward the end of the session, he expressed creativity by painting a picture of the bobo. I ended the session with 10 minutes of psychoeducation on managing stress. I demonstrated and guided him through deep breathing, progressive muscle relaxation, and a self-soothing butterfly hug. After walking Kevin back to the waiting room, I prompted him to demonstrate his new skills for his parents and asked them to practice at home each day.

Bugs All Over You

In the fourth session, Kevin began with rolling cars again followed by punching Bobo, providing him with a familiar rhythm and routine. Once he established his sense of mastery and power, he collected toy spiders, snakes, and bugs and put them on my legs, hands, and shoulders. “You have bugs all over you. You can’t move.” I stated, “You are showing me it is scary to have bugs on me and not be able to move around.”

He exclaimed, “Yes, you are going to be stuck there forever.” I responded, “It seems like it will never end!” Eventually, Kevin decided to rescue me by knocking off the bugs with a sword. His symbolic play reflected his experience during the pandemic of feeling scared and trapped. Yet now he was in charge, rather than being the one trapped. He was gaining an emotional understanding to master his traumatic experience of COVID isolation.

At the end of the session, I engaged him in a children’s book that illustrated listening to his body to notice when he may need to take deep breaths and seek soothing sensations such as rubbing his hands and legs. This combination of child-led restorative play reenactment plus the intentionality of anxiety management skills strengthened his ability to emotionally self-regulate.

Mommy Dies

By the sixth play session, Kevin had gained enough comfort in the playroom that he was ready to play out a hidden fear — mommy dying. He approached the playhouse and put the “daddy doll” upstairs in the office to do his work. The “boy doll” was downstairs by himself watching TV. The mommy doll ran out of the house to go to a work meeting on a nearby table. Kevin drably said, “Mommy went out of the house, got COVID and died.” I reflected, “Super scary and so sad she died.” Kevin quipped, “Yup. Now who’s going to make dinner? Daddy is busy working.The boy will have to go out and hunt for food.”

I responded, “The boy feels all alone AND he knows how to get some of what he needs.” Eventually, Kevin brought in the army to help him hunt for food. I facilitated understanding: “There were strong people out there who could help the boy when he needed it. They kept him safe.”

Underlying Kevin’s fear of his mother dying was the basic existential question of “Will I survive?” Through play, Kevin created his answer — letting strong people help him. During the last 10 minutes of the session, I facilitated psychoeducation by playing a detective game with Kevin. “Let’s list lots of things many kids are worried about these days.” Kevin said, “Losing their favorite toy and their dog running away.” I added, “Family members getting sick, going to the hospital, and dying.”

Then I challenged his all-or-nothing thinking. “There are 100 kids. One kid loses their toy. Does that mean every kid loses their toy?” “No.” “There are 100 dogs. One dog runs away, does that mean everyone’s dog will run away?” “No.” “There are thousands of people. One person may get sick from COVID and die. Does that mean everyone will?” “No. If someone gets sick, they go to the doctor and the doctors do their best to help them.” “Let’s think about all the kids who are playing with their toys, dogs, and family members. What would they be doing?” “Playing fetch.” “Yes! I love to play fetch with my dog.” Since Kevin was calm, he could engage in basic reasoning that most people will be OK and the importance of focusing on the positives in the here and now.

Doctor Superhero

In the tenth session, Kevin walked in with confidence. He rolled the cars, punched the Bobo, and took the baby to the doctor. “Your baby is sick. I am the doctor.” He used the stethoscope, took the temperature and blood pressure, and gave the baby a shot. I reflected, “You knew how to doctor the sick baby and get the baby better.” He got the cash register and declared, “That will be $10,000.” I paid up — a small price for his victory.

Then Kevin put on the Superman costume and flew around the room “saving everyone.” I enlarged the meaning: “You are an important, powerful person who can help so many — even yourself.” With his chin tilted up, he said, “Yup, I’m not scared anymore!” Indeed, his parents had confirmed that he was no longer sleeping with them, and he was willing to stay with a babysitter for them to have a date night.

Reflections

From a Child-Centered Play Therapy perspective, Kevin was experiencing incongruence between his ideal self as a confident, engaging boy, his current self as an anxious boy, and his experiences of isolation and fear during the COVID pandemic. He was not accurately symbolizing the behavior of his parents and other adults in that he interpreted their cautions as a lack of confidence in him. Over months of physical and emotional isolation, his self-concept was of a timid, weak child who was unable to move forward in his world.

Kevin’s time in the playroom with me along with his parents’ support provided him with a developmentally appropriate intervention in a safe playroom with an empathic play therapist, representing a microcosm through which he could master his world. He was able to come to an emotional understanding that his past anxious experiences were about an illness doctors were trying to heal and not about him. His self-concept strengthened to see himself as a strong, powerful boy who knew how to get help, help others, and help himself. Parent consultation, Child-Centered Play Therapy, and psychoeducation were the healing components of treatments that showed such love to this family. Kevin emerged from his isolation and anxiety. He flies like Superman toward a more positive developmental trajectory.

Parents and children experienced suffering during COVID. Many experienced existential anxiety from recognizing mortality, confronting pain and suffering, and struggling to survive. Mental health professionals were trained to support people in crises such as COVID. Yalom and Josselson remind us, “No relationship can eliminate existential isolation, but aloneness can be shared in such a way that love compensates for its pain.”

Reference

1. Yalom, I. D., & Josselson, R. (2011). Existential Psychotherapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 310–341). Brooks/Cole, Cengage Learning.  

The Gift of Presence in Grief Counseling: A Path Forward

Posted on by Psychotherapy.net Team

Grief is an inevitable part of life, one that I personally believe to be among the greatest sufferings of humankind. Yet, while often a source of deep pain, grief can also be a source of great love. That reluctance to let go of someone we cherished is the last act of affection we give to those who have passed.

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Grief is a process of many intertwining emotions. Shock, anger, depression, and confusion may surface, to name just a few. While Elisabeth Kübler-Ross created a helpful formula addressing the stages of grief, it is important to remember there is no right or wrong way to grieve. Contrary to what people may say, each person grieves differently.

Grief is Like an Ocean

Grief is like the ocean; enormous, ever-changing. It comes in waves, ebbing and flowing. Sometimes it is calm, gentle, almost peaceful. Other times it is overwhelming, strong and aggressive. These are the times it can knock us off our feet, taking the wind from our sails. The enormity of loss often weighs heavily. When that heavy feeling right in the pit of the stomach forms, we can feel like we are sinking into it.

On other days, it is almost manageable. Life continues. We get caught up in everyday routines, our pain almost fleeting. A gentle wave comes to the surface when we are hit with a memory or a reminder of our loved ones. We slowly learn to tread water, working to keep our heads above the tide. It can be challenging at first, but we get through. The day passes. Much like the waves in the ocean, our pain is fluctuating.

Can we ever really learn to live well in our grief and move on from the pain of our loss? I feel we never truly part from those we love, and many people don’t wish to. We can, however, move forward and learn to live with our loss, gradually easing the pain. We can adapt, move around our grief, and eventually rebuild a life without our loved ones. Counselling can help reach this goal.

Working with grief in a therapeutic setting has been one of the most beautiful yet difficult presentations for me and the clients I have had the privilege to work with. I have found it important to honour the strength it takes for a client in their suffering to show up each week to face their pain.

Grief counselling is intended to help the client process their thoughts and feelings around the loss. Of course, talking through grief does not take it away, nor minimise the impact the loss has on the client’s life. It can, however, soften the experience, allowing the client to healthily process their thoughts and feelings, holding space entirely for the client’s experience, anguish, and grief, enabling a level of gentle healing to occur.

When beginning to work with grief in the therapeutic setting, I value the importance of firstly holding space for the clients. I emphasize the value of the client’s emotional experience, allowing the raw feelings to surface in a gentle, safe environment. It is important to sit with these feelings, holding the client fully in the presence of their pain.

When Anger Gives Way to Pain

Recently whilst working with a new client in session, they seemed reluctant to visit their grief, presenting each week with anger and deflecting on the initial reason they had begun therapy. Each week they presented irritated and angry, often projecting these emotions at small minor inconveniences that happened within the week, sometimes exploding and intensely reacting as they told their stories. Sessions became governed by anger, with the client unwilling to take it anywhere else. For a few weeks, I allowed space for this anger, and we worked in the moment to afford the client full autonomy in the sessions.

A few weeks on, the client presented another angry story, like the previous week and the week before that, and again over a small inconvenience. As usual, I held space for the high emotions, and once the client had finished their story, silence filled the room. They looked at me for empathy and understanding, but I did not respond to the story on this occasion.

“Would you not be angry at this?” they asked. After some silent pondering, I shared that in my experience of working as a therapeutic counsellor, at times anger can be a secondary emotion, explaining that sometimes if you are hurt in some way you might express this negative emotion instead of emotional pain — that for some, it might be easier to express anger rather than hurt. A pause.

I felt now was the opportunity to move into the next phase of our work, compassionately inquiring about the feeling of anger further. “Tell me, what is underneath your anger?” I noticed the shock at being challenged on their aggression as the client processed this question.

Softly encouraging the client, I invited them to “Stay with the thoughts and feelings that are surfacing,” and in response, they had a deeply emotional reaction to the question. Answering quietly, they said, “grief, my anger is grief.”

Relief washed over them as they identified and acknowledged the emotion. “Ok,” I said as I let out a breath, “let us together hold space for your grief. I know this is hard, I know this is painful, but let us together sit with this pain until it passes, soothes, or settles. I promise you are safe. If we sit with it right here, right now, exactly as we are, it will soften for the time being.”

On Reflection

On reflection, I realise the importance of sitting with these feelings, fully leaning into the experience, holding the client present in their pain and softly working through the emotions. Reassurance and gentle guidance are paramount when working with grief.

Within my therapeutic work, compassion and empathy are a salve to emotional injury. Sitting with a client in their pain is a powerful thing to do. It does not come naturally to a lot of people, as often they will want to repress, suppress, or avoid that pain and those experiences, much like my client did. However, the healing is in feeling them.

Now that my client had accepted their feelings, we began to do the work. Sometimes we would sit in total silence, acknowledging the energy in the room while my client worked through the feelings they experienced, and once the energy shifted, we began to regulate each emotion.

To move into this level of awareness and regulation I often encourage clients to acknowledge where in the body they feel sensations, softly inviting them to explore the feeling with me. “How does that feel? Does it feel hard or soft? Describe the sensation your body is experiencing right now?” This keeps the client grounded, and usually I find the feelings soften.

It may feel beneficial to lead the client into some gentle breathwork, staying present and engaged, co-regulating alongside the client. I may invite them to put their hand on their heart, to keep eye contact with me as we inhale through our noses and exhale through our mouths. This encourages the body to regulate and settle. Once I feel regulation has occurred, we may move into sharing memories of their loved ones, often discussing loving moments or times of laughter.

My clients’ laughs and their glistening smiles as they recount their memories are beautiful moments to witness, and moments I will always be very humbled to be part of.

Questions for Thought and Discussion

What is your reaction to the author’s approach to addressing grief therapeutically?

Is her approach similar to or different from your own way of addressing grief?

Are there particular grief-related issues that you struggle with in counseling?

What personal life experiences have influenced your approach to grief counseling?