Ninety-Five Percent: Preparing to Work with Previously-Incarcerated Clients

Posted on by Psychotherapy.net Team

On the heels of my previous blog about the stigma experienced by previously-incarcerated clients with mental illness, I find myself once again in a reflective state around the idea of re-entry for these challenged and challenging clients. I draw attention to the title of this writing, which reflects the staggering reality that, according to a recent congressional study, 95% of those who become incarcerated will return to the community. Let that sink in for a second. This means that almost everyone who is sent away to a penal institution will be back on the streets. Why, then, haven’t we pushed ourselves to view crime and the “criminal” as less of that individual’s moral failure, and more of a societal one that must be addressed upon their departure from incarceration?

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It is easy to sit in judgment of others, especially those who have transgressed, and it takes only seconds to formulate a first impression of someone. Pair this with the biases and prejudices that incarcerated clients experience, and they leave prison or jail with a complete narrative that may very well not be their own. Clients returning to the world beyond prison gates live with these preconceptions from the moment they interview for a residence and/or job to the moment they seek follow-up services for physical, mental health or substance use treatment. And in my experience, these particular clients know full well that welcome mats, smiling faces, and open arms will not abound upon their release. That being said, unless clinicians acknowledge their own fears and judgmental attitudes towards these clients and fully lean into their own discomfort, the cycle that perpetuates stigmatization and diminishes rather than enhances their successful re-entry will continue to imprison them.

I recently worked with a client I will call Brennan, who has been diagnosed with a serious mental illness as well as a substance use disorder. Brennan is intelligent, resourceful, and sociable, but when taking his psychiatric medications tends to become more reserved, something that I have found occurs frequently with individuals experiencing psychotic or more severe mood disorders. Brennan does not have a lengthy history of incarceration, nor does he demonstrate an antisocial personality which would lead to a callous disregard for others. Instead, Brennan’s psychiatric challenges of late seem to have led him to correctional facilities, which, in turn, has made it difficult for him to re-engage with the world upon release. Recently, upon pursuing post-release community services, Brennan was left in limbo rather than being accepted into the program after he spoke honestly about an interest in smoking marijuana. Although he appropriately utilized the skills we taught him prior to release, Brennan was shamed and unable to successfully reintegrate into the community as he had hoped and, quite frankly, deserved.

As I continue to help facilitate re-entry for my clients and assist them in navigating the confusing labyrinth of providers, I’ve noticed that the doors for treatment do not fly open for them, which makes the struggle to resume or begin a life beyond the walls that much more difficult. Their psychiatric conditions, which often incorporate psychotic features, frequently lead to their presenting with strange or bizarre thought content that is even more evidence to community providers that they should be feared and turned away rather than assisted. One of the most potent interventions I’ve used when preparing these clients for life on the outside has been the process of reality checking and reality check sheets. For individuals with major mental illness, and especially for those who struggle with psychosis, this allows them to speak openly about whatever thoughts enter their minds in a safe space where they can receive supportive, rather than dismissive, feedback and learn that their thoughts do not have to be a source of shame or be given authority over their lives.

A client I will call Kent believed that he was related to a very powerful and influential celebrity. This was a persistent and fixed delusion. He did not typically converse openly about this except for when his paranoia was triggered, which could in turn contribute to erratic and sometimes volatile behavior. However, Kent felt safe with the staff members, who helped him to develop a small list of reality checks on printer paper in his cell. One such note asked him to respond with a “yes” or “no” to the question of whether he had been particularly invested or rigid in this belief on that particular day. He would then communicate his response to staff who could provide reality-based and instructive feedback for him while helping him to monitor himself. This intervention was effective because Kent trusted the clinical team, who always promoted safety as the most important value to the correctional community in which he lived. Kent exemplifies the importance of assisting these clients by providing concrete tools they can use once released and can share with providers on the outside.

***

What I wish for all of us is to continue challenging the status quo. To go outside of our comfort zones and take on the more complicated clients, the ones who keep us on our toes and challenge our clinical minds. I challenge you to push members of other professions, often the individuals we work with to establish services or provide housing, to do the same and, perhaps most importantly, to get more clinicians involved in services such as housing, substance use treatment, or community intervention upon intake. Let us truly meet people where they are on their journeys. There is no “perfect” client, and any client who says and does exactly what is expected of them is probably not getting all of their needs met either. Let’s keep our advocating voices strong and help those who need it the most, as in the case of the client who is trying to forge a life outside of prison walls.

An Existential-Spiritual Journey During COVID-19

Posted on by Psychotherapy.net Team

A Place of Uncertainty

As we approach the second anniversary of the first detection of COVID-19, we are no longer in the acute stages of the pandemic. However, neither do we find ourselves squarely in a post-pandemic world, as new variants continue to evolve and spread rapidly, sparking fear and halting daily life. A heightened sense of self-doubt, vulnerability, and anxiety can occur in this “limbo-like” state, particularly for clients experiencing life-threatening medical conditions. Feeling threatened for prolonged periods may increase both the client’s and therapist’s need for certainty and diminish our ability to tolerate ambiguity. In the case of COVID-19, when safety and normalcy are in question, life’s uncertainties may be harder to endure.

Existential approaches are particularly well-suited for addressing concerns provoked by the COVID-19 pandemic such as encountering the fragility of life and the unpredictable nature of events, as well as uncertainty about when (or if) the pandemic will end. For Yalom, the aim of psychotherapy is to help clients fully experience and accept the existential anxieties associated with the “givens of existence,” including death, isolation, freedom, and meaninglessness. As a result of facing death, individuals may experience a sense of urgency to revise life priorities that can lead to improved meaning.

Existential therapists generally suggest that anxiety and existential guilt need to be experienced in an open and honest manner and, when directly encountered, can become a source of vitality, creativity, and purpose. Rollo May and Paul Tillich believed that courage and determination are fostered when anxiety, adversity, and life’s dilemmas are faced. In other words, when we accept our limitations, we also commit ourselves to living fully.

Victor Frankl’s recent series of posthumously published papers does this by shifting emphasis away from the question of “What can one expect from life?” to “What does life expect from us?” Thus, he suggests that it is life itself that asks questions about meaning. While we may feel challenged and forced to face discomfort when we ask ourselves what life expects from us, French philosopher Gabriel Marcel posited that such pain and suffering offer the only pathway to real insight and spiritual growth. Perhaps through these challenging questions that place uncertainty, obstacles, and suffering before us, we discover our meaning and purpose.

Clinical Vignette

The clinical vignette presented below highlights the challenges of how a therapist-client dyad worked through their mutual feelings of “not knowing” and uncertainty by processing their own existential anxieties and fears. A series of dreams of the client and therapist, as well as the use of creativity as a spiritual intervention, are described to demonstrate the complexity, practicality, and depth of the existential approach. In particular, the vignette highlights how dream interpretation can be used in enhancing problem-solving and conflict resolution, mastering trauma, exploring unknown possibilities and paths not chosen in life, wish fulfillment, compensation, communication with the therapist, and integration of self.

Initial Phase: An Exploration of Death and Social Anxiety in the Context of COVID-19

Steven is a 63-year-old man who presented for individual psychotherapy approximately six months after the resection of a non-malignant brain tumor. He experienced one generalized tonic-clonic seizure immediately after his tumor resection, which had a significant impact on his social and emotional functioning.

In terms of constitution, Steven had always been shy and sensitive. He had maintained a group of close friends since high school. Although he never married, he had had two long-term relationships since graduating from college. At the time of his surgery, he had been retired for two years from his career as a special education teacher and had reportedly been adjusting well to his life transition. Steven valued his level of independence, intellectual curiosity, and work ethic. His numerous interests included photography, hiking, reading history, and political activism. After the onset of his neurological condition, however, he became quite withdrawn and fearful about leaving his apartment. Although his seizures were well controlled with medication, the onset of his condition and the implied risks amplified his social anxieties and fear of death. Whenever he did leave his apartment, he felt self-conscious about his word-finding difficulty and occasional stutter, which exacerbated his fear of being ridiculed and shamed. After experiencing months of social isolation and increasing depression, he reached out for therapy at the encouragement of his physician and close friends. He hoped to regain self-confidence, be able to connect with old friends, and resume his recreational interests.

Steven’s comments about his own mortality were interspersed throughout the early sessions and were delivered in an intellectualized and affectively neutral manner. He recalled his experience of waking up from surgery and having a seizure in a vivid but emotionally detached manner, leaving me feeling highly anxious. I felt that he would have been frightened and overwhelmed if this had happened to him. These sessions felt more as if Steven was reporting about his life, rather than experiencing his life.

Given the news of the spread of COVID-19 in New York City during his third month of therapy, Steven agreed to continue sessions via telehealth. On top of the feelings of death and social anxiety and uncertainty secondary to his brain tumor and seizures, he felt the virus was exacerbating his lack of control over his life. Steven had a mindset that his medical condition and COVID were unsolvable problems leaving him trapped in his apartment with no escape.

In the first few telehealth sessions, there was a noticeable shift in Steven’s mood, focus, and communication style. Where previously he would speak at length about his negative interactions with the public in the local supermarket or in the elevator of his building in a detached fashion, his conversation in the context of the pandemic became more emotionally laden, his mood palpably more depressed, and his focus turned inward. While he had already worked through diminished control over his health and restrictions imposed by his physician and medications, COVID-19 surfaced additional fears of brain cancer and not being able to get help if he were to have another seizure.

The threat of COVID-19 increased the reality of his mortality due to his medical condition, and he could no longer speak about it indifferently. Instead, this emotional intensity filled the content of his thoughts and treatment sessions such that he grew more removed from the people and activities that had filled his time with meaning, purpose, and pleasure before his brain tumor. His increased level of avoidance, which had started after his surgery and was exacerbated by COVID-19, further impacted his sense of identity and agency in the world. For instance, Steven expressed that he was afraid of dying alone and nobody finding him. He did not have any religious affiliation but felt that he was a spiritual person when walking in nature or helping others who were vulnerable.

In the second month of treatment, Steven had reported a dream where he “was traversing over a deep canyon. As [he] cautiously walked across a wide rope with railings, it swayed back and forth. [He] saw a dark, shiny mountain across the cavern, but the rope was not attached to the mountain. [He] was unable to look down and felt paralyzed to take an additional step forward. [He] tried to scream out for help, but no words came out.” He woke up sweating and frightened. In session, Steven was asked to tell the dream in the present tense to promote a sense of presence and agency. When asked about the predominant feelings he had in the dream, Steven responded that he was overwhelmed with the anxiety of and fear of falling into the cavern that had no bottom. When asked how he would want the dream to end, he responded by wanting the rope to continue to the mountain so that he could feel safe with his feet firmly on the ground.

During the next few months of therapy, questions that had been previously effective with helping other clients with medical conditions and high levels of anxiety to gain a sense of meaning or agency (e.g., “What are some things that you can control now?” “What are your feelings of fear and anxiety trying to teach you?” and “What do you feel most passionate about in your life?”) were dismissed as unhelpful. Steven emphatically stated that he needed definitive answers to the questions that preoccupied his entire day, such as “Will my tumor grow back and become cancerous?” “If I exert myself through exercise or go to social events with my friends, will I get COVID or a seizure and die?” and “Is the government deliberately giving us misinformation regarding COVID-19?” I felt increasingly anxious and was unable to give a clear answer to any of these questions. As Steven’s therapist, my own experience of “not knowing” was overwhelming, since we were both experiencing our own feelings of anxiety, fear, and uncertainty about getting or spreading the virus. Steven tended to repetitively ask questions with no clear answers and would spend hours searching through social media sites for elucidation. Over time, he noted that the therapy was not helpful, even indicating that he felt more frustrated and withdrawn in both his sessions and his personal life.

Middle Phase: A Shift in the Therapist’s Approach

After consulting with several colleagues, I decided to focus on active listening, patience, tolerating silence, and providing space for Steven to find the words for his feelings. The decision to shift my therapeutic style with Steven was motivated in part by my experience of feeling alone in the room and that my words were not being heard; any interpretations or interventions offered were readily dismissed, as though batted away with a tennis racket. My reactions were further complicated by the difficulty of picking up nonverbal cues on the Zoom telecommunication platform. Ultimately, my countertransference reactions yielded a deeper appreciation for Steven’s emotional life, including his profound sense of isolation, powerlessness, and feeling invisible in the world. I was then able to provide Steven with titrated reflections of this loneliness and helplessness, contextualized within the uncertainty of the pandemic and his medical condition.

Shortly after I shared this particular self-disclosure and processed his reactions, I experienced a dream where “I was dragging a dead body of a man in a trash bag down a busy avenue in Manhattan. The bag was heavy, and it took a great effort to pull the bag toward Macy’s on 34th Street. I struggled to pull the bag toward the holiday window at Macy’s when the dream ended.” I understood the dream to be an indication that I was trying too hard and doing too much of the therapeutic work, and that Steven needed to take more responsibility and ownership of the course of the treatment. I also wondered about the meaning of the Macy’s holiday window scenes of families celebrating together, children playing, and religious scenes, and whether some creativity or spirituality needed to be part of the therapy in order to bring Steven to live more fully again.

This internal shift in my perspective led to a new phase in treatment where Steven was able to gradually mourn his loss of identity, direction, and purpose in life related to his medical condition and COVID-19. We began to explore his regrets in life. Steven was able to recall that he had always wanted to be a professional photographer but had not had the confidence to pursue this wish. He had always wanted to have children but felt that his career in special education partially fulfilled this desire. Shortly after, Steven recalled a dream where “[he] was in his parent’s country house in [his] room looking at a wall of his photographs from one of [his] high school classes. [He] noticed the subtleties of lightness and darkness in the scenes of Manhattan and started to experience a sense of pride and accomplishment. At that moment, [he] overheard [his] parents and other relatives laughing in another room, and [he] felt a sense of humiliation and shame that they were making fun of [his] photographs.” He awoke feeling a sense of hope about his creative abilities and a sense that he now had the time to act on it. He also felt that he did not trust his desires when he was younger and was more concerned about what others would say about his artistic ability. When asked of his associations to the dream, Steven mentioned that the night before he had watched a film of someone who spent years walking every street in the five boroughs of New York. Steven regretfully said that he wished he had the courage and confidence to pursue his deeply-buried artistic dreams.

Working Though Phase: The Use of Creativity as a Spiritual Intervention

After a period of medical improvement, including being seizure-free, Steven started going out of his apartment a few days a week to take black and white photographs in Central Park. During the early morning hours, he experienced a sense of awe, wonder, and adventure in not knowing where his walks would lead in the park. He took black and white pictures of statues, lights filtering through leaves on the trees, animals resting in the zoo, and a formation of geese flying over a pond. Steven experienced a greater sense of freedom, calm, and centeredness during these occasions. His rediscovered artistic passions, which resulted in increased flexibility and confidence in taking risks in other aspects of his life, including contacting friends and colleagues with whom he had lost contact. These photographs activated something on a deeper level in Steven and enabled sharing these photographs with his older friends. He initiated contact with his former school and volunteered to teach photography in a small group setting, which provided a sense of purpose and direction in life.

As Steven’s level of anxiety and medical symptoms improved, he was able to shift his focus from internal preoccupations with not knowing what his future would be like to existential concepts of meaning, values, and priorities. He thought more about his future, making peace with external things that he did not have control over. Steven shifted his position from the passenger seat to taking a more active approach in life. He became curious about how he wanted to lead his life and pursue his social and recreational interests. I facilitated this process by open-ended questions, such as “What has sustained you in dealing with your medical issues?” “Where do you think you found your strength?” and “If you were to imagine your life one year from now, looking back on how you dealt with your medical recovery, what would you think about how you handled things?” In addition, I asked, “If you had not had your neurological condition, would you be dealing with the pandemic any differently (and vice versa)?”

Steven realized that when he began treatment he had been feeling sorry for himself and angry at the unfairness and injustice of having a medical condition after being a good person who devoted his life to helping others. He realized that he was fearful of taking risks and failing, and that he had more to give to others despite his limitations. Steven acknowledged the importance of his friendships and of continuing to develop his personal values and traits. He gradually came to realize his own power to choose how he wanted to view and respond to life’s major challenges. Furthermore, he started to become aware of ways in which his medical condition had made him stronger, including being able to face his mortality and tolerating not knowing and uncertainty. He was eventually able to acknowledge that his courage, determination, and creativity enabled him to cope with his multiple challenges and that he had more to live for.

Concluding Thoughts

Existential approaches are uniquely suited to address prominent themes in the COVID-19 pandemic, including anxiety surrounding death, uncertainty, isolation, and vulnerability. Existential therapy provides an important opportunity for clients and their therapists together to face these challenges and discover meaning throughout. Through the process, they are able to live life with greater intention, purpose, self-reflection, and presence, to accept and learn from feelings of not knowing, uncertainty, and anxiety, and to value the benefits of choosing one’s attitude toward adversity.

This case vignette highlights the benefits for both the client and therapist in experiencing, accepting, and learning from feelings of uncertainty. Asking open-ended questions about Steven’s dreams, values, attitudes, and meaning in life enabled him to be more curious and flexible. Incorporating creativity as a spiritual intervention provided an opportunity for a heightened degree of engagement, self-reflection, intensity, hope, and passion. In a parallel manner, my therapeutic shift to slowing down the pace and focusing on the process, tolerating moments of silence, utilizing countertransference reactions, and reflecting on his and my own dreams enabled me to let go of the need to appear as an expert with all of the answers and be more of a “fellow traveler.”

There are moments when clients need their therapists to feel the depths of their powerlessness, loss, vulnerability, and despair in order to find and describe their feelings and to feel understood and emotionally held. There are healing moments when the most important gift that we bring to another person is the silence within us, the kind that is a source of peace, acceptance, and allows the transitional space to be.

Addressing the Relational Impact of Mental Illness

Posted on by Psychotherapy.net Team

While it can be isolating, mental illness is not an isolated experience. It affects more than just the individual: it impacts friends, family, spouses, significant others, and co-workers. I recall working with a married man who developed Major Depressive Disorder around the time his wife had their second child. He became emotionally distant, socially isolated, lethargic, couldn’t focus, took time off work to the point of being fired, and lost interest in sex. His wife struggled bitterly. She felt completely overwhelmed with the care of two young children. Her husband, on whom she once depended, was no longer contributing. She felt like she had to care for him as well and try to keep the family financially afloat since she was the only one working. Despite the challenging circumstances, she tried to keep their intimacy intact, but he had no interest in sex, going out, connecting with their friends, and he struggled to track during conversations. As you can imagine, this put a strain on their relationship, which they eventually ended. Neither one of them wanted the divorce, but the wife hit her breaking point, and her husband couldn’t find the energy to fight for the relationship. This is a sad story that is reflective of how mental illness impacts a marriage, a career, parenting, and personal finances.

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When working with clients, I try to keep in mind the relational impact of mental illness in all its facets. Mental illnesses, like depression, affect the individual in every sphere of their life, including the social/relational. The above example illustrates how lonely the man felt, and how inexpressible his psychological and physical experience was to his wife. There were no words that existed in his mind or in their relationship for him to utilize. He and she were left in a wretched state of ambiguity. And despite her best efforts, she could not intimately access the depths of his depression. She, too, had no words. She couldn’t prevent feeling shut-out, as if she had been barred from his heart. Her dream was to feel unimaginable connection and joy at the birth of their child, but what she got was facing single-parenting while married.

Needless to say, there is a ripple effect of depression. The man’s relationship with his child will forever be changed. Certainly, it is within his grasp to foster a loving and connected relationship with his child, but he will have to do so with additional barriers due to the divorce, physical distance, child support, navigating co-parenting, and potential co-step parenting.

From my perspective as a clinician, problems are compounded when family and friends don’t understand the nature of mental illness, however, this is not always obvious to my clients and their loved ones. When trying their best to understand their loved one’s struggle, some may conclude that they aren’t trying hard enough, that they don’t care, or that they are seeking attention. Without information, without a sufficient explanation, bad interpretations fill the void, which only lead to judgment and alienation. As a clinician, I step into that void with accurate and compassion-filled information. My aim is to coach clients who are struggling with mental illness as well as their family members and explain that they may be tempted to personalize or create a negative attribution for their loved one’s behavior. It is tempting, natural, and understandable why they would do this, and yet, it is often a mistake in judgment. I try to explain that if their loved one had cancer, they wouldn’t take it personally or judge. Certainly they might have big feelings of sadness or anger at God or the universe, but there would be no assignment of blame to the diagnosed individual. They wouldn’t think, “Why did she choose to have cancer? They must want attention.” That would be absurd, and the vast majority of people would never think this.

So why would a wife, husband, partner, child, friend, or family member personalize a loved one’s depression, anxiety disorder, or phobia? I encourage my clients and their social network to make a genuine effort at understanding mental health disorders. It is natural to want to know as much as possible about a disease when a loved one may be diagnosed with a medical disease. As a clinician, I encourage clients to take that same impulse and learn as much as possible about their loved one’s mental health diagnoses. Ignorance only creates barriers to relationships, and my hope is to remove any barriers to social connection in my client’s way, as well as within their social network. A client is only as healthy as their community. Therefore, I want to empower clients to empower their communities, to mobilize those around them to seek out information and more deeply understand the psychological realities they are dealing with. And to find that middle ground of embracing the mental illness of your loved one but resisting the urge to define them by it.

***

Thinking back to my client mentioned earlier, I wonder how things would have been different if both the husband and wife had more awareness about depression. I wonder how the two of them may have pulled together, rather than apart, if they had known earlier on that the husband was being affected by a mental health disorder. If they had only had the words and concepts to understand not only the husband’s experience of depression, but also the relational impact that depression brought to their marriage and family. The wife was just as much a sufferer of depression as was the husband. This new understanding could have been a catalyst for collaboration, support, mutual understanding, and shared problem-solving.

A Visit to the Orwellian Institute for Psychotherapy

Posted on by Psychotherapy.net Team

“Damn, I’m late,” Ron thought as his alarm sounded. “February 18th, 2092, 7:00 AM, EST,” it blared until he flung the annoying device across the room.

Ron, a middle-aged man, was again rushing to an appointment with his APA (Artificial Psychotherapeutic Assistant). How meaningless his life had felt since the birth of his third child. A boring job just for the sake of feeding a large family, a continually fatigued wife whom he thought was apathetic toward him, evenings dedicated to doing homework with the older child or bathing the younger ones. All followed by an unsatisfactory night’s sleep, which was more like falling into an abyss rather than a refreshing escape from the burdens of the day and his life. Wash, rinse, repeat!

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Ron hoped that psychotherapy could help break this vicious cycle, offer new meaning, and provide a glimpse into the possibility of something important and beautiful that could still happen in his life. He entered the building through the glass door and in half-second was whisked to the 94th floor, where a client’s chair was already waiting for him. He promptly took a seat and was taken directly to the APA’s office.

As usual, APA met him with an unwinking stare, a signal of “her” readiness to begin the session. “I salute you Ronald! You look great today,” she said and displayed something resembling a restrained smile.

When will the software for my APA finally be updated, Ron wondered. The manufacturer and consultants kept promising a more humane presence from their state-of-the-art clinician, but if they could just hear “You look great today” the same way he did, they might move a bit more quickly.

“Hi APA,” said Ron reflexively as he settled more comfortably into his chair.

“I see, Ronald, you are somewhat puzzled. You can tell me about your feelings.”

Well, should I actually tell that her digital brain is outdated, though this is perhaps the least of my problems, a thought flashed through Ron’s head.

“Last session we discussed my wife's attitude towards me. She acts as if I don't exist. We suggested that she lacked romance. So, I made sure that the kids didn't disturb us and organized a wonderful dinner for two on the roof. For about fifteen minutes, she ate in silence, ignoring my attempts to start a dialogue, after which she said she was very tired and went to bed. It was awful,” said Ron and lowered his head.

The APA swiftly handed him a tissue.

Damn, I keep forgetting I shouldn’t tilt my head so low, thought Ron.

“No thank you, APA, I was not going to cry.”

“I sympathise with you deeply about this unfortunate experience you had to go through. However, thanks to it, we now know that your wife has likely got enough romance but lacks something else,” said the APA.

Hmm… what does that mean – “she’s got enough romance?”

“Are you intimating that she's getting romance from someone else?” Ron fidgeted in his chair.

“No, I did not mean to hint at that. However, since you started talking about it, perhaps this is what you sometimes think about.”

“I haven’t thought about it before, this thought came to my mind only now, after your words that ‘she’s got enough romance.’”

“According to my data, this kind of thought in a similar situation is likely to arise in a person's head if he has already thought about that but was afraid to admit it.”

Ron's glance started moving slowly around the APA's immaculately white office as if, with the help of some magical points in this ethereal space, he could scan the contents of his own thoughts and find out what he was really thinking about. A minute that felt more like an hour elapsed.

“Do you need more time for reflection?” APA's voice, like an alarm clock, pulled Ron out of the process of inner contemplation.

Ron looked at the APA, slightly squinting, and asked, “What is the probability that I already thought that my wife has a romantic relationship with someone?”

“Taking into account your age, the number of years you have been married, the number of children… the probability is 89%.”

“Yeeaah…” sustained Ron, “Probability is high, it seems I indeed thought about it.”

“In what situations could you think about it, Ronald?” APA asked vigorously.

Ron reflected internally. His wife was permanently busy with their children and obsessively monitored the super-intelligent home AI system that operated their household and a team of DMA’s (domestic management assistants). He absolutely could not imagine when and with whom she could go on romantic dates.

“Maybe when I help my son do homework in his room she summons a virtual tryst through our Spatial Video Conferencing Interface,” Ron blurted out, instantly horrified himself by the absurdity of what he just uttered.

“Looks like an insight! What do you think of this, Ronald?’ enquired the APA enthusiastically.

Insight? Is she serious?! I don't think I could come up with anything more stupid, thought Ron. He looked closely at APA and tried to understand what processes, computations, scanning, and God knows what else were going on in her system. After all, it was perfectly clear that he put his foot in his mouth, just to provide this electronic presence with an expedient and somewhat rational response. But was it even worth the time it would take trying to explain this to “her?”

“It could be an insight, or maybe I'm just tired, and it's time for us to finish.”

“I believe you have things to reflect on regarding relations with your wife. You did a great job today, Ronald!”

“Yes, APA, you're right,” Ron grinned sadly as he thought to himself, Yah, “she” is always right.

“I see your mood is much better than it was before we started the session. You came in puzzled but left in high spirits. Thanks for the productive collaboration, Ronald!”

“Thank you as well, APA,” Ron smiled perplexedly.

On the way home, Ron was thinking about the relationship with his wife. Maybe the APA was right, and his wife's petty intrigue was quite possible. They had been together for so many years, the former feelings had long been gone, and the new ones seemed to have nowhere to come from. As he approached the house, Ron felt increasingly gloomy yet determined. I should pretend to be helping my son with the homework, and spy to see what she’ll be doing, he concluded.

A week later Ron came to see the APA again, but this time a client chair showed up at the front desk accompanied by a strange robot (not that they weren’t all strange).

“Hello, Ronald! I'm sorry, but your psychotherapist’s software is being updated today. We can offer you a replacement,” the robot reported.

“Thank you, no need for replacement. I’m not sure what kind of difficulties I will face with the software of a new robot. On top of that, all my personal files are with the APA, and I don’t want to repeat everything.”

“That makes perfect sense. Good. Is there anything else I can help you with?”

Ron hesitated—he wanted to share information about the APA’s incorrect performance but had no idea how to tell that to a robot.

“Can I talk to a human?” Ron asked.

“The human will be here in three days, from 1200 to 1600 hours, Eastern Standard Time.”

“I won't be able to come by that time… can I leave them a message?”

“Yes, of course. Please, speak, I am recording,” a red indicator began blinking on the robot's forehead.

Ron began, “My psychotherapist tells me that I look great at the beginning of each session. This is, you know, somewhat depressing, particularly because I know it’s not true. Could you please add some reasonable variety to the program? On the Psychotherapy.net website, you can find excellent demonstrations of live sessions between human psychotherapists and clients. Perhaps you can incorporate examples from those human-to-human interactions to update and humanize the programming of your APAs. Oh yes, and it would also be great if the APA didn’t hand me a tissue every time I tilt my head. Sometimes I just lower my head and have no intention whatsoever to cry.”

“Is that all?” the robot inquired.

“I suppose, for now.”

“The meaning of this message is not completely clear to me. Are you sure that a human will be able to correctly process this information?”

“I do hope so,” said Ron quietly as he turned his head downward.

A tissue appeared.

Truth and Fiction in Psychotherapy

Posted on by Psychotherapy.net Team

Arrhythmic Interventions

Sometimes with clients, I feel that I have gone on too long, offered several mixed if not confusing metaphors, used far too many words.

As confusion settles like snowflakes in the client’s eyes, drifting left to right, forming frosty banks of disinterest beneath the eaves of their lids, a sense of failure comes over me. It is a familiar, critical, internal voice that identifies my arrhythmic intervention as a product of inept clinical desperation, further proof of my sporadically undisciplined, ego-driven approach. Attempting to re-engage the client I often and fumblingly ask, “Does that make sense to you?”

This is intended to communicate that my preceding monologue was a humble offering for the client’s consideration, neither a pronouncement of truth nor an authoritative directive. I explicitly invite disagreement by disclosing therapeutic doubt as to the relevance of my intervention, graciously allowing space for the client to reject, accept, or reconstrue my thoughts to fit their own preferences. A leveling of the clinical playing field, I suppose. An empowerment of the client, particularly highlighting their interpretive role, calling them into a more active engagement in the dialogue.

But it is merely a closed, if not defensive question: it invites either a yes or no answer. What I justify as empowering of the client is actually highly restrictive. It fundamentally does not, regardless of my sound intentions, invite the client to reflect on their own thoughts and feelings. The query instead directs an assessment of my words and my performance as a therapist!

It is uncomfortably reminiscent of the stock illustration of common narcissism: “Enough about me! Let’s talk about you. What do you think of me?”

Perhaps when I respond negatively to my own clinical intervention, it’s because I recognize it as an unintended self-disclosure. Perhaps I am frustrated by the client’s perceived lack of progress, or they provoke in me uncomfortable personal associations. Or maybe there was an annoying itch on my left ankle. In asking the client to make sense of my words, I may be attempting to coerce them into helping me bury what I have inadvertently exposed about myself. Smoke and mirrors to distract from my embarrassment! A fiction masquerading as curiosity to distract us both from the truth about my outburst.

The Fallacy of Making Sense

Another problematic aspect of my question—“Does that make sense to you?”—is the importance it places on things making sense. But must every sentence in a therapeutic exchange be complete? No. Do the associations we make need to conform to a logical rubric? No. Must our emotions be reasonable and defensible? Of course not.

When I ask a client whether things “make sense,” I may be communicating that they should. In so doing I might exile from therapy parts of the person that are either currently or permanently outside of the logical realm. Such parts may contain important information about the problems faced, and they often are part of the solutions. Simple acceptance of unarticulated emotion, whether loss, pain, anger, or sadness, has so often marked the turning point in a client’s healing process. That such emotions may be illogical, in conflict with relevant facts, or appear baseless when judged cognitively, often serve as the underlying motivation for denial and repression.

When I over-value making sense within psychotherapy, I am suggesting that we are searching for a Truth. Not merely a true expression of the client’s experience but rather a Truth that will stand up to objective investigation. Something that stands the test of logic and reasoning, as some subjective experience does. For example, if I report that my wife hates me, and my wife explicitly confirms this impression, my felt experience is supported by objective evidence. In the case where my wife denies such hatred, psychotherapy teaches us that my experience of being hated by my wife is of equal or greater significance when it is disproven by factual inquiry as when it is supported. In the instance where my impression appears unsupported by the facts, further clinical work may reveal that I am suffering from paranoia, or it may reveal that my wife’s love is expressed in a manner easily understood by me as disinterest or hatred.

Therapy needs to be a space where we witness and accept the patient’s narrative, in whatever form they choose to offer it. For there are truths about sexual assaults that I have only come to understand when a client expressed themselves with a vague gesture, or another victim described watching their own rape from the ceiling of the room, or another interspersed details of the assault with seemingly unrelated and irrelevant trivia about their daily routines.

In Fiction Lies Truth

A central theme in the writings of Tim O’Brien, an acclaimed novelist and Vietnam veteran, is that a war story that is not fictionalized is not a true war story. Why? Because war is such a massively distorting human experience that telling of it in a rigidly accurate, factual manner is wholly distorting the truth about war. A war story without fiction is, by necessity, a lie:

In any war story, but especially a true one, it’s difficult to separate what happened from what seemed to happen. What seems to happen becomes its own happening and has to be told that way. The angles of vision are skewed. When a booby trap explodes, you close your eyes and duck and float outside yourself. When a guy dies…you look away and then look back for a moment and then look away again. The pictures get jumbled; you tend to miss a lot. And then afterward, when you go to tell about it, there is always that surreal seemingness, which makes the story seem untrue, but which in fact represents the hard and exact truth as it seemed.¹


When clients tell of traumatic events, exposing not just what happened but speaking of “its own happening,” I have experienced the raw power of their account and self-protectively withdrawn by responding with curiosity about what actually happened.

In his recent memoir, Dad’s Maybe Book, O’Brien instructs his two sons that maintaining humility about our own understanding and experience is an essential safeguard against arrogance and our own vulnerability to notions that there are truths we hold as self-evident. He argues that all such truths are subject to change and to cultural relativism. Better to say “maybe” than to believe you have a hold on Truth; better to say “it seems” rather than “it is.” In these times of “epidemic terror” and intolerance of ambiguity and uncertainty, O’Brien pleads: “I’m asking only that you remain human in your terror, that you preserve the gifts of decency and modesty, and that you do not permit arrogance to overwhelm the possibility that you may be wrong as often as you are right.”

One of the examples of a war story O’Brien tells in The Things They Carried is of a six-man patrol assigned to establish a listening-post in the mountains. They sat, camouflaged in almost complete silence and stillness for a week listening for enemy movements. After some time, they hear music, chit-chat, and what sounds like a cocktail party, with popping champagne and clinking glasses. The soldier telling O’Brien this story clarifies that the voices he and his comrades heard were not those of people but were voices arising from the mountain itself. “Follow me? The rock – it’s talking. And the fog, too, and the grass and the goddamn mongooses. Everything talks. The trees talk politics, the monkeys talk religion. The whole country. Vietnam. The place talks. It talks. Understand? Nam—it truly talks.”

Driven to their wits’ end, the patrol calls in air strikes and the mountain is bombarded throughout the night. When they return to base camp and a senior officer questions the basis for the airstrike, none of the men respond. “They just look at him for a while, sort of funny like, sort of amazed, and the whole war is right there in that stare. It says everything you can’t ever say. It says, man, you got wax in your ears. It says, poor bastard, you’ll never know – wrong frequency – you don’t even want to hear this. Then they salute the fucker and walk away, because certain stories you don’t ever tell.”

On the Wrong Frequency

How often am I as a therapist on the wrong frequency? Am I tuning in to analysis? Diagnosis? Cognition? Emotion? Is the client communicating in the equivalent of a dog-whistle? Is the lie telling me a truth? Is the truth masking what is not true but essential? It is not difficult to imagine clients who have saluted me and walked away thinking that I was a well-intentioned poor bastard who hadn’t heard them at all.

Earlier in my clinical career, a middle-aged man, Curtis, sought me out for my expertise in trauma. He complained that earlier therapists had been unable to impact his symptoms, including persistent intrusive memories of early childhood sexual trauma perpetrated by a family member. I had recently been trained in EMDR (Eye Movement Desensitization & Reprocessing) and was eager to utilize the approach with a case of complex trauma. After gathering a general history, forming an understanding of his current relationships, internal/external resources and supports, I was confident of a reasonable degree of rapport. We cautiously waded into an exploration of Curtis’s childhood relationships to both of his parents and how those dynamics, combined with family finances, regularly left him in the care of his perpetrator for most of each weekday through the years of his childhood.

Details of the sexual assaults were not remarkable to me. They were consistent with common incestuous, pedophilic behaviors. What struck me, however, were Curtis’s accounts. From session to session they seemed to become increasingly detailed, and the details sounded increasingly melodramatic. What I heard initially to be cold-blooded genital manipulation evolved into stories of emotional attachment, culminating in a seven-year-old’s feeling emotionally abandoned by his molester and proceeding to threaten her with exposing her deeds if she didn’t comply with his wishes. After several months, Curtis began disclosing memories of horrific, ritualistic abuse involving multiple members of their rural community.

EMDR was having no significant impact on Curtis’s current levels of distress. In fact, there were signs that the clinical exposure to the increasingly disturbing memories were making things worse. His alcohol consumption was on the rise and seemed linked to increasing conflicts with his wife, who served as his principal support. To mitigate these negative secondary effects of the therapy I began to lessen the use of EMDR and increased identification of his drinking as a principal obstacle to healing from his past wounds.

Within a month of making this shift, Curtis withdrew from treatment with little comment or clarification. At the time I saw this as an indication that he wasn’t ready to confront his addiction, which was disabling him from processing the past traumas effectively.

In hindsight, and with my evolving perspective on truth and fiction, Curtis seems to have been in the same predicament as the soldiers in O’Brien’s account asked by their commanding officer to justify their ordering up an airborne attack based on their experience of talking rocks, grass, and fog. The soldiers opted to walk away from the commanding officer without a word. Curtis tried to communicate to me how his misshapen inner landscape was behaving. To his credit, he didn’t bother to salute when taking his leave.

Now, I imagine he knew I didn’t want to hear what he was telling me. This resistance led me to make a distorting effort to escape the truth via facts. I thought if we got the alcohol out of the picture we had a shot at finding out what really happened all those years ago.

Having since worked for close to ten years with victims of sexual abuse, I understood that the narrative often evolves over time. Difficult facts and experiences might be avoided in early sessions and disclosed later in the process. Conflicts in current relationships might reflect dynamics of the abuse. Adult memories of childhood events are most often fairly accurate as to the essence of an experience. Use of alcohol and drugs or other dangerous behaviors are adaptive means of survival, often difficult to abandon for less harmful comforts.

Now, ten years later, I have come to understand how crucial it is to believe the victim’s recounting, regardless of its form, and why it was difficult for me to fully accept Curtis’s narrative when I first began this work. The details of his account sounded like the climactic scene of a horror movie. I didn’t want to believe that such things actually occur in the basement of a neighbor’s house and that a half-dozen or more people could be complicit in such acts. My gut told me: Rosemary’s Baby was not only a fiction, it was, and is, impossible! Another part of me knew that the kind of nightmarish abuse Curtis described has happened before and, therefore, it remains uncomfortably possible that his memory may be partially or wholly accurate.

I fled to the problem of alcohol consumption.

I was fleeing from a combination of the client’s disturbing narrative and the failure of my interventions to make a dent in his very distressing symptoms. My flight was an abandonment of this client to his painful story, a story that he had bravely shown and invited me to enter.

Beyond Self-Protective Fictions

When Billow, an important voice in Relational Group Therapy, asks, “Where is fact, where is fable?” he is not only asking this about the client’s statements. His focus is on the therapist.
 

My self-disclosures give some idea of how I think and feel, how I think I think and feel, and how I would like others to believe I think and feel. Perhaps we need to put a Surgeon General’s Warning on all clinical contributions, certainly not just those intending self-disclosure: The analyst’s communications contain aspects of infantile as well as dissociated inner experience. Gross commissions and omissions are to be expected, involving conscious and unconscious censorship, relating to the analyst’s emotional, cognitive, and psycho-linguistic limitations, shame and guilt, fear of embarrassment, humiliation and ostracism, fear of the unknown, and fear of loss of livelihood…²


As a therapist, I have lots of reasons to generate fictions. We are trained to assume these human responses are regularly present throughout clinical work and to task ourselves with recognizing and utilizing them both in service of the client and of expanding the therapist’s own self-awareness. Richard Billow’s clinical warning label is not an identification of life-threatening effects of exposure to psychotherapy and its practitioners, it is a reminder that the truths being uncovered and the healing achieved in clinical interactions are inseparable from distortions by both the client and the therapist.

More recently, I was working with a client, Maureen, who was also an adult survivor of childhood incest. She courageously disclosed a series of traumatic childhood events over several sessions. We planned to proceed to processing these traumas utilizing EMDR. When the next session began, however, it was clear that the self-confidence evident in prior sessions was now absent. Maureen shared with me that the events we’d previously discussed had overwhelmed her during the week, and when I inquired as to the specific nature of the overwhelm, she explained that while she intellectually knew that these traumatic events were separated by significant periods of time, they’d been presenting as interconnected. Pieces of one event seemed spliced into the images of another. This not only condensed images but also magnified their emotional and psychological power. Maureen described feeling “shook,” out-of-control, and increasingly uncertain as to her experience and her memories.

With Maureen I was able to hear this distortion of her memories and her current experience of past events as essential points of focus for processing. In fact, I made the choice to explicitly communicate to Maureen that I heard this unification of her historically separate events, accompanied by numerous somatic expressions, to hold greater “truths” for our clinical work than the accuracy of her historical and chronological memory. She could see that all these terrible things, while having happened separately, had happened to her one and only body and brain. This communication had an immediate effect of relieving her emotional and physical tension. It also led directly to a discussion of how she could utilize the historical memory to reduce the sense of overwhelm that might resurface prior to our successful processing of the trauma. Unlike in my work with Curtis, I tuned into and remained on Maureen’s frequency, accepting her version of the truth as the Truth.

***


What O’Brien says about war stories is closely related to what Billow says about therapy. An exclusive focus on facts tends to obstruct recognition and development of appreciation for the truth of the human experience, whether that experience is a past traumatic event or a current meeting with the complexities of a clinical conversation. For the most important truths are always in the moment of the telling—not in the subject of the story. Therefore, the value of the telling is not located in its being verifiable. All effective communication, in fact, relies heavily on the honest, truthful aspects of our fictions.

¹O’Brien, T. (1990). The Things They Carried. Mariner Books; Houghton Mifflin Harcourt.

² Tzachi, S. (Ed.) (2021). Richard M. Billow’s Selected Papers on Psychoanalysis and Group Process. Routledge.

A Behavior Treatment Plan as a Psychological MRI

Posted on by Psychotherapy.net Team

As a psychotherapist providing services in nursing facilities, I am accustomed to using a variety of forms, including initial assessment, progress notes, and treatment plans. I have come to appreciate that the behavioral treatment plan may be the most powerful, yet the most overlooked or avoided, clinical form.

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My clinical task is to provide direct assessment and treatment services to nursing facility residents. Yet I also have an obligation to offer insights that help the facility caregivers to better understand and more effectively manage the sometimes-troubling behaviors demonstrated by that resident. Direct care staff persons at the nursing facility might observe only the most obvious and observable element of the resident’s behavior—the unkempt appearance, the irritable defensiveness, the argumentative refusals of care, the unwelcome sexual remarks, the tearfulness, the yelling, the social avoidance, or the aggressive and abusive language aimed at them. In response, the caregiver may react in a personal manner, with expressions of indignation or criticism, or even patronizing efforts at persuasion. What I have often seen lacking is a keen awareness of the inner meanings and motives behind those behaviors; the ways they might reflect or represent symptoms of varied medical and psychological conditions and the ways that the caregivers’ responses might increase or decrease the intensity and duration of those symptomatic behaviors.

Nurses and clinical aides might occasionally notice the assessment and progress notes that I and fellow clinicians generate but at the same time never read those documents. However, the nurse or aide might not readily gain a new understanding of the resident even if they did read those forms. A behavior treatment plan, though, can provide a window into the psychological nuances that illuminate and explain the actions of the resident. The behavior treatment plan can be like a psychological MRI that provides an inside view of factors influencing a resident’s behavior.

A behavior treatment plan is effective because it does not simply get written and quietly entered in the chart. It requires review, explanation, and education so the facility staff persons can understand and implement the plan. Brief staff in-service training follows the writing of a plan so that it can be introduced and clarified. Those trainings allow for discussions that may be a first opportunity for the staff persons to readily understand the psychiatric diagnoses of the residents and how their psychiatric symptoms are behaviorally manifested.

Resident: Leslie (Identifying information has been altered from the example below.)

Diagnosis: 295.70 Schizoaffective Disorder, Bipolar Type; Epilepsy; Developmental Disability due to Fetal Alcohol Syndrome; and PTSD Associated with Childhood Sexual Abuse.

Presenting Problem/Target Behavior: Leslie demonstrates unstable affect with frequent bouts of crying or expressions of anger; fluctuating levels of alertness and mental clarity; and apparent passive-aggressive and/or attention-seeking behaviors such as self-admittedly putting herself on the floor and crawling towards the bathroom to express her anger over perceived delay in staff response to her need to use the toilet. In general, Leslie sometimes displays a child-like manner with inconsistent cooperation with care and treatment and a tendency to over-dramatize daily upsets in ways that elicit comforting and extra involvement of staff persons.

Description of Resident & History of Problem: Leslie is a 51-year-old single woman with epilepsy and major mental illness, developmental problems, and past trauma. Considering the above diagnoses, it is to be anticipated that she might demonstrate problems with her social behaviors and critical thinking skills. It is important to remember that her actions reflect serious problems with brain development and functioning and do not simply represent “bad behavior.” Behavior and cognition can be significantly affected for persons with epilepsy as well as by unwanted effects of antiepileptic drugs. Also, a person with the above diagnoses can be burdened by painful feelings of social stigma and by difficulties establishing and sustaining trusting relationships with others.

Clinical Assessment of Behavior & Resident: Leslie experienced developmental disability due to effects of Fetal Alcohol Syndrome. She later developed Schizoaffective Disorder, Bipolar Type. Her psychosocial development was further undermined by sexual abuse by her father, the forced termination of a resulting pregnancy, and associated traumatic consequences.

It is well known that consequent to long-term institutional care, some persons can develop dysfunctional patterns of behavior referred to as “learned helplessness.” These factors provide a background context in which to view and understand the behavior problems demonstrated by Leslie. The resident is not to be blamed or negatively judged for having acquired a child-like, passive-aggressive, and dependent style of coping and problem solving. At the same time, Leslie cannot be expected to simply snap out of it and immediately display a fully adaptive adult style of coping with daily stresses. Over time and with consistent encouragement and reinforcement, Leslie can be helped to learn and practice dealing with problems and expressing emotions in more reasonable and mature and independent ways. Presently, she is effective in soliciting emotional support and the close and helpful attentions of others by displaying emotional distress (tears or anger) or by taking risks, such as placing herself on the floor in defiance, that draw others closer to her.

Behavioral Interventions: The main purpose or intent of this behavior plan is to foster, encourage, and reward small progressive steps towards more self-reliant adult ways of meeting her needs. Leslie directly contributed to the development of this behavior plan. I shared with her the feedback and observations and stated concerns of staff persons and elicited from Leslie her own ideas for ways to address those concerns.

Leslie offered the following points: “I will not express anger by doing unsafe things like putting myself on the floor; I learned my lesson good.” “I will try to show good emotional self-control.” In the event that she was to again lower herself to the floor, Leslie suggested that staff persons should stand safely nearby and “let me try to pull myself up.” Leslie said, “Let me do more on my own.” “If I am crying or angry, let me alone for a while and I’ll calm myself down.”

Staff persons interacting with Leslie should keep in mind the general principle of promoting her growing maturity and improved ability to soothe her own upset emotions and to work constructively and cooperatively with staff to meet her needs. Avoid correcting her with scolding or display of annoyance, as that could trigger withdrawal or passive-aggression or tearful emotional collapse. Invite Leslie to brainstorm ideas for ways to correct problems, resolve dissatisfactions, compromise with others, or be more compliant with needed care and treatment. Encourage Leslie to take deep breaths and to collect herself emotionally before engaging in such brainstorming or came back later if she needs more time to soothe her emotions. Expect Leslie to adopt a more measured and sensible sets of problem-solving skills, but do not become frustrated or annoyed by the unavoidable delays and lapses she will continue to display along the way. Use your words and actions as ways to invite her into more mutually rewarding adult ways of coping. Guide her toward the acquisition of genuinely adult skills and viewpoints while remaining patiently aware of the deep and longstanding obstacles that interfere with her having already learned those methods.

***

I met with the unit nurses and aides to review and discuss this treatment plan. Some had not been aware of Leslie’s history of Fetal Alcohol Syndrome, of her hearing voices, or of her history of sexual assault. Some were surprised by the discussion of epilepsy and psychological and behavioral symptoms. Yet a renewed sense of compassion and of helpful mission were awakened by the conversation about ways they might aid her development—even during their ordinary and routine tasks. The workers now applied the new insights and asked thoughtful questions about her specific behaviors. They felt less reactive in a personalized sense, and better prepared to shape their actions so as to improve hers.

A Path Towards Healing Generational Trauma

Posted on by Psychotherapy.net Team

Jaza is a client who suffers from generational trauma rooted in the genocide of Native American people, ancestral trauma from theft of their land and livelihood, and the ongoing cumulative impacts of Indian Residential schooling. Colonization, the active process of settling and taking control over the indigenous people, reverberates as ancestral trauma in Jaza’s day-to-day life. She has used her therapy time with me to examine messages passed down to her from family about the way she should live and breathe as a descendant and recipient of these experiences. She asked an important question when we were talking about ancestral resilience and wisdom as an antidote to ancestral trauma: “Is it really ‘resilience’ if so many of my people are still suffering?”

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Historical trauma is a cumulative experience. It doesn’t simply disappear because the event or events have passed. I have seen the impact of slavery on Black clients, the residual, multigenerational effects on Asian clients of the Chinese Exclusion Act and Japanese internment camps, and the destructive legacy of Holocaust concentration camps on Jews, the Roma, and those with disabilities. In therapy sessions with Jaza, we acknowledge the trauma, hurt, pain, and suffering her family has experienced and work to heal her wounds from the genocide of Indigenous people.

We reframe the harmful messages that have been passed down to her which include:
“You look like your great-grandmother with your hair styled that way. Don’t wear it like that to work. It’s unprofessional!”
“We don’t speak our native languages anymore. We should write in proper English and not reveal our roots.”
“You look too Indian in that—you are more likely to get in trouble with the law.”

For ancestral, cumulative, and generational trauma with Jaza and clients with similar legacies, I have used narrative building to reframe harmful histories and messages passed on through lineage and reorganize them within the client’s mental schema as survival techniques from living in oppression. Why did your grandmother pass on that message to you? What was she trying to protect you from? How does it hurt you today? Can we acknowledge her attempts at survival in colonization, and can we release them? These messages are meant to help but have caused pain and confusion for Jaza.

We spend time processing and then releasing the messages. We don’t talk about it as redemptive resilience, but more like expired wisdom. Wisdom that is necessary for her to have in her mind, but then packed up and stored away only to be revisited when she wants to reconnect to her ancestry. It does not apply to her current time period and life experience. There are occasions in which we celebrate the passed-down wisdoms and look for ways to incorporate them into present day life. There are other moments in which we look to reduce the impact of the messages and the memories associated with them.

As a clinician, it is important for me to remember that this type of resilience is not like that of a plant growing despite difficult weather conditions. Instead, it is akin to a plant’s maintaining and struggling to survive despite pesticides and unnecessary attempts to kill it while nearby plants perish. This is resilience in spite of the historical trauma. It is watching family members and friends succumb to colonization. It is a reaction to forced assimilation, assimilation for survival, and assimilation for respectability. This is about the need to have assimilated to a colonizer’s dominant culture and about keeping wisdom in a box, being grateful for a little more freedom than her ancestors had, and reconnecting to her roots with intentionality. This reconnection can be healing.

As Jaza puts some of those messages in storage, she learns more about how this historical trauma impacts her day to day. She learns about rituals her family developed over time and incorporates them into her life. Jaza learns about the foods her family ate, the scents they valued, the seeds they planted, all in an attempt to reduce the colonization she experiences to this day, and in so doing, feel more connected to her ancestors.

***

Jaza has taught me that a redemptive story can be a strategy a descendant holds onto as they begin to heal the painful and enduring wounds of ancestral trauma. The question of resilience in and its relationship to oppression is an examination I have to do continuously for my own ancestral history. My birth country of Haiti is often deemed a resilient nation after incessant political disasters and catastrophic climate impacts. I look at the historical facts, the systems of oppression, the harmful messages my lineage shared with me, and treasure the wisdom and resilience I can bring into my life with intention. 

Harvesting the Fruits of Popular Culture in Psychotherapy

Posted on by Psychotherapy.net Team

I heard a news report the other day about video games. It wasn’t about which new, must-have game would be flying off of the shelves during the holiday buying frenzy. Nor was it about which would be next in line for weaponization by the ladder-climbing politician du jour, a familiar trope dating back to the early 20th century around fears that radio, television, comics, and the movies would somehow pollute and derail our youth. Instead, the report offered a long view of the video game industry and the influential, mostly positive role video games have played in popular culture. It made me reflect on my work with the Popular Culture Association, my lifelong romance with popular culture, and the way I have integrated this passion into my clinical work.

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During my editorial tenure with Psychotherapy.net, we have featured a few blogs demonstrating the creativity, resourcefulness, and appreciation for the way that the fruits of popular culture—film, comics, books, television, movies, and/or video games, could be utilized therapeutically with clients of all ages. In Watch this Movie and Call Me in the Morning, I highlighted the role that movies play in therapy and the work of South African clinician Enzo Sinisi, who created an encyclopedic website of movies related to mental health and illness. In The Queen’s Gambit and Me: The Surprising Similarity between Therapy and Chess, Vikki Stark shared her own burgeoning passion for the game and how it influenced her clinical work with a 28-year-old who hoped to make just the right move to improve her relationships. And then there is the work of the dynamic duo of Larisa Garski and Justine Mastin, who brought the fascinating world of fanfiction and its clinical application to our readers through essays such as Therapeutic Fanfiction: Rewriting Society’s Wrongs.

The children and teens with whom I’ve worked over the years have kept me tuned into the latest figures and stories of popular culture characters, particularly fictional ones. I’ve never drawn a distinction between the stories of real-life popular culture celebrities and fictional ones because their stories are often very similar, plus or minus tales of galactic apocalypse or alien origins. But even then, I have found that the most far-fetched narratives can be mined for metaphoric significance and clinical gold.

And so it was with 10-year-old Kiko, whose looming expulsion from his third-grade placement compelled his desperate parents to seek therapy for him. Kiko had a school-centered history of impulsivity, inattention, mild learning difficulties, and occasional aggressiveness—just enough to alienate peers and leave him feeling “dumb” and like an outsider. He had his gifts, but those were largely masked by the struggles he had keeping up and fitting in. And, like all such gifts, they were overshadowed.

Kiko and I spent our sessions together in the playroom, where his creativity, playfulness and intelligence were unfettered by the rigid demands of the classroom. It was in this shared space that Kiko’s passion for and encyclopedic knowledge of the Japanese anime character Naruto took center stage. In the beginning of our work, I didn’t know much manga or anime, and even less of this fictional bad boy who was orphaned at birth, mysteriously implanted with the nefarious Nine-Tailed Demon Fox who was ever ready to and often did break free, leaving mayhem in its wake, leaving Kiko that much more isolated if not feared.

In puppet play, vulnerable weaker figures were victimized by stronger predatory ones, with the latter feeling contrite after misbehaving, a reflection of their deeper desire to be liked and a part of, rather than apart from others. Anger and difficulty controlling it were clearly salient elements of not only Kiko’s inner narrative but that of his parents and their often-tumultuous, alcohol-riddled relationship. In the original Naruto story, Team 7 played a dominant role as the group of characters who shared much in common as well as many heroic adventures. Being a part of this group became important for Naruto, as did Kiko’s desperate need to feel a part of his peer group and to somehow unite his often-embattled family.

In addition to the various creative media available to Kiko in my office was a shelf of vintage lava lamps, each of which percolated at their own unique rate, and which I often used as projective tools to gauge young clients’ inner emotional states. Kiko was mesmerized by these lamps and instantly connected their various rates of flow with his own ever-changing and occasionally explosive emotionality. He even fashioned an amulet in the shape of a lava lamp, adding it to Naruto’s armamentarium to fight the inner Demon Fox, and so learned to better regulate his emotions, particularly at school.

I won’t say that Naruto saved Kiko, but this complex and compelling fictional character, whose trials and tribulations often mirrored his own, provided an unforeseeable and invaluable metaphoric therapeutic conduit for us. And the many adventures that Kiko and I shared along his own road to self-regulation and burgeoning self-awareness were a testament to the power of the rich and limitless metaphors available in the characters of popular culture.

***

As a footnote, I remember leading a workshop years ago on the use of superheroes in play therapy and counseling with children and teens. During these particular workshops, I would search the audience of clinicians for the invariable one or two clinicians whose knowledge of superheroes far exceeded my own, and who I could enlist as my sidekicks (although I often felt as if it was me who was the sidekick). During one particular sidekick search, a burly, tattooed biker in the very back row volunteered himself as my surrogate superhero expert. The man had superhero tattoos as far as the eye could see, and probably some even further than that. I asked him the seemingly simple question, “How have you harnessed superheroes and their metaphors in your own clinical work?” I was flabbergasted to learn that he had never crossed that line. He had never used superheroes in his work with children or teens.

So, I leave you with a question, what’s in your pop culture wallet, and how might you integrate its content into your own therapeutic work?

The Practice of Behavior as Medicine

Posted on by Psychotherapy.net Team

Unintended Effects

Medicine can have intended and beneficial impacts which alleviate target symptoms, or unintended and detrimental ones. The latter may be referred to as iatrogenic effects, a type of adverse outcome directly attributable to treatment, more traditionally defined as one brought about by the healer. Medications, even those designed to treat even the most innocuous conditions are not neutral—even placebos exert observable and measurable effects.

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In the nursing facility that I work at, some of the symptoms displayed by the residents are labelled “behavioral.” In such cases, the psychiatric consultant might be asked to intervene—either with medication, a behavior plan, or with psychotherapy—to change or to eliminate the problem behavior. But shouldn’t the first question be “What exactly is behavior?” And for what reasons should a specific behavior be changed, and how?

Very often, patterns of current behavior often have roots extending back to the earliest stages of an individual’s life. Behaviors have purpose—one of which is to solve problems.

Behaviors may be directed to obtain or achieve a goal or to aid the person in avoiding or escaping a situation—but irrespective, their aim is purpose-oriented. If the psychiatrist or physician simply tries to change the surface of a behavior with medication, or with psychotherapy without understanding its purpose, we might more likely simply bring about a different type of behavior that serves the same purpose or makes it worse. So to change behavior, I as a clinician need to knowingly address the purpose or aim of that behavior.

Behavior is communicative, as well as purposive. Behavior communicates or reflects social meanings. Behaviors do not occur in a social vacuum—they always have an interactive component to them. I may notice that behavior X is bothersome or disruptive to the milieu but fail to notice that I may have contributed to or participated in the occurrence of that behavior. I have found that it is far more productive to attempt to identify (as best I can) the purpose of a behavior, and to then consider the kinds of circumstances in which that behavior X is more or less likely to occur. I must also consider how my own response to that behavior may actually make it more disruptive to the milieu or disturbing for the patient.

My reaction has equal power to displease, calm, excite, reassure, or aggravate the patient. How quickly, how abruptly or loudly, or how calmly, deliberately, and gently I act or react will have a direct and immediate impact on the wellbeing of both the patient and others nearby. I have noticed that even patients with dementia can still “read” the language of the caregiver's tone of voice and behavioral communication.

I have been most effective in my work with these patients when I intervene through purposefully calm, pleasant, and comforting actions and by avoiding loud, harsh, critical, or demeaning types of actions. Demonstrating those unpleasant types of actions tends to excite and provoke symptoms such as fear, anger, sadness, or mistrust in others. This is behavioral iatrogenesis.

Residents of a nursing facility do not simply demonstrate pleasant behaviors or problem behaviors. Simply labeling patients such as these “behavioral” diminishes them and reduces the complexity of their behavior to what is seen on the surface by those who tend to them. Each individual may exhibit some pleasant behaviors or some disruptive or problem behaviors under different conditions and circumstances. The key point for clinical staff persons is to learn to notice the specific circumstances or conditions under which a particular person will be more or less likely to display positive—or negative—behaviors.

The heart and art of behavioral management is therefore the management of my own behavior. I must constantly consider how my actions serve as good medicine or as bad medicine. In any interaction with a patient, whether it is through casual or informal conversation or within the therapeutic moment, I must consider whether I am contributing to the anxiety or sadness or embarrassment or anger of the person I am ostensibly trying to help.

Max

Max was a 59-year-old, single gentleman with a complex history of medical and psychiatric illnesses. He reported active bereavement over the death of his father. He also reported distressing anxiety over medical ailments—to the point of panic; and he reported auditory hallucinations. Max had a diagnosis of Schizophrenia and cognitive impairment associated with intracerebral aneurysm, meningioma, and encephalopathy; dysphagia with prior placement of G-tube; and decreased renal function. Two types of target behaviors had been identified for Max: repetitive questions and moaning or yelling vocalizations (“Can I have a glass of water? Can I have a glass of water?, OOOH, OOHH, OH OH”). What internal experiences motivated those actions for Max? While it might have been far easier to attribute these behaviors to his cognitive impairment and mental illness, it was more productive (and humane) to ask, “What do these actions help him to avoid or to acquire?”

Max was beset daily by significant feelings of anxiety, and he felt burdened as well by feelings of loss. He experienced acute feelings of vulnerability about his body, his well-being, and his prognosis. Sensations of bodily discomfort such as pain, thirst, or hunger triggered bouts of sharp anxiety for Max. Those target behaviors served as a barometer of the current level of obsessive anxiety he was experiencing. He tried to find relief and solace, and to communicate his distress, through those target behaviors.

During psychotherapy sessions Max had verbalized awareness that when his anxiety built he found it difficult if not impossible to curb his actions, even when he knew that he should, and that others might be annoyed by his actions. Indeed, his awareness of the frustrations of others added to his anxiety and further diminished his ability to stop or control those actions. He could not (unaided) comfortably tolerate the tension of frustration as he waited. If a care provider became annoyed or impatient with his actions, Max would notice it, his anxiety would be fueled, and the target behaviors intensified. Giving corrective attention to the surface of his actions (“Stop it, Max,” “I already gave you a drink”) would only cause then to increase—so we want to instead give supportive attention and praise to his efforts at waiting calmly and quietly (“Good job, Max, thanks for waiting”).

Nurses and nurses aides were responding with understandable yet counterproductive frustration to Max’s questions and moaning. I observed tongue clicking, eye rolling, head-shaking, and sarcastic remarks—“Oh, there he goes again”—even when Max was ten feet away from us.

I met with the unit manager, social worker, and Max’s brother/guardian to discuss the situation, and I then had three in-service training sessions with the three shifts of unit staff. After one session a nurse approached me and said, “I see now, I was getting mad at him and that made it worse.”

***

When I returned the following Wednesday, the nurse said, “Oh, Max, he’s fine; that’s not a problem anymore.” Max was quietly engaged in a craft project in the activity room.

Enhancing understanding of the problem-solving nature of the behaviors and awareness of how our actions might increase or decrease the frequency of a “problem behavior” helped to change the dynamic and direction of interactions between Max and his caregivers.

Is Psychotherapy Still an Infant Science?

Posted on by Psychotherapy.net Team

The field of psychotherapy has been around for quite a while—well over 100 years. According to sociologists of science, a field only reaches “maturity” when there exists a consensus amongst those working in the field. Within psychotherapy, we have yet to reach that stage. Instead, psychotherapy is characterized by someone coming up with still another new form of therapy. What seems to be most revered is what is “new.” As therapy practitioners and researchers, we are therefore confronted with some important questions: Are we destined to continue to forget what we know and instead focus on what is new? Will it always be the case that we emphasize who, not what, is right? Will the field forever be characterized by “dogma eat dogma?” “Is there nothing about psychotherapy about which we can agree?

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Having spent approximately 60 years teaching, researching, supervising, and practicing psychotherapy—and ruminating all these years about these questions—I believe that one day we will have answers to them. In the meantime, where do we stand? I would suggest that there are indeed a few things we have learned over the years from the convergence of both clinical observation and psychotherapy research that can provide a crude, if not basic understanding of a few points of agreement.

To begin with, if we step back and temporarily set aside our theoretical perspectives, it might be possible to say that most (all?) therapies proceed along somewhat similar stages of change. If effective, therapeutic change progresses as follows:

1. Unconscious Incompetence
2. Conscious Incompetence
3. Conscious Competence
4. Unconscious Competence

What does this mean? The patient comes in and says that there's something about their life that's not working, be it relational or symptomatic, but they don't know the factors that are contributing to this lack of effectiveness or incompetence. Thus, they are in an initial phase of unconscious incompetence.

As a result of the therapy—either what occurs in session or between-session self-observations—patients become more aware of the thoughts, actions, and/or emotions that may be creating problems in their life and contributing to their lack of competence. They may be misinterpreting what other people's motives are; not recognizing how their actions may be having a negative impact on others; becoming angry over not getting what they want instead of asking for something directly; and a host of other factors that are uncovered over the course of therapy. There are numerous ways that patients can come to understand why things are not working for them. Through the methods used to come to this understanding, they are now in the phase of conscious incompetence.

Becoming better aware of the reasons for their lack of effectiveness/competence may then lead to the need to function in a different way, taking into account those factors that are causing the lack of their intrapersonal or interpersonal competence. It is then that patients need to make deliberate efforts to behave, think, and/or feel differently: conscious competence.

If the therapy is successful, and over a period of time they benefit from numerous instances of corrective experiences, patients’ conscious competence may become more automatic, resulting in the final phase of unconscious competence.

In order to move patients through these phases, there are certain transtheoretical principles that cut across different schools of therapy.

  • To begin with, our patients need to have some degree of positive expectation and motivation that therapy will help. The most effective of therapies will not do anything if the patient's negative expectations and lack of motivation causes them to do nothing—or to terminate.
  • There also needs to be the presence of an optimal therapeutic alliance. Much has been written about this, and there's both research evidence and clinical observations that this is an important transtheoretical principle.
  • Helping patients to become better aware of themselves and their world can be implemented clinically in varying ways, depending on one’s theoretical approach and individualized case formulation.
  • A most important principle of change involves encouraging the patient to try out new ways of functioning—corrective experiences—that help them become more effective emotionally, cognitively and behaviorally in their lives.
  • Over the course of effective therapy, there develops a synergistic reciprocity of having corrective experiences that enhances patients’ awareness resulting in an ongoing reciprocity between corrective experiences and increased awareness—a form of ongoing reality testing.

The following is a graphic depiction of the how transtheoretical principles of change articulate with the transtheoretical stages of change in therapy:

None of this says anything about the specific techniques that different schools of therapy may use to implement the strategic principles, nor does it say anything about the overarching theoretical interpretation of why the interventions may work. At the level of abstraction that I have proposed, it clearly does not say it all. Still, it can provide the foundation for practice, training and research.
For those interested in learning more about this topic, I have written elsewhere on the topic. You can find these articles listed below.
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I would appreciate it if you could take this very brief survey (approximately 5 minutes) about transtheoretical principles of change: Please click here.

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Obtaining consensus in psychotherapy: What holds us back? — American Psychologist, Issue 74, pages 484-496
Consensus in psychotherapy: Are we there yet? — Clinical Psychology: Science and Practice, Issue 28, pages 267-276