All patients are unreliable narrators in that their narratives change as their treatment deepens. Free association, the analysis of dreams and enactments in the transference all affect the patient's understanding and memory of past events. The lapses in memory or affect-laden versions of events are not conscious. However, some patients are not unreliable narrators because of unconscious lapses in memory or understanding — some patients intentionally lie.

I am not talking about sociopaths who do not experience guilt, but rather about patients who lie to preserve their narcissism or to avoid punishment for something they perceive as wrong. Sometimes people lie because they have an intense sense of shame or they have an overly strong superego rather than a weak one.

Children usually begin to tell lies in their preschool years, between the ages of 2-4 years of age. They are imaginative and often fabricate stories as part of playing. Children also lie as a tool to preserve their self-esteem among those who matter to them — parents, friends and teachers. And children also lie to avoid punishment. Lying is a normal part of child development, but when it is treated harshly, the impulse to lie is reinforced and can continue into adulthood.

In some families, lying is encouraged because of a chronically stressful family situation such as alcoholism and/or abuse. If the impulse to lie is pronounced, it can result in the development of a “false self.” In its most pathological form, the false self is set up as real, and everyone thinks that it is the real self. In friendships and work relationships, observers think the false self is the real person.

Persistent lying becomes a maladaptive coping strategy, because covering up a lie is a significant stressor. Since lying is itself stressful, it creates a downward spiral: lying, covering-up, guilt, anxiety, more lying.

My patient Patrick is stuck in a dysfunctional loop that he has been repeating since he was a little boy. He often lies to women to protect them from disappointment or rejection by him, and to protect himself from their angry response. Then he avoids the person he has lied to because he feels guilty. This dynamic gets acted out most frequently in treatment regarding coming to session and paying on time. Almost from the beginning of treatment, he came late to the sessions and paid late. When there was a lull in the session, I brought up the payment of my bill.

“By the way, you have not paid me for last month,” I said.

“Yes, I did. I sent a check to you,” he replied.

“When was that?”

“You think I'm lying to you, don't you?”

“Why would I think that?” I asked.

“I'm furious that you don't believe me,” he said with his jaws tight.

“When did you send the check to me?” I asked calmly.

Silence.

“I…did it this morning before I came here…That's why I came late, because I thought you'd be angry that I hadn't paid you.”

The dynamic began with Patrick’s having anxiety about not paying me on time. Indeed, our agreement was that he give me the check the session after I give him the bill. He knew he did something wrong, but he could not face it. He tried to avoid it by coming late. Then he got angry at me because he projected his own guilt and expected me to be angry at him both for not paying me and for being late. He felt he couldn't deal with my reaction to his transgression, so he regressed to an immature state in which he feared punishment and then coped with the stress by lying.

It has taken many years of analysis to get to the point where Patrick and I can discuss this downward spiral. In the past, each time I uncovered a lie, he responded with narcissistic rage, and it took several sessions to work through. Sometimes, he threatened to quit treatment. Now we can deal with it in a single session. Part of the problem was that I did get angry at him when he was telling me an obvious lie.

“You're angry at me, why don't you admit it?!” he yelled. “What's the point of coming here and talking to you if you are going to get angry?”

“If you don't pay me and then lie about it, I am going to have a negative reaction,” I responded.

“You are not supposed to have an emotional reaction. You're supposed to be a therapist,” he said.

“You mean you can treat me any way you want to, and I'm not supposed to have a reaction?”

“Yes, I think another therapist would be more helpful.”

“So, the problem is not that you haven't paid me and told me that you did. The problem is that I have a reaction to your not telling me the truth?”

“Yes…”

Eventually we developed a more effective way of dealing with it.

“You haven't paid me for last month,” I said toward the end of a session to which he had come late.

“I know. That's why I came late. I expected you to get angry. But you don't seem angry. I know I've done something wrong and then I tried to avoid it by coming late…,” he said.

“What do you make of that?”

“I do something wrong, then I try to avoid the consequence and come late, but that makes it worse,” he said.

“Yes?”

“I provoke you and then I get angry if you get provoked,” he said.

“Yes,” I said.

“The question is: why don't I pay you when you give me the bill?” he said.

“And then what makes it so difficult to own doing something wrong?” I asked.

“I don't know why I don't pay you on time.”

“But that's a separate question from why you need to avoid me or lie to me as a result,” I said.

“Yes, I see, there are two issues.”

***

Patrick and I are getting better at deconstructing these episodes. He has developed an observing ego, and when he comes late, he usually knows he's avoiding something that he's ashamed or guilty about. Together, we scan what's gone on in the recent past to find something he did or didn't do that he feels bad about. Usually he has either overtly lied to me about it or lied by omission. Once we identify what he feels bad about, we are usually able to see a conflict he had/has and identify that as the beginning of the downward spiral.
 

In psychotherapy, clients take us into their homes, literally and figuratively. When they fully engage in the therapeutic relationship, they invite us into their emotional homes, some more than others. They show us the way around and ask for our help because the integrity and stability of their home has been fractured.

Today, with the transition to online therapy, they take us into their homes even more. How often do I sit in a session, like I did with John, who was talking about the lackluster sex in his marriage and, as he did, pulled out a photo of his wife and children? Or Jan, who had just lost her mother and, in deep grief and bereavement, searched for a picture of her parents at their wedding 50 years ago.

Pictures shared in the office via iPhone, iPad, or whatever device that accompanies them, are way more commonplace than ever before. Just the other day, Emily showed me an online picture of what her new home, made of steel drums, will look like.

It is a technologically mediated world, no doubt.

But with COVID-19, we have been given access into our clients’ actual homes. With shelter-in-place, therapy has largely, at least up until now, transitioned to telehealth through video platforms like Zoom, Doxy.me, or Facetime, or for some who can only show us a small bit, by phone.

Much has been written of therapy sessions being interrupted by the family dog or cat, kids in the background or a Grub Hub delivery. For many, these have been moments of new exploration, humor or something in between. How many of us have laughed at the glitches, random incoming texts, or alerts from CNN about the latest stock market plunge or surge. Fortunately, my interruptions have been limited.

Having recently read the New York Times piece by psychotherapist Lori Gottlieb on how the toilet has become the new therapy room and more, I wondered if I had perhaps been too rigid and controlling. I have emailed my clients to assure that they glean the most of our sessions by creating a safe and sacred space for themselves to have our sessions, and even make sure that they have tissues close by just in case we hit on a sensitive spot. I have also asked them to consider taking time before and after sessions to contemplate our work (akin to the drive to and from the therapy office) and that they not just run back to check on the rib roast. That said, not everyone has had privacy; with kids in online learning and the recent work from home status and other family members joining to shelter in place for the period of time, it can become quite challenging for clients to carve out the special space and time that therapy demands.

I have been brought into bedrooms, living rooms, home offices, lanais, cars and even a closet – but not yet a toilet. I have had house tours but have yet to meet other members of the family, with the exceptions of meeting an ex-spouse and a few grown kids.

In these moments, I can’t help but feel as if I am an unintentional intruder into my clients’ personal spaces, although with time and repetition (a therapy phrase), that has softened and I have felt less of a voyeur. Yet with the advent, or should I say the domination, of telehealth, this experience remains new for me. It can be comical watching a client run from room to room in an attempt to find privacy in a closet. This particular client obviously did not receive my preparatory email.

While my reflections over issues of privacy and intrusion are sincere, I am also concerned about the other side of the looking glass, so to speak. What is this experience like for my clients? What do they really see? It’s not just about what we see and experience. We all show up a bit differently as well. I know there are therapists doing sessions from their living rooms, and in some cases a designated bedroom or room with a false background, or even their cars. I have had the opportunity to view the workspaces of colleagues. I am fortunate to have available to me a designated home office, detached somewhat (with separate entrance) from the main house, pretty much (but not failsafe) indestructible to outside forces… no kids, dogs, or random visitors (although the landscapers have made an appearance from time to time). I wonder what our clients see, feel and experience when allowed entry from the virtual waiting room into our personal spaces. This is all curious to me and definitely grist for the mill when we return to (a new) normal.

Entering my clients’ space, having been ‘forcefully’ invited in, has given me a new sense of closeness to them. I wonder what is in the mind of clients who are now given the opportunity to be voyeurs into our lives? What is it like trying to access their emotions and inner states from a car? Given that our playing fields have become levelled (we are both in our homes), how does that affect their relationship with us?

I’m curious. How does the client/therapist relationship change when both have access to the one-way mirror?
 

As we know, the COVID-19 pandemic presents unique challenges to both the client and the therapist. This phased framework for coping with the pandemic was developed by integrating my observations of patterns in client responses with application of developmental and resilience theories and research on the neurobiology of trauma. The framework helped in working with Melissa, a 42-year-old client and single mother of two preteen children.

These phases are presented here in a neat and clean linear fashion, but, the pandemic is anything but! Our clients move in and out of phases based on new and changing information and the complex emotional reactions they must process in response to these changes. Being at an ‘earlier’ phase is not failure. It is simply fact, and we can help clients acknowledge that with awareness and give them the care and support that fits the phase they are in.

Phase I: Shock, which might include a freeze response. In my office in mid-March, we discussed social restrictions and my move to telehealth. She said, “I feel numb… kind of in a daze, like this isn’t real, and I keep forgetting what I’m doing mid-task.” I immediately shifted into somatic based interventions focused on regulation and grounding. I had her feet firmly on the floor, did a ‘sensory count’ orienting exercise looking around the office, and I handed her a weighted blanket to place on her lap.

Phase II: Crisis, when shock wears off and people might move into a ‘fight or flight’ response. Clients sometimes feel enraged, terrified or are in a ‘‘hyper alert’ state of vigilance. When Melissa and I connected for our first telehealth session, she spent several minutes angrily pointing out all the “ways in which no one is handling this.” She told me she was sleeping poorly and found herself scrolling through her phone for hours each day reading news articles and posting on social media. I offered support and reminded her anger and fear were normal responses to an out-of-control situation. We identified boundaries she could set for herself and ways in which she could mentally “take a break” from her pandemic worries and discharge built-up cortisol and adrenaline.

Phase III: Coping, when our resources are marshaled to determine “how we are just gonna get through until this is over.” In coping, people are living and working in ways which significantly overextend them. During the next few weeks as Melissa adjusted to life ‘on lockdown’, she put in long hours trying to make sure her children met every single expectation of their school’s distance learning program. She would then stay up late trying to finish work for her own job in the insurance industry, and frequently would find herself overeating or having “more wine than usual” as a way to numb out the exhaustion she felt. During this time, we addressed Melissa’s feelings of guilt and inadequacy as she tried to “do it all” and found online resources for her to support her children’s learning, and I encouraged her to honestly evaluate how long she felt she could sustain this routine.

Phase IV: Adaptation, which shifts out of coping into an awareness that life changes should be viewed as sustainable and semi-permanent. The focus also slowly moves away from replicating or waiting for pre-pandemic life to return. Clients are able to evaluate, reflect and ask themselves, “What’s working right now?” Melissa began examining, as she put it, “the question of how I want our lives to be for the foreseeable future.” Although she at times moves back into crisis or coping based on current events or new stressors, her sessions now consisted of my supporting her to make decisions which had the goal of balance and sustainability. She adjusted her expectations for online learning, spoke to her supervisor about a temporary reduction in her caseload, started making more time for Zoom calls with friends and recently declared two hours every afternoon as “chill out time” for her and her children to relax, take walks, nap and play together.

It is difficult to be in adaptation without a sense of basic economic security, physical safety and human connection. Melissa had a basic foundation of these experiences which helped her move into adaptation, but the deep systemic inequalities in our country mean many clients will be pushed into the chronic crisis or coping phase. Regardless of what phase they are in, using this framework helped Melissa and I to work together, providing both support and understanding.  

As we know, the creation of a ritualized space between two human beings is often a challenging and intimate endeavor. As an experienced child and adult psychologist, I have learned how to sit with people through excruciating times of suffering, fear, longing and grief. Whether it involves hearing about a difficult relationship or about an acute or chronic trauma, my most important task is to try to feel or imagine what a patient feels or felt at a particular time.

This will involve an understanding of the patient’s psychological strengths and weaknesses, their biology and temperament, their inner conflicts and how they came to be the person they are. Just as important, it is about feeling their disappointments and their delights. My hope is that the patient will be able to discover and embrace something yet unknown. Perhaps there will be a glimmer of freedom or authenticity, or maybe of something frightening or deeply buried. It will be raw, fresh and unmetabolized at first. What is crucial is that this process begins with my commitment to trying to feel what the patient feels.

The nuances of what heals varies tremendously. Maybe it is significant that I am bearing witness to something being remembered or processed, or maybe I offer a different perspective or silent wisdom. However, it is essential that I can also step outside the patient’s feelings to be able to help spark something new. I am not completely in the telling nor in the immediate experience with them. For example, if a patient is talking about a painful experience of being shamed as a child, I am right there, feeling the shame inside myself as I imagine what they may have felt. But I also keep a tiny piece of myself outside the experience to guide the process of meaning-making or to watch it unfold. This is the crack, the perch, where I can live.

But now during the pandemic, it is harder to find that opening. Practicing psychotherapy as of March 2020 has necessitated that I pay attention with a new kind of vigilance. You see, sometimes there is not a time lag between what my patient brings and my own feelings. We may be breathing in the same grief. I am now experiencing fear and uncertainty at the exact moment in history as my patients are. Yes, we both arrive with different vulnerabilities and histories, (although probably with a similar longing for a pretend mother to help us make sense of it all), but the overwhelming shattering of life as we knew it is happening at the same time.

In our meetings, I often hear my own concerns expressed through the filter of who my patients are. “Why is no one taking care of our country or planet?” “Where is a Goddess or an omnipotent ruler to lead us forward?” “Who will rescue us and what do we do with our longings to be loved so we can strengthen our humanity?” “Will I watch my children die?” Sometimes I am suddenly aware that I am sitting with someone who might be articulating my pain in words that I have not yet found.

The pandemic has equalized our “playing field” or our perceptions of the field we share. We are now all “in this together.” A patient may feel permission to step outside themselves and ask, “How are you, and your ‘loved ones’?” The patient’s need to check in with me and ask how I am feeling is much more natural now, and when I answer, I don’t want to be dismissive of their interest in me nor disingenuous with a quick response. As of March 2020, we are more intimate. I will end up saying something like, “I am as well as can be during these difficult times,” or “So much is swirling inside me, I am not sure how to put it into words yet,” or “Thank you for your care. I am sad and scared but finding ways to keep myself buoyant and in the present moment.”

How can I continue to hold myself outside of what we are experiencing to be of best service to my patient? Where can I perch and settle, if only for a moment? How will this mutual uncertainty, while often unspoken, affect our ongoing relationship? These are the questions that my colleagues and I ponder, even in our dreams. Despite my own fear, I know that my experience and kindness will prevail. I am certain that my commitment and love for this work will continue. I just hope that soon the perch will be easier to find.

COVID-19 has changed all our lives… our freedoms, our habits, how we spend our free time and how we interact with our clients. As therapists, we always discuss change with our clients. It is one of things that is constant and predictable. As my (non-clinical but very wise) mother-in-law often reminds me, “Time marches on and change happens.” To be sure, social distancing has contributed to our need, or perhaps mandate, to adapt and exercise creativity as we figure ways to work around the newly imposed restrictions.

One of the most dramatic and life-changing adaptations many of us have had to embrace is the transition towards telehealth. Some important professional standards of care must continue as each of us “marches on” with our new telehealth practitioner label.

Professional boundaries must be adhered to. While these may have been firmly established in your “on-ground” practices, it becomes equally, if not more important, to create your own time/space boundaries when you are connecting with your client by telephone or over the internet. Recreating this within your remote office will be a valuable tool prior to stepping into this realm. It is important that you be aware of seeing what your client will see, which includes what you are wearing, what is in your background, where your children are as you speak with your clients. We are, in a sense, inviting our clients into our personal space, especially if you don’t have the luxury of a dedicated office space within your home.

Just yesterday, as I was walking a client through our final session, this came up from my client: “Can I ask if you’re willing to send me a pic of you in your backyard so I can remember you with a photo?” For some reason this surprised me. The fact is we did have a live video session while I was outside. I thought little of this fact at the time. It got me thinking about boundaries and what I was willing to share. Was this a boundary crossing? Allowing a window into my private beautiful garden… well, after some thought, I decided that sending a photo of a lovely Heliconia Rostrata would be acceptably within my professional comfort zone, and hopefully useful to my client, for whom our relationship and this small glimpse into my world was important.

Know your limitations with the technology that you are using or planning to use. Maybe it’s time to get back to role-playing; first practice your technology with a non-client. You may become aware of small, seemingly inconsequential mannerisms or facial expressions that you use when communicating with someone remotely. If you initiated counseling with a particular client in person, it may take some getting used to on their (and your) part as you transition to a small screen. Your clients may feel more or less open to sharing as the relationship transitions to the virtual space. Expect that you might feel a bit “off balance” with this remote therapeutic work. Be aware and adjust/adapt as needed. If you need more knowledge and training, there are many webinars (both free and not) and certifications available to help you in the transition. Chatting, commiserating, and practicing with colleagues may be another asset to help support you through this time.

Prior to each video session I check out the view as I would in the mirror prior to leaving the house in the morning. Lipstick is a must for me. I also check out the view of me that the client will see. Being aware of my professional dress (of course I want to stay in my workout clothes), is respectful.

Time and energy during the transition is another important consideration. That this “new” way of working may take a bit more time and energy than you initially imagined is inescapable. Creating clear personal boundaries around what schedule is best for you as well as for your family and friends will help you to arrive at a new balance between work and play/family/health. Flexibility, planning and self-care are critical.

With telehealth, the flow of sessions is different. Last week, a client and I were on a scheduled live video session. I say scheduled because I prepare by reading the entire case, which allows me to be in my “work mode.” Time invested prior to the session is considerably different than for on-ground office sessions. This client must not have informed their housemates about the anticipated need for privacy. Six times different people interrupted, and that drastically interrupted the flow. Monitoring and adapting the progression of my thoughts was a challenge and frustrating. It took more energy than usual to pause and return to the flow of my ideas and our conversation. It is important to be mindful of balancing expectations and reality as sessions like this unfold.

Documentation and record-keeping are going to be different as you make the transition to telehealth. In the on-ground therapy office, notes are taken and stored… left behind when you close the door. Certainly, we internalize some of the impressions and thoughts evoked during therapy, but for the most part, they remain safely behind. But once we transition to emailing, texting, and video or voice recording, all information is “out there” forever. Be aware, perhaps even doubly so, about how and what you write and say. Checking in and returning to clarify your message before pushing “send” is extremely important with remote therapy.

A client recently messaged me, “You know everything.” I worried that I was creating the wrong impression with this client… something I said or something I didn’t. And I wrote that in the next message, noting how I had years of experience but by no means knew everything. My message continued with questions around what I could do to ensure a more helpful experience for this client. The client wrote back to let me know that this wasn’t directed at me but was based upon what friends had told her and what she heard on a TED talk. We both got a good laugh out of that one. As you march on, be keenly aware of clarifying, validating and helping clients to identify feelings… since it may be more of a challenge to see and feel these in your virtual office.

All of us feel the impact of the stay-at-home order. While this pandemic has the potential to connect us, it can and will invariably throw us all off balance. And for me the key word is and has been balance, both professionally and personally. As I say to my clients, good, healthy food, adequate rest, movement and fresh air are essentials for positive health, both mental and physical. As clinicians we should adhere to the same need for a new equilibrium as we march on.
 

Every time I opened the door to Jane, I instantly recognized her odour. This used to rattle me at the very beginning of our work together, but after a few months I barely noticed it and simply opened the window to air the room after her departure, almost automatically as part of a familiar routine. She smelled of a neglected child, of sad days spent in unwashed pajamas and binge-eaten lonely meals. Jane was in her late 30s, and the main reason for her being in treatment was her feelings of shame. This is what I, as a therapist, thought, but if Jane were to explain it herself, she would have probably mentioned her anxiety and the emotional disappointments of being single and lonely in a foreign city. At least, this is what she had told me a few years ago as we first met. We had been working together for a few years, and I had grown to like her a lot. She was a bubbly, intelligent woman with an acute sense of humour. We would often laugh together at one of her jokes, and her face would lighten up in a beautiful transformation. Despite these qualities and her professional achievements as an international school teacher, Jane thought less of herself and battled with a feeling of deep inadequacy. In the first months of therapy, we explored her early history at length, to realize that her two parents had never been able to attune emotionally to her. Jane felt constantly unsafe around them, as they would suddenly explode in unhinged fights, often in public spaces such as a restaurant. This would leave their daughter paralyzed with embarrassment. For years, she had hoped that somehow her parents would get out of their bubbles, entirely occupied as they were by their respective work and their arguments, and that they would notice her presence and her suffering. Jane was an only child, and she could acutely remember her constant feeling of loneliness and despair. She would also be constantly torn between feelings of hurt and anger. Her parents would hardly notice, and when they occasionally did, the response was frustration from her mother and indifference from her father. “I feel like I am stuck in a cold shower.” Hearing her murmuring that, I tried to imagine myself naked and exposed to freezing water, unable to escape and paralyzed with confusion. Jane had been living in this frozen state, her development seemed to have been stopped by the cold shower of her parents’ emotional misattunement, their indifference to her childhood needs. I am horrified by accounts of adults who stop their child’s tantrums by placing them under cold water. Not only does it dismiss the child’s anger, but the wet, shivering child is made to feel shame as a result of this treatment. When parents are unable to cope with the overwhelming emotions that their child cannot yet process, it eventually pushes shame onto the child about this powerlessness. This is probably where Jane was stuck — swollen with indignation and overwhelmed by shame. No wonder she had been avoiding showers. Despite some steady friendships, Jane felt lonely and often dismissed or rejected by others. More than once, we reflected on which of her behaviors allowed or invited other people to push her away. Jane was starting to realize that her constant readiness to get angry and to lash out was not helping her interactions with others. She also knew that her stubbornness about not wanting “to make [herself] pretty” for men had trapped her in a place where she felt unattractive. She avoided all forms of exercise and was putting on weight. But what about the smell? Was it some unconscious strategy to put off others, especially potential intimate partners? Not unlike some insects, which have evolved to develop the capacity to produce a very unpleasant smell when threatened, Jane had learned how to keep others at arm’s length. Her conscious desire for a romantic relationship had not outplayed the unconscious fear of being pushed back under the cold shower by somebody unable or unwilling to give her what she needed. At the end of every session, as I would be opening the window, I was wondering whether I should finally tell her about the smell. This risk-taking on my side could open a royal road for exploration of her shame; or at the very least it would push her to change her hygiene routine for the better. But how could I? Pointing out something so potentially shameful could make her flee the therapy room and undo the work we had been doing. Jane was mostly avoiding any situation that would expose her — such as taking on more rewarding projects at work, or physical intimacy. This constant avoidance had saved her a lot of embarrassment but had also contributed to her feeling stuck. I hoped that by facing her shame together, we could help her to develop resilience. In order to get out of the cold shower, she had to take action and change things that had made her feel bad about herself — exercise more, take better care of herself. Jane had been an unhappy but steady user of online dating apps. The rare times she had made it out with a man had ended up with the same scenario: the man either fled after the initial drinks, or they both got drunk and had sex in her messy studio. In the latter scenario, the denouement would always be the same — she would never hear from the man again. This had been the worst and most hurtful part of it all. To be ghosted by these individuals that Jane actually despised served as a constant reminder of her unworthiness — sending her back to the cold shower. She would get out of each dating experience wounded, and it would take her a few months to recover enough strength to give it another chance and take the risk again. No matter how many hours we spent analysing and unpacking her experience, no amount of awareness or insight seemed to help her change the flow of her lonely and unsatisfying existence. I was still pondering about the whole body odor dilemma when Jane came to a session more deflated than usual. She crumbled into the armchair and stayed silent. I recognised her “cold shower” look. She confirmed: she had just gone through another failed attempt at dating. “This was horrible, absolutely horrible,” she cried. My heart sunk. I felt hopeless myself and probably as defeated as her. “What happened?” “This… jerk told me that he was turned off by my smell.” My first reaction was to console her, to hug her, to reassure… but I resisted the temptation. Not now. Not yet. “This is very hurtful. I am sorry this has happened.” Was I? Not really, as this insensitive and probably drunk stranger had done what I was unable to do. He had liberated me from this burden. Was this a therapeutic opportunity? “Do you think this might be true?” “What? That I was stinking?” “Yes, that you had not showered that day?” Jane kept silent for a while. I could see that she was divided between her childish desire to get angry and storm out of the room and the trust that we have built over the years. “I actually had not. My shower is broken… it has been for a while. I cannot get myself to call the landlord, he hates me… I cannot deal with the plumber in French…” Jane’s defenses crumbled all at once; her anger, her intellectual polish, and her sense of humour, everything disappeared, and what was left was the little girl struggling with shame. This feeling was terrifying but somehow, we stayed with it for the rest of the session. We sat with her humiliation together, and Jane had an opportunity to learn that I still liked her despite her body odour, that her shower could be repaired, and that we actually all smell. We were even able to finish with a laugh about us smelly creatures. This incident became a turning point in Jane’s therapy. The insensitive but honest feedback from a failed date turned out to be an unexpected therapy gift. We recovered slowly; after a few weeks, Jane could talk more openly about her body shame. Then, she was finally able to get jogging shoes and try to run her first mile. Eventually she started feeling better about herself and her sense of self-worth became less dependent on others. Jane seemed a little more content with her Parisian life. I felt sad the day we said goodbye. As she had left, I automatically started opening the window… before realizing that the only smell she had left behind was one of a very light, citrusy perfume.

Over the course of my 28 years as a therapist, I have told many patients that therapy is like putting puzzle pieces together. It was a metaphor that most of my patients seemed to like and accept. Like most of us these days, I have extra time due to living with the stay-at-home orders, so I recently purchased a jigsaw puzzle to help manage my anxiety and to enjoy my new-found leisure time. As soon as I began to solve the puzzle, I realized that the metaphor was much more nuanced and complex than I had considered when offering it to my patients. I will elaborate. Seeing What’s There When it was delivered, I first looked at the final product on the box cover. I immediately wanted to solve the puzzle, so eagerly opened the box to see the pieces all jumbled together. I instinctively dumped them scattershot onto the table and turned them all face up. Therapeutically, this represents the jumble of loss, confusion and pain that brings patients into therapy and the awareness that something needs to change. Although we are careful not to dump all the pieces out at once, it is important to help patients take these jumbled pieces of their lives, turn them face up and begin to sort them out. With awareness, patients can better their situations, improve their relationships and lead more satisfying lives. For example, for your patients who have found themselves in a series of unsatisfying relationships, the assemblage is asking questions like: “Is it the people out there that are the problem, or is there a common denominator?” “Do your partners possess negative traits?” “Or perhaps do you bring out those qualities in your partners?” If not clarity, then at least direction may begin to emerge at this point in treatment. Identifying the Borders Next, I had to find the pieces that made up the edges of the picture. What are your patients’ edges, and how do the contours of their lives impact them and others? Here, we can use the term coined by Heidegger (which Binswanger introduced into psychology) called Dasein: Each individual’s being-ness in the world. The three types of being-ness are umwelt (interpersonal relationships), mitwelt (engagement with the immediate environment) and eigenwelt (relationship to the self). The three types of engagement constitute all our thoughts, feelings, attitudes, mental images and more. Where your uncompleted puzzle sits is where their physical, emotional, and psychological boundaries intersect with others, consisting of their connection to the world (welt). Identify and Group the Colors I next had to identify the various colors and textures as I grouped them together. I organized the green-yellows into one section and separated the purples, reds, and blues into others. After the colors and textures had been grouped, continued refinement occurred. I next noticed pieces that composed new colors and textures that I hadn’t seen before. Lighter brown pieces constituted a tree, whereas darker brown ones were the roof of the house. In therapy, this is the process of identifying your patients’ feelings, thoughts, attitudes and overall behavior, as well as clarifying the expectations, patterns, and challenges in their relationships. In fact, discovering existing and previously unseen colors may be likened to recognizing your patients’ ways of being in their relationships. There are aspects of their personalities and ways of thinking and feeling that we can help them to identify. How do they treat their spouses within various contexts, such as when they’re stressed out or in a bad mood, and how does their partner’s behavior impact their emotions and self-image? What is the degree of honesty, rivalry and satisfaction with their friends? What is their attitude about their jobs? Conversely, what is the impact of their attitude (sense of safety, optimism, and fulfillment) and self-image (pride, shame, love, or indifference) on others? Consider the following examples of discovering new colors vis-à-vis interpretations: “I see that you became angry, but I’m wondering if you also felt hurt.” “Is that vulnerability you’re experiencing?” “You felt abandoned when your partner walked out and you followed him from room to room. Was it a response to panic?” As another example, we might help them learn that they are actually not afraid of conflict when all this time they thought they had been. That’s because conflict exists before the first word is spoken. If a patient’s spouse wants their child to have a play date, but your patient is concerned about her not feeling well and would rather she stay at home, that’s the conflict. What they are actually afraid of are the consequences of bringing up the pre-existing conflict. Do they expect (and receive) anger, the “silent treatment,” or rocking an already rocky boat? Another example of further clarification and nuance is when patients tell us they’re shy. “Is that always or in certain contexts – parties, public speaking, or on a first date?” This process can help them reduce their blanket “I am” statements and add new facets to their self-image. Find the Adjacent Issues As I continued with my puzzle, I recognized which sections were next to one another. The corollary to therapy is illustrated in the continuing example about conflict. When patients don’t bring up conflict with their partners, they “hold” the conflict 100%. In fact, their partners may not even know there’s a problem. Therefore, a risk of not acknowledging the conflict is the possible adjacent issue of harboring resentment and living with continuing victimization (which can be very powerful). “I never get what I want.” “I can’t believe how selfish she is.” There is almost always a previously unrecognized issue that lays next to one that they are aware of. The challenge is to recognize what they are and how these adjacent sections fit together. Tolerate and Accept Emotions There were times when I felt overwhelmed when doing my jigsaw puzzle: “This is too hard.” I was also hopeful — “I can do this”; frustrated — “Did they include all of the pieces?”; uncertain — “Will I finish it?”; and accomplished — “I did it!” We are, in a sense, emotional managers for our patients, helping them to self-regulate as they piece together the often difficult experiences of their lives and the underlying feelings. It is important for our patients to tolerate and ultimately accept a wide range of feelings. The goal is not to “get rid of” anxiety, for example, but to reduce its duration, intensity and frequency (the “DIF”) as they increase their emotional tolerance. Consider Process What are you and your patients thinking, feeling, and imagining as your patients figuratively put the pieces of their lives together? The how of therapy is the therapeutic process — everything from the relationship, the way therapy is experienced, what happens within the sessions and the acknowledgment that there are two points of view in the room. The process also incorporates the tribulations, joys, sorrows, frustrations, and hopefulness that we each bring into every encounter. And then there is the possibility that the final product of our therapeutic work may not resemble the image or may vary considerably from their expectation of the goals they brought into treatment. The act of working out their puzzle might have altered the final product. The Full Picture While working on my own jigsaw puzzle, I realized that the metaphor of therapy as a jigsaw puzzle is not as simple as I used to suggest to my patients or even realized myself. To help them solve their puzzles, we (and they) must look at the many aspects of their lives; to sort out the jumble into a coherent picture. As we help them through the process of laying out the pieces, finding their edges, sorting and organizing by color and content, they hopefully will learn to look for and at the bigger picture — how they developed certain patterns of behavior, coping strategies and ways of relating to others. They will come to see themselves more clearly and accept themselves more unconditionally, develop and refine facets of their identity and gain insight into who they are. In these ways, effective therapy — like solving a puzzle — is both a demanding and rewarding experience. But unlike the static and store-bought jigsaw that comes in a box, the puzzle of therapy is fluid, and the final product not always available on the box top.

When a patient reports their history, we listen for content as well as the emotions associated with their recollections. With a discerning ear, we also consider the reliability of their narrative. Even if a patient is not a good historian, it does not mean they’ve lied. There are many reasons patients don’t report an accurate history.

One reason that I find particularly interesting, which you’ve likely encountered if you’ve worked with long-term psychotherapy patients, is the shifting of narratives, stories that change over time. This is not necessarily unreliable reporting. Emotions associated with narratives change with life experience and with that so does the recollection of the events.
Memories, then, are as much a representation of the present as they are of the past. What we hear when we listen to patients’ reports of their past experiences not only gives us history but also offers a window into present emotional states.

For example, my patient Beth reports depressed mood, anxiety and feeling that her life is harder than everyone else’s. In the difficulties of her present life, she remembers a man from her past who she dated on-and-off for a couple of years. This is a good example, because I was seeing Beth in therapy while they dated, so I’ve been privy to her emotions while she experienced the relationship as well as her retrospective examination.

At the time, she had described constant frustration and upset at his lack of emotional availability. Her sessions were filled with lamentations about him and about the relationship. I had the sense that she was cornering him and being overly demanding, because I also experienced that in our therapeutic relationship. But she was unable to withstand any relational analysis at the time. It was too soon in our therapy, and she did not yet have the self-esteem and emotional resilience to tolerate that level of painful introspection.

But years after their breakup and with continued therapy, looking back, she remembered a different man, one who was kind and generous, and who wasn’t unavailable, but rather one who was focused on building his career. She longed to go back to that man – the one she didn’t date. She believed that man would reduce her life difficulties. The sessions over the last couple of years have been dripping with nostalgia for the life she didn’t lead.

If memories change, then perhaps nostalgia is a longing for the life we only see in retrospect. If so, how do we help patients let go of regrets for things they couldn’t have understood at the time they happened? How do we help them understand the role of the life they didn’t lead? And even deeper, how do the unlived lives of people close to us influence our own journey?

I’d been tossing these ideas around for a long time, especially after working with patients who presented with trauma symptoms who had not experienced any clear traumatic event but whose parents did. Listening to their narratives, I heard a similar theme: they absorbed their parents’ trauma when they were young children, mostly when it was communicated without words, when the heaviness was felt but not discussed.

I decided to write a novel exploring these psychological and philosophical questions using characters to gain insight so as not to be limited by the frame of psychological constructs. The book, called Before the Footprints Fade, explores how our memories change with life experience, how we often long for the life we can only see in retrospect, and how we sometimes want to go back to things that had remained unrealized. It also delves into how the unlived potentials of our loved ones can become part of our own struggles and journeys.

How are we influenced by the roads not taken?

In each of us and all the people we know, there are an infinite number of unlived lives; each choice opens some doors and closes others. I wanted to show how this translates intergenerationally, because sometimes patients’ distress begins with the unprocessed feelings of the previous generation.

So, for one of the characters in my book, the father’s choice to give up the saxophone and take a more reliable career path to raise the family became something he felt responsible for. His father’s unlived life becomes part of his journey. It’s greater than just the unspoken expectations from his parents, too. He then struggled in his personal life to shed what others wanted from him, so he could become who he truly was.

Another example is my patient Damon, whose parents’ implicit statements about his success led him to be an overachiever. When he began therapy, despite his tremendous ambition, he had little emotional connection to his pursuits. “It all felt empty,” he had told me.

Eventually, he was able to recognize that his relentless motivation was fueled by a need for validation and the label of “success” rather than any meaningful connection to the work itself. It became an unconscious quest to live out what was expected of him, rather than what he might have wanted had he felt the emotional freedom to choose. Complicating this was the fact that expectations were not obviously stated, making it hard to separate his unprocessed emotions from those of his parents.

Exploring the unlived lives of our patients’ parents and the implicit communications of these unlived aspirations can be very helpful when stuck with a patient, particularly when there is a lack of vitality connected to how they are living or pressure surrounding imagined expectations.

And as I learned from writing Before the Footprints Fade, “You never go back the way you came.” Once we’ve learned, once we’ve grown through life experience, the road back looks different. We are different.

We spend time with our patients exploring their past in an effort to help them better understand themselves in the present. With insight and ego strength, with psychological growth, the emotions associated with memories change. Therefore, we can also understand present emotions by listening to stories about the past.

Perhaps it’s not quite accurate to say that youth is wasted on the young. Wisdom can only come from making footprints, not from following them. We can only be where we are because of where we have been. We can only see our youth through the eyes of nostalgia. If we want to help patients live fulfilling lives, with meaningful and integrated intentions, with emotional freedom, then we must consider the influence of the roads not taken. We want to explore and understand them, realizing that though they may never have actually happened they still – like footprints – can leave a deep impression.

*Beth and Damon’s names were changed to protect their anonymity.