Equine Facilitated Psychotherapy: The Healing Power of Horses within Clinical Practice

Horses are amazing, beautiful animals—everyone knows that. I’ve had a mild obsession since my first riding lesson at age six (Thanks, Mom and Dad!). After twenty-two years of competitive riding, and a few degrees later, I was eager to incorporate horses into my clinical practice. During graduate school, I took a course entitled Animal Assisted Interventions, and while it certainly sparked my interest, at the time I didn’t put a lot of thought into it. My primary focus at that moment, like most recent graduates, was finding gainful employment. Three years later, I found myself wanting to combine my two passions: therapy and horses. At the beginning of 2019, I was able to do just that—I started offering Equine Facilitated Psychotherapy at the North Carolina Therapeutic Riding Center in Mebane, NC.

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Equine Facilitated Psychotherapy (EFP) is a relatively new framework within the mental health field. Experts have long agreed on the healing power of animals, which is evidenced by the recent surge in emotional support animals. Although, I find comfort in simply being around animals, there has always been something unique about horses. After doing quite a bit of research, what I always suspected to be true was confirmed: horses mirror human emotions. Even non-horse people have heard, “if you’re afraid while you’re riding a horse, the horse can sense it.” The reason behind that is the horse’s ability to respond to and interpret non-verbal communication offered by humans.

EFP is deeply rooted in observing the horse’s feedback to a client—and then connecting that information to the individual’s life. For instance, if a client has mild anxiety but can present more confidently, the horse will likely still pick up on that anxiety and may take a few steps back when approached by the client. This interaction then holds space for a conversation around the client’s anxiety which may have gone unnoticed in a traditional office setting. Angela Dunning, author of The Horse Leads the Way, notes, “subtle changes in breathing, heart rate, muscle tension, nervous system, and energy levels offer invaluable information about our true emotional state. Therefore, because horses fully inhabit their bodies, their inherent ability to pick up on these subtle changes is one of the main reasons why equine facilitated practice is such a powerful method.” If a client is not making marked progress within the confines of office, EFP is a great option to have.

Trust building is another large component of EFP, highlighted by granting the horse an option to participate willingly. That is, we emphasize the horses’ consent in activities by not tying them and forcing their involvement. To a client that may not have a lot of autonomy in their personal life, the treatment of the horse speaks volumes. Further, when the horse chooses to participate in the session, the client feels a sense of accomplishment in building trust in that relationship. When a horse makes a choice about whether to participate in an activity, it encourages dialogue around emotional regulation and past trauma, and paints a picture of patterns within interpersonal relationships.

The benefits of EFP are endless, as it can address a broad spectrum of mental health concerns. Aside from the therapeutic results, Equine Facilitated Psychotherapy can also encourage professional growth in mental health practice. Although I personally have an equine background, it is not necessary for the mental health professional practicing EFP to be a seasoned equestrian. PATH Intl guidelines require both a mental health professional and an Equine Specialist to be present in each session. The Mental Health Professional’s primary focus is the client and interpreting feedback as it comes up. The role of the Equine Specialist is equally important, as they operate to keep the horse, and all human participants, safe. The Equine Specialist and Mental Health Professional collaborate to plan activities for each session, which encourages a partnership between the two roles.

Recently, I have been working with a teenage client who was placed in foster care. This client entered treatment with the implicit disclaimer: I will likely not talk to you, and when she first arrived, understandably she was eager to keep me at an emotional distance. With all clients, the first activity I utilize in a session is “Observe the Herd.” This activity is exactly what it sounds like: you ask the client to observe a herd of horses, and describe what they believe the horses are doing and feeling, and why they may be feeling that. This particular client pointed out that one of the horses had walked away from the other, and the horse left alone felt scared and nervous. This provided me with insight into how the client has felt since being removed from her family and guided the structure of further interventions. Though this client was guarded with me, her interaction with the horses was the complete opposite. For instance, when taught to communicate with the horse in order to walk her around the arena, the client was very attuned with the horse's feelings. The horse started to turn, without the client directing her to, to which the client responded, "Oh, do you want to go that way? Okay, we can go that way," while rubbing the horse's nose. She then noted, "I don't want her to feel trapped." That sentiment offered insight into how the client was feeling within her current circumstances, as well as provided a chance to further the discussion about how the horse may feel.

At the beginning of each session, we begin by brushing the horse and catching up on the previous week. During this time, this client is often tearful when articulating her desire to return home. Without fail, the horse she is brushing turns around and nudges her, looks at her or acknowledges in a meaningful way how the client is feeling. She has since formed an amazing relationship with a horse at NCTRC and is quite possibly one of the most open and honest clients I’ve encountered. Through EFP, this client has been able to form a trusting relationship—first with a horse, and then with me. The progress she’s made is truly remarkable.

Equine Facilitated Psychotherapy has completely transformed the way I approach my clinical practice and my lifelong relationship with horses. EFP is a growing presence in the mental health field, and one that—if you have the opportunity—I highly recommend finding out more about.  

What’s the Limit? Maintaining and Understanding Boundaries in Psychotherapy

Anita* was an experienced therapist who consulted with me about a client who consistently arrived late for sessions and refused to leave when his time was up. “I don’t usually have difficulties setting limits with clients,” she told me. “But I’ve tried everything with him, and nothing is working. In our last session, I told him that I was going to have to start charging him for the extra time. He just said, ‘okay.’ And he still didn’t leave.”

We all know that boundaries are extremely important in any psychotherapy relationship, but they are not always easy to define or to maintain. They’re also not always easy to identify.

Defining Boundaries in Psychotherapy

What is a boundary, in fact? I like what a group of physicians has said: “A boundary may be defined as the ‘edge of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role.” I also like what Gary and Joy Lundberg write in their book I Don’t Have to Make Everything All Better: In daily interactions with others, boundaries “are statements of what you will or won’t do, what you like and don’t like, how far you will or won’t go, how close someone can get to you or how close you will get to another person…they are your value system in action.”

These definitions apply to both therapists and clients, yet other factors also play important roles. For instance, how we set and maintain boundaries reflects not only our personal and professional values, but also respect for our clients and their boundary needs. Furthermore, boundaries reflect something important about our respect for ourselves.

In fact, this was one of the problems that Anita was struggling with. She wanted her client to respect her, and his behavior around the scheduling of sessions felt to her as though he was disrespecting her. She was having difficulties finding a way to maintain her boundaries, her self-respect, and his respect for her

Boundaries also reflect important information about a relationship between two people, whether the relationship is a personal one or a professional one. Boundaries can be ephemeral and often confusing, in part because they embody the often-unclear lines of connection and separation in a relationship. In psychotherapy, a significant amount of work is done within the relationship between therapist and client. Individuals have an opportunity to work on their relational difficulties. Boundaries, whether they have to do with office rules, payment, scheduling, electronic communication or a therapist’s personal life can become the medium for exploring, understanding and working on issues that emerge in a client’s life with others.

“Freud sometimes made house calls to do therapy with patients and often interacted with them socially”; such behavior is seen as boundary-crossing today. Yet the Internet has created dramatic changes in traditional boundaries. While some therapists refuse to communicate anything other than appointment times in electronic communication, many others conduct psychotherapy online and by telephone, even exploring the benefits of doing online psychotherapy with clients in their beds.

Boundaries Have Meaning

While both a therapist’s and a client’s boundaries need to be clarified and respected, a therapist’s curiosity about any boundary question that comes up for a client can be an important tool in the therapeutic process. In their Psychotherapy.net essay on doing therapy with clients in bed, Giré and Burgo tell us, “Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of any boundary transgressions.”

For instance, over the years many clients have asked to hug me. Physical contact between therapist and client has long been an area of controversy, and, of course, a question of boundaries. Not only is it significant in terms of potential sexual coercion and assault, but it also raises important questions about both the therapist’s and the client’s comfort with non-sexual physical touch.

I am not a particularly physically demonstrative person and do not always find that kind of contact comfortable. Because I know that to cross my own boundary in those cases would be harmful to the therapeutic work, I have found ways to tactfully and gently refuse the request, often explaining that it is one of my own boundaries that I am careful not to override. Such an explanation often leads to a client’s apologies, and sometimes to a painful discussion of their fear that they are not only unlovable, but also so repulsive that no one would ever want to touch them.

In one instance, with a client who seemed to go out of his way to make himself as unattractive as possible, I asked if it was possible that he actually did not want to be touched. He seemed taken aback by my question, but then he began to wonder out loud. “I think I want to be touched,” he said. “It’s not that. But I think I’m afraid that I’m going to be rejected; so, I sort of set it up that I’m so disgusting that I know that it’s going to happen.” I replied that that made sense to me. I said that I thought he was trying to take control of something that he feared. “It’s better if it doesn’t come as a surprise,” he agreed. “Somehow it doesn’t hurt so much that way.” That client and I spent many years working together, and the process of trying to understand what might be going on with each of us, and within our relationship, helped us to understand some extremely important, complex and subtle aspects of many of his other relationships.

I have learned to share this information about myself with clients in a way that often leads to our finding other ways that they can feel soothed and comforted by me and close to me without touching. In many instances, the process of talking about our different needs has also opened areas in which they struggle with similar issues in their personal lives.

Role Modeling and Boundaries

How we look at and work with boundaries can also serve as a role model for clients, whether it is in the service of protecting their own or respecting the boundaries of others.

For example, there are times when I am comfortable hugging a client. I am not always sure exactly what makes me feel comfortable with the contact, but I have learned to respect my internal communications – the same way that I encourage clients to pay attention to their own wishes not to always do what someone else wants them to do.

Not too long ago, two separate clients who were struggling with painful realities in their lives brought up the issue of hugs. Both had been in therapy with me for some time. One shyly asked if it would be okay if she hugged me. The other told me that I was not to hug her and was not even to look at her sympathetically. In both cases, I agreed to the request. I also asked if we could talk about what their requests were about – what they were hoping for and what they were hoping to avoid. And finally, I asked if they could talk to me about their responses to my response.

I was willing to accept and respond to what they needed, but I also maintained my curiosity about what was going on beneath the surface – what either the hug or the restrictions meant in terms of the larger picture of their lives. In part I was able to provide this kind of approach because of my awareness and respect for my clients’ boundaries and for my own.

Exploring, Understanding and Maintaining Boundaries

To return to Anita: as we attempted to understand her client’s refusal to accept her boundaries, we began to see that the dynamic between them was complicated not only by each of their personal dynamics, but also by social and cultural factors. “I feel like he’s being sadistic,” she said. “By refusing to accept limits that I set, he’s setting up a ‘MeToo’ situation. He’s being an aggressive male and putting me in the position of being a compliant victim. And I refuse to be in that position.”

In his book Attachment in Psychotherapy, David Wallin explores some of the links between a client’s behavior, a clinician’s reactions, and unarticulated, often unknown attachment issues. Because I thought that her client’s behavior might be related to some unspoken, maybe inaccessible relational dynamics, I asked Anita if she could imagine talking about her dilemma with her client. At first she doubted that it would be useful. “Why would I make myself vulnerable in that way?” she asked.

I told her that I thought by sharing some of her dilemma, she might also be putting into words some feelings and relational issues that her client was enacting with her. I said that I thought he might even be relieved that she was able to articulate something that he felt but could not talk or even think about. I said that I also was hoping that by putting her dilemma into words, she would be altering the power struggle between them. She decided that there was really nothing to lose. “I’ve tried everything else I can come up with,” she said.

When he arrived late for his next appointment, Anita brought up the combination of his late arrival and refusal to leave on time. She said, “I’ve been thinking about what’s going on here, and, although I’m not sure you’re going to like them, I’d like to share my thoughts with you. Would that be okay with you?” He nodded, but she said he looked uncomfortable. She then told him what she had told me.

The client seemed deeply moved by her comments. After sitting quietly for a few minutes, he said, “”Wow. I’ve been feeling resentful that you have all the power in this relationship. And you’ve been feeling assaulted by me”. I think you might have just solved a puzzle I’ve been unable to solve for a long time. I haven’t even had a way to think about until now.”

He went on to explain that he often seemed to get into similar kinds of power struggles at work and in his personal relationships with women. “I’ve always felt like I was the one who was being forced to do things against my will,” he said slowly. “But maybe other people feel like you do—like I’m the one who’s pushing them around. That’s really weird. But it kind of explains why people get so mad at me when I’m feeling like I’m just trying to protect myself.”

This insight did not change the power struggle completely, nor did it magically shift the client’s difficulties with other people. In fact, they had to repeatedly revisit the same dynamics both in their relationship and as they discussed his interactions with other people in his life. The client began arriving closer to the proper time for his appointment, but he continued to have difficulty leaving. But now they were able to look at some of the reasons for both behaviors, not as a power struggle, but as an attempt to control both the connection to and the separation from his therapist. Exploration revealed that he found separation extremely painful, but that he was embarrassed to admit how much it hurt him to have to leave—or to be left by—someone he felt close to.

Theirs was a long and productive therapeutic relationship, and the early struggle over the end of sessions became an experience that the two of them referred to over and over again as a template for understanding what was going on when the client began testing boundaries and acting (and feeling) like a rebellious teenager.

Conclusion

Boundaries are crucial to any relationship, including a relationship between a therapist and a client. Yet these often unclear, ephemeral lines between connection and separation and self and other can become the means by which we can understand a client’s self and relational struggles. A clear and consistent frame protects the work of therapy. But that work can be greatly enhanced through the process of exploring, understanding and reflecting on those boundaries.

*names and identifying information changed to protect privacy  

Nightmares are Easily Treatable, Though Too Few Seek Help

Nightmares are common and distressing phenomena that often co-occur with anxiety, depression, stress and trauma, and they are one of the main symptoms of trauma-based pathology. Most people who suffer from nightmares have no idea how quick and easy it can be to stop or change their distressing dreams. Yet, in my experience, and as the literature suggests, clinicians may veer away from focusing on their client’s’ nightmares for fear of potentially making things worse, especially when those nightmares occur in the context of trauma.

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A client I will call Jill woke up with a start, her heart pounding, the fear of being chased by a dark, unknown pursuer still a fresh and very real sensation. As she looked around her bedroom, it dawned on her that she had just experienced a version of the same recurring nightmare that had haunted her since adolescence. Such dreams often revisit in times of stress. They disrupt sleep and can fill the dreamer with dark, foreboding feelings or disturbing images that persist, sending daytime thoughts down darker pathways than they might have gone.

In our therapy session, Jill and I explored the dream, first its setting which was a mix between an office building and her childhood home. The dream ended with Jill crouched on the small balcony outside one of the top-floor bedrooms with the door just opening, the dark man about to find her and try to kill her. In exploring the dream, I invited Jill to pick up a few resources along the way. For example, her gym bag at the front door brought her a feeling of strength and speed as she recalled how she used to compete in distance running. Still an athlete, she sensed how at home she feels in her body. Bolstered by this, she allowed her dream to play forward, following my instruction to simply let it unfold as if she had just pressed play on the dream scene.

When she did this, Jill opted to use her sense of power and speed to leap off the balcony and run through the air, flying away into the night. In other versions of this common pursuit nightmare, dreamers like Jill have chosen to turn and face their pursuer, and often this leads to a conversation that softens the entire encounter, bringing some peace and understanding between aggressor and dream ego. Like any true encounter, the outcome is unpredictable, but in most cases, interacting with the dream aggressor helps.

There are numerous studies demonstrating that re-scripting nightmares can be an effective way to reduce their frequency and distressing impact on the dreamer. In fact, almost any kind of imagined change is helpful. A pair of clinical trials by Krakow and his colleagues in 2000/2001 showed Imagery Rehearsal Therapy (IRT), which involves giving the nightmare a new ending and rehearsing it, to be an effective treatment for nightmares compared with waitlist controls. Since then, many other forms of nightmare re-scripting have shown similar effectiveness. It appears that almost any kind of nightmare treatment has the potential to help, providing the dreamer with a sense of control.

I attended a nightmare research symposium at the recent conference for the International Association for the Study of Dreams (IASD) in Kerkrade, The Netherlands in June 2019. Presenter Kate?ina Surovcová presented a qualitative study of the experiences of social dream sharing of nightmares. She noted that only one in 8 people sought help for their nightmares. She said people are reluctant to share nightmares for fear of being seen as crazy, and because they don’t want to burden others with the darkness of their dreams.

Another recent study, a randomized controlled trial by Carolin Schmid, compared two established imagery-based treatments and showed that all treatments are effective at reducing nightmare frequency and distress, even the control condition! In the study, which had 96 participants, Schmid compared three different imagery-based methods. The first was imagery rehearsal therapy (IRT); the second was exposure therapy, in which the client is repeatedly exposed to their nightmare imagery; and the third, an active rather than waitlist control, asked clients to imagine a safe place. Interestingly, all three methods worked equally well, and all worked with just one treatment session. So, in treating nightmares, it may be that any treatment is better than no treatment, and just one session may be enough to make a difference.

Schredl noted that in nightmare studies and clinical treatment, the distress caused by the nightmare is the most important variable, and the frequency is secondary. He said people’s attitudes toward their nightmares matter, another area where clinical intervention can be helpful. In Jill’s case, the experience of successfully flying off the balcony and away from her pursuer brought a sense of exhilaration and power, and since that session, she has not experienced the nightmare again. But even if she had, Jill said she would now be far more welcoming of it because the original scared and helpless feelings have shifted so dramatically. It is important that clinicians consider forging ahead when clients present nightmares because it appears that almost any kind of therapeutic attention to the dream might make a positive difference.

“Are you Thor?”

We ask our clients time and time again: “What would help you remember your worth?” It can be a difficult question to answer. Using the tool of therapeutic fanfiction, it’s possible to give clients a totem or talisman by which to remember their worth: Thor’s hammer, Mjolnir. We’ve been using this intervention quite a lot recently as Thor is present in the social consciousness by virtue of his appearance on the big screen. For those unfamiliar with the story, Mjolnir was a magical hammer gifted to Thor from his father Odin. As told by the Marvel Cinematic Universe (MCU), Odin enchants the hammer with his words “Whosoever holds this hammer, if he be worthy, shall possess the power of Thor.” Thor himself seems to hold the belief that the hammer is what gives him his strength. It takes him losing his hammer, and being faced with fighting without it, for him to realize that he is not “the god of hammers” but rather the god of thunder. He inherently has the strength within himself. The hammer is simply a tool. This imagery allows clients to see that while it’s important to have a tote—their own Mjolnir—this isn’t from whence their worth springs. Their strength and value come from within. This is highlighted in the most recent iteration of the Avengers films when Thor experiences a bout of depression. While it is never overtly stated, we see him in his home where he has clearly been for a very long time. He has ceased to care for his mane of hair or his god-like physique with the love that he once did. Even during Thor’s depressive state, when he calls for Mjolnir, the hammer flies to him. He is still worthy despite his profound struggle with loss, depression and loneliness. Our clients too have experienced loss and felt despair; lacking in important others to validate them. If clients do not have significant others to help remind them of their worth, their own Mjolnir can serve as a tangible reminder of their value. If clients can place themselves in the narrative of Thor, a hero who has met with some setbacks much like they have themselves, they can use the power of therapeutic fanfiction to find the Mjolnir within themselves. Embodying Thor also allows clients to practice self-compassion. Thor blames himself for what transpired with the destroyer, Thanos, but is this truly the god of thunder’s fault? Or is it the fault of the destroyer, Thanos himself, for creating the situation, when Thor was simply doing the best that he could to manage it? If we can find compassion for Thor, can we not also find compassion for ourselves? A good place to start with a client who is struggling to find their own self-worth is to begin with a character like Thor—one who has inherent power, though it may not be readily apparent. Luke Skywalker wielding the force that is within him, not in his lightsaber, is another great example, as well as imagery of wands for witches, or Wonder Woman’s bracelets. Encourage clients to engage in imaginative world-building with you, their psychotherapist, as a helpful guide. You can spend 1-2 sessions world-building in this way—the key is to encourage your client to find a character within modern mythology that speaks to them. This world-building includes setting the metaphorical scene that the client will inhabit and placing them within that therapeutic context. Once the client has settled on a personal fandom, you can help them begin to cast themselves as this character and to explore the challenges of their daily life in which they need a Mjolnir, a light saber, a wand, or whatever tool the character wields. From there, client and therapist will use the power of therapeutic fanfiction to help the client first foster an increased sense of strength with their own Mjolnir. Once they approach mastery, the clinician will prompt the client to explore the deeper truth: with or without their Mjolnir, they are their own hero. Such was the case for Chris (an amalgam case), a 33-year-old white bisexual cisgender man with whom we have been working for three months around family of origin concerns, specifically a lack of attachment to primary caregivers. Recently Chris’s feelings around lack of self-worth have come to the fore. During one such session, we remarked “if only there was some way that you could remember that you are inherently worthy.” We paused and held the therapeutic space, allowing the word “worthy” to catch our own attention. The metaphor took shape. “Chris, are you a fan of Marvel?” Having worked with us for some time, Chris knew that this conversation was moving in the direction of therapeutic fanfiction and was open to seeing if this would be a fandom fit for him. “Oh yeah! Thor’s cool. I loved his arc in Endgame” “Do you remember the scene where Thor talks to his mother and she says a bunch of wonderful things and a couple of shamey ones?” Chris nods. “He then calls for Mjolnir and the hammer flies right to him! Mjolnir still saw his worth! And of course, Thor had the power inside of himself all along. It was really just validation; a way to remember. We wish that you had a Mjolnir to remind you of your own worth.” Chris was able to take the lead as the author of his own therapeutic fanfiction, talking with us in detail about situations in which his own Mjolnir could be both helpful and healing. Two weeks later, Chris came into session with his own Mjolnir and a story of how his personal totem helped him navigate a challenging situation with a friend. Helping clients find their own Mjolnir is a powerful first step on their journey to embrace the hero within.

Trauma and the Reproductive Story

It’s morning. The alarm goes off, the coffee pot goes on, you decide what to wear, and ready yourself for the day. Consciously, but most likely out of your conscious awareness, you expect today will be similar to yesterday, and tomorrow will be like today. The day’s events may differ, but most likely the routine will be pretty much the same. There is comfort in that.

But suddenly something changes. When a traumatic event occurs, your world is no longer the same, no longer the safe place you could count on. It can feel as if the rug has been pulled out, everything is flying in the air and has yet to settle into place again. And as I will discuss, one’s internal world, one’s sense of self, also can feel dramatically off kilter.

Trauma and the Reproductive Story

Trauma, as defined for the diagnosis of PTSD in the DSM-5, is “exposure to actual or threatened death, serious injury or sexual violence¹. We often think of it as a one-time horrific event—a car accident, an earthquake, a shooting. But reproductive trauma, specifically infertility and/or pregnancy loss, is cumulative in nature. For most patients, by the time they set up an appointment with a fertility doctor or with a mental health professional, they have already gone through a year of “trying” to conceive, and multiple losses. As one patient put it, every menstrual cycle felt like a “mini-death.” And indeed, the losses that patients experience—of their hoped-for baby, their own adult development as a parent, their hopes and dreams for the future, of what we refer to as their “reproductive story”—significantly affect their psychological well-being².

Another way to define trauma, and one that fits with reproductive patients, is to think about infertility as an event that causes the disintegration, not just of a would-be pregnancy, but of one’s entire inner world. It affects every aspect of one’s life: feelings about the self, questions about one’s purpose, concerns about relationships—with one’s partner, friends, family, the world—and worries about the future—how does and will one fit in, what is one’s legacy, what is the meaning of one’s life? These are clearly not minor concerns. Trauma, in general, can be thought of as an event that overwhelmingly shatters core beliefs and assumptions³. For reproductive patients, the narrative that they once held, often as an unconscious guideline for the creation of their family, is no longer tenable as originally imagined. The core assumptions they held about having a family are demolished.

As a clinician who specializes in reproductive issues, I have heard a wide range of stories from women over the years, some of whom proclaim, “I always knew I wanted to be a mom. Even as a little girl that was what I wanted to be. I even decided to become a teacher so I would have the same schedule as my kids;” some that are more vague, “I just thought I would have kids someday;” to some that were more ambivalent, “I didn’t think I wanted kids and then one day it hit me. I hope it’s not too late.” These stories often begin in childhood, as we ourselves are parented. The stories evolve over time and the subtle changes that are made to the narrative become subtly yet implicitly assimilated. It is when the story abruptly goes off course, when a woman can’t have children how and when she wants to, that the traumatic loss occurs.

As I have listened to my patients’ reproductive stories, I have taken note of their core assumptions about pregnancy. The more I, as a therapist, can understand what it means to them—how it enables them to fit into their cultural milieu, how it can make them feel they are on equal standing as an adult—the more I have been able to appreciate and begin to understand the depth of their losses. “Acknowledging their own internal narrative, I have witnessed how patients can begin to heal by attempting to “rewrite” their reproductive story”; they may not know exactly how the story will end at this point, but navigating and choosing how they move forward—especially given all the options that current reproductive medicine offers—gives them back a sense of control.

Allison and Core Belief Disruptions

Allison, 38-years-old, had experienced a recently failed IVF cycle. With only one other frozen embryo, she was planning to try another transfer, but was not sure what would happen if that one was unsuccessful as well. Financially maxed out, she and her husband were faced with some very challenging decisions. Should they try another retrieval using her eggs? Should they consider using an egg donor or embryo donation? Should they adopt?

Today, though, she came into session in tears and in a rage. As she grabbed for the tissues and started piling them up on the coffee table between us, I realized that before I even knew what was causing her such pain, “I was feeling helpless and overwhelmed by her emotional state”. I recognized that this was most likely how she was feeling as well. We sat silently for a few moments while she dried her eyes, and then she blurted out that one of her best friends just announced that she was pregnant—and did so via Facebook for the world to see. “She didn’t even have the decency to let me know privately. She knows what I have been going through. It would have been hard enough to find out she was pregnant, but to find out like this? And all the time I opened to her about my struggles, I thought she cared! I feel so betrayed. I don’t even know how long she has been trying for.”

As I comforted Allison by affirming her feelings about her friend, I began a mental list of all the assumptions she had held, and how many had been shattered by her fertility struggles. First and foremost, and a core belief nearly all people have before they start to try to conceive is, “everyone can get pregnant; it’s easy.” Many people assume that all they have to do is stop using birth control and voila! Indeed, it is so drummed into young men and women to “be careful” that it seems as if getting pregnant happens effortlessly. So often women with no fertility issues, and no sense of how their joking comes across, declare “all he has to do is look at me and I get pregnant!” Clearly this is not funny to people in the midst of a fertility work-up or a miscarriage.

Allison assumed that her friend had gotten pregnant on the first try. Whether this was true or not did not matter; to Allison it was simply unfair. One of her core beliefs, that “life is fair,” and that “the world is a just, secure, and reasonable place,” was disrupted by her friend’s pregnancy. Additionally, the belief that “my friends understand me and are supportive of me; I can trust them” was crushed. The challenge for Allison was to make sense out of this threat to her fundamental beliefs. Not only had she not been able to easily become pregnant, but a trusted friend had, and in the process, betrayed their alliance. Could it be mended? Could the earth right itself again and the pieces fall back into place? As a therapist who has observed the great strength and growth that reproductive patients exhibit over time, I knew it could. But right now, as the tissues continued to pile up in our session, things were not logical, the world was not fair, and I needed to listen to more of Allison’s shaken world. While I wanted to be present to the current dissolution of her reproductive story, I also wanted to encourage her to think about her strengths and resources.

Allison went on to talk about her last IVF cycle. “I don’t understand why it didn’t work. We chose the healthiest looking embryo—I didn’t care if it was a boy or a girl. In fact, I told them to just pick the best one and not tell us the gender. We had all the embryos tested. These were the two that came back normal, so it should have worked. Now we’re down to one.”

Allison and her husband had opted for an additional procedure after the embryos began developing called pre-implantation genetic screening or PGS. The test entails removing a cell from the embryo prior to transferring it to the uterus and checking to see if the chromosomes are normal. There is some controversy in the literature about this procedure, as it does not guarantee the embryos will develop normally. It certainly can weed out embryos that won’t develop, but there are some conditions in which the embryos can self-correct as they develop in utero, even with an abnormal result. The test is often very useful if the woman is of advanced maternal age (considered to be 38 and older) or if there is a known health risk.

“And I did everything!” Allison continued. “I went to acupuncture; I stopped eating gluten and loaded up on pineapple. And I was so good about resting for 48 hours after the transfer. I basically only got up to pee!”

I validated that Allison did do everything she could that was within her control. She did do everything right. Only, with pregnancy, doing everything right is still not a guarantee. This brings us to another core assumption, what I call the Santa Claus theory, and a significant part of people’s reproductive story: “If I am good, I will be rewarded for it (Santa will bring toys)” or, stated slightly differently, “if I work hard at something, I will succeed.” In our core belief system, the opposite of these assumptions is also true. So, as it goes, if I am not rewarded, I must be bad, or if I didn’t succeed, I must not be working hard enough. When people mention this in their reproductive stories, they often reference other people who they feel didn’t do everything right. I have heard numerous versions of how unfair it is when someone had kids and couldn’t afford them, or drank, or had them too young, or wound up getting divorced. I can recall one patient talking about her older sister who got pregnant as a teenager, had the baby, and then wound up living back at home as a single mom. My patient was adamant that she would never do it that way. She and her husband got married first, waited until they had finished college and had a steady income, waited until they could afford a house. In their minds they were doing it the right way, and “when they were diagnosed with age-related fertility issues (commonly known as old eggs), they were naturally devastated”. The assumption, “what did I do wrong to deserve this,” is one that runs deep.

The facts are that a woman between the ages of 20-25 has about an 85% chance of getting pregnant; by 30 years of age, the rate drops to approximately 60%; by 40, it drops to about 35%, and when a woman is 45, there is only a 5% chance that she will naturally conceive. People are delaying having children for many reasons, such as pursuing higher education, the ensuing student loans and financial debt, needing to move back in with parents because of debt, not finding the “right” person and many more. Many people also assume that reproductive medicine will be available to them, and are astounded by the cost as well as the rates of success. For women under 35 going through IVF, there is about a 40% chance of pregnancy; for those over 40, it drops to about 11.5%. So, although waiting until one feels established and able to take care of a child is smart, it also can come with risks if one waits too long. At 38-years-old, Allison’s ability to produce healthy eggs was definitely in decline.

When All Else Fails, Blame Yourself

Because reproductive trauma disrupts one’s fundamental beliefs about how the world is and how it should be, the search for reasons becomes paramount. This is especially true for individuals or couples who have “unexplained infertility” or a pregnancy loss for unknown reasons. Generally speaking, about 20% of infertility cases are unexplained, while the rest can be equally divided into female factors, male factors, or a combination of problems in both partners. In my clinical experience, the bulk of the feelings of responsibility fall on the woman when a pregnancy fails. This is likely due to the fact that she is the one carrying the baby and feels in charge of its care. Whether it’s an early miscarriage, an ectopic pregnancy, a stillbirth, or an unsuccessful IVF cycle, women not only feel like it’s their fault, but also want answers. Unfortunately, there are times when there are no answers.

“Allison’s failed IVF cycle was unexplained”. The embryo had tested “normal” and according to her embryologist, it had thawed well and was “hatching” when the transfer took place. Her uterine lining was in great shape. All systems were go. In a follow-up meeting with her fertility doctor, she was told that these things just sometimes happen, and that it was not her fault.

“How could it not be my fault? It was my body, after all! I wonder if there are things wrong with me that they just don’t know about. Or…if I’m just not supposed to have children.” She was crying again and pulling out more tissues.

In a desperate search for reasons, Allison was blaming herself. The assumption was that she had done something wrong. My impulse was to reassure her that she did not cause this loss, but I wanted to hear her reasoning. So, I asked why she thought she was not supposed to have children. “I know I never brought this up in here,” she began. “But when I was in college…well…” she hesitated, “…I had an abortion. I don’t know how you feel about that. That’s why I never brought it up. I know it was the right thing at the time. At least it was the right thing for me. He was not the right guy, or the right time. I mean, I was in my first year of college. I was just, well, experimenting. Can you imagine? It would have if completely changed my life. But now when I think about it I wonder if that was my only chance, that somehow I am being punished. That because of what happened then, I shouldn’t have children now, when I am really ready to be a mom.”

At this moment, Allison revealed another of her core assumptions: you get what you deserve. It is not uncommon for fertility patients to blame their current reproductive issues on what they perceive as past indiscretions. Whether it’s about partying too much in high school, or promiscuity, or as in this case, a previous abortion, their self-blame is not always rational, and almost never accurate. Searching for reasons, it felt more reassuring for Allison to blame herself for her current loss, than to believe it to be some random event. As paradoxical as it may seem, self-recrimination may actually bring some relief to the internal chaos of a shattered schema.

So many times, when couples are struggling with conception, they are given well-intentioned, but inaccurate advice to “just relax” or “my sister-in-law went on vacation and came back pregnant; maybe that’s what you need to do.” For fertility patients, this popular notion translates into: “you’re not doing it right.” Whether it’s about not being relaxed enough (and who is when they’re giving themselves shots!) or for having negative thoughts (i.e., “I don’t think this is going to work”), women may absorb this into their self-narrative. If only one could control conception through one’s thoughts! There would then be no need for birth control! And throughout history, women have conceived under extremely harsh conditions: during war, famine, following rape. These are clearly not times when women are relaxed. It can be helpful for the clinician to remind patients that conception is not a skill, but a biological process that has nothing to do with thinking.

“Self-blame that accompanies reproductive losses can be destructive and promote a downward spiral of negativity”. Depending on the strength of the blame and feelings of punishment, these adverse attributes can become incorporated into the very core of one’s being, leading to negative self-worth, an all-encompassing feeling of meaningless, and depression. Although important for patients to give voice to their deepest feelings of guilt and shame—doing so can actually provide relief—it is equally important that they are able to regain control and process their self-deprecation in a constructive way.

Grief-work, Coping, and the Reproductive Story

With gentleness, I addressed Allison: “You’ve really got a lot going on right now. Not only are you grieving the loss of this pregnancy, you are trying to make sense of your friend, and you are thinking back to decisions you made in college and wondering if you deserve what’s happening now. No wonder you’re feeling awful.” The message here was clearly supportive, but it was also meant to remind Allison that a failed IVF cycle is something to be grieved, compounded by the questions she has about trusting her friend and her own past decisions. Sadly, losses involving failed cycles and even early miscarriages are commonly treated as non-events by society at large, and sometimes even by medical staff. Because of how medically frequent these losses occur, they can become easy to dismiss—but clearly not for the particular woman it’s affecting.

Feeling disenfranchised in her grief, Allison needed to be able to label it as such and to understand that grief of a reproductive loss is not simple. “If you had a favorite uncle who passed away,” I continued, “you would have a store of memories, lots of photos, and people around you would understand how sad you are. But lots of people don’t really get how significant a failed IVF is. You have put so much effort into this—physically, financially, emotionally—it’s got to feel awful that you don’t have anything to show for it. And you’re not only sad, you’re angry. It’s not fair that this is happening when other people like your friend can get pregnant so easily. It’s also not fair that you got pregnant at a time that wasn’t right for you and that now, when it is the right time, you are struggling.”

I could feel the room sigh a breath of relief. Allison’s shoulders dropped and she nodded. She felt heard and understood. But the next step was to have her consider how to cope with these changes in her narrative. She needed to be able to compartmentalize her grief and have it coexist and intermingle with her strengths and resources.

Here’s where the concept of the reproductive story can help. Our patients come to us in crisis. They are in the middle of their reproductive story and don’t know how it is going to end. They can look to the past, understand how the story began, recognize their assumptions, and see how their hopes and dreams got thrown off course. They are certainly aware of the enormous pain they are in at present. And the ambiguity of the future—will they become parents, how will they get there, what happens if they can’t become parents—is causing significant stress and emotional pain. What they can’t see is how the experience of reproductive trauma can actually enhance their lives in the future, and produce a new and revised life story.

The Importance of Telling the Story

One thing we know that helps people grow beyond their traumatic experience is grief work. This entails feeling the range of emotions that naturally occur and being able to tell their story—to select people. Sharing their story is the essence of narrative therapy. The process reduces isolation, increases the sense of connection with others and creates a feeling of being understood. Additionally, telling the story without feeling judged allows patients to unburden that which they feel most ashamed about. Whether this happens in therapy (as with Allison) or outside of therapy is less important than the issues of trust and safety. Allison’s loss of trust in her friend compounded her already fragile self-esteem.

It has been suggested in research on trauma that there are two systems of storytelling?. One is for public consumption; the other is the story that we tell ourselves. That story, the one deep inside of us, is the one that produces haunting, intrusive rumination, and with it self-loathing and self-doubt. In therapy, we try to access that deep story. In order to heal, that story needs to be befriended and looked at in a different light. Allison’s previous loss through abortion filled her with immense shame. Had she not been struggling with infertility, however, that part of her history might never have resurfaced. But the failed IVF coupled with the repeated attempts to get pregnant the old-fashioned way overwhelmed her. The fact that she could open up about it in therapy and have it be received without judgment was an enormous step for her. Instead of continuing to be self-punitive, Allison was on the road to replace her harsh and self-punishing inner narrative with a more tender, kinder version. This is a process that takes time, as all grief does, as the gradual acceptance of a new story emerges.

I had three goals for Allison at this point. Although laid out here in numerical order, these therapeutic goals are not linear; rather they co-exist as part of the ongoing process that occurs as one assimilates the trauma into a new narrative:

1. Manage her emotions and reduce her negative self-talk. I encouraged her to express her feelings without the harsh self-critic that was so deep-rooted. Labeling what she was experiencing as grief helped to validate that her loss was real. I also encouraged her to reach out to others for support—carefully. I suggested some local peer-led support groups to contact so that she could find other people who would really have empathy for her story of trauma and loss.
2. Work on ways to craft new narratives, new schemas. Allison found it helpful to think of her reproductive story as evolving. She thought about her remaining embryo; what if it didn’t work? While some people take comfort in focusing on the present and not delving into the “what-ifs,” Allison needed to have a plan ready in the wings if her next attempt didn’t succeed. Although she had yet to make a firm decision about anything, giving space to contemplate the future was allowing her to think about a new narrative.
3. Recognize that her core assumptions about pregnancy, her relationships, and feelings about herself were changing. Trauma can be thought of as a turning point. There was the time before, and the time after. Beliefs about oneself and how the world works can significantly change. And, as will be discussed, post-traumatic growth following reproductive losses can be quite life-altering in a positive way.

Out of Loss There is Gain

There have been numerous studies focused on posttraumatic growth (PTG) and the positive gains that can arise from challenging life crises?. Whether it’s recovering from a life-threatening disease, surviving a car crash, or witnessing a mass shooting, people can grow, change, and appreciate life in profoundly different ways.

As we have observed with Allison, trauma challenges fundamental assumptions—about oneself, one’s relationships, and the fairness of the world. The disruption to one’s narrative or schema commonly results in negative responses such as intense anxiety, depression, anger, intrusive thoughts, and/or feelings of numbness. Physical reactions are also common: headaches, gastro-intestinal upsets, fatigue, or a general sense of not feeling well. While the consequences of trauma result in psychological and physical distress, personal growth can occur in its aftermath as well. There is a cognitive restructuring that occurs in order to rebuild a sense of the future, and focus on what it takes to cope and find meaning. It’s important to note that the ability to grow does not signal an end to the trauma, the pain, or the distress, but they live alongside each other to create a new worldview.

A greater appreciation for life in general is a common characteristic of growth after trauma. There is often a newfound sense of gratitude for the everyday, a not-taking-things-for-granted attitude. For people dealing with reproductive trauma, research has shown that when they do become parents—however they get there—they tend to have a better relationship with their children, with greater emotional involvement?. The speculation is that the parent-child relationship may be strengthened because of the great lengths it took to become a parent, and the appreciation for their family becomes heightened.

From clinical experience, I have seen infertility and pregnancy loss patients grow in extraordinary ways, whether they are able to eventually have children or not. So many who have been down this road want to “give back” as a result of their experience. One couple made memory boxes for other parents and delivered them to the hospital where their daughter was born still. Another woman took to Facebook to educate the community as to what to say, and what not to say, when someone is struggling with fertility issues. Others have taken the opportunity to reevaluate their careers; I have worked with many women in healthcare, including mental health professionals, who decide to change focus and specialize in working with reproductive patients. One nurse opted to return to work in obstetrics so she could be there at the front lines and provide care to those in need.

“As people balance feelings of loss with a sense of growth, the strength that emerges is distinct”. Knowing that bad things happen, that we are all vulnerable, and that—most importantly—we can get through it, increases one’s resiliency. A new core belief can develop: “I am a person who is tough, hardy, and can handle just about anything!”

The Reproductive Story Ends

Our reproductive stories have a beginning, middle and end. As discussed earlier, patients enter therapy in the middle of their story at a heightened state of loss and pain. Using the story as a therapeutic tool addresses the inner beliefs and core assumptions of pregnancy and how it was supposed to be. Whatever the trauma or loss that has brought them in to our office, this experience is clearly not how their reproductive story was supposed to unfold.

One of the pluses of using the reproductive story in treating patients is that they immediately get it. Although there is a great deal of psychological theory behind it, it’s instantly recognized and understood without any psychological jargon. Knowing that they are in the middle of their reproductive story, gives them a sense of a timeline. Where they had felt a loss of control, they can utilize the idea of their story to edit, rewrite, and come up with new possibilities. They can try on different endings: if I use an egg donor, how will I feel? Can I emotionally and physically handle another miscarriage? If we decide to stop trying, how will our lives have meaning?

The reproductive story allows patients to understand the personal meaning of pregnancy and family, and the depth of what is lost when the story and their core beliefs go awry. I have the opportunity to explore these narratives, and the trauma they have experienced opens doors to explore new possibilities in creating a family, and in the broader context of their lives. Although their reproductive trauma has changed them forever, they also can embrace the ways in which they have grown through the process.

Postscript

As for my work with Allison, over the course of the next several months she continued to progress in a constructive way, between grief and growth. She was preparing herself for her next IVF transfer with the one remaining embryo. In looking at options beyond that, both she and her husband agreed to “wait and see” and keep the option of using an egg donor on the table.

The day she walked into my office beaming I knew she was pregnant. Her blood test results came back with a really high beta and had doubled, meaning that the embryo was developing as it should. We celebrated, cautiously, as we knew that there are never guarantees with pregnancy. She was trying to enjoy the here and now, even though it was filled with anxiety about all the things that could possibly go wrong. I normalized this for her; everyone who has had a reproductive trauma is anxious about a subsequent pregnancy, another loss. Gone are the days of that innocent assumption that getting pregnant and having a healthy child is natural and easy. As I welcomed her into the next chapter of her reproductive story—pregnancy—I reminded her that whatever happened, we would get through it together.

References
(1) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013.

(2) Jaffe, J. & Diamond, M.O. (2011). Reproductive trauma: Psychotherapy with infertility and pregnancy loss clients. Washington, DC: American Psychological Association.

(3) Cann, A., Calhoun, L.G., Tedeschi, R.G., Kilmer, R.P., Gil-Rivas, V., Vishnevski, T., & Danhauer, S.C. (2010) The Core Beliefs Inventory: a brief measure of disruption in the assumptive world. Anxiety, Stress & Coping, 23:1, 19-34, DOI: 10.1080/10615800802573013.

(4) Van der Kolk, B. (2018). Trauma conference: The body keeps score. www.pesi.com.

(5) Tedeschi, RG & Calhoun, LG (2004) TARGET ARTICLE: “Posttraumatic Growth: Conceptual Foundations and Empirical Evidence”, Psychological Inquiry, 15:1, 1-18, DOI:10.1207/s15327965pli1501_01

(6) Golombok, S., Lycett, E., MacCallum, F., Jadva, V., Murray, C., et al. (2004). Parenting infants conceived by gamete donation. Journal of Family Psychology, 18, 443-452. DOI: 10.1037/0893-3200.18.3.443.

“I Want You to Be There.”: Accompanying a Client Through a Death

“Hey Kevin? My mom has had a stroke and is in the hospital. It’s really bad this time.” My client’s voice quivered, and I could hear fear rippling through it. After asking a series of preliminary questions, I closed my computer and headed to the car to drive to the hospital. It had been, until that moment, a free afternoon of writing and grading assignments. I pushed aside the nagging voice listing all the things that would not get done and focused instead on my client and his mother. He was about five years old when I first met him and his mother nearly seventeen years prior. A single mother, her son was attending an afterschool program where I had been counseling for about a year. He had many neurodevelopmental challenges, along with ADHD, anger and emotional outbursts that resulted in physical altercations with teachers and peers. I worked with him through elementary, middle and high school, and eventually helped him through the transition from high school into adulthood. Each year of development brought new challenges, but with those came developmental achievements so that by high school, he no longer experienced meltdowns and functioned very much like a neurotypical adolescent. If ever there was a picture of the analogy of “mama bear,” it was my client’s mother. She had lived a hard life, complete with childhood attachment trauma and a string of relationships with adults that had neglected and abused her. She had finally found love in my client’s father and had managed to create a safe and loving home for the three of them. They did not have much in terms of money or possessions, but she was committed to doing whatever was necessary to get her son the help he needed. I had numerous parenting sessions with her to help her understand her son’s challenges and how she could him. Over the years, due to a lack of available counseling as a result of low income, I ended up doing a lot of individual counseling with her to overcome previous traumatic events that had plagued her for many years. She had also experienced health problems for many years which was a constant source of worry for my client. He, like many young people on the autism spectrum, found a special sense of safety with his mother. She was a source of strength for him, and while they had their battles during his teen years, she was the most important person in his life. As I drove to the hospital, my mind raced with thoughts of worry over how he would cope if he lost her. And what about his father who was now on full disability? How would my client navigate it all? Upon arriving at the hospital, we found out the news was not good. My client’s mother was not breathing on her own and there was little brain activity. For the next several days, there was no change and finally the doctors met with my client and other family members to tell them that there was nothing that could be one. The process of shutting off life support would be necessary. I remember feeling a number of conflicted feelings. I truly cared for this woman and admired her strength and resolve in the face of many life challenges. A survivor of childhood neglect and abuse, she had a special place in my heart. I felt the sadness and anger of immediate grief, and an overwhelming sense of helplessness seeing her lying in the hospital bed hooked up to tubes and wires. But my client needed me. Right now. He was scared and worried, having immense responsibilities and decisions thrust upon him in just a matter of hours. I found myself having to shove aside the grieving and shift my focus to him. Finally, after much deliberation, my client chose a date and time for the removal of life support. He called me to let me know. “I want you to be there,” he said; “I want you to be with me when it happens.” I assured him that I would be. The final hours were excruciating at times, yet it brought a sense of honor to be a witness and to help my client say goodbye to the person he loved more than anything in the world. I stood by my client and his family members, laughing at funny stories, and offering words of comfort and encouragement. As his mother took her final breath, I held him and felt the heaving tension of unadulterated grief in the muscles of his back and shoulders, and the hot tears flying from his eyes. I prayed silently and wept too, for I realized that I had lost a dear client who had trusted me with her most valuable possession. I stayed with my client through the evening as he navigated the details of the handling of the remains and made preliminary funeral plans. The funeral soon followed, and he delivered one of the most beautiful eulogies I have ever heard. It was an amazing experience to witness the poise and spiritual grounding of this young man who, at one time, struggled with social situations and expressing himself. The ethics codes divide our world as therapists into neat little boxes that work so well on paper. Yet, at times, thrown into the fray of life with all the ugly that comes with it, we find ourselves in roles that are uncomfortable and unfamiliar. My journey into the shadow of death with my client forced me to be a case manager, community liaison, spiritual guide, and at times, just a simple human being who joined another human being in the process of grief and loss. I have learned through this experience that our work is sacred, and that the therapeutic relationship can stretch far beyond the 50-minute safety zone of an office. At times, I did not want to be in this position, and I was uncomfortable. Now; however, I see that in the discomfort, both mine and my client’s, was growth for which I am now very thankful.

Monitoring Engagement in Clinical Supervision

This blog post is a rejoinder to my Psychotherapy.net article, Seven Mistakes in Clinical Supervision. Here, I start by expanding on mistake #4, which is the failure to monitor engagement levels in clinical supervision, and then provide a way to deal with this issue.
 

Once we are able to escape the trappings of the first three mistakes in clinical supervision by avoiding too much theory-talk, helping our supervisees in their circle of development, and teaching them to marry the use of outcomes and alliance data to guide the treatment process, we can turn to thinking about the actual engagement levels of our supervisees.
 

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Let’s ask ourselves, What is clinical supervision for?

Ultimately, the aim of supervision is to help therapists develop so that their clients may reap the benefits. Edward Watkins noted in his 2011 review of clinical supervision impact on client outcomes that “If we cannot show that supervision affects patient outcomes, then how can we continue to justify supervision? The benefits of supervision on supervisees alone are not necessarily sufficient.”

And in order to ensure optimal learning benefits for our supervisees, we need to keep our eye on the ball regarding engagement level in supervision. As I previously mentioned, eliciting feedback from clients sounds simple in theory, but is not an easy thing to do in practice. In supervision, paradoxically, it can be even harder to give and receive feedback, given that there might be overlapping roles or a collegial relationship outside of the supervision context. Given this, I would argue that all the more, some kind of formal and systematic procedure for monitoring the engagement levels—whether the supervisory work is “on-track” or “off-track”—is necessary.

Here’s How

Instead of leaving it to some type of bi-annual or annual review—which is often too late—I propose that supervisors formally elicit feedback at the end of every consult. This allows real-time calibration so that the learner’s feedback can be fed-forward into the subsequent supervision sessions.

Now, I don’t know about your part of the world, but here in Australia, when we ask, “How has it been for you?” we typically get the response, “All good!” The aim here is to get nuanced feedback that can help you adjust and refine the process of supervision for that particular supervisee. This is why, not unlike the process of asking clients for feedback, I recommend that supervisors learn to take a pitstop near the end of a consult and use some form of engagement tool. This provides some distance and reflection for the supervisee to think it through.

An example of a supervision engagement inventory, The Leeds Alliance in Supervision Scale (LASS)

How Do You Know the Effectiveness of Your Supervision?

Let’s circle back to the question that we asked ourselves earlier, what is clinical supervision for? If client improvement is the primary reason for clinical supervision, monitoring supervisee’s engagement alone is not sufficient. We also need to monitor the effects of supervision on client outcomes.

This can happen on two levels:

1. Single client outcome, based on the case discussion in supervision.

  

This is a simple but critical piece that supervisors tend to miss. It is important to close the loop after a supervisory session to see if your guidance helped to improve things for the particular client. Did the therapist try what you suggested? Did it have a measurable impact?

Take notes on what helped your supervisee, and what barriers were faced in their attempts to implement the ideas discussed in supervision.

2. Improvement in supervisee’s overall performance.

This is where alchemy happens. Beyond just a case-by-case discussion, you want to keep an eye on the therapist’s overall development as well. Supervisors can help a therapist discriminate what are case-specific issues to adapt to specific clients’ needs, and what are non-random issues that surface repeatedly for the therapist.

Supervisors have a real opportunity to influence when they learn to look at the data, spot patterns and help supervisees figure out what to work on that is influenceable and predictive of improving their outcomes.

References:

Wainwright, N. A. (2010). The development of the Leeds Alliance in Supervision Scale (LASS): A brief sessional measure of the supervisory alliance. Unpublished Doctoral Thesis. University of Leeds 

An Ending Without Closure

Being a psychologist is a deeply rewarding and meaningful profession, but it is often tinged with a sense of loss and a lingering concern over my clients. I regularly form complex, genuine and caring relationships with a multitude of clients, but these same people can and often do disappear from my life, leaving me to ponder how they are faring and whether they are safe and taking care of themselves.

One client in particular returns often to my mind; I wonder if he gained some semblance of control over his substance abuse issues, whether he was able to resist prostituting himself again for his food and rent, or whether he was alive at all.

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As with the other clients I work with who have severe borderline pathology, it was challenging to determine which serious, self-destructive behavior to begin treating first. Should I focus on his growing weed, alcohol and amphetamine addiction? What about the self-harm scars adorning his arms and legs? Or the chronic, suicidal thoughts that had consumed him since he was 10 years old?

The smiling young man in his twenties who greeted me in our first session was attentive but difficult to connect with. He responded to my initial queries with short, practiced responses. He had already visited with multiple therapists and been hospitalized several times beginning at a young age, and he understood his role to be compliant but not forthcoming. Those early sessions forced me to slow down my typically quick therapeutic pace and to meet him where he was. The focus was simply to get him to trust me, to validate his pain and to reframe his self-destructive behavior as an understandable, albeit unhealthy, coping mechanism. He had experienced a great deal of shame because of the various traumas he had endured, so it was soothing for him to feel understood and accepted.

One of the struggles in working with clients with borderline pathology is that there is often a different crisis that has transpired each week that threatens to become the focus of the session, crowding out the larger, more pervasive patterns and issues. I would try to spend some time each session dealing with whatever had happened over the previous week, while focusing on behaviors and thought patterns that were impediments to his health. An ongoing theme of our work was self-esteem, which I have found undergirds many mental health issues. If a therapist can effectively improve a client’s sense of self-worth, issues such as depression, anxiety and self-destructive behaviors often begin to improve.

In those early sessions, I had explained to my client that self-esteem can manifest as an internal, critical voice. We can recognize that voice because it tends to be vague and it disparages our basic personality and worth. For example, if my client ate too much at a meal, his inner critic might say, “You are disgusting and have no self-control.” Or if he was avoiding a task and laying on the couch instead, it would yell, “You are so lazy.” I encouraged him to pay attention and to try and notice this critical voice, and then to yell back at it. I told him that when he heard the critic in his heard criticizing him, he should say, “Shut up critic, go away!” I explained that through repetition, noticing and responding to the critic in this manner, he would diminish its intensity and frequency, and feel better about himself.

In addition to his self-esteem, we also worked diligently on his distress tolerance. This client, like many of those with borderline pathology, felt emotions intensely but didn’t know how to manage them. Since he couldn’t express them in a healthy way and didn’t feel justified doing so, he would internalize them, manifesting as self-harm or binge eating. We worked on identifying and accepting his emotions and then discussed ways to self-soothe. Due to his intense self-hatred, he often struggled to justify treating himself kindly or performing otherwise self-calming activities. In time though, he would occasionally come into a session and report back on something he had done to feel better, earning much praise and support from me.

Over the two years we worked together in weekly sessions, I developed a great deal of sympathy and concern for this client. Even at his young age, his life had already been exceedingly difficult, and I worried about his future. How would he find and maintain work? Would he meet a partner who would treat him well? Would he go back to school? With each new crisis, my apprehension for him grew. The worry morphed into sadness, as I grew to acknowledge to myself how little control or influence I had over my client’s life. I could provide compassion, strategies and tools, along with a safe environment, but I couldn’t save him, despite how much I wished to.

Eventually, my young client moved out of his home and found his own place, though he moved several more times within just a few months, as he struggled with landlords and finding money for rent. The frequency of our sessions diminished, and often several months would pass before an email would arrive, requesting a session.

It has now been a year since I have heard from him. In our last session together, my client was struggling to maintain his new job at a coffee shop. He was also feeling lonely and drinking too much. We discussed ways for him to feel better and explored options in his community where he could receive further support. Whether he followed through on these recommendations, I don’t know.

In my more hopeful moments, I reassure myself that my young client likely availed himself of at least some of the resources that we had discussed, given his desire to get healthy and improve his life. Surely, he wouldn’t have gone through with all of our therapy sessions if he didn’t harbor some optimism for a better future. Yet my worry and doubts remain to this day. All I can do is hope that wherever he is, he is safe and knows that I am here if he needs me.  

Daryl Chow on Reigniting Clinical Supervision

Supervision at the Crossroads

Lawrence Rubin: Good morning Daryl. Thanks for sharing your time with our readers. Your research and writing suggest that supervision as it has traditionally been practiced is in crisis. What is the crisis in the field of supervision that you are responding to in your work?
Daryl Chow: I think there are weaknesses in the status quo practice of supervision, and that is something that we should pay attention to and do something about. I think change needs to start to grow from what we know from the research, as well as from clinical practice in supervision. We need to do something that's closer towards two domains: helping therapists improve their performance and, while they're doing that, also emphasize what they are learning. So,
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time.
LR: What does it mean to help supervisees or therapists grow and develop, as opposed to just performing in supervision?
DC: In my online course, Reigniting Clinical Supervision, we make an important distinction from the get-go between coaching for performance and coaching for development and learning. Coaching for performance is one way of doing clinical supervision where we help each therapist improve in the stuck cases they are presenting in supervision. This is indeed important in helping them work through the clinical issues that may be blocking progress or preventing them from making inroads in their work with clients.

But I also think what supervisors need to support is an undulating process of helping clinicians with their stuck cases, while also trying to glean general principles with which they can help clinicians then create or identify patterns that are showing up through these stuck cases. It is a matter of looking closely at the cases in which the clinician is not making progress in order to help them in their own personal and professional development. This transcends a case-by-case supervisory discussion in order to focus on the therapist’s growth edge; those skills and characteristics that are generalizable, or what Wendell Berry talks about in terms of agriculture, which is solving for patterns. So, these two worlds of coaching, or supervising for performance and development, need to come together in the supervisory relationship.

If you look at the literature right now from Edward Watkins and others who have done great work in the study of clinical supervision, we have not made any progress. If the outcome of effective supervision is reflected or measured in client improvement, we have not actually moved the needle.

Tony Rousmaniere and his colleagues wrote a paper in which they concluded that
the variance in client outcome accounted for by clinical supervision is less than 1%
the variance in client outcome accounted for by clinical supervision is less than 1%, which means not much, right? That's concerning, because we put so much time, effort, and money into supervision. So, while I don't think I would use such a strong word as crisis to describe the field of clinical supervision, there is definitely a need for change. I really think that we are seeing things slowly changing on the ground level and there are people who are trying to change what we have come to accept as standard practice in supervision. 

Supervising for Development

LR: Okay, so what is the supervisor actually working on when she is focused on the supervisee's development?
DC: Well, the short answer is specific stuff such as the supervisee’s learning objectives. And their learning objectives are based on their performance. I will give you an example. If a clinician was to seek help from a clinical supervisor, that clinician (the supervisee) would first need to have a baseline of their performance, not just at the client-by-client level, but based on a composite of cases that they're seeing that provides them with enough reliable client outcome data.

And then, from those results, they would try to figure out where they're at before deciding where they need to go and what issues they need to address in supervision. I think that's a critical first step, because better results in in clinical supervision as measured by client outcome are obtained sequentially, not simultaneously. By that I mean we need to figure out where the supervisee is at. If their clinical outcomes are average, that really doesn’t say much about what they need to do in order to improve their performance. It is a matter of taking the second step, which is zooming in or focusing on those areas of clinical practice and therapeutic relationship where that clinician needs to improve. Simply focusing on the fact that the clinician is “average regarding their clinical outcomes,” doesn’t tell the supervisor where she needs to focus her lens regarding the supervisee’s skills and development.

So, as an example, if a clinician’s performance was average compared to international benchmarks, the supervisor would then focus in on those cases in which the clinician was stuck. They might listen to some recordings of the clinician’s work to discover that the clinician and the client did not develop therapeutic goal consensus. And it is often the case that
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions. You and I both know that the goalpost changes as we go, right?

Sometimes the goal is to figure out the goal, to figure out what is or should be the focus of the session. Then the therapist and supervisor work on that one specific area. And then—and this is the critical piece—if the clinician and client are indeed working on goal consensus, it's important for both the therapist and the client, as well as the therapist and the supervisor, to follow through with the work towards that goal and then determine if doing so actually had an impact on therapeutic outcome.  
LR: And just to define the outcomes variables you're talking about—are you talking about outcomes in the client progress, or in the supervisee’s behavior?
DC: I think you hit on an important note, because the feeling of benefit for the therapist does not mean actual benefit for the client that they work with. Remember, we're dealing with two steps removed from the office, so we need to make sure that the work we are doing with the supervisee translates into positive outcome for the client. It's almost like a paradox if you see two overlapping circles. Yes, it's about the supervisee’s performance, but if you focus purely on their performance, you're not going to go anywhere with the client. You're going to be riddled with anxiety. "Am I doing well? Am I doing badly?" And there's so much judgment involved.

We need to see the impact on our clients and see if our learning leads to impacting the people that we're working with. If the learning was focused on goal consensus, we want to see that it actually translates to an actual impact on the clients that you're working with on that level, on one client at a time. But we also want to see if that helps you to move up your effectiveness above your baseline. 
LR: It seems you're saying that, if a supervisor is good at his or her job and guiding the supervisee effectively in the deliberate practice of therapy, then the client will by definition improve.
DC: Wouldn't you expect that?
LR: I would, but isn't it possible that—and I'm not trying to be provocative—but that a supervisor may be very effective in guiding the supervisee or the clinician in deliberately practicing their craft, but the client doesn't improve? Does that mean that the supervision failed? Or might it just be that something was missed? In other words, can you have good supervision and still poor therapeutic outcomes? Or do poor outcomes in therapy mean that the supervision was not effective?
DC: That's a really good point that world-champion poker player, Annie Duke, talks about in her book, Thinking in Bets. She makes a very important distinction which I think we need to think about slowly and carefully. And the point that she was making is:
we tend to conflate outcomes with process
we tend to conflate outcomes with process.

She says that when we get a poor outcome, let's say in the game of poker, we think that our process is responsible for that outcome. She says we tend to conflate the two. If you take some time to think carefully about how you're making decisions, how you're building the process and making a good plan, then if the outcome is bad, don't make that conflation too quickly.

Because in the game of poker, just like in the game of life, there's a lot of random noise, a lot of things that are beyond your and my control. But if you understand with the help of a supervisor that you are working on something critical—in our case, goal consensus because we know the effect size for goal consensus is huge, then it becomes a matter of focusing more directly on building that particular skill in supervision, not other skills unrelated to goal consensus.

And if goal consensus is indeed important—even if one client doesn't work out well, you don't want to go and throw the baby out with the bathwater. You want to just go back and refine goal consensus building skills again. Close the loop. And this is one thing supervisors and therapists can do, is to make sure that, after a discussion, they close the loop.

It sounds so plain and simple, but I think it's really something that's lacking in supervision as well as clinical practice, that people don't really close the loop by figuring out ways to refine the important skills in supervision that actually impact client outcome. If you continue doing this with other clients, will this have an impact as well? 

Deliberate Practice

LR: Along these lines, you have an upcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, with Scott Miller and Mark Hubble. How can supervisors use deliberate practice to improve not only their supervisee's performance but their own performance as supervisors?
DC:
When we are working in supervision… we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client.
It's a brilliant question, and I know, Lawrence, we've talked about this. My belief at this point is I think that it is critical. We are really in the early days of this type of investigation, but I think it's an important area to work on, and here's why.

My belief is that knowledge is multilevel. When we are working in supervision, we are doing just that because we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client. And let me just use an analogy from the world of music. I'm always impressed by not just what the musician does in a music studio or how they work. I'm always interested in who else is in the room. And one of the things that comes up very often for me is the role of the producer. Sometimes it's the group of artists itself, and sometimes it's someone else.

And a couple of people that stick out to me are Brian Eno, who has worked with Talking Heads, Madonna, U2, and Rick Rubin who has worked with death-metal bands like Slayer. He's worked with many Hip Hop artists. He's also worked with the late Johnny Cash. There’s something about being in the presence of these types of producers that brings out the best in the musicians.

My question is twofold. One, what the hell are these producers doing that brings out the best in the musician? But I also am interested in how I can help others and myself be able to become more like a coach or mentor the likes of college basketball’s John Wooden. And the one thing that I think is becoming a little bit clearer as I go is that we really need a system of practice, a way to systematically organize ourselves around how we think about supervision. So, when I say system, it just means as simple as: how do we track outcomes?

My mentor and collaborator, Scott Miller, talks a lot about feedback-informed treatment. To me, measuring what we value is key, because measurement precedes professional development, so it is critical to help people, supervisees in this case, to systematically track their outcomes and to have a system of coaching already in place by the time they come into supervision.

And then we develop a taxonomy of deliberate practice activities so we know where they're at in the baseline, how to help them figure out a way to deconstruct the therapy hour and then pick up little things that they can work on. So, I guess my short answer, or rather my long answer is really, to figure out a system that can function as a platform from which we can begin to work on the more nuanced stuff in the role of supervisor. Am I making sense about this? 

A Portfolio of Mentors

LR: You are indeed, Daryl, and related to this notion of the producer and artist working in collaboration, you recommended that clinicians build a portfolio of mentors. Does that mean that, even though supervision is, as you call it, a signature pedagogy, that clinicians should build a production studio of sorts with other professionals? 
DC: As much as supervision is a signature pedagogy for our field, what's interesting for me of late is how people reaching out for consults or coaching often follows having given up on working with a supervisor for various reasons, unless they are in an agency setting where that is provided. But, yes, I think the idea of a portfolio of mentors is to say that
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you.

And what you want to do is to create a community of people that you can turn to, that you can talk with, and then maybe a certain person you turn to more routinely. For instance, I've known a supervisor for more than a decade, and I always return to her. But if there was something else that was missing, or I wanted to stretch out and pick another mind to think of it from a different perspective, I would reach out to other people, even people who are so-called experts, and send them an email. I would ask them, "What's the fee? Can I come talk with you?" And most people are friendly. 
LR: In a way, isn’t that what you are trying to provide through your online supervision training, Reigniting Clinical Supervision?
DC: My focus for Reigniting Clinical Supervision is to help clinical supervisors design better learning environments that sustain real development for therapists, so as to achieve better client outcomes. The choice of an online learning platform is not a mere substitute for live teaching. Instead, gleaning from the best of what we know of optimizing learning, adopting a “one idea at a time” drip-based method of delivery of content and maintaining learner engagement, helps the busy practitioner weave what they learn into practice, and return to renew and reconsolidate new knowledge as a result of being in the course with me and other clinicians/supervisors.

Here’s how I think about the difference between a live training and how Reigniting Clinical Supervision is designed: A real-time training/workshop is like a river. It is a constantly flowing torrent of ideas. If the learner steps out of the river for a few minutes, or needs some time to think, he is now behind. The learner may be able to ask questions but needs to constantly try and catch up and not fall behind. A chance for a revisit of the content after some time of reflection is not possible, with only the notes or slides that you've captured.
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time, and pace herself as she moves along; the water remains the same. This stillness allows for pausing, revisiting the material, reflecting, and connecting with past knowledge. Online learning at its best allows for the learner to ask questions, revisit the materials, and for the person to master a difficult segment before moving on.
LR: Within this community of mentors model, there are different factors that predict therapeutic outcome. They include goal consensus, alliance and repairing therapeutic ruptures. Can the same principles be applied to improve supervisor performance and development?
DC: Hopefully, that's paralleled or modeled within the supervisory work. I would encourage supervisors to also elicit feedback within the supervision. And most of us do that, but it is also important to do it in a way that's a little bit more about a ritual. This would mean using some quick check-ins that give the supervisee some space to think about it, and then to explore the nuances of the supervisor/supervisee relationship. It's much harder when you really know somebody well, like the supervisor knowing the supervisee, to give feedback.
LR: Have you experienced working with expert clinicians who are lousy supervisors?
DC: I'm thinking of the converse. So, let me look back in my mind. I don't mean this in any disrespectful way because I really respect this person's work. Jay Haley of the strategic school of family therapy talked about this and said that he was really good as a supervisor, but not as good as a therapist [laughs].
LR: I think of myself as being a better supervisor and teacher than therapist. In your language, perhaps that’s because I have not deliberately practiced therapy.
DC: Yes, right.
LR: I've performed therapy, but in the words of Scott Miller, I've not deliberately practiced it. So, it's interesting that just because someone may be a very competent clinician, it doesn't mean that they have the patience or skill to guide a fellow clinician as a supervisee, and vice versa.
DC: This harkens back to your question about the role of training supervisors in how they do deliberate practice, because, to me, there are overlaps, of course, but there are also distinct skills required in their roles as supervisors and therapists.
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction.

Cardinal Supervision Mistakes

LR: Talking about getting lost in the weeds, you wrote an article for us about seven mistakes in clinical supervision. If you were to pick the top two cardinal mistakes from that list of seven that supervisors make, which ones flash red to you, and what can supervisors to do about them? 
DC: This is tough because the language around mistakes is all negative. I think, for me, the one that I've seen in my own experience and through my own mistakes is that of too much theory talk.
I think we talk too much. On the ladder of abstraction, talk is quite high up there
I think we talk too much. On the ladder of abstraction, talk is quite high up there. Bear in mind, when we're in supervision and in the absence of the actual client, we spend all our time talking in abstractions, at the level of theories about the client rather than about the therapeutic relationship.

When we're doing that, we've got to bear that in mind, that we don't have that person there, and we're talking at the level of theoretical abstraction, so many steps removed from what is occurring between the supervisee and the client. It's very easy to speak of it from whatever orientation or whatever philosophy you hold, without joining the dots of what's going to ripple down into the actual therapeutic relationship where the real work is happening.

Another big mistake in supervision is that when the clinical work is stuck and the supervisee and client are not making progress, the supervisor may say something in an attempt at being supportive to the supervisee like, "Well, at least they keep coming back, right?" In this instance, the supervisor is doing little more than what I call, patting them on the back–encouraging the supervisee without giving her any clear direction out of the stuck situation.

I'm really conflicted about that statement that I hear very often. Is that good enough for you, that they still come back? Or what else? What else can we be thinking of? How do we escape this domain of just talking on their level and to be able to make some real impact?  
LR:
Another big mistake in supervision is…encouraging the supervisee without giving her any clear direction out of the stuck situation
I know that being able to effectively conceptualize a clinical case, to think about it from different theoretical perspectives, is important. But you're saying, Daryl, that sometimes we err on the side of overthinking the theory at the expense of guiding the supervisee in building the relationship with their client, and then we congratulate the therapist for minimal progress? Seems like damning by faint praise.
DC: Yes and no. I think all prudent supervisors know that therapeutic relationship really matters. And by therapeutic relationship, let's be clear, it's not just about the emotional bond, even though that is one critical part. But the other part is the focus, which is about the goals, the directionality, where it's going. The next is also about whether there is a cogent method for both the therapist and the client. Are we in agreement? Is there a fit in where we're going? All those things relate to the therapeutic alliance.

I think most people are focused about that. But as you will see in the upcoming blog that I am writing for Psychotherapy.net, I will be talking about the three types of supervisory knowledge. One type of knowledge is about the content knowledge, about the clinical case, about the psychopathology. Those things are necessary but not sufficient. The second type of knowledge is the process knowledge about how you engage with somebody who's, say, depressed? How do you engage with somebody who's anxious? That's a process or type of relating kind of knowledge. How do you have that kind of conversation? As David Whyte, the poet and philosopher, would say, "the conversational nature of reality." How do you engage in that? How do you come into being with another person into that field? But the third one is conditional knowledge, which is; if you're working with somebody who's depressed due to bereavement, it's going to be very different than when you're working with somebody who is depressed as well but due to, say, domestic violence. The context is very different, and you need to figure out a way of relating with them given the different situation. So, by considering all three of these in supervision; playing into the content knowledge, process knowledge and conditional knowledge, I think the supervisor can synergize them for the benefit of both the therapeutic work and the development of the supervisee. The supervisor and supervisee having this multi-level conversation will benefit both the client and the supervisee. 

The Humble Teacher

LR: What do you see as some of the important personal qualities of an effective supervisor or a clinician who might become an effective supervisor?
DC: For me, of course,
a good teacher is somebody who is willing to be a good student
a good teacher is somebody who is willing to be a good student. If I'm picking a supervisor for myself, I'm always looking for somebody who implicitly—and it's not something that people would say explicitly, is willing to be wrong, willing to seek the counterfactuals, and then to have by default a stance of humility not just because they're trying to act humbly or bragging about their humility.

This humble teacher will say, “Hmm. Oh, hang on a second. I've really never thought of that.” And they're rethinking. That, to me, is interesting. And it's not because they don't have a wealth of knowledge. It's because this is dis-confirming what they know. And that's so exciting. That's like fresh air, you know, when you're working with somebody that way.

Additionally, somebody who has mental models or mental representations and concepts in their head about different ways to think about clinical situations and suggestions for the supervisee. They know that when they're facing this kind of situation, they have what Gerd Gigerenzer calls fast and frugal heuristics. They have little maps of how they will approach stuff. You know, they've thought it through before. They have ideas in their memory bank that they will pull into their working memory.

And you know that because when they're just giving off-the-fly statements, you know that it's off the fly. But if you know that they've thought about it, you realize their mental networks are vast. They know that it's an “if-then” situation, and they're thinking about it and all kinds of communications. That excites me because that shows to you this person has done some thinking before meeting with you. 
LR: Is this what you refer to when you say that true experts think like novices, or beginning therapists, while true novices think they're experts? Is it related?
DC: I think so. [chuckles] I think so.
LR: I like that idea that the expert supervisor, who may or may not be an expert clinician, has these—what did you call them—fast and frugal heuristics? Was that the term that you used?
DC: That's right, and I mean that's the term from Gerd Gigerenzer, who studies cognitive science. He talks of the importance of having these sorts of heuristics. You know, the way we've been terming it is mental representation. Things that happen might not just be easily explained using therapeutic models but by different ways of thinking. Like, what do you do if you meet somebody who is angry or depressed in the session? These heuristics or maps are not like stock answers but are based on clear principles that flow from these mental representations. What do you do with somebody who doesn't have a goal? How do you work with them? They have a rough and ready guide.

At the Cutting Edge

LR: So, the supervisor should aspire to flexible thinking, drawing on different belief systems, different ways of looking at the human condition, different interpretations of the same clinical presentation? It sounds like the advanced supervisor is out at this cutting edge of creativity, untethered to any one way of thinking.
DC: Yes.

This domain of creativity is something I'm really interested in. I think one thing we need to remember about creativity is that it's about something novel and something useful coming together? Wouldn't it be great if supervisors were not restricted to thinking solely in terms of the field of psychotherapy in the course of doing their supervision, and could bring in greater creativity?

Just thinking about architecture, music, art—thinking about other aesthetic forms and how all of these can inform ways of thinking. Coming back again to the example about goal consensus, why do we need to only think about this within the domain of psychotherapy? Why don't we learn about how other fields and business organizations think about creating focus? 
LR: So, we should consider using a flexible system of metaphors that transcend psychology and psychotherapy. When we first contacted each other, I mentioned that there seemed to be almost a spiritual undertone to the way that you described your personal philosophy of living and helping. Am I seeing it correctly, that there's a certain spirituality or spiritual dimension to your work as a clinician and a supervisor, and perhaps we should embrace that as well?
DC: Well, I'm grateful that you picked that up. To me, the answer is yes. And I think that's personally a deep embedment in my life. I was raised a freethinker from my Singaporean days. You know, this means I'm free to think or whatever that means. But I converted to become a Catholic when I was 21. When everybody else was running out of the Church, I was going back in. So, to me, that was my start.

But I think, fundamentally beyond religion, what's really driving me on a first principle level is human dignity. And the way I think about this is that
if a person comes to seek help and opens up to another person, that's a sacred moment
if a person comes to seek help and opens up to another person, that's a sacred moment. We need to honor that. We need to figure out a way that we can help each other come alive, because it's not just about creating purpose and meaning, but it's really to help each other come alive. And the therapist needs to come alive. The therapist needs to be alive and kicking and playful and to be able to ignite that. And the therapist also needs help and guidance from a supervisor. And for the supervisor to do that, the supervisor also needs to come alive. 
LR: I remember Bill Moyer’s interview with Joseph Campbell at George Lucas’ Skywalker Ranch. He said to Joseph Campbell, “So, you're saying that people are searching for the meaning of life?” And Campbell said, “No. People are searching for the experience of being alive.” How does that find its way into the world of supervision, that tripartite relationship between supervisor, supervisee, and client? Where does that element of being alive get infused in that three-level process? And whose responsibility is it?
DC: Sounds like a family.
LR: Yeah, doesn't it?
DC: Yeah. I think everybody is going to come into play. I think it is the interaction. It's this ecology of a systemic perspective that's going to be important. How does it come alive? You know, I think we need some kind of platform for this to work, which we have talked about. But I think it critical is to keep this conversation going. Once we see that therapists are working hard to improve in what they are doing—once they figure out the baseline, once they figure out what to work on based on the baseline, then they develop a system to help them do their practice on an ongoing basis. And that they see the payoff of what they're doing.

It's like your child who's worked hard for the math test and starts seeing see the result. There's the real payoff. I mean the whole temperature of the room changes. Their focus becomes more intrinsic. And at that point, the role of the guidance is going to evolve as well. There's always going to be state of change. You’re right when you pointed out that quote from Joseph Campbell as well. That's something I'm very familiar with, and I think it's important that we continue to keep the conversation alive within clinical supervision as well as at the level of the therapist and client. 

Fanning the Flames

LR: So, just as we encourage clinicians to take care of themselves and to grow and to rest and to seek meaning and a reason for being alive, so too must supervisors continually replenish and rest and grow and seek internal expansion, because if they wither, then the supervisee withers and the client withers. Who are the roots, and who are the leaves in this tree? It's a quite interconnected system.
DC: [chuckles] It is. It's just like our world now, isn't it? I mean I'm suddenly reminded about this teenager from Sweden that's really been striking me about what she's doing. I don't know if you follow the news about Greta Thunberg and how she's doing this protest about climate change and rallying a million teens around the world to protest about how the adults in this world had better take this seriously. And she's been going on global forums just speaking about this.

And I heard one of her speeches which she starts by saying, “Our house is on fire. What would you do if your house was on fire?” And she expands on that. And I think that's so important, that somebody her age is speaking about this. 
LR: So, supervisees must find ways to, in your words, reignite supervision. I have one last question. You were born in Singapore, you live and practice in Australia, and you've traveled the world doing training in therapy and supervision. What have you noticed about teaching and supervising cross-culturally?
DC:
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people, trainings and our roles as therapists and supervisors. But, of course, each culture has its own subcultures that you're dealing with. But to me, really what's striking is how much similarity there is. We're all in the same boat.
LR: What do you mean, the same boat, Daryl?
DC: We're all struggling to get better. We all want to. I mean all therapists and all supervisors want to do a better job. And that propels us. That makes us stay hopeful. It makes us invest time, money and effort to go and do CPE [continuing professional development] activities. You know, we're all trying to get better. But what's implicitly underneath that wish to get better is worry. We do worry about, “Am I getting any better? Is what I'm doing really helping to translate?”

And people are asking this question as they are looking deep, long, and hard. And I think the onus is on us as a collective, as a field, to start to come together, to start to build this brick-by-brick, to help out from the therapist's level and the supervisor's level, and to help us build this house, build it up again, and to help us to get just that 1-2% better each step of the way. Because the payoff and the morale that comes with that is going to move us even further. 
LR: So, if everyone in that multilevel relationship strives to be a little bit better, then the whole system becomes better.
DC: That's right.
LR: If client outcome improves, then that goodwill is shared beyond the therapeutic space. If the supervisor is dedicated to practicing their craft, then they are in a better position to teach clinicians. And if clinicians practice deliberately, they are in a better position to help their client. And that is consistent across cultures.
DC: That's right. And, you know, I'm not the only one who is doing this, but I think I've started doing this whole thing about clinical supervision because I think we are a critical piece to the puzzle. And I think this one little story might help to illuminate this. You know, this gentleman, he knocks on his son's door, and he says, “Jamie, wake up, please. Wake up. You've got to get to school.”

Jamie then says, “I'm not going.” And the father says, “Why not?” He says, “Well, Dad, there are three reasons. First, school is so dull. And second, the kids tease me. And third, I hate school anyway.” And the father says, “Well, I'm going to give you three reasons why you must go to school. First, because it's your duty. And second, because you're 41 years old. And third, because you are the headmaster.”
LR: [laughs]
DC: I think we play that critical role. We do need to show up. And when we show up, we then need to think about what's our status quo and what's the one thing we need to start in order to refine our work to bring us alive again.
LR: To play that instrument a little better, to hit that tennis ball a little straighter, to run a little bit more efficiently. The supervisor must have a commitment to continued growth and development if the supervisee and the client are to improve.
DC: Yes, and I will say one last thing, if I may, Lawrence.
LR: Of course.
DC: If we use the musician analogy, I don't think it's to play the instrument a bit better.
LR: No?
DC: I think it's to play the instrument well enough but to be able to become better songwriters. I think that's a tougher job, because you can get technically better as a musician, but to write the next Hard Day's Night or Yesterday or Bohemian Rhapsody, I think that's a different skill. And I think we need to find a way to become better songwriters in our field.
LR: So, we can make better music together and because the audience is indeed listening.
DC: That's it.
LR: I think on that note, Daryl, I'm going to say goodbye, and on behalf of our readers, thank you so very much.
DC: Thank you.

Internal Emigration & Online Therapy

“I was born in the wrong place,” one of my online clients told me. She is someone with fidgety feet and a knotty relationship with her homeland. Growing up she had felt out of place in her native town, tucked in the middle of Pennsylvania. I keep hearing different versions of this harsh statement, from clients from various cultures and social backgrounds.

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The feeling of not fitting in, not belonging to their original environment, is shared by many emigrant writers. Edward Said’s account of this experience is probably the most quintessential: “There was always something wrong with how I was invented and meant to fit in with the world of my parents and four sisters. Whether this was because I constantly misread my part or because of some deep flaw in my being I could not tell for most of my early life. Sometimes I was intransigent and proud of it. At other times I seemed to myself to be neatly devoid of any character at all, timid, uncertain, without will. Yet the overriding sensation I had was of always being out of place¹.

Said’s experience of being deeply flawed, his constant uncertainty and confusion about his own worth, are all indicators of various degrees of feeling shame related at least in part to his sense of not fitting in.

Joe Burgo, a psychotherapist and the author of a recent book Shame, insists that: “Unreciprocated affection or interest will always stir emotions from the shame family. As part of our genetic inheritance, we want to connect with a loved one who will love us in return; when our longing is disappointed, when we fail to connect, we inevitably experience shame, however we name the feeling². The motherland, which does not love us back, is similar to a parent that fails to meet our expectations of love. Both unfortunate situations naturally result in feeling that something is deeply wrong with us.

One of the ways we can cope with such circumstances is by leaving our original place altogether. For some, the decision to emigrate, often a difficult one, is unconsciously driven by the need to avoid shame provoked by the discordance between who we are and who we are expected to be in order to fit in. In many cases, the choice to leave home is the best survival strategy. The most obvious examples are queer individuals from countries that pathologize and punish homosexuality: they flee their homes in order to be able to freely live their lives in the way that feels right to them.

But such physical escape is not always possible. Individuals who grow up feeling that they do not fit in countries that they cannot leave for various reasons (e.g., an iron curtain of any kind, family situation, physical handicap, economic dependence) feel trapped and disempowered in the face of such an unresolvable conflict. Not being able to escape the place that is rejecting them only reinforces the feeling of shame triggered by a constant experience being different and not fitting in, and of being excluded.

When emigrating outwards is impossible, the only way of fleeing such reality is inwards. My own Russian culture offers abundant examples of such a psychological strategy for subsisting in an unfriendly reality. Soviet history gave us not only the concept of internal immigration, as mentioned by Angus Roxburgh in a recent Guardian article on life in the 70’s, but also a rich cultural heritage, which thrived “underground” despite the intermittently tyrannical regime. Many artists—Shostakovich being probably the most striking example—lived a paradoxical experience of inner freedom in the middle of an oppressive outer reality.

Russian emigrant writers give us a powerful lesson of resilience in dealing with hostile but inescapable realities. Through their art, they created inner bubbles of freedom, and often had to evolve in parallel realities like Joseph Brodsky who, decades before emigrating, introduced the notion of an “indifferent homeland” in his early work inspired by the quintessential poet in exile, Ovid.

Emigrant writers such as Brodsky or Nabokov’s use of a foreign language for writing is emblematic and has deeper meaning: they claim a new freedom from constraints imposed by their culture. Committing to a chosen second language, despite the difficulties and losses that this choice implies, is a powerful affirmation of individual freedom. This second language, according to Kellman, becomes the tongue of the parallel inner world and a language of freedom.

The same is true for some of my clients living in the state of internal exile. They often reach out to a therapist who speaks English even though it is not their mother tongue. This choice certainly complicates their therapeutic journey, but also allows it some unexpected depth and richness.

When I meet with clients who evolved under an authoritarian regime (e.g., Saudi Arabia, Putin’s Russia, China), I recognize the strength of this coping strategy. Our sessions happen online through videoconferencing systems, as the clients are often unable to find a suitable support in their home countries. The regimes they live under have no love lost for therapy, which aims at empowering the individual; they usually opt for a kind of punitive psychiatry, which was so well developed in the Soviet Russia. Its aim was, in Brodsky’s words, “to slow you down, to stop you, so that you can do absolutely nothing…”

Evolving in self-created bubbles of parallel realities drives us even further away from those who share this harsh external reality with us. This further isolation can only deepen the shame that we already feel about being deeply flawed and not fitting-in. Those who are restricted to these self-created inner worlds often display some recurrent symptoms: depression, anxiety, low self-esteem, and constant self-doubt.

Online therapy can offer these inward emigrants a third space, located outside of their unfriendly environment, on the outskirts of their inner reality. In these two conflicting worlds, they are alone, but in the virtual space of therapy, they find a friendly person in front of them, open and curious to learn about their worlds. The online reality shared with their therapist eventually becomes a safe space to reflect on the painful discordance of their inner and outer worlds.

Communication media that online therapy actively uses for its own scope often play an important role in dealing with life in unfriendly inescapable surroundings. Many of my clients living in the state of internal emigration turn to social media on the internet to find like-minded peers and feel less alienated and less ashamed.

There is an intriguing parallel between the voices of the free radio that had offered an opening towards the other side of the curtain during the Soviet times, and the social media of today. The latter is more interactive by nature. During the Soviet times, one was only able to listen and feel connected by a stranger’s voice talking in one’s own language from the other side of the divisive wall, whilst modern technologies offer the possibility for a dialogue, often in English used as the lingua franca.

I have witnessed many situations in which such an outlet kept individuals sane: Saudi women who connect with each other in the ethereal space of freedom; a gay man from Siberia finding connection with those like him and acquiring some form of validation of his own experience; a queer young woman in Putin’s Russia working for a liberal news online platform and through her work connecting with those whose thinking she can share.

Online therapy with a transcultural therapist, who evolved on the other side of the wall, in a different and often freer reality, becomes an ultimate opening for individuals who experience their external realities as oppressive. In some lucky cases it can shake up the juxtaposition of the two incompatible realities the individual is locked in and offer something else—a less lonely space in which they can experiment with fitting in, belonging and imagining other, less lonely and shame-filled, and freer possibilities.

References

(1) Said, E.W. (1999). Out of place: A memoir. New York: Knopf.

(2) Burgo, J. (2018). Shame: Free Yourself, Find Joy, and Build True Self-Esteem New York: St Martins Pres.