I just finished writing a book for psychotherapists on helping teenagers and young adults with autism. This topic does not get much coverage in the clinical literature on autism, as treatment books focus most often on children. This blog post will share some major points from the book. Autism is a neurobehavioral condition impacting social comprehension. It is often described as impacting “social skills,” but that is much too limiting. Autism impacts how an individual perceives the social world and interacts with that social world. Individuals with autism literally have a different way of perceiving social relationships, and they use skills they find appropriate given those perceptions. Autism makes up “who the person is” and not just “what the person does.” Having Autism makes up a major part of the answer to the all-encompassing question teenagers and young adults ask: “Who am I?” Therapists can help older clients take on this challenging question by helping them answer more specific questions like: “What does being a person with Autism mean?” “How do I want to live my life as a person with Autism”? “How important is it to have friends and what sort of friends do I want to have?” “How much am I capable of doing on my own?” “How much independence can I hope for?” “Where do I agree and disagree with my parents and teachers in terms of what they expect from me?” “How much do I care (and why do I care) about how people respond to my Autism symptoms?” Applied Behavior Analysis (ABA), the primary treatment approach used for autism, emphasizes learning skills to replace behaviors that are causing problems. ABA still plays a major role in treatment for Autism for teenagers and young adults. Using the questions listed above is an effective way of determining what skills the teenager or young adult needs to learn. So, for example, once your client has worked with you on what sort of relationships he or she wants, you can use ABA approaches to help them learn skills needed for obtaining those types of relationships. But what you are making clear is that you are not taking a “one-size-fits-all” approach to what skills to learn. You are not telling your client “You need to have friends” or “You need to do more with other people.” You are helping your clients decide what they want, even if it is different from what their parents, teachers or healthcare providers think they should want. Addressing disagreements between what young clients and their parents want from therapy can be a real barrier to progress. Everyone wanting to have the final say in what gets addressed can be more challenging with this type of therapy than any others. You have parents who are used to guiding their child’s treatment, and then the child (now a teenager or young adult) who is tired of being told what they should want or what goals they should have. This is even more of an issue with autism because childhood autism treatment requires heavy parental involvement. Backing off on this involvement, so that their child can have more say over what gets addressed, can be difficult for parents. I remember one client, a teenage girl with autism just starting the 11th grade, whose main issue was disagreements with her parents. Her goal was to interact with her peers more at school, but she was not particularly interested in more social activities outside of school. But her parents wanted her to do much more socially. They had another daughter who they described as a “social butterfly” who was often at parties and out with her friends. When they saw that their other daughter (my client) did not have much interest in parties, they determined that something was “wrong” with her and that her autism symptoms, which she dealt with all her life and had been under control for years, were causing her problems that she did not see. My client had considerable disagreements with her parents about this issue and was really starting to resent them for it. She was comfortable with her limited social activities and did not want to do much socially outside of school (but did want to do more socially in school). Her parents disagreed and we had to address this issue before deciding what direction treatment would take. This sort of disagreement is not uncommon for families of a teenager or young adult with autism. Given how intense autism in childhood can be and how involved parents often are, they may come to expect their child will not fully understand what they need from treatment. Having family sessions, where everyone is given their say but the therapist makes clear that the young client must be listened to, can help parents recognize the validity of their child’s views. It can also give the therapist the opportunity to talk with the parents about how there are different perspectives on what makes social relationships meaningful and what to expect from friendships. When I had the chance to discuss these issues with my client’s parents over two family sessions, they were more receptive to considering what their child wanted socially. They were actually initially quite angry at me for “giving in” to their child and treating her too much like an adult. It was only after we discussed these issues in depth, and everyone had the opportunity to express their views without interruption or criticism, that the parents were receptive to allowing their daughter to set the goals for therapy. Therapy for autism in the teenage and young adult years is more individualized than therapy for autism during childhood. One example of how this works out is that “social scripts” are used as opposed to “social stories.” Social scripts are based on discussions during the therapy sessions specifically addressing what the person wants in terms of social relationships and what situations they find most difficult in reaching social goals. Social stories, on the other hand, emphasize more general rules that are used across a variety of social situations. Many types of therapy approaches used effectively for treating different conditions for teenagers and young adults can also help individuals with autism. Mindfulness, cognitive-behavior therapy and relaxation therapy all have been found effective for treating anxiety, depression and anger comorbid with Autism. T client can learn how to use these skills to reach the social goals they set for themselves. Perseveration and self-stimulatory behaviors are common problems in autism that need addressed. They typically get addressed as clients identify the negative responses they get from other people because of these behaviors. Using the “Red Card/Green Card” exercise is one effective approach for this problem. Essentially it involves helping the person practice suppressing their repetitive behaviors by allowing them periods of time to talk about whatever they want (including perseverative topics) without interrupting them when the “Green Card” is up, in exchange for focusing on specific topics the therapist brings up when the “Red Card” is up. I have also found reviewing material related to the “neurodiversity movement” to be invaluable for helping determine effective ways of helping teenagers and young adults with autism. This is not a therapy orientation per se, but is a philosophical movement emphasizing that autism, along with other neurobehavioral conditions, is best thought of as a “difference” and not a “disorder”. Reading material related to this movement can give you a different perspective on helping make therapy for someone with autism as beneficial and individualized as possible. Reference: Marston, D. (2019) Autism & Independence: Assessments & Treatments to Prepare Teenagers for Adult Life. PESI Publishing & Media: Wisconsin.
My First Private Patient
The following is an excerpt taken from The Fear of Doing Nothing: Notes of a Young Therapist by Valery Hazanov, published by Sphinx, an imprint of Aeon Books © 2019 and reprinted with permission of the publisher.
My First Private Patient
Climbing up the stairs from the subway stop on 13th Street, I reached for my phone and saw a text from a former classmate. It was August 2015; I had just received my license.
“Val, it’s been ages!” she wrote. “How are you? Did you start your practice already? Someone asked me for a referral: a professor from Moscow who’s looking for a Russian-speaking therapist in the city. I don’t know him, but his son works with Daniel and sounds really nice … Would you be interested? Let me know and we need to get drinks!”
“The man, I learned from his son, was a microbiology researcher in his seventies who came to New York for an experimental treatment of cancer”, with which he had been diagnosed a few months earlier.
“We would like you to work with him on themes of positive thinking and optimism,” the son told me over the phone. “We understand that it might be crucial for the success of his treatment.”
I did not have a practice, but quickly (Israeli style) arranged something for the following Friday: John, the leader of the men’s group, lent me his place near Central Park. It was a good-looking room with many ancient artefacts, an enormous sofa, and a window that looked onto a leafy courtyard with two benches.
I came thirty minutes early and as I was waiting for Mikhail Alekseyevich to arrive, I photographed the room with my phone camera and sent it to my mom and a few friends in Israel.
“Look at you, Doctor!”
“Beautiful, Valery …”
“Can we come for a session?”
I was standing by the window, trying to imagine who I would meet, reflecting on the irony of my first private patient being from Moscow, thinking about the type of Russian he might be – in what sociological box from my past would he fit …
A buzz at the door. We begin.
***
“Here?” an older woman asked nervously as she was wheeling in Mikhail, who seemed disinterested, slumped in his wheelchair, looking very thin, turning his gaze to the window – away from me.
“Hi, I’m Valera. Nice to meet you.” I shook their hands.
They introduced themselves.
“Welcome to New York, Mikhail Alekseyevich,” I said after his wife had left the room.
“Puzzling city …” he replied in a pensive voice.
“How so?”
“I don’t know. Who are you? I didn’t quite comprehend from my son. He keeps taking me to all these appointments. Are you a doctor?”
“I’m a psychologist.”
“A psychologist? He didn't mention…I’m surprised he brought me here, I never understood what psychologists do.”
“Me neither.”
““You tell people that everything will be alright?””
I laughed. “Something like that.”
“How old are you?”
“Thirty-three.”
“Young, young … And where are your parents? In Moscow? Here?”
“My mom lives in Colorado and my dad is in Israel, where I grew up.”
“My God. You have no one here. How do you manage?”
“I run a lot.”
“I see. That’s good. So tell me, psychology, is it even scientific?”
“I don’t think it’s scientific.”
“You see, Valery, my cousin’s daughter in Moscow is a psychologist,” he said with a grimace. “She tried to explain many times … She’s a singer, she does yoga, she lights candles that smell nice. She told me that there are three ways to be happy, but I can’t remember them … What’s a psychologist then? What exactly do you do?”
“Have you read The Grapes of Wrath?”
“Yes. Many years ago.”
“Remember the guilt-ridden uncle who’s dying to talk to someone and ends up drinking instead?”
“Vaguely.”
“The family needs to keep moving, if you remember. There’s no time for what he needs. He keeps bugging them, wants to tell somebody, anybody, what happened to his wife and how it was all his fault. He’s breaking down, he’s feeling ashamed. He’s lonely and misunderstood. I talk to people like him.”
“And?”
“Sometimes it helps. Sometimes it doesn’t do anything.”
“What will it do to me?”
“I’m not sure yet.”
““How will you ‘cure’ me? Tell me to forget that I have cancer and look at the positive things in life?””
Checkmate against the psychologist by the Russian researcher, by generations of people who did it all by themselves, who withstood Stalin and the World War and the Gulag and never complained and kept on going. No need for therapists, thank you very much, we’ll manage by ourselves. But tell me, psychologist, what is your plan? Will you tell me that everything will be fine and I’ll whine a little and feel sorry for myself?
“I don’t think I’ll do that. It sounds like a terrible idea,” I said.
“What then?”
“You tell me: maybe you want to fight, maybe you want to let go.”
“Oh, I don’t know. Honestly, I don’t even know what I’m doing here. ‘It’s a new treatment,’ they said to lure me. ‘You don’t have it in Russia!’ Big deal. All I wanted was to die in Moscow and that’s not going to happen. But I don’t want to talk about that…I don’t want to talk about myself. I’m gone, I’m not interesting anymore. In a moment I’ll be back to dust: a forgotten man in a forgotten place. You, on the other hand! You’re young, so young … You have a future, you have something to look forward to, something to hope for, something to wake up to in the morning that is not a CT scan or a blood transfusion or a ‘lab analysis’ or a ‘Mr. Barsky, have you given a urine sample this morning? Was it too yellow, Mr. Barsky? We’re a little worried, Mr. Barsky.’ ‘Oh, are you?! A little worried?’ I don’t want to talk about that nonsense. I want to talk about you.”
“I understand. What would you like to know?”
“For example, where do you live?”
“I live in Brooklyn, by a park that’s called Fort Greene.”
“A big park?”
“Not too big, I see it from my living room window.”
“Nice. Who do you live with? You’re married?”
“I used to be … I live with my best friend.”
“Well, that’s not the worst.”
“It’s not.”
“Do you like New York?”
“Not particularly.”
“Why not?”
“Because it’s a place that’s good at separating people; not so good at bringing them together.”
“Interesting. What’s your favourite city then?”
“I like Jerusalem.”
“Why?”
“It’s chaos, it’s the Middle East, everyone’s in your face. That’s more to my liking.”
“You’re an interesting type, Valery…I wonder what’s behind the mask, though!” he said, smiling.
I laughed. “”Behind the mask of a psychologist there’s another psychologist, and then there’s another one – until there’s a person.””
He laughed too. “Another question: what did you have for breakfast?”
“I had coffee and toast with strawberry jam.”
“I can’t have that, you know? Dietary restrictions,” Mikhail said, sighing.
“Mikhail Alekseyevich,” I said after a pause. “Your son told me that your cancer is at the fourth stage.”
“That’s right.”
“How has it been?”
The ping-pongy nature of our conversation never stopped. Mikhail didn’t want to tell me how it had been, but he also didn’t want to leave. He lingered in the office even after I had told him that our time was up. He wanted to talk about music, about places in New York that I liked, about where I grew up in Moscow.
John’s cozy room, the garden outside, my life’s story – it was all a respite from his painful reality: torn from his home, dying from cancer, treated by people whose language he did not understand.
Was it a psychotherapy session if I told him more about my life than he told me about his?
As we said our goodbyes, I wasn’t sure if he wanted to return or not. “Let’s be in touch,” he said as his wife was wheeling him out.
“I left the session feeling that I had met Nabokov’s Pnin” – a Russian intellectual in exile, never fitting into his surroundings, not quite sure what to do in America, how to be. Clearly not a person who would voluntarily stumble into a psychotherapist’s office asking for help. Smart, witty, playful: I really hoped I would see him again. I hoped that I had placed enough hooks, dismantled the psychologist stereotype he had had in his mind – it was the only way in, I felt. One word of jargon, one “It must be so hard for you,” one “I feel that you are experiencing some ambivalence about seeking help, Mikhail Alekseyevich,” one “There is something scary about opening up and talking about ourselves,” and he would have walked away, never coming back. “Americans,” he would have thought, “psychologists,” he would have told himself, “why can’t they talk in a normal way?”
A few days after the session, I called him.
“Yes, dear,” Mikhail answered in a soft voice. “I’m listening.”
“Your son told me that you haven’t been feeling too well.”
“Oh, you know, it’s to be expected with my diagnosis. But how are you? Did you have a nice weekend? Did you spend it in the city?”
“It was alright.”
“What did you do?”
“Went for a run, wrote in the library, met up with a friend.”
“Nice, very nice. Good for you.”
“Will I see you again, Mikhail Alekseyevich?”
“Sure, why not? But there is a small problem: I can’t leave the place I’m at anymore because of my condition. That’s what they told me, I’m stuck here.”
“I’ll come over.”
Three days later I appeared at the treatment facility in which Mikhail had been hospitalized. It was one of those modern places that are part hospital, part living apartments. There were inspirational quotes on the walls and names of donors. The rooms were given names like “Mist” and “Four Winds”. It looked like a getaway hotel by the hot springs, except that all the residents had cancer.
Mikhail was sitting in a wheelchair when I came, his tiny body covered with an enormous woolen blanket, pointing to the table next to his bed with medical equipment: “Needles, stupid needles …”
“Only a week had passed since our first meeting, but he looked much weaker and sicker”.
“First things first,” he said. “Are you hungry? Would you like to eat something?”
“No, I’m fine, thank you.”
“Well, at least allow me to pour you some tea.”
Drinking tea together, we eased into a conversation about Russia. Mikhail was dismayed by what was going on, telling me about how politics had ruined science, how people didn’t feel free anymore, how it all looked familiarly scary.
“Why does it feel like a damn cycle?” he wondered. “A predetermined fall to the abyss.”
“It does feel like a tragedy … We know how it will end but can’t do anything about it.”
“Exactly,” he nodded.
“When I think of Russia,” I said, “I only think about the very distant past, and about Moscow, which I absolutely love. It’s not the ‘right’ approach for immigrants, we’re supposed to hate it, to bemoan the glitzy, materialistic behemoth that Moscow has become. ‘Oh, how terrible! They only have Gucci boutiques all over, what happened to our Moscow?’ But beneath it, beside it, apart from it…You have the little squares, the theatres, and they renovated nicely, and I just love the feeling of walking there. It’s a funny thing to go back. You know they have this train from the airport that goes to the centre? Then you can take the metro, two stops to Kiyevskaya, around where I grew up. Last time I was there I got out of the train and was amazed: it’s like it hasn’t been twenty-five years, it’s like I never left. Strange feeling.”
“You’re a nostalgic person, my friend.”
“That’s true. But…there is this idea of a Country, of what it stands for, its values, etc. Living here, I’ve been thinking a lot about the bubbles, the niches in which we live; the Tuesday mornings and the Sunday afternoons. And sometimes they have nothing to do with the Idea, with Putin, with the ‘political situation’. It’s either good or bad. It’s a texture of living that either works or doesn’t.”
“I know what you mean.”
“I talk a lot for a psychologist.”
“I wouldn’t know.”
“Tell me something.”
“I was thinking about my family when you were talking. How we all spread around, like birds who flew to find warmer climates and never came back. My two sons are here: one in New York, as you know, the other one in Boston. They did well, I think, I hope.”
“How often do you see them?”
“Once a year, maybe twice. Tatyana and I visit occasionally, stay for the summer, spend some time with the grandchildren. Sometimes they would come visit us in Moscow. But it’s a peculiar feeling: after all this time, all this flying around, I am sitting in Four Winds ready to die and be buried, and where? Where do they bury people here?”
“I think in Queens, maybe in the Bronx.”
“Okay, ‘Queens’. What the hell is Queens? What does it have to do with me, with what I have done in my life?”
“It has something to do with your children and their children.”
“True. But it’s still odd, this whole thing. What is a place? What does it mean to be from somewhere, to live somewhere? I don’t know anymore.”
“Me neither …”
We never met at John’s place again. “Every week, at varying times, based on Mikhail’s medical procedures and condition, I would come to sit with him by his bed”, or take him to the porch outside Four Winds.
We did many things together. We watched YouTube (a scene from Tarkovsky’s Sacrifice with Bach’s St Matthew Passion superimposed was his favourite), we talked about his research and what he thought needed to happen to it, about the papers he wanted to finish but felt he would never be able to. We talked about Russian literature, about immigration, about Israel. We ate fruit and snacks. I brought him a ginger ale once (he had a sudden craving), and a chocolate bar another time – I don’t remember if he was allowed to eat that …
“Thank you for coming,” Mikhail would always say when he saw me. “What’s the news?”
He liked when I described, in detail, a certain place in New York, like a park, or a building.
His face would light up. “What do you see when you enter it? How big is it? What is its exact circumference?”
I never knew, of course, but I would google it in his presence and we would talk about that and I would learn things like the area of Riverside Park (266.791 acres) or the year the Avery Library at Columbia was founded (1890).
With time, and only after starting with the perimeters and context of his life, we were able to go deeper – dreams, regrets; soul stuff.
“What do you miss the most?”
“I miss my sofa in Moscow! I’m serious! We just bought it, it felt like a big achievement …”
“Funny.”
“I miss being needed.”
“Yeah …”
“No one needs me now. Who am I? An old man who’s waiting…waiting to end this.”
“What exactly do you mean by needed though?”
“Someone calls: ‘Prof Barsky, what do you think we should do with this experiment, this paper?’ etc.”
“What about your family, how do they need you?”
“I don’t know. Now, I don't know. I feel like I’m just a bit of a nuisance.”
“Judging by their relentless attempt to keep you alive, it doesn’t feel that way.”
“True. Maybe they got attached.”
“What do you mean, ‘maybe’?”
“Well, yeah, definitely.”
“It’s just that the work was at the centre of your life…Now that it’s been taken away you probably wonder what’s left.”
“You’re right. Not much. And let me be completely honest: I don’t know how to face this, Valery. I really don’t. Can modern psychology help us here?”
“I’m not sure.”
“Have you ever worked with dying patients?”
“No, I haven't.”
“So, what do you think, how should I do it?”
“Big question…Words like ‘meaning’ or ‘acceptance’ – you know them, you don’t need me to repeat them. But then how else can we talk about it? I’m not sure…Maybe reduction of bitterness? Making it a project of extreme gratitude to what’s around, to who’s around? I mean, it’s true for me as well – can’t hurt.”
““Coming to terms, coming to terms,” he said with a smile. “I’ve never done it!””
“We all suck at this. But tell me stories, it helps.”
Often when we sat on the porch he would put his hand on mine and we would be silent for a few minutes. Then, he would remember something recent or very distant, associatively it seemed, and tell me about it.
“There was this type, what was his name…Ah! Igor Bogdanov, yes, yes. Anyway, it must have been in the Seventies. We were just starting out, he was at my department then and we had a trip together to Nizhny Novgorod, to give a talk or something at the local university. We took the train from Moscow, seven or eight hours, I don’t remember, and delved into a conversation about the department, its politics – the usual stuff. And then he turns to me, I still remember it, and says: ‘Misha, you know what? You’re too gentle for science.’ That’s what he said: ‘too gentle’.”
“Are you?”
“I don’t know. Sometimes I think I was. Science, you see, you need to fight there, you need to push, forget about everything, about everyone. I am not sure I was able to do that. I have regrets, Valery. I live with certain regrets; I think I could have done more. Publish more, teach more, forgive me for the pathos: discover more.”
“Yeah…”
“I can’t shake these feelings off. I understand in my head: ‘You’ve done a lot, stop!’ But it doesn’t feel like that, it doesn’t feel enough.”
“How will we get you there?”
“I thought you were the expert!”
“I thought we had agreed it’s not scientific!”
He smiled and shook his head.
“There is this question in psychotherapy that I frequently think about: whether it is a process that’s supposed to make us feel better about who we are or to change who we are.”
“And what do you think?”
“I think, ultimately, it’s about acceptance.”
“Okay. But it bothers me, it does. It’s such a childish thing to be bothered with. I mean, how infantile: I am sitting here thousands of kilometres away, forty-five years later, ready to die, still thinking about that comment.”
“But what bothers us always feels childish. That’s inherent in ‘bother’.”
“How so?”
“‘How un-Stoic of me, why can’t I regulate myself, how am I swayed by stupid emotions…’ That’s what we think when we are ‘bothered’ by something, no? But what’s an emotion? It’s the basics, it’s us as a kid, it is childish.”
“Okay.”
“I have a friend in Israel who told me a story once. During his reserve service in the army he was stuck for weeks in a remote base somewhere. One of his friends came to him there in the camp, I think he was doing the dishes or something, and his friend goes: ‘Yona, you know what I realised? You’re a lone wolf.’ My friend told me that he could never forget that comment. It’s nothing, right? Completely innocuous. But that’s the thing: it’s always simple. A word, a sentence that hits something real. And then we obsess over it and feel foolish, or, if we’re lucky, relieved – in psychotherapy…”
“Was he a lone wolf?”
“Probably.”
“And if he were your patient would you have tried to change that?”
“I would have told him: when you hunt, hunt together sometimes, brother.”
Mikhail laughed, but then stopped. “And what would you tell me?” he asked, closing his eyes halfway. “Do you think I was too gentle?”
“I don’t know,” I said. “But if I had to guess, I would guess that your gentleness was a gift from God that made you the scientist that you are.”
***
The treatment facility in which Mikhail had been hospitalized was in a constant state of buzz. There were doctors and nurses and relatives and other patients in perpetual movement. There were many TVs and they were always on and for some reason it was CNN and the news, most of the time. There were people with different-sounding professions that would come, every couple of minutes, it seemed, to the room and talk about physiotherapy that needed to be done, “management of care” that had to be managed, financial decisions that needed to be made, Mikhail’s diet, furniture that could be brought in or out according to Mikhail’s wishes, books that they were able to order for him in Russian and he should explore this opportunity because not in every place was it possible but it was possible there and if he would only ask…
Is the mobile phone working okay? Is the Wi-Fi signal strong enough? Would he prefer a vegetarian option for dinner? Does he need more channels in his cable? There are now options in Russian.
Mikhail, weary, deaf to this all, was motionless in reaction to this spinning around him. “Why can’t they leave me alone for a moment?” I imagined him thinking. “Why all these questions?”
“I don’t know if it’s true, but I felt that his life had been about protecting his sanity”, his focus, from the intrusion of this energy of mundane concerns. I don’t think that just because he had cancer that was slowly killing him, he became a person who could not stand any of that, who could not bring himself to care about that non-important nonsense. And I sympathized with him, obviously, and felt that it was appropriate that we were meeting at that frantic facility and not in a secluded office, because suddenly it emphasized an essential part of psychotherapy: its fending off of corrosive distraction – standing firm in the face of the never-ending attacks on the things that matter. Sorry for the clichés, but it did feel like we were creating an island, and we tried to protect that island together. And he was not just a patient, but rather a collaborator in that process, which was as much mine as his, I believe.
Whatever was going on in my life in the months of August and September of 2015, wherever I was – Mikhail was with me, transcending the confinements of the “consulting room”. Like a good friend who becomes a part of your daily existence, to whom you say that you feel tired, or that you like your tea with no sugar but with lemon, or that your back has been bothering you recently and it’s annoying. Somehow, he became that person. “He liked to call me on the phone, between our sessions, to tell me a story, or a joke, or ask for my “opinion” about something”. “Valera, milenkiy,” [my dear, in Russian] he would frequently conclude the conversation, “I miss you.”
Gradually, it became difficult for Mikhail to talk. He would take long breaks between sentences, holding his head as he tried to say something. “Valera,” he would say, “do you think we can fully be known by another person?”
“I think there are parts of ourselves that remain forever only ours.”
“Yes, yes. It’s true … And that’s what remains?”
“What do you mean?”
“That’s what we take with us?”
“I think we take more.”
“Maybe. It’s just that sometimes I think, what was it all for …?”
“You’re in a bad mood today.”
He laughed, weakly. “You’re right. It’s just … I don’t know how I can accept this. I had visualized something different.”
“What?”
“First of all, yes, and forgive me if it sounds infantile, but this was supposed to be happening in Moscow, in my apartment. I mean for heaven’s sake, I spent forty years there.”
“What else?”
“I didn’t achieve enough. I just didn’t. I was okay, I was a good researcher, but I could have done more. Much more. And it bothers me. Why didn’t we meet twenty years ago, Valery? This isn’t relevant anymore…What can you tell me now that will change that? Nothing!”
“Twenty years ago I was thirteen.”
“You know what I mean.”
“You mean that I was a top therapist at thirteen. I think you’re right.”
“Be serious.”
“There’s nothing to be serious about. It’s a bunch of thoughts in your head. It’s a fantasy that you created because you had thought that life is measured by some yardsticks that kept evading you, that kept getting higher and becoming unreachable. We make ourselves miserable believing in this nonsense, myself included, but it’s all about letting it go. And it’s never too late and you know it. You know it’s not too late because you can still think and you can still feel and you can look around and say, ‘Thank you very much world, God, universe, fate, me…’ – whatever you believe in – ‘for giving me my wife who has cared for me all my life, my two great sons, and their children who will be coming to my grave because that’s how they were raised. And thank God for at least one article or paper or invention that actually mattered for something and wasn’t just a bunch of words.’ You can do it right now.”
“Valera…”
***
A few more weeks had passed when I came to his room and saw that he couldn’t get out of bed anymore. He would lie, eyes closed, hand on his forehead, in pain, mumbling something to himself. He would try to get up on his elbows when I came, sometimes succeeding, sometimes not.
“Well, that’s what it’s come to,” he said in a shaking voice. “What should we talk about?”
“How is your pain?”
“Oy…” he sighed. “Look at my hands,” he said. They were all pink and swollen. He was dying.
And “I remember looking at him, understanding how ridiculous my thought was, but also that I couldn’t help but think – “Why? Why is he going? In what way is that fair?””
“Did you get some sleep tonight?”
“I did, I think.”
“Can you eat at all?”
“A little bit …”
“Can I bring you something?”
“No, no, I am okay.”
“Do you want me to read you something?”
“Yes, please.”
“Okay. Believe it or not, I’m reading you this from my mobile phone.”
“Wonderful.”
“‘And there in the middle, high above Prechistensky Boulevard, amidst a scattering of stars on every side but catching the eye through its closeness to the earth, its pure white light, and the long uplift of its tail, shone the comet, the huge, brilliant comet of 1812, that popular harbinger of untold horrors and the end of the world. But this bright comet with its long, shiny tail held no fears for Pierre. Quite the reverse: Pierre’s eyes glittered with tears of rapture as he gazed up at this radiant star, which must have traced its parabola through infinite space at speeds unimaginable and now suddenly seemed to have picked its spot in th
The Tiger Woods Analogy for Therapists Makes a Roaring Comeback!
On April 14th of this year, Tiger Woods won the 2019 Masters Tournament at age 43, creating a sports story which NBA legend Michael Jordan called, “the greatest comeback I have ever seen.” Just for the record, this was Tiger’s fifth Masters victory. This, mind you, after some of the top pundits predicted he would never win another tournament, much less the Masters.
But what, if anything, does this amazing accomplishment have to do with the practice of psychotherapy? Well grab a 9 iron, or preferably a putter, and indulge me while I explain. Also, you need not be a golfer or even a putt-putt mini-golf aficionado to benefit from this information.
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In 2007 I wrote a brief chapter titled “The Tiger Woods Analogy: The Seven Minute Active Listening Solution,” for Lorna L. Hecker and Catherine Ford Sori’s wonderful book The Therapist’s Notebook. Volume 2. In the book I show precisely how to prove to yourself that the “Tiger Woods Analogy” I am about to describe impacts your therapy sessions. Using a trusted friend playing the role of the client, I share an experiential activity with two trials where the “client” provides you with a rating concerning your effectiveness as a helper. In this exercise, the “therapist” is first instructed to let their mind wander while listening to the “client”; following which, they are told to hang onto every word the “client” says. In such an exercise, you will discover that your helper rating is significantly higher when you are listening versus when you are contemplating the purchase of your next cell phone plan.
I will now share the rudiments of the analogy with you. Let us assume that I am faced with a four-foot putt. Is there a good chance I will miss it? Indeed, there is an excellent chance. Now, let’s challenge Tiger with the identical putt. Even as well as Tiger putts, he doesn’t sink them all, so yes there is a chance Tiger could miss it as well.
But the key difference will become clear if both of us are asked to attempt the exact putt once again. In my case, I will likely be clueless as to why I missed the first putt and I am afraid there is a very high possibility I will miss it once again. Well, how about Tiger? Could he miss it again? It is possible, but the odds of this occurring will be much lower. Why? Tiger will consciously or unconsciously say to himself, “Hit the putt a little more to the left,” or “loosen your grip on the putter,” or whatever.
Tiger is aware of why he missed it. He has insight into his behavior. He is constantly watching his performance and listening to feedback. Me, not so much or maybe not at all.
Now let’s apply this to a counseling or psychotherapy session. How many times when a client is talking, are you thinking about your daughter’s birthday party, your son’s soccer game, or your larger than life credit card bills? (And if you answered “never” then I know you are lying…at least to yourself.)
If you are beginning to think that the point of this blog is, “Oh Dr. Rosenthal, I get it. I promise, I’ll never zonk out, stop listening, and I’ll hang on to every word uttered by every client,” you are delusional. Sorry, that’s not going to happen. Albert Ellis reminded us for more years than we care to remember, that humans are fallible and are far from perfect.
There will be times when you are daydreaming and not totally listening to your client, merely because that is a part of the human helper’s psychotherapeutic experience. The point is that after reading this blog (and preferably performing the exercise fully explained in the Therapist’s Notebook with a trusted colleague who will be rating your effectiveness), I want you to be like Tiger attempting the putt for a second time—intensely aware, insightful, and fully cognizant of your behavior and therefore bringing yourself back to listening to your client ASAP.
Hence, in the future when you begin thinking about whether you should order the chicken or the beef fried rice after the client’s session ends, you will have this amazing larger than life insight that maybe you ought to recall the Tiger Woods analogy and pay a wee bit more attention to what the client is trying to convey.
No matter how you use it, knowledge of this analogy, even though it is extremely valuable, won’t transform you into a master therapist, and it sure as heck won’t allow you to putt as well as Tiger, but it will go a long way to improving your active listening skills.
Unlearning to Learn
Eternally inspired by and forever indebted to the philosophy of Wabi Sabi – Nothing lasts, nothing is finished, nothing is perfect
Being young in the field of psychotherapy, does not really permit us to share lofty professional insights or postulate what this monumental field entails. If psychotherapy were a person, then we would recognise ourselves in the early phase of courtship. Nonetheless, we believe that our shared inspirations are worth documenting, and it is certainly worth acknowledging what this field has given us and how it has shaped our being.
Wabi-Sabi
Psychotherapy as a school is a development of the Western world. Alongside being introduced to the nuances of counselling and psychotherapy as a part of our academic adventure, we have also been influenced by Eastern philosophies from our birthplaces and neighboring lands. One such ideology that has had a deep impact on our personalities and perspectives is the Japanese philosophy of Wabi-Sabi. In its essence, Wabi-Sabi emphasizes impermanence, incompleteness and imperfection.
In many ways, “Wabi-Sabi embodies authenticity, beauty in fallibility and transience”. It also entails appreciating the ordinary, that which we may easily overlook in our pursuit of the extraordinary, or in the case of psychotherapy, the abnormal. We are still absorbing the learnings that Wabi-Sabi has bequeathed us. However, there has been a beautiful and serendipitous confluence in our learnings from this philosophy and our pursuit of psychotherapy as a profession. Though this article is not so much about Wabi-Sabi, we cannot deny those occasions in our therapy sessions where we have had delightful Wabi-Sabi encounters. We hope that through this article, even though discretely, this trail of our psychotherapeutic unlearnings and the Wabi-Sabi learnings will converge for you as well.
Awe and Authenticity
Psychologists and therapists often describe their profession as a holistic enmeshment of the personal and professional, an experience in unadulterated authenticity and a dynamic narrative of its own. The more hours we spend working with clients, the more we are amazed at human strength, potential, resilience, growth and adaptability. Also, the more hours we spend working with clients, the more we are amazed at how much we can change. It is precisely this sense of awe, and several reflective conversations, that compelled us to give clarity to and expression of our thoughts.
By the very nature of the profession, therapy involves, if not demands, almost continuous self-reflection—a positive yet strenuous occupational hazard. Just like the surgeon finesses her skills through experience, the therapist becomes more present through practice. Psychotherapy is a unique space that provides the therapist with daily, challenging life-altering perspectives. At the same time, it also allows for a renewed appreciation of the mundane, the ordinary, and that which we take for granted.
“Clients may underestimate the profound impact they have on their therapists”. Therapists are neither blank slates nor are they “experts.” Do therapists know the human mind, theories of normality and abnormality, and modes of treatment? Of course, we spend years studying them. Do we know to “fix” every problem for every client? No, we do not. The point of therapy has never been to “fix” anything, at least from our subjective standpoint and theoretical orientation. Even though “doing” therapy is often easier than “being” a therapist, “doing” does very little for the natural process of healing. Therapy after all is a healing relationship that facilitates reduction of overt symptoms and enables psychological well-being. It took us both considerable time to understand and acknowledge that it is the therapeutic relationship between the client and the therapist which is one of the many pivotal healing points. The therapeutic relationship may catalyse significant shifts in the way a client may perceive interpersonal relationship outside of the therapeutic space. This relationship in some ways is the vehicle that helps the client carry their changes from within therapy to outside of therapy.
Power and Fallibility
Media, unfortunately, has done little to promote the profession and benefits of psychotherapy. Instead, it has mystified the process of therapy (you must be crazy to go to a therapist!) and sensationalised the role of therapists—therapists can read minds and pick up impossible micro expressions. We do painfully regret the lack of these superpowers. What happens in reality is that very fallible human beings called therapists stumble, and doubt, and learn, and then learn even harder in order to best help their clients. It is this very ambiguity in the nature of the profession that makes the therapeutic journey both rich and adventurous for the therapist to embark upon. We have grown to recognize the ambiguity of life in general—not just for our clients but for ourselves. Ambiguity is defined as a situation that is complex, novel and insolvable. It makes drawing concrete interpretations difficult and may imbue a person with uncertainty. It’s not pleasant for most people, but tolerating ambiguity might just be the ticket to being a more grounded therapist. If therapists were to have a superpower, it probably would be tolerance of ambiguity.
We believe that at the very essence therapists are people, with beliefs, values, opinions and personalities. They are also people who have biases, needs, faulty assumptions, and introjected patterns of thinking. Therapists, just like their clients, are fallible beings. Irvin Yalom, our personal hero, in his book The Gift of Therapy¹ notes that the therapist and the client often trade places in the therapy room, each learning from one another. Yalom’s view of therapy, as a journey that two fellow travellers take together, is supremely reassuring to us novices. Therapists always place the client’s needs before their own. However, this does not mean that the therapist is unaffected by the therapy process. Rather, we believe it is impossible to not be affected by the suffering and pain that is contained in the room and subsequently not rejoice in the victories and potentials of our clients. Therapy entails a very real human connection.
Curiosity and Trust
The client–therapist alliance is that of trust, fidelity, and curiosity; a fascinating blend. The client entrusts the therapist with painful or ambivalent information from the “real” world. The therapist attempts to soak in this information, remaining curious at all times about the client’s life without projecting anything from their own. Thus, the attempt is to maintain objectivity by seeing the information in itself. This provides the therapist with a formative playground to test and retest their own existing belief systems as the objective lens aids them to see the previously recorded data in a newer light. It is this genuine curiosity that helps a therapist look beyond their own preconceived notions, beliefs, and knowledge.
Therapists are cognizant of the notion or at least attempt to be conscious of the idea that people see the same situation differently and from their own frame of reference. The therapist must be reverent of that. This is comparable to an octagonal prism. When white light passes through, the prism separates it into spectrum of different colours. These colors are similar to the varied human perspectives that we hold at different points in time. This prism metaphor gives us the solace that in the therapeutic set up, one reality can be perceived in many ways.
All human beings are subjective in their interpretations and analyses of issues, therapists included. The world looks pink when we wear pink glasses. Thus, our core values as humans remain phenomenologically ours. We recognize that everyone has their own subjective world. Therapists specialize in recognizing these intricate subjectivities. It’s what helps them remain non-judgemental. Therapists are cautious in assuming and careful in hypothesizing, and amidst all that, authentic.
Unlearning to Learn
It is our fundamental premise that both clients and therapists learn and unlearn in therapy. For the client, learning can be anything from forming a trusting relationship to altering destructive actions. For the therapist, the process of learning might in fact be a process of unlearning. It is our personal belief that has its roots in early psychodynamic theories that during the early stages of our development we learn or rather introject without careful evaluation, a number of beliefs and values. Some of these beliefs are adaptive and others are not. These beliefs help us operate in society and we cling to them like an infant to their primary caregiver. When we attempt to change our maladaptive beliefs, we face resistance from within. This is because of our inability to tolerate cognitive dissonance (holding two or more clashing thoughts at the same time). We often stick to our more maladaptive beliefs even in the face of contrary evidence to maintain equilibrium. This is where the tiresome, yet fruitful, process of self-reflection comes in. Self-reflection helps us unlearn our introjected beliefs that hamper our own growth and progress. Because the “personal” interacts with the “professional,” for therapists, unlearning in personal life affects professional development and vice versa.
Self-reflection is an active, arduous vehicle in this grand process of unlearning. Many other aspects of the art of psychotherapy facilitate this unlearning automatically. One of these is learning the power of narratives. “When we try to view the client as a storyteller, we appreciate the complexity of their characters and the power of those complexities”. As we help them weave their otherwise fragmented life episodes into a meaningful journey, we learn from their stories. This process of stitching the disjointed pieces into a meaningful narrative often mechanically diffuses some of the previously held pre-conceived notions. For example, imagine working with a real world “bully.” Now imagine that this “bully” presents as unruly, aggressive and oppositional. What would our natural reaction be? How understanding would we be of that behavior? How difficult would it be to propel our empathy wagons? Now imagine that this “bully” tells you why they have chosen this role. They explain to you their story, their family, their parents, their life. How would you feel after learning about their phenomenal world? Would your feelings change? Would it be a little easier to empathize?
Knowing and understanding that the “bully” had a story to tell, that they were influenced by the negative experiences in their life, and that those negative experiences invariably propelled them to assert dominance and a grip over self might have mitigated the negative feelings that some of us held towards them in the beginning. Interestingly, as much as we attempt to maintain an objective lens to avoid biases, narratives help us unlearn objectivity in order to appreciate the client’s phenomenological realities. And this dual process functions simultaneously and rather beautifully. The key unlearning here is that no absolutist response really exists.
The Power of Witnessing
As therapists, we also use the technique of paraphrasing and summarizing to the client about their own narratives. Oliver Sacks³ has eloquently postulated that “We speak not only to tell other people what we think, but to tell ourselves what we think. Speech is a part of thought.” Hence, paraphrasing has double edged benefits. On the one hand, it gives a newer perspective to the client about his/her own problems and at the same time it gives both the client and therapist the opportunity to stay on the same page and to postulate that the story is being understood from the lens of the client. This helps the client to unlearn his or her cognitive fallacies associated with the story, and at the same time aids the therapist in creating a renewed understanding of why the client behaved in a certain way. The technique of paraphrasing/summarizing by the therapist, gives clarity and opportunity to reframe our thoughts, check our biases, and better understand narratives.
“The process of witnessing change and resolution in another human being is powerful and overwhelming”. Also, as therapists we are constantly utilizing ourselves as a resource to bring about progress. The therapist by default experiences shifts and alterations in their own worldview further reiterating the notion that nothing lasts. On rare calculated and sometimes spontaneous occasions, depending on therapist preference, we use the technique of self-disclosure with our clients or admit our fallibility to them and share the human connection. This is our attempt at normalizing vulnerability, treating the client as an equal. This vulnerability is also utilized as an instrument of moral support for the client. This self-investment on the part of the therapist is another step to assure the client that they are being viewed as both unique and normal. Often, once a human invests a little in a joint process, it is hard to operate independently from one’s own prejudices. We unlearn the shame in vulnerability and instead embrace it. Or like Brene Brown suggested, we learn to believe in the power of vulnerability.
One of our most treasured learnings in this process so far has been that an “average” life is worth living. To come to this realization, that what has been termed “average” by the larger society is in fact normal and fulfilling, is a big one for us. We have unlearned that purposeful life exists only in the extraordinary life path. We are trying to normalize average, both for ourselves and our clients. Better yet, our vision is to glorify average. Reciprocating to the client that their so-called average lives filled with failures and anxieties are not just normal but also acceptable, gives us average beings the courage to bask in the glory of our own average narratives.
We have taken it upon ourselves to unlearn as much as we can and to stay true to our authenticity and curiosity during this process. As we attempt to disentangle the web of the distorted learnings we have accumulated in life so far, we are learning to engage in compassion toward ourselves. As Noam Chomsky said, “I was never aware of any other option but to question everything”². This is perhaps what this profession is doing to us—inciting us to question the most scrupulous nuances of our present being.
References
(1) Yalom, I. (2002). The Gift of Therapy: An open letter to a new generation of therapists and their patients. New York, NY: Harper Collins Publishers
(2) Chomsky, N. (2004, November 30). Question Time [Interview by T. Adams]. Retrieved April 27, 2019, from https://www.theguardian.com/books/2003/nov/30/highereducation.internationaleducationnews
(3) Sacks, O. (1989). Seeing Voices. New York, NY: Vintage Books.
Circle of Development: How Clinical Supervisors Can Help You Get to Your Growth Edge
As a clinical supervisor, it is vital to help our supervisees move into their zones of proximal development, or that learning/experiential space just beyond their comfort zone (CZ)¹. But in order to do so, the supervisee’s current realm of abilities and limitations needs to be well-defined. This entails figuring out when they are at their best, how they conduct a typical session, what parts of them shines through, and how effective they are in aggregate. In other words, supervisors need to first help their supervisees figure out the bounds of their CZ so they can begin to push beyond it.
Supervisees must regularly pose questions to themselves such as, “What am I used to doing in sessions?” or “What did I do well” or even ”Was there something I did or said that stands out which might have contributed to the development of my client’s progress?”
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We get comfortable with what we do well. Naturally so. The only problem is, if we fail to take the steps, our comfort zone can become our hell zone. What was once helpful with a particular client or type of client can become problematic or ineffectual. Think about your parents. If you were blessed with good enough parents when you were little, imagine if they used the same cuddly warmth and nurturing tendencies with you when you were a teenager. That wouldn’t have worked. You would have rebelled with angst. Past attempted and seemingly successful solutions can become today’s problems.
Here’s one of the axioms I have come to rely upon which defines the bounds of my current comfort zone (CZ): Provide clear and playful strategies to clients at the end of each session.
Over the last few years, I found myself drawn to being more playful and improvisational. This wasn’t how I used to be. I was constantly plagued with the question, “Am I doing this right?” Then I begin to realize that once I freed myself up to be more playful, I felt more flexible and less certain. This new mindset was unsettling and shook things up for me.
Other practitioners’ CZs that I’ve come across are founded in the following axioms:
“Be attentive and follow a clear treatment protocol.”
“Explore a person’s strengths and resources.”
“Develop clear treatment goals from the beginning.”
“Able to attune and empathize with my clients.”
First, and as noted above, it is critical that as supervisors, we help our supervisees to regularly ask themselves, “What did I do well?” “What stands out that I contributed to the development of my client’s progress?” This shall be your comfort zone.
Second, we need to help our supervisees to stretch out of their comfort zones and move into a less comfortable terrain that I call the learning zone (LZ). Our field has become obsessed with figuring out the how to improve, and less on taking the time to help individual practitioners figure out the what to improve. We need to get the sequence right. Figure out the what before the how. Especially in the realm of what we call clinical supervision, the supervisor plays a critical guiding role in helping to shape and identify learning objectives that are not only personalized, but ever evolving through the professional’s development over time.
It’s important to base your supervisee’s LZ on two critical pieces of information:
1. Their overall clinical outcome data, and
2. Feedback from a coach who knows their work.
By looking at the supervisee’s aggregated outcome data, you can begin to spot any glaring patterns. For example, early in my profession, I was shocked to find out that my own clinical outcomes for clients presenting with relational issues were the poorest compared to other presenting concerns, even though I was steeped in the systemic perspectives. Your role as a supervisor is to point out what the supervisee can’t see and lead them in the right direction.
Here’s my own current LZ as a therapist: I would like to learn to help clients face the feelings that they avoid. It’s so easy to continue validating and, as a result, getting lost in the interaction with my clients, while missing the opportunity to go deeper and help them with their difficult and painful emotions.
Other common LZs that I’ve come across in clinicians include:
“I would like to learn to improve the way I start my sessions.”
“I would like to learn to improve the way I close my first sessions.”
“I would like to learn to improve the way I elicit feedback at the close of a session.”
An excellent way to think about developing your supervisee’s LZ statements is to do this sentence completion exercise with them: “As a therapist, I would like to learn to…” Take it as a given that they will be struggling with this for a while. Give them time for this. Avoid non-specific definitions like, “I want to improve my engagement skills.” Narrow down to something more concrete and workable.²
For instance, if your supervisee’s data suggests that many of their clients come only for one session and drop out after that, you may be tempted to state that their LZ is “…to improve my return rates after the first session.” I see this more as an outcome goal. That is, you want X to influence Y, and “Y” is your outcome goal. In this case, you need to specify X and work on this.
Typically, when practitioners try to identify their own learning objectives, they tend to identify theoretically specific areas to work on (e.g., how to better conduct two-chair work on the inner-critic; how to employ a solution-focused approach when working with exceptions). Meanwhile, after examining their aggregated baseline performance metrics (more on this in upcoming blogs) and watching samples of their sessions, what I often end up proposing that supervisees work on is more fundamental and maybe even less revolutionary (e.g., how they begin a session, how they develop an effective focus, how they deepen the client’s emotional experience and how they end a session).
Most therapists and supervisors I know are life-giving and affirming. However, instead of simply bolstering their esteem with praise and consolation (A common refrain that I hear supervisors give, “Well, your clients came back to see you, didn’t they?”) without actually helping them identify their learning zones, we are doing our therapists and clients a disservice.
Finally, once we can identify our supervisee’s comfort zones and help them to move into their learning zones, we need to be able to guide them in articulating their panic zones (PZ). Panic zones tend to trigger feelings of being overwhelmed or may cause re-traumatization, which is not ideal for adaptive learning and personal growth. Panic zone materials are usually either too far a stretch in terms of the content to be learned, or the topic at hand might have triggered personal and/or professional ghosts of the past that have not been addressed.
Here are some common Panic Zones self-statements that I’ve encountered:
“Trying to learn what my supervisor says I should be focusing on, when I do not fully agree.”
“I know I should be working on difficult emotions like anger, but I do not feel ready at this point.”
“I tend to take critical feedback personally.”
“I just do not have the time and energy for this.”
It is important not to skip this step of helping your supervisee to identify their PZ. Doing so can help to remind them what not to do, or what not to focus on at various phases of their professional development.
Our circle of development is not static; it’s dynamic. If there is movement and directionality in the supervisee’s development, what used to be learning zone material might evolve to into the domain of the comfort zone. Likewise, what was previously panic zone materials can shapeshift into the realm of their learning zone.
The aim of helping our supervisees in figuring out their boundaries of their comfort, learning and panic zones is to clarify, magnify, and guide your supervisee’s messy and non-linear of professional development².
In the next blog post, I will address the critical value of teaching your supervisees to systematically monitor their clinical progress and how to use it beyond simply an assessment tool.
P.S.: My collaborators and I know how hard it is to figure out the key learning domains that therapists can spend their time and effort to deliberately practice. This is why we turned to what cutting edge research has to tell us, deconstructing the therapy hour, and we developed a comprehensive guide called the Taxonomy for Deliberate Practice Activities (TDPA) (Therapist’s and Supervisor’s version) (Chow & Miller, 2015). This is expanded upon in our forthcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness (Miller, Hubble, Chow, 2020). But for now, if you are interested to receive a copy of the TDPA worksheets, drop me an email.
References
Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. In D. S. Prescott, C. L. Maeschalck, & S. D. Miller (Eds.), Feedback-informed treatment in clinical practice: Reaching for excellence (pp. 323-355). Washington, DC, USA: American Psychological Association.
Chow, D. (2018). The first kiss: Undoing the intake model and igniting first sessions in psychotherapy. Australia: Correlate Press.
The Murder of Hope
Hope
During my short time as a mental health therapist, I have become aware that when a client enters my office for the first time, they are not alone. I am no longer surprised to find that they bring with them a crowd. Sometimes the client is young, as April was, not quite a teenager but perhaps not quite a child anymore either. She brought with her a myriad of people—family members, friends, classmates, crushes, and her abuser. I saw some of them immediately as our eyes first met, and I instantly recognized the power that they held over her, in her consciousness, daydreams and nightmares. They sat down with her and I could feel their grip, I could feel the fear in my own chest over what they had done.
There was another being that I had only recently become acquainted with. Her presence was not quite as potent but was steady from the start. She entered the room as soon as April did and invited me into a dance of both creativity and pain.
“It was not until this presence was murdered that I came to know her as Hope”. In the weeks that passed after April chose to end her life, I got to know the heavy stone of grief that had settled in my stomach. I spent hours resting my hand on chest, on my belly, breathing in this pain that felt more complex than just the loss of April. I turned it over in my hand, wondered what was there, in my grief with her. In the weeks that followed, I realized that this rock was not just holding April, but another being: Hope.
When I look back on my time with April, I can distinctly remember the first time that Hope made herself known. April had come into my office as if it was her own and flung my blanket onto the ground, spreading it flat with the tips of her fingers. She pressed her cheek onto it and traced the shapes below her. “We can lay on it as long as we don’t put our feet on it,” she told me. I laid next to her and she spoke of her dreams. So easily, she named her abuser as he was and told me about her body. As she did, I could feel the terrified child in me reach toward the terrified child in her, and then she was there. Hope made her entrance in this easy connection, breathing into me what could be. I began to feel, in this tangled mess of articulate children, the beginnings of an older woman.
Even before Hope was murdered, I spoke to her. It began in my car, after we met. I left each session and imagined what Hope was like—a bold, creative, quirky teenager who loved her friends ferociously and spoke to her pain with tenderness when it arose. She dressed in ways that made her feel empowered and felt safe to express her creativity, her passion, her fears. I imagined an adult woman who lived her days with gentle passion, unafraid of her desires and longings. A woman who wrapped others in her own sense of embodiment, who believed that healing was possible, who advocated for herself as fiercely as she did for others. It was easy to see the ways that this energetic, playful, imaginative child could become a wildly creative and embodied woman.
I must admit that in many ways Hope was not only made of the girl. She was made of the girl that I once was, who was much more withdrawn and fearful. She was made of some of my creativity, my passion, my wildness. She was made of some of the woman I am and some of the woman that I also long to become. Hope was free and tender in ways that I sometimes am not, and she was made of the sort of reckless dreams that I held around this beautifully courageous child.
Pain
Therapy with children is a wonderfully playful mess composed of hours of Jenga, making houses out of shoeboxes, outbursts, laughter, and moments of stunning articulation. Some children enter therapy tentatively, but for April it was not the case. With April, every activity involved a story, involved imagination and intricate webs spun between characters, both fictional and real. Amidst these stories, she’d tell me her own: about the abuse, and the terror that gripped her at night, and the maddening ways that one tries to make sense of such harm. She wondered about her fear, her desire, and how these things become intertwined. She asked questions that my child-self would have been far too scared to ask: “Am I still loved?” “Do I still belong?” “Is there something wrong with me?” In these questions there was no escaping my own fear, my own history with assault, my own terror that something is wrong with me. Questions I’d asked and supposedly answered as an adult, and yet.
And so, in these ways she began to ask me into her pain and demanded that I also acknowledge my own. As my own therapist put it so clearly, “there are some clients who invite you into more of your own healing.” I felt Hope here, too. As we stood in the lobby and said goodbye, April easily rested her hand in mine. I could feel two children speaking to each other, holding their own pain, holding each other’s pain. I could feel my own, adult hand, and I could feel Hope. I could feel the beginning of an exhale I longed so much for April to have. A type of exhale that is kind and purposeful and full of her own hopes and dreams—what a feeling it would be to witness. I knew, and Hope knew, it would not be easy to get to this exhale. And yet we believed that she was capable of it—perhaps not of entire days or weeks or years of settling into her own breath, but moments. Moments where joy and freedom were allowed.
And perhaps this is where the ache of death was felt the strongest. That when April decided she could not live any longer, she took with her two beings that I had grown to love fiercely. I have spent so much time thinking of the girl who sat in my office, the girl who played and laughed and bellowed at the top of her lungs in the lobby, completely unashamed. I have thought about the girl who spoke with astonishing clarity about those who harmed her, who bravely revealed her fears and her pain without looking away from me. I have thought about her hand in mine and her loudness and her lovely oddities. And I have missed these things fiercely.
As I have sat with my grief, as I’ve held the ache and numbness, I have been angry. I’ve been angry that when she killed herself she also murdered Hope, a being who I needed for April, but who I also needed for myself. As I’ve continued since April’s death, I’ve often wondered about Hope. I’ve wondered if she matters, now that she’s dead. I feel angry that I did not get a say in her departure—perhaps this is unwell of me, to have tangled myself up in April’s Hope so much that now it feels as if a part of me has died, too.
I’m furious because this is not what I signed up for. I signed up for pain, and for a long, difficult battle towards some sort of wellness, but I did not sign up for this. I did not sign up for creating this beautiful being with another person who gets to decide if they want to die and take Hope with them. The tangle of grief becomes nearly unbearable as I think of Hope. The girl and I, “we made her together, we crafted her from laughter and tears and imagination”. She was formed from a goodness I can still feel sitting at the base of my throat, a goodness that I have yet to let go of. As I live and know that she is dead, I want to cling to Hope and ask her to stay somehow, without half of her being. Without the girl, Hope is dead. And with her, the goodness.
It’s been nearly impossible for me to grasp that perhaps the heartbreaking truth is that Hope, for her, is dead. As much as I have taken this rock of grief in my stomach and wanted to smash it into the ground and say, “No! You cannot take Hope with you, too!” it must be true that Hope has also been killed, and there is so much grief in that. Letting go of April and her Hope will perhaps forever be molded into the being of my own Hope; the woman who I am and who I hope to become. Letting go of the girl means that Hope lives in me as an ache. She continues to grieve and rage and long for the goodness that once was. She sits and cries with those who also grieve the loss of the girl, and she keeps going, still holding the ache. In some ways it feels easier to stay in the anger, to argue with the girl, with Hope, to hold them here with my grief. Settling into the despair is harder, is a continuous reminder that yes, she is gone. They are gone.
Risk
Shortly after April’s death, I read these words in a blog by Jerusha Dressel: “Hope is a choice to stay.” The months after her death marked a death for me—in my personal life, and in my work as a therapist. I struggled to believe that I would ever feel connected to another client again. I sat in this feeling of death and wondered, where is Hope? Months after she would begin to make an appearance, for just a moment. I would see her after a productive session, and I would hiss at her: “get out of here.” Connection with my current clients brought a newfound sense of risk and dread: if I care about them, if I love them, they could die. And if they do, a part of me will die again. I wanted to do everything in my power to keep this from happening again. Perhaps if I don’t allow myself to love, to feel deeply connected and hopeful, then therapy will not hurt so much. I will not risk losing a piece of my soul again.
In the same breath that I hated Hope, that I wished I would never see her again, I also longed for her to return. I longed to feel connected again but feared so much the consequence that most of my being would not allow it. When I could not find her in myself I thought back to those words: “Hope is a choice to stay.” In this way therapy feels like a constant entering into the terror of Hope: afraid of the death and the grief that connection might bring, and yet. Hope is a choice. To keep listening, to keep feeling, to keep holding the trauma of our lives and each other’s lives. There is an excruciating beauty in the invitation to enter these spaces of pain and betrayal, and I began to center myself again in that truth. We are wired for connection. Amidst tremendous suffering, we are not required to see the ending—to see Hope of recovery or health or happiness. Somehow, in the despair, we can choose again just to stay. To behold each other’s stories. To feel the pain deeply and fully and remain with each other in it.
Hope and I will continue to be on hiatus. As I grieve and rage, I do not want to see her. And yet I know that every day as I choose to re-enter all that is therapy, she is around. A part of her has died. A part of me has died. And still, we stay.
Jay Lappin on Family Therapy—The Long View
A Social Justice Lens
Lawrence Rubin: Good morning Jay and thanks for sharing your time with me. You’ve been practicing and teaching family therapy for several decades, in which time certain issues affecting families continue to remain relevant while other hotspot issues have gained prominence. May we start off by addressing some of these hotspot issues that family therapists need to address?
Jay Lappin: Sure. I think that one of the constants has been around social justice and poverty. We see the effects of the political decisions being made by different administrations and their changing priorities, including most recently around immigration. One of the things that I remember from my interview with Sal Minuchin a few years ago was him saying that, back in the day when we first started doing family therapy, we thought that they could change the world one family at a time. There was this thoughtful pause, and then he said, “We were wrong.” And that’s what got him into doing larger systems work, and myself as well.There are wonderful efforts by non-profits like The Annie E. Casey Foundation who are really taking this on, and it also still continues with family therapists who are doing home visits in impoverished communities which built on the early years of social work, and then on the work of Sal and others like Braulio Montalvo back in the ’60s. But we haven’t changed the world just yet.
LR: For the average family therapist who is not on the Southern border or who’s not in one of those areas where he or she is likely to see these families impacted by immigration policies or poverty, what guidance can you give them around working with families suffering social injustices?
JL: I think just being aware that social injustice exists, that there are commonalities among all families and their circumstances, but also as unique differences between families. That systemic perspective helps a lot. I just had a case involving a young man, a minority kid in a school system where there was a big incident. Because of my good fortune of working at the local clinic and being aware of the systemic issues, the line of questioning I used for the parent took a different turn. It was more of a talk about what the community was like and what it was like to be a minority family within a majority-culture town. And it really felt like things changed in the sense that there was space for that conversation. And I think that we can all make that space about those differences and be aware of them.
LR: There’s so much of a necessary push these days for therapists to become sensitive to and aware of diversity issues affecting individuals and, of course, families. So, is it our ethical obligation when working with, as you say, a minority family in a majority system, to bring in these social-justice issues, even if the family doesn’t address them? Is it our obligation?
JL: I think so, especially for those of us that are majority-culture folks. I know enough that I know that I don’t know enough about a minority family’s location in society. And I think to pretend that it’s not there is doing a disservice to the family and to the process of therapy. And, you know, the thing in systems work and all therapy is that you read the feedback. So, what happens when we open up the space for that conversation and what does it lead to and how does it change what we’re doing in the therapy? At the end of the day, they still want things to be better for their children, and that’s cross-cultural. I think we can do better when we create space to have those conversations.
LR: Do we expand a social-justice lens beyond culture and race when working with families these days? Are there other hot-button social-justice issues—you mentioned poverty—that we need to open the door to and invite into the family therapy space?
JL: Well, income differences. The vast majority of clients in my private practice, are majority-culture folks—middle-income and well-situated. The issues of social position, money and resources are still there, although on the other end of the spectrum. It’s all a part of the soup that we live in. I don’t see there’s any downside to working with these clients necessarily, but it’s very easy to get kind of a narrow lens just because that’s who’s in front of you.I remember a story Sal told me years ago during an interview. When he was young he had a psychology teacher who was a fan of Rousseau who made the case that delinquents were part of a larger system and the social institutions in which they lived. During the time that Sal was in high school, his family went from very good circumstances to losing pretty much everything as a result of the Depression. They lived in poverty. Sal’s story was about reminding ourselves how lucky we are, but also the obligation we have to all members of society. As family therapists, we must be open to conversations with families around the issues that are important to them, ones around which we may have little direct experience.
The Temptation of Sameness
LR: Clearly then, family therapists must be humble, aware and sensitive to the needs of minority-culture families. What about other hot-button issues like the breakdown or denuclearizing of families, and the newer ways that families are coming together—gay and single-parent, step, adoptive and foster families?
JL: I think one of the great things about being a family therapist is that you get to bear witness, to be a part of that change that you’re talking about. In family practice I see more and more of those denuclearized families that come in with different combinations. The classic ’50s Ozzie-and-Harriet family is changing and in a big way. But at the end of the day, they are all still families. They still love their children, and that crosses those old boundaries. We still have to do our jobs, but the context is shifting, and I think it gives us more possibilities, too, to think outside of the box.
LR: So, these new ways that families are coming together present challenges and opportunities for family therapists to expand their core skills? Are there specific ways that family therapists can expand to open up to these changing ways that families come together?
JL: Yes, I think that one of the ways that we get to do it is by working with different populations, because there is always the temptation of sameness. We do what we know. But, you know, there’s that old saying, “if you want to know about water, don’t ask a fish.” We can put ourselves in situations in which we feel different and that we experience other families. Home visits, I think, are a great way to do that. You can tell a lot about families, about how they live together, and it also stretches us a bit. I think both young and old therapists need to have an opportunity to do that. I think it helps our work and stretches us.
LR: Are you saying that the changes affecting families and the way that families are adapting to those changes is a clarion call to family therapists to dig deep, push hard, keep climbing learning curves and look for new ways to connect with new families, because each family that walks through your door is different?
JL: I think it’s all about difference. A picture is worth a thousand words because the picture is what the talk and the words are about. So, for example, Sue Johnson‘s work with attachment understands that talk therapy is necessary, but it’s not sufficient—it’s really about the enactment. It’s the felt experience of those different situations and pushing ourselves that challenges limiting patterns. You have your bag of tricks and you get reliant upon them, and, why? Because they work, after a fashion. So, it’s about taking a risk.And, that’s fair because it’s a risk for a family to come for treatment. Sal had this great saying that families are wrong about two things when they come to see us. First, they’re wrong about the location of the problem. It’s not the kid. He or she is an identified patient, so it’s the family system that’s the patient. And second, families are mistaken about is who is going to fix it. They look to us, but our position is that the inherent strengths are there in a family, that they have all these over-determined patterns, which is what brings them to us. So, I think, in this respect, we’re not asking any more of the families than we are of our ourselves, and I think that’s more fair.
LR: If Sal said that families come in with two errors in thinking, one is who the patient is, and the other is who will fix it; what might be some of the fundamental thinking errors that family therapists bring into their work?
JL: Oddly enough, the same two things. It’s a challenge. Family therapy can be tough, because you have all these people in a room. One of my early fatal mistakes with a family was when I thought I was being this wise, young guy that could figure stuff out quickly. It was a family I’d seen only 10 or 12 minutes in which the father was a plumber. So, I start spouting off—“blah, blah, blah, you should do this, you should do that” and the man turned to me and said, “How can you tell? You only met with us for a few minutes.” And because I was young and even more stupid than now, I said, “Oh, well, you’re a plumber.” And he said, “Yeah.” And I said, “How long does it take you to figure out that there’s a leak in the basement?” And the guy just looked at me with a lot of anger. I never saw the family again. So, either it was a one-session cure, or it was an abysmal failure. But I remember that I really hadn’t respected them. I hadn’t taken the time to join, and I was trying to be show-off. “Look how much I know.”So, I think it’s always the read-the-feedback thing, and we learn from the families as much as they learn from us.
An Alphabet of Skills
LR: Sal Minuchin taught you (and others) the importance of enactment, joining and challenging. How do you teach these fundamental skills to new family therapists who may be intimidated or challenged by a family?
JL: We came from an academic tradition where you teach theory, you teach theory, you teach theory, and then you practice. And Jay Haley had this great idea that you have people do things first and then retrospectively go back and say, okay, what happened? What happened when you turned to the mother and asked her to talk with the son? What was going on with you?So, it’s more that style of teaching where you’re consistent with the model of having people do things. When I teach, it’s lots of role plays, making up families. And then I have just some basic rules that I’ve come up with over the years, like thinking of joining as a traffic light—you have a red light, a yellow light, and a green light—and when you’re working with a family, you should always be in the yellow.
For instance, in New Jersey, you go through the yellow lights, and in South Philly, people don’t stop at stop signs. You kind of roll through the intersection. And I say if it’s green, that means it’s a bit too easy—Lyman Wynne had this expression of the rubber fence where you’re working with a family and you think, God, I’m really joined well, like it’s really the strength of homeostasis. So, green, not so good. Yellow, perfect.
But I’ll tell them if it’s a red light, you have to rejoin. So, if you’re trying to frame something or get an interaction going and you’re just getting that red light, then you say, okay, I need to reconnect, find another way to make this happen. It’s that constant reading of the feedback, and when you do role plays or approximations of families, then you can say, “What was that like when the family wasn’t with you on that? What happened? What did you come up with?”
And then you’ll go deeper with the students, and they can say, “Well, you know, it reminded me of this, where I felt this way.” So, okay, how are you going to shift that, because you’re going to be working with families. You’re going to have that capacity to be flexible. It’s like muscle memory almost, that you have to do it over and over again.
LR: You had said that Minuchin also taught you about the strategic use of self in the room. How important is this in the teaching and learning of family therapy?
JL: You probably don’t have it down in Florida, but here in New Jersey and Philadelphia, we have row homes which all look very similar from the outside. They’re each the same size and distance apart from each other, have the same foundations and the same layout. It’s like a rectangle. But when I used to do a lot of home visits, going from one person’s home to the next could be completely different. The next person’s home could even be on the very same block. So, that for me was a metaphor because my foundation is in systems work and structural theory, but the larger framework, what’s in the house and how they live, is up to the families.I think you have to just do it or it would be like reading about how to play guitar. That’s great if you already know that “A” has three sharps, but unless you’re playing it and having somebody saying to you, “What was that? Where were you going with that? What did you want to do? Let’s see if you can come up with another way,” you’re not going to improve your skill set. I lament the loss of one-way mirrors and taping. It doesn’t happen as frequently as it did back in the day.
LR: My experience has been that there are a lot of people out there doing family therapy, charging for family therapy, writing about family therapy, lecturing about family therapy, and they don’t seem to understand or really appreciate systems theory. They’re not students of the foundational theory that drives all models of family therapy. And I lament that. Do you see that as a problem?
JL: I remember talking to Sal and Braulio about this. They had this idea that you could have what is called an alphabet of skills. The idea was if you taught these skills, you could be a competent family therapist. And, indeed, many people did and are.But Sal said, that having an alphabet of skills is like teaching somebody the alphabet and then expecting that they can write sonnets. Like the idea of putting a room full of monkeys at typewriters who would type a Shakespeare play, by chance, after thousands of years. Having an alphabet of skills is necessary but not sufficient to practice competent family therapy. So, people need a bigger container. I think that what you’re talking about is having the systems foundation. It’s a deeper, bigger container to hold those ideas and to have the freedom to experiment. You’ve got to know where this stuff comes from, and I think it helps to have that foundation.
And I Got Dinner
LR: What are some of the personal and professional obstacles that family-therapy trainees need to overcome in order to eventually practice effectively as family therapists?
JL: I think first is finding an agency that values home-based family therapy. Back in the early days of clinic work, especially in the cities, you’d have people come for outpatient therapy, crowd the waiting rooms, and then you there’d be a large population of people that you could see.The shift to home-based family therapy, which, as you know, followed in the social-work tradition of doing work in people’s homes, changed things, so that people, especially poor families, didn’t necessarily have to get to a clinic. By going to people’s homes, you very quickly get a sense of what is happening. When I first went into private practice, I only had a handful of clients, so when I saw families, one of my requests was that they invite me for dinner. It was great, because, literally, within minutes, moments, you would have a whole set of new ideas. The theories I had about families when I went to the house was…
LR: Out the window.
JL: Right exactly. It was very humbling at times. And I’d have the kids show their rooms and their stuffed animals and their toys. And it was just such a rich environment, and then we’d have a family session after dinner. I got dinner.
LR: And they got therapy. And you did a hell of an intake by wandering through their rooms and sitting at their dinner table.
JL: Yeah, it was great. I think that the home-based work is really remarkable, and it’s a challenge. I remember being a research therapist on one of Duke Stanton’s projects with heroin addicts and their families. In those days, you’d have these massive cameras and tripods and all that stuff that you’d be lugging into people’s houses.So, in the middle of these intense moments, you’d think, oh, boy, this is really it, we’re going to tip the scales here. And then the dog would run through the scene or somebody’s diaper was wet, or the phone would ring. So, you would have all these multiple things happening at the same time, and you would have to figure workarounds. And you would really get a lived sense, an experienced sense. As opposed to talking about it, you were experiencing it.
LR: Clinicians and trainees attend workshops where clinicians show these wonderful, rarified clips from magnificent and timed interventions; but the reality is that families are messy. Families are complex. Families are chaotic. And maybe that’s one of the reasons why some people run from family therapy like the plague while others run to it. I wonder if there’s a difference in would-be family therapists regarding their tolerance for complexity, chaos, and ambiguity.
JL: Yeah, you’re right. It could be very chaotic at times, noisy…I just think it’s such a privilege to see the family in total, because when you see the kids individually—and, certainly, there’s a place for that in the context of family work—it’s not the same. You get so much more if you can see the whole family. For me family work is the best, and one would hope, even from those rarified clips, that people get excited about it and want to do it.
LR: I’m a child therapist, a play therapist, and I always say to my trainees that when you see a kid, they’re going to bring their family along with them. You have to be open to inviting the family in. So, is child therapy, by necessity, family therapy.
JL: There was a recent piece in The Inquirer about a Yale study on children that were anxious. The bottom line of the study was that they figured out that one of the principal causes of the kid’s anxiety was the parents. And I thought, are you kidding me?
Appy Hour
LR: What a surprise!
JL: So, their treatment model was having the parents figure out ways to help the children tolerate anxiety so that they were no longer hovering or helicoptering. And, really, when you think about it, it’s more of a systemic version, but it’s under the heading of teaching the kids.Years ago at the clinic where I worked there was research on pain. This fellow Sam Scott, who was one of my supervisors, a brilliant guy, had studied some with Erickson. Sam and Ken Covelman and Bruce Buchanan, who was my partner in teaching at the clinic, were working with families to develop ways to have kids who were experiencing extreme pain through psychosomatic and physical illnesses, get calmer.
Sam and the crew had developed this wonderful script that accounted for systemic interactions between the parents and the kids. The parent would say, “What we’re going to be working on today is helping you to feel more relaxed.” And then, in parentheses, the parent would have something that they would read to themselves that would say something to the effect of, “And while helping my child to relax, I want to breathe more slowly and thoughtfully.”
Just inserting that spacing or that timing helped the kids and the parents simultaneously to relax, which is different from the kind of individualized mindfulness training where you’re just teaching a kid how to relax. The back and forth accounted for the relational context.
I was teaching a family therapy course a few years ago at Penn and Drexel, and I realized that there were no students in the class that were as old as our youngest child, and I thought, “Oh, God, I am so ancient.” So,I created this thing called Appy Hour. At the beginning of class, the students would present apps that were helpful in teaching relaxation skills. It’s corny, but it was great, because they were all about finding these very cool apps. And if I see a kid individually, I’ll have the kid teach the parent how to relax and show what they learned on an app. As you were saying earlier, having that systems foundation just helps you think differently in a situation.
LR: So, whether you’re working with an adult, a husband, a wife, a lover or a child, you can work with any individual within a family, and as long as you are thinking and acting systemically, you’re helping everybody. You’re not targeting one person, even though one person may be the person that you’re working with.
JL: Yeah, there was a really good, two-part CD that Alan Cooklin and folks from England put together, and I had the privilege of interviewing Braulio Montalvo for it. I asked, “What are some of the seminal ideas about Minuchin?” This tape is called “Inviting the Family Dance.” Braulio said, really, the most important thing for him was Sal’s idea about part to whole. When you’re working with part of the system, you always keep the whole system in view, no matter who is in the room. If you have the kid, a parent or both parents, you’re always thinking of the whole system as kind of a backdrop. So, it’s reflected in having a kid learn an app and then teaching it to his parents or teaching it to her brother, moving from that idea of part to whole.
Tango with Me
LR: You’re engaging and empowering the whole family. In the linear world of individual psychotherapy, the push is toward evidence-based practice and manualized treatments. Has this push been part of the story of family therapy?
JL: I think, historically, one of the reasons that family therapy is around today is because, in its early years, family therapists took on the challenging populations—eating disorders, schizophrenia, delinquency, minorities—ones that for a lot of reasons resided at the margins of the prevalent psychodynamic and psychoanalytic models of the day. It was as if family therapy was being told, “Fine, do what you will—see if you can do better! And boy, did they. For Structural Family Therapy (SFT), the challenge to the status quo began in the Sixties at the Wiltwyck School for Boys in New York. Minuchin, Montalvo and others frustrated by the poor outcome with individual treatment decided, “This isn’t working—we have to do something different…”With support from an NIMH grant, Structural Family Therapy researched the development of a family/systems-based model with poor, minority delinquents and their families. Their research and the early bones of SFT were published in the 1967, Families of the Slums. Absent the internet, there was tremendous synergy and cross pollination—Minuchin making his way out to MRI and meeting Bateson, Haley, Don Jackson; Murray Bowen doing his work with schizophrenics; Whitaker’s developing his Experiential model; Satir’s Conjoint Family Therapy published in 1964. It was as if a whole new language and culture were sprouting up, rules were broken, the one way mirror and the capacity to videotape changed everything. And, like Gil Scott-Heron said, “the revolution will be televised,” and it never stopped.
LR: Along related lines, is manualized intervention antithetical to family therapy?
JL: I think there is a place for manualized care. Ultimately, I think that every therapist has to make their treatment their own. Sal would talk about the family dance, a “Tango.” Sue Johnson also has embraced tango dancing as a metaphor. And there’s some of us who are old enough to remember Arthur Murray’s Dance Studios where they would have the feet painted on the floor.
The Long View
LR: Steps! Actual, certain, steps that are important to take, but also instilling the importance of the therapist bringing their own person and adapting to constant changes. You know, “Dancing with Arthur Murray,” that would be a good family therapy article.Jay, you’ve mentioned in our phone conversation and in this in this interview about your relationship with aging. How has this relationship with aging played into your work as a family therapist?
JL: I think it’s made me more appreciative and humble, and grateful for the work. It’s the best job ever, really, when you think about how lucky we are to be part of people’s lives. And I think being a parent and being married for 48 years has given me perspective that I didn’t have when I was younger and new to family therapy.I think the aging process, being married a long time, having kids and grandchildren, the good fortune of amazing supervisors, mentors, students and clients, alongside experiencing painful losses of family, friends and clients, all of it gives you a certain perspective. Also, reading the Persian poet Rumi and Thich Nhat Hahn’s wisdom has slowly but surely shaped my appreciation of time and impermanence. I really value those present moments with families and with couples and individuals. I just continue to pinch myself about how lucky I am to be able to have that, and that people invite me into their lives to help them, and I do the best I can.
LR: How has this appreciation found its way into your clinical work with families?
JL: Someone I see experienced a profound loss of a child. All of my own family-of-origin issues played out alongside the experiences of this particular family. My youngest brother was 5 when he died of leukemia, and it had a profound impact on my family. Our oldest son, after he graduated college, came down with non-Hodgkin’s Lymphoma and he’s fine, and I’ve had malignant melanoma.Years and years ago, Sal and Pat Minuchin used to host these summer events at the end of the externship. People would come to the clinic for training from all over the world and Sal would host barbecues and there’d be teaching and learning. I was sitting in a group of students, and he was going around asking them about their families and their kids and so forth. He skipped me and went to somebody else. Afterwards, I said, “Sal, I know that you asked everybody about their families, but you skipped me. How come?” He said, “Because you don’t have any children yet.” And then he said, “It makes a difference.” When you live that experience, your perspective, for better or for worse, changes. Of course, he was right.
Once you have children, once you’ve experienced those kinds of losses, how can it not affect your worldview?
I think I’ve been more appreciative of that, and I think that shows in the way that I still challenge overdetermined patterns in the family, and challenge the ideas people have about themselves and always assume a strength-based model. It’s the therapist’s responsibility to come up with a context for those different slices, or, as Dick Schwartz would say, those parts of themselves that can be more manifest in a room, and then to recognize them when they happen.
Forrest Gump Meets Jay Haley
LR: You’ve jokingly referred to yourself as the Forrest Gump of family therapy. It’s a great metaphor, since you’ve had these incidental but powerful moments with the likes of Sal Minuchin, Carl Whitaker, Paul Riley, Braulio Montalvo, Marianne Walters and Barbara Bryant-Forbes. But you also have to be a Forrest Gump in your clients’ lives in order to be fully engaged with them at their own pivotal points.
JL: Larry, did I tell you the story of how I became a family therapist? My Jay Haley story? It’s to your point of being Forrest Gump and just being aware. In 1972, my wife and I got married on September 2nd, and I was drafted into the Army on September the 20th. I was very lucky that one of the nice things that Nixon did, if we can say that, is that he said only people that volunteer to go to Vietnam would go to Vietnam. So, I thought, okay, I’ll take my shingle, you know, shovel shit for the next few years, at least I’m not going to ‘Nam.So, I got out of being sent, and through a series of, again, Forrest Gump-like events, I wound up in Fort Gordon, Georgia and was assigned to work in the Mental Hygiene in the stockade and in the maximum-security block. I was seeing prisoners and thinking, “I have no idea what the heck I’m doing with these guys.” I was sitting in cells smoking, 26 cents a pack, how could you not smoke, and thinking, “Shit, I’m really lost here.”
So, I went to our psychiatrist, who was a man by the name of Art Warwick, who looked like—even then, Alan Dershowitz, who smoked a pipe. He had kind of fuzzy hair and wire-rimmed glasses, a brilliant guy. And I said, “Art, I’m lost with this stuff about how to see these guys.” I said, “Is there anything I can read to help me be a therapist, because I have to counsel these guys?” So, he’s smoking a pipe in a very cliché psychiatrist way and he puffed a few and said, “Get Strategies of Psychotherapy by Jay Haley.”
So, I sent away for it and the thing finally arrived and I started reading about Haley and Erickson and I just thought it was incredible. I wanted to do this kind of therapy.
The years went by and lo and behold, I wound up working in Philadelphia Child Guidance Clinic. I meet Jay Haley, and my head was like a dirigible because I couldn’t believe I was getting to work at that clinic. So, Art and I stayed in touch. I went to see him and we were sitting drinking beers, and talking about Army days, and I said, “Art, by the way, when you recommended Strategies of Psychotherapy to me, is that because you saw me as a good, strategic, structural family therapist?”
So, Art had this shit-faced grin on. He was smoking a pipe again. He kind of looked at me and said, “No.” I said, “No? how come,” and he said, “Well, your name is Jay and Jay Haley’s name is Jay and I thought it was kind of funny.”
Parting Words
LR: That’s your illustrious, effing origin story! You are Forrest Gump, Jay.Would you offer some parting words for the people who are going to read this interview, whether they are brand-new family therapists, graduate students, seasoned therapists, or old horses like yourself? If you had to condense your wisdom into some Salvador Minuchin-esque type of statement that people will be quoting 50 years from now? No pressure though, no pressure.
JL: Yes. Sal was a poet, as was Braulio. I think I would say, do family therapy—it’s the best job you’ll ever have. And whatever job you have after that, it will help you. It will help you with the people that you serve. It’ll help your family. It’ll help your children. There’s no aspect of your life that it won’t touch, and in a good way. And it’s a gift, and you’ll say your thanks for it.
LR: You had me at hello, Jay. I really want to thank you for sharing your stories, your wisdom, your decades of experience, and I anticipate many more wonderful stories.
JL: Thank you, Larry.
How to Maintain Your Therapeutic Dignity with Blood Dripping Down Your Chin
When we moved from Dallas, Texas to Fayetteville, Arkansas back in 1993, I quickly realized that any therapeutic anonymity I'd experienced in Texas was a big “not happenin,” that is unless I wanted to hole up in my house and never partake of food, fun or the festivities that went on in my lovely new hometown. The place was too small and just Southern enough where your business wasn’t just yours.
Now, after practicing 26 years in Arkansas, I'm far from reclusive so I regularly run into people I’ve seen as patients. I’ve been aware of how running into one another in public might impact their relationship with me and any work we did together, but often it was the result of simply living.
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I'd been in Arkansas for about four years when I auditioned and earned the role of radical feminist and socialist Emma Goldman in the vaudeville musical TinTypes. I came on stage at one point in roller skates, singing raucously and playing violin…badly. I worried a bit, “Does anyone really want to see their therapist doing that?” When I played the passionate Desiree in Little Night Music, a patient told me they had to quit seeing me, “Because you kissed another man.” I explained about how kissing on stage is not really kissing, and we looked into her feelings. My son had a horrific tantrum at a toddler birthday party that violently came to a halt when his very hard head bounced off my lip, causing blood to spurt all over me and him. And of course, the story in my head became, “Hmmm…are those moms I’ve seen questioning my competence?”
It's like trying to live your real life while also retaining some amount of therapeutic professional respect and dignity—in roller skates and with blood dripping down your chin.
Since that fateful afternoon, I've taken even more risks—and hope that the ethical disclosure gods don't chew me up and spit me out. For several years, I've had a blog and a podcast and I'm quite open there as well. I respect that this isn't everyone's cup of tea. And might not, depending on your theoretical orientation, sound like good, responsible practice. But I've come to believe that we as therapists may be unintentionally enabling the silence of mental illness stigma by not being more up front about our own struggles.
Don't get me wrong. I use discretion. I go many a day without saying a word about myself. My job is to listen, to hold, to contain, to suggest, to educate, and to guide. However, I've revealed that I went through a divorce when I think it will be helpful. Actually, two divorces. But that's not the point. I've also disclosed that I have performance anxiety, panic attacks, and a history of anorexia, again, when I think it's helpful for the patient. And I reveal that I've been on both sides of the couch—as patient and psychologist.
The criteria? If it's truly helpful to the patient and not about some need I have to “share.” What I've experienced is that my openness is respected. My vulnerability and risk—helpful. People now tell me, “Your openness about your own vulnerabilities gives me more permission to do the same.”
This all came dramatically to the fore two years ago, when I presented in a local This Is My Brave show. If you don't know this organization, it was begun by Jennifer Marshall, who'd been blogging anonymously about her bipolar disorder for years. It was only when she came forward—as herself—that her blog's audience skyrocketed. And she realized that her vulnerability mattered. The organization now hosts programs both nationally and internationally, featuring people with mental illness telling their stories to a live audience.
When I agreed to do it, I thought it wouldn't be anything. I'd already been writing about my anxiety. So, what could be difficult about it? Once again, my own running narrative was ill-conceived. It was quite emotional. And hard. Yet I'm so glad I did it. I've revealed my own vulnerability, my own passions, and my own struggles. Bloody chin and all.
A Tale of Two Cars: Interpreting Therapeutic Play
Sam came to our session with two wooden cars he had made in occupational therapy. When I asked hi how things were going, he made a few comments about not wanting to return to his father and stepmother’s home. He seemed pensive and sober, but had little more to say. Instead, he seemed to be increasingly absorbed in playing with the wooden cars—one a larger Model T, and the other a smaller “Buggy.”
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Like many 12-year-olds, Sam was not especially fond of talking, particularly about the problems that had led to his hospitalization. I made some additional attempts to engage with him verbally, but eventually I, too, became more absorbed in what Sam and the cars were doing. Sam was steering them wildly around the top of my desk. Sometimes one or the other, or both, would come screeching to a halt, right at the edge of the desk, which seemed to be a cliff. At other times, they interacted with each other, and, on a couple of occasions, the little one pushed the big one off the cliff.
As I was drawn more deeply into the drama that Sam was playing out, I began to think about our session somewhat differently. At a minimum, Sam’s involvement with the cars seemed to reflect, among other things, the discomfort he had just displayed about discussing his problems. Maybe the best thing to do was to drop the questions and engage with Sam around the play. I started narrating what the cars were doing: “Hmm! The big one is towing the little one. . . Now they’re spinning around each other. . . Wow! They hit each other that time!”
It felt like Sam and I were more engaged now. But what, exactly, was going on here? The interplay of the cars seemed to be more than a mere resistance or fantasy about driving. What was being played out between the cars was intense—a dynamic and developing relationship of some kind. It appeared that Sam was using the cars to express something emotionally significant in the medium of play. An interpretation seemed to be called for.
Psychotherapists have had mixed feelings about interpretation throughout the history of the field. In the early days of psychoanalysis, Freud and others believed that insight gained through interpretation was the primary curative factor in psychotherapy. It was generally held that in order to be effective, an interpretation had to be accurate in all its details. However, Edward Glover later pointed out that while many of the interpretations reported by earlier authors had probably not been entirely accurate, those same interpretations had often, apparently, been quite effective. Furthermore, evidence was starting to accumulate that a good therapeutic relationship was more helpful to patients than intellectual insight gleaned through interpretation.
Nevertheless, some sessions—like the one with Sam—do seem to involve an alternate form of meaning-making in which interpretation may play a useful role. And so, in this situation I found myself pondering just what Sam might be trying to communicate to me.
Perhaps the little car was Sam and the big car was me, trying to get him to talk. But the intensity of Sam’s play suggested that the dynamics within his family were more likely to be relevant. One possibility was that the big car was Sam’s father—but most of Sam’s conflicts were with his stepmother, whom he resented for taking the place of his biological mother. Indeed, Sam and his stepmother had been colliding into each other and spinning around in circles for years. I ventured an interpretation:
“The little one and the big one are pushing against each other, kind of like you and your stepmom fighting with each other.”
“Mm-hm.”
Not very enthusiastic. Maybe I had jumped in too quickly. Or maybe the interpretation that I had ventured was off the mark. The big car might be Sam’s biological mother. She had been described as physically and verbally abusive, abandoning Sam with his father on several occasions. After custody was given to Sam’s father, Sam’s biological mother had been involved with Sam only sporadically, staying away for long periods of time and intermittently making promises to visit Sam but not following through.
More play. Now, the big car drove headlong off the cliff and crashed into the canyon below. Then, slowly, it returned up a mountain road, back to the top of the cliff.
“Gee, it drove off the cliff and then it came back!”
“No. This is another car.”
“Ahh!” I said. I had the information I needed.
“You know what I think?” I said. “I think what’s happening in your family is like what’s happening with the cars. When the big one went off the cliff, the little one was left alone, like you were left alone when your biological mom went away. Then another big one came, like your stepmom; and now you and your stepmom have to try to get along with each other and help each other, like the two cars towing each other. But it’s really hard because you still miss your biological mom. You don’t know when you’ll see her again.”
“I don’t think I’ll ever see her again.”
“Really?”
“Yeah.”
“It’s hard for a kid to lose a parent.”
“I think the more I don’t see my mom, the more mad I get.”
We talked about this. He expressed anger that when he had recently said he wanted to get in touch with his biological mother, his father and stepmother had replied that this was not a good idea. I suggested we discuss it with them in our next family meeting.
That night, Sam had his first good evening in the hospital, and over the next few days he shared, first, his anger, and then his hurt, about his biological mother’s many failures to visit him.
In the next session with his parents he called his stepmother “Mom” for the first time. At the end of that meeting he gave her the big car and said, “You can take this home.”
How Self-Disclosure of Learning Differences Guides My Clinical Relationships
Origins of Empathy
Part of my initial interest in becoming a psychotherapist and coach stems from my personal experiences struggling with learning differences. I am interested in using some aspects of my life to help other young adults with similar diagnoses navigate their challenges. It is reported that 75 to 85 percent of young adults on the spectrum are unemployed, and although the exact statistics on unemployment among adults with other learning differences are not known, it is widely thought that they also face a variety of barriers.1 The clients that come to my practice often say that they are struggling to manage their workload, navigate interpersonal situations with colleagues and bosses, and establish friendships and romantic relationships. “Preserving the uniqueness of their challenges while drawing on my own experiences is a tricky balance as a psychotherapist”, but I have developed a few strategies for doing so.
Fellow Travelers
My clients frequently find me through my writings for the NVLD (Nonverbal Learning Disorder) project, a non-profit that disseminates research and builds awareness regarding this unique visual-spatial disorder. One of the first things I tell them is that everyone’s experience is unique, and that my job is to help them to navigate their lives while also drawing on some of my own personal experiences related to common issues such as self-disclosure in the workplace, creating organizational systems and finding mentorship. The key is to listen fully to their stories and experiences, helping them to brainstorm and find their own solutions, while also offering, when appropriate, some personal anecdotes that might be helpful for their specific situations. An example could be a client who states that he or she is not sure how to best self-disclose their learning difference to their employer. We may explore ideas about different times and places to self-disclose, and I can talk about what I have learned from my own experience. I have found that many clients often appreciate this approach, stating that when I speak from a personal viewpoint it helps them to trust me more and feel as if I can relate better to their experiences.
If transference in psychotherapy normally consists of unresolved feelings and expectations that are placed onto the therapist–oftentimes in an unconscious attempt to recreate or approximate a past relationship, and countertransference is the therapist’s resulting conscious and/or unconscious feelings that are projected onto the client, “the therapeutic relationship between two young people with learning differences is ripe for the enactment of these feelings/experiences”. I often find that the clients I work with report a feeling of safety and security, perhaps seeing me as an older sibling or parental figure, especially when they describe feeling understood or supported by my being in a unique position to empathize with their learning differences.
Transference & Countertransference
One client, whom we will call Joyce, frequently contacted me after our therapy had ended in order to ask questions that usually began with “since you have and know about NVLD…” Because our work together had ended, I redirected her to another therapist who practiced in my office, but she did state that she had felt a sense of security and safety with me that she may have felt earlier with her mother, whom she used to call to help guide her with difficult situations. In some ways, she may have unconsciously seen me as a parental figure helping her to navigate difficult questions related to her job and personal life.While working with male clients, I have often found that the transference/countertransference relationship may take on a different form. This is due to the fact that there is an element of both bonding and competition; many of the young men I have worked with may have a complicated history with women, especially regarding rejection and feelings of emasculation, a topic about which they may look to me for understanding. While I do not usually disclose my romantic status or experiences, by validating the unique challenges of dating with a learning difference and providing some practical steps for managing these feelings, I establish a bond with these clients, who describe previous male friendships in which they discussed these issues. A dynamic of male companionship can often form between my clients and me. However, some of my male clients have also seen me as a source of competition, and have reacted strongly, stating “you don’t know anything” or “how can you understand me?” Admittedly, it may be uncomfortable for some of my clients who see me as a “success story,” especially when they are struggling to find work or build interpersonal relationships. This is also a dynamic that I try to work through with them, making space for it to be discussed in the therapy room.
I attempt to use my countertransference as an indicator of not only how I should respond to the client in the room, but also of when, if and how I should self-disclose. A dynamic of male connection may lead me to respond to a client’s disclosure regarding rejection in the dating world with a few suggestions for improving one’s strategies, perhaps with the caveat that I have learned from my personal experiences. Depending on my relationship with the client, I may also use my countertransference as an indicator of my familiarity with certain aspects of the client’s professional experiences. For example, I remember identifying with a client I will call Michael, when he described challenges figuring out certain aspects of his job, as I have had similar experiences. However, if a client expresses competition or hostility towards me, I may also notice a feeling of defensiveness that arises in me, which will cause me to be more cautious regarding self-disclosure. Again, “countertransference can be an indicator of when and how to self-disclose”.
In my clinical work, transference and countertransference are often sparked by the patient’s vulnerability in the therapeutic relationship, something that individuals with learning differences will sometimes go to great lengths to conceal. Sometimes, they will hide behind a veneer of competence, lest anyone discover their sometimes painfully embarrassing challenges. The transference and countertransference dynamics in a therapeutic relationship often emanate from these struggles becoming visible, causing relief, vulnerability and perhaps shame at the same time. An articulate and thoughtful client, whom we will call Jenny, recounted how she had transferred to a reputable private school to receive more academic support and was subsequently abandoned by her previous friends, who stated, “So you think that you are better than us?” Despite distancing herself from her new school’s perceived “preppy” culture, she was reticent to explain that she had enrolled there because the workload and lack of individual attention at her local public school had become too onerous to handle. Quite the opposite of feeling “better,” her true reasons for transferring were a source of embarrassment. Hence, she described feeling “invisible” to her former friends, as they had falsely assumed she must have chosen the school for its supposed prestige. Jenny’s story prompted me to reflect on how many of my peers had also judgmentally questioned my parents’ decision to send me to small private schools, with statements such as, “Wait! How many people go to your school!? That’s weird.” Not to mention, “Are your parents rich or something?” I stated to her, “It is so frustrating and somewhat ironic when people assume you attend a private school because your rich parents want to help you escape the chaotic real world of public education, instead of the reality that you would do anything to be able to thrive while attending a school with over thirty students per class, loud and confusing hallways, and overwhelmed teachers.” Jenny thanked me, and although I never disclosed my experience, the fact that I had made hers visible created a positive transference between us. In that moment, I may have seen her in a way she would have wanted to be seen by an empathetic friend.
“Group therapy sessions necessitate a different kind of self-disclosure” and create a different stage for the expression and integration of transference and countertransference into the therapeutic work. I led a small group on developing dating skills for young men on the spectrum. The participants asked me, “Do you have a girlfriend,” and “What dating experience do you have?” I did not answer the first question but did confirm that I had faced some the challenges in this area. I added that I had developed some strategies and techniques of my own for finding success. My self-disclosure sparked an ongoing discussion of the struggles of dating between the group members, a discussion in which I was a participant in but not the expert leader. In other words, my self-disclosure leveled the playing field, so to speak, which facilitated a deeper and more meaningful conversation in the gruop. Because the participants acknowledged that they did not feel comfortable speaking about these issues with anyone else, the transference that may have developed was that of a relationship between intimate friends. Regarding my countertransference, I also felt a sense of kinship with the other participants.
Self-disclosure regarding around my learning differences and a careful monitoring of the related transference and countertransference relationships with certain clients has enriched my clinical work. My clients have had both positive and negative reactions to my self-disclosure, which has provided an important opportunity for deepening the clinical relationship. While not all my clients react positively to knowing that I also have a learning difference, the majority have developed a trust and willingness to explore how my self-disclosure may help them in treatment. Although I will continue to make sure that sessions focus on clients and not on myself, I believe that, overall, my decision to self-disclose has been a positive experience for clients.
Resources
Carley, J. M. (2017, April 13). The Employment Shift: Rethinking Autism Employment Initiatives. Fallbrook, California , USA.