In the post-Soviet world, boundaries were scarce. Growing up in the Russia of the 1990s, I had a heightened awareness of crumbling walls. Though that time felt mainly liberating, it was also scary; many of us felt unsafe in this new suddenly-turned-turbulent, wall-less world.
Unsurprisingly, in the same 1990s, learning foreign languages became the most obvious and appealing choice for many Russian youngsters, myself included. It was our way of pushing the barriers. “When I proudly announced to my father that I would pursue studying linguistics, he bursted out in anger” saying that languages were futile and would not give me any tangible skills. Growing up in the Soviet Union, my father had never had an opportunity to master a foreign language. This skill was not on the state’s agenda for its citizens, probably another means of keeping the iron curtain in place. In the most classical Ivan Turgenev way, what was the most liberating and empowering choice for me reminded my father of his own inability to speak any tongue other than his own, naturally triggering a feeling of shame.
Jhumpa Lahiri, an American writer of Bengali origin, reflects on her relationship with Italian, a language that she learned later in life and adopted for her writing. Her love affair with Italian resonates with my own feelings about speaking other languages and abounds in separations—shut doors, locked gates, permeable skin: “A new language, Italian, covers me like a kind of bark. I remain inside: renewed, trapped, relieved, uncomfortable.” This sensitivity to separateness is familiar to many of my multilingual clients who evolve on cultural boundaries and countries’ frontiers.
Language as Boundary
I have ended up practicing psychotherapy in three languages that were not originally mine; and through dialogues with my displaced clients, I have realized that learning a foreign tongue not only opens new doors but, in some cases, also becomes a way of installing a boundary where there was none.
In environments where we must put up with an intrusive parent who does not respect our boundaries, or with a totalitarian state that scrambles our personal space, we survive in different ways. Some make inner safe spaces of creativity, like my artist father; others actively rebel and flee to a different land, like many of my emigrant clients and myself. When leaving is the only way to develop better boundaries with the original context and with others, mastering a new language becomes a crucial step towards this goal.
“Much of my therapy work with displaced individuals happens through video conferencing”, thus we keep our regular sessions even when they return to visit their parents for holidays. As they connect “from home,” they sometimes choose to use their second language (when we share one), in order to protect their privacy from their family members. These sessions open a window to their original context—a concrete opportunity for me to get a sense of the place which they come from.
This way, I get to enter vibrant Indian houses filled with the whir of fans; small Russian kitchens where I can nearly smell the sour cabbage soup of my childhood; Victorian manors straight out of British novels; and other colorful contexts in which my clients were brought up. In such situations, the language that they have acquired later in life acts as a shield protecting them from the intrusiveness of their home; something that was not possible for them during their childhood.
The Case of Andrey
In the case of Andrey, the first and only session we had in English offered a fascinating opportunity to reflect on his past. Andrey was a Russian violin player who had made a life in the United States. He came to therapy because of his feelings of shame about his failure to find stable orchestra work and about his deteriorating marriage.
We started off rather smoothly, as Andrey was able to identify the main reason for his struggles—his incapacity to be emotionally present with others. He was fearing intimacy and had found refuge in music, which now seemed to isolate him from his wife and friends. He would easily blame himself for his shortcomings, never questioning the adequacy or fairness of others, nor the environment itself. Was he unable to secure a stable orchestra appointment because of a lack of talent, or was it due to the competitiveness of the field and bad luck? Despite his multiple prizes and other achievements, it felt clear to Andrey that he was just not good enough.
This tendency to take the blame too quickly and entirely made it difficult to access his real feelings. This was another boundary—a cover up—a way of hiding from the more complex reality in which others failed to meet his needs. I was feeling frustrated with having to constantly point out this unbalance when Andrey decided to go back home for Christmas.
His parents were living in a small town in the very North of Russia. Snow covered much of the industrial squalor for six months in a row, offering an immaculate landscape to those who would dare to go outside; many preferred to contemplate this view from behind a frosted window. Andrey had often felt guilty about not being back home more often, but the trip was complicated and costly.
Just after Christmas, he connected from his parents’ flat, the very one where he had grown up. In the background, I could spot the familiar, trapped-in-the-past decorum of a Russian kitchen. To my surprise, even before I could greet him, Andrey kicked off in English. “My parents are just behind the wall,” he said in a whisper; “so for them, you are an American colleague, and we are talking about a forthcoming concert.” It felt odd to be suddenly transformed into an American musician.
The stigma associated with mental health issues and therapy was still omnipresent in this remote corner of Russia. In order to be able to talk openly, Andrey had to use our shared second language. His English was fluent, but during the first minutes, I had to make an effort to switch off an uncanny voice in my head that offered synchronous translation of his words back to Russian, our usual therapy language.
In Search of Sanctuary
During the session, Andrey recognized that having privacy had always been a struggle when he was a child: his mother always insisted that the doors of their small flat should stay wide open. “Why are you closing the door?” her high-pitched voice would resonate in the small flat every time Andrey would try to isolate himself in his small bedroom.
Maybe she wanted to make sure that her teenage son practiced his violin, or she was just too scared to be alone in front of her own inner realities. Back then, unable to find any space unpolluted by his mother’s intrusive presence, Andrey found refuge in music. She was not a musician, and through interpreting the most rebellious and passionate Romantic pieces, he was able to express his anger, his pain, and his isolation.
With time, this protective boundary turned into a fortified wall, efficiently separating him from others. His wife was bitterly complaining about the lack of intimacy that was haunting their marriage. He found it increasingly strenuous to get out of this space, or to let her in. Their marriage was on the brink of failure.
As Andrey was talking in English from his parents’ kitchen, we managed to recognize his feeling of shame, nurtured by the pressure to succeed that he had always felt. In his native town, the only hope for a brighter future was to work hard and be chosen for the Moscow Conservatorium. His father was a violin teacher in the local music school for children. He was drinking most of the evenings, as a way of escaping his own disappointments. Andrey had always known that he had to become a solo player to realize the dream his parents had instilled in him. But bursting out to the bigger classical music world had come with a price—the competition was such that Andrey had quickly realized that the soloist career was not for him.
During that ‘kitchen session’, Andrey told me how, the day before, he had picked up his grandfather’s old violin inherited by his father. He had not played the family instrument in years. Its sound, smell, and smooth touch brought up so many memories—the first time his father had let him play that violin was after he had successfully passed his music school exam, opening the direct path to Moscow…and freedom. What a pride he felt back then, what a commitment to music! All this had faded away, he had now lost these higher aspirations, after years of teaching American kids in a foreign language that he would never master as he mastered playing violin.
His parents had grown older but had not changed. His father was drinking less, as his health had deteriorated. But he had kept following his son’s artistic career with anguish. His mother was suspicious of his “frivolous” wife (she was French and a dancer). She was also pressuring him about having a grandchild. Andrey strongly suspected that she was eavesdropping from the corridor every time he was speaking to his local friends over the phone.
Andrey was not able to open up to either of them, out of fear of being judged or causing distress. His mother had a habit of crying, slamming doors (only to insist that they remain open later), and threatening him with heart failure. They were totally unaware of his anguish about his unemployment and his collapsing marriage.
“Ironically, Andrey had never been able to share all this in Russian”. The perceived neutrality of the English language may have provided the necessary distance for him to get in touch with the feelings he had previously been avoiding as unacceptable or threatening. What had allowed this shift to happen? Was it the juxtaposition of his original environment (filled with familiar significant objects like the old violin) with the neutrality of his second language that had built a bridge between his younger and adult selves?
In retrospect, Andrey recognized that being able to connect with me from his parents’ place had allowed his adult part (usually pertaining to his “life abroad”) to penetrate his original home. He felt supported and valued by me, as he had never been able to feel at home with his parents.
Maybe the fact that I could understand both facets of his life helped this integration—I was familiar with the peculiar culture of the intimate Russian kitchen conversations. I was also familiar with the intricate dynamics of the broader professional music world. Making links and recognizing echoes between these two realities that constituted his fragmented world, helped Andrey sort through his struggle. After all, he did not really have to endure the continuous pressure of his professional world. This was no promise of a sustainable subsistence. Once he recognized the shortcomings of his original environment, Andrey was finally able to think more creatively about his career and find other less mainstream ways of developing his potential.
Soon after that session, Andrey returned to the United States, and we have never spoken again in English. At the opposite side of the border, our native Russian is a perfect shield to protect our therapy space when his French wife is around. The session in English has remained our shared anchor, a time when we both started to see and understand him better.
I became a psychotherapist because I wanted to help people feel better. I’m sure all therapists share that motivation. In my master’s program, I learned about cognitive behavioral therapy (CBT), and that no other type of therapy had as much research evidence to support it. I was drawn to its promise of rapid relief from suffering.
I sought out a doctoral program where I could receive specialized training in CBT for depression and anxiety. During my training, I saw firsthand how a few weeks of treatment could lead to big improvements in symptoms—not for everyone, but for many.
As an assistant professor I joined a leading center for the treatment of PTSD and OCD, and I witnessed the power of CBT to reopen lives that had been completely subverted by these conditions. When I found that cognitive and behavioral techniques weren’t always effective, I sought training in mindfulness and acceptance-based approaches. I wanted to be equipped to help everyone who came to me. Just as when I began this journey, I wanted to be a healer.
Later, I added CBT for insomnia so I could treat the frequent sleeping problems I encountered in my work. I began writing about the power of CBT to relieve suffering, first on my blog, then through a co-authored account of recovery from OCD, and then in two self-directed books on CBT techniques. I developed a blog and a podcast under a label that captures cognitive, behavioral and mindfulness-based approaches: “Think Act Be.” I was fully immersed in the evidence-based model, and I continued to be inspired by the successes I witnessed.
And yet I often remembered best the people I couldn’t help—the ones who came to me for a few sessions, or for many months, and never experienced lasting progress. They seemed to feel just as depressed, just as anxious, just as gripped by constant worries or obsessions as they did on the day I first met them. Some felt worse. My inability to help them weighed on me as I felt I’d let them down. Sometimes, when they left my office in obvious emotional pain, I cried at my desk.
Another Form of Healing
My work with Evan comes to mind (details changed to protect his identity). Evan was in his fifties and had been dealing with anxiety, depression, and obsessional thinking for his entire adult life. I introduced the standard CBT and mindfulness-based strategies, which Evan struggled to use. He experienced some relief from the meditations I led him in, but otherwise continued to have debilitatingly severe anxiety and depression. I could have blamed his lack of progress on his infrequent practice between sessions, but I didn’t believe that was the whole story, or even most of it. Whatever the reason, I couldn’t help him find relief.
And yet Evan often expressed his gratitude for everything I did for him. Like what?, I often wondered to myself. On one occasion when he thanked me “for everything,” I told him I wished I could do more to take away his pain. He expressed how much relief he found in our meetings, and particularly in the meditations I led him in and which he diligently recorded for listening between our sessions. “And you listen to me,” he said, “and you don’t give up on me. And I can tell sometimes when we’re talking that you’re feeling what I feel. And that’s huge.”
Many other names and faces stand out from over the years, people whose symptoms I seemed unable to touch. No one ever yelled at me or demanded that I do more to help them. Some expressed frustration at their continued suffering, occasionally directed at me, but most were entirely gracious, even grateful despite our lack of progress. Some even referred their friends or family members to me. It took me several years to realize that some of the deepest work I’ve done as a therapist has been with individuals whose symptoms didn’t improve.
This realization didn’t come until a few years ago as I sat with my friend Jim at his kitchen table. Jim had been battling an aggressive form of cancer for two years and had just learned it had returned. I didn’t realize as we sat there that it was the last time I would see him; Jim died two months later.
What surprised me in our final conversation was the gratitude Jim expressed for his treatment team. I expected he would be disappointed in them; after all, he was receiving the most state-of-the-art cancer treatment in the world, and yet it hadn’t kept his cancer away. I could imagine being bitter if I were in his shoes, and not at all happy to have to return for treatment.
Quite the contrary, Jim described how grateful he was for the care he’d received over the past two years. He noted that his medical team had extended his life, giving him time to put his things in order. He had been given more time with his family than he would have had without treatment. He was dying, and yet he was thankful to those who had done all they could to help him.
And more than the cutting edge care they provided, Jim seemed to appreciate that they cared. Jim wasn’t treated as a cancer case, or a research trial number. He was a complete human being, with a family, with hopes and fears, and likely a foreshortened future. The professionals with whom he worked provided compassionate care right until the end.
When I went through my own debilitating illness—much less severe than Jim’s, I learned what it meant to receive compassionate care. By my count, I saw 13 specialists over a 4-year period, and none of them was able to completely resolve my health problems. And yet most of them provided another form of healing—not of the body and mind, but perhaps of the spirit. I would leave their offices feeling a little less alone, a bit less afraid.
A True Presence
When I was in my late thirties, I was diagnosed with open-angle glaucoma. My optometrist who detected it reassured me that I wasn’t “guaranteed to lose my vision,” but the prospect of going blind hadn’t occurred to me until his reassurance. I didn’t ever want to not be able to see my kids.
The ophthalmologist I was referred to treated me with two rounds of laser surgery in each eye. The first involved boring a hole in the iris, making a tiny second pupil to decrease the dangerously high pressure inside the eye that could destroy the optic nerve. The second was meant to dissolve the blockage in the eye’s drainage ducts, allowing the pressure to return to normal. Unless it wouldn’t!
I learned through my own research that these procedures are effective in about seventy-five percent of patients. Thankfully, mine were successful and my pressures have been in a healthy range for the past few years. But I was struck by the failure rate of this treatment, given how directly it seems to target the root of the problem. Examples like this one abound across medical specialties; whatever the medication or procedure, the success rate of evidence-based interventions is significantly less than one hundred percent.
In light of the limitations of modern medicine, we shouldn’t be surprised at our limits as therapists. And yet many of us are quick to assign blame when a client isn’t showing obvious improvement. Often, we’ll blame the client, assuming there must be personality pathology or that they “don’t want to get better.” We may assume the symptoms bring secondary gain. We might prefer to believe that the treatment is effective, but the client just isn’t ready for change. These factors may be present, but they also have the convenient effect of letting us off the hook. It’s not us, it’s them.
The danger that I found in my own reaction to ineffective treatment was running ahead of the client, as it were, and trying to pull them along. This tendency showed up in things like assigning homework that I knew they weren’t going to complete, so at least I could feel like I was “doing something.” My conscience could be clear. Except it wasn’t, because I knew on a deep level that I wasn’t meeting the person where they were. They needed me to walk alongside them, to sit down with them when they sat to rest. They needed my true presence.
Our presence is what matters most. Otherwise, we would dispense therapy techniques from vending machines, or in fortune cookies. Even self-guided CBT books are written with a personal and encouraging tone. It’s crucial to feel that the guidance is coming not only from someone who is supposedly an authority, but from someone who wants the best for us, who’s in it with us. The relationship with an author matters.
Lessons Learned
I suspect I’m not alone in finding that my eagerness to help is actually unhelpful at times. For example, when Rick told me he felt like his life “hadn’t even been a prelude to anything,” I immediately jumped into cognitive therapist mode. My knee-jerk assumption was that this belief was exaggerated; after all, Rick had done many things in his life–graduated at the top of his high school and college classes, worked abroad, completed law school.
“Is that true?” I asked with skepticism. Immediately I knew I’d missed the mark. Rick wasn’t asking me to change his mind, especially not before he felt I’d really heard him. The truth was that his life hadn’t turned out the way he’d imagined. He’d come close to getting married twice, but never tied the knot, and he never had children. And despite his intelligence and education, his major struggles with anxiety and depression had left him unable to work since a year after he got his law degree. His life consisted mostly of tending to his garden, reading the news, and occasionally seeing a friend.
While I may have been on the lookout for distorted cognitions, on an unconscious emotional level I was motivated to look away from the deep pain expressed in Rick’s statement. It would have been much easier if I could have fixed his thinking and taken away his unhappiness. “See! It’s not that bad,” I wanted to say. But maybe it was. And the life Rick had lived wasn’t a problem I could solve.
As a therapist, I have come to appreciate the importance of remaining with and tolerating my discomfort and feelings of inadequacy, if I am going to serve as a full human being to those I treat. I must make peace with what I can’t change. Otherwise, I run the risk of compelling my clients to fight on two fronts, as they must contend not only with their suffering but with my expectations that there must be a solution.
All of this probably seems patently obvious to many therapists, perhaps especially those from a more psychodynamic background. Maybe my tendencies are specific to CBT, or to me. I do suspect CBT fosters some of the expectation about taking away symptoms, but I imagine some form of that expectation lives in all of us in the healing professions.
Sometimes life-changing work gets done while the symptoms are unchanged. For some that might mean connecting with the strength they have to meet their challenges. Others may discover the life that’s possible even through ongoing struggles. Still others will have their experience validated after a lifetime of being told what they felt wasn’t real or will simply feel less alone.
A Broader Lens
Hopefully it goes without saying that I still want to help people reduce their symptoms, and I want to offer each person all the tools that might be useful. Accepting the limits of my abilities and the value of our presence doesn’t mean I must stop trying to reduce suffering in any way I can. It’s also not a way to settle for less than optimal outcomes for my clients. And it certainly doesn’t mean that I have secret insights into what my clients really came to treatment for and that MY job is somehow to get them there.
I still want everyone I treat to experience less anxiety, better sleep, fewer OCD compulsions, or whatever else they came to me for. I provide referrals when I don’t feel that I have the expertise a person needs. At the same time, I’m trying to use a broader lens through which I see a person’s experience. As physician Rachel Naomi Remen suggests, there is a difference between fixing and healing. This stance isn’t a cop out, as I used to believe—a way to make myself feel better about my lack of skill. Rather, it’s a recognition of the reality that there is pain I cannot take away, and that “treatment success” is a bigger concept than can be easily captured in data from a randomized clinical trial, or from a well-validated self-report measure.
Therapy is as complex as any human relationship, with effects that potentially penetrate much more deeply than the apparent symptoms. The best we can do for anyone is to provide compassionate care until the end, whether that means a triumphant recovery, ruinous tragedy or the wide expanse in between.
I’ve also come to recognize that the end of our time together is not the end of the person’s road to healing. For some the time we spend together will be transformational, while for others there will be no obvious effect. For many others, the work we do together will plant seeds that grow only later, well after therapy has ended. It’s easy for me now to recognize the hubris in believing that the evidence-based therapy I offered was the person’s last hope. Now I know that I’m only ever part of a longer journey.
“I’ve always had trouble throwing things away. Magazines, newspapers, old clothes. What if I need them one day? I don’t want to risk throwing something out that might be valuable. The large piles of stuff in our house keep growing so it’s difficult to move around and sit or eat together as a family.”
“My husband is upset and embarrassed, and we get into horrible fights. I’m scared when he threatens to leave me. My children won’t invite friends over, and I feel guilty that the clutter makes them cry. But I get so anxious when I try to throw anything away. I don’t know what’s wrong with me, and I don’t know what to do.”
These statements are typical of clients with whom I have worked who suffer from what the DSM-5 calls Hoarding Disorder (300.5), a variant of Obsessive-Compulsive Disorder. Hoarding is a disorder that may be present on its own or as a symptom of another disorder. The other disorders most often associated with hoarding are obsessive-compulsive personality disorder (OCPD), obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and depression. Less frequently hoarding may also be associated with an eating disorder, pica (eating non-food materials), Prader-Willi syndrome (a genetic disorder), psychosis or dementia.
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These clients have extreme difficulty parting with common everyday objects such as magazines, newspapers, used cups, household supplies, foodstuffs and various forms of waste material. They may also compulsively acquire and then accumulate other items and commodities including clothing, mechanical parts, toiletries, CDs, DVDs and toys. There really is no limit, and each hoarder and the objects they hoard are unique.
Hoarding is not the same as collecting, as collectors tend to look for specific items and often organize and display them in well-maintained settings. Collectors also express a sense of pride about their possessions, enthusiastically talk about them, feel satisfied when adding to their collection(s), and can budget their time and money.
Individuals with hoarding disorder often experience severe distress at the thought of getting rid of their possessions. This results in their homes filling with clutter that disrupts their and others’ ability to use and, when severe, navigate living and working spaces. Individuals may engage in hoarding behavior for sentimental reasons. They not only feel, but deeply and intractably believe, that an item is unique, irreplaceable, or serves as a reminder of a cherished memory. Others attribute their hoarding behavior to instrumental reasons, clinging to the belief that one day these items will be useful. The psychological and physical burdens of hoarding may lead to unhealthy and dangerous living conditions, as hoarders are often reluctant to allow people into their homes to clear safe paths, remove contaminated or dirty items or to fix broken heating systems and appliances. Unlivable conditions such as these can lead to divorce, eviction, or loss of child custody.
Hoarding typically develops over the course of many years, sometimes beginning at a very young age and continuing throughout an individual’s life. Generally, in individuals living alone, the hoarding tends to develop more quickly and intensely than for those living with others. However, significant time must generally pass before the hoarder’s condition becomes very severe and impairing. It is the secretive and insidiously progressive exacerbation of the disorder that prevents those on the outside from immediately recognizing the hoarder’s issues and symptoms, and from facilitating the required intervention for the hoarder.
My work in hoarding arose through my interest in OCD, when a man once came to see me, reporting extreme concern for his children who didn’t have a bed to sleep on as the home was in disarray. The father was prominent in the community and was therefore expected to regularly invite guests to his home, which he was never able to do. Meeting the children was terribly sad as I learned firsthand about their isolation and the conditions in which they were living. My heart truly went out to the children and my memories of those interactions drove my future desire to treat and research hoarding. Upon meeting the wife who was the hoarder, it was evident that she was very socially presentable and an active member of the community. If you had met her outside of her home without knowledge of her home’s condition and clutter, you would’ve had no indication that she was a hoarder. This is very typical of most hoarders, and sadly perpetuates the hoarder’s resistance to treatment.
Many hoarders ultimately agree to seek therapy in order to avoid eviction or other negative consequences. When clinical intervention has been facilitated, which is often coordinated by those in the life of the hoarder, cognitive-behavioral therapy (CBT) has been demonstrated to have good efficacy. In such cases, it may be appropriate for the therapist to first specifically focus on helping the patient achieve greater insight into their personal situation, symptom severity, and necessity for change. Successful treatment is much more likely to be achieved and continued when the patient maintains awareness in these areas, and seriously engages in their intervention work.
Hoarders who are not determined to develop and exercise coping skills often don’t sufficiently engage in treatment to the point where they achieve long-lasting and sustainable progress, rendering them vulnerable to resuming their hoarding behavior. When CBT protocol intervention is appropriate, it focuses on four domains: information processing, emotional attachment to possessions, beliefs about possessions, and behavioral avoidance. The therapist will perform techniques such as cognitive restructuring and exposure therapy in order to challenge the patient’s beliefs about maintaining their possessions and the strong sentimental value placed on the hoarded belongings. Furthermore, the therapist will engage the patient in talking about commonly avoided and experienced situations related to hoarding that are intended to provoke anxiety, while allowing for the development of more adaptive coping techniques.
It is long and hard work to help the hoarder emotionally and cognitively disabuse themselves of their attachment to the things with which they’ve surrounded themselves, but quite rewarding to all impacted when the symptoms relent, and the stuff recedes from their lives.
Aimee (an amalgam of several of my patients), came into session, plopped onto the couch and said, “It happened again. Just like I knew it would.” Aimee was a 35-year old woman who came into therapy over a year ago, describing a series of failed relationships with men. She wanted to understand why it never worked out.
It can be a quandary for therapists to distinguish between outside, uncontrollable circumstances, and the patient’s participation in creating the opposite of what they consciously want. There are no absolutes. We have to understand each individual story and the patient’s unique psychology.
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Intimacy is scary. Letting someone see behind the walls we use in everyday life is scary. Sometimes people protect themselves by continuing to choose relationships that are destined to fail over and over–different bodies, same problems.
Aimee went on, “He gave me another excuse as to why he couldn’t see me this weekend. I knew he was blowing me off, so I asked him what was going on and he said, ‘I don’t think this is going anywhere. It’s the same sentence the last five guys have said to me. What’s wrong with me?” She buried her head in her hands.
Let’s face it, relationships are complicated. It’s hard to meet people who we want to be with, and who also want to be with us. Some parts of this we have no control over. What we do have control over is removing our own obstacles to finding the love, the commitment and the relationship we want.
Having seen this dynamic so many times in therapy, I decided to write a novel exploring this very theme. I began the story, as I do with all of my fiction writing, with a question. In this book called, Where You’ll Land, the question was: Can we choose who we love?
Alex Daily, my protagonist and a psychology graduate student, meets Will. The relationship is filled with passion but is quite tumultuous; the angst from both characters, as well as some of the secondary characters, forces them all to look at the obstacles that are in their respective ways.
As psychotherapists, we all know that we don’t see things about ourselves until we are ready. It can be a nail biter to sit with a patient, observe their conflict and self-sabotage, and know that the patient is in their own way, while also knowing they are not ready to garner the awareness that leads to change.
Timing of interpretive comments is vital for insight. We have to respect patients’ defenses and we can only guide them toward the awareness they are ready to have. Our job is often clearing out the weeds (defenses) so that the flowers can be seen, while watering the flowers (fostering innate strengths) so that the patient can grow into who they really are.
Toward the latter part of the book Alex has an insight, “She kept making the same mistake over and over until she realized that if she wanted a different ending, she had to have a different beginning.” This was also my client Aimee’s dilemma.
There is an irresistible draw toward the familiar, even when we say we want to change. If we hope for a different ending, sometimes we have to rework the beginning.
But where is the beginning? For Aimee, it began with not feeling her needs were met as a child. Whenever I explored how she didn’t feel taken care of in her relationships with the men she dated, she associated that to similar dynamics in her family. She’d choose men who reconfirmed that her needs were either too much or that she wasn’t good enough.
I redirected the session. “Maybe we can talk about what Jake wasn’t giving you throughout the relationship. What you don’t get from each of these men.”
“I feel like they could leave at any moment. I’m always anxious. I want someone who will be there.”
“Could you be confusing anxiety for attraction? Maybe the anxiety has to do with knowing they can’t meet your needs, the way you felt sometimes when you were younger.”
She contemplated. “That makes sense, intellectually. But it doesn’t feel that way. I can’t make myself be attracted to the guys I’m not attracted to.”
When it comes to feeling those emotional sparks – chemistry – understanding these conflicts is a dense conundrum. We have to create curiosity. We have to ask different questions.
“True. But I think we have to start asking what you’re actually attracted to, since you’re choosing men who make you feel on edge. How is that attractive?”
She flitted her hands around. “I – It’s not.”
“Let’s try looking at the anxiety as a sign that something’s wrong, not that something’s right.”
“OK,” she said.
We spent many sessions discussing how when there was anxiety, it was usually a sign that her needs were not being met. And we talked about her right to have needs and to allow someone who wanted to meet them, close.
I don’t believe we can control physical attraction entirely, but we can change some of what we are drawn to and we can control the decisions we make regarding who we allow ourselves to open our hearts to. If we are being open to people who continually disappoint and frustrate us, who perpetuate narratives from our life that are painful, then we need to ask why we are deciding to fall for the same type of relationship. And as therapists, we need to guide our patients to be curious about these questions. Because as Alex comes to understand in her story and as Aimee came to understand after a few more failed relationships:
Maybe we can’t decide who we fall for, but we can decide who we want to be with when we land.
As I offer therapy online, many highly mobile and displaced individuals naturally drift into my practice. “We meet in a couchless space unattached to any physical location”, or rather suspended in between the two places—my office perched below the Parisian rooftops and the often-fluid, ever-changing locations of my fidgety clients.
Sometimes they connect for our sessions from a hotel room. I always pay attention to my client’s surrounding—and when an unfamiliar background sparks my curiosity, I naturally inquire into this new place, and we spend some time locating ourselves. The client might tell me about the country or town they are currently in, about this particular hotel or the area.
These “hotel sessions” tend to bring up “a sense of discomfort that resembles lostness—a feeling of displacement, of not-quite-being there,” in the striking words of a wandering writer Anna Badkhen. As a displaced person myself (I grew up in Russia but now live in France), I can easily relate to this feeling, and every time I notice an anonymous hotel room behind my client’s back, my heart sinks in recognition.
Lorraine
One day I stumbled on an essay by Suzanne Joinson dedicated to “hotel melancholia”, and the author’s experience reminded me of so many of my mobile and displaced clients; especially, Lorraine.
“Lorraine’s consultancy work made her travel constantly”. She would usually spend a four-month period in a country, only to then move to the next assignment, always located in a different country, often on a different continent. I cannot remember ever seeing her connecting from any other place than a hotel—she was my quintessential ‘hotel room client.’
Lorraine was in her mid-30s, bright, successful, and extremely lonely. After a few sessions, I finally asked about whether she had a “base.” Lorraine marked a short silence—her beautiful pale face rarely showed any emotion: she did not. Her very few belongings were stored at her parents’ basement in Canada. She had given up on having a home years ago. She travelled light; just a big suitcase and a laptop.
Lorraine lived in hotels, usually big chains—comfortable, impersonal and exactly as Suzanne Joinson describes “it was fun, for a few years, until suddenly it wasn’t.” I came into the picture when the fun had gone. However, Lorraine never complained—it was “not too bad”, and, after all, every couple of months she would be allowed a break to spend a few days elsewhere. These short trips would be just enough to keep her sanity.
In our co-created placeless bubble, we communicated in English—a second language for both of us. We also had French in common, but Lorraine had unequivocally chosen English from our very first email exchange. She confided that she felt more comfortable in this language that she acquired as a teenager when her family relocated to Canada.
“Lorraine was a Third Culture Kid”—brought up by a biracial family in a country that was neither of her parents’ original home. She was half-Korean, half-French.
Why was she in therapy? Sometimes I wondered, as she seemed rather content with her transient life. Talking with her often created a strange cognitive dissonance—I sensed her distinct unhappiness, but she would never verbalize it, never express any deep dissatisfaction or nostalgia for a home or a relationship.
She had friends of course—mostly dispersed all around the globe. She would visit them during her breaks, sometimes for an adventurous holiday, sometimes in their homes in case they were freshly settled and building a family. Strangely, after these trips Lorraine would not express any more desire to settle or to attach than usual. “It was nice,” she would comment.
Lorraine seemed attached to her itinerant lifestyle more than to anybody or anything else. She did not seem to miss her parents. Their presence in her adult life seemed to create more hassle than anything, as they got used to asking her for help in doing their paperwork, relying on their daughter’s indisputable competence. In her constant relocating from one place to another, being able to deal with paperwork efficiently was a question of survival. Efficiency was something Lorraine valued highly. I learned that in her vocabulary “being inefficient,” meant many other things too; like being overwhelmed, exhausted, or emotional.
When she was a child, her family moved a few times for her father’s professional assignments. I never really got a sense of how it was to grow up in her family. She was an incredibly docile child and later a very capable adolescent, never creating problems for her parents. She simply did what she was supposed to do and did it well. She worked hard at school, gained a commendable degree and went on to take a lucrative job. It seems that in her family everything was about efficiency. Her Korean mother was a perfectionist and would get very upset if something was not done exactly how it should be, whilst her French father was hard on people who did not live up to his expectations.
Emotions had little or no place in this family. For somebody as well educated as Lorraine, she had little awareness of her emotions and struggled to name her feelings, usually using the words “bored” or “frustrated” to cover up other emotional experiences.
In therapy, she was hard work for me.
Holidays and Homes
Of course, occasionally she would travel back to Canada to spend Christmas or Easter with her parents. Every time I offered to maintain our session during those holidays, she would decline—too busy with playing catch-ups with family and friends. So, I never had an opportunity to have a glimpse of her childhood home, and my attempts to suggest that such session ‘from home’ would be interesting, never produced results. This house in Canada that she never really described felt ghostly to me, and I wondered if she had the same feelings about it.
Interestingly enough, when her parents retired and decided to sell their family house, Lorraine seemed indifferent. They bought an apartment in the South of France, in the village they used to visit during their European holidays. Wasn’t she sad about her childhood home which contained her memories, her things in the basement, disappearing forever? No, she was not. After all, she always knew her family would never settle there forever. Almost all of her friends from that place had already left and had either settled elsewhere or were travelling around the globe.
Would I feel the same numbness if I was to lose connection with my original town? This thought only fills me with sadness. Even after living all my adult life abroad, I still feel attached to my native Saint Petersburg, where all my childhood memories reside. Lorraine’s displacement was of a different nature; she grew up out of place, with no deep roots in any of the cultures she was surrounded by. The Korean world was only barely familiar to her; she identified herself as French, but even that belonging had some clear limits.
This state of things was going on for quite a while. Lorraine moved from one country to another a few times, and I grew more and more frustrated with the lack of depth that our work was presenting.
Occasionally, I would be travelling too, and also connect for our sessions from a hotel room. The first time this happened, Lorraine looked strangely annoyed. She was even less talkative than usual, and I could sense that something was going on, but as usual she resisted my questions.
“Would your bad mood be linked to my being elsewhere than in my office?” I asked.
She paused, seemingly perplexed. “Maybe.” She was used to seeing on her screen my now familiar background, filled with bookshelves and artwork. The consistency of place that our sessions offered her was actually something that meant a lot to her. That ‘double hotel session’ was not a breakthrough in any spectacular way, but something had shifted, allowing more awareness into her displaced condition.
Several weeks after that session, Lorraine passed through Paris, and we were finally able to meet in person. I always feel a mixture of excitement and apprehension when an online client of mine visits my city, and we plan for an in-person session. Not having a screen between us breaks the settled frame; with some clients it feels like a welcomed change, with others less so. In Lorraine’s case, I was hoping that the encounter could bring some interesting grist to the mill.
Facetime
She sat in front of me; composed, pale as usual and much smaller than I had ever realized—a not unusual surprise of screen relationships. All the semblance of closeness we were able to build online seemed to dissipate. Lorraine was back to her shell.
She was between two assignments, but not for long, and seemed ready, almost eager, to move into the new hotel located somewhere in the Southeastern Asia that was soon to become her “home” for the next four months. She had already checked its situation—it was one of her favorite chains and was equipped with a decent size gym and a swimming pool. She seemed a bit lost, homeless for real, without the hotel room that usually would contain, at least temporarily, her belongings and her life. She made no comments about the area of my office, or about the room that she had seen only on her screen before.
“How do you feel about us being in the same room?”
“Not much, maybe a little uncomfortable.”
She was not used to sharing her room with anybody; she actually never had. Her childhood family home was big enough for everybody to have their own bedroom. They rarely spent time together downstairs, as both parents had their own office space. When she would come home from school, she would usually grab something from the fridge and retreat upstairs, directly to her bedroom.
This was actually the first time Lorraine was sharing some tangible details about her childhood. As she spoke, I could finally picture this big, perfectly organized house surrounded by snow. Her mother loved white lacquered furniture and was always preoccupied about keeping everything in perfect order and maintaining all the surfaces spotless. This was probably the reason why Lorraine was never allowed to invite friends to her house; and none of her birthday parties took place at her home. Her home had always felt like a hotel to her—it was comfortable, clean and temporary. Since a very young age, Lorraine knew that she would leave and go elsewhere. Her childhood was about waiting for this to happen, and now that it had finally happened she did not really know how to live any differently.
Now, as an adult, she had to learn how to develop an attachment, to a place, to a person. Our shared online space was a tentative model; a little relational bubble in which this process hopefully could begin. At this point Lorraine was not ready to fully grasp that the life she had built was as dysfunctional as her childhood. The defensive walls that she had built in the past were still in place, protecting her from the terror of her attachment-less reality.
Was our original creative project the wish to love and be loved by our mothers?
What happens if that creative project failed and your mother wasn’t able to acknowledge, respond to, and reciprocate your love?
I like Harold Searles’ writing. One of his papers, ‘The Patient as Therapist to His Analyst’ from Countertransference and Related Subjects (1979), deals specifically with Searles’ idea that the patient is unwell in relation to how their original therapeutic strivings (In Searles’ view, the wish to love our mothers) failed.
Searles’ paper came to mind recently in my work with trauma survivors.
In my private practice, I have worked with a number of people who have suffered early and sustained trauma. The psychotherapy often succeeds in helping these clients build up more of an understanding of what happened to them in their early life. It enables reflection and the construction of ideas and thinking that goes some way to explain what happened to them. It frequently throws light upon why they have been attached to self-destructive behaviours throughout their life.
In the psychotherapy, periods of self-limiting and self-destructive behaviour are explored and the client often becomes more relaxed and confident. They become better able to think and reflect on themselves and to collaborate constructively in the work. But when the session ends, they retreat, withdraw and often fail to build on what they have been doing in the therapy.
When we meet for the next session, they explain that they have not wanted to think between sessions about the work we were doing in case the work did not have its intended or hoped-for positive effects. Instead, they retreat or shut down.
One client, a particularly creative woman I will call Mo, had wide-ranging ideas and a number of projects that interested her that she would have liked to develop and work on. But, the pattern Mo was attached to was that she would go no further than to think briefly about her projects and then shelve them. Mo’s attitude toward her creativity contained a powerful repressive dynamic.
I came to think about this repressive dynamic, this limiting attitude to herself and her ideas as reflective of the failure of her first creative project—Mo’s wish to love and be loved by her mother. Mo’s relationship with her mother never developed into a loving reciprocal one. Her sense was that her mother may have been in a state of undiagnosed post-natal depression. It seems there were particular problems in Mo’s early home life. Partly as a result of this she was often left neglected and abandoned for long periods. Mo’s wish to love was met with anger, rejection, and resistance.
I came to understand this as part of the transference to the therapy and then began to see that it might be understood as describing the relationship Mo had with her own creativity. Though Mo could have very interesting ideas that captured her imagination in her sessions, she would later abandon them and leave them ignored, only to hesitantly pick them up again in the next session.
This led me to think about the way our creativity, not just our capacity to have an idea, but more particularly the possibility of following our ideas through, might be bound up with our original maternal relationships.
In psychotherapy, a client starts to develop a greater understanding of themselves and what they went through early in life. They become better able to reflect and to develop more benevolent and caring attitudes to themselves and others in the sessions. But outside of the therapy, they do not manage to sustain these attitudes. They return to a position in which they put themselves down at the expense of others and remain fixed to limited expression of creativity. The attitude they express to their own creative ideas contains thwarted, complicated and destructive impulses.
Have they transferred to their own creative selves, expressions of the sense of failure and disappointment they experienced in their original maternal relationship? Do they treat their creativity as an inferior object to abandon at will? My work with Mo has led me to think that a consequence of early trauma and abandonment may be reflected in the way people struggle to pursue their creative projects in later life.
Could this apply to your patients? Has their creativity become caught up in the pattern of their original creative failure(s)? Instead of writing their novels or memoirs or even other less lofty creative projects, do they continue to struggle with failed beginnings? Is the repressive early relational world that they experienced what they become destined to locate and repeat in their attitudes to you and their therapy?
Is it possible that through the shared creative therapeutic venture that you can both come to see the problems they experienced in their relationship with creativity as reflective of problems in their earliest relationships? Could you use that information or insight to help them change and improve their relationship with their creativity?
Many therapists are unfamiliar with the Deferred Action for Childhood Arrivals (DACA) program and have little experience serving clients and families with DACA status. I lived in Mexico City for almost 3 years, earned my masters degree there, speak Spanish, and have worked with many immigrant families over the last six years, and thus I feel a civic duty to share my experience and knowledge with the psychotherapy community.
DACA is a temporary protected legal status (TPS) created by the Obama Administration in 2012 to protect children from deportation after arriving without legal authorization (usually with undocumented parents). I use the word “undocumented” instead of “illegal,” because “I believe that no human is illegal”. We don’t call a 14-year-old driver “illegal,” or a 17-year-old drinker either. Language matters; we want to use inclusive, respectful and empowering language—after all, as therapists, language is our primary tool to promote healing and change.
There are roughly 800,000 DACA recipients in the U.S. (not including the additional 300,000 who are eligible but don’t have DACA status), approximately 75,000 of whom reside in California, and around 40,000 in San Diego. Most are Latinx, have undocumented parents and have migrated in search of safety and economic opportunities unavailable in their countries of origin. You can also use the term “DACA-mented” to describe the unique experience many DACA-mented folks experience of feeling like a foreigner—unable to access government assistance such as student loans or the vote, yet simultaneously feeling like the U.S. is the only place to call home because most DACA recipients grew up here. It is very important to be aware of how the individuals and families with whom you work self-identify. For example, I have a few female clients who have told me that although they appreciate the term “latinx,” they prefer “Latina” instead to emphasize their pride in being female.
To make matters more complicated for families of DACA status, on September 5, 2017 the Trump Administration canceled the DACA program. Although current recipients can still renew their status every 2 years for $495 plus legal fees, no new applications are being accepted. There is currently no guarantee of permanent residence or citizenship as DACA status only provides a social security number, authorization to work, and a driver license. The future of DACA remains undecided in two pending Federal court cases. Added to this, a majority of DACA recipients have parents who are undocumented, which is terrifying for them given the increasing anti-immigrant sentiment and recent increases in ethnic profiling, detainments, raids, distressing executive orders, and deportations.
Resilience
Clearly this population is at risk and needs competent, knowledgeable and supportive mental health practitioners. DACA families commonly face poverty-stricken households and neighborhoods, PTSD, agoraphobia and depression, and other psychological distress emanating from family separation, and a realistic fear of leaving the home for fear of deportation and societal discrimination. Our job as therapists is to educate, understand, heal and help manage the numerous traumas related to fearing for their own and their family’s future. The exclusionary and dehumanizing messages, xenophobia, and ethnocentrism rampant in the current political rhetoric has contributed to the hyper-vigilance and fear this population faces daily. It’s vital that these families attribute their pain mainly to the adverse events and unjust immigration circumstances instead of to themselves personally. More crimes are committed against undocumented and DACA families than by them. They live and contribute to society the same way that legal citizens do—working, studying and paying taxes. Yet they aren’t afforded the short or long-term security of citizenship, which can be so easily taken for granted. We can’t afford to ignore that one’s immigration and legal status, which in many ways form the bedrock of identity, have become so politicized on the national stage at the expense of the individual caught in the rhetoric.
Although this discrimination can gradually erode physical and mental health for families of DACA status, it’s crucial to recognize and appreciate the resilience that I have witnessed in my clinical work with this is population. Even though health settings tend to focus mainly on the risks and deficits associated with DACA, undocumented and mixed-status families, Latinx DACA recipients and their families, have in my experience been a strong group of people. “Latinx DACA and mixed-status families tend to be hopeful about a better future”, even given the current political climate. Immigration scholar and professor Dr. Carola Suárez-Orozco at UCLA refers to this as “immigrant-optimism.” They also tend to value education and have a robust work-ethic—many are excelling in schools and in their jobs. Moreover, these families tend to be closely-knit and extremely affectionate, loving and supportive, a major sign of strength. Unfortunately, this has been periodically pathologized as “enmeshment” by Western-oriented therapists and other practitioners who are not as knowledgeable about cultural norms and sociopolitical contextual variables affecting our clients.
The resilience doesn’t end there; DACA recipients often benefit from the advantages of being bilingual, binational, and bicultural, which is correlated with increased employability, cognitive flexibility and enhanced capacity for perspective-taking. I have witnessed immense cultural pride, religious and spiritual strength and social support within this population. There is also a present-time orientation—contrasted with the greater emphasis on past and future in the U.S. that helps affected families enjoy and appreciate their time together and to stay closely knit and loving, despite the fear of uncertainty always lurking in the background. Understandably, DACA recipients have reported that “coming out” publicly has been tremendously difficult; many parents coach their children to be furtive with their immigration status for protection and unity. This appears to be very appropriate given the associated risks of “going public.”
Consistently witnessing these families strive, grow stronger, wiser, and more resilient as time passes and therapy progresses, has not only encouraged me to continue this work but has also instilled a sense of vicarious resilience within me. As I mindfully reflect, I feel that I have grown stronger and wiser personally and professionally from continually seeing these families do so time after time. I owe this vicarious resilience to this population’s courage in their work with me. Next, I’ll share a brief snippet of my work with one family. I’m eternally thankful to this family for allowing me to share their story, of course with their identities concealed.
Sergio
Sergio, age 17 and a DACA recipient since 2013, was brought to therapy by his parents, Tina and Jorge, who were concerned that he hadn’t been sleeping or eating well, had been struggling academically, worrying excessively and had become increasingly nervous and irritable. His parents brought him to California when he was 11 months old in search of better economic opportunities. They hired a “Coyote” to cross from Tijuana—fortunately, they were neither abused nor robbed en route which are very common occurrences.
After a careful assessment, Sergio met the diagnostic criteria for Adjustment Disorder with Anxiety. Jorge, his father, had been suddenly detained by ICE (Immigration and Customs Enforcement) when walking from the car to a restaurant where he had planned to dine with his wife and Sergio’s two siblings. Jorge was detained for the night and released in the morning. Sergio remembered experiencing a panic-filled and sleepless night following his father’s detention. Although Jorge was detained only briefly, a court date for the following year was scheduled at which time his deportation would be decided. This only added to his son’s sense of impermanence and anxiety. We don’t currently know the extent to which Jorge’s previous DUI contributed to his arrest or will factor into the court’s impending decision regarding his status. I have collaborated with Jorge’s lawyer in documenting what I considered would be an adverse impact of deportation on Jorge’s family.
Sergio has shared that he constantly worries about “having to be the man of the house” and having to help raise his younger brother and sister if his father is deported. He also worries about his own future in the country since the DACA program was rescinded last year. Because Sergio is old enough to understand and psychologically strong enough and high-functioning, we have collaborated on a “family preparedness plan.” Fortunately, Sergio’s family is closely-knit and resourceful and has supportive relatives in the area who have lent his family money to cover Jorge’s legal fees. Sergio also speaks English and Spanish, a big plus when he enters the job market, and has maintained a 3.84 GPA up to his senior year in high school. We have discussed the traumatic nature of his father’s arrest along with the wider socio-political injustice and hateful rhetoric that have contributed to his symptoms; shifting the narrative from believing something is wrong with him to his anxiety being a normal response to abnormal circumstances. Together, we have highlighted the strengths he’s developed from coping with this uncertainty. We also review mindfulness strategies to embrace the here-and-now, so that he may sleep better, and utilize EMDR to reprocess the horror that periodically torments him from that day.
“It’s essential to emphasize that therapy has significant limitations if wider sociocultural and political influences are not considered in the work”. No therapy can resolve the uncertainty of Jorge’s future in this country with its increasingly strict immigration policies. Helping families talk about injustice in therapy is a step toward effectively managing it. In fact, Sergio shared helpful information with his community such as the app Migrawatch for warnings of any future raids in real-time, which we agree has helped his anxiety symptoms. As Sergio’s therapist, I know that symptom management isn’t enough and realize the importance of opening a dialogue with him and other such clients. I also consider it crucial to share my personal commitment to progressive politics and public advocacy of immigrant rights that have helped Sergio and his family embrace their resilience, and that will hopefully challenge the injustice in his own community.
Therapeutic Tips
Here are some practical tips I hope will be helpful in your own practice if you have the privilege of working with clients like Sergio and his family. Additional information can be found in the article Ten Psychotherapeutic Considerations to Assist Young Undocumented Latinx by LaRoche, Lowy & Rivera(1)
Remind them in the informed consent that disclosing their status, is never part of your mandated-reporting requirements, and unwaveringly commit to confidentiality.
Shift problem-saturated narratives around DACA and U.S. immigration-policy toward resilience.
Emphasize their many strengths alluded to above; use them as assets in treatment-planning.
Help families create a “preparedness plan” in the event that a member is suddenly deported, and capitalize on other aspects of their lives that they can control in the here-and-now. This can include appointing guardianship for children and referring families to the “Toolkit for DACA Families” by Chavez-Dueñas and Ademes(2). Be careful that although this helps by increasing a sense of power/control, these can initially foster anxiety. The same is true for rehearsals of the plan or confrontation with officials. DACA families have the constitutional right to “remain silent” and contact their lawyers in response to police, ICE, or immigration officers.
Use a genogram to help families understand the current makeup of their transnational extended family. Unlike the generic caucasian nuclear family, Latinx families often include non-blood relatives, who should be included in the “preparedness plan.”
Check your assumptions; don’t assume they speak Spanish because their parents brought them here from Latin America.
Speaking and learning some Spanish is always a plus.
Be bold; don’t only have the LGBTQ pride flag in your office but have the butterfly symbol to show your support for this population.
Remind them that Title IX prohibits discrimination based on ethnicity, nationality, or race for organizations that receive federal funding; DACA recipients arguably are included.
Since these families don’t leave their homes because everything is fine in their native countries, it’s vital to know why they left and their immigration story, which is likely to reflect trauma and separation, and help clients understand and overcome trauma from these adverse experiences.
Encourage families to use the app Migrawatch to see if a raid is taking place
Know the limitations of weekly therapy in helping families cope with intense and chronic immigration stressors and societal discrimination.
Collaborate with a multi-disciplinary group of lawyers and medical doctors.
Use your privilege! Utilize your civic rights to advocate (a good therapist is always a good case manager) and censure deleterious deportation policies through organized protests and rallies, and calling local politicians or elected officials. As therapists, I believe we have a civic duty to advocate for this community and promote sociocultural transformation. As therapists, we cannot be quiet or neutral in the face of the numerous injustices this population faces.
In the words of Dr. Martin Luther King, “In the end, we will remember not the words of our enemies, but the silence of our friends.”
In my previous blog posts, I discussed the difference between shame and guilt; both of which are painful, self-evaluative affects. Guilt involves the evaluation of a specific behavior and therefore, offers the opportunity for reparation. If Gary fails a test and feels guilty, he believes he can do things—like study harder—that will relieve some of his guilt. Even the thought that he is able to do something, alleviates some of the distress from his self-evaluation.
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If Gary perceives himself to be a loser who can never do anything right, then he is experiencing shame. Although shame can be transient, there are people whose experience of shame (shame-proneness) is pervasive; meaning that at the very core of their sense of self is the feeling of being small, insignificant and/or bad.
In my most recent blog post in this series, I discussed how shame-proneness compromised empathy, causing conflict and turmoil in relationships. Another lasting and painful consequence of unresolved shame is shame-based depression.
Depression is at best, an umbrella concept, not easily understood or reducible to a diagnostic label. Just because people share symptoms does not mean the cause is the same. Think of all the different underlying reasons for a headache. If we are to hope for good psychotherapy outcomes, we need to understand the causes of the symptoms, not an easy endeavor with distress as broad as depression.
When depression is shame-based, it is not only the symptoms that debilitate, but also the ingrained belief that the person does not deserve to feel better. Because fundamentally they feel bad, small, unimportant, the suffering feels congruent. Relief feels foreign and undeserved. If the shame basis of the depression is left unidentified, improvement will be a tortuous, uphill battle for both you and your patient.
Take Madeline (an amalgam of patients suffering from shame-based depression), for example. She’s a 39-year-old woman who came in for depression and reported a lifelong history of related symptoms. She described apathy, anhedonia, problems with motivation and concentration, appetite and sleep disturbances as well as feelings of worthlessness. As the therapy progressed over the first year, it became clear that Madeline experienced deep-rooted and chronic shame.
She regarded herself as unintelligent, unattractive and uninteresting. In response to these feelings, she developed grandiose aspirations to compensate for her supposed deficiencies that no one could ever live up to. Consequently, she experienced continuous and inevitable failures which confirmed and perpetuated her shame-narrative.
“I’ll never be intelligent. Everyone knows more than me,” she said, averting my gaze.
“Can you tell me more about that?”
“I need to read every single book on a particular topic before I’ll feel knowledgeable enough to have a conversation about it.”
“Does that seem a realistic endeavor?”
“I have to. It’s the only way I’ll feel smart enough,” she said flatly, fighting a frown.
“I worry that you are setting yourself up to fail by having expectations that are impossible to reach.”
“I never meet any of my goals, anyway.” She crossed her arms.
“You’ll never find a feeling of accomplishment or meaning if you keep setting insurmountable goals. I’d like to understand why you’re doing that. What would happen if we worked together to set realistic goals, things you can accomplish?”
“Well, then I might feel better.” She released a sarcastic laugh. “I wish that was a joke. I don’t feel like I deserve to feel better.”
“Tell me more about that.”
“No one ever supported me or any of my interests. I was told I wasn’t good enough. And it’s the truth, isn’t it? Look at my life. I’ve done nothing to be proud of. Failed at everything I ever tried or ever wanted.”
After I better understood her shame, I realized that despite our seemingly strong relationship, Madeline continually undermined the therapeutic process. Every time she started to feel better, she’d set these impossible standards, which ultimately confirmed her feelings of not being good enough, of being a failure. Of not deserving any relief.
Madeline knew nothing but her depression. She held onto it as if without it she would descend into an unfathomable void without it. When patients have a history of emotional abuse, as she did, where disparaging statements are woven through the fabric of their identity, the depression is often shame-based. And the treatment is extremely challenging. We have to help our patients to find ways to question, then challenge and finally close the book on their shame-narrative.
To some degree, all depressions contain an element of shame. But in Madeline’s case, it was pervasive, evolving more like a personality trait than a cluster of symptoms, making it harder to treat. Her shame caused her to perpetuate her own distress.
I combined humanistic, psychodynamic and cognitive-behavior therapy for Madeline. Psychodynamic, to help her understand how the shame evolved through her childhood experiences of emotional abuse; humanistic to focus on helping her identify and foster the many strengths she did have and to help her find meaningful pursuits where she could feel her endowments; cognitive-behavioral to help her with her thought distortions. I had her keep a journal of the false narratives. Every time she had an experience that disconfirmed them, I had her write it down. For example, she thought no one liked her and as a result, she was socially isolated. Every interaction where someone complimented her or showed interest in her, every time someone asked her for advice, she wrote it down. This was to reinforce different statements about who she was.
The more Madeline discovered her unique strengths and used them and felt them, the better she became at recognizing the falseness of her narratives. And the more she understood the distortions, the better she became at pursuing goals that were attainable.
I also did some psychoeducation in the second year of our treatment. I explained the shame and tried to help her understand her depression. Madeline had become curious and open and was able to introspect even in areas that were very painful.
Madeline developed an observing ego. She became more cognizant of her distortions and began to question their validity. In order to help patients recognize their shame, we need to listen closely to these narratives. We need to identify the shame. And then, we can adjust our therapeutic techniques to meet our client’s unique needs. We need to believe they deserve to get better and can get better, even when they are undermining every step of the process. But for the deepest and most lasting change to occur, they need to believe in a narrative free of shame.
Life presents us with many challenges; successes, failures, negative and positive experiences, and everything in between. Usually, when challenges occur, teens try to manage them on their own. As a marriage and family therapist who believes that we all possess the ability to overcome these challenges, helping my young clients to navigate them is particularly rewarding.
I practice and teach mindfulness including the Morita concept, which is about seeing and experiencing things as they are–in Japanese this is referred to as “ARUGAMAMA,” to accept things as they are. I am aware that the only way for me to find out how things will turn out is to begin taking on a challenge despite how anxious I may feel about it.
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Japanese psychiatrist, Masatake Morita stated that the reason why we may feel anxious or scared to take action is because we have a desire to do well. He framed this as “A desire for life.” If we can try not to be overly concerned about the outcome, we may not feel as hesitant to take on challenges. While the Morita concept teaches us to be mindful about our feelings, it does not ask us to forget what we set out to accomplish. We must realize that the process of achieving a goal often does not happen overnight and that the process may involve a series of mundane steps that we must constantly take. While we may not necessary to enjoy the process of meeting our goal, we must not forget there is important value in accomplishing what we set out to achieve.
I recently had several opportunities to discuss this topic with groups of Japanese high school students who were visiting the United States during the summer to learn how to mindfully take on a leadership role. I was asked by their program coordinator to present how I managed to live in the United States as a young Japanese woman and achieve success. I was also asked to share the same mindfulness techniques, including the Morita therapy concept, that I teach my clients when they face life's challenges.
During the discussion with these Japanese students, some realized that it is very natural to experience a spectrum of feelings as they go through life. They told me that they have more positive attitudes when taking small steps to achieve a goal rather than focusing on one big action. These students learned that life will continue regardless of how they felt in the process, and in fact, many of them already did take an action regardless of how they felt, in order to achieve their goals.
As part of my PowerPoint presentation, I discussed how my life was full of both failures and achievements. I was not aware of the Morita concept when I was a young student, so I gained the necessary life skills the hard way in order to persevere after failure. After my presentation, I asked these students to participate in a short activity to demonstrate how they could pull themselves together in a challenging situation that I created for them. As they struggled to figure out how to achieve their goals, they acknowledged their negative feelings, struggled, contemplated with their fellow students, came together to support each other and laughed when they were able to work through their challenges even though they did not feel empowered during the process. I was impressed with their ability to overcome how they were feeling by reminding themselves of their purpose. It was a powerful experience for me as well to witness the shift in their mindset and see how they were feeling at the end as well.
I thought it was ironic that my teaching of mindfulness, which is rooted in Japanese culture and specifically in Buddhist philosophy, to these young Japanese students was taking place in the United States. In other words, they came all the way to the United States to learn something from their own culture.
As they go through life, I sincerely hope these students remember the Morita concept when they face a challenge and can use it to help them in managing their response to their difficult feelings. After all, it is natural to feel bad when we must do something that we are not enthusiastic about, even though it is necessary in order to achieve a goal. Acknowledging all the feelings as they are, “ARUGAMAMA,” frees us from the need to fight them. We just must find a small action that we feel comfortable enough to take today, tomorrow and every day until we reach what we set out to accomplish.
For a small mindfulness activity suggestion, you may want to discuss the following with your teen clients:
Is it true that you must feel good in order to tackle our challenging or new tasks? Why?
Explore what your anxious feeling is trying to tell you? Why is it there?
Can you be worried about tomorrow and experience what’s present at the same time? How so?
How can you be mindful when you face challenges?
What is your goal or value in life and your current tasks?
Lawrence Rubin: You’ve dedicated your career to college counseling, working with students who appear to experience many of the same problems clinicians encounter in outpatient clinics, crisis centers, and substance abuse facilities. Are college counseling centers microcosms for the clinical world outside of the campus?
Janelle Johnson: I would definitely say what we’re seeing at community colleges and at universities around the United States is reflective of what’s going on in the nation
LR: Can you give me some examples?
JJ: There has been a trend where colleges have been able to provide more support services so students can attend. In the past, these students were not able to attend because of a diagnosis or not having the right medication. They couldn’t perform in college. But now we see a lot of students coming that have schizophrenia or bipolar disorder and we have disability accessibility services to help them. Here at our college,
one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability
one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability.
LR: So, they come in with previously diagnosed mental health conditions which may run the gamut from adjustment and anxiety disorders all the way out to schizophrenia?
JJ: Absolutely. We see students every day that may have a lifelong diagnosis, who are able to come to college now, but they need resources around their diagnosis. Student counseling services often try to work with their outside providers because we see ourselves as providing supportive counseling. At larger universities, there is access to medical providers to help with monitoring medications. It depends on what your setting is at your school. If a college center does not have a medical provider, then we obtain a release, so we can actually work with a psychiatrist or a therapist that’s not on the campus, especially when it comes to monitoring medications for more serious diagnoses.
Emerging Adults
LR: So, these students that you’re seeing who have come with diagnoses are accustomed to being in treatment, are they open to being referred back into the community, even after they’re in a college counseling setting, or do they hope the counseling center will give them all they need?
JJ: That’s a very interesting question. It depends on their maturity level and how they’ve worked with medications in the past. Even with a seemingly simple diagnosis like ADHD students will often say, “I had these accommodations in high school. They sent me to a counselor.” Perhaps they had more of a medical professional do an assessment. But they come to college with the idea “well I’m in college now, I don’t need any of this.” I think most colleges experience students who come to college and try to maintain, but whatever their diagnosis is we also know that this is an age where certain mental illnesses start to show up.
Sometimes there’s an incident that brings a student like this to the counseling center where, depending upon its size, they may be able to receive an assessment. Large schools like the University of North Carolina has around 30 people on staff with psychiatrists, licensed psychologists and licensed counselors. But in a smaller private school or community college, we send them out into the community for some type of assessment or we refer them back to professionals they may have seen in the past
LR: So, a third of the students who visit the counseling center come with a previous diagnosis and may be accustomed to treatment, and they may be receptive to referrals back out into the community. What about the other two thirds? The ones who come to you and may not realize that they’re struggling or may have an emergent psychiatric disorder. How do you hook them?
JJ: What we see, especially with younger students, is emerging adulthood—that transition where they’re starting to be responsible for themselves. We try to talk to them about how they want to live their lives and how they want to express themselves as adults. In the past, when there have been mental health issues, a lot of that push either came from the parents or the school. Whereas in college, I think one of the mental health hooks that we offer them is saying, “you know, these are decisions you can make yourself. How do you want to be?” We give them some options as compared to the past where they were told what to do.
I’ve met a lot of students who were actually on medications for ADHD or who were taking antidepressants. Their parents said to them, “oh, you don’t need this anymore” and took them off. They were in that gray area of not functioning that well but having that parental oversight to get things done. And
then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t
then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t.
LR: So, these are emerging adults with whom you try to work developmentally around taking responsibility and seeking resources, which sometimes helps them to reach out for and effectively use treatment.
JJ: Yes, and at the community college level, we try to partner with community agencies so oftentimes, we can make those referrals right in our office with the student sitting here. We can put the student on the phone and facilitate appointments.
Getting Them Hooked
LR: So, you may actually be the frontline for these kids. Do you find that some of these students are resistant to the services that you provide? Or resistant to being referred out for more serious problems that they may not even think they have?
JJ: Yes, I think that we do see some resistance. The BITs (behavior intervention teams) or campus care teams sometimes need to intervene when students become disruptive in the classroom learning setting. We talk to them and try to engage them in counseling. Faculty and other students try to be patient, but I think when a student becomes disruptive, we try to figure out what’s going because we tell them that they are jeopardizing their ability to be on campus.
LR: It sounds like you have to be a little more heavy-handed or hope that the campus support teams can build enough of a relationship with the student and walk them over to the counseling center.
JJ: That’s absolutely true. You know, some people are very compliant. Other people are interested in finding out what’s going on with them because they may have that feeling like, “I don’t want to keep living like this. I don’t feel good.” But, then other students have a hard time recognizing that their behavior is disruptive or that there’s any issue. It really depends on how they’re supported when they’re at home and then how they’re treated. Sometimes I find students with very high intellectual functioning have their own unique mental health issues. It’s really difficult with some of those students because you can talk to them very intellectually and they can process what you’re saying, but
they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school
they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school.
LR: Is there a specific student that comes to mind?
JJ: A young male student I recently spoke with had a bipolar-one diagnosis and had recently received an ADHD diagnosis. He was watching his peers advancing on to their master’s degrees while he was struggling to complete school—but having this very fatalistic attitude about himself and about his ability to complete. But when you speak to him, when you look at his courses and grades, he’s got As. Schoolwork is not an issue but he lives in this sort of fatalistic place. “Why am I doing this? I’ll never amount to anything. I always fail at everything. Look what all my peers have already done.”
I think oftentimes a student feels overwhelmed on the campus and sort of wanders into our area hoping that someone will speak with them. What we usually do in that case is to obtain a release. We try to follow up to let the outside providers know that perhaps the student is in a downward spiral and perhaps he needs his medications checked.
That’s also where Cognitive Behavioral Therapy (CBT) comes in. It helps the students to look at thoughts that really aren’t helpful—the misconceptions that they have about themselves which sometimes can be very challenging.
LR: Do you get a sense, at least on your campus, that there’s a stigma associated with going to the counseling center or being seen coming out of the counseling center? And if so, how do you address that on campus?
JJ: I have a sense of that most campuses are working really hard with different kinds of programs to remove that stigma around coming to the counseling center. We see different initiatives like the JED and Active Minds programs and peer support groups. I could give an example like suicide prevention. Some campuses do things where they lay out backpacks in the quad for how many students have been lost. And then they have a place where you can come out to honor somebody you’ve lost or write something about yourself—some kind of thing where you can participate. I feel like there is increasing recognition of mental health on campuses and getting help if you need it.
On our campus, in particular, and I think on a lot of campuses, we do classroom outreach. We appeal to students to refer other students to us. Sometimes we find that’s even better than faculty referring students. Staff bring students over. But we find sometimes if your peer, another student says to you, “Oh my gosh, you’re just going through a horrible time. You know there are counseling services here on campus? You know, let me walk you over there or let me show where that’s at.” We find that’s really beneficial.
Challenges of Dual Enrollment
LR: Yours is a two-year college. But there are also high school students on campus. Do you find that these young people have unique clinical problems and challenges?
JJ: We’re seeing a lot of early admission, college dual-credit high schools on campuses. And at Santa Fe Community College we do have a high school right on our campus. It’s even happening at some four-year schools where there’s a high school house. They have some high school teachers and some high school curriculum, but almost immediately students are being placed into college-level classes. What you see happening is
they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next
they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next.
Regarding the mental health of these particular students, some are very high functioning, very motivated, but some of these students are in this fast-track program because they’ve not done well in the traditional public high school. They’ve had conduct problems or social interaction problems. The parents think, “we’ll take you over here to our college so you’ll be able to take college classes and you’ll be in this high school but it’ll be a lot more flexible for you.” But these students who haven’t performed well in the past may have an inability to follow through and can’t really manage themselves in college. One of our counselors in particular had a student with a very high level of ADHD who didn’t come to the counseling appointments on time. This sort of high school/college program can actually create more anxiety and more unmanageability and adjustment disorders for students.
LR: So, these kids may not be in an appropriate fit for college life just yet?
JJ: Perhaps, but it’s hard to say. What schools are doing with this early college high school programs are really a positive move for a lot of students because I think high school has let a lot of them down. I think high school is a really difficult time for a lot of students because of pressures around social media and bullying. So, being on a college campus really helps them be with other college students who are motivated to get a degree. But there is always the question of whether they are developmentally ready or mentally ready. And while there is a high school counselor here for those particular students, they are spending a lot of time on other things like scheduling and achievement testing.
Addressing Suicide on Campus
LR: Suicide rates are very high in the college-age demographic. How are college counseling centers set up to address that?
JJ: I think a lot of college counseling centers are trying to address that with different kinds of programming. The JED foundation, for example, offers programming for college campuses. Active Minds is another one that offer all kinds of wellness programming for campuses that also addresses suicide prevention. Also the American Foundation on Suicide Prevention in New York.
Suicide is the second-highest cause of death for our demographic.
Suicide is the second-highest cause of death for our demographic. Even if you go up in age a little bit, which is the demographic for a lot of community colleges, then suicide is the third-highest cause of death. So, I think on most campuses we are all actively working with programming and bringing support.
At Santa Fe Community College we actually have a certified faculty member do Mental Health First Aid Training. Mental Health First Aid is a program that originally came out of Australia that has been embraced in the United States. It’s a day-long program for people in the community who are not mental health professionals. Here at Santa Fe, it would be our campus community—our faculty, staff, other students who take the training.
LR: So, when it comes to the more serious disorders, and suicide in particular, it’s critical that college counseling centers work in conjunction with community agencies and have programs on campus so that students are never alone. And neither are college counselors alone because they’re always linked to other resources?
JJ: Right. College counselors work with these different available resources, create their own programming or belong to these organizations that provide free programming.
The idea is to eliminate the stigma, raise awareness and have people participate.
The idea is to eliminate the stigma, raise awareness and have people participate. The campus is a community and we encourage students to participate in these suicide prevention programs and to be part of a campus community that supports helping students reach out. People need to recognize the signs and to be comfortable approaching people.
Disconnected from Families
LR: On a related note, we know that LGBT youth are at particularly high risk for suicide. How do you address the needs of these students?
JJ: A lot of campuses are looking to find ways to support students who are in the process of self-identifying or have someone on their staff assigned to programming in that area who works on removing stigma. In New Mexico, which is a very Catholic state with a lot of immigrants, some of these families persist in saying to their children, “your religion doesn’t accept this. You can’t do this. If you do this, you can’t live with us.” So, we try to work on that by asking these students, “How can you speak with your family? How do you want to live your life?” These students still recognize their religious teachings but don’t want that being used against their identity.
LR: So, you try to work within their families and with the cultural issues that impact their emerging LGBT identities?
JJ: Campuses will either look for programming or design their own programming around supporting these students, and then work with them on these issues in counseling.
A lot of these students actually feel safer on campus than they do at home.
A lot of these students actually feel safer on campus than they do at home.
LR: Speaking of unique challenges, what about first-generation college students.
JJ: I do believe they have unique clinical challenges because many of them do not have a history of going to college. Additionally, many of these young people also have to help out financially in their homes. So they live at home, come to college but also work to help pay the rent, the utilities and the car payments. And then there are issues around their transition to adulthood. We help them speak to their parents about what they need to be a successful college student.
Some of them will say “my parents are making me feel like I’m crazy because I need more time to study and I can’t take care of my little brother or pick him up from school every day.” It’s an interesting dynamic that plays into their mental health because when they don’t feel supported or understood at home, they experience anxiety, depression and acting out behaviors. It’s not that families don’t support going to college—they absolutely do. But they don’t know what that means or what it looks like.
Raising Awareness
LR: There’s a lot of research into the short and long-term effects of adverse early childhood experiences and the need for trauma-informed education. The idea is that some of these kids are coming to school with such a heavy trauma burden that they can’t concentrate, can’t relate and are at high risk for drinking or self-harm. Have you seen this on your campus and how do you deal with that?
JJ: There are different kinds of trauma. Here
in New Mexico, we have a lot of Native Americans, so we talk about historical trauma
in New Mexico, we have a lot of Native Americans, so we talk about historical trauma. In addition to these historical events, some of our students come from a background of trauma in their home or in their childhoods. In the college counseling setting, we work with these students around issues of safety, peer support and collaboration—empowering the student to have a voice while they are exploring their issues. We are not dismissing what has happened to them but we’re looking at how the therapy works for them, helping them to move forward with that trauma and not to feel re-traumatized by being in our college setting.
LR: Are drinking and substance abuse significant problems on college campuses?
JJ: We’re not seeing it as much on commuter campuses like ours that do not have housing, although I do think it is a presenting problem in our counseling centers. It’s different on residential campuses, and particularly in the dorms. But we do see students coming to campus who are inebriated, or who have problems that other students are reporting. They may be coming to class and they sound like they’re drunk or other students can smell it on them.
I do think it is an issue that is hard issue to address. College counseling centers try to work with students on maintaining their sobriety. I think if they’re actively using or they can’t even function then it is critical to refer them to treatment center. Another student may binge drink only on weekends and otherwise be high functioning, but it also starts to catch up with them. They may not be getting proper nutrition, or may be having problems with sleep, hygiene or relationships. These effects of drinking begin to interfere with their functioning in the college setting. With these students, we try to talk more about responsible drinking and help them to understand how their drinking interferes with their learning and progress and help them explore how they can be more responsible.
Serving our Veterans
LR: You had mentioned that you have a veteran’s program on campus? Are there unique clinical needs for these students?
JJ: Often college campuses have veteran support centers which provide resources for veterans and their families. These resources include counseling services. Although we are not housed with the veteran’s service center on our campus, veterans know about our counseling services. We also have a veteran’s hospital in Albuquerque, New Mexico, which is about 60 miles away and a veteran's counseling center in Santa Fe.
Our veteran’s center also brings counselors onto our campus about once a week to meet with the veterans. This is not to say that some of the veterans don’t come to our regular college counseling center. Having served first and then coming to college can be a challenge and clinical needs depend on whether or not they are a combat veteran. The
combat veterans may feel that there is a stigma around coming to the regular college counselor
combat veterans may feel that there is a stigma around coming to the regular college counselor who hasn’t experienced what they have or have a military background. Larger campuses actually hire counselors who have served in the military. This can be helpful because veterans have trauma about reintegrating. They’re used to following authority and a more established and structured day. Sometimes they have difficulty with younger students who aren’t respectful.
LR: Or knowledgeable!
JJ: Sometimes, these younger, less sensitive or aware students don’t conduct themselves very well in class which is very troubling for veterans. And then of course, we do have veterans that have PTSD or depression; situations that require more treatment. But a lot of times, I think it is more about adjustment, depending on how long they served and the college program they’re in.
CBT and Beyond
LR: We’ve been talking about various treatment needs of college students and I know that CBT and other empirically supported treatments are the rage these days. I’m wondering if it also dominates the college counseling landscape.
JJ: I think there is a lot of support on college campuses to use research-supported therapy modalities. CBT has a lot of related therapies including DBT, solution focused and even positive psychology. The reason it works in our setting is because we’re tasked to triage students that come in. There can be a high need for services and students oftentimes wait to get in to see a counselor or a mental health provider. So, I think we want to use therapies that we know can assist with more immediate behavior change.
We don’t have the luxury for long-term care with students.
We don’t have the luxury—and I don’t know if it is a luxury—for long-term care with students. So, those kinds of therapies can really be useful. You can give the student homework and worksheets—something they can hold onto so that they can feel like they’re moving forward and like they’ve accomplished something. I’ve even had students with whom I’ve suggested a reward system to help when they were struggling with something and want to see improvement. Larger campuses can even incorporate these kinds of therapies into a group setting and can direct students to be part of therapy groups.
LR: Would you say that college counselors are pressured to use these proven methods and not encouraged to use creative-expressive modalities that incorporate art, play and music?
JJ: We’re not forced to do that—it would depend on the counseling center and how many staff members they have. I do see the creative going on as well. In New Mexico, Southwestern College offers a master’s degree in art therapy and I’ve had interns from there on my campus who have done art therapy with our students and they’ve really liked that.
There is some room for creativity, but you have to be working to move the student forward especially because you’re working in a limited timeframe; a college semester or a college quarter and then there’s a break and they go home. I am at a community college where we are looking toward a goal-oriented type of therapy. If they bring in extreme trauma or are in an abusive relationship or are fighting an addiction, treatment is better is referred to a community partner. We use whatever modality is supportive of their counseling and helps them to meet their goals.
And for most of them, their goal is to complete college, find a career and move forward. So, we try to facilitate that. If there is a major mental illness diagnosis, we make sure that they have a community provider who may be doing something like DBT groups. I don’t feel like college counseling can replace that.
College Counseling Competencies
LR: With regard to the provision of treatment, what are some the unique competencies that a college counselor should possess?
JJ: At the university level, a lot of schools hire licensed doctoral-level clinical directors. The counseling staff is sometimes made up of licensed counselors. In New Mexico, I’m a licensed clinical mental health counselor. Some college centers hire licensed clinical social workers who are in clinical practice. That’s is the more traditional set up. Our organization, the American College Counseling Association expects that any counselors working in a college setting be licensed.
What we see in California is an interesting example where most of the universities are using doctoral level licensed psychologists in their counseling centers. In their community colleges, they are using master’s level clinicians. But they don’t have licensure at that level. It’s hard for me to talk across the board, however the American Counseling Association has been working on licensure portability along with licensure accountability.
I would say that if you’re going to work in a college setting, you should be licensed in the same manner that you would to work in a private practice or at any other clinical facility—you need the degree and the experience that comes from practicum and internship to do this work. Unless, that is, you’re in a college where they’re calling you a counselor and you’re doing academic advising or something like that. If you’re in a college mental health counseling center, you’re doing the same kind of work anybody would be doing as a mental health professional anywhere else. The scope of your practice may be limited in that you have to do more community resource referrals. But, your knowledge and ability including understanding the DSM, various diagnoses and treatment modalities fully impacts your work every day. You need to be able to do it.
LR: Do college counselors need to like teenagers and emerging adults? Wouldn’t that be a prerequisite?
JJ: I think that you want to be able to work with that population. Three years ago, I started an internship program here at Santa Fe Communi
