Therapy: A Poem

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Therapy

In that billowing silence.
A silence to loathe and love,
like the first gasp of submersion at the pool.

In that silence I examined the paintings
on your wall and thin splits between the floor boards,
the leavings caught in them – crumbs and dust
and once a tiny blue bead. In the roaring
silence while I scrambled away from my edges,
I came to know well the hem of your skirts
and the lay of your hands on your lap. Still.

Each Tuesday I sat in the corner of your couch,
ringed by a wreath of damp tissue.
You rocked in your chair.

Sometimes I thought
you were a beatific witch
just waiting with your gentle prods
to send me back into my seas,
to push me under, over and over,
sometimes I thought you invented the pearl
I sought – a mean joke on me.

I thought you knew what I was going to say next,
knew my interior as if it were written in a code
for which you held the key.
Sometimes I liked this, then I didn’t.

How still our bodies were! While I dangled
over the fire at the bottom of my darkest pits,
writhed in the salt of my ordinary wounds.
How quiet and desperate that year of weekly hours.
How seasons of light dwindled
and blossomed across the planks of your floor,
how my singular and universal dreads met
and wrestled under your watch.

How I wanted to crawl into your lap
and have you stroke my hair
and say there, there,
and how, in a way,
never touching me,
you did.
 

On Quitting The Practice of Psychotherapy

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Workplace Wounds

My name is Michael Sussman and I’m a recovering psychotherapist.

By this I don’t mean that I am a therapist who attends Alcoholics Anonymous, but rather that I’m in recovery from being a therapist.

I made a decent living as a clinician, and took great satisfaction in helping people in distress. Over time, however, the strains of practice overwhelmed my own coping capacities and I was forced to close up shop. Ironically, it appears that working as a therapist aggravated the very same wounds that first drew me to the field.

Like many practitioners, my early family experiences groomed me for the role of psychotherapist. As a typical middle child, I felt unsure of my place in the family and hungered for acceptance. I dealt with these insecurities by becoming mother’s little helper and confidante. Outwardly, I did all I could to help her care for my younger brother. But underlying feelings of jealousy and malice toward the intruder drove me to torment my brother on the sly. This, and my failure to somehow heal my parents’ troubled marriage, left me with deep reservoirs of guilt and remorse. As I’d later learn, such feelings—along with intense needs to atone and make amends—supply a powerful impetus toward pursuing a career in the helping professions.

Unfortunately, they also provided fertile soil for the development of emotional illness. By the age of 15, I was already showing signs of depression. In my late teens I dropped out of college and joined a cult, and by my early twenties I was bouncing in and out of psychiatric wards with bouts of both depression and mania.

I eventually stabilized enough to return to school and earn a bachelor’s degree in music composition and performance. And who knows? If I’d become a professional musician or a music teacher, perhaps I would never have suffered another episode of severe mental illness Instead, with considerable trepidation, I entered graduate training in clinical psychology.

From the start, graduate school undermined my emotional stability by weakening my defenses. As I learned in class, we all employ an array of defense mechanisms to help maintain psychological equilibrium. These protective strategies tend to function largely outside of conscious awareness. Why? Because our psychic defenses—like a nation’s military strategies—must remain concealed in order to be effective. If you become aware, for instance, that you’re using denial to avoid facing painful feelings, those feelings are more likely to emerge.

By gaining understanding of these defensive maneuvers, my own defenses were inevitably compromised. And in a variant of what has been dubbed medical students’ disease, I began experiencing the symptoms of the disorders we covered in class.

If studying psychopathology was a bit dodgy, actually working with disturbed people turned out to be downright perilous. The empathy that allowed me to tune in and connect with patients also left me vulnerable to taking on their pain. In addition, I was ill prepared for the enormous burden of responsibility entailed in caring for the sick. During my third year, a middle-aged patient of mine jumped to her death from the window of her 20th-floor apartment, shortly after transferring to a new therapist. Though devastated by her death, it only intensified my dedication to the calling.

But as the years passed, the emotional toll mounted. Overly dedicated to work, I neglected my social life and grew increasingly isolated. Rather than freeing me from an introspective disposition, clinical practice only deepened it. And while clinical successes were exhilarating, they did little to assuage the guilt from my childhood “crimes.” Clinical setbacks and failures, on the other hand, intensified my inner sense of badness. Far from bringing redemption, the practice of psychotherapy engendered in me what the psychiatrist Richard Chessick termed soul sadness.

Ultimately, my career was cut short by full blown major depressive episodes requiring electroshock treatment. I’m better now and have had former patients literally plead with me to return to practice. But my susceptibility to depression precludes me from providing emotional stability to others. Moreover, I can no longer ignore the fact that practicing psychotherapy is hazardous to my own health.

Recovery

So, what broader lessons can be drawn from my saga?

First, wanting to help people is not sufficient reason for becoming a therapist. Admissions committees must help applicants explore their hidden motivations for practice.

Second, although a mild to moderate degree of emotional conflict needn’t be problematic, training programs ought to be wary of admitting applicants with a history of serious mental illness.

Third, all applicants ought to be fully warned about the potential dangers inherent in learning and practicing psychotherapy, and therapist self-care should be included in the curriculum.

Fourth, the last bastion of the stigma of mental illness appears to be within the mental health profession itself. It can no longer be denied that a substantial percentage of practitioners are significantly stressed or impaired. It’s imperative that the professional community stops fostering shame, and begins creating an environment in which struggling clinicians dare to reach out for help and support.

Meanwhile, I’m writing fiction. I’ve spoken to several former colleagues who are also in recovery. One runs her own bakery, another owns a bookstore, and a third raises llamas. What’s disturbing to contemplate is that, in all likelihood, there are thousands of therapists out there who ought to be doing something else, but continue to practice.

*This article was originally published in the May/June 2013 issue of New Therapist magazine.

Counseling Kids: When a Cigar Is Just a Cigar

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Nine year old Malcolm was one of the fortunate clients. Because his family had a very modest income a local counseling center with a sliding fee scale was seeing Malcolm on a pro bono basis. Better yet, the agency was providing free transportation for him on a school bus. His emotional difficulties began two years ago after his parents got a divorce. He was now living with his natural father and his new step-mother.

Treatment seemed to be working well. Then it happened and it changed everything. One day while riding to the agency, he pointed out the window at a very upscale, plush shopping center and exclaimed, "My mother owns that shopping center."

The bus driver (who was trying to talk some sense into the young man) said, "Now Malcolm, that's not true. You know your parents don't have a lot of money and they surely do not own that shopping center. You lied. Now you need to admit to the other kids you a not being honest and apologize."

Malcolm began crying and insisting his family really did own this center. The kids on the bus starting yelling at Malcolm and insisted he owed all of them an apology. The incident ended with Malcolm screaming at the top of his lungs at the children who taunted him.

The bus driver dutifully reported the entire incident to the clinical director of the organization who thanked him and swung into massive therapeutic action. They knew Malcolm was depressed since the divorce, nevertheless, the clinicians had never seen anything resembling this seemingly psychotic like break from reality and tendency to lie, combined with extreme hostility.

The treatment plan was stepped up to a whole new level. Instead of Malcolm seeing only an individual counselor, he would also be placed in group counseling and play therapy. He was also referred for an extensive battery of psychological tests, a medical management session with their psychiatrist, and a session with the neurologist at the agency. He was also referred to a therapist specializing in anger management. Malcolm's progress (or lack of it) would be assessed 30 days later at a case conference in which all the aforementioned psychotherapeutic players would be present.

Finally, it was the day of the big staffing but there was one new treatment player on the field. David, a graduate student serving his practicum at the facility.

The meeting began with the clinical director turning to David and asking, "David, this is a fascinated case. How do you think we should proceed with our intervention with Malcolm?"

"Well sir," said David, "since this is my first day here I haven't had time to read the record. Like everybody else, I just recall that his natural mother is filthy rich. I'm sure we can all remember the firestorm of publicity in the newspaper and on television when she built the upscale giant mall down the street from us. Right?"

The room was dead silent for what seemed like eternity. You could hear a pin drop even if you were using construction worker grade ear plugs during the staffing. Score one for Malcolm!

Since Freud was the master of symbolism, the story goes that around 1920 somebody wanted to know about the symbolism of Freud's own propensity to smoke upwards of 20 cigars a day. The Freudian interpretation at the time was that a cigar was a phallic symbol. When confronted by his fellow analysts about his own behavior Freud remarked, "Sometimes a cigar is just a cigar."

As of late, scholars have come to the conclusion that the famous "sometimes a cigar is just a cigar" statement attributed to Freud is false. Or to put it forthrightly, Freud never said it. My humble two-cents regarding Freud is that even if he never said it, he should have!

But here's the point. If 20 years from now Malcolm is lying on an analyst's couch babbling on about his tendency to smoke cigars, the analyst would do well to keep the notion in mind that sometimes a cigar really, truly is . . . well just a cigar.

A Short Piece on Disrespecting Teenagers

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We have an American cultural norm to disrespect teenagers. For example, it’s probably common knowledge that teens are:

  • Naturally difficult
  • Not willing to listen to good common sense from adults
  • Emotionally unstable
  • Impulsively acting without thinking through consequences

Wait, most of these are good descriptors of Bill O’Reilly. Isn’t he an adult?

Seriously, most television shows, movies, and adult rhetoric tends toward dismissing and disrespecting teens. It’s not unusual for people to express sympathy to parents of teens. “It’s a hard time . . . I know . . . I hope you’re coping okay.” Even Mark Twain had his funny and famous disrespectful quotable quote on teens:

“When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much the old man had learned in seven years.”

This is a clever way of suggesting that teens don’t recognize their parents’ wisdom. Although this is partly true, I’m guessing most teens don’t find it especially hilarious. Especially if their parents are treating them in ways that most of us would consider unwise—at least if we were treated similar ways in the workplace.

And now the neuroscientists have piled on with their fancy brain images. We have scientific evidence to prove, beyond any doubt, that the brains of teens aren’t fully developed. Those poor pathetic teens; their brains aren’t even fully wired up. How can we expect them to engage in mature and rational behavior? Maybe we should just keep them in cages to keep them from getting themselves in trouble until their brain wiring matures.

This might be a good idea, but then how do we explain the occasionally immature and irrational behavior and thinking of adults? I mean, I know we’re supposed to be superior and all that, but I have to say that I’ve sometimes seen teens acting mature and adults acting otherwise. How could this be possible when we know—based on fancy brain images—that the adult brain is neurologically all-wired-up and the teen brain is under construction? Personally (and professionally), I think the neuroscience focus on underdeveloped “teen brains” is mostly (but not completely) a form of highly scientifically refined excrement from a male bovine designed to help adults and parents feel better about themselves.

And therein lies my point: I propose that we start treating teens with the respect that we traditionally reserve for ourselves and each other . . . because if we continue to disrespect teenagers and lower our expectations for their mature behavior . . . the more our expectations are likely to come true.

Psychotherapy with Transgender and Gender Nonconforming Clients

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The Unbearable Otherness of Being

Imagine making your way in a world where your physical appearance makes others uncomfortable, anxious, confused, or uncertain about themselves. Your very presence may be perceived as a threat to another individual’s sense of self or sexual orientation. Everywhere you go, people stare at you—sometimes discreetly, often blatantly—leaving you very little room to walk unselfconsciously through life. The reactions you experience from others, while the result of ignorance and sometimes mere “curiosity,” do nonetheless harm you, for you are perceived as “Other.” At times, people’s reactions are more hostile, the result of conscious and unconscious fears about what it means to deviate from gender norms, and you may be verbally or physically assaulted just for being you.

This is what it’s like to be a gender nonconforming or transgender individual in today’s world. Though there is increasing awareness and tolerance around gender issues in certain small segments of American culture, the truth is, the level of misunderstanding, ignorance and prejudice that surrounds gender nonconforming people as they go about their lives has created a mental health crisis in our society. To illustrate the epidemic nature of this crisis, here are a few statistics from the American Foundation for Suicide Prevention’s 2014 Report, “Suicide Attempts among Transgender and Gender Non-Conforming Adults.”

In a pool of 6,000 self-identified transgender respondents:

  • 41% had attempted suicide
  • 60% were denied health care and/or refused treatment by their doctors.
  • 57% had been rejected by their families and were not in contact with them.
  • 69% had experienced homelessness.
  • 60-70% had experienced physical or sexual harassment by law enforcement officers.
  • 65% had experienced physical or sexual harassment at work.
  • 78% had experienced physical or sexual harassment in school.

For gender nonconforming individuals, the very nature of their sense of “self” lies in marked conflict to society’s gender identity “ideals” and social scripts. The resulting prejudice (transphobia and homophobia), whether explicit or covert, often manifests in forms of denial, invisibility, harassment, bullying or, in more extreme cases, assault and murder. As if this weren't enough, gender nonconforming and transgender persons may be further marginalized by their ethnic and racial identity, economic status, physical abilities, and age.

More subtle forms of discrimination exist, many occurring within the helping professions, including mental and medical health, nonprofit support services, legal and government institutions and public schools. Overpathologizing, misdiagnosing, maltreatment (including refusal of services), neglect and demonization are just some of the ways transgender individuals are routinely discriminated against within systems whose mission is to support and serve. These discriminatory practices are carried out by providers who fail to become educated and respect, protect, or provide treatment that is appropriate, impartial, and equal to the care given to other clients. Following, I will attempt to provide the nuts and bolts necessary for aspiring clinicians who wish to work in a culturally competent manner with their gender nonconforming and transgender clients.

Gender and Language

I often remind my colleagues, students and clients that we all have a gender identity and diverse manners in which we choose to engage in self-expression. As a cisgender female (i.e., I identify with the gender I was assigned at birth—female), I am conscious of the great extent to which I can embrace the everyday conveniences of being privileged. I am not ostracized for my gendered self, and no one questions my choice in using a public restroom. For gender nonconforming and transgender clients, this problem is known as the “bathroom issue.”

We practitioners need to become fluent and speak the same language as our gender nonconforming and transgender clients. In doing so, we demonstrate the intention of promoting respectful communication that expresses an intricate set of thoughts, ideas, and feelings associated with sex, gender, sexuality and identity. The language used among this diverse community is multifaceted because finding words to articulate complex notions of identity is arduous. In fact, the youth in my office frequently inform me, a gender specialist, how some of the language and concepts I use are now outdated. Nonetheless, staying current with the language being used within the gender nonconforming community is an important part of being not only a culturally competent therapist, but an empathically attuned therapist. Such language literacy also enables mental health professionals to understand concepts, organize thoughts, foster discussion, exchange ideas, and support the community in the least confusing, shameful, and harmful way. Familiarity with the community’s positive expressions of self and identity not only helps clients feel understood, but ensures that therapists don’t rely on clients to educate them—an all-too-familiar experience for cultural minorities.

The following list presents a very general overview of how we come to understand the meaning of sex, gender/gender identity, gender roles, and sexuality for our gender diverse clients and ourselves. It’s important to remember that these terms are constantly evolving within the gender nonconforming, transgender, queer or transsexual communities, as well as by the practitioners who intend to help them. Gender nonconforming and transgender identities include but are not limited to: Transgender (TG), female-to-male (FTM), male-to-female (MTF), transgirl or transboy, girl/woman (natal boy), boy/man (natal girl), they/them, bigender, gender fluid, agender, drag king or queen, gender queer, transqueer, queer, two-spirit, cross-dresser, androgynous. The terms FTM (female-to-male) and MTF (male-to-female) encompass a spectrum or continuum from those who identify as primarily female or male, to those who identify somewhere in the middle or both (e.g., queer). Between these two posts or “extremes” (female and male) lie most gender nonconforming individuals.

The sexual orientation of gender nonconforming and transgender clients is a separate identity and should never be presumed or assumed. It refers to the gender one is typically romantically and sexuality attracted to (e.g., homosexual, heterosexual, bisexual/pansexual, polysexual, asexual etc).

Becoming Gendered

It’s important to think about how we become “gendered.” In part we do this by the way we organize and construct language. Most of the English language is “gendered,” constructed in a way that makes it difficult to deviate from strictly binary conceptions of male and female. We tend to acknowledge and refer to one another through pronouns, and consequently become gendered in our relational experiences. For example, when we frequent our local coffee shop, “Excuse me, Sir…Mam…May I have a large coffee?” Here is a simple example of how we have already ascribed gender to a complete stranger.

As clinicians, we need to learn to ask and address our clients appropriately. More importantly, we need to develop the capacity to become conscious of our own gendered ways. Specifically, we need to ask all our clients about their gender identity and development as well as their gender pronoun preferences. The youth that show up in my office often challenge this binary model most of us are so accustomed to, and request to be referred to as: ze, hir, one, or the plural “they” “their,” “them.” Interestingly, I often find myself arguing with my cisgender colleagues, who get caught up in grammar policing, about the importance of honoring the self-identification of these clients. The English language is constantly evolving, after all, and human and civil rights struggles play an important part in its evolution. At the same time, it’s important to not make any assumptions about people’s identification preferences. Plenty of gender nonconforming or transgender clients prefer to be referenced by conventional pronouns such as “him” or “her” because it feels congruent with their internal identity.

People tend to be preoccupied with gender long before a child is born. “Do you know your baby’s sex?” is a constant question for pregnant parents. Sex, in this case, refers strictly to the external genitalia of the child rather than their potential internal gendered self. “Gender is assigned prenatally and from that moment it determines—and severely limits—acceptable gender expressions and desires.” Our early training begins with our parents’ color selection for our nurseries, the names we are given, and the activities we are encouraged to enjoy, and because we want their love and approval, we emulate what is desired of us. We internalize the societal roles, behaviors and beliefs ascribed to us by the culture around us (including that of our family) and may not know that any other way of being is possible. Boys get blue items, are given toy trucks and guns, and are prompted to be assertive and confident. Girls wear pink, are given dolls to play with, and are encouraged to be empathic and compromising. These behaviors, beliefs and customs are socially constructed—situated in the context of historical time, social class, ethnicity, culture, power, politics, physiology, and psychology—but they are deeply entrenched in our psyches and ways of being.

Clinical Practice

As the presence and experience of transgender people has entered both public consciousness and mental health facilities, clinicians are now beginning to think about transgender/gender issues. However most clinicians are not trained to identify clinical themes prevalent for transgender and gender nonconforming individuals, and consequently misunderstand their mental health and their global treatment needs. Our traditional training fails to address gender and sexuality development for transgender persons from a nonpathological perspective. In addition, negative countertransference from providers and institutions is common and lends itself to discriminatory practices or, worse yet, thoughtless analysis of clients’ needs that may lead to irreversible medical interventions. Common feelings and attitudes for inexperienced clinicians toward these clients may include anxiety, fear, disgust, anger, confusion, morbid curiosity, and rejection, all of which can severely compromise the therapeutic relationship, our ability to help, and an individual’s identity development and transition process.

The journey of self-discovery for gender nonconforming and transgender individuals is laborious and often lonely because, simply put, the desire to become more congruent with their “True-Self” in body and mind may require a shift in physical identity. Children tend to be the most disadvantaged in this phase of life as they may be required to repress their desires to play with “cross” gendered toys and are left feeling ashamed to admit their favorite colors and activities (e.g., the boy who is prohibited from playing with dolls and having a pink bedroom).

As gender nonconforming individuals become more psychologically distressed they often feel the need to have a more congruent experience of their internal and external selves. They may need to first embrace a social transition—choosing an alternative name that reinforces their internal identified gender, dressing in a stereotypical fashion that supports their gender identification and engaging in “cross” gendered behaviors. In my clinical experience, when given the permission and support, gender nonconforming children and adults tend to become less anxious, depressed and gender dysphoric as a result.

However, some gender nonconforming and transgender individuals have a persistent need to modify or transition the physical attributes of their body to the opposite of their ascribed birth gender. This process is often too confusing for most people to comprehend, and is especially difficult because one’s gender expression and behaviors are typically the initial identifying marker for organizing one’s relational experiences among others. The clients with whom I work often desire bodily change not only to feel more congruent with their internal self, but with the hope of being experienced relationally as they truly are. For example, my transgender FTM clients use heavy-duty binders to flatten and contain their breasts so that they will not be mis-recognized as tomboys or lesbians. This experience of congruence tends to reduce gender dysphoric intrapersonal and interpersonal experiences. Our transgender clients need additional support around the use of physical and medical interventions, so it’s all the more important that we be well-educated and sensitive to these issues.

Gender Dysphoria

The new addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), released in May of 2013, has removed the diagnosis of Gender Identity Disorder and has re-classified Gender Dysphoria as a clinical condition that gender nonconforming, transgender and transsexual clients may experience. Gender dysphoric symptoms arise when one’s self-concept and expressed gender in relation to their ascribed gender is “incongruent.” The psychological distress that results from these internal and external conflicts can lead to dysphoria, depression and a host of other conditions commonly experienced by transgender or gender nonconforming individuals. This turmoil is often created by internalizing the “gaze” of the world around them, i.e., they experience a great deal of psychological discomfort due to being publicly misgendered. Yet, it is also important to note that many gender nonconforming and transgender clients do not experience Gender Dsyphoria. They tend not to make it to our consulting rooms.

What of the clients who do end up in our offices? If a gender nonconforming or a transgender client and his or her family seek our support, are we available to console them, educate and advocate on their behalf, and offer culturally informed and sensitive treatment to the client and the family without getting caught up in our own agendas? How do we determine whether a child is an appropriate candidate for social transition, hormone blockers or even cross-hormone interventions? How do we determine whether the child is an appropriate candidate for genital reassignment surgery, which is often irreversible? How do we think about their fertility options and future family plans? How do we help a transgender child assigned female at birth who is in distress after his first menstrual period? Some of these interventions may seem radical, but if we fail to educate and train ourselves adequately around these issues, we can actively cause harm to our clients. Self-harm (body mutilation), substance abuse, homelessness, suicidal ideation or even suicide attempts can result.

A number of other conditions emerge in gender nonconforming children, particularly when their families aren’t able to provide the support and unconditional love that is necessary for them to thrive. These include adjustment issues, depression and anxiety disorders, trauma, substance dependency, and characterological pathology. Clinicians must be aware that families, too, must be educated about transgender issues, learn skills for coping with the child’s gender change, and be able to mourn and seek social and emotional support for themselves. And, of course, many clients may have co-occurring conditions, such as Autism spectrum disorders, that are beyond the scope of this article.

When treating a client with a gender nonconforming or transgender identity, clinicians may find themselves involved in a few situations unique to these clients. They may be asked to assess and substantiate a client’s preparedness for various biomedical interventions—usually involving the Real-Life Test/ Real Life Experience or a Gender Readiness Assessment—which involves encouraging a gender nonconforming client to begin living in their self-determined gender role and then assessing the impact of that experience. For example, some clients might experience a reduction in gender dysphoric distress, while others—say those whose family or community context is hostile to their nonconformity—may experience an increase in symptoms. Though this assessment is no longer required by the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People published by The World Professional Association for Transgender Health, many medical providers and insurance agencies require it for coverage.

Bridging the Gap

A transgender or gender nonconforming individual’s psyche and the issues they face are very complex—and at times, convoluted—with complications in the psychological, medical, legal, and social realms. Because of this complexity, and the severity of their suffering, it should not be left solely in the hands of clients to educate their clinicians, nor should these clients be put in the vulnerable position of relying on their clinician’s empathy to determine whether they will receive the care they require. An ignorant clinician who responds negatively to such clients—even if only at an unconscious level—can cause untold harm and make it that much more difficult for clients to seek the help they so desperately need. We need to take responsibility for becoming educated and seek guidance from gender specialists—trained providers who can inform clinicians about transgender history and integrate traditional psychoanalytic and psychodynamic perspectives with queer theory.

Diane Ehrensaft, PhD, director of Mental Health at the Child and Adolescent Gender Center in San Francisco, and her colleagues are doing groundbreaking work in this area, bridging the gap between developmental, biological, queer and psychoanalytic theory using what she calls a “Gender Affirmative Model.” She draws upon Winnicott’s ideas of “true gender self” and “false gender self” in formulating her notion of gender creativity to better understand gender nonconforming and transgender children and adults. Turning prevailing wisdom on its head, she argues against labeling gender nonconforming invidividuals as dysphoric and instead views their varied gender expressions as fluid, dynamically intertwined between biology, development, socialization, and cultural context in time. Gender is not binary and may change over lifespan.

Understanding the issues that gender nonconforming clients face creates the possibility of an authentic and empathically attuned treatment that can be a true corrective emotional experience. Having the competence and confidence to administer a Real-Life/Gender Readiness Assessment can make all the difference in our patients’ lives, allowing them to socially transition and integrate their gender identity with other aspects of themselves. Thinking of the client as whole is instrumental to their overall well-being.

Not until we as clinicians grapple with our own gender identity, behaviors, and attitudes can we begin to utilize our assessment skills in developing diagnostic impressions, identify and observe our countertransference feelings, and implement treatment interventions that will lead to a balanced internal and external sense of self that improves a client’s overall quality of life. I encourage all my fellow colleagues to become more cognizant of the their own identities, values, and beliefs, and particularly to confront their fears and prejudices when working with transgender individuals. We must become mindful of what we ask—and do not ask—in our clinical interviews.

We also mustn’t assume that gender nonconforming clients are coming to us because of their gender or sexual identity and be open in creating our hypthotheses about our clients’ needs and desires. Let us accurately reflect the true clinical condition with which our client’s struggle. As I noted at the beginning of this article: imagine making your way in the world where your very sense of being makes others anxious, confused, and uncertain of themselves. By becoming culturally competent, we will be better able to provide an empathic approach to treatment that considers a range of gender nonconforming expressions and behaviors as healthy, as an authentic gender identity and bodily presentation, albeit variant from societal expectations. Gender deviation is not pathological, and if you think it is, you’ve got some work to do. On the other hand, it’s important to not be reflexively “progressive” and mindlessly support a transition that is not first deeply understood clinically.

Reflections on the theory of gender development, diagnostic conditions, and clinical treatment implications must include the role of the clinician as a gatekeeper to another’s self-determined gendered body, heart, and mind. The exploration of the transference-countertransference relationship is paramount, regardless of whether you are a case manager, a medical doctor, or a psychotherapist. Let us play with gender, and in our journey, discover the kaleidoscope of possibilities for clients as well as for ourselves. As providers, it is our social responsibility to change the role of the clinician from a gatekeeper to one who can form a therapeutic relationship that offers a way for clients to integrate their sense of self in relationship to the other that can hopefully be emulated in the outside world. A solid sense of self is likely to build confidence and self-esteem that will foster healthier relationships and diminish uncertainty and fear, decreasing the risk of self-harm and—hopefully—violence toward gender nonconforming and transgendered individuals.

Recommendations for Clinical Practice

  • Ask your clients about their gender identity and preferred pronoun. Explore their internal experience and how it impacts them interpersonally.
  • Foster multiple and integrated identity development: race, ethnicity, gender, class, sexuality, profession etc.
  • Educate parents about the importance of not pathologizing the gender expression of their children.
  • Treatment interventions should include allowing children the space to explore their gender expression, family education and support, as well as parental support to mourn the loss of their fantasies about their birth child's ascribed gender.
  • Collaborate treatment efforts with the providers involved, e.g., social workers, endocrinologist for hormone blockers and hormone treatment, family therapist, and treatment team staff.
  • Remember: Gender nonconformity is a natural expression of human development and experience.
  • Do No Harm: Seek consultation from a gender specialist. Monitor countertransference and refer out if you are not able to act fully in the best interest of your client.

Clinical Resources

  1. Report of the APA Task Force on Gender Identity and Gender Variance.
  2. Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7.
  3. Achieving Optimal Gender Identity Integration For Transgender Female-to-Male Adult Patients: An Unconventional Psychoanalytic Guide For Treatment (2008), Karisa Barrow.
  4. Gender Born, Gender Made: Raising Healthy Gender-nonconforming Children (2011), Diane Ehrensaft.
  5. The Transgender Child: A Handbook for Families and Professionals (2008), Stephanie Brill & Rachel Pepper.

Deconstructing Gender: Self-Exploration Exercise

  • What is your own gender identity?
  • How old were you when realized you were a “girl” or a “boy?”
  • Who and what made this clear to you?
  • Did you agree with your parents clothing choices for you as a child?
  • What activities did/do you enjoy?
  • Have you expressed your own gender identity differently over the course of your life?
  • How do you feel about your body? Your genitalia?
  • What messages have you received about your gender and from whom (e.g. parents, media, religion etc.)? Were you “policed” by others around your identity, gender roles and social practices or body?
  • How has your gender shaped your beliefs, social engagements and practices?
  • What have you been allowed/encouraged to do because of your gender identity and what limitations have you faced (e.g. social sanctions/promotions)?

Thomas Moore on the Soul of Psychotherapy

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Therapy Isn't Healing

Deb Kory: Thomas Moore, you are a writer, a theologian, a psychotherapist, a musician, a former monk, and a professor. You lecture widely on incorporating aspects of the soul into daily life, and have written many books on the subject, including the bestseller, Care of the Soul. You've just released a book called A Religion of One’s Own, which seems in part intended to bring meaning back to the word and to argue against the secularization of modern life. Since our audience is primarily psychotherapists, I'd like to first ask you about psychotherapy: How you define it and what role do you see it playing in bringing soul back into the world, and into your clients?
Thomas Moore: I go back, as I always do in my books, to etymologies. I like to think about how people first thought about the use of the word since the very beginning. The word therapy has been around for a couple of thousand years at least, and originally among the Greeks it meant to care for or attend to. I like that meaning of the word. It never meant to heal or to fix or anything like that. In fact, there's a passage in Plato where a student asked Socrates what he means by therapy, and Socrates says, "It's like someone who takes care of horses. They give them water and food and take them for some exercise and clean their stalls. That kind of thing is therapy."

So it's an interesting definition of the word. Then if you put psyche with it—psyche is the word for soul—you get psychotherapy, to care for the soul, to attend to the soul. That's how I see therapy.
I'm not interested in helping a person get along in life, and I'm not interested in helping them improve or get better as a person. That's more of an ego kind of project. I'm interested in the soul, which is deeper.
I'm not interested in helping a person get along in life, and I'm not interested in helping them improve or get better as a person. That's more of an ego kind of project. I'm interested in the soul, which is deeper.

When someone comes to me for therapy, I'm always listening at a very deep level, because I want to know what their soul is hungry for. I listen to their stories and look for where they are getting in the way of their soul’s unfolding. What is trying to emerge? Where are they headed in spite of themselves?
DK: So you are against the whole idea of therapists being healers?
TM: Yes, pretty much.
DK: Can you say more about that? Is it because it’s too omnipotent a role?
TM: Yes. I think the idea of care is different from helping or healing. Healing sounds like you're really going to once and for all fix this person and resolve their problems or get rid of their pain. Sometimes, in fact most of the time, what I feel I have to do is be with the person in their suffering or their pain, and in the moment I may hope that we get to the point where they don't suffer anymore, but I don't think I can get there by being the hero and thinking that I can get rid of their pain. I can't. But together what we can do is see what's going on and, as they get to be closer to their deeper life, their attitude in life shifts and they usually make different life decisions. Those things tend to resolve the pain and the suffering.
DK: So you don’t necessarily feel responsible for what happens in therapy?
TM: I don't feel responsible, no.
I'm rather shocked when I hear from some of my clients that they've been in therapy with people who tell them what they should be doing. I can't imagine it because I don't know—who am I?
It’s tempting at times to tell people what I think they should do, but I don't think that's my place. I'm rather shocked when I hear from some of my clients that they've been in therapy with people who tell them what they should be doing. I can't imagine it because I don't know—who am I? I don't have any special insight or any kind of revelation about people's lives. So what I do is I go with them and I try to get a glimpse of who they are and what's wanting to emerge.
DK: That’s in striking opposition to all of the manualized and “evidence-based” psychotherapy that’s currently in vogue.
TM: I'm not interested in any of that.
DK: You're kind of outside of that system altogether.
TM: Totally on the outside of that system.
DK: It sounds like part of what you've been trying to do throughout the course of your career is to critique that system, because it's in every profession in one way or another. Perhaps that’s what you mean by secularization?
TM: Yes, it is.
DK: It’s almost as if science, itself, has become a religion.
TM: I think when you secularize, the ego comes to the foreground, in the sense of, “I know what's going on. I need to be in control.” My approach has been more what I would consider a religious approach, in the deepest sense—not as part of any particular religion, but rather appreciating and acknowledging that there are things going on that I don't understand and can't control, but I can help with by being an attentive listener. I respect what's happening in a person, and I try not to listen to it with the thought that I know what's best or I know what's healthy. I never use words like that—“healthy” or “correct” or “right.” I watch my language carefully and try to let the soul of a person be revealed. When they see who they are at that soul level, they can make better decisions for themselves.

A lot of people have not had much education in psychology, and they don't really understand too much what's going on with their emotional life or their relationships. So we have to go deep into it where they can see what's happening, and then make their own decisions.

“Who Wants to Adapt to a World That is Crazy?”

DK: You also said that you're not interested in helping people get by in the world. Is part of that because the world is kind of nuts?
TM: That's certainly a part of it. Who wants to adapt to a world that is crazy? I've been saying ever since I first wrote Care of the Soul that if you do care for your soul you're going to be quite eccentric because, for one thing, that's where your individuality is.
If you do care for your soul you're going to be quite eccentric because, for one thing, that's where your individuality is.
The more you get in touch with your own soul, the more individual you become. Jung called this work individuation, and I think that makes sense because you become more of an individual from being in tune with who you are.

Another piece of this modern approach that I don't agree with is this idea of having some kind of standard for normalcy. We have these standards that are expressed in these lists of disorders, the DSM-5, but behind all of that is the assumption that there is such a thing as being normal and well-adjusted. I would probably have a very different type of DSM myself because I'm not interested in adjustment and being normal so much as really being in touch with that deep place. People may not fit in very well when they do that. They may be odd, and their friends may wonder what's going on with them.
DK: Do you see yourself as radical?
TM: No, not at all. But I was in Berkeley a couple of months ago, and I was at what was considered, I guess, a radical radio station, and I was just talking about things that, to me, seem quite ordinary. Afterwards the two people interviewing me said that I fit into their program quite well because it was also radical. But I don’t see myself as radical; I’m quite traditional.
DK: Am I right that you didn't get any kind of traditional psychological training? You didn't go through a psychotherapy school, right?
TM: Well, my training was actually in Rogerian therapy. I did a lot of counseling work when I was doing my PhD in religion. I did my religious studies work at Syracuse University, which is a very broad program. I studied world religions in one phase of it and depth psychology in another phase and the arts, especially literature, in the third part. These three parts came together to be the focus of my study of religion. When I was doing that, it occurred to me—I don't know why—that the only way I could really learn psychology would be to also train as a therapist. So I did.

A lot of my work was in counseling psychology, which was mainly based on Carl Rogers' approach. I did a lot of coursework and supervised practice, practicums, and led groups. Usually you can get a license if you have a PhD in religion or if you have some background in religion plus some psychological training, and I had both, so I put those together and got my counselor’s license.
DK: Did you decide at a certain point to leave the constraints of being licensed or are you still licensed?
TM: No, I just moved to another state, and the state I moved to requires the kind of therapy that I just don't understand or really want to do. So I no longer do therapy as such as a licensed therapist. I counsel people on this work of the soul based on my books, and I tell people that I'm not a therapist in the sense that people do it today and that I can't do that kind of therapy anymore. I mean, I probably would do it if the system were set up in a way that I could fit in, but I can't, so I don't. In fact, it’s just not what I do at all.
DK: What is it about the system that you can't abide?
TM: Well, a number of things. I'm not interested in quantified studies at all. That's never been a part of my life. I'm trained in the classics. I know Greek mythology very well. I know history and the history of philosophy and theology and medicine.
I’ve never become a Jungian analyst because I feel it’s too narrow for me. I don't want to have to fit in with the language and ideas of Jungianism.
That gives you a great deal to work with. Anyone who knows Jungian psychology would know that my background in religion and mythology are perfect for a Jungian analyst. I've studied Jung for years. In fact, a week ago I was in Canada speaking to a Jung society, and I'm going in a couple of days to a Jung society in the Southern United States. I speak to Jung groups frequently because I do know Jung well. They're interested in my background in religious studies and the arts and also my work over all these years, all these books about the soul. So that’s an area where I could fit in more easily, but I’ve never become a Jungian analyst because I feel it’s too narrow for me. I don't want to have to fit in with the language and ideas of Jungianism.

A Religion of One's Own

DK: Your most recent book, A Religion of One's Own, is that a play on Virginia Woolf?
TM: Yes, it is.
DK: My sense from reading it and from reading many of your works is that every system of belief or philosophy is too narrow, that you're fundamentally ecumenical. You love to dive deeply into various traditions, but you’re not interested in being a certified member of anything.
TM: I don't think anyone should be confined to one particular system of belief.
If you really want to be someone who is alive in what you're doing and not just following a system, then you want to make it your own in some way.
I wrote A Religion of One's Own to make that clear. It could also be “a psychology of one’s own.” It’s important to honor the traditions and you can study any branch of psychology you want, but I think if you really want to be someone who is alive in what you're doing and not just following a system, then you want to make it your own in some way. I happened to take it pretty far in making it my own.
DK: You're a little eccentric.
TM: Yes. That's exactly it, and that's just the way it is. I'm surprised because I'm not a radical type. I'm kind of an easygoing person. I don't challenge the world too much except in my writing. In my style, I write a lot of things that go against the themes of the times and the spirit of the times, but I don't do it in a style or a manner that is confrontational. I simply present and say, "Well, if you want this, great. If you don't, forget it."
DK: So your style isn't confrontational, but your ideas are or could be perceived as such.
TM: Yes.
DK: I’m imagining with this recent book you’re being critiqued both from the Left and the Right.
TM: Yes.
DK: There’s a fair amount of religiophobia on the Left and there are a lot of therapists, in my experience, who harbor a not-so-subtle contempt for religious people. Or rather, some religions are considered okay: Buddhists are fine, Mormons are not. This really goes unchallenged in therapy culture.
TM: Yes, I agree.
DK: And then on the Right you’re probably just seen as an apostate. Are you getting challenged on that at all on this book tour?
TM: A little bit, but very little actually. People get the idea right away, and they're interested in it. The majority of people who hear this idea say to me, "Well, this is what I've been doing and thinking all along, and it's really helpful for me to have it articulated."
I’ve had feedback from people saying that they don't need religion. The secular world is all they need.
That's the response I get most of the time. Now, maybe there are people out there who are more traditional in their religious practice who just aren't interested and so aren't talking to me. On the other hand, I’ve certainly had feedback from people saying that they don't need religion. The secular world is all they need.
DK: I'm thinking of people like Bill Maher, and a lot of these so-called “new atheists” who think that religion is the root of all evil.
TM: The problem I have with them is that they usually pick a very childlike or fundamentalist type of religion and critique it as if it stands for all religions. Take me on, you know? Years ago, actually, I tried to have a debate with Carl Sagan because he was saying that a lot that goes by the name of religion is superstition. We had set up a debate, but then just at the point when we were making the arrangements he developed cancer, so it never happened.

Critiquing the most simple-minded and fundamentalist forms of religion is easy. I critique them, too, and have a lot of that kind of atheism in me as well. I have no problem with that; but when you look more deeply at the richness and depth of so many traditions, when you get right down to the subtleties, I'd hate to see us turn into a totally secular world.

DK: How do you deal with the reflexive antagonism that people have toward religion? If you were speaking to a group of therapists who were more of the secular type, how would you argue for integrating more of this soul work into therapy?
TM: I have worked with psychiatrists and other kinds of therapists, and a lot of them come to me and they want to open up. They want something more in their practice, but they don't know what that would be. I try to give them background, history, a lot of examples, a lot of material—to let them see the intelligence of the spiritual traditions. I present it to them as someone who really loves these traditions, but I'm not a member. I'm not defending them. I'm not that kind of person.
DK: You're not an “ist” or into “isms.”
TM:
I don’t actually participate in the Catholic Church, but that’s because I think they don't want me. I'm not sure it's because I don't want them.
No. I'm not. I'm not in one of these traditions either. Though I sometimes call myself a Zen Catholic, because in my own life, I was born into Catholicism. It's not something you just set aside intentionally; it's something that's just part of you. I don’t actually participate in the Catholic Church, but that’s because I think they don't want me. I'm not sure it's because I don't want them.
DK: Do you think you'd be excommunicated?
TM: Oh, yeah. There is plenty of grounds for that.

With therapists, though, I try to give them an intelligent approach to how to include spiritual matters in psychotherapy. I try to show them that you can't really separate spirit from soul. I talk about the difference between those things and how you can't separate them.

The Planet Has a Soul

DK: Can you talk about the difference between spirit and soul?
TM: Well, it's dicey in a way. In the traditions that I follow, the spirit takes us away from our bodies and our appetites and our relationships and our everyday lives in order to have a big vision, a cosmology, a cosmic vision to ask questions about how the world came to be or how to live and to meditate and pray. These are all things that take us up and away.
DK: Those are spiritual.
TM: Yes, and these things are good, very valuable and important.
The spirit takes us away from our bodies and our appetites and our relationships and our everyday lives in order to have a big vision, a cosmology, a cosmic vision to ask questions about how the world came to be or how to live and to meditate and pray.
But the soul at its depth has not been developed very much. There are many traditions that deal more with the depth of our everyday life, like the importance of home and the deep fantasies and emotions connected with home. Memories of home and the need to be at home and to feel at home with what we're doing, the importance of family and feeling family even if it's not literal. It might be the family spirit at work or in your town, to be living a sensual life or a sexual life. A lot of spiritual people have trouble with sexuality because it's in another direction. It seems to be a problem. So what I try to do is speak for those things, for the soul. I'm also someone who loves the spiritual as well. I value both of those directions.
DK: So the soul is more grounded. It's more earthbound.
TM: Yeah, definitely grounded.
DK: Is there more of an ethical dimension to it?
TM: Yes, there are ethics, but it's a different kind of ethics because soul ethics are rooted in, let's say, your love of the planet or your love of your place, your home, or your appreciation for the individuality of people because you know people directly. That's a more heart-centered ethics. But there is another important kind of ethics, which is spiritual, which would mean you have a vision about the planet and about history and people and how we need to behave. All of that kind of thing could be very spiritual. So I like to have those two together. You need both motivations for an ethical life.
DK: Given you're deeply rooted in your own ecumenism and ethics, what do you think our role is in trying to make the world a better place? You say we aren’t healers, that we help people only in the sense of getting people connected to their soul’s hunger. What about the world beyond the therapy room? Are we bound by ethics to try to, for example, fight against climate change and all the ways humans are destroying the planet and each other? Or is that separate from our work as therapists?
TM: Let's go back to the definition of therapy: care of the soul. One interesting aspect of soul is that in the traditions about the soul, it's not just humans. The planet itself has a soul. I’ve got some documents here in my study from five or six hundred years ago that say that the planet has a soul and that the things on the planet have a soul. So if psychotherapy is care of the soul, the care of the planet is a kind of psychotherapy. Do you know what I mean? You don't just care for people or individuals.

I do a lot of work with hospitals and have been for a long time. I go into a hospital and I try to talk to the doctors and nurses especially about the importance of family because the illness a person has is a soul illness as well as a body illness, and the family plays a role because that's part of a person's deep life. It's a very important part. So we try to talk to hospitals about the importance of including the family. Not just tolerating them, but really seeing them at the very center of illness, both to heal and even being partly responsible in some ways.

A Psychotherapy of One's Own

DK: I have been licensed for about a year after a very long process, many thousands of hours of unpaid labor and studying and writing a dissertation and post-doc hours and licensing exams, and I feel a little bit like after all that time I'm starting from scratch in a way. There was a lot along the journey that simply wasn't useful and I almost had to fight to keep my soul. There were things that I brought to my clients from the very first day that I value—just a certain way of loving and being with people that I feel is the most fundamental part of the work I do—more than any theories or techniques. Yet hardly anyone ever mentioned the word “love” in all my years of training. I felt like I had to fight to retain the soul of my own work and to not get all weird and rigid and overwhelmed with the whole professional side of being a therapist.

There are people I know who are seeing 10-12 clients a day, trying to pay off school loans, pay the mortgage—it can become a real grind. In private practice therapists often don’t see other therapists at all except in passing on the way to the bathroom between clients. It can be a very lonely business and it’s easy to feel isolated from the more systemic problems of the world. I do see myself as a bit of a radical and an activist, and it doesn't align very well with this ten-clients-a-day paradigm that keeps us from connecting with each other and leaves us too exhausted to think about larger world issues.
TM: Well, you might have to define psychotherapy as your own. For example, after doing therapy for a number of years I discovered I could be a writer and live that way. But I've seen myself as a therapist-writer, in the writing itself, which I try to do in a therapeutic way. Some people don't like that, but that's just the way it is.
DK: What don't they like?
TM: People think it's not substantive enough because I don't write academically or reference research studies. I'm writing therapeutically, so it doesn't look so substantive, but the average reader knows. I get feedback all the time from people saying, "This book came to me when I really needed it." I must have heard that a hundred times in the past week.
DK: That's all the evidence you need, right?
TM: It’s a different way of being a therapist. I also learned when my books began being read around the world—today it's a small globe so the books get out there—that therapy is not a narrow thing. When I work with an individual then, I really like it because it's a piece of a much bigger work that I'm doing.

After publishing Care of the Soul twenty years ago, immediately I began getting invitations to speak at medical conferences and hospitals and medical centers. I never intended to do that.
DK: That must have been surprising.
TM: It was very surprising, but you see, that's another example of what I do.
After doing therapy for a number of years I discovered I could be a writer and live that way. But I've seen myself as a therapist-writer, in the writing itself, which I try to do in a therapeutic way.
I go into a hospital or go to a medical conference. I'm the therapist really, and I'm representing the soul of the situation. So I try to work with doctors and nurses, and I listen to them and see what's going on there and I talk to them the way I would as a therapist. I talk to them about the soul of their building, "It's not doing well right now. What can we do to make it fit into this whole process more?" So all of that, to me, is therapy. Just as Socrates says that taking care of your horses and feeding them, that's what he means by therapeia or therapy, I'd say going into a hospital or going into your own home and looking it over and seeing how it is and what it needs also is therapy.

Looking at the planet and saying the planet needs us too, and we're not going to solve the problem of global warming just by convincing people that it's a moral need or your life is at stake. We need a therapy of the world. We need to be able to say, "There is reason for this. This is your home. Get motivated. Take care of it."
DK: That's not confrontational, right? Because that's not your approach.
TM: No, I don't agree with that approach.
DK: Can you say more?
TM: When we take the confrontational approach, we polarize right away. We tend then to see ourselves as right and the other person as wrong. And then we get into some type of moralistic debate that goes nowhere.

The Passion of James Hillman

DK: I think it would be interesting for our readers to know a little bit your relationship with James Hillman. It sounds like you two were very close. He was one of your teachers?
TM: He wasn't a teacher exactly, but he was a mentor. He was a friend more than anything. I met him in 1970 and I started corresponding with him in about 1973. He was living in Zurich at the time, and was sending me articles he was writing. I had been studying Jung very intensely, but I really liked Hillman's revision of Jung, the fresh direction that he took Jung's work. Then, just by accident, he and I ended up in Dallas, Texas. I was teaching at Southern Methodist University, and he got a job at the University of Dallas. So we both ended up in the same city by a fluke and that’s when we became very good friends. We did a lot of things together socially, spent a lot of time together the two of us, and we have a very similar type of temperament. Well, not temperament, but background and interests. He was very confrontational, and so when working together it was interesting because we had two very different styles. But we were passionate about the same things.
DK: What were those passions?
TM: We were passionate about psychology moving into the culture rather than just being individual. In fact he gave up doing individual therapy after a while.
DK: I didn’t realize that.
TM: He didn't agree with it.
DK: Then what did he do?
TM: “Therapy of the world,” he would call it. There's a tradition in the old writing, it's called anima mundi, the soul of the world. He picked up that theme, and he would give lectures and work with city governments, and give talks at political meetings and he would say he was bringing a “soul orientation” toward those kinds of subjects and those concerns. When we weren't in the same place, we exchanged a lot of letters and postcards because we didn't have email in those days. We were friends for over thirty-five years.
DK: You presided over his funeral, right?
TM: I did, yes. He was Jewish and he always had interesting things to say about my Catholic background, so it was kind of surprising that he would ask me to officiate at his funeral, but I think it was based on our friendship and his knowledge that we shared so many ideas about religion and psychology.
DK: My sense is that you can feel like you have much more in common with people from other religions than your own when you come from this more ecumenical place.
TM: That could be what it was, yeah. In our conversations he was always being the depth psychologist and trying to see in a deeper way what was happening in the world around him, so I learned a lot from him just being with him and used his work pretty directly at first. One big difference between us in our work was that he didn't have a very positive opinion of the spiritual dimension. He was good at criticizing it, but didn't have a real appreciation for the spiritual—and I do. So in that way we were very different.
DK: But he was into the concept of soul, right?
TM: Yes, but not in a spiritual or religious context.

“To really love a soul, even if it's weird and strange”

DK: Can you give us a sense of how you work with clients?
TM: Well, I started off by saying before that I'm not so interested in managing a person's life. That's not what I want to do. That's not how I see psychotherapy. That's something else. Psychotherapy is care of the soul. It's therapeia, serving the soul. So when someone comes to me, from the very beginning I'm interested in their soul. What are they coming in with? What's not visible? Not even what they tell me because they don't often know that deep level of themselves. So I don't just take everything at face value, but I do look for signs and try to join them. I agree with you that it’s based on love—love of the person and love of the material and what they're going through. There's a love. I learned that from Hillman—to really love a soul, whatever's going on, even if it's weird and strange.
DK: And dark.
TM: Yeah, dark. Whatever it is, you appreciate it. So I do that, and then I would say most of the time I spend working with dreams. My work is almost all dreams. It's not interpreting dreams. I don't say, "Give me your dream, and I'll tell you what it means, and we'll apply it." But I do ask people to bring their dreams because what I hear from their dream is this deeper level. That soul level comes through in their dreams. At first it takes a while to get it because the dream images are confusing initially. After a while you get to know the individual person's set of images in their dreams. I absolutely need them. I couldn't do the work without them. The dreams give us the direction to go in and what to talk about and how to understand what's happening.
DK: Does your interest in dreams stem from your study of Jung?
TM:
I've studied the imagery in religions, their stories and narratives and rituals, so when I hear a dream, I see a lot of those rituals and stories in the dream.
I think it came from Jung, yes. When I first started reading Jung, I was really taken by his own dreams, especially what he talks about in his memoir, Memories, Dreams, Reflections. He talks there about his own dream work being central to his life. Instead of talking about what's going on in the external world, most of what he writes about is this dreamland, this deep fantasyland. It was very substantial and really made an impression on me. There was so much more there than if you just talk about what's happening on the surface.

His other work, especially his alchemical work, also draws on dreams and shows the connection between alchemy, mythology, and the dream. I've studied the imagery in religions, their stories and narratives and rituals, so when I hear a dream, I see a lot of those rituals and stories in the dream. This was Jung's method too, to compare an individual's dream to what you know about religion and mythology and even art.
DK: Do you bring those associations into the therapy and give them some context?
TM: Yes. You compare them or just see them interact with each other, and that helps you see much more of what's going on in a dream, which otherwise could be quite confusing. Jung felt that if you know myth and religion and the arts well, then you'll have a much better chance of working with dreams, and that’s just what I did. The first thing I did in my studies of religion was to read Jung’s collected works. After that I was able to study all of these religions and their traditions with Jung in mind. I was always thinking, "How do they speak about what's going on in the psyche and the soul?" I bring that background in religion to the dream work. Then I see what's going on in a person's life, and I can see the roots of it more.

Airplanes and Rivers

DK: Can you give an example?
TM: Sure. I write about this one in my book, and I got permission from the dreamer to make it public. This was a young man who came to me with some OCD, some obsessive compulsive practices, little rituals that he did.

The first dream he told me was that he saw these sharks in a river, and he originally wanted to go down to the river. It looked like a nice thing to do. But then when he saw the sharks, he backed away and went away from it. That was the first dream. Well, that tells us quite a bit really. Right away you've got a river, and a river itself is a tremendous image in the history of religion. There are so many great rivers. I'm not saying that his river was one of those, but knowing about those rivers you have a deeper sense of what it means in a dream to have to approach a river.

Very often it might be something like this river is the stream of your life or the stream of your time going on as you experience it. If there are sharks in it, you may not want to go into it. Obsessional practices sometimes look like people are afraid to really live. They have these practices that keep them at a distance, that keep them protected. So that gave us a lot of help right away in the very first ten minutes of working with him. Then we just keep going, more dreams, more stories, and we get deeper and deeper. Not just the surface behavior, but what's going on deep. We discuss the person's family life, childhood, and you see the themes there. A person only has so many themes in life, and they remain, they don’t change radically over the course of one’s life.
DK: And they remain in the dreams?
TM: They come and go. Dreams tend to be cyclical. You may have a series of dreams that have a certain type of imagery in them for maybe six months or up to four or five years, but then they may shift. Or they may come back again later in life. For example, I could talk about my own. I had a series of airplane dreams that lasted maybe eight years, and then they just stopped coming. So the dreams may not last forever, but it’s interesting when they stop. You can ask yourself, "Why did they stop right now?"
DK: Were yours plane crash dreams?
TM: No. My dreams were about trying to take off in a city. The planes would try to get into the air, but they weren't on an open runway. They were in a city trying to take off.
DK: And what did you come to understand about that?
TM: Well, I felt all along that I needed to adjust to the world more. I had to grow up, essentially. I had to live in the culture more. In fact, my books got me more and more into society, into people's lives. As I got more grounded in the world and in society, that dream no longer appeared.
DK: I also have recurring airplane dreams. I was just going to ask you about them.
TM: Yes, go for it.
DK: Mine are also usually in a city, and I witness a terrible plane crash. The context is always different but basically I witness these horrifying plane crashes over and over again, and I can't do anything about it, and I'm completely freaking out. It's devastating every time.
TM: See this is interesting. Can we talk about that for a minute?
DK: I would love that.
TM: So my first reaction to it is that the interesting thing about it is that you freak out. It's not that the plane crashes. I think it's okay that planes crash in the dream because sometimes that high-flying, that airy kind of existence has to come down and you crash. I would connect that with the Icarus myth, the story of Icarus who flew too high to the sun and his wings melted, and he crashed down to the earth. So there's a kind of crashing that takes place when you fly too high or when you're flying too long, that kind of thing. I wouldn't explain this dream that way, but these thoughts would be in my mind as I thought of our continuing conversations. So I would think, "Well, this is an issue where it may be necessary for planes to crash, but that really bothered you. You really have a hard time with that.”
DK: With the fall?
TM: Yeah, with the fall.
DK: That resonates with me.
TM: You used the word fall. That would take us into all that mythology of the fall that's in the book of Genesis, you know the fall of Adam and Eve. There's a lot written about the fall, a fall from innocence, or a fall from whatever. So there's so much there already just without even knowing anything personally about it. There's a lot there to think about before we go too far.

DK: It's so different from the experience of having someone go, "Well, that sounds like depression." So often we therapists get habituated to using language that really lacks imagination. Even in this one minute improvisational therapy that we just did, the myth and the story and the way that you responded just now was almost with a kind of excitement. As opposed to, "Tell me about your sleep hygiene” or “what are your automatic thoughts?" That kind of rote diagnostic way of relating to clients.
TM: Yes, exactly.

There's No Done

DK: Do you tend to see people for a long time? How does therapy end? You don't want to make them better, so how do you know that they're done?
TM: There's no done.
DK: There's no done?
TM: No. There's no done. There can't be.
DK: I like that.
TM:
Therapy is care for the soul, so it's not about seeing a particular person or using a particular method. A person may decide, "I'm not going to do this anymore," but one hopes they'll continue to care for their soul in some way.
Therapy is care for the soul, so it's not about seeing a particular person or using a particular method. A person may decide, "I'm not going to do this anymore," but one hopes they'll continue to care for their soul in some way. They may find another therapeutic thing to do. They may take up gardening or make movies or something that will really be good for their soul. In going through that process, they're going through a process very similar to what therapy is.

That's the beauty of Jung's idea of alchemy. He thought that alchemy was the model for the therapeutic process. We can go through any kind of alchemy any place in life. Getting a new job, that's an alchemical process to some extent. You have to process it, go through various stages, and so the therapy never has an end. That doesn't make any sense.
DK: Do you ever fire people?
TM: That's a good question. I don't recall that happening. No, I never did that. Most of the time when people want something, there are a couple of reasons why they would stop. One is that they want something they think I'm not giving them. They want something more specific. They wanted just the practical stuff. I tell them I can't do that. That's not what I do. I don't just say that. I try my best to go deeper into whatever it is they bring up.

On the other hand, some people just don't want to face it. If we had an hour talking about your dream, you'd have to face some things that are not so easy to do. When people hear about dream work, they think “oh, that sounds fun!” But it turns out to be very challenging and some people find it to be too much and so they just leave. I usually think that it's too bad because the process seemed to be getting somewhere.
DK: So you've been fired, but you've never fired anyone.
TM: No, I don't think so.
DK: Well, thank you so much for taking the time to share a bit yourself with our readers. It’s been fascinating.
TM: Thank you, it’s been a pleasure.

The No-Fee Session

Posted on by Psychotherapy.net Team

I live in a neighborhood in New Jersey where people say hello to one another in the street even if they don’t know each other well. One man stood out for me in the many years I am living here: He doesn’t say hello even though he sees me several times a week. He doesn’t even bother to nod his head. I could never understand what I had done to him, but I just felt as if he hated me.

One day not too long ago I was surprised to get a telephone call from him. “I really need your help, he said. “I need to talk. My son who is in his early 20's punched me in the face – lightly, but still a blow.” I understood very quickly that though he wasn’t injured physically, to be attacked by one’s son had to be a trauma. I gave him an appointment – a midday hour the following day and he showed up at the given time.

He went into detail about the incident and asked me all kinds of questions. His main purpose was to be helpful to his son, get him “the right medicine” as he called it. He wanted to know who I could recommend that might “help him.”

“Does your son feel he has a problem,” I asked.

“No, he thinks I have the problem.”

And then the man gave even more detail about a long and somewhat tortured relationship with his wayward son. “I could never give him what he needed.” He described his son as “lost and adrift” and again asserted that his son was in great need of “psychological help.”

“What does your son want from you?” I asked him.

“I don’t know,” the man said. “I don’t think I ever knew. All I know is that I have got to send him somewhere to get help.”

I can’t put my finger on exactly when, but I had the distinct feeling somewhere within the first 20 minutes of the session that this man had no intention of paying me for the session. He was going to take and take. He asked question after question about my experience. He sighed and talked, sighed and talked. The idea occurred to me that just as he had failed to say hello to me all these years and perhaps just as he had failed to give to his son, he would fail to give to me. Although it was hard to tell from one session, it seemed that he had little interest in knowing anything about himself and evinced even less interest in knowing something about his son. He wanted a 'solution.' At the same time as this realization dawned on me I threw myself into the work, giving him the best possible session I could give, listening and feeling the feelings as if he were giving me a million dollars.

As I listened to him, I saw the lines of trauma etched on his face. He was 57 years old, but looked somewhat older. I caught a glimpse of him as he walked toward my office. He didn’t walk so much as trudge as though he were walking through invisible snow drifts even though it was summer. Further discussion revealed that he was the son of elderly holocaust survivors. His relationship with neither his mother nor his father was what you would call “loving” or even “pleasant” in his words. “They are very bitter, un-giving people,” he explained. Apparently, he had inherited and internalized one thing from his parents: the idea that “nothing good can or ever will happen to you” and he lived his life accordingly, investing as little as he possibly could get away with.

It was not long before the session time was used up and beyond. Even as I rose to signify the end of the session, he remained seated, being both talkative and acquisitive. It felt that he was trying to extract as much as he possibly could from me.

It would have been tempting to broach the fee with him then. After all, he wanted something from me, wasn’t I entitled to “get” something from him. Quid pro quo, give something, get something. Isn’t that an idea that everyone can understand, even one with a distorted sense of entitlement?

I have come to understand, however, that often people’s sense of entitlement stems from not from evil or even greed, but is a maladaptive way of addressing their traumas. They are still angry about the long-ago past, but they don’t know that. Instead, they seek reparations perversely — through something that feels like exploitation to the other, but they are unaware. For such damaged, wounded people, the language of quid pro quo, though utterly reasonable to you and me, can be experienced as a trauma. It is especially ironic (and enraging) because his own stance with the world is far more exacting and exploitative than the language of even exchange. It was more like: do for me and maybe, just maybe I will do for you.

Finally, he got up at the end of the session and weakly thanked me for my time. He made no mention at all of payment and neither did I make mention of it. We shook hands and he left.

When he walked out of the office, surprisingly, I did not feel the way I thought I would feel. Oddly, I felt enriched. He had given me a chance to understand him even as his view of the world and his son were distorted. I had made up my mind that my only objective was to provide him with a healing experience. Under no circumstances would I allow him to be re-traumatized even as he was a traumatized man who unconsciously traumatizes others, I knew he could only ingest kindness. Nothing else.

I had honored our profession and was nourished by the feeling of having done the right thing.

A few weeks later I saw him in the street. To my utter surprise he said hello to me for the first time. He updated me on his son’s status and then said, “You can send me a bill for the session.” He said it half-heartedly, I think, hoping that I wouldn’t actually do it, but there was a trace of sincerity there. It gave me cause to feel that perhaps with my kindness, I contributed a little bit to his healing.

After the Diagnosis: Helping Patients Cope With their Emotions

Posted on by rezendevknowfully.com

The New Normal

“I just got diagnosed. Now what do I do?”

The focus of my professional work is on helping patients to cope with medical diagnosis, so I hear this question a lot. But many psychotherapists tell me that their patients also talk to them about their health issues, including sudden, serious medical diagnoses.

As mental health professionals, we may provide the only opportunity that newly-diagnosed patients have to talk to someone in this situation. The traditional medical establishment is equipped to help patients from a medical, but not an emotional, perspective. Family members and friends are also suddenly thrust into the emotional chaos surrounding the diagnosis, and often need help with their own emotions and helplessness.

Our patients facing a medical diagnosis look to us for help in sorting out complicated and scary feelings during a highly stressful time so that that they can move forward in their lives. In this regard, our job is to help patients define and embrace a “new normal” —with a positive self-image, retention of as many cherished routines and rituals as possible and supportive relationships—but also help them to integrate the effects of treatment and make ongoing lifestyle adjustments. Patients facing a diagnosis want nothing more than to be as normal as possible.

If newly-diagnosed patients are able to get needed emotional support early on in their diagnosis, they will be that much better prepared to cope as they move forward with their treatment. As therapists, we help them to prepare for the road ahead.

Medical Diagnosis=Stress

Receiving a catastrophic medical diagnosis is a stressful and sometimes traumatic event. Newly-diagnosed patients feel an immediate sense of uncertainty—life will never be quite the same. And life may end. And like other stressful events, our minds and bodies are hardwired by nature to react. The initial reaction is shock, as our conscious minds essentially shut down while, subconsciously, this information is processed.

As the shock fades, it gives way to one of three reactions that occur in response to stress: flight, freeze, and fight. The flight response is primarily an emotional reaction, and patients may be so caught up in their emotions that they may not be able to make objective decisions regarding their condition and its treatment. On the other hand, those having a freeze response may be unable to acknowledge their feelings at all or may have a fatalistic view, either of which may result in inaction. Those in fight response are best equipped to deal with a new diagnosis. They have access to their emotions as well as their logical resources, and are able to harness both as they face their illness. Most important, patients can be taught how to be Fighters.

These basic reactions impact the kinds of emotions that newly-diagnosed patients experience, and how they cope with these emotions, as well as how they deal with their diagnosis from a rational standpoint (e.g. information-gathering). For better or worse, how patients cope during those first few days and weeks after receiving the diagnosis will have implications throughout their treatment process—from decision-making to coping with the treatment to ongoing recovery and life management. And if those patients find their way to the office of a mental health professional, we can play a formative role in their journey.

The First Reaction

Whether catastrophic or chronic, almost invariably patients describe their reaction with one word: shock. People often experience numbness, as if they are in a trance, or simply have “no feeling at all.” The experience of shock is often associated with disbelief or a sense that their emotions might be so strong that they should be held at bay for fear that they might be overwhelming. There are of course exceptions. For example, when a condition from the past is recurring, or when symptoms over time have rendered the diagnosis inevitable, patients may report an initial feeling that “the other shoe has finally dropped” or that they are about to go down a road that that they have previously been on. Still, it is only human nature to cling to that possibility that “it won’t happen to me.” This belief is mainly unconscious; after all, most of us don’t spend our time assessing our chances of getting hit by a medical diagnosis.

Carole described her reaction when she was first diagnosed with cancer.

"It was like the world suddenly stood still. I mean, all I could hear was my own breathing, and the thumping of my heartbeat. At first, I was completely numb, and I wasn’t thinking anything. And then I started saying the word “cancer” over and over. Still, no feelings. But deep inside, I realized that, no matter what, my life was never going to be the same."

The initial shock may last a moment, hours, days, or may continue on, as the patient’s emotional and rational sides are both struggling with the news. If you have been through the experience of a diagnosis, you might remember how you first reacted, or didn’t react, to the news; or maybe you have seen someone else go through it and felt your own helplessness as you watched them struggle.

In a way, being faced with a diagnosis, while not usually a death sentence, is similar to hearing about a death. As Carole, in the example above, described her diagnosis—nothing will ever be quite the same. Newly-diagnosed patients are left with the knowledge that, yes, bad things can happen, that they really aren’t invincible after all. And the diagnosis —whether it requires extensive treatment that interrupts normal life for months or longer, or whether it requires medication and alterations in diet and lifestyle—will at some point require the patient’s acknowledgement and full attention. Knowing that this looms ahead can also be initially overwhelming for the patient, and the healthcare professionals they are working with may or may not be able to provide emotional support for their patients.

During this time of initial shock, patients are often not open to more information, nor willing to discuss their diagnosis and what it means. It is difficult to communicate with patients who may be unable to hear or comprehend what they are being told, which presents a particular challenge to their healthcare providers who may need to begin a medication regimen and/or make a decision about the path of treatment. The newly-diagnosed patient may need some time and space to sit with the news, and if the healthcare professional pushes them too hard to discuss the treatment plan or to make a treatment decision during this time, the patient may become defensive and refuse to talk further, potentially becoming even more resistant.

Patience is required. Human beings can’t be forced to take in more information than they can process at any given moment moment, and often the best way to help patience move through this early stage is to be willing to sit with them, offering support while being sensitive to the readiness of the patient to process this news. Psychotherapy can provide vital support during this time, a chance to vent about the frustrations and the fears.

Clearly, sensitivity to how a patient is responding must be balanced with the level of urgency in taking any necessary action. For example, it may be appropriate for the therapist to act as a patient advocate by encouraging the patient to schedule a follow-up appointment with their healthcare provider to further discuss the diagnosis and formulate his/her questions. And even to help the patient formulate a list of questions to ask their healthcare provider. Scheduling a follow-up session with the patient to discuss and process what they learned in this second appointment can also be invaluable.

The Three Fs

Accepting that life is going to change is the first step toward coping with the emotional impact of the diagnosis and making decisions. Though newly diagnosed patients come to this realization differently and at different times, most patients fall within one of the fight/flight/freeze responses.
 

Fight Freeze Flight
Positive Thinking Isolation Empowerment
Rigidity Helplessness Emotional Coping Skills
    Rational Thinking

Flight: The Case of Dave

The best way to introduce the Flight response is through a case example of a newly-diagnosed patient I’ll call Dave. An active man without a history of health problems, his diagnosis of a heart condition took him totally by surprise. His physician presented him with what she thought was the best recommendation, which was a triple bypass, and then suggested that Dave go home and do some thinking before making a decision.

Dave later reported that the sense of shock continued not only that evening, but for a couple of days afterward. He couldn’t believe that he, of all people, was being told that he was in anything but top condition. And his heart? Not a chance. He told his wife only that his doctor was watching his heart, but that he was absolutely fine, which of course she was skeptical of but knew better than to push if Dave wasn’t ready to talk. Dave describes the next few days like this:

"”Once the numbness started to wear off, I kind of went into a panic mode. It was like I had this thing around my heart and I wanted it cut out as soon as possible.” I was afraid to think because I was afraid I might talk myself into doing nothing, or that I might put too much strain on my heart. I imagined my doctor as my savior. I wanted to put all of my faith and trust in her and have her direct my path. I was in such a rush, I asked her to call the cardiologist she had recommended to try and influence him to schedule me for surgery as soon as possible"

While Dave is placing all of his trust in the first physician he encounters, he is also running toward the treatment that feels most expedient. He is not considering the implications of the treatment, in terms of side effects, recovery, and ongoing lifestyle management. As a result, he may later discover that this is not a treatment that he was prepared to deal with, which has implications for ongoing compliance as well as dissatisfaction with his healthcare provider.

The flight reaction has other implications as well. Individuals in this state may—out of a sense of panic—run toward unproven alternative treatments with potentially alarming results. They may also be susceptible to the recommendations of healthcare providers with whom they feel comfortable with emotionally but who may not offer the best treatment option. For example, they may profess to “love” their practitioners, which can preclude them from obtaining a second opinion on the diagnosis, investigating treatment options, and at least checking into the credentials and track record of their physician. Patients in Flight reaction may also attach themselves to an unproven, non-medical treatment with potentially alarming consequences.

The flight reaction can also result in such strong emotions that patients are unable to access their logical mind. Excessive crying, expressions of anger, giving in to fearfulness—these responses signify that a patient is also in flight of a different sort—not toward the first available treatment or the most loved practitioner, but instead running away from their diagnosis.

Freeze: The Case of John

Not all patients “take flight” toward the first available treatment. Some don’t take flight at all. Instead, the initial shock gives way to sitting and staring into space, waiting for the nightmare to pass, or for someone, often a family member, to step in and take charge. This is understandable. After all, between the shock of the diagnosis, and their perception that they are unprepared to make the decisions that are suddenly thrust upon them, or that they have no hope, they are essentially immobilized.

When in freeze reaction, emotions appear to stop working, not because they are broken but because they are being tightly held in place. And while this might be an opportunity for the rational side to kick in and take charge of the situation, logic without emotion is not necessarily going to result in rational thinking, as evidenced by John.

"I just sat there when the doctor told me, and I guess I’m still just sitting still. I can hardly get out of the chair, to tell you the truth. I kind of decided to be philosophical about it. I don’t know much about this but I do know that statistically, the numbers are against me. I mean, what can I do when fate isn’t on my side"

John is using the defense that individuals in freeze reaction often adopt: refusing to react emotionally. Not getting actively involved in learning about the condition and its treatment. Unfortunately, this also means giving up.

Essentially, the freeze reaction is an extension of the original feeling of shock, but with some key differences. Shock is the mind’s way of shutting down the emotions, and allowing the brain to process the information, before reaction. Patients in freeze reaction aren’t consciously suppressing their emotions, but their emotions are nonetheless inaccessible to them. They may think they are being “rational” based on their view of the facts, but there are risks involved when the logical mind is operating without the emotions.

Patients in freeze reaction, because they are operating without their emotional side, may adopt an attitude of hopelessness and helplessness. By not allowing themselves to work through the initial emotions, like anger and fear, they essentially remain stuck. Often they refuse to discuss their condition any more than absolutely necessary with their healthcare professionals, and may avoid telling family members as long as possible. Whereas patients in flight reaction may completely give themselves over to their emotions at the expense of rational thinking, patients in freeze don’t acknowledge their emotions, which leads inevitably to avoidance isolation.

One characteristic common among patients in freeze reaction is an unwillingness to make decisions about their treatment. They rely on their physicians, possibly working with family members, to make these decisions for them. In essence, they decide not to decide.

Fight: The Case of Marie

Being open to emotions can result in an inner sense of optimism and hope. If this optimism is balanced with rational thinking, patients are in the best position to make treatment decisions, deal effectively with treatment and lifestyle changes, and otherwise cope with the changes and challenges that may arise as they face the future. These are the fighters.

Fight doesn’t necessarily imply aggression and, in fact, sometimes patients resist this word because of that association. “Being a fighter means being empowered in terms of understanding the diagnosis, the options for treatment, and what lifestyle adjustments need to be made in the near future and beyond.” Being empowered is about arming oneself with emotional coping skills as well as rational thinking.

Fighters acknowledge the feelings that arise as a result of hearing the diagnosis and continue to honor their own emotions. It would even be reasonable to say that dealing with the emotional aspects of a diagnosis opens the door to rational decision making. Fear may, realistically, never fade away. The anger and disappointment may flare up at times. But emotions like fear and anger, when they are acknowledged and experienced, may also give way to hope, optimism, and a renewed passion for life.

Marie said it this way:

"I sat and cried and asked 'why me?' for quite awhile, maybe a few days. And then I stood up and said, 'I am going to fight this beast. I’m not going to let it beat me down.' The next day I made a list of who I needed to talk to, where I needed to go for information, and what I needed to start planning for. That doesn’t mean I don’t feel overwhelmed sometimes, because I still do. But I’m also in active mode."

Marie didn’t hold back on her emotions but, instead, faced her disappointment and fear. She sat alone with her emotions and, in her case, had a good cry. She also discussed her emotional reactions with a member of the healthcare team, who was comfortable being a “listening ear.” Had she not taken the time to experience how she was feeling, she would have been forced to sit with a large block of emotion, and it would have essentially taken all of her mental energy to hold it down. By doing so, she was able to start asking questions and making decisions.

Patients in fight reaction are more prepared to take action with their condition. By working through their emotional reactions—feeling their feelings and expressing them to supportive listeners—they are not running from their feelings, nor are they so overwhelmed by them that they can’t think. The result is a sense of self-confidence that comes from being aware of, and open to, emotions. Fighters also have access to their rational minds. This doesn’t mean that they are in perfect balance every day, or that they don’t have bad days when nothing seems to go right, but they are on the whole able to search for, and process, information. They are more likely to ask questions and to evaluate alternatives. They take more control over their treatment decisions and the ongoing lifestyle adjustments that they need to make.

Their balance of emotions and logic results in an attitude of empowerment toward their healthcare and the individuals who deliver it. For some patients, the fight attitude comes naturally; they may be more temperamentally inclined towards this kind of response to adversity once they move beyond the initial shock. These individuals will sometimes present challenges to their healthcare team, because they tend to be much more active in their own treatment, and believe that the ultimate decisions regarding sources of information, treatment alternatives, and lifestyle adjustments, lies in their own hands. However, the healthcare team can work with patients experiencing freeze and flight reactions to create and enhance fighter skills.

Psychotherapy: Bridging the Gap That Healthcare Professionals Can’t Fill

Healthcare professionals are not expected to be psychotherapists or counselors, nor to deliver direct mental health services to their patients. On the contrary, attempting to counsel patients without the benefit of being a trained mental health professional can be harmful to the patient and risky for the untrained professional. But newly diagnosed patients often have a hard time processing the overwhelming information they are bombarded with by their healthcare providers, and this is where psychotherapy can play a vital role.

Often patients are so flooded with emotion when they first receive their diagnosis that they aren’t really listening to what they are being told; they might “hear” it, but not be able to make sense of it and, as a result, they may miss key pieces of information or misinterpret what they’ve heard. This can be frustrating and alarming for the healthcare professional, who may or may not have the patience or skill to help their patients through this initial phase. Psychotherapy can help the patient to cope with the fear and anxiety that may be preventing them from processing information about their diagnosis and their treatment options, and to evaluate the options from both rational and emotional perspectives.

This can also be a good time to involve family members in the therapy. They often need support as well in processing and understanding the diagnosis, figuring out how best to support the patient, and deciphering what their role will be throughout the treatment process. Both patients and their families and close friends may not yet have the words they need to discuss their feelings and reactions with each other, and therapists can play an important role in helping to facilitate communication between patients and their loved ones.

Newly-Diagnosed Patients in Psychotherapy

A new medical diagnosis brings with it the probability of change—in routine, in relationships, in self-image—and human beings are creatures of habit, not wired to embrace change. Uncertainty about the future and what challenges might soon be presented, fears about loss, including finances, relationships, favorite activities and one’s future dreams are all a part of what the newly diagnosed patient brings to therapy.

Some of the factors that influence the way an individual reacts to a medical diagnosis include:

  • Perceptions of the severity of the diagnosis—Patients often have minimal information about their condition when they first receive their diagnosis, or erroneous information, or a vague awareness of the condition but not enough of the facts to evaluate it in terms of the implications for their own lives. These perceptions —and misperceptions —may lead to an emotional reaction that is not consistent with reality. Alternatively, patients may be well versed in their condition and experience emotions that are realistic and consistent with its severity. Either way, perceptions have a direct influence on emotions.
  • Personal coping style—Some people grow up in families in which emotions are always on the surface, and family members are encouraged to express how they are feeling. In other families, emotions are not so acceptable, and are suppressed. Newly-diagnosed patients who don’t have a history of being comfortable with their own feelings will most likely have difficulty talking about, or expressing, how they feel.
  • Prior experience of illness—Newly-diagnosed patients who have had a past illness may experience some of the same feelings that they experienced in the past. Having already dealt with a medical diagnosis may have provided them with coping skills to deal with a new diagnosis; alternatively, the diagnosis can reignite fears and other feelings that they had hoped not to re-experience. Patients who have helped a friend or family member cope with a medical condition may react similarly.

The Unanswerable Question

Newly-diagnosed patients inevitably ask one question: “Why me?” This may be a medical question, as the patient tries to understand the medical reasons behind the diagnosis, though there is usually an undercurrent of self-punishment—“If only I’d eaten better” or “if only I didn’t smoke” this would never have happened. People may also feel guilty about asking this question, as it can seem to suggest that it would be more fair and right if it happened to someone else. And patients may also express acceptance, but nevertheless ponder the randomness of life.

The point for therapists is not to answer this question. For many patients, “Why me?” opens the floodgate to releasing their own emotions, because it is a way of articulating that basic question of fairness and the role of fate, core issues that patients grapple with as they begin to process their diagnosis and move toward acceptance and empowerment. Ultimately, “Why me? is an existential question, and as therapists, we can use it to delve more deeply into the meaning of life for our clients and, if appropriate, work with them to cultivate a deeper connection to their religious or spiritual communities and practices.

Facing Difficult Emotions

When I first met with a patient I’ll call Yolanda, who had been diagnosed with cancer, she said:

“All I could think about was how concerned my doctor was when she told me I had cancer. I had never seen this look on her face before, and I just kept thinking that if she was this concerned, I must be in big trouble. I felt like I was on the edge of a cliff and I needed to hang on to something but there was nothing to hang on to. And at any second I might go falling into the darkness.”

During the course of our counseling sessions together, I was able to help Yolanda identify the emotions that she was experiencing, especially those that she thought she “shouldn’t” be feeling (I always begin by kicking the positive-thinking police out of the room). I also supported her as she began to deal with her diagnosis on a day-to-day basis, including giving the news to her family, making the treatment decision, undergoing surgery and chemotherapy, and making lifestyle changes. Helping Yolanda recognize, accept, and cope with the emotions around her illness allowed her to move into an empowered fighter position.

Yolanda gave voice to her greatest fears about cancer. As we worked through the “why me?” question, I told her about similar experiences by other patients facing cancer to help normalize her reaction. It’s important for people to remember that they are not alone and that many have walked the path before them. I also encouraged her to arm herself with real facts by asking questions of her treatment team and information-gathering on her own, and at her own pace. Information is an antidote to fear.

As Yolanda faced her fears about her cancer diagnosis, I encouraged her to express other emotions as they arose. Allowing herself to be angry was an important step for her, as she was able to express her frustration at having to take a break from her active life to go through treatment. As she stated, “I want to scream at life and how unfair everything is!” During a later session, as she was beginning cancer treatment, she talked about attending a wellness lecture and leaving feeling ashamed that she “might have avoided this if I had taken better care of myself.” And during chemotherapy, she expressed sadness that she wasn’t able to “be the mother that my kids need me to be.” Yolanda needed the opportunity to express these emotions in a safe, non-judgmental environment so that she could continue to cope with her day-to-day life and responsibilities.

Challenging Harmful Beliefs

As patients react to the stress of their diagnosis, their fundamental beliefs about life are put to the test, many of which, from a Rational Emotive Behavior (REBT) perspective, may be irrational and therefore lead to reactions and emotions that are unproductive and self-destructive. I was able to gently help Yolanda to identify beliefs that resulted in, as she said, “beating up on myself” and “telling myself that I shouldn’t feel the way that I do.” Irrational beliefs common to newly-diagnosed patients include:

  • My life will not change unless I want it to.
  • I must be available to the people who need me at all times.
  • If I live a good life, bad things won’t happen to me.
  • If I don’t keep a positive attitude, other people will think I am a failure.
  • If I don’t maintain control of my emotions I will collapse.

“I can’t emphasize enough the importance of first and foremost being a supportive, listening ear in the true sense of Carl Rogers—non-judgmental, unconditional positive regard.” This is what patients need most when they first get diagnosed. Motivational interviewing techniques can also be helpful in assessing readiness and introducing alternative ways of coping.

As Yolanda was ready for me to move from the role of supporting and normalizing her emotional reactions to examining her beliefs and understanding the connection with her emotions, I used a more active approach to help her identify her triggers, reframe her irrational beliefs, challenge either/or thinking, recognize and replace negative self-talk with health-enhancing affirmations and use progressive relaxation techniques.

A Note About Grief

Newly-diagnosed patients often go through a grieving process, and this can be an essential step in coming to terms with their condition and moving forward with treatment and lifestyle adjustments. When they grieve, they are beginning the process of accepting that a change is occurring in their life. Regardless of the diagnosis, accepting that life is going to be different in some way, and that these changes are out of their hands, is an important step forward. For many newly-diagnosed patients, their diagnosis causes them to take a look at one or more of their basic beliefs about life and to reevaluate them. This may be the first time that they have looked at these beliefs and how they affect their actions and emotional reactions. During this process, assessing a patient’s spiritually, and encouraging them to seek spiritual guidance in whatever way is meaningful to them can be helpful in getting through the grieving process.

Sensitivity to the Influence of Culture and Gender

It is also important for healthcare professionals to be aware of the influence of culture and gender. Cultural background can influence how patients interact with the medical establishment, how they experience and express emotions, and their willingness to accept mental health intervention. Gender can present further complications in expressing emotions around illness as well as in getting informed. In Western culture, women tend traditionally to be more active medical consumers than are men.

Working with the Healthcare Team

The healthcare professionals that are working with newly-diagnosed patients can greatly benefit from the ability to understand and recognize how patients are reacting to their diagnosis, and psychotherapists can play an important role in consulting with them. Understanding whether a patient is having a flight, freeze, or fight response, for example, will guide healthcare professionals in gauging their readiness to receive information, so that it is presented in a manner in which patients will most likely be receptive. Those in flight reaction may need some additional emotional support while those in freeze reaction may need some coaching in interpreting what they read and hear with a sense of optimism. Fighters may ask a lot of questions for which the team needs to be prepared. And going forward with treatment and recovery, patients who don’t become fighters may continuously erect barriers to compliance and life management.

I often work directly with physicians and, depending on the wishes and permission of the patient, will contact the healthcare team to share information and, as needed, to advocate for my patient. Where possible, maintaining open communications with healthcare providers, and offering to support them during especially difficult times during and after treatment, can be invaluable to the patient. Many healthcare providers also recognize the emotional component as key to enhancing recovery and ongoing compliance and are happy for the support.

Offering the healthcare team an understanding the patient’s particular reaction style can help them tailor their approach in ways that leverage the patient’s strengths. We can specifically give the team advice about how best to:

  • Present information on the condition and its treatment
  • Coach patients through the treatment process
  • Make recommendations on lifestyle management
  • Encourage patients to seek support with activities of daily living
  • Monitor ongoing compliance

Preparing for the Road Ahead

Finally, I always tell my clients: You are not a diagnosis. Your diagnosis is only part of who you are. Remind yourself every day that you are a fascinating, multi-dimensional creature with a past, a present, and a future that belongs to you and to you alone. Embrace life and your potential to live your life, with all of its triumphs, set-backs, surprises, and detours. Now, let’s get prepared for the road ahead!

Howard Kassinove on Anger Management

Posted on by Psychotherapy.net Team

“I can see your bald head”

Christian Conte: Dr. Howard Kassinove, how did anger management became a central focus for you?
Howard Kassinove: When I went to graduate school, the central focus seemed to be anxiety, and the physiological or biophysical aspects of emotion. So we studied heart rate, sweating, pupillary response to light—but all with regard to anxiety. I then went out to study with Joseph Wolpe and of course his major area was anxiety. But he really put me in touch with this notion of approach versus avoidance behaviors—moving towards, moving against, or moving away from. I was also trained by Albert Ellis and he was very interested in emotionality in general.
But with that background, once I went into private practice what I discovered was that lots of my patients were angry at each other. Husbands angry at wives, parents angry at children, adolescents angry at their parents, and I had been ill trained. I really didn’t know much about it, because anxiety was the major focus of my training. So I began to study and read and my practice moved along. But then in about 1992, I really decided I had to get some kind of a handle on this. So with my then Ph.D. graduate student Christopher Eckhardt, now a professor at Purdue, he and I just started cold calling people in the field of anger: Charlie Spielberger, Jerry Deffenbacher and a range of figures. We put together an edited book, which included all aspects of anger from Spielberger’s measurement to Sergei Tsytsarev and Junko Tanaka-Matsumi’s cross-cultural perspective, and this was the beginning of me becoming centrally involved.
Then I started doing more cross-cultural research—in India, Russia, Romania and many other countries. We collected data on anger in all these other countries and I did a number of doctoral dissertations on anger. One of the most important was with my colleague Chip Tafrate, who of course is doing books with me and did the video released this month by psychotherapy.net. He did a very interesting study in which we would try to insult people—“I can see your bald head!”—and Chip would ask people to respond in different ways. One was, “How could you say that to me? That’s terrible. I can’t stand it!” And the other was, “It’s unpleasant that you’re saying that. I wish you weren’t saying it, but I can tolerate it.”
CC: The old Albert Ellis stuff.
HK: Albert Ellis, exactly. We even had a controlled condition where I would kind of insult you like that, and you would say things like, “A stitch in time saves nine.” What we found was that both the Ellis rational ideas and the distracting statements led to anger reduction.
CC: So for you it centers on cognitive behavioral techniques—on changing the thoughts around and having people learn different forms of self-talk.
HK: Yes, but my original training was at Adelphi University, which is a very psychodynamic place. One of my great heroes always was Karen Horney, because she spoke about the tyranny of the shoulds well before Ellis did. She spoke about moving against, moving away from, and moving towards people. So I also have that background.

What Exactly is Anger Management?

CC: Obviously anger has been around as long as there were human beings, but in the news over the last several years it seems like anger management in particular is getting more attention than it has in the past. From your perspective, what exactly constitutes anger management?
HK: Let’s go back to the beginning of modern anger management—Ray Novaco’s 1975 book, Anger Control. Prior to that we were not really dealing much with anger management. Ray came on the scene and became a major figure, but the word “control” has kind of disappeared and now we talk about “anger management.”
I think of it as developing less intense disruptive responses to aversive stimuli. The fact is that we live in a world where there are lots of aversive stimuli:
People take our parking spots, students tell us we’re lousy teachers, our wives and husbands tell us that we didn’t mow the lawn correctly. We are kind of bombarded with this aversive stimulation environment. Lots of good things occur in the environment, of course, but the bombardment with the aversive stuff leads us either to be angry—”How dare you say that to me?! You know you don’t have any right! You should treat me with more respect!”—and it can also lead to anxiety, when we’re being threatened by someone in authority or someone with a knife or gun.
CC: Sure.
HK: So I think that anger management in a broader sense is emotion management or emotion regulation. I try to live my life in the most mellow way possible. Most of the time these days I succeed. But it’s not only anger or annoyance I want to bring under control; I also want to bring anxiety under control. This is where Rational Emotive Behavior Therapy (REBT) has played such a central focus in my own life. Lots of abrasive events occur in life that are overwhelmingly unpleasant. These days I try and leave them there—whether it’s difficulties with my own children or difficulties with my students or my car or whatever. So in the broader sense, it’s emotion management.
CC: That’s exactly the word I use: emotional management. You’ve developed what you call the “anger episode model.” Can you talk a little bit about the evolution of that?
HK: As the years were going by, I found myself becoming kind of disgusted with the notion that kids are lazy, people are stupid—this kind of broad overarching condemnation of people. Instead, because I became more and more of a behaviorist as time went along, I wanted to speak about how people behave in particular situations. You might become angry at your wife, let’s say, when she does something wrong, and you might yell at her and maybe even demean her verbally in some way. But I bet you wouldn’t do that if you were at a state dinner with President Obama, because in that environment you’re going to behave very differently.
So I found myself moving away from the notion of “he’s an angry person,” “she’s such an angry woman,” to the idea of—how can we deal with individual situations? We started to develop the notion that people have “anger episodes” and that led to the anger episode model. The more episodes we can help them bring under control, the more likely it is they will become more generally controlled.
It’s kind of like an incremental model. I don’t think we can really change broad-spectrum personality. If I define personality as the cross-situational stability of behavior, then what I’m trying to do is change behaviors in a number of situations with the hope that eventually through generalization people become less angry.
CC: That’s fantastic.
HK: We needed a very specific and relatively simple model that we could teach to our patients.

Triggers

CC: I really identify with what you’re saying. You put people in different situations, they respond in different ways. I say to people all the time, “If I gave you a million dollars, would you respond in the same way?” They say, “Well, I don’t know if I’d be that angry if somebody cut me off in traffic if I knew I was getting a million dollars.” So we really get at the heart of those thoughts.
You talk about triggers, and I wondered does it always, from your perspective, take an outside trigger to set someone off into an anger episode?
HK: I wouldn’t necessarily say it takes an outside trigger. Something has to initiate the sequence, but it can be an inside trigger. It can be a memory of what you did to me yesterday, how you treated me as a colleague or as a student or as a professor yesterday. I remember when you gave me the mid-term examination and you were unfair then. I’m quite sure you’re going to be unfair now. That’s an inside memory. But most of the time, I still see anger as a social, interpersonal process.
Most of the time, I’m going to become angry at a person or a group of people because of something that I perceive they did wrong. Let’s face it—I’m looking around in your office right now; I bet you don’t get angry at your bookcase.
You don’t get angry at your doorknob. You don’t get angry at your carpet. But you might get angry at your wife or your children or something like that. It’s always the social, interpersonal process. But it could be what the kids are doing today, or it could be you’re lying in bed and remembering what they did yesterday.
CC: That’s so powerful. I’ve specialized in working with people convicted of violent crimes and people are always really fascinated by the intense experiences I’ve had. I wonder if you could recall for us memorable and intense situation you encountered throughout your years in anger management.
HK: That’s an interesting question. I run an anger management program at Hofstra, and it’s housed in a generic building that has little children who are learning how to read, people who are having marital problems, and kids who are there all day as part of a child care center. So we’re always worried—is there going to be an intense anger problem? I’m always worried about my students, who are upstairs behind closed doors with anger patients, many of whom come from the probation department, and they’ve been convicted of anything from pushing and shoving to murder. They have histories. I’m always concerned. But I have to tell you that in the last nine years, we have had zero intense anger problems.
CC: Many new therapists are intimidated whenever it comes to working with angry patients. They’re scared of dealing with angry people, so I have my own approach to orienting them to the work. What’s something that you teach new therapists to do if they find themselves intimidated by the anger of their clients?
HK: Well, look at how I approached you, Christian, before we started this interview. I even made fun of your bald head.
CC: Yes, you did.
HK: Right? This is really important. The interpersonal therapeutic relationship, for me, is critical. You have to know how to not make every interaction into the most serious problem in the world. Most people, I find, are willing to kid around with me. They’re willing to take my barbs, my probes, my jabs, and that’s really what I say to students. Let your clients know that you’re in their corner. You know, “I understand you have been sent by your wife, sent by your husband, sent by the judge, from the probation department, and I’m going to be as respectful of you as I can, but I’m also going to jab you a little bit.” Then I ask, “Christian, would it be okay if I jabbed you a little bit? Can we play together like that?”
I think the only way people really get better is if we engage in reinforced practice in the office. So if I’m going to consider you as my patient for a moment, I might say things like, “Well, Christian, we’ve learned a bit about your life. You’re married and you have two children, and I know that you’re having troubles with your wife, who sometimes calls you lazy. Would it be okay if I called you lazy?”

The Comeback

HK: I’d talk to you a bit about that, and then I’d say, “Well let’s start off with some deep muscle relaxation.” I would make sure that you and I are on the same page, but then I would think about some kind of a hierarchy of insults. I’d start off with, “Well, Christian, take a deep breath. Just let your body relax. Consider what a nice day it is. I can see the sunshine behind you there. It’s really a nice day. Are you ready?”
CC: Yes.
HK: Here it comes. “You know, Christian, you seem very immature today. Take a deep breath in, and out.” So that was very mild.
CC: Very, yes.
HK: As the weeks go along, it’s going to escalate to, “Christian, you’re damned immature. Do you know that?” Then I’m going to go up to, “Christian, what the hell is wrong with you? How could a man of your age be so goddamned immature?”
CC: That’s awesome.
HK: And we’ll do two things. One, I’m going teach you to engage in those cognitive coping responses. So for example, say it to me.
CC: All right. Howard, you seem awfully immature.
HK: I understand what you’re saying. Thanks for sharing it with me.
CC: So you’re kind of putting me off there. That’s a sure sign of immaturity. You seem really immature.
HK: You have a real firm impression. It’s unpleasant to hear it, but I do want to thank you for sharing with me. It shows we have an honest relationship. Thank you.
CC: That’s great. That was a good comeback.
HK: What I’m trying to do is teach the patient a way of responding that, first of all, does not inflame, because—actually come at me again.
CC: Howard, you seem awfully immature.
HK: What about you? I mean, look at that shirt that you’re wearing. It’s like something I would wear around the supermarket or something, and here we are being interviewed! There’s that come back. Or, I could teach you another comeback—try it again.
CC: Boy, Howard, you really are immature.
HK: Yes, Christian. I bought a new hard drive for my computer yesterday.
You don’t know what to do with that, right?
CC: No, that totally threw me off.
HK: In my therapy, I try to, first of all, focus in on in your particular family or life, what are the adverse verbalizations that you might be receiving? That’s what I want to hone in on. I try to teach you either to relax deeply and not respond, to say something that’s really totally silly like, “I got a new hard drive,” to thank you for being honest, to say, “It’s unpleasant. I don’t like to hear it, but I can tolerate it.” So I’m teaching a variety of responses, you know?
CC: That’s great. It’s fantastic. I love the immediacy of the role-play right there in the moment.
HK: It works pretty well. Not all the time, obviously. I’m so interested about your work in the criminal justice system. Some of those people are kind of tough cookies.
CC: Yeah. Some of them are tough to crack, but overall, even though we’ve never met before this interview, there are so many things that you’re saying that I’m putting into practice. It’s so fun to be even in a role-play on the other end of that for even just a moment. It’s just great.
Tell me about your co-author. How did you get involved with Raymond Chip Tafrate?
HK: That’s kind of a funny story. Chip was originally my PhD student, and he was just going to become a practitioner and open up a mental health center. But then when he and I did this dissertation together on anger, we started to form this close bond. He went on to become a professor in a criminology and criminal justice department in Connecticut. We just bonded. He’s a wonderful man. If there is one thing I’ve learned—I’m sure you’ve been a professor also—there are just lots of things I don’t think about. We are both experts in the field, but you and I can really learn from each other.
And I thought I could learn from Chip. He’s thoughtful. He’s grounded. He comes out of a literature base now in criminology, that’s a little bit different from mine. Even though I taught him originally about REBT or relaxation training, he also studied with Ellis and he taught me about motivational interviewing. He really turned me on to that. So it’s just been a synergistic relationship.
CC: Well the book you wrote together, Anger Management: The Complete Treatment Guidebook for Practitioners, is extremely well done.
What’s something that you know now that you wish you could go back and tell yourself as a new therapist?
HK: I think I’d tell myself to be happy with small gains. If I can just teach that person not to rebel when the boss says, “I’d like you to stay an extra two hours tonight,” and not to flip off the boss, I’m happy with that these days.
CC: I think that’s so deep for people to get and really understand. Those little things, when people have been thinking one way their entire lives and all of a sudden now they can go that extra two hours and look at it differently, I think that’s big. I think learning to appreciate that is really big.
HK: I’m kind of unhappy when I go to some of the professional meetings these days. I hear about one-session or three-session or five-session treatments for Disorder X. I think we have a lifetime of learning. We have all kinds of reinforcements and punishments and incentives that are with us all day long. You really need time, and that’s something I didn’t understand as a young person.
Many times the judges here will mandate people to come see us for twelve sessions, twenty-four sessions. It’s not enough.

CC: I totally agree.

HK: I have a cousin who is a family court judge in California, and she says she recommends people for fifty-two sessions. I said, “I’m praying for that.”
CC: I just moved back to Pittsburgh, Pennsylvania, a year-and-a-half ago, but I was a professor at the University of Nevada before that. I co-founded a center for violent offenders in South Lake Tahoe, California. So in California, if they commit a violent crime, they are sentenced to fifty-two weeks of anger management. That’s standard. But in Nevada, just on the other side of state line, if they get in trouble there they were only sentenced to twenty-six weeks. I found in my own research that people did not make the kind of changes in twenty-six weeks, not even close, to the ones who were sentenced to fifty-two weeks. So I am a big proponent of a long treatment. Here in Pennsylvania, I’ve have judges say, “If they need a session or two.” A session or two to change a lifetime of anger? That’s just funny.
HK: Sometimes we ask patients, “How much anger management did the judge tell you you need?” “Today, just today.”
CC: “I just need to come to this one class.”
HK: If there’s anything I’ve also learned it’s that change comes about not from a class, not from education, but from practice. I teach my students practice makes better. We have to get these people into our offices and practice better behaviors with them. I even had one case, one of my students, where we started to transition from kind of barbing him and insulting in the office and frustrating him in the office, to out in the real world. So this patient happened to have worked as a shoe salesman, and what my student did is he went to the shoe store and without the patient seeing, pushed over a whole batch of shoes. This guy used to respond with great anger, but we wanted to see if we had done anything. Indeed, he responded very well. So I think practice makes better, starting in the office, going to the natural environment. That’s one thing I’ve learned that I really didn’t fully understand as a beginning therapist.
CC: I wholeheartedly and really sincerely appreciate this interview and this time with you because it’s tremendous to listen and hear and say I agree. I mean, two people practicing in totally different parts of the country and our experiences sound so similar. To me, that’s grounded in truth. There’s an essence to that change that obviously is just there regardless of words.
HK: Thank you.

Fear and Consciousness: What I Learned from a Bike Accident

Posted on by Psychotherapy.net Team

"Smile, breathe, and go slowly." — Thich Nhat Hahn
 

I got doored on Saturday night. I was riding my bike out to dinner with my husband and a guy in a big SUV opened his car door into the bike lane without looking and knocked me over. My face hit the pavement, I still don’t really know how my teeth weren’t knocked out, but my lips were cut and bleeding and my forehead was gashed and scraped. It happened so quickly and was so scary and weird.

Immediately kind people came up to me and asked over and over “are you ok?” “are you ok?” I didn’t want to answer yes because I didn’t really know. I was sitting on the street with blood all over me and I wasn’t sure if I was ok. I assessed my pain, my mind, my body. But when I didn’t answer immediately people began to say, “she’s in shock”; “she might have a concussion.” Although I was reluctant, the hostess at the Chapel bar across the street called the EMTs to come and assess me, and I didn’t argue.

When the EMTs arrived, they crowded around me, about four or five people, and began firing questions at me about what happened, “were you wearing a helmet?” “do you take any blood thinners?” “do you remember what happened?” “is this painful? is this?” Again I had the impulse to stay quiet and try to think before I answered questions, a state of being that was a bit unfamiliar to me, a person who normally anxiously blurts things out, responding as quickly as I can to anything that comes at me.

When they determined that I might have head trauma and drove me to the hospital on a back-board, an epic round of this activity began. At the trauma center people swarmed around me, some asking questions, some doing things to me, sometimes introducing themselves and explaining what was going on, sometimes not, questions, questions came one after another. I began to feel at home in my temporary (of course it was temporary) stillness. I was alive, I was still a human body, my man was with me, I was going to go home. I thought about the questions and answered them. At one point I said, “I need to cry a bit now” and I did. It was strangely wonderful.

And the funny thing was, the more chaotic it became the more calm I grew. I felt like a still, benevolent presence in my neck brace, slowly breathing and thinking about what was happening‚ exactly what is usually so hard to achieve internally. It was only when I was home and quiet later that I felt shaky, scared, and overwhelmed, but I think I had more tenderness for myself than I normally would. For instance, I would not let that internal voice berate me that the accident was somehow my fault. A breakthrough for sure.

What all these interactions reminded me of was nothing more than my own mind. It was as if by experiencing a state of high-anxiety all around me I was given some distance from that way of being in the world. All the pedestrians and EMTs and doctors were like representations of all my worries and concerns, they were each vying for attention so they could do their job, and so they could help and even save me. But what helped me was being safe in my own mind, feeling calm, thinking about what was happening and speaking when I knew something.

I greatly respect and feel gratitude towards all the kind people who helped me that night, they were doing their jobs wonderfully and I would not want them to behave any other way. What I mean to offer here is idea that life’s experiments with us can lead to a better sense of how we’d like to be present in the world.

I don’t recommend a bike accident to get to experience a tiny little shard of perception, but I bow to its terrible wisdom.