9/11 One Year Later: A Psychotherapist Reflects on His Experiences at Ground Zero

Posted on by Psychotherapy.net Team
As we pass the one year anniversary of the terrorist attacks of September 11, 2001, Americans are reflecting on the toll this event has taken on our collective consciousness. Due in large part to the power of the media to magnify this spectacle to epic proportions, it is arguably the most traumatizing event in post-modern times. As mental health professionals, we can witness the reverberations of 9/11 from a unique vantage point. Although clients in my private practice have rarely cited the terrorist attacks as a presenting problem, there was clearly a great deal of thought and energy devoted to reassessing priorities and choices. In the first month following the attacks, it was impossible for me to conduct a psychotherapy session without acknowledging the tragedy. My clients and I had a rare opportunity to share moments of mutual empathy that deviated from the usual limits of the therapeutic relationship.
 
Despite this, my professional activities felt inadequate in addressing my own need to do something more in response to 9/11. When a colleague told me of her positive experience as a Red Cross disaster mental health volunteer, and the need for assistance with the relief effort in New York City, I felt drawn, compelled, to join. After completing the orientation and training classes provided by the Red Cross, I found myself reconnecting with the idealism and passion that first attracted me to human service.
 

Arriving in Manhattan

I arrived in New York on 12/19/01 ready to do my part. I completed the necessary in-processing at headquarters and took a cab to the hotel room provided by the Red Cross in midtown Manhattan. Negotiating subways, cabs, and crosswalks was challenging at first, but I was soon able to pick up a bagel and coffee and make it to the downtown A-train without being late to my destination.
 
Getting to know the city firsthand helped me appreciate the changes that had occurred since 9/11. I was told that in the aftermath of the disaster, New Yorkers became more open than usual, with some people actually talking to strangers on the subway. Those I encountered were genuinely appreciative of the volunteers from out of town, expressing an uncharacteristic sense of their vulnerability, and need for assistance. The 9/11 attacks made us all painfully aware of the limits of our technological infrastructure, and the fragility of our human bonds.
 
I was assigned to a huge tent next to the 16-acre pit at Ground Zero, which served as a respite center for the firefighters, police officers, and other workers. This site was staffed round the clock, and I worked the 4pm to midnight shift in the dining area where the recovery workers took their breaks. Our duties at Ground Zero consisted of circulating around the tent, striking up conversations, and offering support and information. Interactions with the workers ran the gamut, from chitchat about upcoming football games, to personal discussions of the search for missing friends. About half of the contacts were interested in talking about the recovery work, but far fewer were willing and able to express feelings about the disaster.
 

How Ground Zero Stretched the Therapeutic Role

It became clear early on that the workers were making a great effort to suppress their emotions in order to carry out their difficult tasks. Almost all of the workers had lost at least one friend or colleague in the World Trade Center. In this intensely chaotic yet controlled environment, the appropriate role of mental health volunteers was to engage Ground Zero workers in a delicate dance between small talk and existential validation. It felt as if we were there primarily to bear witness to the experiences of the Ground Zero workers, as they endured 12-hour shifts recovering human remains, struggling to keep their exhaustion and grief from interfering with the mission.
 
Balancing this unconventional therapeutic role, alternating between schmoozing and debriefing, proved to be terribly fatiguing at first. It was a stretch from the more evocative style of my mental health practice. At times, I felt as if I was carrying the unexpressed grief of the recovery workers back to my hotel room every night as I searched myself for the empathic response to their ordeal. Processing my experiences on a daily basis with other disaster mental health volunteers rewarded me with the awareness that our mere presence at Ground Zero was our greatest contribution to the workers there. “We weren't expected to have any words of wisdom… and nobody did.”
 
Some of my disaster mental health colleagues in New York worked with family members of victims who were openly grieving and verbalizing their experiences. My assignment at Ground Zero was quite the opposite; in fact, it may have been the location in Manhattan where one was least likely to witness the venting of feelings.
 

Herculean Efforts and Unexpressed Sorrow

Being present in this hallowed ground, with the sound of heavy equipment, and the smell of combustion and decomposition ever present, was a trying task for everyone there. The Herculean effort of the recovery workers, to postpone their natural emotional response, was both impressive and poignant. A group of firefighters sat at a table, laughing and joking about some trivial issue, after hours of raking through the piles of debris in search of missing colleagues. One police officer, who led his cadaver dog into the pit to assist in the locating of bodies, told me of the difficulty of suppressing the horrible images he encountered when he returned home to his wife and children. A fire captain solemnly acknowledged to me that, even after three months, the recovery workers were driven by the desperate hope that, somewhere in the six-acre pit, a living soul was waiting to be rescued.
 
Among the recovery workers there was a continuum of emotional expressiveness which appeared inversely proportional to the individual's proximity to the disaster. That is, the closer the worker was to Ground Zero, the less emotional expression was evident. In general, the firefighters were the most guarded and difficult to approach. I am not sure why, but they did suffer the largest overall loss in their ranks (close to 10%). The various police officers were more receptive to interactions with the disaster mental health workers. Perhaps the most approachable and, ironically, underserved group of workers at Ground Zero were the ironworkers, welders, heavy equipment operators, drivers, engineers, and other construction workers who were contracted to clear the site. Unlike the police and firefighters, these workers had no professional preparation for working around human remains. Add to this the reality that many of these men and women had worked nearly every day since 9/11, without break either by their own choice, or by virtue of the critical nature of their skills, and it is becomes clear that they represent a segment of victims of the WTC disaster that warrant closer attention.
 
I had never felt such a heaviness of unexpressed sorrow, though it resonated deeply with my own personal family losses prior to 9/11. My evocative skills were not useful at Ground Zero… I felt burdened, at times, with the violence and trauma that was ever-present yet still mostly unprocessed. Over my two weeks in lower Manhattan, my PTSD response took the form of sleeplessness and fatigue. Yet, too, I was surprised at the absence of nightmares that I had expected would occur. Perhaps the daytime witnessing of horrors made such nightmares superfluous.
 

Leaving Manhattan… Returning Home

The practical function of the disaster mental health professional at Ground Zero was as a vessel, or conduit of pain to facilitate the recovery work; I knew that I would have to carry my share of it home with me.
 
The Red Cross cautioned the volunteers that when we returned home people would ask about our experiences. They suggested that we would find it difficult or impossible to convey our true feelings and experiences to those who had not been there. That was indeed an understatement! Even here, in writing this account, do I find it so hard, so inexplicably difficult to express my experiences fully.
 
As the days and weeks passed, I felt more and more as if I had walked away from a battleground—with all the grief, psychic numbing, and survivor guilt that goes with such trauma. Indeed, I had walked away from a battleground—it was not "just a feeling." I had crossed the line between observer and participant, and no professional objectivity would suffice. My mental health colleagues and anyone else who ventured close to the unprecedented injury and destruction of the 9/11 attacks knows of what I speak. “This ineffable experience is captured best, not in any words, no matter how well expressed, but in the silent glances between workers, the hugs of those that care, the hope of those who courageously carry on in spite of loss and despair.”
 
Despite the routine debriefings provided by the Red Cross, I left New York with more than a lifetime's worth of intense images and sensations. I intuitively knew that my disaster mental health experience would be life-changing, but I did not know exactly how.
 
At first my clinical practice felt boring in contrast to what I had witnessed in New York.I felt different, as if I had expanded, or gained access to parts of my own life that I had not seen before. At first my clinical practice felt boring in contrast to what I had witnessed in New York. I found myself reaching to find the relevance in the complaints of the worried well, which suddenly felt terribly trivial. My style shifted, temporarily, to a less patient, more emphatic "let's get on with it" tempo. I soon became aware that I was unwittingly projecting my need for catharsis onto my clients. This awareness was the first step in beginning to understand what all this meant to me. I too, needed to know and understand my feelings, to express and share my fears and sorrows, and take the risk at experiencing catharsis in my own life.
 
Opportunities to share my disaster mental health experience, both publicly and privately, have given perspective to my images of Ground Zero, and grounding to my emotions. I feel more vitally connected to my soul and less attached to old assumptions. My work has settled into a serenely energized stance. Now, when I am sitting with my clients, I feel that we are more in touch with each other's humanity than before-or rather, more than I had previously allowed.
 
At Ground Zero, my instincts were all I had to work with; they have since become my most valuable therapeutic resource.

Edna Foa on Prolonged Exposure Therapy

Posted on by rezendevknowfully.com

Exposure Therapy Explained

Keith Sutton: Welcome, Dr. Foa. To get started, why don’t you tell us a little bit about what exposure therapy is. Many of our readers may be unfamiliar with, or may not remember much about, this type of therapy.
Edna Foa: Exposure therapy is used mostly with anxiety disorder. The idea is that people who suffer from anxiety disorders—who get anxious when they confront safe situations or objects—are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of. So if the fear is a normal fear—like the fear of driving on the track when you see the train whipping by very fast—you don’t want to teach people to get over it. You don’t want to change people’s fear of driving over the track just in front of the train, because normal fears protect people from doing things that will harm them. The idea behind exposure therapy is that the therapist helps patients to confront or approach what they’re afraid of, because the things they’re afraid of are intrinsically not dangerous. Through exposure to these situations, they learn that there is no reason to be afraid of these situations. The disaster they expected does not occur. Originally, exposure therapy was derived from animal studies. In these experiments, scientists condition a mouse to become afraid of a red light by pairing the light with electrical shock. And after a certain numbers of pairings, the mouse will start showing fear responses when the red light is presented, even when it’s not paired anymore with shock. We call this response a conditioned fear. Then if we want to eliminate the mouse’s fear of red light, we present it with a red light without the shock. After repeated presentation of the light without shock, the animal stops showing the fear reaction to the light. That’s called extinction. In the ’60s and the ’70s, several experts, in England and the United States, translated the animal results to human beings and said, "Let’s suppose that the anxiety disorders—such as claustrophobia or fear of heights—are like a response that was conditioned. The person was conditioned to be afraid of elevators even though being in an elevator is not dangerous. So how do we eliminate the fear of elevators? We instruct the person to ride on an elevator many times until the fear is extinguished."

KS: Is that what’s called the flooding of the anxiety?
EF: Well, it’s called flooding if the therapist conducts the exposure very abruptly. And it’s called systematic desensitization if the therapist is doing the exposure very slowly in small increments, and if he pairs the exposure with relaxation. There were big debates in the '60s and the '70s about what works better, and whether flooding is dangerous. Some experts, like Wolpe, thought it was dangerous to do flooding because the person will actually become more rather than less fearful.
KS: Yeah, common sense would make you think that, wouldn’t it?
EF: No, not really. According to some theories, flooding should make the patient feel worse. But according to other theories, abrupt exposure should extinguish the patient’s fear more quickly, so it is actually more efficient.
KS: One of the central ideas around the exposure is that the anxiety peaks within a reasonable amount of time and decreases. Is that right?
EF: Well, it depends. Not necessarily. Let’s say that somebody is afraid of going to the supermarket. People with panic disorder, you know, are afraid of going to places where they cannot escape quickly, like sitting in the first row at the movies. It takes longer to get out from the first row than from last row. Experts did abrupt exposure, getting patients to sit in the front seat from the start of the therapy, and other experts said, "Let’s do it incrementally—let them sit in the last row first, and then in the row before the last, and then two rows before the last, and then five rows before the last."
KS: Is that the exposure hierarchy?
EF: Exactly. Gradual exposure gets patients used to each one of those stages, and eventually the patient will sit in the first row. Now, studies have found that doing abrupt exposure is as effective as doing gradual exposure, except that the patients in the gradual exposure suffer less. But flooding doesn’t really make them worse, as Wolpe thought. So we know now that we can do flooding, or we can do systematic desensitization. Both work. Today, experts don’t quarrel about this issue anymore; all therapists use more or less a gradual exposure, but not as gradual as systematic desensitization, because that takes too long and is unnecessary.So that’s what exposure is. Now, how does exposure work? It works because of a mechanism that we call extinction. Extinction is not unlearning what you learned, but rather it’s learning something new—it’s learning that what you were afraid of is not dangerous. Some experts say that the mechanism is the reduction of the anxiety—that gradually you’re less and less fearful. This is called habituation. But habituation is not an explanation for why patients get less fearful with exposure therapy.My theory is that exposure reduces fear and anxiety because the patient learns that the bad thing he thought would happen to him does not happen. Therefore, it’s very important to plan in a way which will ensure that the thing the patient is afraid of will not happen during the exposure. Let’s say after being raped a woman starts to be afraid of going anywhere by herself after dark. The therapist then plans exposures to places that are not safe after dark, and she is attacked again. That’s not a good exposure, because it doesn’t teach the patient that what she was afraid of does not happen.I always give the example of a person that is afraid of big dogs, but not of small dogs. The therapist decides to treat him by exposure to dogs, and brings to the session a small dog. Well, because the patient is not afraid of small dogs, this exposure will not work. Exposure needs to include the things that the patient is afraid of. The therapist then brings a big dog to the therapy session to do exposure. The patient enters the room, sees the dog, and gets very fearful. With the encouragement of the therapist, the patient slowly approaches the dog, which the therapist holds on a leash. When the patient gets close to the dog, the dog jumps on him and bites him. This is again not a successful exposure, because what does the person learn from it? He learns that he was right all along, that big dogs are dangerous.
KS: It reinforces that belief.
EF: Exactly, it reinforces rather than extinguishes the fear. So that’s the way exposure works. In order to implement therapeutic exposure, the therapist has to find out what the person is afraid of, then make a list of these things and organize this list from the not-so-fearful situation to most fearful situation, in a kind of hierarchy. In order to create a good hierarchy, the therapist teaches the patient to assign a number, on a zero-to-one-hundred scale, to each situation. This number signifies how much fear the patient would have if he would be confronted with this situation. It is important that the therapist makes sure that the situations on the list are not really dangerous.The therapist chooses a situation by saying to the patient, "Let’s choose a situation that is about forty on the scale. Which of these situations do you think you are able to do for homework next week or in the session with me?" The patient selects a situation and begins to practice approaching it, staying in the situation until he feels that the anxiety goes down and realizes that the fear is not realistic.So exposure works through two mechanisms. The first is that the situation elicits the patient’s fear—there is a match between the situation that the therapist is presenting to the patient and the patient’s own internal fear. The second mechanism is that the exposure situation contains information that is incompatible with the information that the patient has in his mind. In the example I gave you about the dog-phobic, if the patient is afraid that large dogs will bite him and the therapist presents him with a large dog that, over several instances, does not bite, the patient will cease to be afraid of big dogs. Patients don’t really need to be in the situation a long time—they don’t need to wait until the anxiety dissipates completely. They just need to be in the situation long enough to realize that what they feared would happen does not happen.

Transforming the Wounds of Racism: An Autoethnographic Exploration and Implications for Psychotherapy

Posted on by rezendevknowfully.com

A young boy splatters my painstakingly finished painting, taunting me to go back to where I had come from. I accuse his ancestors of plundering my nation: "Look what your people have done to my people." (Saira, eight years old)

The stories of colonialism that my father had told me suddenly came to life and I felt bold and proud as I looked to my teacher for further confirmation. She remained silent as the other children laughed at me. I found myself shrinking away in that moment of humiliation. I think about that experience quite often and I imagine what might have happened if my teacher had affirmed my words. Especially, now that the cultural landscape has changed and I see white women with henna tattoos, and Indian fashions, designs and music everywhere I look. It is curious that what was once denigrated is now accepted and desired. This is both inexplicable and inspiring to me.

My brother and I are in the garden gathering brittle autumn leaves for the fire, savouring the sweet evening air in our lungs. Two white teenage boys peer over our back fence and throw stones and litter at us alongside racist jibes. I feel they are treating us like animals in a zoo; I feel fear rise in my belly but feel compelled not to show it. My father appears and gently asks them if they would like to join us. I feel bewildered and betrayed by his reaction. The boys sit beside us and floating embers settle in our hair as we eat baked potatoes plucked from the fire. We make reluctant and inquisitive eye contact with one another and as the fear dissipates, I can see they want to be a part of this simple activity of togetherness. (Saira, ten years old)

Racism was a part of the backdrop of our lives. It was not discussed and I was given no guidance on how to make sense of it. It is only now, many years later, that I recognise the gift my father gave me that night: he showed me that I could acknowledge and stay with the disquiet and dread of racism and that I could find ways other than fear and dread to be with it. During my dissertation research on this topic, I held onto these memories like a talisman.

Authoenthnography as a way to understand racism and trauma

I wanted to become a therapist who was not bound up in the rigidity of her boundaries, so that I could begin to stretch and push the boundaries of otherness and sameness. As a psychotherapist, I wondered how racism is explored or avoided in psychotherapeutic work. I saw that racism can often enter psychotherapy in a disguised form as it is difficult to express due to the fearful and defended nature of racism. This results in racist trauma being overlooked and minimised, which can be oppressive and silencing in itself. In this work, I have tried to illustrate how stories were told and understood in order to facilitate empathy with groups that are sometimes neglected and marginalized.

Autoethnography¹ has developed from ethnography, anthropology, sociology, and cultural studies and serves to challenge traditional historical relations of power. Autoethnography is different from autobiography in that it describes the conflict of culture and identifies how one becomes othered within a cultural and social context. This method of research allows us to remake and understand subjective experience from creative and analytic first-person accounts of people's lives. It makes use of interviews, dialogues, self-conscious writing, and other creative forms to facilitate an expanded awareness for the author and audience. Autoethnography is the study of the awareness of the self (auto) within culture (ethnic); it is a way to connect the personal with the cultural.

I have tried to create a more heartfelt space where wounds can be subjectively named and understood. I wished to engage in new ways of thinking about how therapists' life events can change practice and awareness for themselves and the field. The illuminated relationship between the researcher and the researched is made transparent in this work as it took me to places, internally and geographically, that I had never been…

This is not just a story about racist trauma—it is a story about longing, loss, and discovery. It weaves back and forth in time, and as a result, it is written in both the present and past tense.

Straddling two worlds

As a child, I was a keen observer, soaking up the living memories of my parents' homeland, of dance, song, and food that produced solidarity and unity. As a group, they felt alienated and displaced from all that was familiar. My aunts told and retold stories; this helped them maintain their cultural voices, and this collectively made them a powerful force in my life. The men were on the edges of these stories and were largely uninvited to storytelling as it was felt they were both "too important" to be burdened with the tales and too "weak" to bear the sorrow associated with them.

I straddled both the ancestral and modern worlds, and I was given the gift of being able to find myself within these stories. Despite the fact that these mementoes of my heritage were somewhat fragmentary, I was still left fascinated by them. My aunts came from a culture that emphasised togetherness and unity. In their dependent and highly emotional world, they sought kinship and solace with each other. This was in part because they became increasingly ambivalent about their splintered place and identity in the world due to the forces of migration.

As I grew older, I started to embody a western culture, and it became apparent that cultural differences were intolerable to my family, as any individuation was an annihilation of the collective. I felt increasingly like an outsider, both inside and outside the home. I was inexplicable and perplexing to them, particularly when at 13, I dyed my hair pink and daubed hand-painted feminist slogans over my clothes. My family clucked with pride when I responded to their coaxing by wearing a sari for a family event. I felt such sensual pleasure in the swaths of beautiful pea-green silk that I did not want to lose its "magical qualities." In turn, [I refused to take the sari off, ruining their hopes by experimentally skateboarding in it.] I was continually challenging their ideas of what a traditional Asian woman should represent and grappling with the contradictions and paradoxes inherent in this process.

Myself as witness

How do I trace the roots of my estrangement and disconnection from these men who were central to my life, to my heart? I have waited for a long time for them to come home—psychically, physically, and emotionally. I have always wished that they would be returned to me, like at the end of fairy tales. Through my research process, I felt like I was making the decision that I could not passively wait for their return any longer. Whilst being immersed in this research, I felt a strong need to reclaim my deeply yearned for yet seemingly irrecoverable lost connections.

I did not know for certain when I started this research that my father, uncle, and brother were lost to me by racism and its effects. These experiences were unheard and unspoken in my rambling and rather tribal family. I believe the speaking of racism evoked fear and shame that might further tear at the fraying fabric of my family. Racism, for me, was bound in the wrappings of humiliation and silence. It was so tightly swathed, I only heard it as a fearful whisper. I have subsequently discovered these traumatic racist experiences ranged from vague, insidious and intangible experiences to shattering, violent acts.

As I felt the oscillations of these unspoken narratives inside myself, it led me to create musings, fantasies and assumptions about the subject matter. I sat at my desk, feeling bewildered and paralyzed at the horror and pain of the family narratives, and despair at their disconnection from me, wondering how it was possible to get closer to the subjectivity of such experience. This possibility felt charged, potent and unfathomable. I deliberated and wondered repeatedly if I should speak with my family about the research—would it harm them further? What are the ethics of taking this into the public world? What would the research do to our relationship? Issues around confidentiality buzzed around my head and my colleagues and I talked about them incessantly.

I questioned the possibility further: What will my peers make of me? Would I be derided and discounted by the "therapeutic community" for revealing not just myself, but also my family? Would I be able to produce something evocative, powerful, and representative of our experiences? Is this the story of significant men in my family or my story of loss? Can I find the words for trauma that sits beyond language to describe what cannot be spoken? The question remained with no easy answers.

My father's scars

My father was disillusioned and troubled when he fled to England to practice law in the 1940s. His best friend and neighbour during the partition in India stabbed him. He only mentioned the scar on his stomach in passing when I pressed him to let me into his interior world. He believed Britishness embodied fairness and justice as he had been successfully inculcated into the colonial belief that he and his kind were inferior. He beamed with pride at redefining himself as a "brown English man" and negated his "primitive and corrupt" cultural origins with vitriol, never wishing to return.

In remaking his identity, he resolutely refused to believe that his struggle to secure a job as a barrister was due even in part to his colour. He was a dishwasher, a porter, and a lift attendant—all the while, trying to maintain his respectability and pride. He would arrive to work with his bowler hat and impeccable pinstriped suit each day. then change into his overalls to start his shift. He was inaccessible to us as he strove to carve out a place in the world, and his identity was embedded in his need to work hard and achieve. His failure critically punctured his self-esteem.

The eventual disaffection and disillusionment with his idealization of Britishness seemed inevitable. However, its impact was made worse because he was unable to digest the racism he endured. He saw the hostile, racist persecutory world making him feel small and powerless. He seemed to see racism and oppression everywhere. These crises led him to alcoholism and admission to a psychiatric hospital for depression.  “He sat on his prayer mat and cried like a child as he spoke of England like a lover that had abandoned and disappointed him.” He turned away from it as he had his homeland.

In turning away from Britishness and all it represented, my father turned further away from me. Had I come to embody what he could not bear? I could not find any comfort in taking my distress to him and he could not bear the weight of his child's woundedness. The effects of his trauma marked our family, and although we did not live through his trauma, we did live within its confines.

It is frustrating to feel the familiar inaccessibility in his death as I did in his life. What would he have discounted or embraced in these descriptions? My father was a harsh man who shielded himself from the world and eventually lived a hermit-like existence, but he gave me the best of his capacity to love. All I can name is what I know: that every day I spent with him he was unpredictable and closed off, living in a desolate land. I could not find him anywhere. And now I cannot quite find him in the untranslatability of these narrative descriptions.

While my own father was busily being a perfectionistic workaholic, my mother was whimsical, dreamy, furiously caught up in her culture and clan. My uncle represented a world of calm and safety. How do I adequately describe how much I loved my uncle? I have always found great comfort in looking at his face, the familiarity I felt in watching him smoking his cigarettes—his recognizable outline meant that my life slotted into place.

My uncle leaves… the unanswered questions

I now realize he was a mere young man at the time, but seemed then to offer a very different quality of attachment. I remember him driving a maroon Mini with a squeaky leather interior that I would slide around on. He would sit with me on the stairs when I had undigested bad dreams about cowboys and Native American Indians and would speak softly of worlds full of magic and kindness until I felt safe enough to fall asleep again. He taught me to gently put the needle on the record and wait breathlessly until the song would start in the smoky recesses of his room. He would capture my crinkle-nosed smile in his photographs and I felt rewarded with his attention and gaze.

His leaving to emigrate to Canada when I was six felt like an unanswered question and for a long time I wondered why he left, and yearned for him to come back. His absence was profoundly painful to me as a child. I wondered if my mother had sent him away or if his new wife asked him to leave. As I grew up, a part of me imagined it was due to racism. Not that I knew much of his experiences with racism, but I overheard fragments of conversations of how he "hated England," and that "terrible things happened to him." It led me to conclude that racism was the only conceivable reason he left. Why did I assume it was racism? Had I made something up? Perhaps it helped me believe as a young child that something terrible took him away rather than facing the fact that he had chosen to leave me.

"It felt embarrassing to talk about the humiliating aspect of it, your sense of masculinity is wounded and injured, you feel that you should have taken a stand but you did not feel able to as a man." (Saira's uncle)

Early on, I asked my uncle what he thought about my research—was it meaningful to him? He said he had many stories of racism and its associated trauma that he had not spoken of, yet they were still alive inside of him. I instantly felt relieved that these experiences were real and not entirely the result of my imagination, although I feared I would not be able to hear and bear these stories. How might the telling of these narratives benefit him? At this stage, I felt lost in the littering of these broken attachments and in a turbulent state of anxiety and confusion, although later I recognised that this was a place of important struggle and sorrow.

Unwelcome in the new world

My uncle arrived in England from Pakistan in the 1950s at 10 years of age accompanied by a throng of older and younger sisters with kilos of sweating Indian sweets wrapped painstakingly in silver foil. However, the family was ill-prepared for the cold as they arrived in the dead of winter in only their thin cotton shirts. All 10 children started their life in Britain in an asbestos-ridden caravan, confused and unsettled after coming from a place of wealth and comfort. Later, the family moved into one room with little space, and their material conditions worsened. They lacked any comprehension of the new culture or landscape they faced. This migratory journey remained an untold story because it evoked shame of their struggle to find a place of belonging and the emotional and literal poverty of their experience. The exodus was supposed to be rich with offers of new possibilities, the enticement laced with the promise that they would be rewarded if they worked hard and managed to forget the familiar sun, and the textures and colours of home.

My uncle was pleased to find that people were initially curious about him, his history, and difference. Later, this changed and it seems humiliation and shame coloured much of his experience as a young man. He remembers standing at a bus stop racially abused whilst those in the polite orderly English queue silently looked on, witnessing him being scorned and disrespected for simply existing. He felt the disdain when he was spat at for embodying and personifying otherness, his palpable foreignness and physicality making him a threat to himself. The skin he represented made him exquisitely visible and invisible.

"Look what the cat's dragged in" was his greeting on the first day at his new job; he was 16. He felt cheated; where was the promise of a better life? Then he was threatened with a knife in a public bathroom where a gang of men in a savage racist attack set upon him, dousing him in their anger and fury. He felt unwelcome in the new world.

He walked around in shame and isolation, wondering how he could make a mark on the world when his voice had fallen away. Humiliation tearing at his throat, he swallowed the contempt and its effects began to house themselves inside of him.

Connection and disconnection

My brother on my Uncle's shoulder, me in the park… I chew on the long feathery grasses that sway in the wind, shimmer in the sunlight; I thought I was eating the sunshine. (Saira as a young child)

These are the happiest times I can remember. I felt connected to the world and myself when I was with my uncle. My adoring view of him was in part due to the way he invited us into other worlds of music, song, and nature. I was full in the stillness.

He and the white English woman that he loved and hoped to marry sat together in the ordinary familiarity of the train carriage. He loved train journeys, watching familiar landmarks appearing and disappearing from view as the train juddered out of the station. This defining journey turned bad for him as a heavily built white man sitting across from him began to mumble and then roar at how "his kind" had defiled his partner's virginity, taking something from him—from all white men. “The pain of past racist violent blows he had experienced did not compare in their intensity to this expression of violent hate that was coming at him now.” The torrid racist expletives bounced around the walls of the carriage, exposing and belittling him.

The emotional impact was initially shock; he described feeling a numbing paralysis in his body. As they decided to escape and disembark at the next station, he wondered how his body would support him, when it felt so insubstantial. Time slowed to a stop as he felt the flush of disgrace and helplessness overcome him. The other travellers in the carriage looked on, some with interest, others with avoidance; did they find themselves agreeing with this man's hate? Is that why they did not protest? Or was it fear that this contempt would be directed towards them?

He felt his girlfriend was defiled in her association with him; it was as if she was contaminated by the colour of his skin into something more sexualised and objectifiable. They never spoke of this incident, but it was the beginning of the end of their relationship, because in that long moment, amongst all of the shame and emasculation, was her witness of his diminishment.

When he moved to Canada, he left me too, but more poignantly he left himself. The racism that had infused his world disconnected him from himself and those around him, such an unspoken cruelty when contact and connection was the gift he gave me.

"Racism was not the main reason I left"

I journeyed to Canada to meet my uncle, 30 years after he left England. To engage in a dialogue about something so personal and painful leaves me anxious and curious. I am researcher/niece/ psychologist/ therapist/child all at the same time. These multiple selves offer a dynamic shifting of one into the other, each adding a new voice. He is a stranger to me now, but there is a strong memory of childhood intimacy that attracts me to him. Yet I feel shy. I want to hide away in my researcher/therapist self to anchor me, but this dialogue requires courage to be intimate and honest. I wonder if I am capable.

We sit in his basement with a scratchy blanket on our knees, as I anxiously wonder if my new tape recorder will work. At the same time I wonder how my husband is, as I left him making polite conversation with my uncle's wife upstairs. Are they wondering what we are discussing downstairs?

He says slowly, "No, racism was not the main reason I left." My long-held assumption momentarily floats away. What does this mean now? He tells me he came to Canada to begin again: a new life, a new job. He does not want to be perceived as someone who cowardly ran away. Did my questions about his leaving further diminish him? It seems to me that he needs me to clearly understand his reasons for leaving. I feel a need to honour this, while still I wrestle with what this means for me and for him. Self-doubts creep in… Were my assumptions off base? Was I too committed to these assumptions before hearing his version of events?

Acts of reinvention

It is as if racism had blighted his life for many years; the hurt and the vividness of the memories live on and become ignited as he speaks of it after 40 years. He says he felt like a victim, which left him terribly alone and split him apart. He says, "I don't know if white people could relate, or appreciate the racist experience. You have to be on the receiving end of it. Only our people could understand this shared experience, to know what it is like to be spat at, to be hated. I do not know if they would be able to really make a connection. You have to live through something like that."

He became vigilant and wary of whiteness. It has been 30 years since he experienced such overt racism, yet he still sees all white people as outsiders. I can psychologically understand this but emotionally it does not fit for me. I cannot feel this way because our narrative experiences are different.

His own racism remains unacknowledged. He does not see it as racism, but rather as a wish to preserve the integrity of his culture, with the lines drawn in a colour-coded way. Whiteness must be kept out or at best treated with a large dose of scepticism. I try to wonder with him whether his racism precedes or emerges from his own racist trauma. How does whiteness threaten his cultural and religious beliefs? I try to get into a dialogue about this, but he is rigid and fixed in his ideas just like those who hated him for what his skin represented.

It seems these feelings became more pronounced when he began to reinvent himself. This reinvention of himself, he believes, was born from the isolation and emasculation of the racism that penetrated him. He needed to recreate and recapture a self by finding value in his culture after coming from such a place of shame. He found a resilience and strength that came from his community and culture, mainly from his spiritual connection to music. He made these connections to preserve a self that had been discounted. “He felt embraced and accepted in this place… a place to stand with his hurts.”

The more toxic effects of the shame and indignity went away, yet he remains mistrustful of anyone who tries to get too close. This mistrust includes me and I realise there is an awkwardness that sits between my uncle and me that does not go away.

I felt deeply hurt and angry by the racism he described, but more so that he had nowhere to take his woundedness. I begin to wonder if I in some way represented the England he had to leave behind. How do I speak of my anger at being left and feeling forgotten? I try to talk about this but the words do not come out right and they stick in my throat.

He reads the narrative that I have taken from him and insists he has nothing to add or

change. "It's an accurate description and it's interesting to know of you through doing this," he says. He sees my expression of sadness at his leaving England as his failure; I cannot quite find the words to explain how much he meant to me that made his leaving so agonizing for me. Is it too late? It is as if he has already turned away. His world seems to exist of outsiders and insiders. I think I begin to exist somewhere in between for him, as the residual effects of this trauma mean that he remains far away.

As we are preparing to leave, he shows me photographs he took of me as a child from an album as closed as his past. He tells me that his happiest memory of those times was the crinkly smile that I saved for him as a child. Despite this, I feel heartbroken all over again.

Healing some wounds

As I listened to and then transcribed my uncle's story, he maintained power over his words as he revised and amended his descriptions. I wrote the narrative piece that he had editorial control over. He was able to acknowledge his loss of self due to racist trauma, but the recognition of his resilience and his sense of agency was made real by the act of linking events to his act of self-expression. I noted that his resilience was activated to survive adversity. He expressed this resilience in the form of forgiveness: "I have survived so much and learned that forgiving others (racists) has helped me have another chance at life."

I grappled with the need to see my uncle as a survivor and hero, and preserve my continued idealisation of him. I can see how he continues to bear terrible scars that I naively believed could be bridged by this research. Yet, what was healing was making sense of these previously unspoken trauma experiences that we were no longer compelled to exclude, a behaviour that was normalised within the family. These narratives brought validation and the possibility of new attachments. However, this narrative was not entirely healing with orderly resolutions.²

My uncle's residence abroad meant the dialogue we were able to share in person was concentrated over a week and followed up by telephone and email contact. I felt disappointed that I did not have more time with my uncle in the research, but is this not how I began, lamenting the loss of my time with him? He seemed unengaged after a time and denied wishing to change the material in the text after the first few revisions. He said there were no negative effects of the research on him, but I wondered if he felt discomfort at our increased contact. I have now not heard from him for a number of months and suspect he wishes to re-establish some distance and renewed separateness. I have honoured this for now and so I continue to feel his absence every day.

In writing about racism and trauma, I am writing about my life, family, and community, which is quite charged. I have become careful not to contribute to the splitting in the world of racism, or in believing that the racist monster prevails and that those of colour are helpless and victimised. I have found that by opening up categories and sitting in between these splits and divides that I can see the situation more clearly. I cannot simply hate the racist, because I have loved those who have voiced racisms of their own, like my father and my uncle. Similarly, I have been touched by this work, wrestled with forgiveness and humanness, and appreciated that the resulting embodied awareness may go a long way in creating connections across divisions.

Coming home again

A gang of boys corners me and threats me, but they become half-hearted and change their minds because they are unsure of where to locate my colour or ethnicity. I feel initially relieved and then angry that they do not recognise me for what I am. I try to call them back. (Saira, eight years old)

I go to Mexico, Mexicans claim me; in Italy they speak to me in Italian that I grope to understand; in Paris, the police stop me and assume I am an Arab; and in India, they do not know where I am from. A client comments to me about how much she despises Pakistanis and how relieved she is that she can speak openly of her contempt, as it becomes clear that she thinks I am from Jordan. (Saira as an adult)

My family would joke and say, "You may as well be white." This was not just a form of shadism, but to emphasize my difference from them. My skin colour is not easily identifiable, yet I am kept othered and my difference is imagined. All of this points to the idea that skin colour is unimportant in itself, but the projections, internalisations and consequences it carries do matter. We cannot ignore or minimise this impact as sometimes it becomes a matter of life and death, be it physical or psychological.

I internalized the shame of my cultural difference, and my Asianness seemed inexplicably both a bad and a good thing. I have struggled with the shame that glued my insides together and writing this has been a battle of sticking and unsticking those glued parts. This work gave shame a place to speak from. I have wrestled with finding my voice and I recognise that the humiliation and guilt at being a witness to racist trauma has been like an eighteenth-century corset encasing me and defining my shape. I have reframed this narrative as one of transgenerational and intergenerational racist trauma. I intimately feel the terrible loss and abandonment by these significant males. Now I am less bound up and defined by this trauma. I am not sure, though, where I go from here.

The effects of these traumatic absences have left emptiness in my life, and acknowledging the pain and sadness of missing these men who were once vitally present has changed something between us. I am able to love them just as they are in the hope that there will be moments when they will be returned to me, which happens every now and then with a smile a word, a gesture, or a memory.

I am changed in other ways, as well. This is best illustrated with an ordinary encounter of getting into the same taxi with four years in between.

Sometime during the beginning of my research, I slide into the taxi as I register the racist hate in the taxi driver's eyes; he glares at me. I am surprised and uncomfortable as I inhabit his confined territory, his taxi seems like a closed-off, taut world of hate and revulsion that leaves me unsettled and unsafe but reminds me that this work means I have to be able to dwell in this place. (Saira)

Four years later, my research is in the final revision process, and another taxi ride…

After spending an afternoon revising my research, I am cooking rice with my mother… the aromatic Indian herbs and spices envelop me… nice to be home again. I feel a mixture of self-consciousness and pride about my project. I get into the waiting taxi preoccupied with these very thoughts. I look up and slowly recognise it is the same taxi driver. He recoils from me, as if I am able to pollute and invade his being. I look at him steadily, filled with curiousity. Where does this contempt come from? What does it do to him? I experience what I can only describe as warmth, expansiveness and loving compassion for him. I happily beam at him because he is representative of the journey that has reshaped me. I do not experience his hate as a terrible wound. I feel no fear. I am not shamed. In that moment and for a long while afterwards, I feel completely free. (Saira)

The implications of autoethnography for psychotherapy

I think about autoethnography interacting with psychotherapy not necessarily as an approach in itself or a distinct form of therapy, but as a set of attitudes towards self and other which can facilitate the creation of an internal bridging and connection. This means that rather than having a set of explicit tools to work with racist trauma, therapists are required to develop and seek out heightened processes of awareness and embodied ways of being. This awareness migrates into practice in a more accessible and less defensive way by helping the therapist engage in highly sensitive and profoundly painful areas of the client's story through varied subjectivities and reframing processes.

The interaction between autoethnography and psychotherapy is also a journey of personal discovery and a self-reflective process. This work became a therapeutically available surface that I could work on inside and outside my own therapy, transforming the relationships with those in research that I love.

For myself as a therapist, “this journey has enhanced my capacity to be more accessible and present in my client work”. I also feel more able to generate conversations and dialogue about racist trauma and the racial experiences of my clients in the therapeutic relationship. Through disentangling racism within myself and others, I find there is an encouragement of an alternative state of awareness that is more self-reflective, and less guilt-ridden and avoidant. This process produced a deepening of understanding and processing of self-generated and self-defined identities that was empowering as it undermined racist and racial stereotypes and helped me to encourage my clients to do so. I think I am better able to seek out such disconnections and attempt to create a worked for connectivity where I can be less constrained in my language and thinking, having developed the capacity to be more available to enter into the webs of racialised discourse in my clinical work and in myself.

Autoethnography can be a profoundly useful way of accessing memories of complex racially traumatic experiences that may be implicit and built upon sediments and layers of racial slights and injuries that contribute to psychological grief and social maladjustment. Skin colour plays an important part in structuring of the world, and the colour coding of the self and psyche. As therapists, we are called to work through this for ourselves and our clients; otherwise it will reappear as the therapist's unexamined countertransference and will perplex and confound the therapy.³ The engagement with otherness takes us out of what is seemingly familiar and encourages us to travel to alternative places within ourselves. It is from this position that I wish to dissolve detachment, isolation and marginalisation to create connections and healing.

Refuse to wither and die

These stories have found a home inside of me, and I realised that I have been writing this story for the whole of my life. Now that it is committed to paper, I can see how it has helped me to love.

Notes

2 Franks, A. At the Will of the Body: Reflections on Illness (Boston, Houghton Mifflin, 1991).

3 Dalal, F. Transcultural perspectives on psychodynamic therapy; Addressing external and internal realities in The Journal of Group Analysis, 30 (London, Sage publications 1997) p. 203.

4 Bronson, P. Why do I love these people: The families we come from and the families we form (London Harvill Secker, 2005).

For further information on authoethnography:

Ellis, C. The ethnographic 1, a methodological novel about autoethnography ( NY, Altamira, 2004).

Gottschalk, S., Banks, A. and Banks, S.T. Fiction and Social Science, By Ice or Fire, (Walnut Creek, Altamira, 1998).

Getting Off to a Powerful Start in Couples Therapy

Posted on by rezendevknowfully.com

I am pleased to offer you this lesson from my online couples therapy training program. It has been adapted from a lecture, and includes commentary from Michelle, our moderator, as well as comments from the audience. This will give you a glimpse into some of my principles for “Getting Off to a Strong Start” in Couples Therapy.

In this article, we’re going to focus on the following points:
  • Getting Off to a Strong Start
  • Three Types of Goals and Effective Goal Setting Questions
  • Six Essential Elements of Early Interviews
  • Developmental Change vs. Behavioral Change
  • Identifying Vulnerable Feelings
Speaking of “strong starts,” let’s get going on our lesson…

Getting Off to a Strong Start

Ellyn: Today, we’re going to talk about getting off to a very strong and powerful start in couples therapy. And I’m going to teach you principles that have to do with both your mental set, so how you think about what you’re doing in those early sessions and how you position yourself with clients; and I’ll also be teaching some specific how-to’s. But this is not a cookie-cutter approach.
 
You will be looking at integrating pieces of this in the way that works for you, and also integrating pieces in terms of what is best for the kind of couple that you’re working with. I’ll highlight some of the pieces that work better with some couples and some that work better with other types of couples.
 
First, getting off to a strong and powerful start means you being a leader. By the time you’re finished with this course, “I want you to feel like you are a leader—that you are active in your work, you’re not reactive, and that right from the beginning you’re getting the couple’s attention.”
 
You’re establishing yourself as somebody who is strong, and somebody who understands and is able to help them. Also, they’ll know that they’re going to do the work and that coming to therapy is not waiting for you to wave a magic wand. If they will do the work, there is hope they can get out of the conundrum that they’re presenting to you.
 
The tone that you set from the very beginning is crucial and is based on the answers to the following questions: Do you see pathology? Are you looking for pathology or are you looking for developmental stuck places?
 
Seeing impasses as developmental stuck spots will help you and your couple be more optimistic. You’ll be able to inspire them that they, in fact, can overcome and can get out of their negative cycles.
 
Your style and what you pay attention to will indeed determine the direction of the therapy. I am always thinking, “How do I challenge my clients to develop themselves and to look at the development of themselves as something that is positive, that’s exciting, that can be rewarding and not something that’s a drudge or way too difficult for them to do?”
 
There are predictable reasons for why relationships fail. The primary issues that most couples struggle with are:
  • There is a lack of development in either or both of the individual partners.
  • They have a repetitive history of re-triggering emotional trauma in each other and not repairing it.
  • They don’t have the ability to repair when they hurt or do damage to one another.
  • They lack skills or knowledge.
Couples often don’t understand why they are struggling. They think that there’s something wrong with them or something is inherently flawed about their relationship. When you are thinking about the couple in front of you, the goals that you are going to set fall in one of three main arenas:
  • The couple is coming to you for change, growth and development.
  • They are coming to dissolve the relationship, to be able, in fact, to say goodbye to one another, to go through a divorce or separation, to get help with the kids and the parenting and in the process of separation to resolve any resentment so it doesn’t fester and impair their future relationship or their parenting.
  • They need help making a decision. A common one is, “Should we stay together or separate?” Maybe one wants to have a child and the other one doesn’t, or there’s some kind of move or job promotion situation that’s creating enormous difficulty about whether they’re going to stay where they are or move. And of course, there is, “Shall we get married or shouldn’t we get married?”
You can slot each of your couples into one of these three areas as you begin to think about goals that make sense for them.

An effective couples therapist will, over time, become both decisive and incisive and be able to sustain positive momentum. So when the couple starts backtracking, or when they start getting bogged down, those are times that you want to intervene and intervene quickly so that you can keep the momentum moving forward in a positive way.
 
It is absolutely essential that you not get stuck in their negative cycles or allow their negative patterns to go on for a long time in front of you. You only need to see it briefly so you understand what they do.
 
Michelle: At that point, Ellyn might you point out the cycle that you’re seeing and explain it back to them?
 
Ellyn: Yes, I will point it out, because having a grip on the negative cycle is the beginning to disrupting it. It’s the first step of changing it. So as long as you’re sure that you’re not doing it in a negative, judgmental or critical way, pointing out their negative cycle can always be an effective intervention. What we’re going to look at a lot is the essential elements of early sessions and the whole process of goal setting.
 
Too many couples ignore their shortcomings and do not seek help until it is too late. Therefore you have people very often coming in to see you when they think it’s too late, when you might wonder if it’s too late—and indeed, sometimes it is too late. But the patterns have been going on a long time, and that’s why getting their attention and assessing with them whether they’re there to dig in and do the work is important. If the couple is ready to dig in and do the work, one of the things you want to ask yourself is do you have the time to see them? Do you have the time to work with them?
 
When I do a first session, I never do it shorter than a double session. It’s almost impossible to assess a couple, in my opinion, in a 50-minute hour. You’re talking about assessing two individuals and the relationship. Most of us would never spend just 25 minutes assessing an individual client, so I’m always asking people to come for a double session to begin with.
 
Usually when I’m getting started with a couple I want to see them frequently. I want to see them for a minimum of two-hour sessions, and this is especially true for those that are disorganized, hostile, fighting or on the verge of splitting up. It’s not a good idea to accept a couple who is in a bad situation if you’re not going to be able to make time for them in your schedule.
 

Essential Elements of Early Interviews

  • Make contact with each partner
  • Understand the problem
  • Name feelings being experienced
  • Empathically embellish those feelings
  • Describe the destructive cycle, but…
  • Set a clear direction… a way out (including delineating the importance of containment, repair and autonomous change)
  • Define your role and your expectations for them
These essential elements are spread out through the first couple of sessions. The first essential element is making positive contact with each partner. That is, establishing the relationship and being able to understand the problem from each partner’s perspective. Sometimes it takes more work to understand it from one partner’s perspective than the other.
 
As you’re listening, name feelings that you’re hearing that are being experienced. Be able to empathically embellish them, to describe the destructive cycle and point out a clear direction for change. Delineate the importance of each partner containing their reactivity. Another part of the early sessions is defining your role and expectations for them as clients.
 
Making contact is something every therapist learns in psychology or counseling 101. One way to assess how hard it’s going to be to make contact is to ask your clients when they first come in, “How do you feel about being here even though we haven’t done anything yet?”
 
Their responses to that question will let you know who’s going to be easy and who’s going to be difficult to connect with. It’s a common situation for one member of the couple to say, “I’m so relieved. I thought we would never get here. I’ve wanted to come for a really long time. I’m glad we’re here,” and for another member of the couple to say something like, “I don’t believe in therapy. I didn’t want to come and I think this is just a waste of time.” It’s pretty obvious who’s going to be the harder partner to make contact with!
 
Other aspects of making contact include:
  • Being friendly, kind and interested.
  • Appreciating their anxiety. Couples therapy is more unpredictable than individual therapy.
  • Acknowledging lack of control over what the other partner says or does.
  • Hearing their story in the context of the structure you provide.
  • Giving lots of positive strokes can be highly valuable in the early sessions.
Particularly, I like to highlight areas where I see a partner taking a risk, where I see them making themselves vulnerable and where they’re stretching themselves. I will do a lot of positive stroking of those aspects rather than focusing on anything that I think is contributing to their cycle. I also think it’s helpful to appreciate their anxiety. “Couples therapy is harder in many ways for partners to come to than individual therapy. They think to themselves, “It’s unpredictable what my partner is going to say about me.”” In individual therapy we have complete control over that, but in couples therapy they’re often anxious about what’s going to be revealed.
 
Another thing I would let the couple know is that I will provide a safe structure and context for them to tell me their story. So if the partner keeps interrupting or keeps saying, “No, it didn’t happen that way,” I’ll say, “Wait, stop. I want to hear the story from each of your perspectives.” I want to get the whole picture and not let them be interrupted by the other one.
 
Michelle: Can you say a little bit about the beginning of the session when you ask them the question, “How do you both feel about being here?” and one person seems motivated and the other one not? Can you tell me what you do with that information? Do you orient the sessions differently?
 
Ellyn: Yes. When one person says they’re motivated and the other person says they’re not, I know it’s going to be essential for me to make contact with the partner who’s not motivated. I’m going to be especially observant about how I make a connection with that partner.
 
“Sometimes making that connection might be as simple as saying, “I’m glad that you came in today. Do you know that you can come to couples therapy and not have to change anything about yourself?”” Because they are so afraid that the focus is going to be on them and that they are going to be required to change. You will always have better buy-in for homework with the motivated client. So I am less likely to give the unmotivated client homework until I have a stronger connection with them.
 
I’m working to understand the couple’s problem both cognitively and affectively. The problem that they are bringing to me is usually understandable based on a couple of things: It’s understandable and predictable based on the attachment style of each partner. It’s also predictable based on the developmental stage. For example, if the couple has been together more than two years and they’re still stuck at the symbiotic stage, that’s going to be a problem, and that’s going to require them to be able to work in the area of differentiation.
 
The problems that they’re coming to you with will be a function of their arrested development—and once you have a full understanding of our Developmental Model of Couples Therapy, you’ll be able to describe that to them. It’s also predictable based on how long the partners have been together. A couple that’s been together just six months is not going to have any effective differentiation and I can’t possibly expect that they would.
 
On the other hand, with a couple who’s been together for 10 years, has a chronic history of conflict avoidance and has never differentiated, I know that it’s going to take a lot of risk, push and challenge for them to get out of that if they’re going to change the core dynamic of their relationship. Part of understanding the problem is asking helpful, insightful questions. In that process I want them to begin to think more deeply about what they’re saying. I also want them to understand the problem from an emotional or affective standpoint, so I’m going to be feeding back a lot of their feelings as well.
 
Here is an example of how you might describe a destructive cycle. I made it a little more complex than you might with most couples just to put a variety of both feelings and behaviors into it. I might say to Sally, “When you feel hurt by something that Ted says, it’s difficult for you to tell him that you’re hurt or to request an apology. Instead, when you feel hurt, a part of you wants to hurt him back so you tend to criticize him.”
 
Then to Ted I might say, “When you feel criticized by Sally, your tendency is to disengage and withdraw. Sally then ends up feeling lonelier, and instead of the two of you being able to repair and reconnect, the cycle keeps escalating. It keeps repeating and each of you is left in pain.”
 
Then I might ask them how they’re responding to what I’ve just said. And I look for their non-verbal cues, as well, to see if they agree with me. Are they connecting with what I’m saying, and does it make sense to them? Then you are able to not only connect with their feelings, but empathically embellish on them even more. The more you empathically embellish on your clients’ feelings, the more understood they’re going to feel, and the more able you’re going to be to confront that partner later on.
 
I want to have those moments of good empathic connection early on. Those might come from commenting on their deep loneliness or their helplessness, or you might say to a client, “You have tried and tried. You’ve tried everything and you’ve been really stuck, because nothing at all is changing. In fact, it looks to me like at this point you’re beside yourself with frustration and you wonder if there’s even a way out.”
 
A lot of people will nod their heads or begin to cry. They really know that you know how hard it has been for them, because they have been trying. And they didn’t know what to do. They didn’t know how to get out of that stuck position. So they might feel like you get and understands them.
 

Goal Setting

Michelle: A lot of couples at that point will also say, “Yes, you’ve got it.” Their anxiety will come up and they’ll say, “Okay, so what do we do about it?” And they’ll want to move fast at that point.
 
Ellyn: Right. And because they want to move fast, that can actually be a good bridge to goal setting. It’s not enough to be understood. I know that it is going to take change on the part of each person to change the dynamics between them. So I’m going to spend some time now talking to you about goal setting.
 
When you hear the words “set goals,” it’s so prevalent in our culture that it sounds like it should be something easy to do. And yet “to do good goal setting with couples is an incredibly sophisticated and complex skill that takes time.” It’s usually integrated into several sessions. It’s not something you can do in just one session unless you have an incredibly insightful couple who’s been in therapy before and they know what they want to do.
 
The more disorganized the couple is or the more hostility there is, the more challenging it’s going to be for you to arrive at effective goals. And I want you to come away from this lesson actually being able to reflect on the couples that you’re seeing and really ask yourself, “In which of these cases do I have strong goals that make sense and that will help move this couple forward?”
 
If your answer to yourself is, “I don’t” for any particular couple, then you can back up and say, “This is a good time to reassess. Let’s see what we can look at as the next goals to undertake.” One of my favorite cartoons is of two couples talking in one couple’s living room. One says to the other, “The work being done on your marriage… are you having it done or are you doing it yourselves?”
 
The reason I love this cartoon is because so many couples wish that the work would be done for them. They come in either hoping that you have a magic wand that you’ll wave to change their partner or that they can sit back, wait and watch for their partner to change.
 
That’s why the skill of getting each person invested in changing something about themselves that will move the relationship forward means that you’re dealing usually with character issues in each partner. You’re also dealing with motivation issues and possible resistance to therapy issues.
 
What is an effective goal? To me an effective goal is one that requires an individual to do some self-reflection and self-confrontation. And you’re asking the couple about their values and you’re implying that a change is needed in their pattern of reactivity. You’re asking them to self-select some new standard of behavior and to hold themselves accountable to whatever the change is that they are working on.
 
One way to think of the change needed in their reactivity is to think about what this person needs to stop doing in order to create the space for change to occur. You might think about it in terms of what this partner needs to start doing, or what both of them need to do differently that would enable them to take risks and move themselves forward.
 
Michelle: Ellyn, do you ever explain to your couples the concept of making a shift within themselves? I think that’s counter-intuitive to most couples when they come in, because they believe the problem is with their partner.
 
Ellyn: Yes, I do, and one of the things I talk about with some couples is the principle of autonomous change. What I mean is, not saying, “I will only change if you change,” which is a common thing that partners do—they tie their changes to whatever the other person does. I tell them, "If you make changes regardless of what your partner does, you will be able to have a very rich learning opportunity, because as you make changes, you’re going to see what unfolds; you may be very pleasantly surprised by the changes that start to occur, or you may find that your partner does nothing." Saying something like that is actually directed at both partners, including the partner who may be inclined to do nothing because they’ll realize that it’s going to be observed if they, in fact, are doing nothing.
 
A good solid goal will be clear and it will contain action and behavior. You and I know some about the intrapsychic change that’s behind any particular behavior, but by putting it in behavioral terms for them it becomes concrete and somewhat measurable.
 
When you’re looking for these changes in behaviors and actions, you’re also looking at whether the person has a real motivation to accomplish them. If there’s no motivation to change, it’s a useless goal and not one that I want to accept.
 
If somebody says to me, “I should pick up more clutter. I should pick up after myself,” I might say back to them, “I wonder how badly you really want to do that. Is that something you want for yourself or something that you think somebody else is telling you that you should do?”
 
Usually they’ll say, “I’m getting so much criticism from my partner that of course I think I should do it.”
 
And I might say back to them, “I wonder how picking up would be helpful to you. Is there anything that you can see that would motivate you to begin to pick up more?”
 
That can go into a 20- or 30-minute conversation until you get the piece of motivation that would genuinely be motivating for that partner to start to clean up more clutter. You’re always looking for goals that are individually focused, not dependent on what the other person does. The goals can be contradictory, and by that I mean even as extreme as one partner saying, “I’m here to get help with ending this marriage and I’d like to do some of the steps that are involved to end this marriage in a good way.” The other person might say, “I’m here to build a positive marriage and I do not want this marriage to end.”
 
Even though these are such contradictory directions that will create anxiety in the room, they are genuine for each partner. And then you can figure out what that literally means for each of them to be able to carry those goals out. Always remember that knowing the presenting problem is not a goal. Typically, couples will say things like, “We have a communication problem and we need to communicate better.” Nothing about that is a goal.
 
“Don’t assume you have goals and objectives when you know the presenting problem.” When you ask most couples why they are there, the typical response is a description of their partner’s failures, shortcomings and things they do badly. They want to get relief by having their partner make the necessary changes. It’s very rare for them to describe to you what they need to do in order to strengthen the relationship.
 

Homework Assignments

Over the years I’ve challenged myself to come up with lots of different ways of setting goals with couples. I’ve used lots of different kinds of questionnaires, and I’m encouraging you all to experiment with what works for you in your practice and what works with different kinds of clients.
 
One very simple form instructs them over the week to go home and answer the following five questions:
 
What type of relationship do you want to create? I give them examples to help get them started: “You might say you want to create a loving intimate relationship, a relationship with a lot of team work. You might say you want a more companionate relationship.”
 
How do you want to be as a partner? This is asking for a frank self-assessment. How do they in fact want to be? Do they want to be somebody who makes time for the relationship, somebody who wants to negotiate solutions that are working for both people? How do they want to be in their day-in-and-day-out life?
 
What do you want to learn about yourself or the relationship? This is a request for cognitive knowledge that each partner would like to obtain. An example would be understanding your patterns as a reflection of some early childhood experiences.
 
What do you want to stop doing? Common examples are blaming, name-calling, withdrawing, or avoiding conflict.
 
What do you want to start doing instead? In evaluating responses to this question you are looking for constructive behavior that each partner will do when they stop doing the behavior that is contributing to the negative cycle.
 
Before I have people take it home and fill it out, I give them some examples of answers. A lot of times people will say things like, “I want to stop blaming and criticizing. I want to start giving my partner more positive strokes. I want to start saying what I appreciate and I want to start looking for more win-win resolutions.”
 
I ask them not to share their answers with each other until they come back the following session. Then I have them read their responses to each other and we work at refining what makes sense as a goal. You can also use this form to assess their progress as you go through the next few weeks.
 
Here’s another questionnaire I sometimes give couples as homework:
  • What do I want to learn or understand?
  • What do I want to stop doing? 
  • What do I want to start doing differently to build a more loving, giving relationship? 
  • What is most urgent for me?
One couple, Cindy and Jack, answered these questions. When they came back here’s what they had written:
 
Jack said, “I want to learn where my blind spots are that come from my family of origin. I want to stop withdrawing, and start being less defensive. It’s urgent that I be more able to do what I want to do.”
 
Cindy came back and said, “I want to learn about where I get stuck in loving my husband. I want to stop being like his mother and accept that I am his equal. It’s urgent that the abundance in our relationship continue.”

What do you think is wrong with these goals?
 
Participant: I think that neither one of them actually said something concrete about what they could do. They talk about what they want to happen, but they aren’t coming up with anything concrete that they could do.
 
Ellyn: That’s right.
 
Participant: “Learning my blind spot” might be necessary to understand and to stop withdrawing, but under what circumstances or how would he do that?
 
Ellyn: That’s right. There’s nothing concrete here; it’s vague. You don’t get a sense of what they’re going to do. With Cindy we don’t have any idea of how she might be like his mother and why it would be important for her to stop being like his mother. “When you ask the question about what’s most urgent, urgent usually has a timeline, not something so open-ended as wishing for “the abundance in our relationship to continue.””
 
For Jack, you can’t picture what he really means by being less defensive. And when he said that it’s more urgent that he be able to do what he wants to do, I wanted to know what kinds of things he wants to do. When I pursued that with Jack, he felt like it was completely impossible to spend any of his non-work time away from Cindy. When we began to define it further, one of the things that was urgent for Jack was to have the ability to have some individual time alone each week. And then it went even further that he wanted to be able to take some golf lessons. So we were getting into something that could disrupt the intensity of this enmeshed, conflict-avoiding couple.
 
Next Cindy started to refine her goals and it shifted to, “I want to understand why I feel depressed when Jack and I disagree. I want to stop walking out of the room when we have a disagreement. I’d like to learn how to talk through a conflict from beginning to end, and be willing to listen to Jack’s side. And it’s urgent that I stop catastrophizing conflict to mean that the marriage is over.” She was a very conflict-avoiding partner who was fearful. She would become extremely anxious at any moment there was conflict and because she would get so anxious she would leave, disengage, or get out so that the conflict couldn’t surface. She was terrified that conflict would end the marriage.
 
I talk about the principle of character a lot with couples: when you’re in a committed partnership, it tests your character. It tests your character in a way that most other relationships don’t test your character. It’s easy to be nice, warm and loving when you fall in love with somebody. And it’s easy to be nice, kind and loving when everything is going right. But when your partner acts like a human being, do you get indignant?
 
Do you get incensed that your partner is human and has normal flaws? Can you accept that maybe your partner gets a little anxious and testy if they think you’re going to be late for an airplane? Or if they’ve had two or three cranky kids all day long and feel spent, when you walk in the door and they don’t say “hello” to you in the best possible way, can you give them a break? Can you be forgiving?
 

The Three-Circle Exercise

To finish up this lesson, I am going to give you one more concrete way to set goals. At the end of the article, you will find a diagram with three circles, called “Uncovering Vulnerability and Shifting Negative Patterns.” This three-circle exercise is a way to establish more effective goals.
 
I ask partners, “When you are at your worst, how do you act with each other?” Sometimes I’ll even brainstorm a list and put it on a white board that I have in my office. We’ll create a little list of things like “get critical, blame, yell and break things.” Encourage them to tell you what they do when they’re at their worst. I choose four of the items in this list and write them in the circle diagram.
 
The next part is tricky. “Ask them to tell you the emotion that is hardest for them to show to their partner when they’re at their worst. When they’re at their worst the way that they act is covering a more vulnerable feeling.” In this particular case one client said, “When I puff up and get grandiose I’m covering up fear.” We worked to get to that. “When I break possessions I tend to be hiding the fact that I feel a lot of shame. When I scream and escalate it’s usually covering up the fact that I feel inadequate and helpless. When I yell, I don’t want my partner to see that I’m feeling very vulnerable or fearful.” Write four of their answers in the second circle diagram.
 
Then circle number three is designed for what they want to do instead of these things. When they’re at their worst, what do they want to shift that will make a definite change in the relationship? And here what that client said was, “What I want to do instead is I want to say that I’m frightened, be able to admit that I did something that may have been stupid and unthinking, and know that that’s just human. I also want to be able to take deep breaths and be able to take a timeout.” And the last one was, “I want to be able to say ‘I don’t know how to help you now,’ to my wife.”
 
I sometimes ask clients to take these diagrams home and post them somewhere that feels comfortable: somewhere they can look at them and refer to them. It gives you a wonderful tool when they come back and they’re talking about having had a difficult fight or difficult interaction. You can ask, “Where does it fit on here? Were you able to stretch at all? Were you able to do something new? Were you able to take a risk? Were you able to show your fear? Were you able to show that you felt vulnerable?” This is a powerful way to set some effective goals.
 

Conclusion

One way to know if your goals are effective is to see if the partners begin to grow and change. Over time they’ll assume new roles with each other, new responsibilities, and new ways of being. And the relationship will begin to move through its stages of development and become increasingly more interdependent.
 
I want you to ask yourselves, “Is there noticeable change in the couples and partners I’m working with or are they just spinning their wheels?” If they are spinning their wheels I would say it’s time to go back and reset goals with them. Couples work is one of the most rewarding, wonderful things you can do with your time and it will always challenge you to stretch and grow. It is not for the faint of heart.
 
If you would like to learn more about the couples therapy training program from which this lesson was excerpted, please go to http://www.couplesinstitutetraining.com/developmentalmodel. Or if you’d like to read a handout to prepare your couples for being in couples therapy please go to http://www.couplesinstitute.com/freehandout.

Don Clark on Psychotherapy with Gay Clients

Posted on by rezendevknowfully.com
Ruth Wetherford: Don, thank you for letting me interview you today for Psychotherapy.net. I’m so pleased.
Don Clark: Well, I am delighted to be your interviewee.
RW: Thank you. Let's start with a brief introduction for those who don't know you, or who have not read Loving Someone Gay, You say on your website that this book is so associated with you it's practically part of your name.
DC: Yes.
RW: What would be a general outline that would orient people to your work?
DC: That would be the book Someone Gay: Memoirs that I wrote, which is about 350 pages long. But I assume what you want is a thumbnail sketch of what my life as a therapist has been like?
RW: Yes, but first give us an introduction from before you became a therapist. You describe in Memoirs being born in 1930, during the Great Depression, which influenced you strongly, because though you grew up in New Jersey in relative poverty, you still had opportunities that gave you your strong desire for education and your love of learning, which has guided you all your life.
DC: It wasn't relative poverty. It was poverty. As in, we moved frequently because we couldn't pay the rent. And my parents really were basically illiterate. My father could not read or write. My mother was able to do some reading and she was the writer. My father's writing was limited to signing his name to things, which he did very meticulously. But there were fortuitous events. Perhaps everyone has them, I don't know. Like when I was in the eighth grade, I hated school, because of course being socially at the bottom of the totem pole you get picked on by other kids. Recess was a nightmare.

But in the eighth grade, bless her heart, my teacher must have seen something, and pulled me from the back row up to the front row of the class, and started smiling at me. And I don't remember a teacher ever having done that before. So I started paying attention to her. And her passion seemed to be diagramming sentences in English. Instantly I became the best diagrammer of sentences in the class. Since that had to do with words, which I had been playing with all by myself unbeknownst to other people-trying to decipher Shakespeare, for instance, which I had decided was a secret code like the ones being used by the Allies and the Nazis. I was already enamored with words, and I had already tried writing poetry, but all of this was unknown to any teacher. So we were in this together, now, the teacher and I. We were doing words. And I became her darling and she became my darling, and when it came time to do the eighth-grade yearbook, she appointed me chairman of the committee. I ended up writing the whole yearbook, and I did it in poetry!
RW: That illustrates the power that an individual can have in a child’s life.
DC: Oh, god, teachers, absolutely.
That one teacher in eighth grade saved my life, I'm sure. I would have been working in a factory like my siblings.
That one teacher in eighth grade saved my life, I'm sure. I would have been working in a factory like my siblings.
RW: How did you come into psychology?
DC: Well, I always had to work, of course. Money was always needed in the family. And so one of the jobs I took when I was in high school was an usher in the fanciest movie theater in town. In the beginning I was only allowed to work days, but when I became sixteen I was able to work evenings. And I remember one of the first evening programs I saw was Spellbound with Gregory Peck and Ingrid Bergman. Of course, I fell in love with both of them immediately. I fell in love with a lot of movie stars during that period, male and female. And the males were silent; the females I could talk about. And I wanted to be just like her. She was a psychologist, interestingly. She was acting as a psychoanalyst in the film, but she was called a psychologist. So, duly noted, I thought I would be a psychologist, so that I can save young handsome men like Gregory Peck who have had these awful things happen to them that they can't remember, but I'll help them remember and they will be cured.

So when I got to college, at Antioch in Yellow Springs, Ohio, I started out as a business major, then I became an art major. Then, I took a couple of hospital jobs in the Antioch work-study program. The first one was hideous. The second one was wonderful, at Chestnut Lodge, which was the mental hospital in Maryland that Harry Stack Sullivan had been the control analyst in when he did his writing, and he was followed by Frieda Fromm-Reichmann, who was still there at the time. I had a chance encounter with one patient who had been mute for years. I was nineteen or twenty years old at the time. For whatever reasons, I think she fell in love with me, and I was able to get her to talk and to move and to ambulate, to the point where I was able to take her on a train trip to visit her mother in New York City, which everyone considered to be a total miracle. Frieda Fromm-Reichmann offered me an analysis at fifteen dollars an hour, which of course I could ill afford, but I understood it was a bargain, if I would stay and work with this patient, which I was delighted to do. By the way, Morrie Schwartz–the sociologist at Harvard, who became known for Tuesdays with Morrie– got fascinated by it and he recorded a meeting with me every week a about this. Everybody was trying to figure out why it was working, how this was happening. Now I know why it was working, but then I didn't.
RW: Why do you think it was working?
DC: I really cared about what she had to say, and I cared about her. She had not had that before. Even in her analysis there, her presumed analysis, which was a joke since she was totally mute, no one was giving her any warmth. So the first time we met was when she raised herself up off the floor and threw herself at me, literally, and I caught her in mid-air. Her legs were wrapped around my waist, her arms were wrapped around my neck, she was grunting and salivating, and she was kind of a mess. But I said, like a well-trained twenty-year-old on the staff, I said, “Mary, I think you’re trying to tell me something.”
RW: But you did it with kindness.
DC: I cared about her, and I came back at night on my own time when I was off duty to sit with her and draw little boxes and ask her questions and say, “If the answer to this is yes, just put a mark here. If it’s no, put a mark there.” I’m laughing and almost on the verge of tears, because it sort of reminds me of Ann Sullivan with Helen Keller. No one had taken the trouble to do this with her. And I wouldn’t have either, had it not been that she had thrown herself at me.
RW: Right.
DC: I guess that makes me a sucker for people who throw themselves at me.

The Importance of Empathy

RW: You’re talking about the role of empathy.
DC: Yes.
RW: As a key ingredient in what makes psychotherapy work.
DC: Empathy and warmth. Showing that you really care.
RW: Showing it. And feeling it.
DC: Yes.
RW: How long have you been a psychologist? Half a century? When would you say empathy emerged as something that psychologists talk about as a key ingredient?
DC: God, I don’t know. I mean, in a way, in the writings of Harry Stack Sullivan you see some of it because, as far as I know, he was the first person saying, “Look, there are two people in the room. And it’s not just this cold analytic idea about the patient, and you sit behind the patient with a pad and paper and write things down. There are two of you there. There’s an interaction going on between the two of you. Pay attention to it. Pay attention to what you’re feeling, pay attention to what the patient is feeling, and to what the interaction is between you. Be real.”
RW: Right, like Carl Rogers.
DC: Yes! Carl Rogers, absolutely.
RW: Who else has influenced your work?
DC: Well, in terms of the analytic school, that was it,Stack Sullivan, Frieda Fromm-Reichmann. Gosh, Carl Rogers played a big part. I was already very interested in what he was doing while I was an undergraduate student. I remember going to the library, I think he had one book published so far, and everybody was making fun of him…
RW: Do you want to say anything about your mixed feelings about Fritz Perls?
DC: Oh, I spent some time at Esalen in its heyday in the early '70s, when I was on a Carnegie grant mission studying the new human potential movement. I really paid attention to what the Esalen staff were doing. I was permitted into the royal presence of Fritz Perls, who was the reigning diva there at the time. And of all the people I studied on my Carnegie sabbatical from university teaching, he put more fear into me about what was being done with all these new things than anybody else. I named in my report Marion Saltman, who was a woman who did play therapy with adults on a houseboat in Sausalito, as the person guaranteed to do no harm, and often did a lot of good. I named Fritz Perls as the person who was most likely to do harm while sometimes doing a lot of good. He was very good at what he did and very smug.
He was like a surgeon who went into the operating room, did everything exactly right, laid the guts out on the table, and then smiled at the young residents and said, "Okay, you take over now," and pulled off his scrubs and left.
He was like a surgeon who went into the operating room, did everything exactly right, laid the guts out on the table, and then smiled at the young residents and said, "Okay, you take over now," and pulled off his scrubs and left. And I witnessed one, and know about another one, where following his dramatic interventions, the people went into psychotic episodes. Now, I'm sure he rationalized that as saying, "Well, that was what they needed to do." One of them was the wife of a colleague in the university where I taught. I don't think that's what she needed to do. And it brought a lot of grief into that family for both of them. So, I have mixed feelings about his diva behavior.
RW: Well, it sounds like it wasn’t compatible with the importance of empathy.
DC: Right.

Early Struggles for Gay Rights

RW: Going back to the work you're best known for, Loving Someone Gay, you talk a lot about the importance for gays of being visible and resisting discrimination in any interaction that you have energy to deal with. If you hear a slur, if there's legislation, if there's something in writing, etc. I believe this is important for a gay person to become able to do. This is something you did in your efforts toward depathologizing homosexuality within professional psychology. What were some of your activities toward that?
DC: Oh, boy. Well, the roots of this are back at Antioch when I was an undergraduate there, because it was, and apparently is going to be again, a very social activist school. I think within the first weeks that I was there as a naive eighteen-year-old freshman from New Jersey, we were picketing the barbershop in downtown Yellow Springs, Ohio, population 2,000, because the one barber in town would not cut black people's hair, saying he did not know how, because they have different hair. Well, that was just a small example. Actively advocating for disempowered people permeated the school, and during the time that I was there, people took it really, really seriously. So, going back to Mary, the woman at Chestnut Lodge, perhaps I wouldn't have been smart enough to do what I did.
RW: If you hadn’t had the Antioch experience.
DC: If I had not already been immersed in that very well.
RW: So you were primed for this struggle. Because Stonewall* was in the summer of ’69.
DC: June '69. But I was already rolling before that.

Coming Out as a Gay Psychologist

RW: Yes. So how did you address professional psychology about this?
DC: Oh, god. I think I started writing letters to the editor. I know I wrote a letter to the editor of Time magazine, when they did a big expose about gay people, and my father-in-law at the time was devoted to Time magazine. And I was beginning to get it, that if I said, "Hey, I'm the expert in this field because I am gay," that's where I was going, that's what was beginning to happen, other therapists backed off. They had no credentials. But Time magazine, lo and behold they printed my letter as the lead letter two issues later. My father-in-law called my wife and said, "Hey, Don's letter is the lead letter in Time magazine this week. I don't know what he's talking about, but isn't that great?" And I wrote letters to the APA (American Psychological Association) too. I was beginning to get in touch with other gay therapists, mostly not out yet, but it was happening. The groundswell was beginning to happen, when I moved back to California, in January, 1971.
RW: Being gay was still officially a mental illness.
DC: Oh, absolutely. Absolutely. And I could lose my license. I had a license in California, one in New York, and I could lose them in both places for “moral turpitude.”
RW: If you were homosexual…
DC: Guaranteed, if you’re homosexual, because the law describes homosexuality as criminal, the church describes it as sinful, and psychology describes it as a mental illness, you’re going to be tossed out because it’s moral turpitude.
RW: Well, when I was taking abnormal psychology in graduate school in 1971, it was still in the DSM-II as a mental illness, right between alcoholism and personality disorder. How did it get taken out of the DSM, and what was your role in that?
DC: I think the first public appearance about it, per se, was here in San Francisco at a Western States Psychology conference, and I was the new kid in town, but the word got around fast, I had come out, and I had left the university and come to San Francisco specifically because I had decided to start a full-time private practice devoted to gay people.
RW: Were you the first in San Francisco?
DC: Absolutely. Or anywhere.
I was the first one to say, "I'm gay. I'm devoting my practice to helping gay people, their families, and their friends in any way I can."
I was the first one to say, "I'm gay. I'm devoting my practice to helping gay people, their families, and their friends in any way I can."
RW: You were full of moral turpitude.
DC: I certainly was. So at the Western States meeting, there were four of us presenting on a panel on homosexuality, organized by John Neumeyer. I think all of us were gay, but I was the only one that was going to say it. I didn’t know I was going to say it actually, until I got up, and as I stood in front of the microphone, before I had said anything, I looked at the audience, and what I saw was a big room, packed with about 250 people who were very interested in what homosexual people might be like.
RW: Wow, big room.
DC: Well attended. Very well attended. I stood there, I looked, and I just opened my mouth and said what I was thinking and feeling, which is, "You know, as I look out at you people, I'm sorry to tell you, I think I see the same smug faces that I've gotten used to seeing at psychological meetings. People who either think they know all about homosexuality and have decided that it really is sick, or people who are in some way or another just beyond this. You don't even have to think about it. You can just come and be amused. Well, okay. Here's what I want you to do, for your amusement and mine. I would like every man in the audience to reach out with his right hand and put it in the crotch of the man seated nearest you."

At which point there was a standing ovation, and I think John Neumeyer nudged over close to me and said, "There are no laps out there now." But that did a lot for me. I realized if I could stand up there and call them out on their prejudice and their smugness, all I had to do was talk about what I was thinking and feeling, and people were going to listen. And they did. So from there on, I kept using my slightly false pretense in saying, "Hey, I'm the expert on this. I know about it. I'm gay." And what are you going to say to that? If a black person says, "Hey, I know about being black. I'm black," and you're white, what are you going to say?
RW: Was there any backlash against you?
DC: Yes. But I didn’t care and it truly didn’t matter. Everybody said, the friends that I interned with out here, said, “Oh my god, you’re committing professional suicide. Never mind losing your license, you’re never going to be able to have a full-time private practice. You’re going to be persona non grata.” Au contraire. I had started a little practice in Menlo Park and one here in the city, seeing which would work better. Both of them were filled immediately.
RW: Beautiful.
DC: No problem getting customers. Both of them were filled, and filled with gay people who wanted to talk to someone who would understand what they were talking about.
RW: And who would not think it was a diagnosable mental illness.
DC: Absolutely.
RW: How did it stop being that?
DC: Well, you see, as soon as a few psychologists started to be visible and probably gay, and then visible and gay, and then some more thought it might be safe to put a toe out of the closet… as soon as we started to be visible, gay psychologists’ organizations formed. All the liberation movements were happening at one time. And the time was right. People could smell it. It was going to be okay.
RW: The paradigm was changing.
DC: Yes. During that time, I joined a committee that was working with the San Francisco mental health association, or the county mental health association I think, working on this problem, trying to figure out if homosexuality might possibly be considered not a mental illness. It was amazing. From this committee, Sally Gearhart, Rick Stokes and I became the feared trio on the speaking circuit, because Sally knew the bible inside out and she would come wearing a dress or a suit and stockings and high heels. Rick was a lawyer, knew the law inside out, and he had been hospitalized for this mental illness by his parents as a youngster, and I think given shock treatment, as I recall. I was the psychologist, I was out. So all three of us were out: law, religion, psychology.
RW: It must have been around that time that the APA made the change.
DC: You know, it was actually the American Psychiatric Association.
RW: They were first.
DC: Well, because they move faster. They were just working on it at the same time. And there was actually only a thirteen-month difference between the two associations. But it looks like there’s a longer time-span because the American Psychiatric Association did it in December of 1973, and then not a month later but the following January of 1975, the American Psychological Association did it. The American Psychological Association’s change was much, much more comprehensive. The ones that lagged far behind, of course, no surprise to anybody, were the psychoanalytic people who didn’t come out for another five years, I think. But wanted to make sure they wouldn’t get shot. So then the book.
RW: Then the book. This all led up to Loving Someone Gay.
DC: I wrote it in ’75. At first, nobody would touch it with a ten-foot pole.
I got a scolding letter from the Editor in Chief of Basic Books, saying, “Doesn’t this man, he calls himself a psychologist, and doesn’t he understand these people are sick and they need help? And this is not going to help them, it’s going to help them deny their sickness.”
I got a scolding letter from the Editor in Chief of Basic Books, saying, “Doesn’t this man, he calls himself a psychologist, and doesn’t he understand these people are sick and they need help? And this is not going to help them, it’s going to help them deny their sickness.” Finally, after a year of many refusals, when Celestial Arts agreed to publish it, they sold out the initial five thousand copies before the publication date, which was January of ’77. We were really happy. But soon it collided with Anita Bryant**, so I was suddenly wanted on television and radio all over the country. Being basically an introvert, I hated the idea. But I knew… where would this kind of publicity ever come from again? So I did that. I spent about a year doing that.
RW: How many copies did the book sell?
DC: Beyond count, I mean, truly there were many printings, many different editions, in many languages. It was in two different kinds of paperbacks, mass-market editions, which was where the count got lost because nobody could figure out how many copies Bantam or New American Libraries sold. But that was why I was getting fan mail from people all over the country. Also hate mail. The ones that moved me the most were exactly, exactly the ones I wanted-the kids who had been able to sneak into a little drugstore in Podunk nowhere and get a paperback copy of this. And they suddenly knew there was another gay person somewhere out there in the world, saying, “It’s okay, it’s okay.” Now I get emails from all over the world.

Doing Psychotherapy with Gay Clients

RW: So, Don, turning now to the issue of therapy with gays, what are some of your thoughts about how psychotherapy with gay people, men and women, is different from and similar to therapy with straights?
DC: Well, we have to get into the psychodynamics of what does it mean to be gay. And, not in the interest of selling more copies of Loving Someone Gay, I really would encourage those who are interested to pick up the 5th Edition, the new one, and read it, because I can only give a few words here. The main special dynamic for a therapist to understand is that a gay person goes through a different maturational process than a straight person does. We actually go through two at the same time. We get matured through the steps as if we were straight people, and also as gay people.

The different dynamics in development of the gay childhood, young person, adolescent, and so on, is that even today, let there be no mistake, most gay people are growing up invisible. They are having to learn how to become adult as straight people do. They're also having to learn at the same time what to do with being invisible, with having nobody know who they really are, with being terrified of what would happen if they were known. Black people grow up in black families, usually. Jewish people grow up in Jewish families. Gay people do not grow up in gay families. The vast majority of the time, they do not have any support around who they are.
There is nothing comparable in the human experience. It is as if the gay child is the result of having an egg from outer space planted in the uterus of the mother
There is nothing comparable in the human experience. It is as if the gay child is the result of having an egg from outer space planted in the uterus of the mother, and then appears looking just like the people who live on this planet, and grows up, develops, but all that time something different is happening inside this person; and he or she understands early not to let it show, or not to let it show enough that he or she will get into trouble because of it. And trouble, is indeed, what awaits most of them. So, you live two lives. You hide the life of your true self.
RW: As an alien.
DC: An alien, who has these strange and different feelings about other people of the same gender, which you dare not reveal; and you learn to live as if you were having all the same feelings that your parents, and the preachers, and the teachers, and the police, etc., are having.
RW: So you’re saying that when a person discovers that they are defined by the majority as being in some way deficient or sinful or ill or illegal, that that creates a secret part of themselves, that they can’t gain approval of, and so they have to hide that. And that split between what they hold inside and what they express is part of the development that therapists must understand.
DC: And that the therapist needs to go back with them and visit through every level, every age level, every stage of that development. How has it affected them as they grew up? If they knew when they were five years old, what was like that? If they still knew when they were fifteen and were maybe even experimenting with having sex and nobody knew, what was that doing to them? How did they feel? What did that tell them about themselves? Because it affects people differently.
RW: You don’t want therapists to stereotype gays.
DC: And you always have to be on their side. It doesn’t matter how it looks to you. It matters how it looks to them. The biggest mistake is for therapists to think or say: “I’ve been studying this for years, I know what you’re thinking. I know what you’re feeling.” No, you don’t.
RW: What do you see as some of the implications of this for therapists?
DC: Well, there are a few things I put into Loving Someone Gay, aimed at everybody who wants to help gay people:
  • Number one: The gay person probably has learned to feel different. Keep that in mind.
  • Two: A gay person may have learned to distrust her or his feelings. Very important for a therapist.
  • Three: A gay person may have a higher degree of self-consciousness.
  • Four: A gay person may have decreased awareness of feelings, such as anger generated in response to a punitive environment.
  • Five: A gay person, often invisible, as such to others, is assaulted frequently with attacks on character and ability.
  • Six: A gay person is more likely to fall victim to depression.
  • Seven: A gay person may be tempted to dull the pain that surfaces, by making use and misuse of alcohol and other drugs.
  • Eight: A gay person who is respected and loved, but who is hiding his or her true gay identity and facing what she or he believes would be a ruined life, if the truth were to be discovered, is at a high risk for a fatal accident, or a seemingly inexplicable suicide.
  • And, nine: A gay person usually has lived in two worlds simultaneously.
This is why
I believe it usually is much better for gays to see a gay therapist than a straight therapist, and the therapist must never, ever hold back on revealing that they're gay.
I believe it usually is much better for gays to see a gay therapist than a straight therapist, and the therapist must never, ever hold back on revealing that they're gay. Otherwise they're acting like they're ashamed of it. They have to be able to be supportive, and the first thing that I tell young trainees is you always say something positive and affirmative when the person says anything about sexual desires, sexual fantasies, sexual whatever. If it's homosexual, you're there. You're on it, you're with it, you smile, you sit forward in your chair-
RW: Say more about why you believe gays and lesbians are better off seeing a gay or lesbian therapist.
DC: If a gay person walks into your office with a seemingly small or large problem, you may make the mistake or thinking that you can deal with it just as you would for any other person. Well, that's not true. Maybe if they just want advice on whether they should contact a lawyer because they're getting a divorce, yeah, you can deal with that just as you would with a straight person. However, if you're talking about psychodynamic issues, from day one, everything is different. They are very eagerly watching you to see if you might have any idea of what their life is like. And chances are, unless you have been through it yourself, unless you, too, were born gay and had some decent therapy yourself, so that you could explore your own internalized homophobia, which comes with the course for gay people and for not gay people.

We all have internalized homophobia because we live in a homophobic culture, which is not that unusual. Most cultures on this planet are homophobic, which is a term that was created by George Weinberg, who was a statistically oriented psychologist in New York City. He hit on exactly the right word. If you're phobic about snakes or spiders–two familiar phobias that people have–it doesn't necessarily ruin your life, but you certainly don't want to go near them, and anything that hints of them is going to make you a little uncomfortable, to the extent that for many people, with snakes for instance, seeing a picture of a snake in a book makes them consciously and/or unconsciously uncomfortable. It's just, "I'm not sure I want to go there."

Okay, so now you have a homosexually inclined client in your office, and you, as far as you know, have never had any of those feelings yourself. Or maybe you did and well, you took care of it. You're all grown up now. You've had your therapy. What are you going to do? You know, how are you going to let this person know that you really understand what he or she is feeling? My opinion, I don't think you can, unless you've been down that road yourself. And even then, unless you've had some expert help from other people like you, who have been down that road before you, who can help you to see that it really is okay to be you.
Whatever the presenting problem is, you don't go anywhere with your client unless you have that magic thing called rapport.
Whatever the presenting problem is, you don't go anywhere with your client unless you have that magic thing called rapport. And you're not going to have that rapport unless you can illustrate that you have genuine, genuine empathy. And you can't have genuine empathy if you don't know anything about the world this person came from.
RW: Well, you know there is such a big range, from low to high, of empathy or experience with gay people, within a distribution of therapists, as well as a range of how much a therapist has examined his/her own homophobia, so, it is confusing to me for you to say that you feel like gay people should only see gay therapists. Is that what you mean?
DC: Well, if I had my druthers, that would be true. I don’t think it’s possible, of course, because there are not enough gay therapists to see all the gay people who need to be helped. There is another solution. I don’t think we’re anywhere near doing it yet, but if therapists who are not themselves gay, and have not confronted their own internalized homophobia, were willing to become really, really, really familiar with the experience; to immerse themselves in it. A one-day, continuing ed course, or lots of reading about it doesn’t quite do it. It doesn’t give you the feel of what it’s like to be such a person.
RW: That is true. The subjective experiences are much more enriching to one’s understanding.
DC: So, if you’re a therapist who is not gay oriented, not gay yourself, and you want to really familiarize yourself with what it’s like to be in this world, to be one of these people, go where they go. Do what they do. Have lots of them as friends. Have lots of them in your home. Have your children be familiar with them. You know, if you’re not that comfortable, you’re not there.
RW: Well, I agree with that. But doesn’t it seem like there are other things that are very alienating besides just the fact of being gay, and having that be a secret. There are so many things about the self that are denied, cause a lot of shame, and cannot be accepted in different social circles, families, communities, cultures. And that the effective therapist knows that it’s this individual person’s experience of their situation that is important to learn, and to be open to it. And to ask the questions empathically. Isn’t that your point? Do you think it’s possible for a straight therapist to be sensitive to a gay client?
DC: I think it’s possible if you are willing to learn. That when that person sits down in your office, someone is sitting there that you have to assume you don’t understand.
RW: Like what you were saying earlier about Carl Rogers, that got him laughed at.
DC: Yeah.
RW: What advice would you have for straight therapists that you already haven’t mentioned, in working with gay clients?
DC:
Get out into the community. Get to know gay people. Get to appreciate what is better about the life they are living than the one you are living.
Get out into the community. Get to know gay people. Get to appreciate what is better about the life they are living than the one you are living. Be honest. Find out something you’re envious about. If you can’t find envy in another world, you’re not open to that world. So, maybe that’s enough about that. Get out, read about it. You know, meet people, go. Eleanor Roosevelt used to immerse herself in black culture. She didn’t sit home and read a book about it, she got out there and did it.
RW: Don, you quote Horace Mann as having a philosophy that influenced you. What was the quote?
DC: The quote, which is on the one monument that exists on Antioch’s Yellow Springs campus, is Horace Mann famously saying, “Be ashamed to die until you have won some victory for humanity.”
RW: Would you say you have fulfilled that challenge, and what is that victory?
DC: Well, I’ve tried. And I think I have. Probably through the book, since it has reached so many people and obviously done a lot of good, or they wouldn’t be writing me and telling me that. It’s certainly more of a contribution than I ever thought I was capable of making. And I’m still stunned that it happened, that I was blessed with being able to do this.
RW: Yes. Well, thank you so much for spending this time with me.
DC: Any time.

H2O Under the Bridge: A Case of Trichotillomania

Posted on by rezendevknowfully.com

The Concerned Hairdresser

"Dr. A., I'm so glad I caught you," a soft, earnest voice said. "This is Sebastian from Sebastian's Guild Salon in San Francisco."

"Do I know you?" I asked.

"No, we've never met before," Sebastian said, "but I understand you specialize in trichotillomania."

Sebastian's precise and deliberate pronunciation of the difficult word indicated perhaps a more than casual level of familiarity with the disease. "Have you been diagnosed with trichotillomania?" I asked.

"God, no!" he exclaimed, "unless you consider baldness a natural form of trichotillomania…"

"No, baldness is quite different," I said, appreciating the caller's attempt at levity.

Then, injecting a good dose of drama into every superlative, Sebastian added, "Well, if I still had my hair, the very last thing I would do is compulsively pull it out! I simply love and respect hair too much…This is not about me, Doctor, but about my dearest friend—who is also a top client of mine. She has the worst case of trichotillomania you have ever seen. I've worked with her for almost ten years now, but as creative as I am with hair—and I'm pretty good at what I do!—I've finally run out of tricks to cover up her bald spots. They're bigger than ever now, and I have less of her hair to work with, so I am officially giving up and asking for your intervention."

"Why doesn't she come in for a consultation?" I asked.

"She won't come in alone," Sebastian answered. "She needs me for moral support, she says, even though she might change her mind if she spoke to you. You seem very nice and, umm, quite friendly for a shrink. Forgive my prejudice, Doctor, but I've had some awful experiences with your profession in my day. This is not about me, so I won't go into how I was restrained against my will and given medications intramuscularly—intramuscularly!—or how I was court-ordered to get shock therapy—shock therapy! But, thankfully, all that is behind me now. H2O under the bridge…So, going back to my friend Pat, I really do think you would find me quite helpful if I came in with her. I don't know if you know this, but hairdressers are their clients' confidants, and I can give you quite a bit of important information about Pat that she may have forgotten—or that she may not even know about herself!"

Although quite worried about what I was agreeing to, and about the considerable additional baggage Sebastian was sure to add to the mix, I could not create obstacles to Pat's first visit when she seemed to be in such great need of help. "If Pat is OK with your accompanying her, I am OK with it, too," I said. "Let's all meet and go from there."

"Sounds good," Sebastian said. Then, taking on an even more theatrical air, he added, "I do have one last question, Doctor. It's for my own personal peace of mind, really. Do you think I've been enabling Pat's behavior all these years by doing such a good job covering up her bald spots? I'm so very guilt-ridden by that thought! It just breaks my heart to think I may have been part of the problem instead of being part of the solution. To think that, for years, I jokingly called her Loulou, even giving her a parrot for Christmas one year, instead of pushing her into treatment, causes me intractable insomnia. Please, Doctor, tell me that I have not contributed to my best friend's devastating problem…"

Sebastian was referring to Loulou, the world's best example of trichotillomania across species, a parrot from a French novella by Flaubert with "his front blue, and his throat golden," who displayed a "tiresome mania" of compulsively plucking his own feathers. As delivered by Sebastian, however, this obscure literary reference came across as more show-offish than cultured. His penchant for high drama, combined with his feeling of victimization by psychiatry, made for an intriguing but potentially combustible personality mix that left me both very curious and very nervous. Despite reminding myself that I would not be his doctor, I was already concerned about what role Sebastian would play in his best friend's treatment.

"I believe you wanted to help Pat the best way you knew," I said, trying to reassure him. "It's not unusual for patients with trichotillomania to go for many years before seeking professional help, and most of them don't have talented hairdressers helping them out! I doubt that Pat would have come to see me much sooner if you had not been involved all these years, though I cannot say that with complete certainty. I'm glad, however, that you have now decided to help her get psychiatric care. It's absolutely the right thing to do."

Trichotillomania: An Impulse Control Disorder

Although the usual course of trichotillomania has been well described, much is still unknown about its causes and treatments. It is estimated to affect around 1 percent of the population, with women being more at risk, although women may also be more likely to be included in the statistics because of a greater willingness to seek treatment, whether from a psychiatrist or a dermatologist.

Diagnostic Criteria for Trichotillomania:

A. Recurrent pulling out of one's hair, resulting in hair loss.

B. Increased tension immediately before pulling or when trying to resist the urge to pull.

C. Pleasure or relief while pulling and immediately following.

D. The pulling is not better explained by a skin condition or other medical or psychiatric illness.

E. The pulling causes significant distress or disability.

The overwhelming anxiety people feel before the behavior and the relief that comes with the behavior are shared by other impulse control disorders as well, including kleptomania, pathological gambling disorder, and compulsive sexuality (although the last is not formally included in the DSM-IV). In all these conditions, the pathological behavior varies, but a thrilling sensation is present, which distinguishes them from OCD, where the patient rarely derives any pleasure from the compulsion. So, whether it is the hair pulling in trichotillomania, the shoplifting in kleptomania, the betting in pathological gambling, or the repetitive cruising for sex in compulsive sexuality, these behaviors are experienced as pleasurable, although the patient is also guilt-ridden and tortured by them and is usually well aware of their negative consequences and the long-term damage they cause.

The pleasurable aspect of impulse control disorders can make them more difficult to treat than OCD, because patients are being asked to relinquish an action that, although problematic, is also enjoyable on some level. Another consequence is that patients miss these behaviors and the thrill that accompanies them when they cut back, and they may feel restless and irritable as a result. This withdrawal-like state has been likened to the physiological withdrawal from addictive substances like alcohol and is, in part, why impulse control disorders have also been referred to as behavioral addictions. In fact, Laurie, a forty-year-old nurse I treat for trichotillomania, describes the struggle to resist her pulling urges as "getting the shakes" and compares this state to what her husband, a recovering alcoholic, felt when he abruptly stopped drinking.

Another feature that distinguishes impulse control disorders from OCD is that the behaviors seen in impulse control disorders are often acted out without awareness, almost unconsciously. Laurie, for instance, would often tell me, "I didn't catch myself pulling until it was too late," or, "By the time I realized I was doing it, I had a bald spot already." Similarly, patients with impulse control disorders like kleptomania, pathological gambling disorder, or compulsive sexuality can feel so disconnected from reality and so out of touch with the risks they are running that they can momentarily justify the stealing, betting, or promiscuous behavior, minimizing what is at stake. In contrast, patients with OCD are usually very conscious of their behaviors and often keep detailed mental or written lists of the compulsions performed and the time spent performing them.

Yet similarities with OCD do exist, leading some experts to refer to impulse control disorders as obsessive-compulsive spectrum conditions. The spectrum concept has been championed by Dr. Eric Hollander, a psychiatrist and researcher at Mt. Sinai Medical Center in New York, who has detailed important parallels among these disorders. For instance, in both OCD and impulse control disorders, people experience bothersome, intrusive thoughts. In someone with OCD, the intrusive thought may be an irrational contamination fear after shaking hands with a stranger. In someone with trichotillomania, the intrusive thought may focus on how one particular hair feels different in the way it touches the forehead. Further, the intrusive thought in both OCD and impulse control disorders is usually associated with an irresistible behavior the person feels compelled to perform, such as hand-washing in OCD or hair-pulling in trichotillomania. This behavior, whether it involves ten minutes of hand-washing in OCD or pulling out a particular hair that feels different in trichotillomania, is often repetitive, stereotyped, and acted out in rigid patterns.

The First Session

Pat followed just behind. As I reflexively do when I am expecting a patient with trichotillomania, I focused on her hair first. My initial impression was that it looked artificially perfect. The immobile, meticulously arranged fringe in front and the impossibly symmetric outward flips on the sides clearly indicated that Pat was wearing a wig. As she shook my hand, I could feel the sweat and tremor in hers.

"I'm glad Sebastian called to make this appointment," she said. "I know it's overdue."

"I'm glad he did, too," I said. "I understand from my brief phone conversation with Sebastian that you have been suffering from trichotillomania for a long time."

"She has," Sebastian interjected. "Where do you want me to start?"

"Maybe we can have Pat start," I suggested.

"He knows me so well," Pat said, "and it's embarrassing for me to talk about this."

"Trichotillomania is probably more common than you think," I said, "and you're in the right place now to do something about it. We can take a break later if this becomes too much for you, but can you tell me how this problem began and how bad it has been lately?"

A long, heavy silence followed, interrupted by Sebastian's muddled outbursts as he tried to control his urge to speak on behalf of his friend. He distracted himself by rotating his rings and moving his swivel chair in semicircles.

"It would be easier for me to just take my wig off," Pat finally said, turning toward Sebastian as if to invite his help. "What you will see is worth a thousand words."

Before I could object to what seemed like an extreme gesture happening too early in our meeting, Sebastian sprang up and positioned himself behind Pat's chair, the speed and energy of the jump causing his chair to complete a full turn on its axis. Then, deftly working his palms underneath Pat's artificial locks, he squeezed both index fingers between scalp and wig, slightly loosening the wig before dramatically and quickly lifting it. Pat closed her eyes, as if she was too ashamed to face me. My eyes, too, briefly closed. I felt like I was somehow violating Pat without meaning to. Before I could establish any rapport with her, before I could offer any meaningful reassurance, an embarrassing problem that she had steadfastly kept from medical professionals for years was now abruptly revealed before the clinical gaze of a complete stranger. Something about the way it had happened felt violent, and for a sad moment, I wished I could roll back the less than five minutes of our meeting and have another chance at my first interview with Pat. But of course there can only be one first interview, and despite my regrets about the course of events, I had to make an assessment of the problem that was now being presented for my evaluation.

The natural light brown hair that Pat's wig had concealed appeared brittle and uneven. It was pulled up and collected in an anemic bun on the vertex of her head. Three one-inch bald spots on the sides were visible through the thin strands that snaked their way back from her forehead. These spots appeared red, indicating inflammation from repetitive damage to the scalp. In part to cover up the bald spots, in part to cover up the redness from inflammation, brown makeup the color of her hair had been applied to the bald areas, complicating the patchwork of color and texture. "See? That is all the hair I have left to work with," Sebastian said, as he regretfully shook his head, sounding unusually subdued and hardly desensitized to the sight. He then released Pat's bun very gently by pulling out the single needle-thin clip holding it, taking the utmost care not to lose one more precious hair in the process. Pat's natural strands fell down, showing a variety of lengths resulting from recurrent bouts of plucking.

"I have these creams I use," Pat said, opening her eyes to locate in her purse two tubes of steroid-based lotion. "My dermatologist prescribed them for me."

"Do they help?" I asked.

"Not really," Sebastian quickly answered. "And neither do all the hypoallergenic products I've prescribed," he added, stressing the "I." "We have a basket in my salon that my helpers jokingly call 'Pat's basket.' It contains a complete line of fragrance-free, dye-free, and paraben-free pomades, shampoos, and conditioners. Very expensive designer products that only our Pat gets to use."

"And what are parabens?" I asked.

"You haven't heard of parabens?" Sebastian retorted, shocked at my ignorance of a seemingly very important toxin. "It's a poison in the estrogen family," he explained. "It's been shown to cause breast cancer. It's usually found in underarm deodorants, but many commercial hair products also have it."

"I'm not familiar with the research on parabens," I said, "but I'm not surprised that all these measures have not helped Pat. They rarely do in trichotillomania, unfortunately."

"So should I stop using these creams, then?" Pat asked, pointing to the tubes in her hands. "I'm not fond of using steroids on my scalp, anyway. I heard they can cause hair loss. Just what I need!"

"Low-strength steroid creams that you apply to the skin should not cause hair loss," I said, trying to reassure her. "Dermatological interventions like these can help with the inflammation and infection that pulling can cause, but they do not deal with the fundamental cause of the problem. They address the consequences of the pulling but not the pulling itself. That is why a psychiatric approach has a much better chance of success."

"'A psychiatric approach?' I don't like the sound of that!" Pat said, looking at Sebastian as though to enlist his sympathy by reminding him of the scars the "psychiatric approach" seemed to have left him with.

"I do," was Sebastian's quick answer, delivered forcefully as he stroked the wig he had placed on his lap. "We've been in denial about this for much too long, Pat."

"How long, Pat?" I asked. "How long have you had this problem?"

Pat paused a bit as though still pondering the benefits of a psychiatric approach, then answered, "I guess it started when I was fourteen or so. Back then, I would just twirl my hair. Innocent enough, right? But then I somehow discovered the joy of pulling, and I haven't been able to stop since."

"The joy of pulling?" I repeated after her, intrigued by her choice of words.

"Yes, pulling, for me, actually feels good," Pat answered. "It calms my nerves."

"She's even used the word orgasmic once—jokingly, of course—to describe the sensation," Sebastian ventured, lowering his voice and looking away from his friend as he pronounced "orgasmic."

"Sebastian!" Pat yelled, reprimanding him for crossing a boundary she clearly did not want crossed.

"Sorry, sweetheart," Sebastian said, sounding genuinely apologetic as he reached over to squeeze Pat's hand. "We have to be completely honest with the doctor if he is to help us."

"It's an anxiety-relieving behavior, Pat," I explained, "so it doesn't surprise me that you experience it as pleasurable—most people with trichotillomania do. That is one reason trichotillomania can sometimes be challenging to treat. I will be asking you to stop a behavior that, at some level, you find soothing." Then, after a brief pause, I added, "But saying you find the behavior soothing is simplistic, of course. Even though the behavior itself feels good, you obviously don't like the consequences, and you don't like the fact that you have the disease. You wouldn't be here if you did."

"I can absolutely, unequivocally, and without reservations, tell you that I hate the fact that I have bald spots!" echoed Pat, nodding in agreement as she squeezed Sebastian's hand more tightly.

The Pleasures and Perils of Pulling

Although many people with trichotillomania pull hair from their scalps, pulling also commonly targets the eyebrows and eyelashes, as well as facial and pubic hair. In fact, the natural tendency for the disorder is to migrate over time, so that a person who started pulling hair from one site may, for reasons that are unclear but do not include running out of hair in the first site, switch to pulling from another location.

The resulting bald spots cause great embarrassment and guilt for the victim, who will often go to great lengths to hide them. Commonly used cover-up strategies include creative hair styling, wigs, excessive makeup, hats, bandanas, and false eyelashes and eyebrows. The disfigurement can lead to avoidance of social situations, dating, sexual relationships, activities like swimming and other sports, and even exposure to windy places.

Despite the Threat of Surgery

"What happened to your neck?" I asked.

"It's acting up again," she said. "My right arm is so numb and tingly I can't get anything done. It happens every so often, usually when my pulling is out of control."

"What's the association between pulling your hair and numbness and tingling in your arm?" I inquired.

"Well, there's this area at the upper left side of the back of my neck, right about here, that I enjoy pulling from for some reason," Pat explained, slipping her right index finger under the brace to demonstrate the location and grimacing with pain as she did. "The problem is that this part of my neck is not easy to reach with my right hand, which is the hand I use for pulling. Well, imagine spending two to three hours a day, your right arm wrapped behind your neck, and your neck bent forward, as you focus on finding more hairs to pull. Now imagine doing this for years… Talk about repetitive motion injury! I have a bulging disc in my spine as a result, and it's causing pain to radiate down my right arm. The brace is to immobilize my neck so I can avoid surgery."

"And does the brace help with the pain?" I asked.

"Yes, it does, as long as I wear it," Pat answered.

"Does it help in other ways, too?" I asked. "Does it reduce pulling as well by preventing access to your favorite pulling spot?"

"Well, yes," Pat answered, "but that's one reason I take it off when I should be wearing it. When the urge to pull is too strong to ignore, I simply take the brace off."

"Despite the pain?" I asked.

"Despite the pain."

"Despite the threat of neck surgery?"

"Despite the threat of neck surgery. Isn't that crazy?"

Dating Stress

"Well, they certainly get worse around stress," Pat replied, "especially dating stress. I'm an attractive—except for my hair—and successful mortgage broker, forty-two, still single, and with no prospects for intimacy as long as I have this problem. The thought of finding myself in an intimate situation that might expose my problem is enough to send me into a panicked frenzy."

"So the bald spots prevent you from dating because they're too embarrassing, and when you do find the courage to date, the stress around that leads you to pull even more," I recapped.

"Exactly," Pat concurred. "It's a vicious circle, and I'm caught in the center of it! I haven't gone out on more than two dates with the same guy for a very long time. The likelihood of some form of intimacy taking place on the third date if things go well is too scary to contemplate…What if he crosses the four-foot normal social distance and gets into my personal space? What if he approaches me in bright light for a kiss and spots the thick brown foundation covering parts of my scalp? What if he runs his fingers through my hair? What if? What if? What if?"

"That is really tragic, Pat," I said. "The idea that even with men you do like, you have to resist seeing them a third time and feel forced to end things prematurely…"

"Absolutely," Pat said. "I always sabotage things to turn the guy off and avoid seeing him again. Like this last guy Sebastian introduced me to, who turned out exactly as Sebastian had described: a handsome, gentle, successful Realtor—a nice Jewish boy, really. And did I say handsome? Well, it came up on our second date that his sister had OCD and, as kids, she would spend three hours in the shower every day while he waited patiently for his turn, and as a result, he now won't allow any of his clients to buy a house with less than two bathrooms…Well, instead of empathizing with his childhood experience or using it as an invitation to open up about my own personal struggles with rituals, I went on to make fun of his sister's OCD in the most insensitive way imaginable! And I wouldn't shut up! Imagine, half-bald me making fun of his poor sister's showering rituals! Talk about the pot calling the kettle black! Well, needless to say, the third date didn't happen.. . And when Sebastian started asking what went wrong, the best I could come up with was, 'Well why don't you date him if he's so perfect?' I don't have to tell you that I haven't forgiven myself for this fiasco yet…"

"So you were intentionally pretending to be a mean person to turn off a guy you really liked so he would not want to ask you out on a third date," I summarized.

Pat nodded, her eyes welling up. This painful real-life example of the consequences of her illness brought Pat's tragedy home to me. Her tears drew me in. More than at any point in my meetings with her, I was able to get past wig and brace to appreciate the real hurt that lay much deeper than the outside manifestations of her illness, disturbing as those were.

I struggled to show Pat I was caring without losing control over my own reservoir of feelings. My theory has always been that you have to project resilience and empathy, almost simultaneously. Any "breakdown" on my part could be interpreted by Pat as a sign of weakness or inexperience and might lead her to doubt that I possessed the emotional backbone and resolve needed to address her problem.

On the other hand, by closely identifying with Pat and openly and transparently sharing my feelings with her, perhaps to the point of tearing up in her presence, I might be- come more "human" in her eyes, thus enhancing our doctor-patient bond. But is this not what Sebastian and other people close to her attempted to do, without lasting success, and are patients not looking for something different from their doctors? And what about my own mental health? Should I not be protective of that, too? Is there not a limit to how much I can identify with patients' problems before I, too, succumb to depression, negatively affecting my own life and severely impairing my ability to help others? Should I not be more like an oncologist, a cancer specialist who empathically delivers bad news all day but who does not bring these tragedies home and is able to sleep peacefully at night?

My internal debate was interrupted when Pat's growing discomfort with the subject of dating and this sad memory started manifesting itself in pulling urges that she seemed close to acting on right there in my office. I could see her reach under her brace with her right hand to that favorite spot in the left upper back part of her neck. I shook my head in an effort to dissuade her from pulling, a gesture I hoped she would interpret as "Don't do it." I wanted her, instead, to process with me the negative emotions our conversation was bringing up and to discuss other ways to dissipate them.

But before I could say anything, I heard Pat's voice come out, almost pleading.

"Please…just one more," she whispered. Then, withdrawing her hand from underneath the cumbersome brace, Pat reached for a much more conveniently located hair sticking out from the side of her wig. With a deliberate, firm motion, as she held the wig in place with her other hand, Pat pulled one more hair—from her wig. I may be imaging this, but I think I saw Pat's tense facial features immediately relax.

Treatment

It is very common for people with trichotillomania to comment that, by the time they "catch" themselves pulling, it is too late and too much damage has already occurred. Increasing self-awareness aims to bring pulling into consciousness. I usually start by identifying with my patient the situations that are likely to trigger pulling. For example, after tracking my patient Laurie's trichotillomania problem over two weeks using a daily pulling log that I asked her to keep, it became apparent that Laurie's worst pulling occurred while driving. With this information, I could tailor an intervention that targeted this high-risk situation. I asked Laurie to keep a pair of gloves in her car to wear whenever she drove. This seemed to reduce her pulling by taking the tactile pleasure out of it.

Competing responses are more socially acceptable, harmless behaviors the person can substitute for pulling. These are usually objects that provide some tactile stimulation, such as a stress ball the person can squeeze when feeling an urge to pull, a rubber band to pull on, or a makeup brush to stroke.

Motivation enhancement helps people with trichotillomania understand and remember why they want to stop pulling. With the therapist's help, the patient develops a list of reasons for stopping. For Laurie, the list initially included feeling more comfortable in social situations, feeling like she did not have to explain herself to anyone, setting a good example for her children, and finding healthier ways to release anxiety. Laurie posted the list on her bathroom mirror to serve as a daily reminder. I kept a copy, too, updating it as needed based on Laurie's progress in therapy.

Changing the internal monologue involves confronting assumptions about pulling that provide justification for continuing the behavior. For example, instead of "I've done so much damage, what difference does it make if I pull one more hair?" the patient is taught to shift her thinking to "Hair pulling is like self-mutilation, and I deserve better than this." Instead of "I'll only pull one hair and stop," the puller is taught to say, "I've never been able to stop at one hair, so I'm not going to test myself."

As with OCD, anxiety can trigger trichotillomania. Relaxation training can diffuse stress, thereby reducing pulling. Helpful self-relaxation techniques include deep, rhythmic breathing, visualization of a pleasant, soothing scene, and progressive muscle relaxation where the person is taught to tighten and then relax each muscle group in sequence from the toes to the scalp. Patients practice these tools in the therapy session and then apply what they've learned in the outside world to reduce pulling when they feel anxious.

Research studies on medications for treating trichotillomania are limited but do suggest that the SSRIs and clomipramine—all serotonin-based drugs well established for OCD—can be helpful. However, for most people, medications should be combined with therapy, as this is likely to give better results than medications alone.

"Treating trichotillomania can be long and difficult," I warned Pat, "but trichotillomania is treatable, and you shouldn't let the effort and time it might take us to control the symptoms discourage you."

"I've never been in treatment before," Pat said, "and I'm as motivated as I can be to get better."

"You told me you were most likely to pull while sitting at your computer at work," I said. "Here, I want you to take this stress ball. Keep it on your desk at all times and try clenching it in your fist when you feel the urge to pull."

I handed Pat a squeeze ball that a drug company rep had given me. I believe he meant it for my personal use—a way for me to handle stress on the job, so I would subliminally associate the relief I got from squeezing the ball with the product he was marketing. It had Paxil emblazoned all over it in phosphorescent blue. The bright colors caught Pat's eye, and she seemed momentarily amused. She gave the Paxil ball a good squeeze and seemed to approve of its consistency. "I feel better already," she joked. Shortly after that, though, her amused look morphed into circumspection. "But the problem is, most of the time I'm not even conscious of pulling," she worried. "How can I reach for my squeeze ball if I'm not aware that I'm pulling in the first place?"

"Excellent point," I replied. "That is why there is a parallel component to this therapy to make you conscious of the behavior itself. It involves having you collect the hairs you pull every day and put them in individual envelopes with the date and number of hairs written on the outside of each envelope. You then bring the sealed envelopes with you to our weekly meetings, and we use them as an objective way to track your progress." Hearing this, Pat's circumspection changed into utter disbelief. And not without some irritation. "Did I hear that right?" she protested, sounding both incredulous and annoyed. "You're asking me to bring a week's worth of hair stuffed in envelopes to your office every week? Is this a joke? Did I forget to mention that sometimes I lick the hairs I pull? Do you still want me to collect them? I'm sorry, but this is a bit on the disgusting side, and I find it hard to believe that people actually do it! I'm afraid your treatment, Doctor, is too embarrassing for this patient."

"I agree that there is an embarrassing aspect to this, Pat," I said. "But some people do it—and with good results, I might add. One way to look at this is to say that we would be using the embarrassment factor to our therapeutic advantage, almost as a motivator. Here's how it works: the fact that you are saving and counting the hairs will make you more aware of the behavior, and the embarrassment of having to produce these hairs in my office every week will discourage you from pulling."

"I still can't believe this," Pat continued, already sounding a bit more resigned and a bit more accepting of the unconventional treatment recommendation. "Can't I just take a pill? Paxil, for instance? I already have their ball! It really would be a lot cleaner…"

"It would, for sure," I agreed. "But in my experience, behavioral therapy is at least as likely to help with trichotillomania as medications are. Plus, it is free of side effects!"

"Unless you consider embarrassment a side effect, that is," Pat quipped.

"I consider embarrassment in this case to be part of the intervention's mechanism of action." I said. "I look forward to seeing you in a week. Just make sure you seal those envelopes!"

Paperwork

"Pat, our trichotillomania patient, just stopped by," Dawn said. "She says she's sick with a cold—although she sounded perfectly fine to me! Anyway, she said she needed to rest and wouldn't be able to make it for her weekly appointment today. She did drop off some paperwork for you to review, though. She said it was important that I get it to your desk soon."

"Do you know what it's about?" I asked.

"I haven't a clue," Dawn answered, "but it looks very official. Seven nicely sealed envelopes, all dated and numbered, although the numbers don't seem to follow any sequence. Insurance company correspondence would be my best guess."

"I think I know what this is about," I said, feeling a bit guilty at having Dawn unknowingly handle a patient's hair—especially hair that might have been licked! At the same time, I really did not want to go into a detailed explanation of what Pat and I were up to. This was a hairy Pandora's box best left closed for now. "Just save the mail in her chart until her next visit," I said.

"I can sort through them now if you want," Dawn replied. "Her insurance probably just wants more documentation before they'll authorize more visits. You know how I can sweet-talk insurance companies into almost anything…"

"I know your clout with insurance companies, Dawn," I said, "but no, really, this should wait until Pat's next appointment…Have you had your lunch break yet?"

Progress

"The neon writing has rubbed off on my hands," Pat announced at the outset of the session. "I think I need a new squeeze ball!"

"That's a good sign!" I replied. "It means you've been taking full advantage of it. You've been doing the hair-collecting part of the treatment, too; I got your envelopes last week."

"And I have another week's worth for you here," Sebastian added, opening his black leather messenger bag to produce a stack of seven sealed envelopes. He looked numb and somehow mechanical as he handed over the envelopes, with none of the drama I had come to expect from him. Pat looked away. "It was either me coming with Pat today to hand-deliver these to you or Pat mailing them to your office," Sebastian added. "She has a very difficult time bringing the envelopes in, although she is religious about collecting the hairs!"

A quick glance at the numbers written on the envelopes revealed a slow decrease in the hairs pulled, from around 150 some two weeks earlier to about 100 now.

"It looks like you are doing a better job controlling your pulling," I commented.

"I'm more conscious of it," Pat explained, "and that translates into better self-control. Plus, I really don't want to have to bring them here, so when I pull now, it's when the urge is impossible to resist and the squeeze ball fails to make it go away."

"May I interject something here?" Sebastian broke in, looking more animated. "I mean, that is all fine and dandy, but it seems to me like we're missing the point. We're not addressing the root of the problem, if you will excuse the pun. I mean, what is causing this? Why is she pulling in the first place? Why does someone as normal as Pat self-mutilate like this? I can't see how squeezing a ball or collecting saliva-soaked hair can be a long-term solution…A band-aid maybe, but as long as the deeper issues troubling her are not addressed, it seems to me that the problem is likely to come back again."

"Well, what do you think, Pat?" I asked.

"I'm torn," Pat answered. "Part of me says, 'Whatever works, I'll take it,' but another part craves some kind of explanation, some kind of answer."

"I can understand your frustration, Pat," I said, "but—as is the case with so many conditions in psychiatry, and in medicine in general—we are far better at fixing the problem than at telling you exactly why you were the unlucky person who got it. Take diabetes, for example—"

"But this is not diabetes!" Sebastian interrupted, becoming louder and more irritated. "Can't you see? Deep inside, Pat-the-patient hates Pat-the-person, and this is her way of punishing herself. We need your expertise in reversing this, so she can start believing she deserves better. Unless she starts liking herself again, she will never stop this self-mutilation nonsense…When I brought Pat in here, I was hoping you would help us get there. I suppose I could have had her work in my salon, sweeping hairs off the floor and stuffing them in envelopes all day long. I guess that would have fixed the problem, too, but I chose to bring her here instead, hoping for more than that!"

"I could not agree with you more that Pat deserves better than to have to deal with this problem," I said, trying hard to hide my irritation at Sebastian's interference in the treatment Pat and I had agreed on, and which already seemed to be bearing fruit. I felt that a change in treatment approach could sabotage Pat's recovery, now in progress. I also wondered about the role his own history of unsatisfying psychiatric treatment might be playing. "I just do not believe that spending hours in expensive therapy to try to come up with a story that may or may not be true about why Pat pulls her hair will ensure that the behavior goes away," I added.

"And I can't see how stuffing hair in envelopes guarantees anything either," Sebastian snapped back.

Feeling that continued confrontation was unlikely to lead anywhere and hoping to talk with Pat alone at the next visit, I suggested we postpone any decisions regarding the future course of therapy until our next meeting, when we would have more data on Pat's progress. Then, clearly addressing Pat, I said, "My recommendation is for you to continue with the hair-collecting and squeeze-ball tools until I see you back in my office in one week." I then discreetly slipped a brand new phosphorescent stress ball into her bag.

The Absent Patient

"Pat is not exactly an ex-patient, Dawn," I corrected. "Not with a piece of mail arriving from her every day…In a strange and unique way, Pat remains a very active patient."

"In a very strange and unique way," Dawn quipped. Then, after a brief pause, she added, "I just can't understand why she hasn't responded to our calls. It's been almost two months already. Maybe I should stop by Sebastian's salon and check on her. I'm thinking of getting a perm before the baby comes anyway."

"Absolutely not, Dawn!" I interrupted. "Perm or not, you are not to have a conversation with Sebastian about our patient. That would be a breach of confidentiality, and I cannot allow it."

"My, my, are we short and testy!" Dawn exclaimed. "Who's the pregnant one here, Dr. A.?"

Besides the obvious ethical concerns around patient privacy issues, one explanation for my irritability with Dawn was my defensiveness around the mention of Sebastian, who, in a sense, had been right to confront me, although he could have done it more tactfully and without the I-could-have-told-her-to-do-that-myself attitude. Like him, doctors—and perhaps especially psychiatrists— want to understand the why behind the symptom and feel some insecurity admitting their ignorance. After all, as doctors, we are not only called upon to fix a problem; we have to try to explain it, too. Only after a satisfactory explanation can patients avoid the triggers that brought on the symptom in the first place and thus feel confident in their recovery and the permanence of the fix.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders—from the "schizophrenogenic mom" whose aloof and diffident nature somehow led her child to start hearing voices as a young adult to, more recently, the conceptualization of major depression as simply a disease of "too little serotonin" that is easily treated with medications that raise the levels of this neurotransmitter in the brain. Doctors should feel less threatened answering "I don't know" to questions that push the boundaries of medical knowledge, and patients should not necessarily interpret this "I don't know" to mean "I can't help you."

But even in the midst of my defensiveness around my inability to produce a satisfying cause-and-effect story to explain Pat's pulling, I could not help but notice that the discreetly written numbers in the upper left corner of Pat's daily envelope continued their steady decrease, from around 150 on the envelope at the bottom of the pile to less than 15 as the two-month anniversary of our last meeting approached.

Then, at exactly two months after our last encounter, Dawn paged me with her phone number followed by 9-1-1. I called her right back. "What's the emergency, Dawn?" I asked.

"Dr. A.! Pat is here!" she answered, out of breath. "She wanted to personally drop off an envelope with me, but I told her I wasn't comfortable playing the intermediary for her anymore, and she would have to give it to you in person this time. Should I schedule an appointment for her, or…

"I suppose I can squeeze her in right now," I interrupted, trying to downplay my excitement at seeing Pat again. "Have her come up," I said. "No! Dawn, wait! Is she alone?"

"Yes, she is. Don't worry!" Dawn reassured me. "I'll send her right up."

Barely two minutes later, Pat and I were sitting face-to-face in my office. She exuded an air of both refined elegance and serious business in her white pantsuit with oversized lapel, decorated with a large sunburst brooch whose shiny silver surface echoed the large metal hoop handles of her white leather purse.

It was a mark of undeniable progress that I was struck by other aspects of Pat's appearance before focusing on her hair. Pat was no longer presenting herself as someone who, because of deformity or extreme self-consciousness, was working hard to go unnoticed. That afternoon in my office, Pat had a physical presence, and a self-assured, attractive one at that! As to her hair, it was not lifeless or perfectly symmetric (as in fake), not overly luscious or flowing (as in exaggerated hair product advertisements), and not uneven, brittle, or combed-over (as in "trich hair"). It was pulled back in a neat-looking bun on the vertex of her head, with no random hairs sticking out from the bun or the sides, and no evidence of redness, bald spots, or makeup on the scalp underneath.

"You look very good, Pat!" I exclaimed. "But where have you been?!"

"I have something to give you," she said, avoiding my query into her extended absence.

"OK, but you did not answer my question," I insisted. "It's been two months!"

Before I could press her further, Pat slowly separated the large silver hoops of her bag, then quickly snapped it open to reveal a familiar-looking envelope.

"Please open it," she requested, handing me the envelope. "I'll explain—or try to explain—afterward."

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it. Just "Dr. A." in large script.

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it.

"Just open it," Pat insisted. "That's the last thing I will ask you to do for me."

So I did. I opened the white envelope labeled "Dr. A." and found it completely empty inside.

"I'm down to zero!" Pat said, flashing a big smile.

"That's great news, Pat!" I said, my surprise visible. "I'm proud of you."

"I do feel like I owe you an explanation, though," she said. "After our last meeting, I felt like…"

"You don't really owe me an explanation, Pat," I interrupted. "Feel free to explain yourself if you want, but you don't 'owe me an explanation.' I was just worried about you, and I'm thrilled to see that you are doing so much better now."

"I'm doing better for sure," Pat said. "In fact, I can't stay too long! I'm meeting my date in a half-hour."

"You're starting to date again! That's as good a sign as any that things have drastically improved. Is it the same nice Jewish boy you liked so much, by any chance?" I asked, excited that a promising, prematurely aborted relationship might get another chance. "He seemed to really like you, too, as I recall, but you sabotaged the whole thing out of embarrassment that he might find out."

"Who? God, no!" Pat said, letting out a loud laugh. "Didn't you hear? Well, there's no reason why you should have heard…"

"Didn't I hear what, Pat?" I asked, intrigued.

"Well, it turns out he was…Well, he and Sebastian are, umm, together…" Pat said hesitantly. "As like, dating each other," she added. "In fact, Sebastian perceived you as wanting me to pursue my relationship with Neil—that's the guy's name—which I think made him a little jealous. In retrospect, that explains some of his outright hostility toward you last time we all met. I'm very sorry about that, by the way. You didn't deserve it at all!"

"That's OK," I said. "H2O under the bridge, as Sebastian would say. But I must tell you I'm very confused now. Wasn't Sebastian the one who introduced you to Neil in the first place?"

"He did, he did," Pat conceded, "but I'm now convinced that he was using me to test some hypothesis he had about the guy all along. Frankly, I'm confused, too. I could sense Neil was interested in me, but I also know he's seeing Sebastian now. Maybe he's bisexual or something… Anyway, it doesn't take a psychiatrist to guess that I'm a little mad at Sebastian right now. But it's nothing that he and I won't get over in time."

"Well, this is all very fascinating but also very sad, Pat," I said, wanting to give her an opportunity to process her feelings around what had happened. "I know how close you and Sebastian were, and I hope you can salvage your friendship."

But the non-doctor part of me was also simply curious, in a way that was perhaps inappropriate—more gossipy than clinically relevant to my patient. "Tell me more!" I said. "Do you think the two of them are a good match?"

Fortunately, however, Pat would not indulge me. "Well, I could go on and on analyzing this," she said, "but what purpose would it serve besides prolonging the same pointless drama? The fact is, I've moved on, and it's all H2O under the bridge at this point… Plus, you don't want me to be late for my date, now, do you? Thanks for everything, Dr. A. Really, thank you."

With that, Pat stood up, gave me a hug, and disappeared into the labyrinthine hallway of our clinic, sounding a lot more confident in her step and a lot less anxious.

The Psychiatrist's Lot

But what to do with two months of hairy correspondence? Except for the final empty envelope, which I held tightly in my hands and then pinned to the wall in my office, I pushed the rest of the stack toward the edge of my desk, letting it drop off into the trash can. The thud of the falling pile as it hit the bottom caused a feeling in me that, however tinged by a sense of loss and separation, I can still best describe as satisfaction.

Excerpted (with permission) from Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession by Elias Aboujaoude, MD. Now available in paperback and on sale. For more information and to order, please visit the publisher's website, UC Press, or read reviews and purchase at Amazon.com.