Author: Psychotherapy.net Team

Finding Ways to Communicate with Clients About Their Symptoms

Posted on by Psychotherapy.net Team

Some nursing homes tend to have few, if any, residents with major mental illnesses. There are other facilities that have many residents with a mental illness, and those are the nursing homes where I prefer to work.

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Many of the clients I see for psychotherapy have a long history of mental illness. Few, though, report having been educated in helpful ways about the symptoms of their condition. When education has been presented, it may have been in technical language that might be perplexing or off-putting for the client. Finding ways to communicate effectively and sympathetically with a client requires artful attunement to the inner experiences of that person.

A 50-year-old lady with a diagnosis of anxiety, described her symptoms as “sweats, shaking, very nervous, and feeling pulled away from things.” A 72-year-old lady movingly described depression as “a heavy something that weighs on your brains, and you can’t think beyond that feeling — until someone helps bring you out of it.”

Asking someone to describe the symptoms of a mental health condition can be a helpful way to begin the process of deepening and clarifying their self-understanding. It can also be helpful to use some of the language and concepts of the client as a starting point, while avoiding sole reliance on technical jargon about mental illness. I’ve found that many clients have developed a defensive deafness to such language, anyway.

Helping Clients Understand their Symptoms

One way that I approach conversations with clients about their conditions and symptoms is through an exploratory series of questions:

How do you know when you are experiencing depression, (anxiety, bipolar symptoms, difficulty telling the difference between things real and unreal)?

How do others know when you are feeling depressed (anxious)?

Do you sometimes feel depressed, anxious, or have mood changes, or have maybe unreal experiences and others don’t notice?

What might others need to pick up on to recognize when you feel depressed, anxious, or afraid?

In general, individuals experiencing anxiety and/or depression may be interested in and receptive to education and discussion about their symptoms.

Yet many persons with a schizophrenic illness might deny the condition and rationalize the symptoms — due to stigma and shame, and due to limited capacity for logical reasoning. “I don’t have schizophrenia, I’m psychic; I get psychic attacks,” suggested Martha, who, nonetheless, is sometimes willing in therapy to directly acknowledge her schizophrenia, and her peculiar experiences as being symptoms.

Therapeutically educating a client about symptoms of schizophrenia might start with distinguishing things that are subjectively real from those that are objectively real. We might discuss inner perceptions and beliefs that may be real subjectively but may not be objectively real. Some already feel as though they live in a separate and inward world, somewhat apart from others.

Recently, I have begun experimenting with using a Venn diagram of three overlapping circles to illustrate differences between subjective and objective experiences. The first circle, on the right, is labeled as the client’s inner, or subjective world. In that circle are listed several of the specific symptomatic experiences already discussed in therapy, that the person might confuse as being real. The second circle, on the left, is labeled as the outer, or objective world. The overlapping middle circle represents the client and me in therapy, looking into each world to make connections and distinctions. Here is a compilation of some selected items from the right-hand circle for five clients: psychic attacks, mind-boggling thoughts, curses and accusations made by voices, paranoid thinking, anger, depression, anxiety, my make-believe world, messages received from the TV or radio or unseen persons. The list in the left-hand circle would include the facility, medical and psychiatric diagnoses, and related care and treatments.

I draw arrows to show, for example, how the experiences in the inner world circle are symptoms of the psychiatric diagnosis in the outer world circle, and how medications and psychotherapy from the outer world circle are intended to address the symptoms. Clients have shared poignant responses to lessons learned from this approach.

Cameron said, “This helps me understand mental illness. I feel relieved when we talk like this. I get it mentally, about what’s going on.”

Betty said that “Nobody ever told me this. It makes me understand what’s going on in my head better.”

“That means we’re on the same page, I appreciate that,” suggested Martha. “You understand what it’s like for me.”

Richard said, “Sometimes I think it’s real, and sometimes I don’t; it’s hard to tell. It relieves my mind when we talk about it.”

Donald said that “I’ve gotten a lot more mature and rehabilitated talking to you, Tom. I just don’t know what to say sometimes. It’s a big thing for me to get up to this level of reality. It’s your words that make me feel I’ve turned.”

For multiple reasons, it can be difficult to educate people with schizophrenia about the psychiatric nature of their subjective experiences. I had the impulse to try the Venn diagram with one client, and his response encouraged me to try it with a few others, as well.

***

I don’t use this approach with all clients, as some may be too delusional at the time to experience benefit. The people I have tried this with each showed some willingness to question the validity of their unusual subjective perceptions and beliefs. So far, I have only tried this approach with these five clients, and I have been pleasantly surprised, and touched, by their responses. Other therapists may wish to experiment, as well, with this simple, yet promising technique.

Questions for Thought and Discussion
What is your reaction to this therapist’s approach to explaining symptoms to clients?
What methods have you used to help clients understand their psychiatric symptomatology
With which clients might this approach be effective? With which others might it not?

The Wisdom of Therapist Uncertainty

Posted on by Psychotherapy.net Team

“Uncertainty is your space for growth.” – Angela, psychologist

Work hours for many are unpredictable. Political divisions, pandemics, and extreme weather add further unknowns to daily life. In an era that challenges mental health, it’s easy to assume that therapists should be pillars of all-knowing sureness.   

One Fear to Rule them All

But growing evidence suggests that practitioners can benefit from leaning into their uncertainty in times of flux. Skillfully accepting and even embracing not-knowing is linked to better mental well-being and improved decision-making in both clinicians and their patients. “We need to help psychologists view uncertainty not as a horrible thing you need to minimize, but as an opportunity to learn and grow,” says Elly Quinlan, a senior lecturer in psychology at the University of Tasmania and a leader in the study of uncertainty in clinical practice.

How humans contend with the unknown is a topic attracting attention in clinical psychology. This critical capacity is measured by gauging people’s “intolerance for uncertainty,” or the degree to which they view unknowns and the unsureness they spark as threatening or merely challenging. (Sample assessment component: “Unforeseen events upset me greatly.”) (1) Importantly, being intolerant of uncertainty is now recognized as a transdiagnostic vulnerability factor for a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. (2) As Canadian researcher Nicholas Carleton writes, this trait (and state) may be the “one fear to rule them all.” (3)

As a result, leading psychologists are targeting uncertainty intolerance as a promising new way to treat many mental disorders. By taking on more unknowns in daily life, patients gain skill at meeting life’s twists with a curious, open mind, rather than fearfully racing to eliminate uncertainty through denial or snap judgment. During one intervention, young adults tried answering their phones without caller ID. (4) An adult learning uncertainty tolerance in therapy challenged himself to delegate more at work. (5) Results are encouraging: in one recent study focused on bolstering uncertainty tolerance, worry and anxiety in people with generalized anxiety disorder fell after treatment to levels experienced by the general population. (6)

Now Quinlan and others increasingly see uncertainty tolerance as a needed skill for psychologists themselves to practice. Psychologists interviewed for a small quantitative study led by Quinlan reported primarily negative responses to situations filled with unknowns, such as an ethical dilemma or the challenge of selecting treatment for a high-risk patient. (7) The psychologists, who had diverse levels of experience, reported anxiety, feeling inadequate, frustration, and anger. Some avoided complex, ambiguous cases or left a client in order to escape uncertainty. “I actually could not resolve that uncertainty, so I shifted the client to another clinician,” said one.  

Such markers of an inability to manage uncertainty are associated with both anxiety and with burnout, conditions that undermine well-being and decision-making skill. In one study of 252 psychologists, their uncertainty intolerance in client care and in daily life predicted burnout (8), a form of exhaustion that up to 40 percent of mental health providers experience today. (9) Uncertainty intolerance is also linked to overtesting, according to studies in primary care medicine. (10)

The Importance of Uncertainty Tolerance

In contrast, psychologists who accept the intrinsic uncertainty of their work and see not-knowing as an opportunity for learning, as discomfiting as that may be, tend to have higher mental well-being. Angela, a psychologist who participated in another of Quinlan’s qualitative studies, advises younger peers to “treasure the darkness a bit. Uncertainty is your space for growth.” (11) Uncertainty-agile clinicians ask, “What is this ambiguity or my uncertainty telling me?” instead of rushing to bury or eradicate the unknown, says Quinlan, whose research has inspired her to assure her trainees that it's okay, and even helpful, to not know.

By recognizing uncertainty as a path to wisdom, providers gain time and space to consider nuance and alternative perspectives. In a speed-driven world where experts are expected to be all-knowing and ultra-decisive, psychologists often “long for the magic wand” of the quick, clear answers, observes educational psychologist Daniela Mercieca of the University of Dundee. But “it is only by allowing ourselves to be uncertain that we are open to shock and surprise … and complexity.” (12)

How can psychologists learn to recognize unsureness as an opportunity? Efforts to map uncertainty tolerance are so new that interventions to teach this skill set to practitioners are sparse in both psychology and in general medicine. One intervention found that training in non-judgmental mindfulness helped trainee psychologists become less stressed by uncertainty. (13) Other studies have shown that exposure to the visual arts or the humanities can boost uncertainty tolerance in medical students. (14) Quinlan plans to begin formally testing uncertainty-tolerance strategies for trainee psychologists in a few years. 

There may come a day when healthcare practitioners will be routinely taught to manage uncertainty as a way to improve their well-being and their efficacy. But until that time, perhaps clinicians can learn from the peers and patients around them who find wisdom in accepting life’s inherent unpredictability and in realizing that at any one moment they might not know.

Recently, two young practitioners found that openly admitting uncertainty in their practice felt unexpectedly liberating. The opportunity arose in 2020 as cognitive behavioral therapist Layla Mofrad and psychologist Ashley Tiplady worked with Mark Freeston of the University of Newcastle to develop a group intervention to teach uncertainty tolerance to patients just starting to receive care for a range of disorders. (15) To model the intervention’s content, they explicitly talked to one another and to patients about the program’s unknowns, ranging from outcomes of this novel treatment to how a tech outage might affect the day’s schedule.   

Most patients who completed the “Making Friends with Uncertainty” intervention showed significant improvements in their anxiety and depression and nearly half became more tolerant of uncertainty. Moreover, the facilitators themselves found that working with, not hiding from, uncertainty improved group solidarity and their own ability to be partners in care. “It’s easy as a therapist to jump into trying to make things feel more certain … we tried to hold back from that,” says Mofrad, adding that this approach returns therapy to its ideals. “The best therapy will always have an uncertain element, and the best therapists are those who will ask questions, be curious, and not stick to a rigid framework.”

Note: All quotes are from interviews with the author unless otherwise noted. Due to an editing error the references below have been updated as of 4/24/2024


Questions for Thought and Discussion

1. What were your impressions of the author’s premise about certainty and uncertainty?
2. How comfortable are you with uncertainty both professionally and personally?
3. In what ways might you carry forward the author’s research in your own clinical work?  


References

(1) Carleton, R. N.; Norton, P. J., & Asmundson, G. J. G. Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.

(2, 15) Mofrad, L., Tiplady, A., Payne, D., & Freeston, M. (2020). Making friends with uncertainty: Experiences of developing a transdiagnostic group intervention targeting intolerance of uncertainty in IAPT: Feasibility, acceptability, and implications. The Cognitive Behaviour Therapist, 13 (49), 1-14.

(3) Carleton, R. N. (2016). Fear of the unknown: One fear to rule them all. Journal of Anxiety Disorders, 41, 5-21.  

(4) Unpublished material shared with the author by Stephanie Gorka and Nicholas Allan of Ohio State University’s College of Medicine.

(5) Keith Bredemeier Assistant Professor at the University of Pennsylvania Perelman School of Medicine Center for the Treatment and Study of Anxiety, in discussion with the author, September, 2023.

(6) Michel Dugas et al. (2022). Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults with Generalized Anxiety Disorder. Behavior Therapy, 53 (6), 1147-1160.

(7) Quinlan, E., Schilder, S., & Deane, F. P. (2021). `This wasn’t in the manual’: A qualitative exploration of tolerance of uncertainty in the practicing psychology context. Australian Psychologist, 56 (2), 154-167.

(8) Malouf, P., Quinlan, P., & Mohi, S. Predicting burnout in Australian mental health professionals: Uncertainty tolerance, impostorism, and psychological inflexibility. Clinical Psychologist, 27 (2), 186-195.

(9) O’Connor, K., Muller Neff, D., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74-99.

(10) Korenstein, D., Scherer, L. D., Foy, A…Morgan, D. J. (2022). Clinician attitudes and beliefs associated with more aggressive diagnostic testing. American Journal of Medicine, 135 (7); also Lam, J. H., Pickles, K., Stanaway, F. F., & Bell, K. J. L. (2020). Why clinicians overtest: development of a thematic framework. BMC Health Services Research, 20 (1011),

(11) Fewings, E., & Quinlan, E. (2023). ‘It hasn’t gone away after 30 years.’: Late-career Australian psychologists’ experience of uncertainty throughout their career. Professional Psychology: Research and Practice, 54 (3), 221-230.

(12) Mercieca, D. (2009). Working with uncertainty: Reflections of an educational psychologist on working with children. Ethics and Social Welfare, 3 (2), 170-180.

(13) Pickard, J. A., Deane, F. P., & Gonsalvez, C. J. (2024). Effects of a brief mindfulness intervention program: Changes in mindfulness and self-compassion predict increased tolerance of uncertainty in trainee psychologists. Training and Education in Professional Psychology, 18 (1), 69-77.

(14) Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56 (12), 1163-1173.   

Terminally Ill Pediatric Patients and the Grieving Therapist

Posted on by Psychotherapy.net Team

When asked about the favorite aspect of my (dream) job, I could talk for hours. I feel passionate about working in a pediatric hospital setting with chronically ill children and their families. Each day brings new challenges. I enjoy inpatient and outpatient sessions, parent consultations, family work, collaboration, and advocating for this population any chance I get.

On the contrary, when asked about the least favorite aspect of my job, my response is far less glowing and enthusiastic. I work with children from various departments within the medical center, including oncology, cardiology, trauma, and solid organ transplant. It is inevitable that I encounter children who are terminally ill. I will never understand why children die. Experiencing the death of a child is the most painful part of my job, and it will never make sense to me although logically, I know this happens. On the other hand, I feel honored to be a small part of the most vulnerable time in a family’s life, and to walk alongside them in their journey of grief and loss. Helping a family and their child during end-of-life care is arduous work. It has been impossible for me to not be deeply impacted working in this arena.

I will never forget the first patient with whom I worked that received a terminal diagnosis. I was an intern completing my graduate work. Because I speak Spanish, I was privileged” to work with more challenging cases. I remember sobbing to my mentor at the time, not understanding how a child could die. In response, my mentor neither chastised nor criticized me. She agreed with me and mourned with me. She supported me through that experience and reminds me even to this day that we are human. That support has stuck with me as I continue to mourn the deaths of children with whom I work.

When I was first asked to write a post related to working with terminally ill children and their families, I hesitated, perhaps not wanting to open old wounds and visit the pain that comes with this kind of work. But as I’ve experienced more child deaths over the years, I wanted to share my thoughts and feelings and am humbled to share my stories.

The Dying Child

The dying child has a variety of emotional, physical, and spiritual needs. They have questions and often want information about what is happening to them. The child who is terminal often feels unsafe and understandably anxious. One word I’ve frequently heard, particularly from the parent, is “brave.” In my experience, many parents of terminally ill children find inner strength in the strength of their own children. I remember one child who was aware of her prognosis comforting her parents, reassuring them that she would be “okay.” She arose each morning and worked hard to remain connected with her parents, family, and friends. I also try to remember, even in the face of their strength, that these children are scared. As I have discussed with many families, fear and bravery can, and often do co-exist. For me, bravery is moving forward even in the face of fear.

To Tell or Not to Tell

A glaring ethical question is whether a child should be told they are terminally ill and that they will die. In my experience, many medical providers and members of the psychosocial team believe a child should be informed of the severity of the diagnosis; whereas parents often do not wish for their child to know. Many parents believe children will “give up” if they are aware of the prognosis. To the one, children often know something is very different or not right. They may be confused and desire open communication to understand what is happening within their own bodies. It is my job to provide caregivers with this information and connect them to the Child Life department if they would like guidance regarding how to tell their child. It is not my job, however, to advise them on what to do or impose my own beliefs. The decision is ultimately up to the parents.

The Dying Child’s Family

The families with whom I’ve worked represent a wide range of cultures, faiths, religions, abilities, and beliefs. It has been imperative for me to work with them through a very focused lens of acceptance and understanding of end-of-life issues so that I can be as useful as possible. When learning about a family’s culture, it has been important to know and appreciate the family’s beliefs about the afterlife as this has guided me when discussing their child. Faith can be an important coping skill and protective factor when a family receives news of a terminal diagnosis for their child. However, challenges may arise because of a family’s faith. I have met with Christian caregivers who struggle with the balance of faith and science. Many worry that preparing for end-of-life care, such as transitioning to hospice, considering a DNR, or planning the funeral indicates they are not “good Christians.” Connecting families to spiritual care has been crucial when the family’s faith is important to them.

Families are often faced with challenging decisions regarding end-of-life care. Many parents process these decisions with the child’s therapist. Some parents worry that focusing on the child’s quality of life and reducing seemingly futile treatments will be perceived as “giving up.” I have often worked with caregivers who struggle with the continuation of treatments that are painful, and sometimes even agonizing, for their child. While they want what is best for their child, the decision to extend that child’s life can be tortuous.

Complex and anticipatory grief can make the adjustment to a terminal diagnosis that much more difficult. It is challenging for caregivers to be fully present while still grieving the impending loss of their child. In addition, siblings are often overlooked as a necessity for the dying child’s care. I recall the family of a dying child with whom I facilitated sibling play therapy. My goals during sessions were to connect with each child and help them connect to each other. During those sessions, the child with the terminal illness often felt ill and lethargic. The sibling first requested that the patient play with her in many ways. However, as sessions progressed, the sibling learned to allow her sister to lead. For example, instead of two chefs working at a restaurant, the sibling was the chef who served the tired patron a meal. The ability for families and siblings to find strength to cope always amazes me.

Hope vs. Denial

It is not uncommon for me to receive proclamations from the child’s medical teams that the family is in denial about their child’s diagnosis. I will never forget sitting down with a particular mother to discuss her child and family. She said, “I know what the team thinks. They think I don’t understand what is happening. I understand. I am just choosing to have hope. Hope in a higher power. I know my child’s doctors do not have the last say. I have hope that God will heal my child.” Hope is not denial. Hope is an adaptive and positive coping skill that bolsters a child and family during outstanding hardship.

The Challenges of Working with Dying Children

I was fortunate to be surrounded by deeply empathetic people during my internship, when I first experienced the death of a child patient. Since that time, I have met many medical providers who have been able to build an emotional tolerance for this kind of work out of necessity to care for their patients. I have always been thankful for their skill at addressing the physical and medical needs of these children and their families.

As a therapist, however, my role is to attend to the emotional needs of the family — their strengths and fears along with, of course, their presenting concerns. I have learned the importance of allowing space for all feelings, including my own, when a child’s death is imminent or has occurred. I used to believe I was not able to grieve the loss of a patient. My grief meant nothing compared to the limitless grief of the family, friends, community, and bedside staff. However, I quickly and poignantly came to see the disingenuousness of this belief. I have learned that the only way I can be fully present for the child and their family is by remaining firmly anchored in my own humanity and vulnerability.

I have certainly heard words like compassion fatigue, secondary trauma, contagious emotions, and empathy trauma bandied about, and how any of these experiences can lead to burnout. One extreme challenge I’ve experienced when meeting with a terminally ill child and/or their parents has been the pressure of meeting with a healthier patient immediately afterward. I will never forget receiving news a patient with whom I had worked for years died two minutes before a session with another patient. I still question whether I was able to offer unconditionally positive regard to that second patient as I struggled under the weight of what had happened moments before. Shifting those emotional gears was a challenge.

Over this and related experiences, I have had to learn ways of grieving to avoid burnout. Showing my own humanity and vulnerability within the boundaries of safe relationships and work friendships has made me a better therapist and afforded me an outlet for my own emotions. I remember working with a chronically ill child for over a year who received a terminal diagnosis. As her illness progressed, I transitioned to working with her parents. I learned to never schedule a session with another family or patient directly following these interventions. After these emotionally dense and intense sessions, I would schedule five minutes to cry. I would shut my office door and have a few minutes to allow myself to experience these heavy feelings and an emotional release. I have learned that by allowing myself to grieve, experience, and understand my own humanity, I have become a more empathic person. This has, in turn, allowed me to continue to work with this population and alongside grieving families.

Guilt and Perspective

There are several challenges and, not surprisingly for me, blessings when working with this population. One glaring emotion I often experience is guilt. When leaving the hospital for a vacation or holiday, I must inform the families of newly admitted patients that I will be gone for a few days. Many families say, “Have fun!” or “Merry Christmas!” The typical “you too” does not suffice in this scenario. The extreme guilt I felt as a young therapist was overwhelming. Then, with two healthy pregnancies and subsequent maternity leaves, and now, with two healthy children, I am often surprised by waves of guilt. Over the years, these waves have decreased in size and duration. I know I have a role to fill to support these patients and families, which will be impossible if I continue to focus on the guilt I feel.

On the other hand, I feel deeply grateful to work with these patients and families. Their strength and steadfastness are astounding. In addition, this job fills me with immense amounts of perspective. I recall a mother saying to me, “I don’t know how you do this — choose to come to work with these sick kids every day.” I replied, “I don’t know how you do this — show up for your family every day with vulnerability, strength, and support.”? Small arguments at home or my childrens’ typical tantrums seem so manageable when compared to the hardships families I work with endure. This often leads me back to guilt. It has taken me years to focus on the perspective and honor I feel instead of allowing guilt to overcome me. I realize this helps me be a better therapist for the children and families with whom I work.

Countertransference

Another challenge I’ve encountered when working with this population is countertransference. Loss prompts memories of past losses, with each new one potentially amplifying the pain of those that have come before. This has been extremely challenging for me when working with dying children, especially when I think of my own children. I recall working with a family whose child was nearing the end of her life. The parents and family wanted to make new memories by visiting Disney World, Six Flags, Disney on Ice, and birthday parties. I found myself planning with the parents during parent consultations ways to motivate their child to want to attend these events.

The child wanted none of these outings, instead choosing to remain home and stay close to her parents and siblings. In looking back on that episode, embarrassingly, I wondered if the child was exhibiting depressive symptoms. I naively believed that it would be to everyone’s benefit if she did those things with her family. During a subsequent parent consultation, I suddenly realized I was pushing my own agenda. I mentioned this to parents and that this was not what their dying child wanted. In that moment, I realized the potential power and influence of countertransference when working with dying children and their families. Therapy and supervision are key in instances such as that one.

Boundaries and Self-Care

I’ve always valued the importance and recognized the challenges of maintaining boundaries when working with this population. Our mission at Children’s Health is “making life better for children,” and I genuinely strive for this every day. However, I have encountered specific ethical dilemmas necessitating clear boundary setting. These have included coming in on a weekend or evening when a child is not doing well or nearing the end of their life, wanting to buy gifts or necessities for families who are struggling, attending funerals, crying in front of families, or sharing information with others outside of work. While buying gifts and sharing information outside of work lie within strict ethical parameters, attending funerals, coming to work when not scheduled, and crying with families lie more in the ethics shadows. Attending patient funerals is a particularly challenging ethical domain. Many providers simply do not attend funerals, while just as many others do. It has been important for me to determine if harm might befall the family if I attended their child’s funeral.

Showing emotions to family members is also a sticky issue. Many therapists have been told “don’t cry in front of families!” I have openly teared up with several families.

Therapist as Advocate

Over the years, I have discovered the importance of advocacy. If the patient expresses certain wishes, such as knowing details of their medical/health status or having friends nearby, I share these with the family and medical team when appropriate and after discussing this with the child. My role as advocate has also included helping the caregivers understand their child’s desires. As with the example of the client and her family mentioned above, I helped parents see their child’s perspective and, in turn, meet her needs during the end of her life. We were able to focus on the goal of togetherness and provide her with feelings of safety and connection the way she wanted. This was a difficult shift to focus not only on what the family wants but want the child desired. Legacy building through memory making is yet another form of advocacy, which can be built into the (play) therapy.

Postscript

Working with children who are dying has been emotionally strenuous yet deeply gratifying work for me. Staying present in my feelings while being fully present for the child and family has been particularly challenging. Utilizing rituals to remember and honor a child has been a helpful tool. Our hospital hosts a memorial service each year for employees to grieve patients who have died. Others plant a seed or add a bead to a bracelet for each child who passes. I choose to keep mementos given to me by patients and consider how each child impacted my life and changed me as a clinician. Moving forward is one of the hardest challenges for me as both a clinician and person. I have learned the absolute importance of surrounding myself with others who understand my experiences working with this population.

Avoiding the Adverse Impact of Electronic Communication in Couples Therapy

Posted on by Psychotherapy.net Team

Although it is nearly impossible to break communication habits in the Internet age, I have had numerous therapeutic instances where clients only dig themselves deeper relational holes by attempting to resolve interpersonal issues by texting and messaging their partners. The nuances of tone, emotional body cues, facial expressions, and the imperfections of language that are a normal part of face-to-face interaction, are lost through these digital mediums. The result is often an exacerbation of ongoing communication difficulties. Through my informed voluntary consent at the outset of therapy, I make my position about texting and messaging outside of the therapy hour very clear. Because clients frequently do this, my informed consent includes these statements for reasons that will become clear in the cases below, but also because SMS creates the expectation of an instant response, which I am only prepared to provide in an emergency. I also encourage clients to deal with emotional issues with each other in person, or at least by phone. In this way, the nuances of non-verbal communication and precise language can be more readily perceived, clarified, and addressed.

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Case Examples of Electronic Communication Gone Wrong

Brian and Samantha, a couple in their forties who had lived together for two years, presented the problem of frequent arguments over both trivial and deeper issues. These tensions regularly escalated into withdrawal, name-calling, and impulsive criticism, with old resentments resurfacing. I worked with the couple on the basics of communication, problem-solving, and behavior exchange, and explained the role of lingering resentments. They did well with practicing and understanding these issues, but resentments still lingered, and comments flared up.

After six sessions of rocky and frustrating, ungratifying conjoint therapy, I received copies of text exchanges between them. They each sent me the copies they received without their partner’s knowledge in hopes of proving to me the other’s abusiveness — ignoring my informed consent provision. In one thread, Brian apologized for commenting at dinner that a glass was dirty, saying that he was merely making an observation, not a criticism. Samantha replied, “If you don’t appreciate all I do for you, when you never do anything around the house, you can do it all yourself!” Brian then attempted to clarify his intent, to no avail.

I replied to Brian by text, indicating that my informed consent stated that I do not use the internet for emotional content such as this, and we could discuss it further in our next conjoint session. In their next “post-text debacle” session, Brian did not bring it up out of embarrassment. They continued for six sessions, working on the resentments that surfaced and terminated with improved overall skills; I never found out whether they were able to resolve past resentments.

In another case, I worked with a disgruntled individual client, Belinda, who was in a severely dysfunctional marriage with her wife, Lucy. Her goal was to obtain recommendations for dealing with the anger she felt for several reasons. I explored them cognitively and emotionally, having her align her values with her behaviors. Belinda sent me pages of exchanges going back eight years in which Lucy had historically berated her for everything she resented. Seemingly, Belinda wanted me to agree that she had indeed been emotionally abused.

When Belinda directly expressed outrage at home, Lucy said she “didn’t really mean all that,” to which Belinda told her she could not take it back and they should consider divorcing. In the next session, we explored her situation, and I told her that moving forward, I could not take an additional hour to go over all the comments her wife made in those electronic exchanges but could instead help her to consider some resolution of the contempt and disconnect she felt. I advised that they see a couple therapist, either myself for a 1-2 session consultation, or another therapist. She seemed to have a better understanding of her resentment and how to control it.

***

In looking back on these two cases, I understand the widespread use of texting and messaging in today’s electronic world. Although I discourage clients from using it to discuss emotional issues, I cannot prevent them from doing it, either interpersonally or with me. I believe it’s important for therapists to set an example — and boundaries — by not using electronic media for intimate communication.

Coming Full Circle: Helping a Young Couple Through Their Grief

Posted on by Psychotherapy.net Team

A Matter of Death in Life

After seeing my last patient out, the sun in the back-office windows faded into twilight, darkly illuminating the autumn leaves. I began to feel weekend-ish, looking forward to a long, relaxed walk with Charley in the park, and the single gin and tonic with two limes, which I allowed myself on Friday evenings. As I put the day’s session notes on the desk, I saw the light blinking on the answering machine. One of my grad school colleagues and friend, Ben, sounded mildly upset.

“Hey Liz, I don’t know if you could see someone over the weekend, but a friend of mine just lost a baby to what they think is SIDS. They have a three-year-old son. They’re in shock and want to talk to someone about how to handle it with the kid. I thought of you immediately. It’s kind of urgent. Call me back.”

I sat quietly, letting this request wash over me. Was this a little too close to home, me aged 3 with the dead brother? But this felt urgent to me, as it was my story. Then with certainty and a whole-body-resolve, I thought, I could be of help. I dialed my colleague back.

“Liz? Hey, thanks for calling back.”

“Sure. Give me some details.”

“Upper-middle-class family. Lives on the west side. Dad seriously Type A. Mom too, but she has an arty vibe. The dad, Mark, left early for work this morning and when mom got up later, she thought it was strange her one-year-old daughter Bonny hadn’t woken her up. Claire, the mom, found the baby blue and not breathing in the crib and called 911. Claire tried not to panic, because Angus, the three-year-old, was up. Angus saw the cops and the medics and watched as the baby was taken out of the apartment. I think Claire was really freaking out too. Mark called me — he is a friend of my brother’s — after the baby was pronounced dead at the hospital. He is worried about his wife and his son.”

“I can see them tomorrow morning before yoga. Nine?”

“Sure.”

“Did the father describe the three-year-old’s reaction at all?”

“I think he is usually pretty rambunctious but after it all went down, apparently the kid has refused to talk and is very subdued.”

“Got it. Why don’t you just call them back with the time and give them my name, the office address, and my cell number in case by morning they change their minds. I assume they can afford a full fee?”

“Definitely,” Ben responded. “Great, I knew you were the person for this.”

“Thanks.” I hesitated and then said, “I think I am too.”

Ben was a good guy. We had bonded over leukemia; Ben got sick with it in adolescence and had been able to tell me about that experience. This helped me to know what it may have been like for my brother. Sometimes the universe is a sticky web. We get stuck in with those we need to know.

As I hung up, I realized I was somewhat daunted by the intensity of this referral, but felt it was necessary I take it on. What will I learn by touching the rawest parental grief over a lost child? Would I learn something about what my parents really went through when Jim died, or what I went through then too?  

The weekend feeling vanished, but I was still up to mixing my gin and tonic.

The next morning, I knew I needed to be centered and calm. Before my shower, I breathed in the roses on the terrace and then gave Charley’s belly some extra rubbing. As Charley and I walked to the office, I kept my awareness on what I could take in through my senses: the silver-grey concrete, the smell of traffic, the feeling of my foot hitting the pavement, and the cool morning air. I would have to steady my own feelings, so my own ancient grief did not disrupt what the family needed to bring to me. I had been known to get tears in my eyes when my patients were in pain.

At the office, Charley snoozed under my desk, and I settled into my buttery soft leather shrink chair. I kept working to find the right emotional space to work from — calm, steady, receptive. I didn’t get to stay put long when the outer doorbell rang. Game on.

A Sense of Helpless Defeat

I tried to softly smile as I greeted them. “Hi, I’m Liz Tingley. Please do come in.”

The father shoved out his hand and said, “Mark McNitt. This is my wife, Claire Holm.” They were in their late twenties, both tall, the woman quite thin. She was blond and the man’s hair had a reddish tint. They wore jeans, he with a jacket and button-down shirt. She had on a light-colored linen sweater, her long blond hair held back from her face in a ponytail. Their expressions were somber. Neither looked like they had slept.

I studied her face, pressed lips, red, swollen dull eyes. This plummeted me back to my own mother’s dark hole eyes the morning after my brother died, the look that made me back away so as to not get sucked all the way into her blackness. I felt a muscle in my neck tighten.

Stay in the present, Lizzie.

“Please come in,” I repeated, gesturing toward the adult patient chairs on one side of the room. Mark took his wife by the hand, almost depositing her in the first seat.

Type A alright, but protective too. She needs that now. That memory of my father pulling my mother to him, as we left the hospital where they learned Jim would die, reverberated in my head.

“Ben only told me a bit of what’s happened to you,” I said as I sat back. I made eye contact with each of them slowly, lingering a bit with Claire, her eyes tearing as she met my gaze. “Just tell me where you are.”

Mark reached over to hold Claire’s hand. He spoke first. “In shock, really.” Claire nodded.

“Yes. And it will take a while for that to wear off,” I said softly and paused. “Do you want to tell me about it?”

Claire nodded. “It was a usual morning, except that we had been out late to friends for dinner with both kids the night before. We put the two of them down for bed about an hour or so later than usual. So, in the morning, when I didn’t hear Bonny stirring, I didn’t think anything of it.” She broke down, sobbing. Mark put his arm around her.

She must be feeling guilty, like if she had checked right away, the child might have lived.

“You had no reason to think it wasn’t normal for her to sleep in a little.”

Claire nodded as she sobbed. She pulled herself together. “Angus was playing in his room. I could hear him. So, I put the coffee on first and then went into Bonny’s room. She was lying on her side, with her head in an odd position. When I touched her, I knew something was wrong. She was blue. I screamed, grabbed her up, and called 911. They had me try to clear her airway and do mouth to mouth. When the paramedics got there, they took over. They took her away and I called Mark to meet them at the ER.” She looked down, her voice tapering off to a whisper and then she stopped.

Mark finished the story. “She was already dead,” he said. “The EMTs told me that at the hospital.” In a monotone, he continued, “They let me see her.” He teared up too but bravely went on. “They told me it was an unexplained death and they had to investigate. They called the Agency for Children’s Services and the cops. They’ve kind of been at the house since.”

Claire continued, “They said it’s a ‘SIDS-like’ death, but she was too old for SIDS.” She was trying to hold onto her tears but couldn’t. “She was nearly a month premature, but she had caught up at her one-year check-up. She seemed so healthy.”

“Yeah,” I said, trying to match my tone to hers, this inexplicable crazy fact of her dead baby.

“And Angus,” Claire again began to cry, with a panicked tone.

“That is why we are here, Dr. Tingley, to figure out what to do for him.” Mark sat up straight in his chair, ready for instructions.

Inwardly I groaned. They couldn’t fix this for their son, or for themselves any time soon, and I could see that at least Mark wanted a solution now. They were going to have to live in grief with him and themselves for a long while.

“Yes, let’s do talk about Angus. But let’s not go too fast to him. Before I can share what might help you with him, I want to know more about how you are experiencing today and yesterday. What has this been like for you?”

Claire sat back in her chair, with an air of defeat. “Devastated. And I feel a cascade of things. Exhaustion.”

That’s it, the sense of helpless defeat when you can’t protect your child. Though no one’s fault, it feels like a parental failure. I decided this was not the moment to elaborate this. What agency they had left they needed to carry them through the next few days.

Mark too leaned back in his chair, looked at his wife, and then made piercing eye contact with me. I held his gaze, to reflect the pain I saw on his face. Mark added slowly, “I didn’t know something could feel this bad.”

“Those feelings for you aren’t going away for a long time. And there is a lot to get through,” I replied.

“I know they just have to do their job, but I feel like both the cops and the social workers are very suspicious of us,” Claire reported.

I nodded.

Mark jumped in. “We know we didn’t do anything to cause this. The autopsy will show that. They just have to follow up.” Claire hung her head.

“You want to know how I am?” Mark continued, his tone now angry. “I am so mad. Not at the cops, but this is so unfair. Cosmically unjust. And Angus is suffering.”

Ah, he is trying to protect his son, because he “failed” to protect his daughter. 

“It is,” I said with emphasis, “Completely unfair.”

Mark met my eyes again and a tiny sliver of real connection seemed present, but he was rushing to solve the problem at hand, his son’s trauma from this abrupt death of his sister. “So, what can we do to help Angus?”

I decided to work with his wish for some answers. “What has been his reaction so far?”

Claire grimaced. “I’m not sure what he was doing when I found her, and I was screaming and trying to breathe life into her. He came out into the living room when the EMTs arrived. He looked spooked. And my son is usually a little bit of a tough kid.” Here she smiled just a bit.

Mark added, “He is usually a little bit oblivious and is very active, in his own world.”

Claire went on, “After they took Bonny away, he started to cry and asked where she was going. I feel like I came to my senses then and told him she was sick and going in the ambulance to the hospital and that Daddy would meet her there. He seemed to take that in. I said Sandy, his babysitter, was coming while I went to the hospital too. He asked me to stay with him but then I left him with Sandy. She was reading to him when I went out. We didn’t know what to say when we came back, with Bonny dead.” Claire started to sob uncontrollably.

I sat, looking at them both, trying to generate warmth, allowing her strong affect to flow and for me to receive it. Mark went over to hold Claire, his eyes wet too. Finally, Claire’s sobs receded, and she sat up, grabbed a tissue from the table next to her.

“How does it feel to let it out?” I asked.

She smiled faintly. “It’s not like regular crying. It doesn’t get any better if you let it out or hold it in.”

“Yes, the grief is intense, and it won’t go away altogether, ever. It may, with time, be less intense.”

She nodded, then continued her description of Angus’s reaction to the chaos. “When we got back, Angus was not himself. He clearly knew that something was terribly wrong. He won’t talk now, not a word. And he is not his usual bundle of energy. He kind of just sits there.” Claire paused. “What should we say?”

“It’s hard to know how to explain this to him when you can’t explain it to yourselves,” I replied. Both parents looked so utterly sad, helpless, and young. “I don’t know what you should say exactly, but we can think about it together. It has to be honest. You have to say that she is dead, that her heart and brain stopped working, and that she is never coming back. Do you have any religious views that you want to give him about death?”

They glanced at each other and then said, “No, not really,” simultaneously. That was a good sign; they were attuned to each other. That could go a long way to help them get through this.

“Has he ever stopped talking before?” I asked.

Mark shook his head. “He did have some pronunciation problems and he’s had some speech therapy but no, he’s never stopped talking before. Though he is an action kind of kid usually.”

“How old is he exactly?”

“Three and a half.”

That gave me an idea of how he thought. Concretely. And with probably slightly underdeveloped narrative skills given what else they were saying about his language. It might be hard for him to participate in creating a coherent story about this.

“Okay. Basically, what I said before goes to the main point, to let him know that Bonny is dead.” I watched to see how they would react to this clear statement of the reality. Mark minimally flinched but I went on. “Angus will not understand death at his age. I always recommend the book The Dead Bird by the lady who wrote Goodnight Moon. It is simple and direct. You can read it to him over and over if he wants, to help him understand.”

Mark took out his phone and made a note of the book. “I will order it when we leave.”

I continued, “And even though you tell him once that Bonny is dead, he will likely need to hear it more than once, because he will understand it differently than you think he does. I mean, cartoons make sense to kids; when the guy gets run over and then he pops back up. Permanence doesn’t mean the same thing to preschoolers as it does to us.”

Both parents nodded.

“Don’t force him to talk but keep talking to him. Empathize with his state of shock. Label his feelings, including confusion. Children often regress under stress. His language sounds a little vulnerable. It’s not surprising that he might lose that. He might regress in other ways too, toileting for instance, or not being able to sleep alone.”

Mark almost chuckled. “Claire had him in our bed last night, and he had been in his own room for more than a year.”

“I had to be sure he would make it through the night, Mark,” Claire said, distressed.

“I understand completely,” I replied. “And it was wise. He needs your physical presence more than anything, and to the extent that you can, your emotional presence as well. Children are most reassured by their parents. You need to help him feel safe. Mark, can you be okay with that for now?”

“Of course. Claire, I didn’t mean…” She nodded at him.

Different Ways of Grieving

“One part of this, as you try to manage what Angus needs, is to allow each other to need things that might be different. There is a lot of research suggesting men and women often grieve differently.”

Claire asked, “What do you mean?”

“Let me ask Mark. When are you going back to work?”

“Oh, I’ll want to get back in a couple of days. I can’t imagine sitting around like this for very long.” Claire looked horrified.

“That is what I mean. To feel useful and in the routine can often feel like healing to men. Often, women find they just need more time together. And that conflict can be misunderstood by both. I wonder, Mark, if you really will want to get back to work so soon, and if you will be able to meet your need to do that and balance what Claire and Angus might need.”

Mark looked at his wife. “We can talk about it, of course.” She smiled for the first time.

“When we have the funeral, should Angus be there?” Claire asked.

“Yes, unless there is some compelling reason elsewise. But you need a back-up plan, in case he is disruptive or very upset, or you feel you can’t grieve as you need to with him there. Someone who could take him out and could bring him back. It has to be someone he knows and trusts. Though he won’t understand all the nuances, he will be a part of saying good-bye to his sister, with you and family and friends. That’s what matters,” I said.

I could have cried right then. I had succeeded in pushing my past out during most of the session, but something felt very big, pressing down inside of me, my own emotional exhaustion at trying to hold them and me at the same time. They were hurting and it hurt to see that, to feel the hurt with them, as I suggested what they do for Angus. Why couldn’t someone have said these things to my parents? Why? But I had to push that question away for the moment. I still had work to do.

“This is, not to sound clichéd, a process,” I continued. “It is going to take time. The goal with Angus is to help him have a story to tell himself about this time and about his lost sister, a story that will become part of his life story, that helps him feel that it is coherent and hangs together. To do that, you are also going to have to be willing to be with him over time and to talk about your own sadness and grief and confusion — of course in a modulated way when you can — so that he feels you all together.”

Mark let out a big sigh. “That fits with so much of my gut instinct, but already I can see that Claire’s mother wants to take him out to her house in Westchester, so we have time to cope and make arrangements. But I want him with us. Don’t you Claire?”

“I’m not letting him out of my sight for more than five minutes,” she answered forcefully.

“Is he close to his grandmother?” I asked.

“Well, yes and no. She travels a lot, but when she is around, she is super fun with him.”

Grandparent as playmate. Not what this kid needs right now.

“Some of that will be fine, but more as time goes on. You will deserve breaks sometimes, but now he needs you. As best you can, give him that,” I said softly. Both were quiet for a moment, and I saw Mark disconnect and return to some state of shock.

“I think this is enough for now,” Mark said. “You have given us the start, a preliminary road map. Claire?”

Claire nodded, tearing up slightly, and said, “Thank you Dr. Tingley. I feel like I have some better ideas about helping Angus.”

“I’m glad it feels helpful. It’s going to be a tough row to hoe, but I think you have what it takes to get it done. And remember, like always with parenting, taking care of yourselves is also a way to take care of Angus.” I made full-on eye contact, first with Claire and then Mark. “And remember I am here. Call if you need more.”

Claire bowed her head at me as they stood. Mark shook my hand.

When I returned to my chair, I let the tension of holding myself together through the session evaporate. Silently, I still felt all the same terror, confusion, sadness, helplessness, and anger as Mark and Claire, but I knew I had done decent work with them. I also thought, as Ben had said, that I was the perfect person for this — on many levels. It wasn’t just my 40-plus years in the field, working in childcare with toddlers, where I lived with children’s everyday tears and frustrations, or the career in academic developmental psychology where I learned the research that supported work with young children, or even my time as clinical psychologist, where I found a theoretical frame and the tools to connect with and manage pain and growth. It was all of that combined with my own experience of early loss, that brought me here to be able to do this job, this day. That felt satisfying.

There was another feeling, too. Gratitude. These two grieving people had come to me, trusted me, taken in my empathy and knowledge. I was honored they had let me in at such a time in their lives.

A circle was complete. My career began because I wanted people to take the emotional experience of young children seriously, as my parents had not. I had just done exactly this for Angus. This small child, whom I’d never even meet, allowed me to finish what I started, unconsciously, so very long ago, saving myself, and all the children I had touched in my career, from the denial of their young children’s grief and pain and the aftermath.

A quite different sensation took hold: I am done. I will not be compelled to do this work anymore. My mission is complete. I could work, but I didn’t have to, the compulsion gone. I slumped down, exhausted, and exhilarated. Was there time to get to yoga?

Postscript: I did not see the family again but heard from my colleague that they had relocated to Vermont and had another child. I also did not give up the practice of psychotherapy but now see many more adolescents and adults in my practice.

Using Play Therapy (and Movies) to Heal Attachment Wounds in a Young Child

Posted on by Psychotherapy.net Team

A Troubled and Troubling History

Peter was four. He had just started Head Start programing when his mother announced she was pregnant. It seemed almost immediately after that Peter became non-compliant with any authority. He experienced a disturbance in sleep and appetite, withdrew socially, refused to wear a seatbelt in the car, and misbehaved in public until his mother had to bring him home. Peter hit, bit, threw things, broke toys, and screamed to get his way, and developed an excessive need to be in control.

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More alarmingly, Peter engaged in harmful behaviors, riding his bike across the street in front of traffic, running over a two-year-old with his bicycle, putting a pillow over his mother’s head telling her to die, and deliberately putting toys on the floor to make his grandmother fall.

Peter’s mother reported that at eight months of age, he had rolled out of the bed, resulting in an ER visit and a report of suspected child abuse. During that ER visit, Peter’s grandmother was asked to help restrain him while they took X-rays, which revealed a broken knee cap. DCFS took custody of Peter and charged the mother with neglect. He spent two days in the hospital and one night in a foster home before being returned to his mother.

I concluded that Peter’s school referral and his mother’s pregnancy had triggered the medical trauma, separation, and attachment issues that were contributing to his behavioral and emotional difficulties. In that assessment, I identified several issues for treatment, including (1) intense fear and anger at separation from attachment figures, (2) inconsistency in setting limits/boundaries and consequences for misbehavior, and (3) the use of behavior, rather than words to express himself. At the time of developing Peter’s treatment plan, I noted that his favorite act of defiance was to run outside in his birthday suit (naked). Our first task in behavior management was to have him put on his underwear before his appointment began!

Growth and Understanding through Play

Peter’s mother and grandmother were nurturing and invested in his growth and development, as well as my support team during our home play therapy visits. Books, toys, and movies were abundant in the home. Working with children, I had come to understand that they find comfort and a sense of security in the predictability in movies. Peter was no exception and movies were frequently playing when I arrived.

Using a client centered approach that incorporated themes from movies his parents had allowed him to watch like, Honey I Shrunk the Kids, Titanic, and Jaws, Peter was able to process his experience and communicate very aptly the chaos he felt both internally and externally. He would play these movies, or parts of the movie during appointments, while he built his creations, including his parents and myself with his toys, and then act out the scenes. I saw the parallels between the movies and his life experiences.

He built an elaborate shrinking machine in the living room which, I believe, reflected his feelings of being totally overwhelmed with his world and the multiple changes he was experiencing. As he adjusted to school and the birth of his sister, his shrinking machine became smaller and disappeared.

Titanic reflected the family’s chaos during the time his mother worked away from home, which took her away for extended periods, and other times resulting in her return home after Peter was in bed. The grandmother was left to assume all parenting and childcare responsibilities. Peter would rewind and replay the moment the ship would break in half and sink into the ocean in a perfect parallel to the absence of his mother. He wore out the tape! His mother quit the job.

The presence of Peter’s grandmother in his classroom as an aide helped to heal the attachment wounds that had occurred during his early infancy. She took him to school, remained in the classroom and brought him home. As Peter adjusted to the structure and routine of school and gained confidence in the return home, he became challenged by the learning process and his desire to learn took precedence over his misbehavior. Both parental figures read to him and the social stories of The Bernstein Bears, and his ability to understand and apply what he heard helped him adjust to new and changing social situations.

Peter became able to verbally express his dislike for his sister but never intentionally attempted to hurt her. He would simply pick her up and move her, even when she would unintentionally destroy one of his play creations. One of my repetitive phrases during appointments was “Use your words!” Feelings of resentment disappeared when he was able to use his words and tell his mother and grandmother he did not like his sister because she was messing up his creations. They in turn made more conscious efforts to keep her away from his projects, and to listen when he used his words.

In his play around the themes from the movie, Jaws, Peter was the captain of an imaginary boat in shark infested waters. He brought all the people and things important to him into the boat, his mother, grandmother, sister, and me to protect us. He acted out the shark attack addressing his fears about his safety and nurturing needs. He would replay this scene many times. As the boat became bigger and bigger, the shark infested waters grew smaller and ultimately disappeared. So did his disruptive and aggressive behavior.

***

Peter was phased out of treatment. His mother and grandmother were learning that withholding his movies could quickly bring misbehavior under control, while their nurturance, consistency, and attention to his safety and security needs helped to strengthen and support his positive and social behaviors. Peter was able to play with new friends and enjoy all of the experiences of school.

How a Missed Therapy Session and Self-Disclosure Led to Therapeutic Gains

Posted on by Psychotherapy.net Team

Placing Therapist Needs First

They have always been uneasy feelings for me, ones that I’ve experienced over the years, mostly leading up to the major holiday break. Rarely, if ever, did they arise when I was a beginning therapist. I must admit now, that after having been a clinician for more than two decades, I find myself really looking forward to time to myself and engagement with family and friends over the holiday period — more than seeing patients. I also look forward in some instances to not seeing particular patients. Let me be clear though, that these feelings or desires are in no way a reflection on how I feel generally about working therapeutically or with my patients in general.

These feelings, I should add, typically arise in anticipation of a holiday break, and very rarely during the “normal” working periods during the year. In spite of my rationalizations, I still feel a measure of shame in making this admission. However, I believe that it is better to acknowledge my feelings and have the freedom to explore them without undue censure. I believe that this minimizes the chances of acting them out, although it is hardly a guarantee. My historic silence around this issue probably reflects an internalized taboo against choosing personal time over professional time, especially when clients’ wellbeing lies in the balance. I have chosen to break this silence here in hopes that doing so will benefit colleagues who struggle in similar ways.

I’ve learned that the cost to the client for repressing these feelings is enactment, in the form of forgetting appointments, double booking patients, or last-minute cancellations. While other periods leading up to non-major holidays may also be potential triggers for me, the end of the year is a seemingly more potent stimulus for these specific types of clinical acting out.

Case Illustration

I practice out of a large shopping centre, a setting that offers a combination of a relaxed atmosphere and buzzing intensity — a truly curious blend for me. Having a cup of coffee in the morning before seeing a patient is one of my favourite activities, part of my commitment to caring for myself in a rather small way. This particular day, I was especially excited in anticipation of treating myself to a Jamaican blended dark roast latte with foam. Its exquisite taste and heady aroma came hurtling to the forefront of my consciousness well before I arrived at my local coffee shop, assaulting my senses with feelings of anticipation.

I was nearly a week away from my upcoming year-end holiday and was looking forward to the well-deserved break. I was scheduled to see my first patient at nine o’clock — I refuse to do any earlier sessions because, in essence, I am not much of a morning person. Since I seemed to have plenty of time, “seemed” being the key word, I decided to indulge myself further, choosing to take my latte as a sit down in the coffee shop instead of the usual take-away. I sat at a table and settled in, motioned to the waiter, who took my order rather cheerfully as I made a brief nod to the barista, someone who I had become fast friends with over the past few months.

I made a mental note to stop and check in with him on the way out. He knew exactly how I liked my latte, so I felt I was in good hands. As I sat alone, sipping my delicious “nectar,” my thoughts drifted to the upcoming break. Spending long days at the beach whilst being unencumbered by work sounded heavenly at this point. As I was enjoying this moment of pure self-indulgence, I couldn’t help but reflect on a vague, yet growing recent feeling of not wanting to see patients. And those feelings did not reflect on my work with any particular one. The thoughts revolved around secretly hoping that patients wouldn’t arrive for their sessions (which indeed some did not). I hated the feeling even though I experienced it only dimly at times during this period. I tried to chase it from my mind so that I could continue with my sensory immersion of the moment. But it continued to nag at me.

The Rupture

Suddenly my attention was drawn to the time. It was 9:10 and I realized that my patient had been waiting for a full ten minutes for me. Panic ensued as I tried to unlock my phone. I had a missed call at 9:05 from the patient. I had “accidently” left the phone on vibrate and therefore didn’t hear it ring or pulsate. A rare lapse for me, but a lapse no less. I hastily returned the call hoping that the patient was still in my office, only to discover that they had gone. I detected no hint of anger in her voice, but I was not convinced when she said that I could talk tomorrow about setting up another session.

I apologized, but she rapidly talked me off the phone saying she had to go. I was dismayed, a sinking feeling of guilt and shame wrapped itself around me like a cloak, which I felt everyone could see. I hurriedly raced from the coffee shop in utter shame, upwards towards my rooms. Once there, I tried with profound difficulty to wipe from my mind the feelings of shame and guilt whilst I prepared for my next patient. But Jane drifted into my mind, and it became clear that as hard as I tried, it would not be so easy to forget what had happened. Jane had been a perfect patient in many ways, almost always on time, rarely cancelling a session, and paying on time for her sessions without any reminders. In many ways, she was one of my favourite patients (yes therapists do seem to have favourites, I’m afraid!).

Jane

Jane’s history made my infraction feel all the weightier. Jane and I had worked well together, after all, she took risks in her sessions and tried to be as open as possible. The one element that struck me was her reserve around expressing any criticism of me. Jane had grown up in a household where her parents seemed to discourage any form of criticism towards them. By all accounts, there was little to criticise in terms of their behaviour, but no parent is perfect, and when Jane tried to offer them any negative feedback on behaviour which she found less than desirable, she was immediately made to feel exceptionally guilty for doing so with words such as, “Was our behaviour towards you really so deserving of so much anger?”

After leaving her parents’ home, Jane had remained in an unsatisfactory marriage out of fear of hurting her husband if she expressed dissatisfaction with his frequent, less-than-pleasant behaviour. When she did eventually muster the courage to complain, he reacted predictably; in a manner which she experienced as defensive and counter-critical. The marriage ended during our therapy, after many sessions spent examining in detail why she remained. I listened patiently and attentively, intervening in as neutral a manner as I could tolerate. I am almost certain that some of my disapproval of her staying in the marriage must have leaked out.

About a week following the “incident” of running late, I left a voice message for Jane saying again that I was sorry for the error, and wondered when she would like to come in again. I offered her a free session as I had wasted her time by not being there for her. I knew deep down that the offer of a free session was meant in part to assuage my own sense of guilt and shame over missing the session, although I hoped it might go some way in making amends for my “transgression.” Another two weeks passed without any word from Jane, and I resigned myself to never hearing from her again. To my surprise, she called up one day almost four weeks after the missed session and apologised. She had gotten my messages but had become very busy with a work project and therefore hadn’t had the time to call me. She asked if I could schedule a next session, which I promptly affirmed for the following week at her usual time.

A Therapeutic Moment of Truth

Prior to that next session with Jane, I thought deeply about how I wanted to address the issue of missing her session. While I typically follow the dictum that the patient is responsible for initiating the session, I felt that this was one of the rare instances where I would take the lead. It was an opportunity for me to understand what my error had meant to Jane, to assist her in exploring any thoughts and feelings she had towards me for having committed this error and giving her an opportunity to decide whether she would like to continue seeing me. A hint of reservation regarding this pre-planned intervention did waft through my mind just before seeing Jane, but I ignored it completed (perhaps therapeutic instinct should not be so easily dismissed by us) and decided to proceed regardless. As soon as Jane entered the room, and even before I could speak, she immediately began speaking about her difficulties.

I decided to interrupt her, thinking that the error I committed was plaguing her as it was me. In retrospect, that was just a tad narcissistic of me. I began, “I know I missed our session three weeks ago and I noticed you didn’t bring that up. I realize that you’re having challenges at work currently and that the work issue is at the forefront of your mind, but please indulge me for a moment. We can certainly return to your workplace concerns before the end of the session.” “What are your feelings towards me for missing your session?” A long silence ensued from Jane which was not her typical manner of responding to me. Something was wrong. “Jane, I am aware that you have been quiet for some time after I asked you for your feelings towards me for not arriving for your session.” Again, Jane looked away and continued in her silences. Finally, she said, “There’s no feelings, I am sure it was an honest mistake. You’re making a mountain out of a mole hill.”

Usually, I would let it go at this point, but not that day. I pressed ahead. Perhaps Jane was again refusing to complain, reprising both her marital and childhood roles. Was she passing up an opportunity to do important work? I persisted, “But Jane, I noticed that you didn’t respond to my initial communications with you and even today there appears to be something off in your manner of speaking to me. This isn’t the Jane I know.” I continued, “Please try to look inside for a moment, Jane, and tell me what’s happening between us right now.”

Jane hesitated momentarily but then as if in a fit of fury, the likes of which I had never seen from her before, she spat out, “You could have at least simply apologized to me face to face instead of trying to analyse my feelings!” I was shocked, Jane had never spoken to me so directly and with such anger. I took a second or two for me to gather myself as she pierced me with her gaze. I retorted, “Jane, you’re absolutely right. I haven’t offered much of an apology to you in the flesh. Thank you for me telling me that now. Indeed, my focus on your feelings must have come across as self-serving. I can see that now. I am deeply sorry for having missed our session and I do regret my error; please can you say more about it?”

To my amazement, Jane immediately settled down, looked me straight in the eye and said, “I thought you missed our session because you forgot about me, perhaps I wasn’t as important to you as I thought I was.” I knew that this had something to do with Jane’s early history, after all, she had little experience of being taken seriously if she complained. But I choose instead to focus on the here-and-now between us.

I was not about to waste this golden opportunity to self-disclose, repair the rupture, and help Jane, all at the same time. I replied, “Jane you’re misreading the situation. The fact that I missed our session has nothing to do with you, in fact, it has something to do with me.” I paused and noticed that Jane was now concentrating intently on my words. I continued, “In fact, it had everything to do with me. I missed the session because I was caught up in my own imagination and enjoying some personal time just prior to our session, which caused me to lose track of the time. You see, I was distracted with rather pleasurable thoughts of my upcoming holiday break, and this was the reason for me losing track of the time. In fact, I always look forward to our sessions, however at that point in the year I am susceptible to thinking about my break.”

I anticipated a wave of criticism from Jane, clearly a moment of countertransference, but the opposite occurred. For the first time in our work together, Jane shared her feelings of not being good enough and her feelings of competitiveness with my other patients. In truth, I had no real way of knowing exactly how my self-disclosure would impact Jane, but if I expect honesty and self-revelation from my patients, then I too must take a calculated risk in sessions as much as I expect them too.

***

I’ve learned that self-disclosure does not always facilitate the therapeutic process. It remains a high-risk/high-gain intervention. I may have succeeded in this instance, as I banked on my clinical judgement that my disclosure would be more effective than merely exploring her fantasies about whether she was important to me or not. My disclosure provided concrete evidence to Jane that she was indeed likeable, and while we did work on her need for approval in future sessions, this disclosure on my part led to her feeling more confident in asserting herself both inside and outside sessions and in taking such incidents less personally.

Questions for Reflection and Discussion

What are your thoughts and feelings about the therapist’s experience following the missed session?

How do you balance the demands of clinical practice and your personal life?

How might you have conducted that follow-up session with Jane?

How do you know when you’ve reached your limit on seeing patients and how do you address that clinically and personally?

How to Use Narrative Therapy to Help Clients Locate Alternate Stories

Posted on by Psychotherapy.net Team

As a practicing psychotherapist, I hear a lot of stories. These stories are, without fail, complex, nuanced, and multidimensional. But, often, clients come to therapy with a singular focus on only one element of their larger story. In narrative therapy, the term is “problem-saturated” story. Part of my work as a therapist is to guide clients to widen their lens beyond this problem story and recognize that many of their stories are actually a story within a story (within a story). The act of locating these missing story parts and creating an alternate narrative is a way to alter the problem-saturated story and to clear the way for a new, more accurate, and helpful story to emerge. I enjoy little more than when a therapeutic opportunity presents itself — it feels like a gift. So, when John, a 76-year-old gay man, shared his story with me, it came with a giant bow on it: here was a perfect opportunity for a narrative therapy approach. John’s story began like this. It felt as if he had spent his entire life being “sneaky,” and feeling remorseful for what he described as his “untrustworthy ways.” As he began to share his life story, however, a very different story presented itself.

A Secreted Life

Born in the late 1940’s, John grew up in a small rural town where conservative and traditional values around relationships and marriage prevailed. His parents, both uneducated immigrants, neither understood nor accept homosexuality. When John, in his teens, shared his preference for men, his parents agreed that he should not be permitted to remain in their home. Though they apologized years later and expressed regret for rejecting him, John had difficulty letting go of their implicit message that being gay was something to be ashamed of and, therefore, secreted. The telling of this “thin version” of the story, as narrative therapists call it, seemed to offer multiple therapeutic opportunities. First, we could explore where this story originated. In this case, demographics, social norms of the time, and institutionalized beliefs were what Stephen Madigan might term the “undergrowth” of John’s narrative. Next, we could investigate if this was, in fact, John’s narrative or someone else’s. Parenthetically, clients often “inherit” or are burdened with others’ stories which they take on as their own. In this sense, they become colonized. Getting back, it was, without question, a story his parents had told and not necessarily a story John believed, though he had introjected and accepted it. This is, in essence, what narrative therapy is about; an honest investigation of the stories we tell ourselves. Once clients have investigated these narratives, they are free to begin challenging them, updating them, and cultivating new, more compassionate self-stories.

A Therapeutic Path Forward

I saw my role as guiding the investigation into John’s story. In one therapy session, I asked him to tell me about life as a gay man in the mid-1960s, when he was in his twenties. He replied, “well, we had to be careful.” “Even sneaky?” I asked. He smirked, understanding where I was going with the question. “Well, yes, sometimes we had to be sneaky,” he conceded. We began to discuss how that behavior that John had so automatically viewed as “bad” was, actually, a product of the times, the geographical area, and the social climate. John went on to describe how he found community with other gay men and with straight people who were accepting of his lifestyle. Missing story parts were coming to the surface and alternate story was emerging. John’s “problem story,” for a long time, had been: “I was sneaky. That was bad and therefore, I was bad.” It was now morphing to sound more like this: “I had to behave a certain way at a certain time for reasons that were out of my control.” This is the way uncovering alternate stories works. The more he started telling and revising his story, the more he began to recognize that there was far more to his tale than the theme of ‘badness.’ Musing aloud, John drew a conclusion: “so I guess I wasn’t really sneaky. I was just finding a way to live my life.” “The life that was right for you,” I added. Be clear that in this session, John and his story did the bulk of the work, not me. I merely guided the conversation using a narrative questioning approach. Armed with a new story, John slowly shed his previous negative self-label. More than that, he began to view himself as an asset to humanity rather than as a stain on it. He explained that he had discovered a new fondness for sharing his story with younger generations so that they could understand how his generation’s struggles had helped pave the way for the greater level of inclusion that LGBTQIA+ people experience today. The alternate story ended up being much for helpful to John and to those he shared it with than had been the long-standing problem-saturated story. When clients tell me they are “just rambling” or “going off on a tangent,” I often explain that it is necessary for me to understand their story — and all of its elements. What they may see as rambling, I see as vital to my comprehension of their story. The same way I would struggle to understand a novel if I read only a few pages, I would not fully comprehend a client’s life story if I was given only a few facts. Narrative therapy, for me, is an exercise in wholeness; it encourages clients to stand back and look at their lives from an expansive, panoramic vantage point. From a higher plateau, clients begin to identify story parts that had been obscured and to cultivate a more complete telling of their lives. Part of the honor I experience as a psychotherapist is that I am often welcomed into a client’s story. I can give back by helping my clients to see their stories as important, valuable, beautiful, and nuanced…as are they.

Sidestepping the Dependency Dance in Psychotherapy

Posted on by Psychotherapy.net Team

“Not I, nor anyone else can travel that road for you. You must travel it by yourself. It is not far. It is within reach.” – Walt Whitman

We’ve all had someone text us a single question mark after not responding to them within the timeframe they expect. You know the one. It looks like this:

“Can I come over — 12:00pm?”

“?”

I mean, did your question mark wander off and get lost somehow? Should we head to the front of the store to reunite it with its missing sentence? While I think the use of this orphaned punctuation should be considered a misdemeanor offense, it points to a natural phenomenon about human interaction, especially the disembodied kind most common in the digital universe — when we communicate with each other, there are rhythmic expectations. When we want the rhythm of a conversation to be slower, but someone else wants it to be faster, the single question mark makes its grand appearance.

“I’m waiting,” it complains.

When starting a new relationship, deciphering these rhythms can be a challenge because the response time between parties can suggest very different things. If one party responds to a text message quickly, it might mean they’re interested in the relationship, or it might indicate that their device was simply nearby. Yet if someone responds to a text message slowly, it might indicate they’re disinterested in the relationship, or it might simply mean they’re preoccupied. The signals are unclear and they require interpretation.

If we’re honest, it’s probably impossible to know what someone’s response time actually indicates, but this doesn’t stop us from reading between the lines. But the problem with reading between the lines is that we simply end up interpreting or projecting. When we feel alone, we might imagine that our text was read but ignored, and when we’re preoccupied, we might feel smothered by a quick response back to us. While much of our communication has moved into the digital space, it remains timelessly true: new relationships have a way of tempting our projections.

It’s only after the relationship leaves its early stages that the conversational rhythms fall into place, and the uncertainties become clear. Familiarity with someone’s rhythms comes with time. Similar dynamics also exist within therapy. When the therapist and client are in the process of creating a new relationship — learning, in a sense, to dance together — the rhythms of communication are uncertain before becoming apparent. And while rhythms in a non-therapeutic relationship require time before becoming understood, therapists don’t always have the luxury of time. Fortunately, the therapist can learn strategies to remove these rhythmic uncertainties, and the process of understanding our clients can be accelerated. I certainly have.

The Rhythmic Uncertainties of Therapy

One effective way I have found to remove the rhythmic uncertainties in therapy is to be forthcoming about my own rhythms. Most of my clients have not met with me beforehand, so they don’t know the therapy rules — at least not mine. They don’t know if I take phone calls after 5pm, if I correspond on weekends, or if emails should contain intimate session details. Whatever my own therapeutic rhythms might be, it is my responsibility to make them explicit.

Another area where I have made my rhythms explicit is in my response time to phone calls and emails. Most therapists I’ve encountered choose a 24-hour window, while others choose 48. While I don’t think the timeframe itself matters too much, it’s important to pick a response time and stick to it. This is because when we stick to a consistent rhythm of communication, it elicits important questions about our clients.

“Jessica called me twice in the past 24 hours, is something wrong?”

“James calls me every day. What’s going on here?”

When I create a consistent schedule of responding to my clients, I create a baseline, and by holding my own behavior constant, it helps me to notice any deviations in a client’s behavior. If someone attempts to reach me multiple times within a single communication cycle, sometimes this deviation signals that I need to intervene. A client might attempt to make contact several times because their personal safety can’t wait until the end of a 24- or 48-hour window. Multiple missed calls can be flares shot into the sky.

In other instances, consistent attempts to contact me within a single communication cycle can indicate something much different. This behavioral rhythm often elicits an important question that each new therapist has to learn — and certainly, I was no exception. That question is, “what should be done when a client makes persistent contact and has no intention of slowing down?”

The Dependency Dance

One of the challenges of being a beginning therapist is working with highly dependent clients. While these clients are different in innumerable ways, they also share striking similarities. The stories that bring them to therapy contain universal themes.

One such theme I’ve noticed is that these clients experience a strong sense of helplessness, and as a result, they depend on others for excessive amounts of support. They don’t mean to, but they rely on their relationships to balance and guide them; they turn human beings into handrails.

The difficulty associated with this excessive need for support is often manifested through a dependency dance: a symbiotic cycle marked by ever-increasing client support, and ever-decreasing client security.

Here’s how the cycle has functioned in my own clinical work. Feelings of panic surge within the client, and in response, they contact their loved ones to help them de-escalate. Yet after the panic eventually finds its resolution, the inner turmoil soon returns, as does their need for support. From within the client’s subjective experience of the cycle, each time they’re de-escalated, they feel more convinced that they can’t de-escalate themselves. Receiving help from others unintentionally reinforces their feelings of helplessness. This increases the client’s experience of fear, and then this fear ushers the panic back in with greater frequency. It’s a panic trap.

As the frequency of their panic accelerates, so do their requests for help, and this creates fatigue in their support system. Eventually, and usually with great reluctance, their loved ones exit the dependency dance by either distancing themselves or ending the relationship entirely. Once these supportive relationships end, the client’s feelings of shame become overwhelming. With no remaining handrails in reach, they reach out for a therapist.

In my early days of practicing therapy, it took a process of trial and error before learning how to step into this complicated cycle effectively. My learning curve was steep and uncomfortable. My hope is that by sharing my early mistakes, that I can offer some modicum of guidance to fellow clinicians, both nascent and experienced.

Early Mistakes in Psychotherapy

When I first started working with highly dependent clients, there were three mistakes that I tried to avoid. The first was allowing the cycle of crisis-and-relief to continue inside of the therapy. If I allowed the client to implement their dependent style into our relationship, then the heart of their problem would remain unaddressed. I’d be providing de-escalation services, but this would reinforce their feelings of helplessness, and then their surges of panic would return more frequently. I didn’t want to contribute to the dependency dance.

The second mistake I hoped to avoid was connected to the first. I worried that if the cycle continued, I would undergo the same exhaustion that their support system did. These clients had a long line of exhausted people behind them, and I didn’t want to find myself at the end of that line. If I joined the dependency dance, I worried their exhausted support system would only be replaced by their exhausted therapist.

But the mistake that concerned me the most, the third one, was creating distance in our relationship too quickly. These clients often had important relationships recently ended, and they were bracing for rejection. They had been deeply hurt, and I worried that if I created distance in our relationship too quickly, their feelings of shame would be quickly reactivated. I didn’t want the shame they experienced in their previous relationships to be reexperienced with me.

I spent time thinking about how to simultaneously avoid these three mistakes. How could I elude the dependency dance, protect myself from exhaustion, and avoid reactivating their feelings of shame at the same time? This was hard. I felt anxious and stuck.

Each answer I came up with seemed unsatisfactory, and despite my best efforts, I made all three mistakes multiple times. I took phone calls after hours and scheduled extra sessions, and just as I worried, my client’s surges of panic became more frequent. No matter how I pretzeled myself, their need for my help only increased.

In other cases, I was too reactive. I was exhausted from being overly available with dependent clients in previous treatment episodes, and so I expressed my limits too firmly. These clients ejected from my office as if launched from a catapult before disappearing into the clouds. Their feelings of shame had reactivated, and they quickly terminated the therapy. I couldn’t blame them.

Eventually my mistakes brought me to a solution. I discovered that I didn’t need to choose between my clients becoming dependent on me, or more independent from me. Instead, I could do one before the other. I could first join the dependency dance, and then show them how to end it.

A Therapeutic Strategy Applied

I’ve come to believe that to help clients become less dependent on those in their lives, they must first be allowed to temporarily become dependent on their therapist. With this logic, and joining the client on their terms, I could work to change the relationship from the inside. Instead of telling a client to become less dependent on me, I could show them how to do it, and then they could then learn how to replicate this process within their personal relationships.

But what does temporarily joining the dependency dance mean in practice? Highly dependent clients will request extra sessions and phone calls, and so how available to make myself was the challenge.

There’s no hard and fast rule on this, but I think it’s useful to make ourselves available two additional times outside of our scheduled sessions. There’s a reason to settle on two times instead of one or three. If I make myself available outside of scheduled sessions for one time only, once I start to create distance from the client, it becomes harder to protect them from feelings of shame. These feelings of shame simmer just beneath the surface, and if I create distance too readily, this feeling can be brought to a boil. When this happens, the client’s disengagement from therapy becomes more likely.

Yet being available three times or more creates a dynamic that’s too similar to their previous relationships. If I fall into their old pattern for too long, the client isn’t working on ending the dependency dance, they’ve simply found themselves a new person on whom to become dependent. Yet by making myself available twice outside of scheduled sessions, I have the best chance of avoiding both negative outcomes: the client can avoid shame and early termination, and I can avoid becoming trapped inside the dependency dance.

Making myself available twice outside of scheduled sessions also allows me to structure two different conversations. In the first conversation, I can introduce strategies to help the client work through their feelings of panic, but I refrain from discussing their dependency. There’s not enough trust yet, and the risk of the client reexperiencing their shame is too high.

Instead, I can introduce grounding skills, breathing exercises, and other emotional regulation techniques. It’s important to introduce these strategies in the first conversation, because when their dependency is eventually addressed, I want to remind the client that they already have the mood regulation techniques that they require. More on this a little later.

But the first conversation is just as much about earning trust as it is about introducing emotional regulation skills. What I’ve learned is that when trust is low in therapy, my words must be delivered with more precision. Low trust lowers the margin for error. When clients are skeptical of my intentions or competency, my interventions need to be effective. The dart must hit the bullseye.

The good news is that the reverse is also true. When trust is high in therapy, the margin for error widens. The presence of client trust permits the absence of clinical perfection. My words don’t have to hit the bullseye, or the dartboard for that matter. It’s for this reason that I consider trust-building to be the therapeutic master-skill. It allows me to maintain my effectiveness while remaining imperfect in my practice. When I earn a client’s trust, inevitable errors are less damaging, and the prospect of client improvement despite my imperfections remains intact.

When I introduce emotional regulation skills in the first conversation, I’m also practicing this master-skill; developing trust by making myself available to the client. This is important because for the second conversation, the degree of difficulty increases. My clinical imperfections are more likely to assert themselves, and so I’m going to need a wider margin of error for what’s to come. This next dart is a little harder to throw.

The Second Conversation

Once I’ve built some degree of trust and provided strategies to help the client manage their feelings of panic, I need to exit the dependency dance the next time we meet. If I don’t, I run the risk of exhausting myself and reinforcing their feelings of helplessness. So how do I exit this dance without activating the client’s shame? I can do so by implementing these four steps:

Taking the Blame

Externalizing the Helpless Feeling

Triangulating Against the Helpless Feeling

Affirming that New Rules are for Next Time

Let’s explore an example of how this conversation might sound in a telehealth setting, and then we can unpack the steps therein:

Client: “- -”

Therapist: “You’re on mute.”

Client: “Oh, sorry. Can you hear me now?”

Therapist: “Yes, but now your picture is frozen — wait, now you’re unstuck.”

Client: “ – -”

Therapist: “You’re on mute again somehow.”

Client: “Sorry, how about now?”

Therapist: “You’re good.”

Client: “Wow, okay. Thanks for making the time. I’m feeling really bad, and I just need to talk about things with you again.”

Therapist: “Thanks for reaching out. I’m sorry things continue to be difficult. It sounds like these strong feelings keep rushing over you.”

Client: “Yeah, what should I do about it?”

Therapist: “That sounds really awful. So, I hate to sidetrack us before getting started, but would you mind if I shared something that I’ve been worrying about?”

Client: “Yeah, of course.”

Therapist: “I don’t doubt that these feelings are really difficult to experience, they actually sound physically painful. But I’ve been thinking since the last time we talked, and I’m worried about eventually making things harder for you.”

Step 1: Taking the Blame. When I start the second conversation, I can lean on the phrase “I’m worried about eventually making things harder for you.” There’s a reason this phrase can be helpful. As I’ve discussed, these clients have felt rejected in previous relationships, and their feelings of shame are just beneath the surface. Yet if I express concerns about the dependency dance, not in terms of our own personal difficulty, but in terms of the potential difficulty for them, I can reduce the chances of reactivating these feelings. I can help keep the shame beneath its boiling point.

Now is it possible that I’ll feel inconvenienced by making myself available for this second conversation? Yes. But is it helpful to share these feelings with the client? In this case, I don’t think so.

Perhaps the person-centered therapist will object, “But this isn’t authentic. You’re not demonstrating congruence!” That’s a valid critique. Sometimes there’s a tension between my intention to be helpful and my ability to be congruent. My private reactions aren’t always useful to my clients, and when faced with the choice of demonstrating perfect transparency or perfect sincerity, I want to prioritize sincerity.

While these two concepts might seem identical at first glance, I am careful not to confuse them. The word transparency comes from the early 15th century, and from the Latin nominative transparens. It translates to something like, “to show light through.” Transparency is a pane of glass from which nothing is hidden on either side. But the notion of sincerity means something entirely different. Sincerity comes from the 16th century, and from the Latin word sincerus which translates to something like “whole, pure, and clean.”

While I may not be able to maintain perfect transparency in each moment, I can always work to cultivate intentions towards my clients that are “whole, pure, and clean.” In this case, the disclosure of my own fatigue risks eliciting a shame response from the client, and if I’m to be helpful, avoiding this reaction is paramount. While it’s ideal to practice both transparency and sincerity whenever possible, in moments like these it’s better to prioritize the sincerity of my intentions over the transparency of my reactions.

After expressing that I’m worried about eventually contributing to the client’s distress, I can implement:

Step 2: Externalizing the Helpless Feeling. When implementing this step successfully, it sounds something like this:

Client: “Making things harder for me? I don’t feel that way. What do you mean?”

Therapist: “This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering if there’s this voice that tells you that you can’t manage these moments of distress on your own. My concern is if I talk through these feelings with you each time they come up, I’m agreeing with this invalidating voice. It’s as if the voice is saying, ‘You can’t do this by yourself,’ and I’m saying, ‘You’re right, let me jump in to help.’ Then each time you work through these feelings with me, it reinforces the sense that you can’t do it alone. But tell me what I’m missing.”

This intervention is more directive in nature and so it’s placed between therapeutic airbags, but to help clients approach their feelings of helplessness with more emotional safety, I can also use language that helps them externalize their feelings of helplessness. If I use the phrase, “there’s this voice that tells you…” this invites the client to think about their feelings from a safer distance. Here’s an example to demonstrate how this works.

Imagine hearing the following two phrases and listen for any differences in how you experience each statement. If it’s difficult to notice the differences while reading privately, it might be helpful to have someone read them aloud. Here’s the first phrase:

“You feel like you can’t do this by yourself.”

and the second one:

“There’s this voice that tells you that you can’t do this by yourself.”

Did you notice anything? The first phrase moves us into an emotional space and the second moves us into an evaluative one. This occurs because describing a feeling as “a voice” pulls the feeling out from the internal world, and places it into the world that’s external. An emotion is something we feel internally, but a voice is something we hear externally.

When I invite the client to think of their feeling of helplessness like it’s coming from the outside, this helps them step back from their uncomfortable emotional state. It creates space and emotional safety. This can make it easier for them to think about what they’re experiencing.

After I’ve taken the blame and externalized the feeling of helplessness, I can move into:

Step 3: Triangulating Against the Helpless Feeling. Let’s reenter the transcript to hear how this might sound:

Client: “I guess that makes sense. But what do I do about it?”

Therapist: “Well I think we could team up against this voice that says you’re incapable. I think we could create a practice arena for you to prove it wrong. If we can build some victories where you move through these times independently, then you can grow in your confidence to manage these difficult feelings. But please, push my thinking around here.”

When I externalize the helpless feeling in Step 2, I’m not only creating distance for the client to think about their feelings with more safety, but I’m also laying the groundwork for Step 3. These two steps work well together because by using the “the voice” intervention, I’ve increased the number of participants in therapy by one. Therapy goes from two parties (the therapist and the client), to three parties (the therapist, the client, and “the voice”). And once I’ve created this third party, I’ve created the opportunity for triangulation.

Now, triangulation typically carries a negative connotation and for good reason. It’s used to describe the process whereby two people inappropriately collude to exclude a third party. Triangulation is the reason groups of three are often unsuccessful in adolescent friendships; two friends grow closer to one another by excluding the third.

Yet in this case, the third party (the voice of helplessness) needs to be sidelined, and I can grow closer with my client by excluding it. I can initiate this benevolent triangulation by using the phrase, “we could team up.” This phrase prevents me from challenging the client’s feelings of helplessness directly, and instead I’m able collaborate with them against “the voice.”

That was Step 4: Affirming that New Rules are for Next Time, and this brings my four-part strategy to its conclusion. Here is the therapeutic dialog:

Client: “I hear what you’re saying, but I still don’t know what to do.”

Therapist: “Maybe we can start by reviewing what worked last time. This way I can help you find some relief today, but we can also figure out what to practice next time. Then when you steady yourself without me, you can push back against the invalidating voice that tells you that you can’t manage these feelings independently. What do you make of that?”

The rationale behind Step 4 is when I challenge the dependency dance, I don’t want to increase distance from the client in the same conversation. Instead, I can review the emotional regulation skills from the first conversation, but the client won’t attempt to manage their panic independently until its next occasion. This helps me demonstrate to them that changes to the relationship are not an expression of rejection. I’m not expressing my own need for distance, but instead, I’m creating opportunities for them to disprove the voice of helplessness. I’m not taking space from the client, but together, I’m creating space for them.

Now that I’ve discussed each step on its own and explored the internal rationale, I’ll provide a fuller sense of how this four-part strategy sounds with all four parts together. Here’s the transcript in its entirety:

Therapist: “I don’t doubt that these feelings are really difficult to experience, they actually sound physically painful. But I’ve been thinking since the last time we talked, and I’m worried about eventually making things harder for you (step 1).”

Client: “Making things harder for me? I don’t feel that way. What do you mean?”

Therapist: “This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering if there’s this voice that tells you that you can’t manage these moments of distress on your own. My concern is if I talk through these feelings with you each time they come up, I’m agreeing with this invalidating voice. It’s as if the voice is saying, ‘You can’t do this by yourself,’ and I’m saying, ‘You’re right, let me jump in to help.’ Then each time you work through these feelings with me, it reinforces the sense that you can’t do it alone. But tell me what I’m missing (step 2).”

Client: “I guess that makes sense. But what do I do about it?”

Therapist: “Well I think we could team up against this voice that says you’re incapable. I think we could create a practice arena for you to prove it wrong. If we can build some victories where you move through these times independently, then you can grow in your confidence to manage these difficult feelings. But please, push my thinking around here (step 3).”

Client: “I hear what you’re saying, but I still don’t know what to do.”

Therapist: “Maybe we can start by reviewing what worked last time. This way I can help you find some relief today, but we can also figure out what to practice next time. Then when you steady yourself without me, you can push back against the invalidating voice that tells you that you can’t manage these feelings independently. What do you make of that (step 4)?”

***

I’ve learned that while it’s understandable for the therapist to feel overwhelmed when working with highly dependent clients, it’s important to remember that these clients are living incredibly uncomfortable lives. It becomes even more important, therapeutically, to try to imagine their surges of anxiety, their loss of important relationships, and the sense that life is a spinning room. By working to understand what these clients experience in their emotional and social worlds, it becomes easier to provide support they’ve yet to experience. The real work then focuses on earning their trust, teaching them strategies to reduce their distress, and watching with admiration as they learn to exit the dependency dance themselves.

[Editor’s note: In the next installment of this five-part series, the author will address the challenges of working in the shadows of client suicidality]    

A Healing Journey: Developing Coping Skills in the Face of Trauma

Posted on by Psychotherapy.net Team

She had lived in a major city for years and felt confident and secure in her ability to negotiate public transportation. During the pandemic, she worked from home, like a large portion of the global population. Emerging from that dark time, as people returned to work, so did she. Barely a month back on the job, she was pushed against the wall by a man in the subway, had her purse snatched by a man outside a drugstore, was physically assaulted by a man in a pedestrian walkway that connected her neighborhood to public transportation, and intimidated by a man standing behind her at the pharmacy.

All these events occurred within her neighborhood, an upscale complex near an inner-city transportation hub. The final straw was a shooting incident in a public area she had to negotiate to connect with public transportation to work. Paralyzed with fear she withdrew to the safety of her home behind an iron gate and security cameras. If she ventured from the home, it was with Uber or her husband. She had lost her sense of safety and security. Working from home during the pandemic was safe for her, and returning to the office was not initially a problem. But in the shadow of these frightening events, she began experiencing obsessive thoughts, sleep disturbance, hypervigilance, flashbacks, difficulties concentrating, depression, and anxiety. She reached out for help via telehealth and with the devoted support of her husband, treatment began. In a short period of 11 months working with her, she was able to reclaim her sense of safety and security, and her confidence in negotiating her environment. She was to call that 11-month period, “The journey.” Her name was Sarah.

Preparing for The Healing Journey

Upon initial assessment, my strategic plan was to stabilize Sarah in the face of this crisis, reduce her symptomatic behaviors, evaluate her coping strategies, develop a de-sensitization plan, and incorporate EMDR into the process.

My first step was to remove the pressure of traveling to work so we could begin to address her anxiety as we began to focus on treatment. Fortunately, her employers were very supportive, only asking for documentation to process her request. She was the driver on this journey, so I sent her the document for approval before sending it to her employer. Sarah said when she saw the document, she cried because someone finally understood what she was experiencing. Her anxiety and mood instability diminished with the approval of her medical exemption to work from home.

I typically conceptualize symptom management and coping skills as “tools in the toolbox.” If they are willing, I ask clients to draw a picture of their toolbox and to put their tools inside it. This activity makes an internal process feel more real. I suggest that they add tools as we go along.

At the onset of treatment, Sarah preferred not to use medication. She already had many skills, resources and supports in place. These included her friends, work environment, pets, cooking, reading magazines, gardening, music, exercise, walking, yoga, and art. She and her husband were taking a self-defense program, and he had already purchased a handheld pepper spray for her, which she never left home without. Her husband was her strongest support, ally, and partner in the treatment process, working the plan with her from beginning to end.

During treatment, Sarah was able to share the trauma narrative by describing each incident that occurred. The first step in her desensitization was to describe the walk between her home and the transportation link. Next steps were to have her husband video record the walk for them to watch together which they did, several times.

One month after her first appointment, we discussed using behavior modification and progressive desensitization. Her homework was to develop the plan. She was to work the plan at her own pace, which she did eagerly, logging the steps as she took them, her physiological responses, feelings, and thoughts. We would discuss her journal entries in treatment, and she would modify the plan as needed, especially when barriers and roadblocks seemed insurmountable.

Addressing the Clinical Obstacles

Sarah’s environment provided unanticipated challenges that put her coping skills to the test. Multiple such incidents occurred in their neighborhood; a man fleeing from the police jumping into their backyard while they watched, a shooting in the lobby of a theater before they arrived, teenagers rioting over the weekend, and a man riding a bike in the neighborhood being attacked.

Initially, and each time one of these events occurred, Sarah’s symptoms would briefly re-emerge. During those times, we explored the incident in detail, and how she and her husband responded. We were able to reframe her responses as correct and resourceful choices. She began to recognize that different environments and events required their own unique, rather than blanket responses.

When Sarah did encounter either internal or external obstacles, she would modify her response accordingly, an example of which occurred around her visit to the local drugstore, which was frequented by vagrants. Everything in the store was under lock and key, and customers had to ask for help. During this particular instance, Sarah implemented what we called the “fire drills.” This involved visiting a same-named drugstore in a “safe” neighborhood, and recognizing that it was not the store, but the neighborhood that elicited fear and anxiety. Sarah and her husband concluded the environment they were living in was changing and no longer safe, and that it was time to make a change. Sarah was soon able to apply a related strategy to coping with her fears associated with the tunnel where one of her earlier traumatic experiences had occurred. We successfully added EMDR to her treatment plan.

We had been preparing for termination and scheduled our final appointment. When she came on-line for that session, she excitedly proclaimed, “You are not going to believe this.” She then detailed how she and her husband decided to take the subway home one night after leaving the theater, in front of which there was a protest.

Realizing that while many of her initial fears were justified, Sarah had re-gained control of her life and put her traumas behind her. She had completed her journey both literally and figuratively! She shared her final art project with me, which was a graphic reflection of her healing journey. A masterpiece in every sense of the word; it was being framed as we concluded our work, and was to hang in her new home, as a trailhead of sorts for the next phase of her journey.