Author: Psychotherapy.net Team

Our Time is Up

Posted on by Psychotherapy.net Team

When I arrived at Joan’s, there was construction going on. The elevator I had usually taken was being worked on, so I had to take the service elevator. I asked the doorman what was happening and he said they were making the elevator self-service and doing some redecorating.

“What will John [the elevator operator] do then?” I asked naively.

“He’s retiring. He was over 70.”

Sad I had not said goodbye to him, I frowned. I had seen him three times a week for years and had just taken him for granted. I guess I thought he would always be there.

When I rang Joan’s bell, she startled me by opening the door herself rather than ringing me in. Her face was ashen, as if all the color had been siphoned out and her eyes had small dark pouches under them. I had a feeling of foreboding; I could hear my heart pounding.

“Hi, Rose,” she said with as much of a smile as she could muster.

She opened the door to her office for me to go in and when she walked over to her chair she was limping. I didn’t notice it before because she was sitting in her chair the last couple of times I arrived for my sessions. I wondered what that could be about. Maybe she hurt her leg or needed a hip replacement.

She said, “Instead of lying down today, why don’t you sit up?”

Then I knew this wasn’t about her leg or her hip. Propping up the pillow against the wall under the Georgia O’Keeffe poster, I tried not to breathe, as if that would delay the bad news. I noticed the philodendrons by the window were brown around the edges; she must have forgotten to water them.

“I thought I hurt myself exercising at the gym when I first felt a pain in my side.” Her tone was calm and accepting; I could feel myself exhale. Her gray roots were showing, and her hair was flat on one side as if she had slept on that side and not taken a shower and washed her hair that morning.

“When it didn’t get any better in a few weeks, I went to the doctor, and he said it was probably a hairline fracture. He took an X-ray. Then he called me to tell me it wasn’t a hairline fracture — the cancer has returned. It’s metastasized and it’s cracked my bones in the hip and pelvis.”

I let out a gasp. “Oh, fuck!” My lower back tightened.

She went on unruffled. “I’m going to need a partial hip replacement and they’re going to put a pin in my hip. I won’t be able to walk for several weeks.”

“Will you come back after that?” I asked hopefully, like a child asking her mother if she will come home after she goes away for a trip.

She looked down for a moment as if she were avoiding my eyes. Still not looking at me, she said hesitantly, “No . . . I won’t be coming back. It’s terminal.” Then she looked at me and her eyes were wet with tears. Her shoulders were hunched as if she had given up on trying to sit up straight.

I struggled for breath as a waterfall of tears careened off my face. “How will I go on without you?”

I got off the couch and kneeled in front of her chair, putting my head on her lap and my arms around her. I was quiet; I just wanted to hold onto her.

She stroked my hair and whispered, “You will be fine. You’ve come such a long way; you’re such a good analyst and you have Stephen. You’ll be okay.”

“Joan, I love you true and blue and like glue. I hope you know that.”

“Of course, I do.”

I noticed a run in her stocking and suddenly realized I might be hurting her by leaning on her that way, so I got up and walked over to sit on the couch.

I wondered if Joan felt guilty leaving me in the middle. The problem is you never know what’s the middle.

I pondered the question out loud to Joan. “Maybe that’s why sessions are purposely set up to end at an arbitrary moment — to end in the middle.”

“What do you mean?” The lines around Joan’s eyes had deepened considerably from the last time I’d looked at her face closely.

“Well, they always end after 45 minutes no matter what’s going on in the session. I used to get so angry at you for that. It felt so heartless. It felt like you didn’t care about me.”

Joan laughed and said, “Yes, I remember.” Then she added, more seriously: “There are things you can’t control. We have to live with that.” Her arms were crossed as if she were hugging herself.

“But you seem so calm. You don’t sound angry. Why?”

“Well, you know . . . Of course, you don’t know, but my mother died of breast cancer when I was 16,” she said, knitting her brows. “I think I’ve always known this was going to happen. It’s been a time bomb ticking my whole life. It isn’t a surprise.”  

I was torn between the pleasure at her telling me about herself and my compassion for her having spent her whole life waiting to die.

“How were you able to stand my anger at my mother when you lost yours at such a young age?” I asked.

She tilted her head as if she was considering the question, but then her face grimaced in pain when she tried shifting her body in her chair. “My mother never talked to me about her illness or about dying. My father died when I was 10 and there was never any discussion about it. My mother would say, ‘He’s dead, what’s there to talk about?’ And when she was dying, she never tried to help me, and my brother worked through the loss of her. She didn’t want to talk about it. So, I understood your anger at your mother.”

“So, you were angry at your mother too,” I said with raised eyebrows.

“Yes. Maybe that’s why your analysis has worked so well. I’ve always identified with you. Even rooted for you. My mother used to say, ‘You’ll break your arm patting yourself on the back.’ So, it’s been a struggle for me to feel pleasure at my accomplishments, but it’s been a delight to see yours. I feel so proud of you.”   

She smiled at me again, but her eyes looked sad. “I’m afraid we’re going to have to stop now.”

An old part of me erupted for a moment — I bawled. “You mean stop forever?”

“Yes.”

The eruption was over in a moment. I didn’t want to cause her any more pain than she was already suffering from.

“Can I visit you?” I pleaded.

“I don’t know yet. We’ll have to see. Do you think you can bear that?”

“I don’t know. I guess I’ll have to.”

“Why don’t you wait a month so I can see how I am doing after the surgery and when I start the chemo. Then I’ll know better.”

“Okay.” I got up from the couch and looked into her sad blue eyes and said in a choking voice, “Goodbye. Please remember I love you true and blue.” Then I turned and walked out the door of the office.

***

I contained myself until I reached the street. Weeping turned into bawling by the time I got to Broadway. People turned to look, but kept their distance, walking past me quickly as if they would catch whatever I had. I thought about what I said to her. By then I knew I didn’t need to see Joan in order to ward off my sense of isolation and exile. I had Stephen and a growing practice, and I was feeling full and capable of nurturing. Joan and I had been talking about terminating my treatment soon anyway. I wanted to see her because I cared about her; I wanted to give her my love, but I had stopped feeling desperate for her.

I thought about Frume Minkowitz and my guilt when I had to leave her in the middle of the semester. One day I walked out of my classroom at Brooklyn College and a young woman was standing in the hall with a baby in a snuggly on her chest and two toddlers holding her hands. She was wearing a sheitel and a long-sleeved blouse although it was a warm spring day. She looked familiar, but I didn’t know who she was.  

“Rose?” Her large brown eyes looked intensely into mine, “I’m Frume.”

She had come to tell me she had not only survived the aftermath of my leaving her, but she had thrived. Her smile was radiant as she introduced her three children.

She said, “I’d like you to meet my children. This is Avram, he’s 3.” She raised her right hand to indicate the little boy with peyos was Avram. Then she raised her left hand to indicate the four- or five-year-old with the long pink dress and matching tights and said, “And this is Shoshanna.” She looked down at the sleeping baby in the snuggly and said, “And last but not least, this is Joshua.”

“Oh, my god,” I gasped and immediately felt embarrassed at the inappropriateness of using G-d’s name in response to her.

“I wanted you to know,” she said with a knowing smile, “that you changed my life, and I never forgot you. I had a rough patch for a while but now I have Shmule and our children and I’m very happy. I wanted you to know that.” A tear ran down her left cheek.

This excerpt is taken from "Our Time is Up" by Roberta Satow (2024) and published here with explicit permission of IPBooks.  

The Pros and Cons of Remote Therapy: A Clinician’s Dilemma

Posted on by Psychotherapy.net Team

The classic image of a therapy session is a therapist, a patient, perhaps on a couch, in a small room with a box of tissues between them. But COVID-19 changed all of that. Now, more often, therapists and patients are on screens, each logging on from different locations. As COVID-19 restrictions ease in medical environments, it is time to ask if therapists and their patients need to be in the same room for therapy to be beneficial? 

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Changing Perspectives on Teletherapy

Prior to the pandemic, the thought of working remotely never occurred to me. Even if remote work had occurred to me, the fact that insurance only reimbursed for in-person sessions would have provided a significant deterrent. Four years later, I find myself of two minds when it comes to evaluating the pros and cons of remote therapy — for patients as well as for myself.

Rather than just relying on my personal feelings, I did some research into the effectiveness of remote versus in person therapy. To my surprise, I learned that patients prefer remote sessions more than therapists. As one patient said when I asked her why she prefers remote versus in-person sessions, she commented, “It’s like the difference between TV and live theater. TV is available when I want it, and live theater takes more effort — you have to get the tickets, find parking, etc.” 

I appreciated the many benefits of being back in my office but most of my patients chose to stay remote. The convenience outweighed their desire to travel to my office, and they felt no discernible difference in the quality of the work. This created a dilemma for me as I weighed the cost of leasing my office and the ease of working from home against my personal preference for in-person sessions. Recently I made the difficult decision not to renew my office lease for financial reasons. Adapting to remote therapy has meant changing some aspects of how I practice.

In my mind, the greatest deficit of remote therapy is the lack of a physical presence in a shared space. When I was able to watch my patients walk from the waiting room into my office, I noticed how they carried themselves, their attire, and the mood they exuded. No longer having that opportunity online, I learned to be more specific in my questions about how people were feeling, and I look more closely for changes in appearance. Still, the intimacy of a therapy session cannot be replicated on a screen. Watching someone cry is not the same as being in the presence of someone crying. Nonetheless, I have found, to my surprise, some patients prefer sessions to be less intimate and find it easier to open up as a result. This may mean that the availability of remote therapy is capturing a new clientele for therapy.

But some patients are acutely aware of being alone, and thus find it harder to allow themselves to fully express their emotions during a remote session. I miss mirroring someone’s breath and using my steady gaze to offer comfort in person. Instead of being able to offer a tissue, I now wait as they go off-screen to retrieve one. I literally try to lean into my screen to provide a perception of being closer.

Being apart means many patients struggle to find a safe and private space like my office. Often patients are surrounded by distractions from their home, office, car, or wherever they are having their session. They find it is more difficult to shut out the world when we are not together in my office with cell phones off. Encouraging patients to make the effort to create a private space is part of the work of doing remote therapy.

Furthermore, patients tend to squeeze sessions in between other commitments, diluting the work. No longer having to take the time to get to my office, patients fail to prepare for their sessions or give themselves time to think about the session afterward. I encourage patients to build a buffer into their schedules, but realistically it rarely happens. I am guilty of this too; when I turn off my computer, I am home and no longer have my commute to process the day before resuming my personal life. I have changed my routines, so I have a clearer boundary between being at work and being at home.

Embracing the Future of Teletherapy

Despite these limitations there are important advantages to offering therapy remotely. The most significant gain from the availability of remote therapy is improved access to therapy for more people. Insurance coverage changed during the pandemic to include online sessions, which improved the possibility of finding a therapist. Initially this change suspended the need for the patient and therapist to be in the same state, furthering the potential pool of therapists. (That requirement has since been reinstated.) Finally, patients living in rural areas could find a therapist and have choices similar to those available to people in urban areas. Unfortunately, during the pandemic, demand was so high many people still suffered due to long wait lists. But over time, there is the opportunity for greater access and equity.  

In my own practice, during the pandemic I began work with a woman in her early 80s with physical limitations who could not access my office. The opportunity to meet with me over Zoom made it possible for her to do some significant grief work after losing her husband to COVID-19. Increased access to psychotherapy for a broader clientele is a plus for everyone.

Continuity of care can also improve when weather or travel are no longer impediments to having a session. Prior to remote work, patients had to cancel sessions when they traveled for business or had to attend to a sick child at home. I have found the ability to offer remote sessions particularly helpful with the new mothers in my practice who were experiencing or at risk for postpartum depression.

Some therapists have required patients to come back in person, while others, like me, have gone fully remote. Increasingly, therapists are working for companies which only provide remote sessions; they never establish an office. It behooves graduate school programs to adapt to this reality in their training of new therapists. It is also important that as a profession we do not create a two-tiered system, preferencing one form of delivery over another based solely on personal opinion.

As we live more of our lives online, the limitations of screens may not be felt as acutely by either therapist or patient going forward. New modalities of therapy may even emerge from this change in venue. But it is critical that the effectiveness and limitations of remote versus in-person therapy be studied. For example, people with social anxiety may request remote sessions when in fact in-person work would be more beneficial. When screening new patients, I take into account why they express a willingness/desire to be remote.

The key to a good therapy relationship has always been about fit. This equation used to be construed as the fit between the therapist and patient, but now perhaps we need to expand that idea to the room(s) where it happens. 

Working with In-Law Problems in Couples Therapy

Posted on by Psychotherapy.net Team

One of the most common problems I see as a couples therapist is trouble with the in-laws and its impact on the couple relationship. It can be hard enough for clients to deal with their own parents, let alone their partner’s parents, who may disapprove of them (openly or covertly), be protective of their child (or the opposite, treat their child in ways that make clients want to protect their partner), or feel threatening to clients or the relationship in some other way. Relationships can be tough, and family dynamics especially can be challenging to navigate; combining intimate relationships and family dynamics can pose its own struggles.

The Negative Cycle

Something I see often in my office is couples who struggle with how to handle it when an in-law offends. When their parent does something that upsets their partner, I often see a now-familiar and predictable pattern that I call the “That’s not what she meant” dance. When the partner is hurt, the son or daughter sees a rupture in the family; a slow unraveling of the relationship between their partner and their parent. They want harmony and for the family to get along. So, in an attempt to preserve the relationship between parent and partner, they invalidate their partner’s complaints. It could sound something like this (a dialogue I have seen in my office):

“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”

“She didn’t mean it like that, she was just surprised.”

“But it hurt.”

“You’re making too big of a deal out of this. Don’t worry about it too much.”

[Partner pouts and turns away (or explodes)].

The adult child above likely has good intentions. They hear that their partner is upset, and they want to help. They try to make things better by trying to tell them there’s no cause to worry. But if there’s one thing I’ve learned about the human experience from being a therapist, it’s that feeling understood is important to all of us, and especially aggrieved partners in scenarios like this. When I hear things like “It wasn’t like that,” or “There’s nothing to worry about,” clients feel invalidated and unheard. The partner here is not soothed, but instead left feeling misunderstood and frustrated. They likely long to truly feel that their partner “gets” them and has their back.

To help these clients avoid getting caught in this all-too-common pattern, I try to teach them to validate their partner’s struggles. If their partner says that they’re hurt by something, I encourage them to take that at face value and not try to talk their partner out of their feelings.

A Strategy for Reconciliation

Often, I see that my clients are hesitant to validate their partner’s hurt feelings when they involve the actions of a family member. They may fear that they’ll make the disharmony in the family worse, and that their partner will move further away from getting along with their parent.

In instances such as these, I try to let my clients know that they don’t have to insult their mother or father to validate their partner’s emotions and to show them that they make sense. Showing their partner that they understand why their hurt makes sense and are there for them usually restores harmony in the family, as their partner won’t feel as alienated or marginalized when they know that you are right there with them, and they are heard.

As often as possible, I encourage my client to try responding to their partner like this, with validation, understanding, and support:

“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”

“I’m so sorry to hear that, I can see why that hurts you. You put so much work into dinner and I know how much you love making people smile when they taste your food. And it was delicious. Is there anything I can do to be here for you right now?”

This response shows: I get it, I get you — and your feelings make sense.

Responding like this can help a client’s partner feel safe in knowing that they have someone on their team, and they aren’t alone in their feelings. This increased level of safety can soothe hypervigilance and make couples feel more comfortable and unified when it’s time to go see Mom and Dad, resulting in less tension and conflict.

How to Use Structured Writing to Help Clients Unclutter

Posted on by Psychotherapy.net Team

The clock struck three and Mary was calling me on Zoom. Before I could say “Hi,” she was reading from a crumpled paper held in clenched fists. This was her weekly list of the topics that she wanted to bring to therapy. Her timing gained momentum until her words reached a breakneck pace. It seemed that I was witnessing a contest. Mary was like a game show contestant, reaching for the top prize that came with climbing to the top of her list of priorities.

Mary: The Gravitational Pull of Lifelong Habits

I waited until Mary finished reading, and then after taking a few deep breaths, began the arduous task of adding some modicum of structure to her list — rating the topics, determining their priority, and then talking out the prioritized topics in a bit more detail than she originally planned. Mary dutifully and enthusiastically jotted down notes corresponding to the topic at hand.

While rapport came easy with Mary and our conversations typically flowed, a seemingly interminable pause — you know, those that are unique to online therapy — Mary proclaimed, “I know, I know. I’m not ready to give up being the rescuer.”

“You think?!”

Before continuing, she gave me her usual comedic smirk and said, “But this is all real. I have a vitamin company that I’m running solo because…Um, well. It just happened. Sort of. Slowly.”

Knowing the answer, I asked in jest if Mary was still office manager at the commercial real estate company where she began working 15 years ago. Mary nodded. We turned back to her list. There were a few items that Mary also described as having “just happened.” These included volunteering to cook Thanksgiving dinner for her husband’s family and letting her sister-in-law stay with them for a long visit with an end date that was “to be determined.”  

Prior to that session, Mary had been angry that her daughter had forgotten to place an order for groceries, making it necessary for Mary to stop and bring home dinner for the family on a very cold night after leaving the office. Initially, Mary regarded her anger as a simple and logical reaction to her daughter’s forgetfulness, but because there was already a template in place from an earlier clustering of items on her list, she finally seemed ready to identify another significant pattern of behavior she very much wanted to address, and hopefully change.

“My mother was always angry. She was the Lone Ranger, always putting out fires that we all set. My siblings and father, that is; not me! I did what I was supposed to. At some point, I became everyone’s helper. I guess I learned to do this when my mother became depressed.”

We eventually got to a point in Mary’s processing where she saw that there was a historical satisfaction she received from maintaining order by handling everything around her, instead of accepting the risks that came with engaging, or directly asking for the help of others. When others failed, as they invariably did, Mary felt anger. It wasn’t anger; however, at the perpetrator, but at herself because of her intractable belief that she had to then pick up the slack and failed to do so — and instead, outsourced. This rescue theme permeated all facets of her life.

Mary was circling items on her list that felt optional when she put her face in her hands. After some minimal silence, Mary described how she felt the first time she noticed her mother’s depression. “The sadder she looked, the busier I became. The busier I became, the less my brothers and father were doing. No chores or help around the house in any way.”

Through writing lists and seeing reality in print, right in front of her, Mary was able to appreciate the wide scope of her expectations of herself, and her role in continuing to be the rescuer to prevent the potential for disappointment from others.

Terry: Therapeutic Lessons in Self-Advocacy through Writing

Terry, aged 35, presented in a very warm wool blazer over a buttoned-up Oxford shirt that looked uncomfortable. His mannerisms seemed almost choregraphed corporate professional in such a way that made me think that he was working too hard at appearing polished. I believed that still waters ran deep with Terry, but I delayed my full impressions.

“I just can’t take my life anymore! Oh, no, not like that. I mean, I’m fine. Well, no, thanks to them, I am not fine. Or thanks to me, maybe. I could just leave, but then they need me, and I’m committed to seeing these changes through. I made a commitment. And I need the money. This is a huge opportunity. And, at the same time, this is no way to run a company and no way to treat a human being.”

Terry paused, looking at me almost apologetically. Wanting to normalize his expressive shouting, I nodded as if we were already in a working alliance and immediately went into establishing the presenting problem, before moving carefully into recent history. Terry’s upbringing seemed complex, and his expanded HR role at work which included dispute resolutions and public relations, seemed to mirror those early-life experiences.  

In describing his days, Terry painted a picture that felt very much like a Pollock painting — taking meetings, picking up prescriptions for his uncle, being too tired to enjoy a weekend party, listening to a manipulative employee with a treacherous track record fabricate a story about discrimination, and finally, feeling financially burdened, depressed, alone, and coping with “a heart that feels like it’s doing summersaults inside my chest.”

As he frenetically laid out the complex intertwining of work and family-of-origin demands, once again, I had trouble catching my breath. Like a sports referee, I motioned for time-out, nodding slightly to offer Terry assurance that I wanted to understand everything, and to do so, I needed separation and space between each different subject. Granted, that’s not the effect that Pollock was aiming for, nor would we want to break down and bring order to his works, as chaos seemed to be the goal. But I explained to Terry that while the head-spinning menagerie of topics he was tossing onto the canvas of our session gave us a lot to work with, it would otherwise be helpful if we could indeed structure his topics and disassemble the inner chaos.

I’ve found that one of the many ironies in therapy is that the more issues are linked together, the more important it is to first separate them out. I’ve had good clinical luck by establishing traction with one issue at a time, usually the most current “hot topic.” The high voltage of that topic usually complicates and obscures other issues, regardless of when they arose in the client’s life. Without separating, wires cross, and I have frequently sat in an electrical storm of past and current issues as they collided in a dazzling and confusing Pollock-ian explosion.

Terry’s past did clearly contain some currency. He described being alone most of the time as a child, until his parents rented their basement apartment to his aunt and uncle. His uncle became his mentor. Terry emulated his uncle and grew up having two role models — his father and his uncle. Terry empathically described the contrast between his parents’ old fashioned work ethic of long hours and constant worry about the business, and his uncle’s more creative and impulsive risk taking. His uncle had a wild ride of achieving financial success after living for a time in the basement apartment, moving out and buying an enormous house on a fancy street in Brooklyn, only to lose everything 10 years later and wind up back in the basement, divorced, and working for Terry’s brother.   

Terry’s formative years were spent being caught in a tug-of-war between his father and his uncle. His father wanted to hand the restaurant over to his son and his uncle wanted Terry to go to college. Terry did both, but through the years, he became the go-between for the two men. Unconsciously, he feared rejection from his father and carried this with a constant state of nervous energy and anxiety attacks, somatic digestive symptoms, and an obsessive monitoring of his health. His present work environment had some shared features of his family of origin homelife and ongoing sense of family-based obligations.

Terry was getting visibly angry within three minutes of our second session. He wanted to alleviate the sting from his recent reprimand at work, yet at the same time, he knew that he was in the right, and that his supervisor’s issues of paperwork falling through the cracks was 90 percent due to lack of administrative support and maybe 10 percent human error. Terry needed to fight back with professional decorum, but first, he needed to calm down. My suggestion was to disentangle the different items and then respond to each one — to himself — on paper, as preparation for communicating with his supervisor.  

At first, Terry was irked, reluctantly pulling his laptop open and making a few nominal clicks. As we talked and Terry clicked, we created separate headings for each action item that was part of his entire merging of multiple job receptibilities. This master list with heading included multiple separate jobs that he had been unofficially asked to cover, without any new prospects for hire. Terry was pleased, and I was proud of him. As he gained clarity in the organization of his responsibilities, he also increased his personal conviction — his inner authority. Eventually, through his writing, Terry became fully prepared to meet with his supervisor. The meeting was without the previous subject of Terry being a remedial employee and failing to live up to expectations. Rather, this meeting was direct, goal-oriented, and successful.

The Positive Impact of Therapeutic Writing

In my experience with clients like Mary and Terry, I’ve found that when a client states facts on paper, they are also asserting the following:

1. They have the authority to interpret and define the facts
2. This authority is not subject to permission or approval from another
3. They have custody over the facts, as they are
4. They have the right to communicate these facts to another person, and doing so is not a betrayal or violation

Writing as a means of expressing feelings is well known, but the use of technical, terse writing can also be a valuable therapeutic tool. The tracking done in REBT and CBT therapy fits with clients when they are at a point of delving into activating events, beliefs, and consequences, but so often they also want to fully describe all the different scenarios they live out week to week. They want to take their therapist through a deep dive into the details of what transpired. This can often result in a confusion of ideas, goals, and plans, much like Mary and Terry initially experienced.

Technical writing can also be an effective means of helping a client work through the struggles of day-to-day life, including communication with others. Writing between sessions gives a client the opportunity for greater insight while deciding in advance of session time what is important to focus on. Sometimes, clients uncover a theme for the week as a direct result of writing. Whether a laundry list format or paragraphs, writing can fit easily within sessions on an impromptu basis. While the undesired feelings (dissatisfaction, grief or anger, or irritating tasks such as administrative responsibilities) do not get resolved through pen to paper or typing in a device, there is clarity through organization. This is similar to how balancing books doesn't make the red go to black, but often results in a feeling of ease.

Getting Organized: The Pre-Therapy Phase

After getting a baseline history and general understanding of the client’s concerns, there is a pre-therapy phase, akin to treatment planning. This phase begins by sifting through past and present to hit on the main problem of this moment. What is being experienced now that is problematic? Why is this problematic? What are the consequences? Is any of this problem optional? Could there be any benefits — even the kind of benefits that have more consequences later, such as avoidance? At about this point, I ask my clients to write down the words “Secondary Gains.” Some immediately Google it and some tell me the definition, as if on cue.

Once the main problem is identified, then the work of uncovering the various aspects within the problem becomes the next step. Technical writing is an ideal tool for this phase and can be a useful complement for therapy throughout the process.

The Top Card

My clients are accustomed to me saying that there is only one card at the top of each deck. Before selecting the top problem, it often helps to sort out problems into two basic categories.

In therapy, a problem is not always a separate entity, such as struggling with a recent promotion at work or difficulty adjusting to a new city. Rather, problems are sometimes complex and long standing, such as pervasive anxiety or depression or life patterns stemming from a background of trauma.

Often this pattern results in multiple struggles, where each struggle may seem like an independent problem, but each problem is part of a cluster of circumstances spurred on by the damaging pattern. In session, we take a sheet of paper and draw a line down the center. At the top of the page, we write a title on each side. On the left side is Problem Group A — Discrete Problems, and on the right side is Problem Group B — Overarching Patterns.

Problem Group A, for example, may be difficulty accepting a recent job loss, and Problem Group B typically shows up as a cluster of events or consequences linked to a combination of undesired habits, such as isolation, anxiety, and an endless state of resentment.

Problems from either category require teasing out and separating the different aspects. Aspects often include finding meaning in the problem and uncovering the types of environments and circumstances when the problem feels more present. There is often overlap between the discrete situation problems and the overarching pattern problems. But, even with this overlap, there is ultimately one card at the top of the deck and one situation or state of mind to home in on before delving into the others.

While this strategy may seem formulaic and concrete, I have found it very useful for clients like Mary and Terry, as they have tried, and successfully disentangled, prioritized, and addressed the problems that have plagued them. Doing so has also helped me to breathe a bit easier with clients who might otherwise pull me in the Pollock-like paintings of their lives. 

Ethics or Protocol: Children Must Take Priority

Posted on by Psychotherapy.net Team

A friend offered me the opportunity to join her in her practice, which I gladly did based on my knowledge of her values, beliefs, my love of what I do, and awareness of my weaknesses in marketing and billing. I brought my 20-plus years of clinical experience across inpatient, outpatient, and community mental health settings, which included my skills in assessment, documentation and play therapy into practice.

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I was happy as a clam doing the clinical work, receiving a regular paycheck, and leaving behind the hassle of finding clients for myself. In terms of emotional demands on my employer, I was a non-complainer, and my needs were few. I asked for little and consulted enough to keep her informed of significant treatment issues.

An Ethical Dilemma Arises

As the practice grew, so did my employer’s need to be outside the office, and in her place, there were protocols. One of them was that no written document was to leave the office without her review, which included all letters, reports, and clinical summaries. Clinicians had deadlines and due dates on the documents which left the office, which did not always coincide with her ability to review and approve them. I understood the need for this system with new employees and interns, and that with multiple employees, that was a lot of reviewing. After all, that is what supervisors are for! But as a seasoned professional, I was not new to the field, and I knew my way around documentation and ethics.

I was treating a court-related, post-divorce father with three children, who traveled out of state for visitation with their mother. It was a 10-hour drive. A Guardian Ad Litem, who also happened to be an attorney, was assigned to the case.

The mother had been asked/ordered to participate in treatment and met once with me along with the children. In that meeting, she expressed her resentment and never returned. The father, nanny, and I were sure that the children were being abused and neglected. The children were telling the father, nanny, or myself stories of inconsistent care with meals, medications, sleeping arrangement, and transient care and supervision outside of their mother with other extended family members.

We were documenting the children’s emotional state and physical condition prior to, and after their visits with the mother. I was working with the children individually, as a group, with the father, and/or the nanny, after visitation with the mother to further support the need for intervention to stop the visitation. The judge continued to order the visits for lack of evidence and threatened the father with jail time if he didn’t comply.

We were documenting signs of abuse and neglect; refusal to give medication for a documented health condition, untreated medical illness, injuries, abnormal bruising, weight loss, sleep disturbance, and neglect. The children were scheduled to travel out of state for an extended three week stay. The father was under a court order to send them and severely stressed by the prospect.

In my clinical opinion the children were in danger if they were sent out of state for an extended visit like this. I felt the need to inform the Guardian Ad Litem. The deadline for the childrens’ next departure was rapidly approaching.

At that moment in time, my employer was consulting out of state and not due back until after the children’s impending departure. I fully understood the importance of protocol that the employer had set in place, but there was so much more at stake here than protocol. There was the children’s safety, health, and wellbeing, not to mention my legal liability, that of the agency, and my ethical reporting responsibility. While many reports had been filed in the past, there was not enough hard evidence to file a DCFS report or stop the visit.

I had prior authorization to communicate with the Guardian Ad Litem. I wrote the letter to the Guardian Ad Litem expressing my concerns, and the reasons. Based on experience, I knew my employer would not review the letter before the deadline for the visit, even if I sent it through email. The internal debate was emotional but brief. I sent the letter to the Guardian Ad Litem, and put a copy in the file, knowing it could cost me my job. The children needed to come first.

Because of the court order, the father sent the children to their mother. I did not hear from the Guardian Ad Litem, who did receive it via email, before the scheduled departure. The children survived the visit. Shortly after their return, one of the children disclosed sexual abuse, giving the court enough legal grounds to end visitation. The mother’s parental rights were terminated. The father re-married, and all three children have been formally adopted by his new wife. The children are thriving and progressing developmentally, despite their challenges.

As for my employer and I; we parted by mutual agreement.  

Challenging a Beloved Therapist: A Catalyst to Growth

Posted on by Psychotherapy.net Team

A Break in Need of Repair

“I’ll wear a mask, unless you take a COVID test!” This was the message that I emailed Jeffery, my therapist of 29 years. It was a few days after he returned from a vacation that entailed a long airplane flight. My appointment was the following day.

“Wear a mask,” came Jeffery’s reply. He said he didn’t want to “stick something up my nose,” and was sure he didn’t have COVID because he was masked the entire flight. 

I was startled. His annoyed tone was out of character. I was also surprised to find I wasn’t devastated. In the early years of our work together, I’d been 100% emotionally dependent on him, a child beneath my grownup facade, and the thought that he might be annoyed would have been the end of my world. Now, I knew this was a temporary disconnect, one that could be repaired if we discussed it.

“Let’s do a phone session,” I emailed back. I was at risk for lung infections because of a health condition. Also, I would feel more secure on my own turf if the discussion proved difficult.

When we Facetimed, I saw that Jeffery was home, not in his office. Though dressed in his usual button-down shirt, he was stuffy and hoarse and looked as if he should have been in bed. But he was back to his usual cordial stance.

“Do you have COVID?” I asked.

“Just a cold. I don’t have any fever.”

By then it was common knowledge that fever wasn’t the gold standard for making a COVID diagnosis. I didn’t pursue the repair. He obviously wasn’t ready. I was glad to see him — he’d been away six weeks — but the session was superficial, not emotionally satisfying.

Before our next appointment, Jeffery texted that we should do another phone session, because he had COVID. Again, I was surprised at myself, this time for not wanting to say, “I told you so.” I understood that he could be wonderful 98% of the time and not wonderful 2% of the time.

When we spoke, I tried again for the repair, explaining that I was afraid of getting sick. He said he thought I was telling him what to do, but once he understood why, he was OK with it.

I saw that Jeffery was trying to be conciliatory, but it didn’t make sense. He’d known for a long time that I was afraid of getting sick, in part because I dreaded needing someone to care for me. We had been working on that in sessions. Also, he had never before gotten annoyed when I told him what would make me feel safe, even if he chose not to comply. Most likely, my COVID test request had triggered something in him that had nothing to do with me.   

I grew up in a home that didn’t model the best way to resolve conflict. If my father was displeased at something my brother or I did, he flew into a rage that involved prolonged and intense yelling, often accompanied by physical punishment. If he was displeased with something my mother did or opinions she had, he just yelled. She would answer softly, almost meekly, then later do as she pleased. If he found out, there would be more yelling. Early on, I learned not to rock the boat, a skill that traveled with me to adulthood. I was afraid that people would stop liking me if they became annoyed or angry, so I did everything I could to keep the peace. Now I was stymied.

It was rare that Jeffery let his own issues interfere with our work. In 29 years, that had happened only four other times, the last more than a decade earlier. This was by far the least consequential, but it was the first since I felt like a grownup through and through. I knew that before a meaningful discussion could begin, I would have to wait until he was ready to acknowledge what happened. If this was anything like the other times, that could take months. In the past, I would have discarded the 98% while I waited, just because I wasn’t happy with the 2%. It was a testament to our work together that I didn’t do that now. But gray was a lot harder to navigate than all black or all white.

Healing through Empathic Attunement

At 51, when I began seeing Jeffery, I had already spent 35 years in the mental health system. I’d been hospitalized three times with a misdiagnosis of schizophrenia, lived in a halfway house for a year, and had seen six therapists, each for several years. Though high-functioning at two jobs — weekdays as an I.T. systems analyst, weekends as a librarian — inside I was in emotional pain so great it felt like organ failure.

Relief came only through escape to an imaginary world I called the Atmosphere, where kindly invisible people, more emotionally reliable than real people, understood all my feelings and thoughts. That, and the knowledge that I always had an out: I could kill myself. The one place in the non-Atmosphere world where I was relatively comfortable was at work. I worked seven days a week — to stay alive and to pay for therapy.

Five years earlier, at 46, I learned I had what was then called multiple personality disorder (MPD) and has since been renamed dissociative identity disorder (DID). I was shocked that such a sensational-sounding diagnosis could apply to me. At the same time, I was relieved to finally have a plausible explanation for so much of my past: feeling not real, watching myself from outside myself, talking to faces in the mirror who were not me, functioning on a high level at work yet feeling psychotic outside of work. The diagnosis let me know I was not an alien species. I had a condition documented in clinical literature, said to have been caused by ongoing childhood trauma. That part fit, too.

It was one thing to have a diagnosis, another to find a clinician skilled in treating multiplicity. It would be another five years before I found Jeffery, recommended by a member of the dissociative disorders support group I had begun attending.

Jeffery soon realized that the Atmosphere, which was more real to me than the real world, had developed in response to early attachment trauma. The Atmosphere had been helpful when I was a child, providing the emotional connection I wasn’t getting from my parents, but when I became an adult, it got in the way of my having meaningful relationships with real people. Jeffery believed the Atmosphere had to be dismantled before healing of the multiplicity could take place. His theory, unbeknownst to me until years later, was that I needed to have an Atmosphere-like experience — perfect and unbroken attunement — with a real person: himself. I would then transfer my attachment from the Atmosphere to him, and eventually to other real people.

Over many years, with infinite patience and kindness, Jeffery saw me through the stages babies and toddlers go through when attaching to their caregivers. I may have been in an adult body, but parts of me who were very young still had to learn things as basic as object constancy — that people and things exist even when you can’t see them. Jeffery understood that to my magical way of thinking, I had two versions of him. In-person Jeffery waved goodbye to me at the end of each session, then froze, hand in the air, and stayed that way until I returned. The moment I walked out of his office, Atmosphere Jeffery materialized and remained with me 24/7, knowing everything I thought and felt and did until the start of my next session when in-person Jeffery would be right where I had left him.

In that way, he was with me continuously. Whenever something happened to let me know this was not so (his socks were another color, or he’d gotten a haircut, or worse, I saw the patient before me leave), I would berate him for his betrayal and call him a “deceiter.” He would explain that he hadn’t abandoned me, that I was always in his heart, even if he wasn’t physically with me. His words would soothe me — until the next time.

What went on in any given session depended on which of my parts was “out” (present). There was a sliver of me who was grownup, in particular an administrative part I called AlmostVivian. She kept me functioning in the world but had no depth. The more three-dimensional, feeling parts of me were largely children. These “littles,” who were causing most of the chaos and pain inside me, saw that Jeffery was a safe person, and they gradually began revealing themselves to him. Sometimes the only way I could communicate was by talking in nonsense syllables or writing backward on a piece of paper he had to hold up to the light to read. Other times, a feeling was too big to fit inside me, and I screamed, or hid behind a chair, or wordlessly locked eyes with him in an attempt to connect. And sometimes, ashamed to be visible, I could talk only in the dark, so he turned out the light.

At the start of a session, Jeffery would wait to see where I chose to sit. If it was a chair, he sat in a chair, too. If it was the floor, he would sit on the floor with me. If I was unable to talk, he and I might draw a picture together, taking turns adding a squiggle or something representational, like an eye or a bird. Sometimes we passed a computer back and forth, typing to each other in conversation. I likened our sessions to emotional surgery, where Jeffery dug deep but never more than I let him know I could tolerate. We would both make sure to leave enough time at the end to sew me up, so I could go out into the world and live my life until our next session. The sewing-up routine came to include having toast together, my ultimate comfort food. As we ate, chatting about seemingly mundane things, I would slip in something about my itinerary. “Before I go to work tomorrow, I have to take my mother to the dentist.” Atmosphere-Jeffery always knew where I was. I needed in-person Jeffery to know, too.

There were many bumps along the way, but the more I got from Jeffery what I had previously gotten only from the Atmosphere — feeling seen, acknowledged, understood, and cared about — the more I began connecting on a deeper level with outside people. My cubicle-mate at my I.T. job said, “You seem different lately. More sparkly.” My sister-in-law said, “It’s much easier to talk to you now. You’re more connected.” In my writing workshop, instead of hurrying out as soon as class was over, I began lingering to chat.

It took years, but I finally did “lose” the Atmosphere, and with it, the Atmosphere version of Jeffery. Concurrently, my internal parts were becoming more conscious of one another. While these developments were ultimately positive, adjusting to a new mental map of who I was and how I related to other people was not easy. For a few years, I felt lost from Jeffery, even when he was sitting across from me. A children’s book, Farfallina and Marcel, helped. I kept a copy in Jeffery’s office, and we often closed the session by reading it together. It’s the story of the friendship between a caterpillar and a gosling. One day, the caterpillar says she doesn’t feel well and climbs a tree. The gosling waits below, but the caterpillar doesn’t come down. A long time later, when the gosling has become a goose, he meets a butterfly. As they talk, they find out they each feel bad because they each lost a friend. A while after that, they realize they are the friends they thought they had lost. They look different, but they’re still the same inside.

Confrontation Revelation, and Repair

Jeffery had been my sherpa through decades of monumental changes that literally gave me back my life. Now we were having a tiff about something as trivial as a COVID test. At least I thought we were. From his point of view, the air had been cleared as soon as he understood I was simply telling him what would make me feel safe. I loved this man and wanted everything to be OK between us, so I did my best to ignore the elephant and go on as we had before. But six months later, when he was scheduled to take another trip — brief, but it involved a long flight — the elephant was still there.

“I don’t suppose you want to take a test when you get back, so let’s plan on a phone session,” I said, hoping to start a discussion.

“It’s not going to happen,” he said, smiling as if at a shared joke.

I smiled back, but inside I felt a great loss. The one person who had completely seen and understood me no longer did.

When Jeffery returned, I decided to confront him. I told him again that saying he didn’t want to stick something up his nose had been hostile. He could have just said he wasn’t comfortable taking a test. I repeated that this issue had more to do with him than me. He said he saw it differently. He had always shielded me from things that annoyed him. Now he was allowing himself to be more spontaneous. Then he clarified. During a session, he always saw my point of view, but outside of a session, he felt freer to let his annoyance show.

This initiated a new worry. How many other things had I done over the years that annoyed him? I asked for a list. All he could think of was something from two decades earlier, during the period when I could talk only in the dark. If my session was in the daytime, he had to hang blackout curtains, then take them down when I left.  

In our next meeting, I realized it was up to me to get the discussion back on track. I told Jeffery I had been caught in his forcefield, so I’d gone along with his explanations, but they didn’t make sense. His response: “Just because I disagree with you, that’s a forcefield?” This, too, was out of character. I said I didn’t want to know exactly what sticking something up his nose meant to him. I just wanted him to know that whatever it was had more to do with him than me.

There was silence for several long minutes, during which Jeffery’s eyes went up diagonally, the way they did when he was thinking through a complicated issue. At last, he looked at me and said humbly, “You’re right. There is something. I didn’t know it until now. Thank you.”

This was huge, but I didn’t stop. I brought up what he said about being annoyed outside of a session but not during a session. I told him that was hard to deal with. I needed to know he was a consistent person. Jeffery agreed he shouldn’t have said that. “It was mean and not true. I was just rationalizing my behavior.” That might be, I said, but it still hurt. He nodded his acknowledgment, holding my eyes.

We talked about it for a few weeks. I told Jeffery he was so near perfect that it was hard to know when it was legitimate to call him on something, especially when he kept insisting on his point of view. He admitted he didn’t like to think he had faults as a therapist, so he didn’t see when his own issues got in the way. Then he told me a little about his childhood, no details, but enough to let me know that what occurred between us most assuredly had nothing to do with me. I felt a surge of gratitude to him for his honesty. This couldn’t have been easy. But the elephant was gone.  

Incremental Progress, Monumental Change

At first, I was just glad to have my therapist back. But within months I found myself acting differently outside the therapy room. I had always been surface-friendly with everyone, easy to be around. I rarely became involved in deep discussions because I rarely had strong opinions. Whenever I did have one, if it was contrary to someone else’s point of view, I soon came to feel the other person was right. Now I was finding myself less inclined to remain safely on the sidelines, more willing to take cautious risks and become involved.

Shortly after the air cleared between Jeffery and me, I was asked to become co-chair of an organization I belonged to. While I liked the group and its mission, the thought of having to run meetings where there were sometimes opposing viewpoints — and hurt feelings — was daunting. I declined, explaining my reluctance to the person trying to recruit me. “But you’re so good at handling that kind of thing,” she said. I knew I was, but it was a skill that came with a toll. I was constantly vigilant in my interactions, never fully relaxed. Still, when she continued trying to convince me, I was flattered. She was someone I respected. After a month, during which I thought long and hard, I accepted, having decided it would be good for me to step out of my comfort zone. 

Of all the changes I went through since the start of my therapy with Jeffery, none had announced itself with an ah-ha! moment worthy of documenting in a progress note. Change was so incremental, like the slow movement of tectonic plates, that I never noticed it until a seemingly minor incident, like the COVID-test brouhaha, let me see how far I had come.

It has been said that in psychotherapy, in addition to whatever expertise the therapist has or what their approach is, it’s the relationship that heals. Jeffery was a safe person for me to challenge, and I had become strong enough to trust my instinct that something about his protestations didn’t ring true. While he didn’t agree with me at first, he didn’t try to crush me but allowed a discussion. I saw that we both wanted to reconcile and were negotiating in good faith. Ultimately, the fact that he was big enough to step back and take an honest look at himself, despite his discomfiture, was healing for me.

In my new role as co-chair, I have already been challenged by several disagreements. Each time, I’m initially sorry I accepted the post, but after the issue is resolved, I feel good. When I was on the sidelines, I never took a stand or tried to shape an outcome for fear of upsetting someone. Being involved is more difficult, but also more gratifying. It’s as if I had been snacking before and have only now sat down to a satisfying meal.

At 81, I am still becoming. 

Politics on the Couch

Posted on by Psychotherapy.net Team

I practice in the Boston area, the bluest part of a very blue state, Massachusetts. In the wake of recent world events — Trump’s election, mass shootings, and limitations on access to abortions — most of my patients have until now assumed, not wrongly, that we are aligned politically. For the few whose politics differ from the majority here, they have come to trust that I am open-minded enough to hear their positions without compromising our relationship.  

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It is a long-standing cliché that therapists answer a question with a question. Typically, if patients ask me direct questions, such as whether they should take a new job or get divorced, it is easy for me to parry the question back to them. But some patients’ tolerance for this practice has waned as they want me to make explicit my position on the war. To them, a position of neutrality or silence feels unsafe and, for some, even immoral. As the war has continued, patients’ positions have shifted somewhat but the intensity of their feelings has not lessened.

Existential and moral questions have always had a place in therapy as people struggle to reconcile concerns about the meaning of life. But in the last decade, patients frame wanting to share their feelings with me in the context of feeling safe. Therapy sessions were meant to be “safe spaces” long before that term became part of the vernacular. Promises of privacy, confidentiality, and acceptance are the backbone of establishing a therapeutic alliance and, with rare exceptions, are guaranteed. But, for some of my patients this war shook their sense of what it means to feel safe in some fundamental ways and that has translated into wanting me to agree with them.

Inviting Politics into the Therapy Space

Days after the attack on Israel by Hamas, a patient started his session by saying, “I need to talk about the war, but I feel so afraid of being wrong, I just keep my mouth shut.” He went on to discuss how limited his understanding of the Middle East was and the pressure he felt to take a side. He knew his silence was not read as neutral and that his friend group wanted to know where he stood. 

He also questioned whether my silence was actually neutral, and worried that I too would think less of him for not already having a position. “What do you think?” he asked. “I want to hear how you are talking to your friends.” He hoped I would share my position to model for him what a cogent answer might sound like. Rather than satisfying his request, I chose to discuss strategies for having effective difficult conversations and support his right not to know how he felt at this moment in time. It was a meaningful interchange if not wholly satisfying for him.

Another patient vented her fury about her friends whose beliefs on this topic did not align with her own. She saw the potential for this issue to rupture relationships which had stood the test of time through many other challenges. Now she wanted my help, but she expressed grave concern that I would be unable to understand her position since I am not Jewish.

Despite our long history, I wondered if our relationship would survive this difference. Even though I appreciated the amount of distress she was living with, it pained me to think that given the current state of affairs, the fact that we have different backgrounds could limit her trust in me. We are both choosing our words carefully and I check in with some frequency to see how she is feeling about our relationship.

I have a number of patients who are college faculty members or students, and the heated debates on campus came roaring into my practice. Questions about the positions leaders were taking on their campuses and the implications for future career choices were on the minds of these patients and those who are parents of college-aged students.

Patients with younger children raised questions about how much to discuss the war with their children and how to keep their children safe from hate speech and potential violence. There was a general sense of people feeling unmoored and frightened. Taking time to understand the personal connections to this world event became a dominant theme over the course of many sessions.

Most of my patients do not belong to a religious community. I am by no means an expert on Middle East affairs, nor is that my role. For those who feel devastated or set adrift by current events, they look to me for answers and reassurance that I cannot give. Furthermore, in this day of AI and polarized news feeds, people do not know where to turn for information they can trust. At the same time, they want something more than equivocal answers from their therapist.

A weekly therapy hour cannot solve the problems of the world, but good therapy can promote mental health. The goal of therapy is not to shut the world out, but to help people manage feeling overwhelmed by the world. As the challenges of the world continue to come into the therapy hour, I strive to maintain the therapeutic connection. I might not always pass the litmus test, but I am hopeful that my efforts to encourage patients to empower themselves, improve their skills at having difficult conversations, and increase the number of places where they feel safe to share nuanced feelings will mitigate some of the damage done by this war.  

Donald Meichenbaum on Coping with Loss and Traumatic Bereavement

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi, Don. Thanks so much for joining me today. You are most widely known for your foundational work in developing CBT but it is equally important that our readers know that for these last 35 years, you have been the director of research at the Melissa Institute for Violence Prevention and Treatment in Miami, Florida.
Donald Meichenbaum: (DM) Thank you for the invitation.
LR: You had previously requested that my first question be about the tragic and unexpected death of your wife, Marianne?

The Irony of a Trauma Specialist’s Tragic Loss

DM: We were married 58 years. My wife and I were vacationing in Clearwater, Florida, escaping the snows of Buffalo, where our permanent home is. My wife was tragically hit by a car at a pedestrian crossing. You know they have flashing lights, and this is sort of a warning sign. She was hypervigilant about not trusting people to stop, so obviously she would not have stepped off the curb if the vehicle had not stopped. But for whatever reason, the vehicle continued on and hit her. And in fact, she was lifted by a helicopter from Clearwater down to the trauma center in Saint Pete.I had called her on her cell phone thinking that she was late because she had a Zoom yoga meeting that she usually attended. I got a male voice, and he indicated that she had been hit and taken by helicopter down to the trauma center, but they would provide me with a police car to drive to the trauma center. I got there and the trauma physician indicated that she had already died. I asked to see her, went in and she was covered by a sheet. I pulled down the sheet, and she was pretty messed up from the accident.

I’ve worked with head injured, so I’ve been involved in seeing such incidents. Remarkably, her hand was still warm when I caressed it. There was a chaplain sitting next to us and I asked her to take a picture of me holding her hand. I actually sent that picture to my daughter-in-law who made it into a pillow. So, it was a traumatic bereavement kind of situation.

The irony is that morning I was giving a Zoom lecture for therapists in China on how to cope with traumatic bereavement and prolonged and complicated grief. And by four o’clock that afternoon, I was living my lecture. So, one of the interesting aspects of all this, and I’d be happy to discuss it with you, is what is the immediate and more long-term impact on an individual such as myself, who is in some sense is an expert on the area of interventions — having developed cognitive behavioral techniques.

Interestingly, there are hundreds of these kinds of accidents, many in Florida, of people — for whatever reason, where the driver is not complying with the pedestrian crossing. And there are multiple accidents and deaths in this particular way. So, the issue of traumatic bereavement as compared to a kind of prolonged complicated grief is an issue that I have been preoccupied with. And moreover, I’ll just add this final note before we open it up for your further questions. There are two aspects that are really quite fascinating in the aftermath of such traumatic bereavement.

One has to do with dealing with the grief. And the other aspect that is not readily discussed by clinicians is the sequelae that follow the sudden death of a loved one. And I will give both you and the readers to this presentation, a keyword that will change your life forever. This is the most important thing you should take away from our discussion. And the one word that you need, Larry, that will change your life if you do not already have it in your repertoire, is “passwords.” If you do not have the password of your significant other who died in a traumatic fashion, you are screwed.

LR: You’ll lose access to everything.
DM: Yeah, right. So, at a moment of intimate repose for your listener, they should lean over to their loved one and say, “I love you, but do you know our passwords and how to retrieve them?” So, you know I can fill you in and turn this into a kind of therapy session? And tell you the kind of trauma events, both dealing with the aftermath of the loss of my wife, but also the police reports, the autopsy reports, the life insurance, the banking, all of the credit cards — everything that goes with it.And the interesting thing is, if you are a clinician, one of the things you do in helping me is assessing, what is the lingering impact of this, what was the aftermath like? But it’s unlikely that you would have done that and asked does your social life change, and then a whole bunch of other questions that I’ve put together. In fact, the lecture that I was giving that morning to Chinese therapists, that entire 80-page handout that I provided them with is available to your listeners.

So, if they go to Google – Meichenbaum, Donald, Melissa, Institute – they will be able to download my 80-page tool plus other items on how to treat individuals who have traumatic bereavement and prolonged and complicated grief. So, if there’s anything I say that might be of help, I’m glad for that. And moreover, if there are people who want to contact me, they could do so through the Institute.

LR: I’m fascinated by the one word that you said clinicians, spouses, partners, family members should know, which is “password.” What’s the significance of imparting that piece of wisdom of knowing your partner’s password? And how did it play out in your journey?

DM: To access a number of accounts, my life was such that my wife Marianne was a wonderful wife, a very competent person. She was an actress, and she was a June Taylor dancer. She looked after all of our finances. I’m not a very competent person other than psychology. I’m a really good psychologist. I know a lot.

But when it comes to life, she was what I would characterize as my surrogate frontal lobe. And therefore, I never knew how to run appliances or bank machines or any of these kinds of things, and she looked after it. So, to gain access to that information, you really need the passwords. Fortunately, I have four wonderful children who are competent and loving and supportive, and that helped a great deal. So, we were able to, over a lengthy period of time — trust me, it took more than an entire year — to settle accounts related to adaptive functioning and financial issues and the like.

I won’t trouble you and your audience, but to highlight how unfriendly, how totally unfriendly the system is, to the 1,000,000 people who lost loved ones due to COVID. You know, the 20,000 individuals who died by interpersonal violence. You know, the incidence of mass shootings and all the other kinds of episodes, you know, the 48,000 who have to survive the suicidal death of a loved one. So, this discussion is absolutely remarkably timely, let alone the loss of natural disasters. I mean, just think of all the people at Maui whose lives are just upturned, and the many wars and the like. So, dealing with loss, grieving, traumatic bereavement, and mourning has to be on the top agenda of every clinician.

Difficult Therapeutic Conversations

LR: Working with adult children of elderly parents, clinicians have to enter conversations about what their plans are with and for them. And it seems to really behoove clinicians to engage these clients about the possibility of traumatic loss and unanticipated loss without pre-traumatizing them. How can we do that?

DM: We have to remind ourselves that what makes us effective therapists is the quality and nature of the therapeutic alliance that we establish, maintain, and monitor with our clients. So, to answer your question, I would advise clinicians to not enter that discussion without the permission of their clients. If I were in that situation, I would say something like, “I recently had a personal loss and I had a lot of lessons that I learned. And I was wondering if you would be interested or willing for me to share those.” So, my notion of being a good therapist is always to solicit permission from my clients, no matter what it is I want to ask. The third thing I would do is to say that, “you should feel free if this is not a good time or this is what we want to do, to put you in charge.” Remember that we, as therapists, need to be person-centered rather than protocol driven.

So, it sounds like, Larry, you had a whole bunch of to-do tasks that you think this elderly client or loved one should go through, right? You said you don’t want to traumatize them. Well, I agree totally. You know, so treat them with the same respect that you would want.

LR: How do we have conversations with our clients who may not even have elderly parents, but who are aware that they live in a world where there are dangers around every corner. How do you help clients prepare for the unpredictable without pre-traumatizing them?
DM: I have a kind of style of therapy, and I’ve actually highlighted this. I just put together a legacy course on what makes people expert therapists. As it turns out, 25 percent of therapists get 50 percent better results and have 50 percent fewer dropouts. So, my legacy course is, what characterizes those 25 percent of people and how can I elevate clinicians to that level? I have a kind of interpersonal style of respectful curiosity. And I really want to convey that to the client and wonder if they’re curious as well.I might say things like, we live in — how should I describe it — precarious times. With the COVID epidemic, with unpredictable violence, with multiple disasters and I must confess that I personally wondered to myself, and I wondered if you wondered to yourself about, given the unpredictability of life ever occurring, are we and our loved ones prepared for that? I mean, that’s my style of interacting. So, what I’m doing in that is actually sharing the rationale, and I’m extending an invitation.

My client might choose to take that invitation or not. And moreover, if I am going to see that person again in the future, all I want to do is plant the seed, then I will be able to follow up. I would say maybe this isn’t the right time or I’m not the right person. But as I look around, I think it might be advisable. And even something as simple as knowing the password of your loved one might be a good starting point. So that’s my way of engaging people.

LR: As simple as that. Simple, but complete.
DM: The key, or perhaps the challenge, is to deal with difficult issues in a non-traumatic engendering fashion.

Lessons on Grieving through Personal Loss

LR: In what ways, looking back, has your own clinical work and research helped you in your journey of grieving?
DM: Now that I’ve talked about the sequalae, let me take a moment and talk about the grieving thing. One of the things that’s really important for your audience to know — and there’s good research by George Bonanno and others that in the aftermath of loss — is that whether it’s due to traumatic, violent episodes like this, or whether it’s due to more prolonged, complicated grief as a result of having someone who’s been ill for a long period of time; there’s an expectation and different kinds of deaths have different kinds of impact.The bottom line is you need to recognize that most people are highly resilient. If you look at the data, most people don’t develop prolonged and complicated grief. So, the key aspect is, what distinguishes those who do versus those who don’t? And I even wrote a book called Roadmap to Resilience, that examines this and deals with it. In fact, your audience is welcome, in honor of my wife’s death, to view this and also my legacy course in her memory. So that’s one way of transforming pain into something good that will come of it.

And in fact, the Roadmap to Resilience has been downloaded for free on the Internet by 45,000 people in 138 countries. So now, let’s get to the heart of your question. In fact, George Bonanno wrote a really nice book called The Other Side of Sadness, which I recommend. It’s a nice little extrapolation on the kind of resilience engendering behavior. Therese Rando has also developed a concept that I’d like to comment on, that she calls “STUGs,” Sudden Temporary Upsurges in Grief.”

And in monitoring my own behavior, since I’m a psychologist and good observer, I’ve tracked my own STUGs. These kind of substantial or sudden kinds of upsurges of grief. And there are two kinds of STUGs in my life that I’ve discovered that have important clinical implications. The first STUGs are sort of sudden and unexpected. A song comes up, an invitation comes up to go to dinner with someone who doesn’t know about my wife’s loss. A couple walks by holding hands and lovingly convey their intimate connection.

And that hits me in an unexpected way. I’m moved to tears, and I have a sense of loss and the like. And there’s nothing wrong with that. In fact, I’ve come to believe that each tear that I experience in loss is not only a reflection of the loss and the grief and how much I miss her and the like, but it’s also a tear of appreciation. Of how lucky I was and grateful to have her in my life all these years. And then, I would have never had this career and all that without her. I’m a cognitive behavior therapist, so the whole thing is not that you cry, not that you feel losses.

It’s what is the story you tell yourself and others about that emotion? Each of us, each of your readers of this interview are not only Homo Sapiens, but they’re Homo Narrans. That we’re actually all storytellers. And the nature of the story we tell will determine — I’m going to suggest — whether you fall into the 20 percent who develop prolonged and complicated grief, or you’re part of the 70 to 80 percent who, in spite of the loss, everlasting loss, your STUG is this kind of sudden reminder.

LR: Unexpected!
DM: I sort of expect them, but they come out of the blue, right? The other kind of STUG which is interesting is something that’s a reflection of a prolonged type of routine or activity that we would have engaged in. So, I’m in Cape Cod, one of the things we would do is go down and have our sunset drink on the beach. A saxophone player would often be playing in the background from their beach house, you know, some Cape Cod song that we would have toasted to, kind of thing.Or we have our favorite restaurant, or our favorite hike or something like that. And I’m now doing those activities on my own. There’s another really interesting aspect to this, and that is, is the person who’s surviving the death, male or female? Okay, so most of my social contacts here in Cape Cod, and in other places, are a derivative of my being a partner of Marianne. So, she had a remarkable social network. She was just lovable and likable. There wasn’t anyone who didn’t fall in love with my wife.

And when she died, those social contacts sort of evaporated. People sort of give you occasional email and a “how are you doing?” But you don’t get invited to the same social occasions or dinners or other kinds of activities, so your network is really an important issue. And the important predictor here, especially among men, is loneliness. Okay, and there’s a higher incidence of husbands dying soon after the death of their wife, about 30 percent and so forth, and having other kinds of physical ailments than the other way around.

And then you need to distinguish between loneliness and isolation. Some people choose to isolate — they like being alone and so forth. Loneliness is yearning for this. And so first of all, in the aftermath of both traumatic bereavement and in terms of the mourning process, that becomes important. The other thing that your readers should take away is that there are no stages of grieving. So Kubler-Ross and Ron Kessler’s stuff about going through stages has no scientific basis for it.

And not only do you not have the five stages, but the expectation on the part of the clinician that people need to go through stages, and the failure to do so is a sign of pathology, is indeed problematic and possibly stress-engendering. So, when people don’t get angry, okay, then it’s deniable or they can’t handle their emotions. And I had a pretty good cause to be angry. This happened in Florida, okay? So, the guy who killed my wife got fined 160 dollars and lost his license for three months.

That was the total consequence. Not only that, in Florida — this is a wonderful state to live in if you’re going to retire — you don’t have to have liability insurance on your car. Okay? All you need to do is pay insurance up to 10,000 dollars. The helicopter cost of taking my wife from Clearwater to the trauma center was 68,000 dollars. So not only do I have, look, how much time do we have? You want me to go on and on? So, what am I going to do? And anger we know, gets in the way of processing trauma memories. Of all the emotions, that’s the one you don’t want to give up to. And that’s the one that clinicians should ask about in the aftermath.

So, if you go to the handout that I have, I have put together the most important diagnostic questions that clinicians should ask. Yeah, I give workshops on grief, and I actually bring my pillow and tell people. And I ask, if I’m your client, Larry, what questions do you think you should ask me? You’re a gifted clinician. What do you think are the most important questions you should ask me to see whether I’m going to develop prolonged grief disorders? Because there are now effective treatments. Shearer and others have created really good cognitive behavioral interventions, when I go on and on and review all the literature. So, I can make this a two-way street. I could ask you, what question do you think you should ask me first?

LR: What comes to mind is, how has your life changed?
DM: Wrong question!
LR: Okay, I could probably guess 20 times wrong.
DM: No, no. The first thing you should ask is, “how long ago has this occurred.” Okay, if this happened like last week or last month, that’s different than if it occurred a year ago. Okay? You know, and then there’s a whole set of questions you could ask about the circumstances, like you did at the outset. Okay, so getting to the notion of how you handle this has a kind of implied judgment on your part that I should be handling it.So, am I going to tell you how bad off I am or am I going to say oh, it’s not that bad, right? So, you have to establish a good therapeutic alliance with me, where I’m going to be open and honest. You know, I have trust engendering things, so I don’t know what your agenda is. Anyway, go to my handout.

LR: I will. I will.
DM: Please, I didn’t mean to put you on the spot.

LR: It’s refreshing and intimidating at the same time. What other guidance are you offering to clinicians who maybe are sheepish about asking the questions, or will not openly receive or seek out clients who have experienced loss? 

DM: The first thing — over and above the comment on stages — is that the field of psychotherapy is absolutely filled with bullshit. I wrote an article with Scott Lilienfeld called, How to Spot Hype in the Field of Psychotherapy. The next thing for therapists to understand is that the various therapeutic procedures are equivalent in outcome, and that there are no winners in the race. So that’s the next thing, just don’t believe the hype in these workshops where these people are saying that, “X, Y, and Z works better.”That traumatic bereavement is a common response, will lead to grief and mourning that leads to deteriorating performance is just not the case. So, the second thing that’s really important is that you need to ascertain from the client how to do therapy in a culturally and religiously, and gender-related kind of fashion. You need to ask the person — in my case, whether I’ve had other losses besides Marianne. You need to make me a consultant to you. Okay. And then you need to probe. How did I handle those? And is there anything I learned from them? So, you need to see me as a client as a resource person rather than someone you’re going to treat because you went to some workshop. Okay!

And apropos of the loss and transition website by Neimeyer and colleagues, they have a lot of techniques. Some of them are expressive. Some of these are customary activities that people engage in. So, you, the clinician, need to honor the way in which I want to cope with grief. Okay? And I recently went to a workshop by Mary Francis O’Connor who wrote a book on the grieving brain. And you need to recognize that some of the losses that people experience are natural and a reflection of love.

So don’t pathologize people’s grief or their coping techniques. If I want to avoid certain activities, I don’t go and get rid of the clothing and so forth. And there was a movie that Tom Hanks made that his wife produced called, A Man Called Otto. It’s a bit of a Hollywood version, but they did a really good job on talking at the gravesite. And doing the thing on the clothes. Here’s a wonderful thing that happens. When I cleaned out my wife’s closet, I found out that for the five years that we courted each other, we had written letters. And mind you, that was 1961. She saved all those letters. In 1961, a stamp was four cents. I read those letters as if she was present, each night I take out a couple. I’m now up to 1963, you know that stamps now cost $0.08 in 1963? Her presence, my storytelling, my doing this interview, my reading the letters, are all my own personal ways to honor her memory. The fact that I put the Roadmap to Resilience online for free in her memory.

If you go to the Melissa Institute website, if you’re interested, if you like this interview, go there and make a donation in my wife’s name. We’ve already raised 25,000 dollars for the Institute against violence prevention for her. I’m now in the midst of having done this legacy course of ten one-hour lectures on what makes someone an expert therapist, and then how to take those core principles and the transtheoretical behavior change principles and apply them to a whole host of diverse problems like grief and PTSD and anger and the like.

Each of those courses is only going to cost 150 dollars. Okay, that’s 15 dollars per CEU. All that money is going to go to the Institute in memory of Marianne. So, if you want more of what we’re talking about, track down this legacy course. If you do, there’s the likelihood you’ll be in the 25 percent group and you’ll be able to honor my wife’s memory. You get CEU’s for cheap.

The Role of Resilience in Healing through Grief

LR: You mentioned something earlier on, Don, about resilience as one of the really powerful predictors of how someone will move through their grief journey. Can you say a little bit about what a resilient griever looks like?
DM: In the aftermath of trauma or victimization, and with regard to whatever form it takes, resilience has been equivalated with notions of the ability to bounce back and with dealing with ongoing adversities. And it deals with the notion of personal growth. Margaret Stroebe and her colleagues have an interesting distinction within which people oscillate. That is, they have a variety of coping responses that are loss-oriented or restorative, and future-oriented. One of the things that’s interesting is that people can deal with it as a kind of Viktor Frankl type of observation.That people could deal with any kind of how in their life, as long as they have a kind of why in their life. Some sense of meaning, making purpose. This fits into my constructive narrative perspective that everyone is a Homo Narrans, or a storyteller. So, one of the things that becomes really interesting is how people transform their loss into some kind of effort to help others. So how did the Melissa Institute come about and my involvement therein? So, in the tragic killing of their daughter, Melissa, when she was at college in Saint Louis at Washington University, they have transformed the last 28 years – her loss — into a meaning-making activity.

You can go to the Trevor Project on suicide. You can go to Mothers Against Drunk Driving. There are numerable examples, I give multiple websites of how people have transformed their pain into something good. That doesn’t mean that you don’t continue to have an everlasting sense of grief. There’s nothing wrong with grief. It’s like any other emotion. The key is, what do people do with that emotion? Do they withdraw? Do they isolate? Do they become lonely? Do they use addictions? Do they self-medicate?

So, the key question is not, apropos of the resilience, or that people grieve. The fact that people are in touch with their grief is, in fact, a sign of resilience, right? It’s coming to, how do they honor? How do they memorialize? I deal a lot with returning soldiers. And the other kind of thing is that there are different kinds of losses. There’s loss of people, but there’s a thing called missing loss also. Like imagine people who have individuals who go missing in action. You don’t know if they’re dead right, or in Maui — you know, they haven’t found certain bodies. I mean, does that mean, is there more?

How do I, do I sort of get preoccupied and ruminate about the loss of my loved one, and how I wasn’t there? If I have guilt, shame, humiliation, if I have anger, if these kinds of negative emotions are that which drives me, then that’s the person, those are the folks who are going to be more likely to get stuck, who have hot cognitions and the like. So, you can talk about resilience being the absence of negative stuff, or resilience could be the restorative process on the other end. I don’t know if I’m getting close to your concerns, but…

LR: That resilience, and there are certain personality attributes and certain experiences that predispose people to resilient ways of being, and those people are probably in a better place to move forward in their lives after a loss.

DM: Here’s one of the things I failed to mention. The research indicates that people who have had a prior major depressive disorder are significantly more likely to develop prolonged and complicated grief. So, when I was asking the question, I ask, “Have you had similar losses in the past” and so forth? What we could do is look for vulnerability factors, okay, that are red flags as another tip. To see who would warrant evidence-based interventions, we’re pretty good.

If you look at my core task, there’s a whole way of how we, as therapists, do psychoeducation to educate people about grief. Or how do we help them develop various kinds of coping strategies? And how do we get them to follow through? The big thing is how do you get people who need help to want to come for help? And help them stay there? That’s the artistry of therapists.

LR: Is it more likely that those who have historically reached out to others for help, who have built lives that are rich in community, are just naturally predisposed?

DM: Well, a lot. There’s a fair amount of research by Camille Wortman and Roxanne Silver. Obviously, one of the building blocks for resilience is relationships. I mentioned I have four loving kids who really came to support, I have other people — professionally and others — who’ve come to support. But Wortman then really found a whole bunch of things that people do that are unproductive, that actually make people worse.

They have identified a variety of things that people provide support for, and actually make people worse. Like moving on statements. Things like, “You’re still a young, attractive, bright guy. You’ll find someone. How much longer before you die, You’ll be able to join him. This was God’s mission, He knew something.” So, there are lots of things that social support people offered, so that’s one of the questions you need to ask.

What, if anything, have people done or failed to do that you found helpful or unhelpful, right? Because you want to make sure that you, the therapist, aren’t doing something that I perceive as being unhelpful. So, if you’re a really good therapist, let your patients teach you how to do therapy. Don’t think just because you went to graduate school or took some workshop that you know how. Ask your patient, “What do you think is causing you to still have this lingering grief? And what do you think it will take to help you to move on? And what is it that I, the therapist can do to help you in that process?”

LR: You know, Bob Niemeyer suggests that therapists working in the arena of grief need to be what he calls the guide on the side, rather than the sage on the stage.

DM: Yeah. I like that. That’s a good metaphor. I like him a lot. I’ve read all his stuff. And, you know, my thing is, don’t be a surrogate frontal lobe for your patients. Don’t let the person’s emotions hijack their frontal lobe.

LR: And don’t, as the therapist, let your emotions hijack your presence in therapy. What about those therapists who themselves have had complicated losses, or unfinished business with their own children, parents, and spouses who have died?

DM: Well, I guess those therapists need to be honest with themselves and wonder how it impacts their therapeutic process. Those therapists need to be honest with themselves and decide whether, in fact, they need some therapy. That could help them deal with the issue. And the third kind of issue is, can they strategically use that self-disclosure in a way that facilitates or benefits the patient’s recovery? Rather than saying, you think you’ve got problems with your wife? You want to know what living with cancer has been like? And not only that, my father has Alzheimer’s, and now all of a sudden I have to listen to your shit, right?

So, you can judiciously, strategically say words are inadequate to describe what grief is like. I’ve been there myself. It’s not the occasion for me to share the details, but I want you to know I’ve felt the pain. Okay, I don’t know what the right words are, and you have to say it in an effective way. You can’t say, you think you got problems?

LR: In what way are you — are there any ways that you’re still practicing as a therapist now?

DM: I do a lot of consulting. I work with the head injured thing when people have cases, I train therapists who are doing supervision. I’m not seeing patients now like I did in the past, because I’m not in one place. I’m kind of a peripatetic clinician, so it’s hard to make a commitment to someone being there. I do some consultation with patients by telephone, since COVID.

LR: We could talk for hours Don and I do I hope we talk again. I appreciate your kindness and generosity.

DM: Thank you for the compliment and for inviting me on this journey.

©2024, Psychotherapy.net

Mapping the Heart Of OCD: Going Beyond the Conditions We Know

Posted on by Psychotherapy.net Team

“The heart has its reasons of which reason knows nothing.” —Blaise Pascal

Capitalizing on Empathy in OCD Treatment

Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them what’s the best intervention for OCD, and you’ll get the same answer: Exposure Response Prevention (ERP).

ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their biggest fears and learn not to blink. Intending to conjure up their personal worst-case scenarios — the terror of harming a newborn child, the yuck factor of hands submerged in an overflowing trash can in Times Square, or entertaining the possibility that they just might be a psychopath — ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.

Although highly effective at providing relief for symptoms, ERP is a mind and behavior-oriented approach that misses the most astounding feature of the OCD tribe: their enormous hearts. People with OCD are amongst the kindest and loveliest clients with whom I’ve worked.

And it’s not just my own bias, research confirms this big heart. Recent studies found that individuals with OCD show higher empathy levels compared to healthy controls. They shared the suffering of others in both self-reports and in a naturalistic task designed to test empathy in real time. They also reported more distress over their heightened empathy and are more emotionally responsive and attuned to others compared to healthy controls.

Such responsiveness is at the core of what makes therapists so effective, and yet for those with OCD, it misses two crucial pieces: the self-compassion and self-advocacy to counterbalance a weighted-down heart. Therapist burnout shows it’s possible to be too empathic, but have we ever looked at OCD from this perspective? Maybe we should!

A behavioral approach gives little room to map this expansive OCD heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39-and-a-half-foot pole. Between one quarter and one half of people with OCD decline ERP, in some cases even before it begins.

I regularly take on the challenge of asking myself as a therapist: what more can I learn about this condition by entertaining something completely different? In the spirit of punk rock, what can I glean if I rebelliously take on the mainstream? With its one gold standard treatment, OCD begs the question: isn’t there more we can do to help OCD sufferers find their voice? Perhaps ERP is so popular that few have the audacity to question it. Maybe, as Pascal instructs, the heart has its own reasons. Such was what I learned with and through Kate.

Kate’s Therapeutic Journey

“I almost cried when I read your blog post,” Kate confessed during our first zoom meeting. A cinematographer based in LA, Kate was fast losing hope that she’d ever get past severe OCD that only relented, ironically, when she was on set. “I always thought that I was failing at OCD treatment, not doing it right. Like, why aren’t I strong enough to just sit through the anxiety? But when I read your work, I felt like treatment was failing me.”

Kate read my unconventional theory that OCD arises from an empathic and existential sensitivity that goes unnoticed and unsupported, and turns in on itself. That enlarged heart capable of so much love is also keenly aware of the chasm of loss set before us all. Is it any wonder that the majority of OCD sufferers worry that death might befall themselves or someone they love? Or that the ritual du jour might somehow stave off what we all wish to control? At its root, OCD is a keen awareness of the fragility of life and the myriad spells and incantations we use to hold on to it at all costs, even if we must lose ourselves first.

“My parents and siblings used to poke fun when I was little when I wasn’t ready to let go of my teddy bear like they all did when younger. I carried her everywhere; she was the sensitive heart nowhere to be found in my house. I hated that I couldn’t let her go, and even until recently, I felt that way about my OCD treatment. Why couldn’t I be fiercer and face my fears and just grow up? Why can’t I even do this ERP thing right?”

Kate felt guilty in therapy, too. She admired the OCD specialist who first gave her a diagnosis and regaled her with the promise of ERP. Finally, there was hope that OCD didn’t have to rule her world. If he had saved her — as she so often felt — why wasn’t she more appreciative?

As we talked together, it became clearer: feeling wasn’t on his radar. Her therapist didn’t listen or seem to care about all that sensitivity, and she felt rejected yet again alongside her teddy bear. “What does it matter what your obsessions mean?” he’d shoot back, as if to say, “get with the program, this approach isn’t going to get you anywhere.”

In conventional OCD treatment, obsessions are just noise in the system trying to distract from the most significant mission: full acceptance of uncertainty and ambiguity. While Kate always wanted to make meaning and find ever more intricate forms for her feelings, her therapist just wished she’d keep working hard and be satisfied with her progress. There was little room for her own authoritative and unique voice, all that good fire in her heart.

Kate could also detect something unspoken in her therapist’s heart: how much his identity seemed tied to one singular truth and how it rattled him to entertain otherwise. She vaguely knew something about herself — how she existed in the world — hurt him. But she never put those feelings into words. Instead, they metastasized into self-doubt, self-recrimination, and shame.

It clocked Kate in the face when she recognized her therapist’s philosophy in a meme widely circulating and praised on Instagram in the OCD recovery world: “OCD is just sound and fury, signifying nothing.” Borrowed from Macbeth’s famous line when the walls are closing in on his murderous exploits and he learns of his wife’s death (ironically, Lady Macbeth with her “out-damned spot!” is one of the most famous contamination OCD cases in literature), Macbeth’s phrase is one of horror, lamentation, and hopelessness. The world is a meaningless, obsessional march of tomorrow and tomorrow and tomorrow, a tale told by an idiot.

“What is wrong with me?” Kate wondered. “I’ve always been a failure in treatment just as in life.”

The middle daughter of a highly educated and successful family of Chinese immigrants to California, Kate constantly found herself on the outside. Family members pegged her as unable to let things go, and though they’d never outright say it, weak for not being able to be more driven and hardworking like the rest of the clan. “Even your work is all just fantasy,” her mother complained.

Kate’s sister had already long moved out of the parents’ house at 25 and was now in medical school, setting sights on buying her first home. Her brother, an IT specialist, always seemed to be able to fix just about anything. Kate was the anomaly, still living at home with her parents and never quite fitting into the alpha-driven landscape of her family’s California dreams.

“Why couldn’t she just enjoy the promise of all that beautiful California sunshine?” her father protested. Kate was always adrift in the riptides of her obsessions, what if she forgot the stove was on, burned the house down, and killed everybody’s nascent dreams along with it?

“It’s like I can never do what the mainstream wishes for me. Maybe that’s why I’ve gravitated to indie films so much. It’s my only refuge.”

“I’d reverse that. The mainstream has never really witnessed your profound heart. You have always tried to accommodate the mainstream — your family, your therapist, the world — but it has come at the price of who you really are. Your sensitivity has always been a part of what has made your vision so clear and full. It’s no accident that your OCD largely vanishes when your sensitivity is prized, as it is when you are working on films and the director gives you the go ahead to command what you need to get the right shot.”

Kate always had a whimsical and keenly observant view of the world, and it showed in her cinematography. She always knew which way to angle the camera not just to get the right light or best composition, but somehow, she evoked things out of objects and people that were somehow right there, but beyond them as well. Her prodigious talent landed her on projects that she most dreamed of; it was also one of the few places where she felt free from obsessional doubt.

“Because your parents didn’t see your sensitivity as a gift, it got housed in your own mind, and you had to protect yourself and them from its power. You sensed so much of what was happening in your environment but there wasn’t a place to communicate that. It becomes wild in our own minds, but we need relationships — and art — to tame it.”

Kate is in Good Company

Together, we joked about how many artists and innovators shared OCD and this unique sensitivity, if you were lucky, found a place to give it creative form. How Greta Thunberg, herself an OCD sufferer, marshals her profound sensitivity to the neglect of an entire planet into fierce advocacy to save us all from extinction. How young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis in The Fault in Our Stars and writes of Aza Holmes, the greatest young adult character with OCD in American literature, in his novel Turtles All the Way Down.

Like Kate, Aza seeks her own center. Is she just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself than she is lost again, spiraling about the possible infection she now has unleashed. Compelled to drain the pus and blood, Aza is a hostage of her own self-enclosed system of fear, love, and unboundedness.

The heart figures prominently in Aza’s story too. Her father, also a sensitive soul and unrepentant worrywart, mysteriously drops dead of heart attack while mowing the front yard lawn. Just as Kate is so aware of killing everybody’s dreams and truths in her life, Aza shares a moment of clarity with her boyfriend about the root of her OCD: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.”

“OCD is a sensibility of sensitivity, one that has an exquisite flame for creative possibility but when traumatically misunderstood and misdirected, it burns the house to the ground. If Gabor Mate specialized in OCD (Kate was a huge fan of this rock-star sage) he’d appreciate it with us too. OCD is more than just a biological glitch; nature and nurture are always in conversation, whether we choose to listen. OCD is trying to tell us more than even therapists are ready to hear. There’s interesting music in all that noise.”

Kate was accustomed to having her true interests and concerns fall on deaf ears. Her relationship with this therapist and with cognitive-behavioral therapy itself echoed her ambivalent relationship to her parents: while she was grateful for having been raised and financially supported by them, they minimized her interests as foolish and viewed her obsessions as just more evidence of her immaturity and self-absorption. Without a clear and secure sense of support from these relationships — her parents or her therapist — Kate relied on her own thoughts and rituals to hold her up.

And yet here was the rub! Untempered by any human relationship, these thoughts quickly became savage and cruel, expecting her to be able to live up to what her perfectionistic imagination could dream up: a world of all-or-nothing purity.

Kate suffered from paralyzing obsessions when out in public places, fearful that the looks of others somehow might cause her to implode. Triggered on subways, Kate left the NY film scene for California where she had more freedom to drive solo. But Kate never quite understood why her obsessions centered around this particular theme and not something else.

“It doesn’t really matter,” her old therapist used to say. That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep on going down the rabbit hole. It’s not to be trusted as your friend.”

But Kate, ever-so-fascinated by the motivations of the characters she tracked in the movies she made, knew there must be more. Obsessions had a funny way of both distracting and focusing us on the things we most feared and desired for a reason. Kafka’s Gregor Samsa didn’t turn into a bug just because he had some tic of the mind, but rather because he felt the alienation, oppression, and depersonalization of his family life and modern society combined.

Successfully Addressing the Heart of Kate’s OCD

We worked on a new kind of exposure response prevention, one that dialed down into all of her feelings and associations with her obsessional fear. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others around her. With her big heart, she was so tuned into the unexpressed fears and desires of everyone that there wasn’t enough room for herself. She sensed the fatigue in her parents, their loneliness for their home country, and their overcompensated worries about surviving. They had no idea that internally she was feeling for them, unconsciously trying to imagine every way she could help them control their fate.

She was compelled to avoid any places which might afford too much scrutiny — subways, planes, trains, long car rides— and wisely found the safest place to exist with complete freedom: behind the camera. There, she no longer was the stage for all the unexpressed feelings of others; she could now orchestrate them for her own artistic purposes.

I knew Kate was making progress in our treatment one day when she started our session rather abruptly, “I know you might want to talk more about what we only half-completed last week, but I don’t want to do that. This is what I need today.”

My heart swelled. I loved the grit, fire, and healthy aggression that I knew she needed to have to own herself, even if she risked temporarily losing me. When I expressed this, she was a bit dumbfounded, “You mean, it’s okay for me to ask this? I’m not screwing up your plan?”

“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger; it was Aza’s middle finger. She needed to say a healthy ‘fuck you!’ to the people she loved — her mother, her best friend, even her own OCD — and trust that she was entitled to it. That’s what you’re doing now, and I love it.”

For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.

Together, we found the heart of it, the mystery that constantly hovers somewhere between life and death, love and hate, and disaster and possibility. Like Aza Holmes, who had lost her father, her boyfriend, and her beloved Toyota Corolla Harold, Kate recognized the biggest truth of all: “To be alive is to be missing.” And yet, it’s in that unexpected place where Kate was found again.

A Foster Child’s Painful Visit with his Mother

Posted on by Psychotherapy.net Team

The Child’s Family Visit through the Therapist’s Eyes

His eyes widened with welcome, and a quick smile flashed across his face when he saw me pull in. From that moment, Jason was a 55-pound human-guided missile speeding out the door when I came to transport him and his sister for their weekly family visit.  

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Today he is dressed in a royal blue, short, sleeveless shirt rimmed with white. His shiny new soccer shoes and short white socks are in sharp contrast to his small, skinny, naturally honey-brown arms and legs which have been tanned an even darker color by the sun. His straight jet-black hair falls in a circular pattern around his face. He has a child’s small mouth and nose set in a fragile face. It is his enormous, soft, brown eyes fringed with long, black, velvety lashes that tell his story. His eyes are the mirror of the words his lips will not speak.

Jason is silent on the short drive to the office until he suddenly blurts out that he has lost a tooth as he proudly displays its previous location. I respond with excitement and ask if the tooth fairy paid him a visit. He is silent. When we reach the office, he is the first child out of the car, into the agency, and up the stairs to the therapeutic playroom where his mother is waiting.

He comes to a standstill in the doorway of the room. His eyes reach across the sea of two brothers and two sisters to connect with his mother. Helplessly, they look at each other, and with their eyes, express the pain they feel in separation, without words or touch. After a moment, Jason tenderly greets each of his brothers and sisters with a kiss and a hug. He receives no display of affection in return. There is no expression in his eyes or on his face when he has finished.

Jason doesn’t play with any of the toys but spends the precious minutes of his visit as a helper and a nurturer. He begins by straightening the toy closet. Standing on tiptoe, he arranges the toys, games, and puzzles. When he is finished, he sits with his hands folded and his little legs dangling over the sofa, watching his brothers and sisters play. When the visit is over, he helps them pick up the toys. Jason is a little old man in a little boy’s body at the tender age of 7.

Jason is the first child to hug and kiss his mother goodbye. His arms tighten around her neck as he buries his face in her shoulder. He lingers in this position until his siblings push him out of the way demanding their hug.

Jason steps back fighting off his tears. In the end he succumbs to his feelings. He turns his head to the side to hide the tears as he wipes them from his eyes with the back of his hand. Jason is the only child who cries when the visit is over.

Jason is quiet in the car on the way back to the foster home. He sits with head bowed so I cannot see the tears flowing. When we arrive at the foster home, he is the first child out of the car. He gives me a brief glance as he looks back on his way to the door. His eyes flicker for a moment with pain.

The Family Visit through the Child’s Eyes   

I saw my mom and brothers and sisters today. When Vicki came in her little red car, I called to my sister, “Hurry, Christie, time to go see Mom. Race you to the car!”
I beat her to the car by a long shot. Girls are so slow! I jumped in the car. I got the front seat! I buckled my seat belt. I wished Christie would hurry!

During the ride to the visit, I had so many questions I wanted to ask, “Why can’t I live with my mom? Why am I in foster care? What did I do wrong?” I did ask Vicki, but she said she didn’t know. I thought she just wasn’t telling.

I had a lot to tell mom. I couldn’t keep my surprise inside any longer, so I told Vicki. “See what I did! I lost my tooth!” I held my mouth open with my fingers so she could see the big hole where my tooth had been.

She had to look quick cause she was driving. She laughed and her eyes got really big. She asked me if the tooth fairy left me any money. I had never heard of a tooth fairy.

I wondered if mom would be there. She didn’t come last week. Nobody told me why. They said, “Ask mom!” Funny how grownups never give you a straight answer when you ask them questions!

I jumped out of the car when we got to the office. I ran up the steps to the playroom. I ran to the room and stopped really quick in the doorway. Mom was there! She got tears in her eyes when she saw me. I cried too, I was so happy to see her! I wanted her to kiss me and hug me. She couldn’t because she was holding a baby. She said his name was Adam, and he was my new baby brother! Daina, Katie, Jeff, and Christie came charging into the room. The moment was gone. There was no time for me. I was too late.

I love my brothers and sisters. I missed them, so I hugged them to let them know how much I missed them. They didn’t hug back. They didn’t know how because mom didn’t have time to teach them once the babies started coming. She was always too busy or too tired. I had to teach them hugging. I didn’t mind because I liked hugging. It only hurt a minute because they didn’t hug back. I am used to it by now.

I cleaned out the closet this week, like every week, hoping mom would notice me. Vicki noticed me and said something, then mom said something. I felt really special for a minute. The feeling would have lasted longer if mom had said something first.

When I finished, I went to sit by mom. I wanted her to ask me about school. She didn’t because she was too busy playing with Adam. She wasn’t supposed to be playing with Adam all the time. This was MY visit. I was mad and no one noticed but Vicki.

I got down on the floor to play with my brothers and sisters. There wasn’t anything else to do. Just when I started playing, Vicki said it was time to pick up the toys and say goodbye.

I helped put the toys away and turned to my mom. I put my arms around her neck and hugged her as hard as I could. I hoped if I held on long enough, they would let me go with her, or she would say something. Then the little ones pushed me out of the way to get their goodbye hugs and kisses. I gave up! I decided being the oldest meant being last, even if I was only 7!

I fought really hard to keep from crying on the way to the car and back to the foster home. I tried to hide my head when those dumb tears started falling. Vicki saw my tears. She reached over and stroked my head and neck. Her hand felt soft, and I felt better for a little bit. She said it was OK to be hurt and to cry. I wanted to ask if it had to hurt this much, but I didn’t.

When we got to the foster home, I beat Christie out of the car again. It felt good to be first. I’m not first very often. Vicki was watching me when I ran into the house. For a second, I couldn’t keep back my tears. I guess it was OK to let someone know I was a little boy inside, after all.