Author: Psychotherapy.net Team

Improving Your Clinical Presence with Receptivity and Gratitude

Posted on by Psychotherapy.net Team

Suggested Tips for Clinicians: 

  • Practice methods for strengthening your therapeutic presence.
  • Ask yourself if you are or are not empathically attuned with each client.
  • Explore barriers to full presence and empathy with more challenging clients.

 

A capacity crowd in the large conference hall rose to its feet in applause. Daniel Siegel, renowned author, clinical professor of psychiatry at the UCLA School of Medicine and Executive Director of the Mindsight Institute, had finished his presentation. I too stood with enthusiastic appreciation, not only for this lecture, featuring the clinical significance of therapists’ mindfulness, but for all the ways his research and writing about developmentally informed parenting, neuroplasticity, and the incorporation of science into the practice of psychotherapy. All of these had influenced my thinking and work over the past ten years.   
 

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Dan had begun to move away from the podium when he seemed to catch himself and walked back to centerstage. He stood, fully facing the hall, hands clasped in front, nodded his head and bowed. For our part, the applause of several thousand therapist attendees showed no sign of relenting. Then an event unfolded I have carried with me since. 


It began with the simplest of gestures. Dan took and held Tadasana, a standing yoga pose. His feet parallel and facing forward, Dan released his fingers, opening his hands which moved to the sides of his legs, palms open, shoulders relaxed as he appeared to empty himself and stand receptive before the crowd.  
 

The audience responded with delight and gratitude at this embodied receptivity. The volume of the applause rose, and Dan, smiling gently, took a deep breath. The crowd responded again. Waves of mindful presence, enthusiasm and gratitude rolled through the large hall back and forth, until Dan took a final bow and joined the crowd he had just helped to unify.  
 

Gratitude is amplified by its reception. Reception is its own expression of gratitude. A feedback loop, formed by gratitude and receptivity, generates a mindful, compassionate field that feels very much like love.  
 

Tears rolled down my professional cheeks. I quickly brushed them away hoping the strangers around me noticed neither my intense emotion nor its expression. Unleashed by the power of that loving field, my tears flowed freely and powerfully, apparently straining for release. I felt seen, heard, and appreciated. I was included, a true part of this collegial, communal event. There was a transcendent quality in which this loving field was not so much being created but being acknowledged as existing before this moment. All of us stumbled into an awareness of a much larger and enduring field of love.   
 

I was awed by the immediacy and goodness of the human family. But it was an ecstasy undifferentiated from loss and longing. My tears expressed my grief at how seldom I had been aware of my presence in such a space. Having often felt unseen, unheard, and unappreciated, I suddenly experienced a sense of loneliness and despair of enduring connection. The pangs of longing and the shame of my dissatisfactions with self and others were ignited by my embrace of this mass symbiosis. Yet, there was also relief at the quenching of my childhood thirst for an uninhibited expression of mutual affirmation and solidarity.   
 

In the religious experiences of my young adulthood as a youth minister, a shared faith and religious ritual turned what might have been merely an experience of communal intimacy into an encounter with the metaphysical. My peers and I tasted, not merely the immediate experience, but elements of a universal interconnectedness: with one another, with the Church, and even, it seemed, with God.     


As I grew older and my religiosity subsided, the felt importance of that faith and my need to participate in a loving field never waned. If Dan Siegel had continued off stage to privately appreciate the applause, he may very well have experienced a profound sense of what his work meant to us, he may have been moved to tears and even been motivated to write another great text, but his personal experience of appreciation and inspiration would not have generated the mindful, compassionate field of love we all shared. To generate such a field, he had to turn around and move back to the edge of the stage, putting himself on display. He needed to make the mindful choice to allow his body to express his emotional state, ultimately taking a posture of reception easily understood by the community before him.  
 

As an audience member, I too had a role in creating the moment. While Dan closed his presentation, I might have remained seated, turned to a neighboring attendee and, in a relatively hushed tone, remarked upon an outstanding insight or application. My neighbor may have responded with her own insight and drawn my attention to aspects of the presented theories elucidating my thinking. This might all have had a positive impact on my practice, but none of it would have generated the field of love.   
 

 All of us that day physically manifested our emotional reaction by standing, applauding loudly, and maintaining focus on Dan. We allowed his gestures to carry meaning and translated that meaning into action with vocalizations of delight and even louder applause.  
 

After any professional conference I strive to identify the clinical application of what I have learned, knowing that for me to retain information I need to utilize it. While I came away from that conference with much information, it was this personal, emotional experience that I most wanted to incorporate into my life and work.  
 

But where would this powerful manifestation of gratitude and receptivity play out in the consultation room? Although, as a psychotherapist I am sometimes the recipient of heartfelt expressions of appreciation, I have never received a standing ovation. Nor do I often feel deserving or desirous of one! The emotional waves of gratitude between therapist and client are smaller and quieter and, as a possible result, the loving field we generate is more easily dismissed or completely overlooked.  
 

It is a process that unfolds in many sessions. It unfolds with the subtlety of a raised brow, a silence, the slightest of gestures. It is carried by a word, a smile, a tear. We know it as empathic attunement and the creation of a therapeutic space. It is enacted when a client experiences acceptance in response to long held shame. I wonder how open my stance is in receiving such gratitude. Does the client feel my reception and the gratitude I feel for their gracious expression?  
 

Recently, in a relational-process group I co-facilitate with my colleague Aisha Mabarak, a field of love made a surprising appearance. Sheila* arrived late due to complications at her job that held her past the end of her shift. She reported being exhausted and ill-prepared to share her feelings with the group. 


“I’m in a fog,” Sheila said with an uncharacteristically flat tone. I responded by thanking her for making it to the session and affirming her inclination to take a restful, though present, pose. Aisha, however, had a different approach. Not wasting any time, she asked: “Sheila, why don’t you share with the group a little more about this fog you feel stuck in?”  
 

Sheila proceeded to describe, with increasing emotional range, how deadened she felt by a sense of invisibility in multiple facets of her life. Examples spilled forth of her efforts to meet the needs of others only to be met with thoughtlessness and a glaring absence of gratitude from family members, friends, colleagues, and bosses.  
 

Other group members expressed empathy and support. One member voiced these sentiments succinctly, saying that she felt Sheila’s pain and she was, at that moment, imagining how hurtful and difficult it must be to feel so unappreciated by people who care for you. In approximately fifteen minutes Sheila had gone from a depression-based brain fog to expressing her anger and upset assertively, leading to smiling and expressions of appreciation for her fellow group members.  
 

My inclination to support Sheila by giving her space was intended to express, both to her and to the group, that it was acceptable to feel your pain in session and to choose to set self-protective boundaries. This intervention may have been simply wrongheaded, or it may have, by reminding members of their autonomy, laid the foundation for co-facilitator Aisha’s fruitful follow-up. While I had responded to Sheila’s verbal communication and her depressed presentation, Aisha responded to another expressed impulse—this one non-verbal.  


Sheila expressed her impulse to participate in the group by showing up and letting us know how bad she felt. Rather than disappearing off stage, a space she was also entitled to occupy, she had moved her body to a visible place. Rather than closing herself off, she showed us how she felt, as Daniel Siegel had opened his hands and exposed his palms.  


Aisha’s response might be analogous to the convention applause. This applause was an essential welcoming saying: “Sheila, your sadness, hurt, embarrassment and anger are all welcomed here!” Group members said: “This is your group! Take the time you need. We are here for you. We see you. We hear you.”  


Hearing and feeling this welcoming presence, Sheila responded at first with tears, then with expressions of anger and ultimately with smiles and the laughter of gratitude for the group’s support. The faces of the other members lit up with warmth and solidarity.  
 

*** 


Facilitating such moments of conscious gratitude and receptivity is something I try to bring to all my sessions. Of critical importance is my understanding that my role in this regard is that of facilitator, not creator. It is a powerful, organic experience that can only be had within the context of a collaborative effort. Daniel Siegel, for all his talents and wisdom, could not create that field of love by himself. Nor could the audience of thousands of therapists, even if they were consciously working in unison to do so!  


As a therapist, my receptivity to gratitude only increases the availability to the client of a mindful, compassionate field. A field, that I argue, has the healing qualities of love.  
 

While love is not “all we need” in the consultation room, it is a quality of human experience necessary to both healing and health.  

 

*This client’s name has been changed.  

How to Overcome Self-Doubt as a Therapist

Posted on by Psychotherapy.net Team

“Steve, I’ve decided to stop talking to Marc,” said Sheila, starting the session without the usual pleasantries. I could hardly contain my excitement. 
 

I had been working with Sheila for two years, attempting to help her develop a sense of self-worth. She had been in and out of multiple abusive relationships and thought very poorly of herself. This was despite having two master’s degrees, a rewarding career, and being highly attractive (all societal markers of success). 
 

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Sheila had permitted Marc to enter her life and erode what little self-confidence she had left in the wake of the abuse she had suffered prior to meeting him. She complained of his manipulation tactics and how he had recently “gotten a prostitute pregnant behind my back.” I was ecstatic that she was finally standing up for herself. 


I decided to follow up with a Rogerian type of approach. I feared that questioning might be too confrontational. Instead, I wanted Sheila to reflect on where she got her courage from to finally cut Marc off. Secretly, I wanted to be praised for being a world-class therapist. I wanted to hear that our work had paid off and that she felt stronger. So insecure and immature of me, right?! 


“Say more about that,” I gently nudged. “Well, my psychic told me not to do it,” she replied flatly. Two years of weekly 45-minute sessions invalidated by a single 15-minute psychic reading. It felt as though I had been punched in the stomach. I could feel my face getting numb. I was at a loss for words. 


“She told me that Marc is bad news and has wicked intentions for me,” Sheila continued quite proudly. While I was pleased that she was no longer tolerating oppression, I felt small and insignificant. I also thought of it as a flight into health. One discussion, and now Sheila was cured. It made me reflect on countless times that my therapeutic efforts were dismissed by a client who just so happened to be influenced by a friend, clergy member, or some insight they received on TikTok. 
 

This case caused me to reflect deeply on my role as a helper. Why did I feel the need to be the sole agent of change for Sheila? Why wasn’t I more open to all (other) avenues of support that Sheila could receive? Doesn’t it take a village? I also wondered about how often clients come to me for direct advice. Sheila was no exception. 
 

So many times, I have non-directively responded to “What do you think I should do?” with “What would you like to do?” It is not that I am afraid to answer questions from my clients. I do it often. However, I have found it to be ineffective to give clients direct answers when their presenting problems are highly nuanced—such as relationship dynamics in the case of Sheila. If the advice works, I’m heralded. If it fails, I’m demonized. I find it much more effective, as well as in their interests, to help clients come up with their own solutions. 


Within two weeks, predictably, Sheila was sending Marc a barrage of text messages and outwardly professing all his admirable qualities. There was no longer any mention of the psychic. “What good is that psychic now?” I wanted to cry out but restrained myself. Instead, I maintained a calm, nonjudgmental demeanor and allowed Sheila to tell me all about what led her to reach back out to Marc. 


By the end of that session, Sheila thanked me for “always being there for me.” That was all the validation I needed. She reminded me that while all the men in her life—including her father — were inconsistent, I was the one man who stood by her side. It wasn’t necessarily about giving or not giving her advice. Sheila is smart enough to make her own decisions and deal with the consequences. It was more about the fact that I was the one person who had been there for her. 


I had spent two years of therapeutic effort wondering when I would say something that might resonate with Sheila. However, the true work has revolved around being a consistent and supportive presence in her life. My work with Sheila is far from over, but I do feel that I am on the right track for us to make meaningful progress together. 
 

Questions for Therapeutic Thought 

  • What about the author’s experience with this client challenged you to think about your own clinical work? 
  • What types of clients trigger your own self-doubt and how do you address that discomfort? 
  • How might you have addressed this particular issue with Sheila? 

How to Focus on Emotions to Help Volatile Couples Reconnect

Posted on by Psychotherapy.net Team

Suggested Tips for Practice

  • Develop flexible hypotheses for understanding family dynamics
  • Collaborate with each family member around therapeutic goals
  • Explore your countertransference around complex dynamics in family work.  
Camille and Lance had been married for about seven years when I first met them. Their daughter, Hannah, was four at the time. I typically saw Camille and Lance twice monthly for about nine months. Their central goal for therapy revolved around managing anger during conflict and responding without reacting with defensiveness, criticism, or emotional withdrawal. They each expressed that empathy, or an ability to hear, identify with, and validate each other, was lacking in their attempts to express and resolve conflict.

Conflict occurred for them in vicious, seemingly unavoidable, and endless cycles of attack and withdrawal. Neither Camille nor Lance experienced their relationship as supportive or safe, and both seemed to have little understanding of the cause of their conflicts or dynamics that kept them apart. Lance and Camille regularly experienced hurt and rejection, unable on their own to engage constructively with one another during moments or episodes of volatility. They reported a desire to grow in their marriage by experiencing togetherness, as well as understanding, in the midst of conflict. However, their pattern made it almost impossible to break or heal from these cycles, leaving each of them stuck in perpetual states of defensiveness, criticality, and ultimately the experience of rejection. Almost always, Lance and Camille seemed to be just a disagreement or wound away from their next blowout.  

Assessing the Problem

Camille often expressed her emotion through anger, criticism, or a vigilant effort to draw out an empathetic emotional response from Lance, while his go-to responses were anger, defensiveness, or withdrawal. They described a mutual experience of “hopelessness” regarding navigating and resolving conflict.

Adding to their pain was Camille’s and Lance’s disconnect from social support, as they lived a considerable distance from both of their families and had struggled to build social connections as a couple. There were also pressures related to both finances and Lance’s work schedule.

Camille, having close ties with her family, described her childhood as one in which she was nurtured and supported. Lance, who had very little contact with his own family, characterized relations with them as chaotic and he described a childhood in which he was left on his own for almost everything, including meal and school preparation and doing homework.

A Working Hypothesis

The more Camille and Lance were able to communicate vulnerably with each other about their own emotional hurt—which we distilled down as feeling “misunderstood, unsupported, and unappreciated” — the more they would experience love and mutuality (that is, feeling understood, supported, and appreciated) during conflict and in their marriage in general.

It was clear that Camille’s and Lance’s emotional experiencing during heated conflict occurred at a secondary, reactive level (anger or withdrawal) rather than out of the more vulnerable, primary dimension of their emotion (simply feeling misunderstood, unsupported, or unappreciated). How they expressed their needs for closeness or identity in their relationship determined the ensuing cycles of emotion by which closeness or identity was negotiated.

While it was likely that their current emotional styles and patterns of conflict response were rooted in past experiences, my therapeutic approach was focused primarily on the ways in which they expressed their hurt to each other in the here-and-now of their marriage, especially during conflict.

Clarifying a Goal for Therapy

The central goal of therapy for Camille and Lance was to reach a place where they could begin to experience mutuality and togetherness, as well as understanding and acceptance around their differences, especially regarding their experience of conflict management.

In reporting on goals, the couple agreed that they would “like to be able to set goals and boundaries together,” as they had prior difficulty in meeting common ground. They said of themselves, “we fight mean,” and “we can both be Dr. Jekyll and Mr. Hyde.”

To optimize chances for therapeutic success, every session and intervention would need to be grounded in the goal of facilitating more satisfying emotional experiencing between them, particularly during conflict. The work of therapy would involve increasing expressions of vulnerability in place of reactive expressions of defensiveness and criticism during conflict.

This change was to facilitate the delay of gratification in their individual desires to experience immediate validation, and in its place to nurture the development of a more meaningful and effective way of processing emotion and staying connected through hurt and nurturing intimacy.

Clinical Reasoning

An emotion-focused approach theorizes that couples experiencing difficulties in their relationship often are hiding and or repressing emotions such as fear or a need for attachment, and instead expressing emotions that may be defensive or coercive — primary” and “secondary reactive” emotions.

When these negative interactions solidify into patterns, couples often experience a loss of trust or a heightening of fear in their relationship, therefore further burying the primary emotions.

I theorized that Camille’s and Lance’s pattern of becoming angry or emotionally withdrawn during conflict was a pattern of conditioned defense, covering up primary emotions, cravings for understanding and support buried below the surface of their experiencing.

Clients with whom I have worked typically have internal resources for repair and growth in relationships. Their negative interactional patterns, which often are adaptive, coping styles can therefore be transformed into positive and healthy interactions. In these cases, couples counseling that focuses on emotions can result in transformative experiences.

As a therapist, I don’t see myself as an intrusive mechanic who fixes couples. Rather, accepting and validating clients’ self-experience is a key element in my therapeutic approach. Empathic attunement with couples also involves taking care to provide appropriate validation to one person without marginalizing or invalidating the experience of their spouse. It is a balancing act.

With Camille and Lance, I attempted to provide empathy and safety, as well as to engage in our relationship in a way that was collaborative and in which roles and expectations were clearly defined. Through many challenging and white-knuckled therapeutic hours with conflicted and often disconnected couples like Camille and Lance, I have found that a clinical environment marked by empathy, safety, and occasional structured directives provides the opportunity to build corrective emotional experiences and reconnection. By working in the here-and-now with them, and by integrating their at-home experiences into our in-session work, Camille and Lance became increasingly able to reflect on both their respective inner and relationship experiences in a far more adaptive way.

Intervention and Therapy Process

The family therapist Carl Whitaker advocated a nonrational, spontaneous, and creative experiential presence with clients as a means of engaging them at the hidden symbolic dimensions of their awareness. He said that for real change to occur, insight won’t do the trick. We need to engage each other emotionally.

While encouraging the spontaneous and creative side of therapy, Whitaker also understood the importance of providing focus and structure, “the experience of our being firm,” as he called it. With Camille and Lance, I attempted to use in-session directives that would drive the client-centered and emotion-focused processes in therapy. I also labored to redirect from more-of-the-same conflict cycles to processing the experience of emotion in their relationship.

If they were tempted to explain why they were angry, I let them know that they could choose between carrying on explaining, remaining in the safe position of knowing what they already knew, or exploring how they experienced anger, taking them to what they did not yet know. This was effective with Lance and Camille in facilitating a shift between defending, criticizing, or debating facts to sharing emotional experiences by exploring their own internal processes.

The following is an overview of the therapeutic process.

Sessions 1 & 2  

My hope for these early sessions was to establish a working relationship with Camille and Lance, to open up the space for them to tell their story, to nurture understanding and relationship with them by listening empathically, and to begin to establish a therapeutic vision. At this time, I was focused on noticing and stirring curiosity about emotional experiencing in their marriage.

Camille and Lance described their reason for coming to counseling as “conflict.” They described the early family contexts that shaped them and theorized about their problems in marriage. They described their cycle of conflict as erupting when Lance experienced Camille as being “nagging, preachy, or undermining.” Camille compared Lance to her father many times, which frustrated him. She said she wished, in some ways, that he were more like her father.

Camille and Lance had, in these sessions and in sessions thereafter, described successful experiences of empathy during conflict. Early on, they communicated that when they experienced feeling heard or understood, they felt closer with each other and experienced more successful conflict. I hoped to begin to interact with and facilitate experiences of empathy between them, not merely by talking about these successful experiences of conflict but enacting them in-session.

Session 3 & 4 

My approach during these sessions was to facilitate in-session interaction with their emotions in conflict. During the third session, Camille and Lance reported having a “not-so-good last couple of weeks.” They found themselves frequently getting into heated arguments around Camille, forcing Lance to have conversations with her about subjects that he did not want to talk about.

Lance described feeling “like my whole life is ‘I’m sorry,’” because Camille always “nagged” him about the things that she thought he should be doing. Lance described the conflict as being over “small things,” while Camille argued that they were over “bigger things.”

Lance frequently felt overwhelmed when Camille approached him about multiple concerns at once. Lance said he needed “time and space to breathe and think.” Camille said she wanted to process through these issues immediately.

A large portion of the third session was spent negotiating between them a way of giving mutually satisfying time, space, and understanding while in the heat of conflict. Between sessions three and four, I had them work together on a list of “rules for fair fighting,” which was used as a way of engaging them to establish boundaries and appropriate responses for conflict, a goal that they expressed early on.

Camille and Lance came to our fourth session still emotionally charged from a fight. Both described not feeling heard. I coached them to listen actively, and they reported feeling more heard by the end of session as a result of a slower, less reactive style of communicating around feelings.

Session 5 & 6

A goal during these sessions was to provide in-session experiences of communication between Camille and Lance, exploring and interacting with their emotional processes through emotion coaching strategies. Camille and Lance talked about the patterns of their fights and how they escalated quickly and got “off subject.” I facilitated the practice of active listening in an attempt to promote understanding and slow down arguments.

Session 7 & 8 

During these sessions, we focused on the pattern of conflict between Camille and Lance.

Together we explored body language and other forms of meta-communication. Camille said, “He feels threatened by my body language, and I feel threatened by his.” Lance reported that he was frustrated and felt disconnected. He reported that when conflict is present, “I don’t want to talk about it.” During the conflict, Lance experienced “tiredness, numbness, deadness.”

During session seven, Camille and Lance reported having a conflict around finances after a trip to a wholesale store, where Camille spent a lot of money on things that Lance did not think they needed. During the session, I encouraged active listening and communication between the two of them as a way of assessing and intervening in their emotional processes during conflict.

During session eight, they described “hopelessness” as a common experience during conflict. Camille communicated that she experienced hope and safety when Lance looked at her in the eyes when she wanted to talk to him about something, rather than tuning her out. Lance communicated that he experienced hope and safety when he was given emotional and physical space to sit in the disagreement and then communicate about it again later.

They reported that they had experienced some dramatic and disappointing conflicts as well as “breakthroughs” in the past couple of weeks. During “breakthroughs,” they felt mutually understood and supported. At the end of the seventh session, Camille noted that she kept a record of Lance’s wrongs. I suggested that during the following week she keep a record of Lance’s “rights.”  

Session 9 & 10 

During these sessions, we explored how their personality differences affected their conflicts. Lance expressed difficulty in developing close friendships right now and in speaking up in groups, including with acquaintances and with coworkers. He also expressed being overwhelmed right now in his life, being busy with work, marriage, and parenting, among other things. I shared similar experiences of my own to normalize his experiences.

I noticed a lighter interaction between Camille and Lance during these sessions, which I pointed out. Even while discussing conflict, their conversation was more introspective and less frustrating. Previous conversations, especially about conflict, were less thoughtful and more reactive. I noticed a fresh team-based attitude in their in-session interactions and shared my observations. I also had a brief opportunity to observe both of them with Hannah, who had been waiting in the lobby during our session. They seemed gracious and loving with her.

Session 11  

My hope for this session was to re-join with Camille and Lance after over a month’s break from therapy. Lance reported having begun taking medication for depression and social anxiety after communicating with his family doctor about his concerns. He originally began taking one medication but switched to another shortly after he began experiencing negative side-effects.

Camille and Lance reported having an argument while Lance was feeling “numb” from his medication. During the argument, Lance had not felt attacked by Camille. Feeling unattacked, he had been able to support and validate her, which turned out to be a meaningful experience for her. He reported that it was not meaningful to him because he felt “out of it.”

I explored the differences in the quality of their interactions during that conflict that created a more successful outcome. Camille identified that Lance’s non-defensive stance disarmed her reactive emotions, and they were both able to communicate more thoughtfully and vulnerably.

We explored the difference between primary emotions, such as hurt, sadness, or feeling misunderstood and unsupported, and secondary reactive emotions, such as frustration, anger, feeling “pissed off,” or feeling emotionally numb and withdrawn. After drawing a diagram of these dimensions of emotion, I explored the effects of communicating out of each dimension during conflict.

When one of them communicated out of anger or refused to communicate out of emotional withdrawal, the other either became frustrated or emotionally withdrew as well. During this sort of interaction, they mutually felt misunderstood and unsupported.

We then explored the possibilities of communicating vulnerably and honestly out of the oftentimes buried, primary emotion of feeling hurt or sad. When one of them chose to communicate non-defensively about an experience of feeling misunderstood or unsupported, the resulting mutual experience tended to be feeling “joined together” and “heard.”

Utilizing emotion-coaching and other experiential interventions, I hoped that they would begin to experience a restructuring of their patterns of interaction and of their experience of intimacy based on new understandings and meanings.  

Session 12 

Lance and Camille had a fight immediately before this session. Lance had been feeling exhausted and overwhelmed earlier in the day. When Camille brought him coffee as a gesture of love and support, Lance told her, “That’s the last thing I need right now.” This started an escalation, in which Lance quickly distanced himself and became emotionally withdrawn.

As I attempted to coach Lance to explore his own emotional process of wanting space, he seemed to become increasingly short in his responses and visibly uncomfortable. I found myself compelled to press for responses from Lance, almost demanding cooperation.

At some point, I began to come back to reality, noticing what had been a parallel process between my own experience of interaction and Lance and Camille’s. Changing course, I began to speak with Camille in a reflective way about what Lance may have wanted to say to her.

By the end of session, Lance began to speak for himself, became more engaged in dialogue around emotion, expressed regret for his own behavior, and was verbally supportive of Camille.

Session 13  

Lance and Camille had canceled three sessions since we had met two months prior.

At the beginning of this session, I invited Lance and Camille into a dialogue concerning their commitment to counseling. This carefully initiated confrontation carried a message with it: that they, the couple, were responsible for their investment in counseling, and that I was committed to being invested with them only as long as they were themselves invested.

It was clear that they had discussed this concern among themselves and were already considering termination due to both of their work schedules. I noticed myself feeling proud of my own investment in their therapy and, in retrospect, my own sense of disappointment at their shortage of attendance distanced me from the reality of the two persons before me. And so, I did not expect the explanation Lance would give.

He began to reflect on their experience in therapy over the last year, telling stories of how they had become more capable of engaging with each other in satisfying ways despite disagreement. Having more positive experiences with each other around personal differences and beginning to develop more meaningful social relationships, Lance and Camille expressed feeling less energy towards counseling and more energy in life itself and with each other.

Lance commented, “Before we came in today, I told Camille we might be in a place where it would be better just to sit down with each other over coffee and discuss our relationship by ourselves.” Even though they continued to experience conflict—in fact, they reported having a significant fight earlier in the day—they were becoming more able to be with each other in such a way that was growth-inducing, having developed an increasing ability to self-soothe and remain nonreactively present with one another, rather than growth-inhibiting, reacting defensively to one another out of anxiety experienced in the moment.

At the end of the session, after talking about their progress and increasing sense of responsibility and capability in their marriage, they chose together to terminate counseling immediately. I celebrated with them by discussing their exciting future.  

Reflections on Case Outcome

Camille and Lance, like so many other couples with whom I’ve worked, struggle in knowing how to manage the intense reactive emotions that they feel in the midst of conflict. They became better able to increase their capacities for emotional management and self-direction. They learned that they were not necessarily determined or defined by their impulses.

As Lance and Camille allowed me to sit with them in the midst of their anxiety, anger, and pain to search for bits of hope and seeds of change, I began to see a new paradigm evolving into being in their marriage: one marked by acceptance and stability and driven by intentionality.

Over the course of therapy, as we delved deeper into the intricacies of their emotional experiencing during conflict, Camille and Lance consolidated new positions, attitudes, and cycles of attachment behavior and began experiencing conflict in a more satisfying, growth-oriented way.

Lance and Camille began to take ownership of their own emotions and reactions. As Lance began to acknowledge and understand the ways that he withdrew from Camille at the whim of momentary anxiety, he began to act despite his anxiety, remaining engaged with Camille in an honoring way. As he did, he became more confident and less volatile.

As Camille began to acknowledge and understand the ways that she pressed for resolution on issues of difference, she began to make peace with anxieties that drove her behavior in the relationship. As she did, she became more confident and less volatile.

As intentionality increased little by little over time, confidence increased. As confidence increased, security, rather than anxiety, increased. As this security increased, Lance and Camille experienced an increasingly satisfying and loving relationship.  

Questions for Thought

  • What about the case of Camille and Lance challenged you?
  • What did you think about the therapist’s approach to working with them?
  • What are your own strengths and challenges when working with volatile couples?
  • What night you have done differently than the therapist in this case?
  • Did this case make you want to learn more or less about emotion focused therapy? 

Powerful Ways to Improve Your Presence with Suicidal Clients

Posted on by Psychotherapy.net Team

Suggested Tips for Clinicians:

  • Explore your own preconceptions of suicidality and how they impact your interventions
  • Meet clients where they are rather than where you think they should be
  • Manage your own fears and anxiety around client suicidality
  • Develop a strategic therapeutic plan including supportive clinical resources


***
 

In our first session together, I asked Judy if she had had any thoughts of wanting to die or of suicide. She looked at me as if she wasn’t sure what to say, and then seemed to decide to be frank. “I’ve had serious thoughts about killing myself for a long time now.”

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Revealing her thoughts of suicide was a moment of extreme vulnerability for Judy as she let me know that her pain was so deep that not existing was actually an attractive option. There is a strong stigma attached to suicide, despite greater mental health awareness in recent years, and I’m sure Judy knew that thoughts of self-harm are still considered taboo. She probably knew as well that I had the power to take away her freedom if I thought it was necessary; my consent form let her know as much.

It was a vulnerable moment for me, too. I didn’t know exactly how great Judy’s risk was for imminent self-harm, and the potential costs were high in either direction if I misjudged the situation. Underestimating the risk could contribute to her death, while overreacting could result in a rupture in our relationship or an unnecessary involuntary stay in a psychiatric ward, which is not a benign experience.

These perils and apprehensions notwithstanding, a unique opportunity opened to me when Judy told me she was suicidal. This moment invited me to meet her as a full human being in a deeply human encounter.

Meeting Clients Where They Are

When one of my clients is suicidal, I know they’re in extreme pain, whether physical or emotional. But research and my clinical experience show that pain alone doesn’t invariably lead to suicidality — it needs to be paired with hopelessness. Believing that the pain will never end, however, is strongly linked to becoming suicidal. Having strong connections to other people buffers against the risk of suicide in the face of pain and hopelessness, while feeling disconnected from others predicts more severe thoughts of suicide. When someone I’m treating is in a suicidal crisis, the best I can hope to offer them is hope and connection.

However, I’ve often struggled to give my clients what they need in these moments which are fraught with anxiety. I felt my stomach drop when Judy told me that she had been suicidal. I had lost a patient to suicide about a decade earlier, and the reassurances from everyone around me that it wasn’t my fault didn’t make it any less heartbreaking or traumatic. Since that loss, I feel an even stronger sense of responsibility to help my clients and to do everything I can to keep them safe, while at the same time balancing safety with not wanting to overreact and encourage or require that the person go to the emergency room if the risk is not that severe. The threat of legal liability also looms large if I underestimate the risk and my client ends their own life.

As a result of these competing tensions and fears, there have probably been times when I unwittingly diminished hope, short circuited therapeutic connection, and left a client alone with their deepest pain. I was taught during my master’s program to be sure to “contract for safety,” which meant having the client sign a form that said they promised not to kill themselves. Even as a new trainee I could feel in my core that something was fundamentally wrong with this approach, which seemed like the ultimate gesture of pointless self-interest. It was clear to the client, too, that the agreement was meaningless, and that it was designed to protect me and the clinic where I was working as a practicum student.

Even though safety contracts are largely a thing of the past, I still need to be careful not to give more subtle indications that my focus is on mitigating risk, perhaps not mostly out of concern for my client. Without intending to, I could send the message that I care more about the possibility that my client might end their life than about the pain and hopelessness that are making their life unbearable.

Perhaps I might signal my nonverbal disapproval when a client describes being suicidal and react more positively when they reassure me that they’ll be OK. Or I might try to nudge a client toward agreeing that they “would never act on their urges,” or show with my body language that this conversation is making me extremely uncomfortable. In one way or another, I could discourage future openness.

It's easy to understand my fear in these situations. There is a widespread assumption that if a client ends their life, the therapist must somehow be to blame. I’ve witnessed organizations where there was a presumption that the therapist must have messed up unless they could prove otherwise. This toxic mentality burdens therapists with the illusion of an absolute ability to prevent suicide, but the truth is that a client may decide to end their life even when I’ve done everything possible to prevent it. Not surprisingly, I’ve found it hard at times not to focus on risk mitigation at the expense of the therapeutic alliance and the hurting human being in front of me.

Looking Back

Months later, Judy told me that my equanimous response to her confession in that first session was the main reason she continued in therapy with me. “I was afraid you might have me locked up,” she said, “or that you’d say you couldn’t treat me.” Instead, she felt she could trust me, and that I cared about her and not just about “covering your ass,” as she put it.

But there was a moment when I was less receptive to Judy’s suicidal thinking, which I didn’t understand (or share) at the time. In one of our later sessions a couple of years after that first meeting, she said with conviction that nobody in her family would care if she killed herself. I reacted with an intensity that surprised both of us.

There was no validation of Judy’s feelings, no gentle Socratic questioning to test the evidence. Instead, I replied, “I have to tell you, that is categorically untrue.” I was nearly shaking with emotion. She looked taken aback. I continued, “I can guarantee that your family would be devastated, and the effects would ripple through multiple generations.”

Judy told me later that she was startled by the fierceness of my words and tone of voice, which I attributed to my own family history of suicide. My dad’s dad, a veteran of World War II, died from a self-inflicted gunshot wound seven years before I was born. That loss colored not just my dad’s adulthood but my parents’ relationship and our family’s emotional life. But while I don’t doubt that the echoes of my grandfather’s suicide were in the room when I snapped at Judy, there were more recent and personal forces at play.

For the past few months, I had been in a moderate major depressive episode following a prolonged illness, which included a frequent desire to die. I was plagued by recurrent thoughts that I was letting down my wife and three young kids, and that they would be better off without me. I knew rationally that the last thing my family needed was my suicide, but the thoughts came with such conviction, as if they were established fact, that they were hard to dismiss. When I responded to Judy in that session, I wasn’t speaking just to her. I was addressing my own ambivalence about staying alive.

Based on my clinical experience with Judy and other clients who have shared their suicidality with me, I offer the following self-awareness exercises to enhance your therapeutic presence when you encounter these challenging moments with your own clients.

Foster Awareness

My lived experience inevitably affects my work as a therapist. The more aware I am of my thoughts and feelings around suicide, the more constructively I can put them to use in the therapy room. Just as I might encourage my clients to develop greater self-awareness, I can practice mindfully attending to my own reactions when a client has suicidal thoughts.

Try this: Notice what’s happening in your body when a client is suicidal — are you tensing? Is your breathing restricted? Are you moving away, or adopting a self-protective posture? You can mind your emotions, too. Are you anxious? Annoyed? Sad? Fearful? Take an easy breath in and out and see what it’s like to observe those reactions with a bit of distance, rather than letting them necessarily drive your words or actions.

Question the Story

What I feel often comes from the stories my mind is telling me. By noticing my thoughts, I can recognize that the stories may not be true.

Common thoughts I’ve had in reaction to a client’s suicidality include:

  • I don’t know how to handle this
  • This is going to end badly
  • I’m going to get sued

The thoughts may come as wordless impressions rather than actual statements, such as:

  • Images of the client’s death
  • Being questioned by investigators
  • Feeling inadequate to the task

Try this: Notice when the mind is creating stories. It’s often not necessary (or practical) to do formal cognitive restructuring to change unhelpful beliefs; just noticing that we’re having thoughts that may not be true helps us to hold them more lightly, and to realize there are other ways things could turn out.

Open Continually

My automatic impulse in the face of vulnerability is to shut down: to close my heart, resist discomfort, quickly resolve ambiguity, and fall back on well-worn habits. These default reactions may be effective at managing my anxiety, but they can shut down my flexibility, creativity, and ability to connect with the person in my care.

Try this: When you sense the urge to shut down, take a slow breath in and out, feeling the points of contact between your body and your chair. Then ask yourself, “Can I open to this?” Even if part of us is resisting the experience, another part wants to stay present and to seek connection. Gently nurture that willingness.

Embrace Uncertainty

My mind doesn’t sit easily with not knowing how something I care about is going to turn out—especially when the outcome could be catastrophic. My automatic reaction is to try to resolve the uncertainty as quickly as possible, and to make sure things turn out okay. But when my client is thinking of suicide, the only thing I can know for sure is that they’re in real pain and are looking to me for help.

Try this: Rather than trying to know the unknowable, lean into not knowing what will happen. Accept that you have imperfect knowledge, and that you can decide only with the information in front of you. Make as much space as possible for the outcomes you fear—not because you’re indifferent to what happens, but because uncertainty is the reality you’re faced with.

***

Self-awareness and greater openness are the foundation for all the effective risk-management techniques I’m trained in such as asking about desire, plans, preparatory steps, access to means, and documenting what my clients tells me. I still collaborate with clients to make safety plans, which reduce suicide attempts by over 40 percent — one suicide attempt is prevented for every 16 clients who receive a safety plan — and I aim to take these lifesaving steps in the context of nurturing lifegiving connection.

***
 

Questions for Thought:

In looking back on your clinical work with suicidal clients, what might you have done differently with a few in particular?

What is it about working with suicidal clients that you find most challenging both professionally and personally?

What about this blog touched you or challenged you in a way you hadn’t anticipated?

What might you do differently next time you take on work with a suicidal client?  

Surrounded by the Village Idiots

Posted on by Psychotherapy.net Team

My heart is not a home for cowards.

D. Antoinette Foy 
 

Surrounded by the Village Idiots

The day I opened my private practice as a psychologist, I sat smugly in my office, fortified with the knowledge I’d acquired, taking comfort in the rules I’d learned. I eagerly looked forward to having patients I could “cure.”

I was deluded.

Fortunately, I had no idea at the time what a messy business clinical psychology was, or I might have opted for pure research, an area where I’d have control over my subjects and variables. Instead, I had to learn how to be flexible as new information trickled in weekly. I had no idea on that first day that psychotherapy wasn’t the psychologist solving problems, but rather two people facing each other, week after week, endeavouring to reach some kind of psychological truth we could agree on.

No one brought this home to me more than Laura Wilkes, my first patient. She was referred to me through a general practitioner, who in his recorded message said, “She’ll fill you in on the details.” I don’t know who was more frightened, Laura or I. I was newly transformed from a student in jeans and a T-shirt to a professional, decked out in a silk blouse and a designer suit with linebacker shoulder pads, de rigueur in the early eighties. I sat behind my huge mahogany desk looking like a cross between Anna Freud and Joan Crawford. Luckily, I had prematurely white hair in my twenties, which added some much-needed gravitas to my demeanour.

Laura was barely five feet high, with an hourglass figure, huge almond eyes, and such full lips that had it been thirty years later, I would have suspected Botox injections. She had masses of shoulder length blond highlighted hair, and her porcelain skin contrasted sharply with her dark eyes. Perfect makeup, with bright red lipstick, set off her features. She was chic in spike heels, a tailored silk blouse, and a black pencil skirt.

She said she was twenty-six, single, and working in a large securities firm. She’d started out as a secretary but had been promoted to the human resources department.

When I asked how I could help her, Laura sat for a long time looking out the window. I waited for her to tell me the problem. I continued to wait in what’s called a therapeutic silence—an uncomfortable quiet that’s supposed to elicit truth from the patient. Finally, she said, “I have herpes.”

I asked, “Herpes zoster or herpes simplex?”

“The kind you get if you’re totally filthy.”

“Sexually transmitted,” I translated.

When I asked whether her sexual partner knew he had herpes, Laura replied that Ed, her boyfriend of two years, had said he didn’t. However, she’d found a pill vial in his cabinet that she recognized as the same medication she’d been prescribed. When I questioned her about this, she acted as though it was normal and that there wasn’t much she could do about it. She said, “That’s Ed. I’ve already ripped a strip off him. What more can I do?”

That blasé reaction suggested that Laura was used to selfish and duplicitous behaviour. She’d been referred to me, she said, because the strongest medication wasn’t limiting the constant outbreaks and her doctor thought she needed psychiatric help. But Laura was clear about having no desire to be in therapy. She just wanted to get over the herpes.

I explained that in some people stress is a major trigger for attacks of the latent virus. She said, “I know what the word stress means, but I don’t know exactly how it feels. I don’t think I have it. I just keep on keeping on, surrounded by the village idiots.” Not much had bothered her in her life, Laura told me, although she did acknowledge that the herpes had shaken her like nothing else.

First, I tried to reassure her by letting her know that one in six people aged fourteen to forty-nine has herpes. Her response was “So what? We’re all in the same filthy swamp.” Switching tacks, I told her I understood why she was upset. A man who purported to love her had betrayed her. Plus, she was in pain—in fact, she could barely sit. The worst part was the shame; forever after she’d have to tell anyone she ever slept with that she had herpes or was a carrier.

Laura agreed, but the worst aspect for her was that although she’d done everything possible to rise above her family circumstances, she was now wallowing in filth, just as they always had. “It’s like quicksand,” she said. “No matter how hard I try to crawl out of the ooze and slime, I keep getting sucked back in. I know; I’ve almost died trying.”

When I asked her to tell me about her family, she said she wasn’t going to go into “all that bilge.” Laura explained that she was a practical person and wanted to decrease her stress, whatever that was, so that she could get the painful herpes under control. She’d planned to attend this one session, where I’d either give her a pill or “cure” her of “stress.” I broke the news to her that stress, or anxiety, was occasionally easy to relieve but could sometimes be intransigent. I explained that we’d need to have a number of appointments so that she could learn what stress is and how she experienced it, uncover its source, and then find ways to alleviate it. It was possible, I told her, that so much of her immune system was fighting stress that there was nothing left to fight the herpes virus.

“I can’t believe I have to do this. I feel like I came to have a tooth pulled and by mistake my whole brain came with it.” Laura looked disgusted, but she finally capitulated. “Okay, just book me for one more appointment.”

It’s difficult to treat a patient who isn’t psychologically oriented. Laura just wanted her herpes cured and, in her mind, therapy was a means to that end. Nor did she want to give a family history, since she had no idea how it would be relevant.

There were two things I hadn’t anticipated on my first day of therapy. First, how could this woman not know what stress is? Second, I’d read hundreds of case studies, watched lots of therapy tapes, attended dozens of grand rounds, and in none of them did the patient refuse to give a family history. Even when I worked the night shift in psychiatric hospitals—where they warehoused the lost psychological souls in backwards—I’d never heard anyone object. Even if they said, as one did, that she was from Nazareth and her parents were Mary and Joseph, they gave a history. Now my very first patient had refused! I realized that I’d have to proceed in Laura’s weird way, and at her own pace, or she’d be gone. I remember writing on my clipboard, my first task is to engage Laura.

***

From Good Morning, Monster: A Therapist Shares Five Heroic Stories of Recovery by Catherine Gildiner. Copyright © 2020 by the author and reprinted by permission of St. Martin’s Publishing Group.  

How to Improve Your Therapy with Playfulness

Posted on by Psychotherapy.net Team

Let me tell you the relief I felt when it clicked for me that acting like a therapist with patients was not the way to go — that actually being a real person would be far more therapeutic. The idea of needing to look, sound, and even dress a particular way was the perfect storm for imposter syndrome. And I was constantly fearful that I would be found out in the act. It was clearly unsustainable. I watched my peers gain confidence in their own therapeutic work and realized that it was not just increasingly necessary, but quite possible to find my own style, and have it be unique.

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But being freed of that anxiety naturally brought with it a whole new feeling of uncertainty. While helping my patients find their own sense of self, I had to find my own. And quickly! Coming from an immigrant South Asian background, I grew up with the message that praise follows being able to figure out unsaid expectations and meeting them, prioritizing the collective rather than myself. I became far too skilled at fitting into a mold. I hadn’t stopped to think about who I was or how I wanted to relate to others and myself. I really didn’t have to until I was sitting across from my patients, one on one, and they looked to me to discover their own sense of self. Working with my patients and being more mindful in my personal relationships has been so instrumental in figuring out the parts of me that could also exist. A big part of this is my playfulness.

Ask anyone who knew me before my 20s, and they wouldn’t exactly describe me as funny or playful. I had been highly judgmental of these parts of myself in efforts to tone them down. But in challenging these judgments, I finally found an affinity for sarcasm, cleverness, and wit. I enjoyed gently teasing others in a way that helped them to feel seen as well as better about themselves, not worse. This side of me has been tremendously helpful in my work to the point of becoming a crucial clinical intervention and the hallmark of what it means to work with me. For starters, playfulness as an approach to hot topics has been a way for me to move past sticky spots with the intention of revisiting them with more seriousness at a later juncture. It has also allowed me to foster a sense of trust so that my patients have been willing to take on deeper and more painful topics. Doing so has also allowed them to prepare for addressing difficult emotions and pacing those experiences. Playfulness through metaphor, chuckling, and coyness have opened doors to more, rather than less therapeutic progress. And this has been especially so when patients have been resistant or apprehensive, opening them to the guidance I have been able to provide.

Playfulness and humor are parts of real and healthy relationships, especially those I form with people naturally. Relating to my patients as authentically and therapeutically possible means having to let this come through in some way. I’m very aware that I have an affinity for puns and cheesy humor. I get excited by thought exercises and how metaphors can be extended to perfectly capture added experiences. I don’t shy away from these parts of me; I own them. I want my patients to experience me as comfortable in my own skin so they can laugh at me and with me at first, and then at and with themselves. This is especially helpful with patients on my caseload who are struggling with depression. These patients usually harbor intense judgment and criticism toward themselves. Demonstrating an alternative way to approach the self can be reparative.

Authentic relationships also have a playfulness to them that can function as a reprieve. People generally present to treatment to feel better, to be able to experience feelings opposing chronic distress. Relationships, much like individual people, have range, with seriousness on one end and humor on the other. A therapeutic space must have range, too. The therapeutic space is not simply a reflection of what a patient’s inner experience currently is, but what it could be and hopes to become as well.

In deciding between a tone of playfulness rather than seriousness as an intervention, I often take the lead from my patient. Some patients bring entirely new material altogether, seemingly unrelated to what we’ve been working on, signaling some heightened discomfort and a need for a break. Others directly ask for a lighter session, subtly warning me that they can’t handle more that day. Some patients may need to be pushed, but some simply need to be held. My instinct is to highlight the growth in expressing their needs and implementing boundaries, especially with me. I joke that we could talk about shoes if it would be more therapeutic. I’ve had a few patients actually take me up on it.

I have found that this range in the therapeutic space may even help with patients’ attendance to session and that the playfulness I encourage contributes to a relatively low attrition rate. While at the start, I’m the one to introduce levity into the session, as patients tend to increasingly benefit and join in the playfulness, they begin to initiate this on their own, and the space already begins to feel lighter. That lightness can then be internalized over time when patients are ready.

The intervention is successful when we start playing together. The goal of any treatment includes using the therapeutic work between sessions, a result of being able to internalize the therapeutic relationship. When patients begin to refer to earlier sessions, observations I’ve made with them, or metaphors we’ve developed together, I know something is working. They may pay more attention to my reactions or anticipate what I might ask and answer the question before I pose it. Patients may even introduce their own language or metaphor, presenting with excitement to share with me, knowing I will very obviously appreciate it.

My work with Vaani is a nice example of how effective playfulness can be in breaking through self-imposed barriers to progress. Vaani presented to treatment feeling completely defeated and at odds with herself. She struggled to make sense of her opposing emotions, citing mood swings and difficulty showing her needs and, thus, feeling unsupported by others. Vaani tried to distance herself from her thoughts and feelings by criticizing herself, leading instead to an extremely negative self-view.

At the start of treatment, Vaani looked to me for direction and approval, some sign that she was doing therapy right. I sensed her discomfort with focusing inward and could feel her need to have the spotlight on me. In addition to my usual emphasis on affect, language, and thought patterns, I started to respond with inquisitive and teasing facial expressions when Vaani escaped into not knowing. I would lightheartedly suggest, “That’s such a Vaani thing to say,” and she would laugh along and try again. She started to anticipate moments I would challenge her further, eventually anticipating these stuck points and refusing to take any more comfort in her resistance. She seemed to find some relief in finding metaphors and analogies; in fact, she typically lit up when she could express herself more effectively than ever. Through our work together, Vaani has come to express a feeling of wholeness, a result of being able to approach the judged parts of herself with curiosity, compassion, and humor, rather than shame. Our relationship remains playful as she continues to reflect inward from a place of safety and security.

***

We all want to play. I did for so long but didn’t know I did or didn’t know how, in part due to my cultural upbringing. In realizing this, and the powerful reflection that came with it, I was able to find an authenticity that felt right. I wouldn’t be the same without it, and neither would my work. I thoroughly enjoy working with people who might benefit from this or a similar discovery to feel better, gain perspective, and move toward healing.  

Can Psychotherapy Really Survive the Onslaught of Venture Capitalism?

Posted on by Psychotherapy.net Team

Maybe you, like me, have been receiving solicitations inviting you to join various mental health platforms. Maybe you’ve seen online ads for these new companies with endorsements from the likes of Michael Phelps or Simone Biles and got curious about what they are offering potential clients. Or maybe, just maybe, you’re a dinosaur like me with an established private psychotherapy practice and thought none of this applies to you. In fact, there has been a huge influx of private equity funds into the world of mental health to the tune of over 2 billion dollars in 2020 (an increase from 275 million dollars in 2016) with the goal of changing how mental health services are delivered. Ignoring this reality risks an end for psychotherapy as we know it. Similar to the fate of the dinosaurs—it’s a moment of adaptation or extinction. When private equity funds target a market, it is because they see the potential for profit and growth. Analogous to the consolidation of hospitals and other health care services, the decentralized offering of most mental health services is ripe for the roll-up strategy used by investors to buy and build larger networks, thereby allowing them to wield more bargaining power with insurance companies and providers. Whether or not we realized it, many of us felt this change when insurance companies shrank the clinical hour from 50 minutes to 45 minutes, thus enabling providers to see 2 clients in 90 minutes. The existence of these mental health platforms creates many complex scenarios for clients and providers alike. After doing research and talking with providers who have worked for one of these companies, it is now clear to me that the lines between what is legal and what is ethical are blurred. What is also clear is that when the delivery of mental health changes, the “product” itself changes. We know people are struggling mightily to find mental health providers, especially those in rural areas or those who want to use their insurance. The pandemic only intensified a pre-existing problem of matching clients to clinicians. The ability to use telehealth and receive insurance reimbursement was certainly a godsend for many of us during the pandemic. In some cases, clinicians could even practice across state lines, opening up the potential for new client markets as well as allowing for continuation with clients who relocated. For many of us, this change was nearly seamless. But for the most part, we continued to function as individual providers. The thrust of telehealth platforms is to channel individual providers into what is ostensibly a virtual group practice. The owners of the practice—private equity or venture capital firms—benefit from amassing a large number of practitioners under one umbrella to help leverage reimbursement rates from insurance companies as well as set fees for prospective clients. The benefit for providers is not having to pay for office expenses, billing services, or marketing. But key questions remain as to who “owns” the clients, especially around issues of liability. The most obvious questions arise if a client commits suicide, but there are other important issues in this arena. From my research, there appears to be no consensus about how clients are vetted or if providers can take clients with them if they leave the company. One clinician I spoke with described a virtual speed dating-like service offered to potential clients. They received free 10-minute sessions with a number of clinicians to help them select a best-fit therapist. Other companies just match clients with clinicians who have availability. Some companies require a noncompete clause, in effect maintaining “ownership” of clients when clinicians leave. On the surface, none of these practices are illegal, but it is important to consider how these practices could easily be manipulated to become unethical. What is promised to clients about how treatment will be delivered? And, just as importantly, is this the kind of work that we signed up to do when we chose to become therapists? Adding to these concerns is the pay structure used for clinicians. Many of the companies have a matrix where reimbursement rates are higher if you see more clients. In addition, one practice owner I spoke with who was offered a buyout by one of these companies said that although the initial offer was well above market rate for his practice, the fine print made it clear that he would need to stay on as director and hit various target goals in order to realize his compensation. In the end, he recognized it was a case of “too good to be true.” Losing control of how many clients you need to see and discretion about which clients you will see raises serious ethical questions about quality of care delivered. It most certainly also goes to the heart of job satisfaction. If, as it appears to be, there is high burnout working for one of these companies, which leads to high turnover of clinicians, then what happens to the continuity of care for clients? And if providers’ reimbursement is linked to incentives that run the risk of reducing or compromising patient care, how can we avoid being in a potential conflict of interest? Sidestepping these changes by not joining one of these groups has consequences, too, as the marketplace changes. Individual providers or small group practices may not stay competitive with the reimbursement rates of larger groups in a geographical area. We need look no further than the changes that have come from the consolidation of insurance and hospital markets to see the array of problems that arise when the delivery of health care resides in the hands of MBAs rather than MDs. Despite the glaring fact that there is no clear evidence that consolidation actually improves quality of care, the trend toward changing the landscape for how people will receive mental health services is underway and it is worrisome. Health care has become a data-driven market, from the quantity of services provided to the choice of prescriptions offered. What happens to all the data that is collected? There is a lack of transparency about who owns patient data and how it will be used by companies to increase their profitability. The backbone of therapy is confidentiality, but how can we protect our clients from the accrual (and potential sharing) of data required by these companies? For this dinosaur, the transition to telehealth was an important and welcome adaptation to a pandemic. I benefited from being able to continue to work and not lose income. More recently I have adopted a hybrid practice, seeing clients either virtually or in person. Returning to in-person work reinforces my belief that for some people, telehealth is a poor substitute for the intangibles that come from sitting across from one another in an office. I think back to an earlier adaptation I made when I used to handle all my own billing, when life was simpler and Blue Cross/Blue Shield was basically the only game in town. Eventually, I decided that paying someone to do my billing was cost effective and certainly improved my own mental wellbeing. However, unlike what is happening through this influx of outside money today, none of these changes have threatened my autonomy as a clinician. I am in the twilight of my career and able to be selective about my caseload. It is easy for me to say that I would choose extinction rather than work for someone else. If, instead, I were just starting out, I am not sure how I would manage the current market trends for establishing a practice. But regardless of my individual choice, as a profession we need to be active and aware that simply locking the doors is not going to keep us safe from the real and present threats to the practice of therapy as we know it. Psychotherapy as a field has adapted over time from the early days when psychoanalysis was the mainstay of treatment to the present day when many theoretical orientations are available to clients. As our field confronts the inevitable forces of change, we need to remain vigilant that even if these changes are legal, that the ethics of our profession remain intact. For psychotherapy is an art as well as a science, and the essence of our work has always been about the relationship between provider and client.

***

I am grateful to Dr. Laura Feder and Dr. John Lusins for their time and insights on the questions raised in this essay. For further reading on this topic, I suggest: Mental Health, Meet Venture Capital (APA) The Toxic Impact of Venture Capital on Psychotherapy (AMHA) Venture Funding for Mental Health Startups Hits Record Highs as Anxiety, Depression Skyrockets (Forbes)

Psychotherapy Behind Prison Walls. Does it Really Help?

Posted on by Psychotherapy.net Team

Despite working in the field of corrections for the past seven years and in mental health for ten, there are still aspects of this work that I find jarring. One of the most distressing elements of my work is when working with individuals who have been diagnosed with Autism or some form of neurodevelopmental disorder in which their thinking and relating is impaired. Oftentimes, these clients present as adults but function at a prepubescent to early adolescent level, all while being confined to an environment with other adults whose intellectual functioning remains age-appropriate. This is the equivalent of placing a juvenile with an incarcerated adult.

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I wish that I could say that my experience in working with these individuals has been limited, but the sad reality is that this is an area in which I have unfortunately become well-versed. Not understanding social norms, the criteria for healthy relationships, the importance of consent, and boundaries have been the most common characteristics shared by these particular clients. The challenge of working with these neuro-atypical individuals within the prison setting centers around discussing and helping them address issues of sexuality, not only their own, but as they impact relationships with other inmates who are often far more sophisticated, opportunistic, and at times predatory.

I’ll never forget the day I met Ronald (a fictitious name) because my immediate thought was, “How did we get here?” Ronald functioned much lower intellectually than his stated age, and as a result entered the penal system after misunderstanding social and relational cues. Ronald was then admitted for more specialized treatment after he was taken advantage of while housed in the general population setting. This is not uncommon when impaired individuals like Ronald live side-by-side, day-to-day with others whose primary interests are their own needs, oftentimes sexual. Ronald would often parrot the phrases he heard from other residents, even when they were racially charged or otherwise provocative. He didn’t do these things because he was prejudiced, but because doing so was a symptom of his condition and something that he often did when he felt uncertain of how to fit in. He would then begin emulating those around him that he perceived to be “cool.” In a correctional environment, this is particularly dangerous because it often results in the neurodivergent individual’s being either severely assaulted or deliberately used as a pawn to antagonize someone else or a group of individuals.

Another challenge I’ve noticed with these individuals is when they openly discuss or share their money or possessions without making sure that either or both are returned or made good on in some fashion. Ronald struggled immensely in this domain, as he would often buy things for others who would never return the favor and who wanted to take as much from him as possible. Fortunately for Ronald, staff members became aware that this was occurring, and he was moved to a smaller pod with a focus on psychiatric well-being.

In this regard, the best that neurodivergent individuals entering correctional environments can hope for is attentive staff members and genuine peers who look out for them and help protect them from becoming victimized or taken advantage of. Unfortunately, these helpers are not omnipresent, leaving these residents vulnerable for no other reason than their difficulty interpreting social cues and relating to others who would intentionally hurt them.

I remember talking with Ronald about how he came to the psychiatric unit, and wondering aloud about his understanding of the situation. Ronald was not at all aware of the risks that existed in his peer interactions while in the general population, but did understand quite quickly that he felt more comfortable in a smaller, more specialized, protective unit. Treatment of Ronald has included basic social skills, education around the topic of consent, and continuously openly discussing what a healthy versus unhealthy relationship looks like. Ronald was very clear that he had never before had such discussions, which solidified for me the importance of ensuring that people who are neurodivergent are not left out of conversations that have to do with sexuality. Therapists in the carceral system can be life-altering for these individuals when they take the time to go over the “basics.” It is critical that we put our own egos aside and look at the ways we can be most effective with these particular clients, rather than quibble over which therapy or technique is more effective than the other. When I have opened myself to creative treatment interventions that addressed the developmental needs of my clients, I have done some of my best work and influenced these clients in unexpected and at times very wonderful and rewarding ways.

The treatment unit where I work strives to provide a close knit, therapeutic milieu that allows for individuals with major mental illness and neurodivergence to feel safe, cared for, and to receive the highest possible quality of care. And this has happened when I haven’t been afraid to step outside of the box.  

Re-Directing Clinical Passion: Benefits and Pitfalls

Posted on by Psychotherapy.net Team

“I want to help people!”

This is a desire that motivates all therapists in one form or another. Through direct service, we therapists help one individual, one couple, one family, and one group at a time. Depending on our caseload at any given moment, that adds up to a relatively small number compared to the number of people in our geographic region. We may also help people indirectly through teaching, supervising, writing, and consulting. These activities may help larger numbers of people, although we are less likely to see the fruits of our labors.

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Helping People on a Larger Scale

Through a series of chance circumstances, I had the opportunity to help, potentially, a much larger number of people. After being certified in hypnosis in 1997, I became interested in the growing academic psychological literature on virtual reality (VR). I noticed that hypnosis and VR have a number of elements in common, with both experiences giving access to alternative realities and both experiences feeling “real.”

While I was collaborating on research using VR, George Zimmerman was acquitted of Trayvon Martin’s murder. When some people responded to Black Lives Matter with “white lives matter” or “all lives matter,” I thought these comments reflected a profound lack of understanding of the lived experience of being Black in the U.S. (not that I presume to know the lived experience). I had the idea that VR could be used to help individuals understand the lived experiences of people different from themselves. I began discussing this idea with colleagues and others, offering my idea for others to do good in the world and to help people, if the idea was viable. To my surprise, a venture capitalist offered me enough money to do a proof-of-concept study to see whether the idea worked. I was thrilled. My hope was that if the data came out the way I hoped it would that I could make a difference on a bigger scale.

The study results were very promising and the reactions from participants were equally positive; we were able to change participants’ attitudes and deeply affect them so that they were more aware of how their biases affected others and were motivated and had new learning to treat people different from themselves more respectfully. These results left me facing a difficult choice. Should I close my practice and go full-time into the unchartered waters of building a company to provide this service as workplace training and the opportunity to make a difference on this scale, or let go of the idea and keep my practice open?

Values “High”

The opportunity to have a much bigger impact was enticing. In the language of Acceptance and Commitment Therapy (ACT), building a company to upskill employees for respectful and inclusive behavior, and making an impact on a large scale would be a values rush or high. How could I not choose to build the company?

If you’ve known entrepreneurs or start-up employees through your practice or personally, you know that startups are an emotional roller coaster. I’d seen it firsthand with clients and family members but living it myself was a different story. Yet I felt it was all worthwhile. What we were building was powerful and could help employees treat each other more inclusively. It felt like I was on a mission in a way I’d never experienced in my professional life.

The Downs

Right as we were about to launch the company to the public and start selling our program, COVID hit, with quarantines instituted for an unknown length of time. Work for most people moved from the office to the home. We struggled to adapt and survive. We figured out how to provide the VR experience so people could access it from home without a dedicated VR headset.

As we tried to sell our product to HR and DEI (diversity, equity, & inclusion) leaders, we found ourselves competing with higher priorities – companies were trying to address work fires about COVID-related remote work, as well as the murders of George Floyd, Ahmaud Arbery and Brionna Taylor and how these deaths affected employees. In the end, we didn’t get the traction that I’d hoped for.

The Values Crash

As the company’s money was running low and not enough was coming in, it was heartbreaking for me to realize that three years of work (and no income) would not come to fruition. Instead of a values rush, it was a values crash. In building the company, I’d felt a thrumming sense of purpose driven by the opportunity to influence many people on a deeper level. Now, I was looking at a return to doing clinical work, helping one individual, one couple at a time. I still loved my clinical work when I had left it behind three years earlier but returning to it felt like a let-down.

To me, to use a drug analogy, it was like going from a cocaine high to drinking weak tea. A bit of caffeine just didn’t cut it. I spent weeks, months, in a funk, doing an ACT values worksheet and felt that I had no values—at least not ones to which I wanted to take committed action. The fact that COVID continued to restrict life around me probably didn’t help my outlook. I knew I was grieving, but that knowledge only took me so far. I set a date for myself: come January, I’d start letting people know I was re-opening my practice.

In January, though, I was still struggling to find values and meaning in clinical work. Don’t get me wrong. I like doing clinical work and feel I’m generally helpful to people. But running a company was like directing a musical production with a full orchestra, while working directly with clients was like directing an intimate one-or-two-person show. Each activity is rewarding, but in different ways.

Talking with friends and family helped. Time helped. And getting intellectually stimulated about clinical work helped. I am someone who likes to do a deep dive into training and to learn a new set of skills or approach every few years. Three professional opportunities helped get me really excited about returning to clinical work.

Acceptance and Commitment Therapy
I had it in my sights to get more training in ACT, an approach to therapy that, in part, helps people articulate and then “live” their values. It seemed an apt fit, given my values crash. I had the good fortune to be accepted into an ACT peer consultation training group with experienced clinicians. This wonderful group of clinicians and the training spurred me to think about my eclectic approach in a deeper way. I became excited to use the ACT approach and techniques with clients.

Discernment Counseling
I also had the good fortune to watch videos of Bill Doherty, Ph.D. doing Discernment Counseling with a couple. Discernment Counseling is a specific modality for couples in which one or both spouses are considering divorce. The goal is to help the couple get clarity and confidence in the path they’d like to take their relationship. I’d received this training before starting my company but stopped when I closed my practice. What an honor to learn from him! The videos left me re-engaged and eager to see more couples for discernment counseling.

Ethical Lives of Clients
The third professional opportunity was hearing Bill Doherty speak about his recent book, which focuses on the ethical lives of clients that we, as therapists trained in an individualist culture, may not see or address. Reading his book and discussing his ideas with colleagues brought my systems training closer to the forefront, leading me to think more deeply about the ethical dilemmas our clients face that they may or may not see, and how to raise those issues.

Value Reflection

Although there are things I’d have done differently with my company, I’m proud of the work we did, and of what I learned. I know enough about the failure rate of startups to know that I’m in good company with the failure of my company.

I’m also thankful that I had the opportunity to re-find and re-commit to the values that initially led me to become a clinical psychologist and psychotherapist. It’s exciting to be re-energized by the work as well as intellectually stimulated. 

Useful References

Virtual Superheroes: Using Superpowers in Virtual Reality to Encourage Prosocial Behavior

Using Virtual Reality to Encourage Prosocial Behavior

VR for Civility Training: Envisioning a More Respectful Workplace  

Will Your Treatment Plans Actually Survive a Doomsday Scenario?

Posted on by Psychotherapy.net Team

As a practicing clinical supervisor, and when I have attempted to teach graduate counseling students the differences between the art and science of psychotherapy, I have been careful to flavor my guidance with what I hoped would be just the right amount of professional ethics. And sometimes for good luck, I would add a pinch of legal-speak. But what seems to have resounded most loudly from my lessons were those that were worst case scenario-infused examples of what to do in clinical work to avoid, or at least contend with what one of my supervisees called, “Dr. Rubin’s Doomsday Scenario.” And this particular form of supervision-by-terrorization centered around the simple question, “what if you had to defend your treatment plan and/or intervention on the stand to an overly aggressive plaintiff’s attorney whose aggrieved client claimed that your treatment had caused them harm?

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With the exception of those students/supervisees who were subsequently influenced to reconsider their professional trajectories, the rest learned the importance of justifying their treatment plan and techniques by locating their foundation in the quantitative research literature and/or the position statements/practice parameters/best practices guidelines of respectable and respected clinical organizations such as the American Psychological Association, American Counseling Association, National Association of Social Workers, American Association of Marriage and Family Therapy, American Academy of Child and Adolescent Psychiatry.

So, when I recently met with one of my clinical supervisees who had implemented what seemed to be a creative, and as he related, effective intervention around trauma in a therapy group, I asked him the simple question, “Where did this technique come from?” Quite pleased with himself and the apparent sweet fruits of his empathetic and creative labors, he couldn’t quite recall the source of the intervention. “I did my research….I found it somewhere online,” he said sheepishly, knowing from his experience with me, that such a response would likely be met with less than positivity, enthusiasm, and accolades for his clinical decision making.

“Somewhere online,” I mused inwardly. Oy! Where had my lessons gone? Had I failed him? Had he failed his clients? Would he fail on the stand if even one of the clients in that trauma group complained about his intervention or its unintended aftermath? So, I asked for more feedback to which he responded by saying that he had chosen the exercise for the group because after reviewing their clinical files and having worked with them both individually and in group, and due to their shared histories of trauma, the intervention made sense at that juncture. And because these clients had other group activities throughout the day that did not rely on creative/expressive media, he thought that inclusion of such would be particularly appealing to them and provide them with an alternative means of expressing their trauma-related feelings, memories, and somatic experiences. He added that he had tried using this exercise in the past but was not successful because those clients were far less open about their trauma and generally treatment resistant. Further, past therapy groups had not gelled as did the current one with which the intervention seemed so successful. He concluded his justification non-defensively by saying that group members responded very well to the exercise, seemed generally and genuinely grateful, were able to express their vulnerabilities, and had even highlighted each other's strengths during the debriefing.

Truth be told, I was pleased with what I heard. And I was quite proud with the way he had accumulated his “practice-based evidence” (as opposed to evidence-based practice), had taken the time to study the clients’ individual and collective histories, drew from his experience with each off them and as a cohort, and then tailor-made the intervention to their collective needs. And while that fictitious plaintiff’s attorney might have torn him to shreds on the stand, even if the counterargument was made that this was a well-researched, deliberated, and implemented intervention, he demonstrated a scientific and artistic approach to clinical service delivery. And isn’t that what we hope our interns and counseling students will be able to do some day?

***

I remember something David Nylund once said when presenting at the 2001 Pan-Pacific Brief Psychotherapy Conference in Japan. He mused, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person can reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”

Well, I don’t think that Nylund’s constructivist rejoinder would satisfy that attorney, but it works for me, as did the intervention and justification my intern demonstrated.