Author: Psychotherapy.net Team

The Rest of the Story: Digging Beneath the Diagnosis

Posted on by Psychotherapy.net Team

I remember sitting across from my client, wondering why we couldn’t make any progress with his depression. We had covered the terrain of cognitive distortions, the necessity of making behavioral changes, and even stepped outside the CBT stream in order to address insights he had experienced into the relationship between his childhood and current state of unmotivated listlessness. Nothing seemed to work.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

He didn’t have the kind of sad, angry, irritable depression that practitioners commonly see in clients. His was the kind of depression that stripped him entirely of his energy. For him, it was a daily struggle to get out of bed in the morning, to make his own meals, to take out the garbage, or even to take on the seemingly insurmountable task of doing the laundry. But, I thought, or hoped, that with enough time, support, and psychoeducation, he might begin to budge in the right direction—in any direction. So I put my nose to the grindstone and retreaded familiar ground, covering cognitive distortions once again, revisiting the treatment plan, formulating habit-building strategies, and enlisting social support.

Our clinical stagnation seemed to give way during one session when we began discussing the clients’ interests. He shared that he was a huge sports fan. He religiously checked game stats, participated in online discussion forums, watched basketball, football, and soccer games. He devoutly followed his favorite teams and knew everything about his favorite players and coaches. It was really fascinating to observe the life flood back into my client when talking about this. Following my curiosity, I asked him to estimate how many hours of sports media he was consuming on a daily basis. He guessed that he was consuming upwards of 14 to 15 hours of sports media a day, every day. My jaw hit the floor.

It became apparent to me that my client was not suffering from depression, although his presentation was consistent with MDD, but was in fact addicted to media. So addicted that he had no time, attention, or energy for anything else. And since sports media is so pervasive and readily available in every platform and media outlet imaginable, my client’s addiction was readily fed, monetized, and maximized to the fullest extent. The problem was only worsened by a very forgiving, if not too forgiving, roommate. My client wasn’t working, nor pulling his weight regarding household responsibilities around his apartment. He couldn’t even recall the last time he took out the garbage. I asked if his roommate ever got upset; he said sometimes, but mostly he just ignored it or covered for him (like doing his chores for him and not pressing him on missing rent). That is one forgiving roommate, right?! Sadly, it was also a very enabling roommate. The roommate’s lax standards and minimum expectations were like gasoline to my client’s media addiction fire.

After exploring and reflecting on this new data set, we had a candid conversation—my client was coming to counseling because he wanted something in his life to change. He knew he needed to change. He wasn’t satisfied with the way things were going. Yes, he loved sports and couldn’t get enough of the latest sports news, but at the end of the day, he wasn’t satisfied. He had bigger goals for his life and felt like he was letting himself down by not getting a job, not pursuing his ambitions, and not contributing to the apartment. I put it to him rather bluntly that there wasn’t space in his life for his goals and that his sports media was a form of addiction; one or the other would have to go. He acknowledged that I was right but expressed fear of going “cold turkey” on sports media. So we devised an experiment: if he titrated his consumption of sports-related media down to something more manageable, he would feel more energy and motivation throughout his day? The thought of having more energy to accomplish his goals without the total loss of sports seemed to intrigue him. He committed to running the experiment and would report back his findings next session.

In my career, I haven’t had many spontaneous recoveries, but this, I am pleased and proud to say, was one of them. Something about the experiment clicked for him, and he realized that there was more to life than his media consumption addiction. His dissatisfaction with not making progress on life goals paired with lessened consumption of sport media carved out enough energy and motivation for him to make progress on smaller, more manageable alternate goals, leading to increased self-efficacy. He ran with the motivation boost and parlayed his newfound enthusiasm to accomplish bigger and bigger goals. Even getting outside to retrieve the mail felt good to him. Within a matter of weeks, he was doing household chores, grocery shopping and preparing his own meals, submitting job applications, and reconnecting with friends. I knew our therapeutic relationship was near its end when he got a job and joined a gym. He was feeling good and didn’t see the need for him any longer, for which I was grateful.

***

This clinical experience was an eye-opener for me. It was helpful to step outside the confines of my favored, tried-and-true therapeutic modality and the client’s presumptive diagnosis in order to consider contextual factors that often get ignored. This was the “rest of the story,” as broadcaster and commentator Paul Harvey so famously said, when digging just a bit deeper into the context beneath the headline, or in my case, the context beneath my client’s ostensible depression.

I now make it a regular practice to broach the topics of diet and nutrition, media consumption, social connectedness, feelings about current events, and finances, to name a few. In my better moments, I take time to consider what isn’t manifestly evident in my client’s clinical presentation that may be critical to address in counseling. What have I not thought of or asked about may make the difference for my client. What is going on in their life that they haven’t thought to mention, but may hold the key to their motivation, growth and healing?

Acknowledging the Impact of Cancel Culture on Therapy

Posted on by Psychotherapy.net Team

As therapists we are taught to shy away from making assumptions, and to do the hard work of bringing to light our patients’ inner thoughts and feelings. Unfortunately, the current social climate has cast a chill on posing such questions. Cancel culture is making its way into therapy sessions, to the detriment of all involved. The antidote to cancel culture is trust, not agreement.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Cancel culture is a term that is widely used and not always well understood. It is an attempt to ostracize a person or group for behavior or values that another person or group deems to be offensive. It can manifest as shaming on social media or an attempt to have a person fired from a job. To be canceled is to be persona non grata. The problem, of course, is that what is offensive to one person may not be offensive to another person.

Assumptions abound in this current climate, assumptions that can feel like the third rail in therapy and come from both ends of the political spectrum. Living with litmus tests and fear cannot be good for either the therapist or the patient. Working from assumptions, patients may think they know how I vote, how I feel about book banning or the pronoun “they,” but failure to actually explore these issues can lead to misunderstandings. Every patient I saw the day after Donald Trump was elected sat in my waiting room crying. They felt safe, assuming everyone had a similar response to the outcome. In fact, I know I have some patients who voted for Trump and who hold many conservative beliefs.

Increasingly, I find myself in a delicate dance with patients about what is acceptable to say or to ask. Early on in treatment, patients will often curse and then quickly apologize. I assure them that it’s fine with me if they use profane language, and I use it, too, if I sense it is not offensive to the patient. If patients use language that I find offensive, I may challenge them to examine this choice. It can be as simple as referring to grown women as girls or something more dramatic, such as slurs that evoke harmful stereotypes.

Not surprisingly, when patients are speaking freely, they may voice many beliefs which I don’t share. Keeping the focus on the clinical material is critical, but it cannot be divorced from the current culture. I am thinking of one patient in particular who was very angry with his employer, a white woman like myself. As a white man, he felt discriminated against and resented the perceived preferential treatment others were receiving at his company. He accused me of not being able to understand his outrage because as a woman, I must have benefited from similar inclusive policies. Working to maintain respect for one another and keep the focus on his treatment rather than debating the issues of the day was a true challenge for me. There were times that I worried his unbridled anger might be turned against me and hurt my professional reputation.

Agreement is never the goal of therapy, and yet not agreeing with people now feels much riskier. In particular, the discomfort that comes from disagreement extends to fear when there is a true risk that holding a different stance can lead to being “canceled.” For therapists it may come not merely in dropping out of treatment but in the form of bad reviews on social media or complaints raised with therapists’ employers, or, most dramatically, as a threat of malpractice.

The nuanced, complex work of a therapy relationship naturally has ups and downs over time. Having patients leave a session unhappy, or even angry, might be a consequence of treatment, but not necessarily a sign of bad therapy. But if the therapist or patient is biting her tongue in fear of retribution of some kind, it can impede doing our best work. In a related format, we have seen the unfortunate impact of this dynamic in academia, where untenured faculty, consciously or not, give higher grades to students in hopes of getting better course evaluations and saving their jobs.

To mitigate the impact of cancel culture on therapy, I suggest naming it as a real issue early on in the treatment. It may come up because of a patient’s worry about something in their life, such as speaking out within a friend group, or because of how they vet the therapist on certain issues. If either the clinician or the patient find themselves holding back from speaking openly, this needs to be aired out. Certainly, a neutral stance is not always warranted, and true violations of others’ rights deserve some form of consequence. But for that to happen productively, it is best if it can be an in-person conversation without veiled threats.

In the case mentioned above, I set very clear boundaries around the difference between blowing off steam and making personal attacks. I supported my patient’s need to vent his anger and listened carefully to the root of his hurt feelings. At the same time, there were professional boundaries that needed to be respected if we were to continue to work together. I presented this not as a threat, but as a teachable moment. If I couldn’t feel safe in the room, I couldn’t help him.

To reiterate, the antidote to cancel culture is trust. By establishing trust in the therapy relationship, or any relationship for that matter, the opportunity for understanding improves. People are more willing to listen when they feel heard. Opinions may not change, and feelings may still get hurt, but if the relationship has established enough trust, then we can learn from each other and deepen our connections rather than sever them.

Working Therapeutically with Generational Conflict

Posted on by Psychotherapy.net Team

Conflict between generations in a family is normal and even within bounds, healthy. But strife between loved ones can be painful and distressing, damaging not only some of our most important relationships, but also the self-esteem and sense of well-being of everyone involved. When it occurs between adult clients and their older parents, therapists and clients are sometimes in danger of simply repeating old stories about how the parents failed, disappointed, or abused their children. But it can sometimes be far more therapeutic to use this time to re-evaluate this thinking from a new perspective.

My own non-scientific data gathering from clients, supervisees, students, and colleagues meshes with the results reported in a 2020 article entitled “The Psychology of Family Dynamics Amid the COVID-19 Pandemic” in the Chicago School of Professional Psychology’s Insight magazine. There, the author notes that COVID’s global outbreak, with its accompanying lockdowns, significantly, and often adversely, impacted family relations. Political differences and social anxiety are also impacting families, such that intrafamily responses to COVID and to politics are widening gaps between generations in families all over the world. So much so that there has been a call to expand public health services to address the intergenerational issues with which families increasingly struggle. This was highlighted in a 2020 article entitled “We’re in This Together: Intergenerational Health Policies as an Emerging Public Health Necessity” in Frontiers in Human Dynamics.

A Family in Crisis

Julie* is a married teacher in her late fifties. Her parents are in their eighties. I had worked with Julie when she was much younger to help her deal with a mix of depression and anxiety that she had been struggling with since graduating from college. During our work, her symptoms had improved, she had met the man whom she later married, and she made several important career moves. She came back into therapy for help with some issues related to her teenage son, but before too long, it became clear that she also needed help dealing with her aging parents.

“My dad was a great athlete,” Julie told me. “I learned to respect and care for my own body from him. Mom wasn’t much for exercise, but she was always working in the garden and taking walks. And she cooked healthy meals for us throughout my childhood. But now, Dad just sits in a chair and watches TV all day and orders my mom around. And although she still cooks, it’s mainly mac and cheese, brownies and ice cream—stuff she knows he’ll eat. They’re both overweight now, they both have heart disease, and I can’t see this going anywhere but downhill.”

Julie had tried bringing her concerns to her parents, but each time she did, they both got mad at her. Her dad told her that he was an old man, that he knew he was going to die one of these days, and he was “goddammned going to do what he wanted to do for the first time in his life.” Her mother said Julie should leave him alone—she didn’t want him to get upset and have a heart attack. As was true for many families, Julie’s struggles with her parents escalated during COVID.

“They had a hard time self-isolating during the pandemic,” Julie told me. “Now they’re vaccinated, but I’m afraid they’re not being safe. I’m frightened for them. I kept telling them that if they got sick, what were we going to do? I couldn’t take care of them, because I’d worry about infecting my kids, because we didn’t have a vaccine for teens yet. I was frustrated and angry with them. As usual, they weren’t thinking about anyone but themselves. I kept wanting to shout, ‘What about me? Don’t I count? Don’t I matter to you?’”

A fair amount of our earlier work together had centered around Julie’s childhood relationship with her parents. Initially, she spoke of her parents’ marriage as ideal. “I had a wonderful childhood,” she told me. “So whatever difficulties I’m having now don’t stem from problems growing up.”

She described her father as “bigger than life, a big man, physically, but he was also beloved at work and in the community. When he retired from his job, people giving tributes cried as they talked about how important he was to them personally, how he had helped them move forward in their careers, how he had always been there when they messed up and helped them figure out how to correct a mistake and use it for their own growth, and sometimes for the company’s, too.” After his retirement, he volunteered to coach local football and soccer teams. When she came back to therapy, she still saw him as a special person, telling me that “the kids he coached and their parents all adored him. He played pick-up basketball in the gym with much younger guys up until the minute they shut the gym down because of COVID. He had a weekly coffee klatch with some buddies. He was a busy, active man.”

But Julie’s image of her father changed over the course of our earlier work together. One of the areas that we opened up in that work was her anger at both of her parents. As she told me during that time, “My mom was too docile for him. He was so big, so loud, so stubborn, he needed someone to push back at him. I felt protective of her, and mad at him, so I would stand up to him. We had some pretty big fights. My mom was always trying to get me to back off, leave him alone.”

We could say that much of the work of therapy is, in some ways, about helping clients tell us their life stories, and then helping them understand how their life stories impact who they are, how they live their current lives, and what they struggle with. Most of us have what Esther Perel has called our “go-to-stories,” that is, a story that explains something about us that we go back to over and over again. These stories, which can be as simple as “I was always a go-getter,” or as complex as “I was neglected by my parents my entire life,” can motivate us, give us hope, or leave us feeling helpless and hopeless. In therapy, as Roy Schafer wrote many years ago, we help clients learn how they construct their personal version of their own history, and then we help them start to reconstruct it.

Julie’s go-to-story of a perfect family and a bigger than life dad shifted over the course of her therapy to a more realistic version that she had kept out of her conscious awareness. But unfortunately, as happens perhaps more often than we like to acknowledge, therapy gave her a new go-to-story in which her parents had failed her. Julie’s story about herself changed significantly, so that she was able to move forward as a young adult with a greater sense of agency and self-confidence. She was also able to tap into her anger with less guilt and anxiety. But now that she and her parents were all older, that story was ready to go through another reconstruction.

Rewriting “Go-To” Stories

In the early days of therapy in particular, clients want sympathy for their feelings and their point of view much more than they want to think about what anyone else might be thinking or feeling. But years ago, as I gathered information for my book Daydreaming, I discovered that the stories people were telling me through their daydreams were ways of reflecting on themselves and on other people. Today I see those stories as a form of what Fonagy and other attachment theorists call “mentalizing.” Mentalizing is a process in which a client works to put into words what they imagine another person might be feeling. Children, even adult children, often have difficulty separating their own needs and feelings from what we imagine our parents are thinking and feeling, which can make it difficult to mentalize.

When clients bring in conflicts, I ask them to tell me as much as they can about their ideas about themselves and about other people, including their parents. Following Harry Stack Sullivan’s idea that important truths reside in tiny details, I ask for all of the smallest details they can tell me. At one point, Julie was talking about her teenage daughter’s fights with her dad. I asked her to tell me about one of their arguments. After going into it in great detail, she said, “It’s kind of funny. I’m watching my daughter and my husband struggle to come to grips with the fact that she no longer sees him as having all the answers. I can’t tell who’s suffering more—my husband, who has fallen off of a very high pedestal, or my daughter, who doesn’t know how to think about him as just a person.”

She was silent for a little while, and then she said, “She’s lucky, although she doesn’t know it. My husband is sad, and he’s hurt, but he’s also just proud of her for standing up for herself. I never thought about it this way before, but I wonder if some of that is what went on with my dad. He didn’t have the psychological understanding to talk about any of this, but I did get the feeling that he was proud of me for standing up to him. He’s always made comments about my being more like him than like my mother, but until just now I never thought of that as pride.”

The realization that some of their old conflicts could be seen from a different perspective led Julie to rethink some of her current struggles with her parents. “My dad has always been so strong, so vital. It must be horrible for both of them to see him feeling helpless…and hopeless. No wonder they’re doing stuff they shouldn’t be doing. No wonder they’re eating stuff they shouldn’t be eating. It’s their attempt to get themselves out of this difficult place—and maybe not just the one we’ve all been in during the pandemic. Maybe it’s also about getting older. They would never be able to talk about it, at least not to me. But maybe they’re a little scared about the future. Do they worry about being dependent? Do they hate thinking that my siblings and I will need to take care of them?”

In his classic paper “The Waning of the Oedipus Complex,” Hans Loewald wrote about the difficulty of this change for both parent and child, both of whom lose something as their mutual adoration dissipates in the face of separation and individuation. But, he says, something important is gained by both participants, who can become connected in a different way because of the changes they also mourn. This balance is a fragile one, Loewald tells us, and needs to constantly be negotiated and renegotiated. Therapists can help by encouraging clients to revisit old “go-to-stories” to see if they still hold true, or if they might be revised in any ways based on a client’s changing perspectives on his or her own life.

One day after Julie had begun to consider the struggles with her parents from this new point of view, she said, “I started to think about the fact that they’re in their eighties, they had been expecting life to unfold in a certain way, and suddenly it took a different turn. What were they supposed to do with that, I asked myself? What would I have done in their shoes? And suddenly I realized that they had handled these difficult times really well! Better than some of my friends, even. They’re still together, still talking to each other—more than that, they seem to really love and enjoy one another. That’s pretty amazing all by itself.”

***

Both relationships and identity are, according to the psychoanalyst Stephen Mitchell, an ongoing and ever-changing process. Therapists can help with this process by opening up space for clients to tell their story, and then for them to retell it and revise it as time goes on and they develop into new versions or new variations of themselves. During these shifts, parents, children, friends, and other important people in a client’s life also change; and part of the healing work involves learning and forgetting and learning again that all of us are, as Sullivan once put it, “far more human than otherwise.”

“Insta” Therapy on Social Media: Caveat Emptor

Posted on by Psychotherapy.net Team

A client whom I had been seeing in couples therapy recently contacted me with an urgent question. She anxiously asked, “Could my husband be cheating?” Catching her breath for the briefest of moments, she explained that she follows various “other” therapists on TikTok and Instagram, so she sent me an email with videos she had viewed from one of their sites. The video was quite concerning to me because the “therapist” did not provide any citations for the material she used and made authoritative, expert-sounding statements about which types of people engage in infidelity. This particular therapist went on, without clear context, to intertwine various concepts from different popular theoretical models. These concepts, which included attachment styles, triangulation, the unconscious, and enmeshment, were drawn from the corresponding theoretical models of Emotionally Focused Therapy, Bowenian Family Systems Theory, Psychoanalytic Theory, and Structural Family Therapy. The resulting statements describing the “typical” unfaithful partner were a discordant patchwork quilt, which from a distance seemed to be an integrated whole, or the blanket prediction a fortune teller might offer—something like “there will be change in your life,” or “you are seeking answers to important questions.” This particular experience, along with other recent similar ones with other clients who have asked follow-up questions about information that they obtained from therapists they follow on social media platforms, has prompted reflection upon some questions related to how social media is the “new self help.” These include:

  • How are our clients to evaluate the credentials of therapists, life coaches, trainees, and even graduate students who post on these social media forums? And, relatedly, what is our ethical/professional obligation (or not) to “educate” our clients in doing so?
  • How can our clients verify whether the content they are reading, and perhaps integrating into their lives, is accurate? And relatedly, what is our role and obligation to help them in doing so, especially if what they are reading is at cross-purposes to the clinical work we are doing with them?
  • What are the clinical implications of having an uninvited co-therapist on our treatment team?
  • When might it be our ethical/legal obligation to report one of these “well-intentioned” clinicians who want to democratize the therapeutic process?
  • How can we explore the influence of these other voices on our clients’ experiences and perceptions? And relatedly, should we? Must we?
  • What is the legal responsibility and ethical obligation of therapists who have followers on these platforms if a person who is not their client follows their “advice” and has an adverse outcome? I have not seen disclaimers on most sites that these sound bites are not a substitute for therapeutic services.
Despite the above concerns, I do believe that there are certain benefits to therapists offering online information and general guidance to their audience, although disclaimers, risks and benefits, and the sources of this information and guidance are important to include. Additionally and once vetted, therapists can offer these sites, their information and videos as they might utilize bibliotherapy or cinematherapy. But in the final analysis, we should both practice and teach our clients the therapeutic version of caveat emptor.

I Simply Don’t Want the Agita

Posted on by Psychotherapy.net Team

Having recently retired from my decades-long university clinical training position, and having significantly reduced my private practice, I no longer feel tethered. While my use of the word “tethered” may suggest a state of involuntary constraint, all has been quite by choice and fortunately, according to plan.

As part of my elaborate and strategic exit plan, I crafted a clever, professional, and appreciative “gone-golfing” out-of-office memo with the university and left no forwarding address. But because I have, in the past, received clinical referrals through that encrypted email server, I have not completely separated myself mentally from my role of teacher, supervisor, and clinician. I still occasionally check that email, partly out of separation anxiety, partly out of FOMO, and partly in hopes I might still receive something interesting—a challenge, an offer, an invite, or even the possibility of a few unanticipated bucks.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Then, just the other day, one of those enticements arrived. An out-of-state attorney asked if, as a clinician, educator, and play therapist, I would be interested in serving as an expert witness in a malpractice case against a clinician, also out-of-state, who, according to the plaintiff, had erred in their treatment of a young child while providing play therapy services and divorce/custody-related assessment in the shadow of an acrimonious divorce.

I guess those old circuits had not completely faded, because within moments I had created a litany of considerations and possibilities, and applied a “valence of acceptability” (VOA) to each (1=highly acceptable, 5=highly unacceptable):

  • Divorce, malpractice, and court-related meant high fees and up-front payment for anticipated work involved, from record review to expert testimony (VOA=1)
  • Excitement, intellectual challenge, professional reinvigoration, opportunity to put my extensive clinical/assessment experiences to use (VOA=2)
  • Rapid amortization of the above (VOA=5)
  • Sacrifice of free time (VOA=5)
  • Diminution of already-fragile golf course concentration (VOA=5)
  • Concern over of subsequent litigation against me (VOA=5)
  • Random, unanticipated, but highly likely agita (VOA=5)

Total average unweighted VOA=4.0

Decision=Decline Invitation

Follow-up=Increase Daily Dosage of Vitamin N (No), Play More Golf

With this decision made, I re-contacted the lawyer, who politely asked me for the basis of my determination. Rather than share my entire mental litany, I simply said, “Thanks so much for the invitation to work on this case, but at this stage of my career, I simply don’t want the agita.” He understood and interestingly, revealed his own age, shared the toll these kinds of family law cases take on all involved, and wished me luck on the golf course. Funny thing is that I never mentioned that I played golf, so assume he associated that with retirement and the fact that I live in South Florida. I did not bill him for the 45 minutes of rumination and 15 minutes it took to compose the email.

As a clinician/evaluator, and in particular play therapist who has worked in the shadows of court orders, as well as with young children, their warring parents, and typically zealous, although more often aggressive, non-family-oriented attorneys whom I later found out had their own shares of painful early childhood experiences, the decision made complete sense to me…and still does.

I knew from my own clinical experiences that while the first victim of divorce and custody-related battles is the truth, my own peace of mind typically ran a very close second. And while a sense of gratification often attached to having done a good job, the ensuing sense of relief and goodwill rarely extended to the players in the respective case, and the children continued to suffer the slings and arrows of the parent’s (and attorneys’) unfinished business. And all of this came rushing back as I made my decision.

***

In my previous blog, “Are We Really Ever Off Duty,” I wondered aloud whether I will really ever be fully able to simply cover that “third ear” and re-enter “civilian” conversational life without the desire, need, or intent to somehow help by offering an unsolicited psychotherapeutic salve to soften scars and mend wounds. This particular sense of wondering related more so to that part of my career when I was on active duty, so to speak. But what about when the “gone golfing,” or “gone fishin,” or gone wherever I want to go” sign is officially hung on my door? When will I no longer be drawn to the enticements, at least those of a professional type? Stay tuned, I’ll let you know.

How to Survive Pandemic Pandemonium in Nursing Facilities

Posted on by Psychotherapy.net Team

“We were left too alone at times, in these incubators of COVID at the nursing home, and we experienced true fear, and that fear is still present for me.”
 

“I’ve learned that if you allow yourself to go arm in arm with someone else, you can really accomplish something.”
 

The COVID-19 pandemic has had a tremendously disruptive impact on multiple aspects of personal life and on society across the United States. Yet the impacts in hospitals and in nursing facilities have been especially catastrophic, with shocking numbers of deaths, and severe effects on care providers.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Nursing facilities continue to experience dramatic changes because of the pandemic. As a psychotherapist providing treatment in these facilities, I lost many therapy clients to coronavirus, as 20 residents died in this facility, 30 in that, and 36 in another facility, for example.

In the spring of 2020, during the early stages of the pandemic and as the level of risk rose, my employer placed us on a temporary furlough. Many workers at the facilities, though, had to persevere in the face of cascading catastrophes. I felt so relieved to be home and to feel safe, yet I felt guilty to not be in the facilities when the need was greatest. I recall the anxiety I felt upon returning to the devastated facilities as I dressed in surgical gown, mask, face shield, and gloves before entering the buildings—something I’d never done before.

Plastic sheeting covered the entrances into some of the units, and at one facility the doors of residents’ rooms were covered with plastic sheeting with a zipper in the middle. A 55-year-old man with schizophrenia unzipped the plastic as I approached and handed out two dollars, asking if I’d get him a soda from the vending machine in the staff lunchroom.

A 51-year-old female resident had recovered from COVID infection and was aware of many fellow residents having died, yet she asked me if I really thought it (COVID) was real—she was strongly influenced by ill-informed and insincere information she’d gathered on TV and on social media, despite her direct experience. Such fearful spellcasting continues unabated, and I, along with my fellow workers have had to rely on critical thinking skills to help dispel, or de-spell, malign messaging wherever it appears.

As a mental health professional, I know that isolation can be kryptonite for persons experiencing mental health issues, and yet, to protect vulnerable persons from imminent danger, we needed to subject them to unprecedented degrees of isolation—weeks at a time closed in their room, months with no dining room, no group activities, and no family visits.

There was an early rise in mental health and behavioral symptoms in these facilities, and then an unexpected phase of collective self-suppression—passivity and apathy—as an apparent mode of coping. I was puzzled as one resident after the next stated that they were “okay” when they were immersed in this unusually unpleasant and lonely and anxious time. Were they okay or collectively experiencing a blunting of affect as an element of PTSD, or a type of useful detachment linked with dissociation?

It is still too soon to measure or appreciate the scale of the impact, as facilities continue to experience occasional positive tests for staff or residents. Many facilities have achieved a semi-normal state of daily activity, yet staffing has been decimated, and the need for new staff persons too often goes unfilled. Many TV and print news reports have described the negative impact of the pandemic on hospital staffing, yet few have examined the erosion of staffing at nursing facilities.

In some nursing facilities in Massachusetts, we have National Guard men and women in uniform performing non-clinical tasks: helping in the kitchen, folding laundry, and mopping floors, among others. It is wonderful that the Governor of the Commonwealth of Massachusetts has provided this support, yet it is shocking to see their presence and to know how much they are needed. Some facilities are leaning heavily on the National Guard’s men and women, and on expensive and budget-busting agency staffers. From where will the much-needed workers be found when the National Guard departs?

I admire the valiant, and exhausted, workers—the nurses, aides, directors of nursing, administrators, social workers, housekeeping, maintenance, laundry, food service, and floor care workers grinding on daily through risk and hardships. Call them heroes and they’d shake their head and roll their eyes—dead tired and just trying to get on with it, they’d say, instead.

It’s a challenge for my employer to hire enough clinicians to cover the needs for behavioral health service at the nursing facilities. Some clinicians seem to shy away from nursing facilities, and too many psychotherapists have migrated to telehealth jobs. We are still awaiting the phoenix phase of the pandemic, the rebirth of a personal and a shared sense of mission, as individuals recover from severe and sustained burnout.

For this article, I asked two questions of several residents and staff persons at different nursing facilities. Their responses vividly illustrate the range of poignant human reactions.

What has it been like to live through this period of pandemic in the nursing facility?

Resident: “It was a life changing situation. I’ve had to learn to survive—through all my mental issues; it’s been difficult.”

Resident: “It’s been frustrating, because of the repeated COVID testing.”

Director of Nursing: “It has been awful, stressful, and heartbreaking. But it was impressive to see, in the early stages, how all the people in the building came together to take care of the residents. I still feel like I haven’t coped with it, like I have post-traumatic stress disorder. I’m getting better, but I’m not yet coping as well as I want to.”

Director of Social Work: “It has been very traumatizing, actually, with so many residents passing away and being urgently sent out to the hospital in those early days of the pandemic. We had residents getting sick so quickly, and ambulance and fire people who wouldn’t go up to their rooms to get them—we had to rush sick residents down to the lobby in the elevator to get them out.”

Social Worker: “There’s been a heaviness about it, with unending changes and a sense of not-knowing every day, and a lot of fear. But also a lot of people who have stepped up with great compassion. We were left too alone at times, in these incubators of COVID at the nursing home, and we experienced true fear, and that fear is still present for me.”

Director of Nursing: “It has been extremely difficult for me, emotionally and professionally.”

Resident: “It has been a mixed experience. On one hand, I received good care from the aides—at least in the early stages, and when I was sick with COVID, and I got good physical therapy, and that got me walking again. I also got a little insensitivity, at times, because the workers needed to take care of their needs rather than mine, or so it seemed.”

Social Worker: “It has been sad, and challenging. We lost so many residents. Two years ago today, I came down with COVID. When everyone was in isolation we used Facetime, and we took photos of residents and posted them online, and the families were very grateful. But many of those pictures turned out to be the last ones of their family members. It is still very traumatic for me [said with a quavering voice and streaming tears].”

Administrator: “It has been extremely challenging and emotional. I’ll never forget family members visiting their loved ones—separated by glass windows, talking on the phone, and crying. It has been life changing, and points out things we often take for granted.”

What lessons have you learned from coping with the pandemic?

Resident: “To be kind, to ask for help, to reach out to other people, to accept my circumstances for what they are, and that every day is a new adventure.”

Resident: “You just try to keep your distance from people who are coughing and sneezing.”

Resident: “Being ill with COVID was rough for me, and I learned a lot by surviving it. I was grateful to be in a nursing facility rather than an assisted living program because of the greater amount of care I got here.”

Resident: “I guess I’ve learned that you’re stronger than you thought you were—or we all are.”

Social Worker: “I’ve learned that if you allow yourself to go arm in arm with someone else, you can really accomplish something. I’ve learned tolerance, especially around faulty systems, and I’ve learned to be more grateful than I ever have been.”

Director of Nursing: “That it is okay to feel vulnerable, and not strong; and how important is the gift of life, and how family is the priority.”

Director of Social Work: “I have learned the importance of teamwork. It taught us to work together, and to lean on each other for support. It is important to surround ourselves with a support system when dealing with such unfortunate circumstances.”

Nurse’s aide: “I learned more about a new disease, and that added to my knowledge. It has encouraged me more in my job. When I recovered from COVID , it made me stronger, and made me want even more to help people through my work.”

The process of asking these questions of staff and residents was emotionally powerful. It prompted me to spend time reflecting on my own reactions to the pandemic, and it pointed to the need for additional support to help staff persons manage the pandemic’s impact. So I developed a plan for “Pandemic Processing: In Search of Healing” support groups. Management staff at each of the facilities where I work were keenly interested to hold such groups. The meetings start with a simple relaxation exercise, then comments to set the context for conversation, and then a list of uncompleted sentences that act as springboards to the sharing of emotions.

The purpose of the support meetings is to step from coping toward healing. Coping is short-term efforts to function amidst an enduring stressor. Healing is a gradual process leading to lasting relief. Even while we continue to battle this enormous dragon of COVID, we need to reach out to one another and exchange support and encouragement so that we may emerge as stronger, more resilient, and more compassionate individuals—persons readier and more willing to devote themselves to the service of others.

What Root Canal Surgery Taught Me About Being a Therapist

Posted on by Psychotherapy.net Team

Although I don’t have a full blown case of dental phobia, suffice it to say that I wasn’t looking forward to my root canal surgery that morning. I maturely prepared for the morning’s activity by queuing up a psychotherapy podcast, thinking that listening to it would distract me from the unpleasant sounds and smells of the offending tooth being drilled. While the endodontist had previously assured me that I would feel no pain, my eternal skepticism left me in doubt.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

As the procedure progressed, I found it increasingly difficult to relax—if relaxation is even possible during a root canal. My garbled responses and feeble hand gestures were futile attempts to communicate with the surgery team, and it quickly became clear that my brilliant distract-by-podcast plan wasn’t quite as practical or effective as I had hoped.

So I removed my AirPods, and without a conscious choice, found myself turning my attention inward, focusing on my bodily sensations, and trying to relax as deeply as I could. Although I consider myself fairly attuned to my somatic being—and I use that attunement in my therapeutic work—the length of the procedure and its intensity motivated me to increase and deepen my level of focus.

I first tuned into my breathing, and then into what I can best describe as “energy flow”—although as I write this I worry it will sound a little too “woo-woo.” But whatever one wants to call it, it is something I regularly experience quite viscerally: the sense of energy flowing through my body, often stopping or disappearing at certain locations, such as my waist or hips when seated, but at other times like a creek which goes underground only to resurface later, reappearing in my calves or ankles.

I attended to this current of energy, noticing its ebbs and flows, and its associated sensations: pleasure, tension, openness or closedness, as well as the degree to which I was fully immersed in the experience. Then I began to have images and associations, most particularly related to table tennis, a sport which I’ve been playing for a few years (switching from tennis after developing tennis elbow) and had just played the previous evening at a local club. I’ve been getting coaching from an elderly Salvadoran man who played on his national team half a century ago, and am struggling to take the nice, relaxed forehand topspin shots that I can occasionally execute during our practice sessions and bring them into the matches at our club, only to find myself tightening up during my stroke and hitting the balls into the net. Yet as much as I tell myself that the stakes couldn’t possibly be any lower—what difference does it make if I win or lose one of these matches?—I find it extremely hard to change these habits. And there I was, in that chair, trying to do pretty much the same thing at the receiving end of the endodontist’s drills, picks, and pokes—focus, relax, let it happen.

And here my mind goes off in a number of directions. First, how hard it is to make any changes, and how the essence of who we are is so embodied. Think of anyone you know, and then how they move, whether it’s walking, dancing, or doing one sport or activity. If you see them again 10 or 20 years later, you can probably recognize them just by these movements alone.

And then I think about how we as therapists receive just about zero training in attending to the body, both our own and those of our clients. Sure, we may have been taught at one point how to lead a client in a relaxation or body-focused mindfulness exercise, but that’s likely about it. That’s barely scratching the surface. I realize that in recent years I’m much more attuned to my own bodily sensations when I am doing therapy. Sometimes it’s in the form of an emotional response in my heart or chest or throat, which I assume to be some form of empathic resonance. Often I share it with my client, not as a definitive statement, but merely as an observation, often with a question such as “I notice I feel some emotion swelling up in my chest; am I picking something up from you?” Other times I don’t share it but make a mental note for later consideration. This may take the form of something like, “Hmm, I find myself feeling ___________ (fill in the blank: softer, more vulnerable, tired or restless) with this client and wonder what might be happening between the two of us.”

There are indeed various somatic-oriented “approaches”—but these are far from mainstream, or from being taught in most of the grad programs which focus on “evidence-based” therapies. But there is no firewall between mind and body, and it’s patently absurd that therapeutic approaches should be Balkanized into separate fiefdoms: cognitive vs. emotionally focused vs. somatic. One hears about integration and flexibility as being hallmarks of mental health; if so, we therapists and our battles between theoretical schools aren’t doing a very good job of modeling this.

As I finish this blog a few days later while waiting in the San Francisco airport for our flight to depart after a four-hour delay due to leaking hydraulic fluid, I am grateful that this glitch was discovered on the runway before takeoff. I check into my body and feel the impending relaxation that comes with vacation, despite the false start on the runway. My shoulders are relaxed, my ankles warm, and I feel the energy flowing despite a slight constriction in my crossed legs. I notice a slight sadness, or perhaps melancholy, but am not sure what that’s about. Maybe I’ll sit with that a bit and see what I discover. Or maybe it will just fade away and remain a mystery.

Clients Deal with Ethics Too

Posted on by Psychotherapy.net Team

If you use the phrase “ethical issues in therapy,” every therapist on the planet will assume you mean the ethics of the therapist—confidentiality, client autonomy, duty to warn. Licensure renewal typically requires ongoing continuing education in ethics. Ethical questions show up in our clinical consultation groups in the form of our obligations to our clients and how we make sure we don’t inadvertently harm them. Ethics and our ethical obligations to both clients and the profession are ubiquitous in the fields of psychotherapy and counseling.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Here’s a new thought: clients have ethical concerns, too. And a related thought: we therapists have approximately zero training in how to help clients address these ethical concerns. A partial list of ethical dilemmas that clients bring to therapy includes whether to: stay in a difficult marriage or divorce, maintain a secret affair or end it, cut off or stay connected to a difficult parent, tell a non-vaccinated loved one to skip a family gathering or let them come, keep a family secret or reveal it. And then there are ethical issues that the therapist sees but the client may not, such as when a divorced parent is undermining a child’s relationship with a despised and destructive ex-spouse.

As someone trained in the 1970s, I can tell you how I was taught to deal with these ethical dilemmas. Keep the focus on the client’s personal needs and desires (“What do you need to do for you?”) and steer the client away from the other side of their ethical dilemmas—their sense of responsibility to others. In the language of the day, we learned to discourage clients from “shoulding” themselves.

This “do what works for you” paradigm came crashing down for me in the 1990s, when I worked with a distressed, newly-divorced father I’ll call Bruce, who was about to abandon his children by moving away and starting a new life. He had already done the same thing after his first divorce in another part of the country. He came to a session to wrap up our work and say goodbye. I knew I had to try to influence him to do the right thing by his children, but nothing in my training had prepared me for that conversation. What skills could I call on to navigate between the Scylla rock of silent neutrality (“What do you need to do for you now?”) and the Charybdis whirlpool of prescriptive moralizing (“Just do the right thing for your children”)?

That case, along with readings about the cultural impact of “value-free” individualistic psychotherapy, helped me to realize that the therapy field has a blind spot when it comes to ethical issues in the lives of clients. In this context, “ethical issues” refers to client behavior that has consequences for the welfare of others. We either see clients’ ethical struggles in strictly psychological terms, like the punitive superego, or as something we ought to steer clear of lest we impose our values on clients.

A problem with either of these default positions is that they do carry an implicit ethical message: that the only moral stakeholder is the client. An exclusive focus on asking, “What do you need to do for you?” carries the message that complex ethical dilemmas involving tension between self-needs and obligations to others really come down to one dimension: the needs and desires of the self. For years I told clients agonizing over whether to divorce that “your kids will be fine if you do what makes you happy.” My point is that when clients bring us their ethical dilemmas, we are ethical consultants, like it or not. So I decided it was time to get good at it.

In my recent APA-published book, The Ethical Lives of Clients, I articulate five skills in ethical consultation, using the acronym L.E.A.P.-C: Listen, Explore, Affirm, offer Perspective, and (sometimes) Challenge. Therapists use these skills all the time in our work. Now I am applying them to the client’s ethical issues: listening for the client’s sense of how their actions are or potentially are affecting others, exploring their ethical concerns and the roots of those concerns, affirming their willingness to confront an ethical dilemma, offering perspective on the tension between the client’s needs and responsibilities to others, and, in some cases when there is imminent, foreseeable harm, challenging the client to consider the impact of their actions on others.

After decades of doing this work and teaching it to therapists, I am convinced that skillful ethical consultation not only does not drive clients away—a common therapist worry—it empowers them. With Bruce, I listened to and explored his pain and worries, I affirmed him as a father, I offered a perspective on his importance to his children and the likely consequences if he abandoned them, and finally, when he minimized the impact of his exiting their lives, I challenged him by saying that I was worried that he was treating a short term problem (his distress over the divorce and his desire not to have to deal with his ex-wife anymore) by risking long term damage to his children. I offered to be there for him to deal with his current personal crisis, which I was confident he could get through.

Bruce made a decision that had integrity for himself and his children—he stayed with them and later reconnected with his older children from his previous marriage. In the years since that case, I’ve learned that while there is tension in the short run between needs of self and ethical responsibilities to others, in the long run, human flourishing comes from facing the tension and finding authentic ethical integrity. Helping people in this crucible is part of our job as therapists, so let’s get good at it.

Dr. Shelley F. Diamond: A Psychotherapist Facing Death

Posted on by Psychotherapy.net Team

How to Tell My Patients

My doctor at first thought my month-long pain was probably heartburn, and I said “No, I’ve had heartburn before, and this does not feel like that.” And she said, “Well, take some Prilosec for a week.” I did that, but the pain was getting worse. That’s when she said, “Well, let’s do some tests.”

They tested my urine and blood, which determined that I needed an ultrasound, and that determined that I needed a CT scan, and that showed I needed a biopsy, which diagnosed pancreatic cancer.

All that was very disturbing, of course—medically and existentially. Once I got that clear information, my first thought was, “Oh my god, I have all my patients!” and my first decision was, “I can’t deal with my personal issues until after I figure out what am I going to do about all my patients first.”

I’ve been a psychologist in private practice since July 1, 2006. It’s been over 15 years. I have a full seven day-a-week practice. I had to deal with all the patients that were currently scheduled and those calling for an appointment.

So I realized I had to come up with something to tell my patients. Each person is different, so how would each of these people need to hear this news? Certain patients do everything over email, including arranging appointments, and I realized—okay, certain people I can tell over email. But some people don’t do email.

I knew I would have to tell some people over the phone, and I was concerned this might cause them harm. One older woman only communicated through phone calls, and I knew I would have to tell her on the phone; I knew that would be the most difficult person to tell. In my own life I’ve been told that way that loved ones of mine were dying, and it felt like a horrible way to hear this news. And I didn’t want to tell anyone via text, so I just sent them a text saying “I sent you an important email. Please read it.” It required juggling several different communication methods.

Some of my patients were going through a bad time in their lives, and I knew I needed to wait a few weeks to see if there was a better time to tell them this bad news.

What I realized was that for most of my people, it would be best to compose an email message that I sent them the day before our scheduled session. I had a template with the first paragraph, and then I customized the rest of it for each person.

Most of the people received the subject line: “Bad News.” They needed to have a heads up so that before they opened it, at least they knew it was bad. It would be helpful for a lot of my people to prepare them to open the message.

Then I started out with their name and, “I have some bad news to tell you. I’ve been diagnosed with pancreatic cancer, and I only have a short time to live.” Then I said, “Please accept my apologies for this abrupt change in our relationship. It hurts me to have to share this bad news. I wish this wasn’t happening.” It was important to connect with them in a human way, because anyone knows this is a horrible thing to have to write.

The third paragraph was, “The only good thing is that I know you have learned a lot in the time that we’ve been talking together. We can still have our session scheduled for tomorrow, but that will probably have to be our last session. In the last session we will review the progress you’ve made, because I don’t want you to forget what you’ve learned.”

Each in Their Own Way

I had to send this to about 40 patients. There were a couple of people that I thought were going to need more than one final session. So, for a few of them, I wrote, “If you need more time we can have another meeting, but let’s see what we can talk about tomorrow.” But no one wanted more than one session. I think it was too painful for everyone. The one last session was so intense that they couldn’t open up again in another session.

They all expressed a concern about taking up my time, and I had to reassure several that it was important to me that we have that last session. There was one person who couldn’t respond at all, and just didn’t show up for the last session. I sent him a message saying, “I understand this was probably too much to deal with, and I have known you long enough to know how you feel, and it’s okay.” And then there was nothing else from that person. I knew he needed me to acknowledge that, because I DO know how he feels. I have several patients that I’ve been seeing for years. He was the kind of person who expressed very frequently, “Oh, I’m so grateful for our work together.” He didn’t need to repeat that, I knew how he felt.

I had a different relationship with each person, of course. Some of them needed to say things in the last session, and some of them didn’t. One woman was inappropriate, in that she had boundary issues. She said, “I looked up your home address on the Internet, and I want to come over and feed you soup, and I want to take care of you.” She had an “I’m going to smother you with love” kind of response. And so I had to make the boundaries clear and told her, “I appreciate your intentions, but that’s just not appropriate at this time.”

With her and several other people, I had to immediately connect them to another therapist. That was the other challenge I had—getting them referrals. Because I knew someone like her needed to transfer immediately to someone else. Luckily with her, I was able to identify a therapist I knew would be good, and she did connect with that person right away. Then I was able to say, “Talk to your new therapist about how you’re feeling. I know you’re grieving, and this is your way of trying to stay connected to me, and I know this is part of the grieving process. This is reminding you of all the people in your life who have died and you’ve lost connection with. There is a lot to talk about, and this will be a good way to connect to your new therapist.”

With some people, I had to help facilitate their taking their emotions and using them to be with someone else, because that I couldn’t do that with them anymore.

I’m taking this opportunity to say a little bit about what I did because when it happened to me, I had no idea what to do. Graduate schools and continuing education need to show therapists how to deal with such situations as I found myself in. It seemed up to me to reinvent the wheel, or perhaps even to invent it. The only good thing was that I was very aware that I had to figure this out. I had an intense feeling of urgency. I just used what I felt with my patients to guide me in sensing what each person needed from me in each moment.

And for people who I had seen for many, many years, I was able to say things like “I know you’re in a stronger place now than you were when we first connected, and I know you have the resilience now to deal with the ongoing challenges in your life.” I needed to reinforce some of the ways that I really did know that they had grown over time. To one person I said, “I know you have more confidence in dealing with the challenges in your life. It’s made me happy to see you grow and change for the better over time. I’ve seen you so many years, it feels bizarre that I won’t ever see you again;” validating the feelings that I knew they would have. I would add, “I’m glad I was able to be there for you during your long divorce process;” “I’m glad I was a witness to your changes in emotional maturity over time;” “I know you’re capable of commitment, and I hope you can find someone else who is capable of that.”

Email communication was good because it’s a document that they could come back to. I made sure that I wrote things to people who I knew used written materials in their process. In their last session, they said, “Oh, I’m going to keep this by my bedside, so I can read it again when I get discouraged.” That’s why I sent them these things the day before, and then in the last session reinforced this again. I said, “Let’s talk about your progress and how we can make sure that this grief doesn’t trigger a relapse into your old unhealthy ways of coping with things.” I said, “The only good thing is I know you’ve made great progress, and it’s been a pleasure to watch you free yourself from all the old patterns in your life.”

People responded with, “I’ve never talked to anybody about death like this before.” In the last session, I would ask them, “Who have you known that was dying or died. What did happen?” And 99% of the people said, “We never talked about it. It was just something that you didn’t talk about. It was always something to avoid as a terrible thing.”

One thing I do want to mention is that when I put my original notice to the San Francisco Psychological Association, with the subject line, “Telling my patients I’m dying,” I received an outpouring of support and messages from my colleagues who were wonderful. People were very kind.

One of my colleagues who responded shared that she had also faced cancer, and that she had talked to her patients and said, “I know that it’s scary to talk about cancer and death.” She added, “I’ve had some very good conversations, and it was important to talk about it, and it was helpful to them…We’ve had some profound conversations.” Her saying that really helped me become more conscious of what these last sessions could be. I realized, this is a therapeutic issue, and I need to think about how this could help them to talk about death. Because before that I was thinking, “Oh my God, I’m causing them harm by having to tell them this.”

I knew I needed to be thoughtful about not causing them harm. But my colleague’s message awakened me to the possibility that this discussion could be a profound therapeutic gift. And that is exactly what happened; I would say 98% of the people had an amazingly deep therapeutic session where they opened up about how talking about death was something they’d never done before. Even the men were sobbing. I’ve never heard the men cry like that before, even the very macho kind. They said things like, “I could never talk to my mother or grandmother like this when she was dying,” and, “I wish my mother had been able to talk about this”—they grieved not getting that opportunity before with various people in their lives.

They were able to talk about our relationship and what they had gotten out of being in therapy with me. And they were able to expand it to the idea of death in general, how we don’t talk about it, and were glad that we were able to do so. Some said, “I’m going to live a better life because of this. You’re helping me realize I can’t take each day for granted, and I can appreciate everything more.” “Because this has happened, I’ve reached out to my family and told them that I needed their support.” “Now I feel more connected to my support people because you’ve given me the courage to talk about this, so I’m going to talk about it more with them. You’re helping my whole family.” People were very effusive and heartfelt. I mean, many were sobbing. The only people who didn’t really cry were a few people from cultures that taught them not to show deep feelings, but I could tell they were shocked and saddened. Everybody was profoundly touched. Some said, “Thank you for being so honest about what’s happening,” and “I had people who died, but they just disappeared, and I didn’t even know what happened or why they died. There was no way to get any questions answered.”

Grokking the Infinite

There’s another kind of pain. I’ve almost died many times from eating nuts. I’ve always felt that I wasn’t afraid to die simply because I’d come so close to it before. It was always an experience of just letting go and surrendering to the process. Because what I learned from that is, don’t fight it, just relax. The best thing always in that situation for me was when I realized, “Uh-oh, I’m having anaphylaxis, and so I might die right now,” was to be as completely physically relaxed as possible, and sort of go into a trance. That’s really what helped me. I would go into what I would call a hypnagogic state, where I was conscious, but it’s an altered consciousness. Like just before sleep, for some people. I really use that time as I’m falling asleep or as I’m waking up, to hold onto that hypnagogic state. It’s an altered state, but it’s a very peaceful state. I always associate that with a dying experience because it feels like it’s between worlds.

I remember one of my early existential experiences, when I went on a camping trip with my family. We were outside at night under the stars. I remember I was with my father and we were looking up at the sky, and it was one of those places where there were no lights, so you really could see more stars than you could at my suburban home. And I remember looking at the sky, and at that time, they had this TV show called Ben Casey, M.D., and in the beginning of each episode a Dr. Zorba would write symbols on a blackboard, and say, “Man, woman, birth, death, infinity.” And I remember asking my dad, “Dad, what’s infinity?” And he just said, “Look up at the stars, that’s infinity.” He said something very simple like, “It goes on forever.”

I looked up at the stars, and I felt I could suddenly grok the idea of infinity. It was like the movie about Helen Keller learning the sign for water by feeling the water coming out of the pump. I must have been about eight years old, and I remember this intense awareness of the immensity of the universe. For a moment I felt it, and then the next it felt too intense, and I shut it down. But I always remembered that moment I did let it in, I could let it in, and it has stayed with me all these years. I can go to a planetarium and feel it in a way I couldn’t feel it when I was a little girl. Now I love to go to the planetarium and be absorbed into that immensity for an extended period.

To me that’s what death is, you get absorbed into that infinity, that immense infinity that our human brains are too small to comprehend, the totality of the cosmos. Humans are probably too fragile and limited to hold the voltage of that infinity experience, and so we have to kind of shut it down to some degree. Because when you really think about how vast it is, it’s beyond our capacities. We blow fuses.

As my Zen friend says, Death really is the Great Mystery. And I’ve always said it’s a mystery what the true cosmos is; I don’t believe we can comprehend it. Every human finds some way of explaining it for themselves, whether it’s a religion or a faith or a philosophy. I just think of it as all philosophy, of what helps them tolerate this ongoing uncertainty, that we’ll never know. We cannot know. But we need to know. That’s what being a human is. We want to know, we need to know. We need an explanation.

My recent experience has been sort of a building on that foundation, in that my experiential reality since I’ve been given this diagnosis is that I have a felt sense of my molecules preparing to disperse. It’s very hard to put into words, but I feel my—that’s the only way I can say it—my molecules are preparing to disperse into the cosmos. There’s some—it feels almost physiological, but it’s clearly a psychophysiological experience—it feels like my molecules are preparing to expand. There’s a sense that something is expanding and opening. Every single cell in my body is starting a journey.

It’s very subtle. I feel slight changes in every level: my body, my thoughts, and my emotions. I had to go through a process of understanding what’s been happening to me. I’ve been writing in my journals, and that’s been very good. In these hypnagogic states I’ve been trying to process, how do I conceive of this? I’ve always been prepared to die, from having had childhood medical problems; for so many years I was suffering a lot, and spent most of my life thinking that I would be so glad when I die and be done with all this suffering. I was always expecting to have no problem jettisoning everything.

But I’ve been feeling very good physically these last five years, and I’m 65 now, so I’m having a different experience, “I’m feeling good now! Oh no, I see why people don’t want to die. I’m having mixed feelings because I just figured out how to feel good and now, I must go?”

Another level of it is being aware that my sense of time has changed. I now live with a time reference point that other people don’t have. I talk to people and I’m aware they’re living in a time structure that I used to live in, and I’m not in that anymore. I’m in a different group now. Over the last five years, whatever happened, I’d think, “Well, I’ll do that someday. At some point I’ll get around to that. If it doesn’t happen this week, that’s okay, it’ll happen at some point soon.” I can’t use any of those reference points now.

I’m very glad I had those experiences with anaphylaxis from exposure to nuts, because I know I’m so much better prepared for what I’m going through than someone who’s never had that. And I can tell from talking to other people, the way they are imagining what this would be like is so different. It’s been interesting to talk to people. Some people say things like, “So now you know you’re going to live less than six months, do you have a bucket list? Are you going to go have fun and do whatever you never got a chance to do?”

No Bucket List, Just Gratitude

No. Number one, for my whole life I did everything I wanted to do because I knew I might not live very long. I’ve always done everything I wanted to do. I was never waiting for retirement to do fun things. That would never have occurred to me.

Number two, I have so many things I HAVE to do right now, I don’t have time to go have fun. I’m grateful that I am not going through any medical procedures, because the only suffering I have is pain. Other than that, I feel fine. I can do everything I want to do. My mind is sharp. I’m in charge of everything that’s happening. I’m juggling ten different things. I’m juggling attorneys, and accountants, and doctors, and who’s going to help with my patient files. I’m juggling so many different projects that I probably wouldn’t be able to do if I were sedated or going through some sort of medical procedure.

Another thing I am grateful for—and I spend a lot of time writing about what I’m grateful for—is that I am still mentally fine right now. I didn’t add more side effects from medical problems to my suffering. I have had a certain amount of time to get my affairs in order, for which I am truly grateful. Some people get this diagnosis and they’re dead in a week or other very short time. I’m grateful, I’ve had months, because when I first got the diagnosis, I thought I’d better act as if I were dying next week. “You better get into gear, overdrive, because you may be dead in a week. You have no idea how much time you have.” And so I’ve been very, very active, as much as I possibly could, from the day I got this diagnosis.

I’m grateful that I have lived as long as I have, because I thought I was going to be dead before I was 20. My father died when he was 60, and at the time I thought he was an old man. I was 19 when he died. At the time I thought that at 60, a person is old. And I remember people saying, “Oh, your father, it’s such a shame he’s dying at 60.” I thought, “What’s he going to do after he’s 60?” I remember I didn’t understand why people thought that was a short time to live.

For resources I recommend an organization called You’re Going to Die, which does public gatherings where people talk about death. They tell stories, sing songs, read poems, and they share whatever they need to talk about in terms of an awareness of the fact that “you’re going to die.” I think they are a beautiful organization. They’re here in the San Francisco Bay Area. During COVID they are doing it over the Internet, but they did do them in person.

They have a little coin they give out. On one side it says “You’re going to die,” and on the other side it says “You’re not dead yet.” The whole point of it is to raise your consciousness to be aware that yes, you’re going to die, and we need to be able to talk about the pain of knowing that is going to happen, but we want you to be aware that you’re not dead yet. You need to have both so that you can be present in the moment in a more helpful way.

I also recommend the Ernest Becker Organization (ernestbecker.org). He was a cultural anthropologist who wrote the ground-breaking Denial of Death in 1973. Another resource is Death Café (deathcafe.com), which I have attended in the past.

Thank you, dear readers. I will just say goodbye for now. I hope to encounter your spirit again.

Shelley Diamond, PhD
San Francisco, California, USA
 

***
 

Editor’s Note: Dr. Diamond closed this conversation by sharing the 2019 poem “You Will Lose Everything” by Jeff Foster, noting that she had shared it with people who said it was helpful to them. It begins with “You will lose everything” and ends, “Loss has already transfigured your life into an altar.”

This article was excerpted from a conversation between Dr. Shelley Diamond and Dr. David Bullard on January 23, 2022. 
 

In Praise of Termination

Posted on by Psychotherapy.net Team

I don’t think I’m the only one, at least I hope not, who feels an immense pressure to produce a “win” with every client. I feel like I owe clients a positive outcome and if I’m not able to produce, then I’ve let the client down. This pressure leads me to put the blame, if that’s the right word to use, on myself. If the client is struggling in any way; if they aren’t seeing results; if they aren’t motivated; if they aren’t putting in the effort to complete their homework or follow the steps in their treatment plan, I am the one who failed, according to that lingering, irrational neural circuit. All that changed after one fateful conversation with a colleague.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

I remember unburdening my woes on a colleague regarding a couple I was working with. I told her that every week the couple would spend their time complaining about each other. We would discuss their relational problems ad nauseam, inevitably arriving at the same place when they would proclaim some version of “If only we could just do X, then everything would be better.” They would get so excited, and I could hear their thoughts as if broadcasted; this idea was their silver bullet. The excitement was palpable as they left the office with an action plan, only to return the next week to tell me they hadn’t done anything we’d discussed. This pattern repeated week after week. I found this baffling. But, as I told you, the reason had to be that somehow I dropped the ball. So each session I’d go into overdrive and dissect what didn’t work and strain every last neuron in that circuit to come up with yet another dazzling idea, which, as you guessed also wouldn’t work.

I finally finished telling my colleague about the couple and downloading all my feelings when she looked at me and said in a matter-of-fact tone, “You’re way more patient than me. I would have fired them long ago.” “Huh?” I replied. Fire my client?! I had never done this or even considered this as a possibility. As I asked her more questions, she explained that when you have a client like this, the problem may not be you, or even them. Maybe the timing isn’t right. Maybe they aren’t in a place to make change. Maybe it’s easier to dream about change than actually doing it. Maybe the fit isn’t right and they would be better served by another clinician. Or maybe I needed to draw a line somewhere, and tell them that I could no longer work with them if they were not willing to follow through.

My colleague was making this pretty clear, but I honestly needed her to spell it out for me. She told me to make continuation of the therapeutic relationship contingent upon their completing their homework. If they said they would commit to a date night once per week, then I needed to raise the stakes and make doing the date night actually matter. They clearly valued coming to therapy every week since they were willing to pay for something that wasn’t producing the results they allegedly desire. The fact of the matter is, she went on to explain, that there could be a hundred different reasons why they weren’t actually following through, but in the final analysis, I was not doing them any good by smoothing over their failure to complete the homework or follow through with other therapeutic suggestions.

Yeah, I had to sit back in silence and take a few minutes to digest this. My first thought was, “Well, isn’t this kinda mean? Or, at the very least, won’t my client think I’m being kinda mean?” My colleague disabused me of this idea rather quickly. Holding my client accountable does not have to be a mean thing to do, nor does it mean that I am being so. This can be done in a very professional and respectful manner, and even in a way that may at some later time lay the foundation for real therapeutic progress—you know, planting seeds! Besides, I would hold myself to no less of a standard. I would not let myself off the hook if I committed to something and then never followed through. So why the double standard? Why do I look the other way with clients, but not with myself? Further, my clients most likely hold themselves to this standard when outside the office. So, why the double standard? Why do they look the other way when it comes to their relationship?

This question was very challenging, but incredibly helpful. I went back to my couple, nervous but motivated to put these new ideas into practice. I let them know, respectfully, that I noticed a pattern of them not following through on homework. And that if they wanted to continue working with me, we needed to agree that doing so was dependent upon their completing homework. My heart was in my throat when I said this, but to my surprise, they had little to no pushback. Despite their agreeing to the terms, the next week they had not completed their homework. As I said I would, we decided to wrap up therapy.

Fast forward a few weeks.They called me asking if they could come back, but they said this time would be different. They would not only agree to the homework-related conditions for termination, but they committed to actually doing their homework. Suffice it to say, they did, and the change they so badly wanted started materializing.

***

In reflection, I learned a lot from this couple and from my colleague’s insight. This lesson has stayed with me and affected my work with virtually every client since. I no longer place immediate blame on myself for clinical failure (although I do reflect often on how I can do better). Rather, I am more broadminded when things aren’t working. I’m more open to the option of terminating the therapeutic relationship, and, in fact, I see it as a potentially important step in the healing journey of some clients. I share with my clients that termination can be an act of empowerment. If the client feels like they aren’t getting what they need from a therapist, they should not feel beholden to stay for the therapist’s benefit. Instead, I encourage clients to broach the topic of termination, to explore other options, and to find what works for them, as I am now in the habit of doing.