Author: Psychotherapy.net Team

Survival Strategies

Posted on by Psychotherapy.net Team

Survival Strategies

Stories have to be told or they die, and when they die,
we can’t remember who we are or why we’re here.
–SUE MONK KIDD
 

A few years ago, I was giving a presentation about mental illness to a group of schizophrenic clients and their families. My hour-long talk included a description of symptoms, medications, and various forms of available treatment. After I was done with my talk, I took some questions, the group had a brief discussion, and we ended for the evening. As I was putting away my notes, one client came up, vigorously shook my hand, and said, “Good job, Doc. You’re just a suppository of information!” He then spun on his heels and left.

At first, I thought this might be a loose association. Then I began to suspect that he was telling me where I could put my “expertise” concerning his illness. Regardless of his true intent, whenever I begin to take myself too seriously, remembering that I am a suppository of information helps me to put things into perspective.

We do serious work. At times it can overwhelm us. Too often we are left to discover the risks and pitfalls of the profession on our own. Therefore, it is helpful to begin training with some strategies to increase our chances of having long and enjoyable careers. Following are a few “survival strategies” that I have found to be particularly helpful.

Don’t Panic in the Face of the Pathology

When I reflect on my past experiences, the clinical situations that have most challenged my ability to remain calm and centered have involved the following:

  • Suicidal threats and behaviors
  • Self-mutilation
  • Child sexual or physical abuse
  • The reporting of traumatic experiences
  • Dealing with a client’s sexual interests and/or advances
  • Bizarre psychotic beliefs

If you are facing any of these, you need to remember survival strategy Number One: Don’t panic! A competent clinician remains competent in the face of these kinds of challenges. Anxiety is the enemy of rational problem solving, and panic leads even experienced clinicians to operate from survival reflexes instead of therapeutic knowledge.

Clients with painful experiences and frightening symptoms are accustomed to living in a world where others avoid and reject them. Our ability to remain empathically connected to them through the expression of their suffering sets the stage for therapy to be a qualitatively different relationship experience—?one where they are accepted, pain and all. Whether they are telling stories of their traumas or acting out their struggles in the therapeutic relationship, remaining centered, attentive, and connected is the foundation of our ability to provide a healing relationship.

Another reason not to panic is more subtle and more profound. Victims of trauma and abuse often find that sharing their experiences is extremely upsetting to listeners, so much so that they end up having to take care of the very people who are supposed to be taking care of them. Many victims report that others can’t tolerate knowing what they have been through and, sadly, this is often true. Victims learn to edit or silence themselves to avoid upsetting others, being rejected, and having to cope with the emotional reaction their victimization engenders. Not telling their story is the most untherapeutic outcome possible. By not panicking, you allow your clients to share their painful experiences, which frees them from slipping into the familiar but untherapeutic caretaker role.

One of my first clients was a young man named Shaun. He had a flair for the dramatic and would stride around the consulting room making grand gesticulations while wrapping his problems in eloquent words. On one occasion, he threw open the window and sat on the sill. He took the cord from the blinds, performed some clever knot making, and came up with a perfect hangman’s noose. He dangled the noose from his hand, swinging it back and forth like an executioner. Every so often he would look over to check out my reaction to his nonverbal communication. Alternately, he would lean out the third-?story window to the point where most of his torso hung outside.

This was my first clinical panic. I thought, “Oh, great, I’m going to be known as the intern with the client who jumped out the window during a session. There will probably be a famous lawsuit with my name on it. How will that look in my evaluations?!” Each time his head disappeared out the window, I turned around to look at the one-?way mirror, behind which my supervisor and other students were observing the session. With the expressiveness of a tragic opera character, I mouthed the word “help!”

In his wisdom, my supervisor chose not to intervene, and Shaun, fortunately, never jumped out the window. I later came to realize that Shaun was testing my ability to cope with his behaviors; he knew he was a handful. He wanted to see if I had the courage and centeredness to remain calm and stick with him in ways that his family and friends could not.

Over the years, I have had to deal with clients showing up at my door with gashes in their wrists, fathers threatening violence because I reported them for abusing their children, and tales of the most depraved human behaviors (the latter while working with victims of political torture and sadistic child abuse). Clients have had seizures, gone into diabetic comas, and experienced long and painful flashbacks during sessions. Although I haven’t always known the best thing to do, I always remember survival strategy Number One – – don’t panic. If I don’t panic, I can think about what is happening and what I can do.

Experience counts. The more you deal with situations like this, the easier it is to stay calm. Part of this is developing a “memory for the future” – – ?meaning that, over time, we become accustomed to facing frightening and dangerous situations, which are followed by conscious problem solving and good outcomes. Repetitive experiences like this form an emotional memory that we have access to in crisis situations and that reminds us that things will work out.

In addition to a growing sense of confidence, it also helps to have crisis – situation action plans prepared in advance. For example:

  • Early in supervision, discuss with your supervisor, in detail, what you should do in case of various emergencies such as when a client is a danger to himself or others.
  • Put emergency phone numbers, including your supervisor’s, on speed dial.
  • Schedule potentially problematic or dangerous clients for times when your supervisor or other backup professionals are present.
  • Alert others around you when you are meeting with a client who makes you uneasy so that they are on alert and can serve as backup if needed.
  • Pay attention to your subtle feelings and instincts about a client and discuss them in supervision

Expect the Unexpected

Never underestimate the value of preparation in being able to successfully deal with crises and problem situations. This leads to survival strategy Number Two: Expect the unexpected. When extreme situations do arise, keep some of the following principles in mind:

  • Don’t catastrophize. A client’s strong emotions such as angry outbursts and uncontrollable sobbing tend to shift in a matter of a minute or two.
  • Maintain boundaries. If a client has a feeling, it does not mean you also have to have it.
  • Stay centered. If you sit calmly, it will provide a sense of safety and calm to your client.
  • Provide structure. When a client is emotionally out of control, it is often helpful to provide gentle but firm instructions, such as “I think it would be helpful if you would sit down and focus on your breathing – – let’s do it together.”
  • Provide hope. While understanding your client’s feelings, also remind him or her that things will get better. Many clients find hope in the fact that you have helped others with problems similar to theirs. Tell them stories of clients similar to them who had positive outcomes.
  • Discuss strengths and resources. It is easy to forget our strengths, resources, and accomplishment when in a crisis. Taking a couple of minutes to discuss these at the end of a difficult session not only provides hope but also yields clues for additional interventions, such as the reestablishment of relationships and activities that have been forgotten during difficult periods.

I received a call on a Sunday morning with a request that I meet a young girl for an emergency consultation that afternoon. When I arrived at my office, I found Sandy slumped down in a chair, looking half asleep and half in shock. She looked so emaciated, her color so bad, that I felt immediate concern for her physical health. Once in my office she told me in an emotionless tone that she thought that she had been raped the night before in a parking lot outside of a nightclub. She was home for a week from her East Coast prep school and had gone out dancing with some friends. As was her habit, she had drunk to the point of unconsciousness, so she couldn’t recall whether the sex she had was consensual or not.

Sandy’s words flowed like water from a cracking dam; she wanted and needed to tell me everything on her mind and in her heart. She described a long history of bulimia, cocaine use, binge drinking, a number of serious automobile accidents, failing grades at school, and her victimization at the hands of numerous boyfriends. Sandy also told me of her loveless childhood and her parents’ sending her off to boarding schools from a very young age. She spoke for almost 90 minutes and I didn’t interrupt because I sensed her need to finally share all of her pain with someone who might be able to help.

Sandy said that she had “half a dozen” problems, many diagnoses, needed to be in several support groups, and felt that there was no hope for her. What had happened to her the night before wasn’t atypical for her; what was different was her feeling of hopelessness and thoughts of suicide. After this, she became silent, glanced over at me, sat back into the couch, and gave me a look that said, “Okay, your turn.” I was so immersed in her story and so impressed with her emptiness and pain that it took me a while to turn my attention to what I would say.

Sandy’s life clearly felt out of control. What I wanted to do was to take all that she had told me and to present it back to her in a way that demonstrated to her that I had heard what she said, understood the depth of her suffering, and could provide a perspective and plan that would give her hope of having a better life. I thought about all she had told me and came up with some ideas. This is what I told her: “Sandy, although it feels like you have many different problems, it seems to me that you have one core struggle – – the need to feel loved and cared for.” I thought that this might be correct because I could see Sandy’s posture change as the first tears poured from her eyes. “My sense is that although your eating disorder, alcohol and drug use, and bad relationships all seem like different problems, they may all be attempts to cope with the loneliness and anxiety you feel every day. Even your car accidents, where you drive your new car into a tree, may be a way to tell your parents something is wrong. With each accident, instead of hearing your pain, they only have another car delivered to your school.”

Having one central problem as opposed to “half a dozen” made Sandy feel a sense of hope. She took off time from school and I began to work with her and her family around issues of attachment, bonding, parenting, caring, and love. Sandy’s family wasn’t ideal for her, but she needed to learn that many of her parents’ emotional inadequacies were not because she was unlovable but because of their own limitations. They needed to learn that their daughter needed more than money from them and Sandy had to learn a healthier way of asking for what she needed.

Having one central problem as opposed to “half a dozen” made Sandy feel a sense of hope. She took off time from school and I began to work with her and her family around issues of attachment, bonding, parenting, caring, and love. Sandy’s family wasn’t ideal for her, but she needed to learn that many of her parents’ emotional inadequacies were not because she was unlovable but because of their own limitations. They needed to learn that their daughter needed more than money from them and Sandy had to learn a healthier way of asking for what she needed.

Crisis as Communication

As with Sandy, crises are often forms of communication–ways of communicating when words can’t be found or aren’t heeded. Many clients struggle with suicide and there are few clinical situations more difficult to deal with. Suicidal acts, gestures, and ideation make us concerned for our clients and ourselves. We are all told that we have a duty to protect our clients, but what is the best way to do this and still preserve the therapeutic relationship and the client’s confidentiality? These are difficult clinical situations that we learn to cope with but never get easy.

Roberta had been depressed for years. She told me that every few years she would try to kill herself in ways that were fairly lethal. Over the years, Roberta had come to understand that her suicidal actions were desperate attempts to gain the love and attention that she never felt she was given by her parents, siblings, or friends. Although it was clear to me that she wanted to live, I was concerned that she would someday miscalculate these calls for help and accidentally kill herself. One afternoon, she came to my office with a clear plan to commit suicide later that evening. As she described her detailed plan of getting a gun, going down into her basement, and setting the stage for her death, I grew more and more frightened. Her description was so detailed, I could vividly picture every stage of the process. I raced through options in my mind: barring her from leaving my office, calling the police, taking her to a hospital, and so on. I tried not to panic, stay calm, and think through the logistics, complications, and risks of these options. All of the interventions that came to mind had been done by Roberta’s previous therapists and had led to her ending each relationship. Was there something else I could do?

Still struggling to remain calm, I asked Roberta what she hoped to accomplish by attempting suicide. As she spoke, it became clear that she wanted her brother to know how alone and hurt she felt. She wanted him to feel guilty for not paying better attention to her. This soon flowed into a discussion of her wanting me to know these things about her inner experience and my empathic shortcomings. Roberta somehow felt that a suicide attempt was the only way she could make me understand the intensity of her pain.

By the end of the session, I had somehow assured her that I understood the depth of her suffering and why she would commit suicide, but that a suicide attempt (as a form of communication) would be redundant to what I already knew. I also assured her that I wanted our relationship to continue and that her past hospitalizations always resulted in so much shame that she discontinued her work with her therapist. Roberta and I made a standard suicide contract and scheduled extra meetings to help her through this difficult time. For me, the most important aspect of this session was my ability to avoid panicking, remember my training, stay in the role of a therapist, and hang in there with Roberta’s experience.

Don’t Try to Reason with an Irrational Person

This is survival strategy Number Three. It will save you hours of wasted energy and keep you from missing the important emotional realities behind much irrational behavior. Although we can generally rely on reason to aid us in finding solutions to complex problems, it doesn’t always work. Some people have such a firm image of what is true that they cannot be swayed by reason. The emotional circuits of the brain are easily capable of inhibiting or overriding rational thought; some clients only see things that fall in line with their prejudices and beliefs. Those fighting with God on their side seldom stop to think about the god leading their enemies into battle.

For a number of years, I worked in a hospital ward with actively psychotic individuals. I saw clients in both individual and group therapy and participated in many ward activities. During a session with a woman named Wanda, I became aware that she believed she was a few months pregnant. In discussion with the nurses, I was assured that this could not possibly be the case and that Wanda was suffering from a delusional belief. It made no difference that the nurses had told this to Wanda; she remained steadfast in her belief that she would soon be a mother.

To complicate things even more, during one of our sessions, Wanda revealed to me that she was pregnant with a cat! I liked cats, but this one caught me by surprise – – I still hadn’t learned to expect the unexpected–and I decided that I definitely needed to do something. I suggested that she bring this belief up in group therapy later that day, assuming that when the other group members heard her story, they would help Wanda to realize the impossibility of her belief.

Based on my suggestion, she waited her turn in group and made her joyous announcement. Although there were some doubters at first, by the end of the hour Wanda had convinced the group that it was possible for a woman to become pregnant by a male cat if the conditions were right. Amazed and impressed by her skills of persuasion, I nevertheless refused to give up my reality campaign. After the group meeting, I asked the nurse to schedule a pregnancy exam so that Wanda could hear from a physician that she was not pregnant. That had to work!

The next week Wanda came back from her pregnancy test just beaming! She told everyone that she had been to the doctor and was happy to announce that her kitten was doing fine. In fact, she had even spotted a few whiskers during the pelvic exam. The group began planning a kitten shower and, under some pressure, I agreed to contribute a litter box. The nurses cried with laughter when I told them about the kitten shower my group was planning for Wanda. They had learned long ago not to argue with Wanda’s delusional beliefs. Apparently, I was not the first intern who had tried to get her to engage in “reality testing.” Wearing a sympathetic smile, one of the nurses suggested that I might have bumped up against the limits of psychotherapy.

We run into irrational beliefs all the time. The chronic alcoholic client will insist he can drink in moderation; the emaciated anorectic client will adamantly claim to be obese. Rather than feeling compelled to impose your reality, sit back and discover what the world looks like through their eyes. Be patient and understanding. As most people go through the process of therapy, they steadily reevaluate their beliefs with gentle, strategic, and well-timed doses of reality. As Wanda demonstrated, “in your face” reality testing doesn’t always work. Even very delusional clients often realize that their reality differs from yours. Your empathic availability may do more to bring them to consensual reality than any rational argument, and it will protect you from feelings of frustration that may be counterproductive.

Instead of trying to impose my reality on Wanda, I needed to learn that, despite her mental illness, she desired to be loving and nurturant. Wanda was coping with other realities – – separation from her family, getting older, and never having children of her own. Her needs to nurture and be fulfilled as a woman were the eventual foci of therapy, as they should have been from the beginning. She needed to take her medication on a regular basis, so she could be home with her family, and her family needed to know how to care for her illness. Perhaps now I would have started therapy by going to the animal shelter and getting Wanda a kitten.

Don’t Forget a Client’s Strengths

After you’ve spent years in classes focusing on abnormal psychology, diagnosis, and treatment, it is easy to see pathology in every action and behavior. But, as Freud suggested, not every cigar is a phallic symbol. Because people are coming to therapy for their problems, it is easy for both client and therapist to get tunnel vision and forget to see the positive aspects of their lives. If your client has struggled with anxiety, depression, or trauma for a long period of time, they may have lost sight of the people, accomplishments, and good things in their life.

In your quest to diagnose and treat pathology, remember that every client possesses at least one strength. Whether that strength is a musical talent, the love of a pet, or a burning passion to ride motorcycles, it may boost self-esteem or motivate change. A desire to see lions in their natural habitat–or to show up a high school counselor who said they would never amount to anything-can be used as leverage to take on new challenges and inspire new behaviors.

Describing resources and strengths may help to put the problems you plan to focus on in perspective. Keep in mind, however, that this needs to be done with great care. You run the risk of having your client think that you are not taking their problems seriously and that you want to avoid their negative feelings. They may actually have a point if, based on your discomfort with their troubles, you try to steer the therapy in a way that communicates to them “just look at the bright side” or “keep a stiff upper lip.” With this caution in mind, try to balance your attention to “problems” with attention to “strengths.”

I have been pleasantly surprised on a number of occasions at the positive results I’ve gained from encouraging (and sometimes even harassing) clients into describing their strengths. I’ve found that encouraging clients to review their past accomplishments, positive relationships, interests, hobbies, and passions will actually lift their spirits. Having them reconnect with activities of interest as soon as possible in the process of therapy can also enhance their receptivity to what is focused on during sessions. When people feel sad and guilty, they often deprive themselves of positive experiences. If you prescribe these as part of the therapy, they may feel less guilty about doing them and rationalize their enjoyment as “doctor’s orders.”

Attending to Attachment in the Treatment of Incarcerated Women

Posted on by Psychotherapy.net Team

It was a sunny August day when I took a brisk walk across campus to get to the part of the facility that housed the incarcerated women with whom I would soon be working. I remember feeling fully ready for this new endeavor and eager to have a new clinical experience. As I entered the facility, waiting to be buzzed in through the double locked and heavily-reinforced doors, I immediately noticed how bustling the unit was. Looking around, I saw women hustling to their textile-industry jobs, rushing to their various group rooms, meeting for education classes, and heading outdoors to play volleyball. Taking in all of these varied activities, I became poignantly aware of one of the obvious similarities among the residents—most of these incarcerated women were of child-bearing age.

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In my clinical experience with incarcerated men, I have worked with some invested fathers, but the theme around children has tended to be less pronounced than it has been when working with their female counterparts. With the women, I conducted more grief and loss groups than I ever had before, with waitlists that never seemed to get any shorter. In those groups, I became immersed in the nuances of the lives that lead women to lose their parental rights. My heart broke for these women who found themselves in the position where they were perpetuating family traumas despite their best efforts not to.

Jillian, I will call her, was a woman similar in age to myself, whom I worked with up until her release. She and her child’s father both struggled with substance use, having been consumed by the nation’s opioid epidemic. Jillian came from an impoverished family in a rural area that was severely under-resourced, often having to make the decision between paying the electric bill or being able to afford prescription medications. Jillian was very candid that she used illicit drugs, but that she was drawn to selling them because doing so was a direct road to fast money, which in turn allowed her to provide for her daughter in a way that she had not been provided for herself. Jillian and I would meet weekly in sessions that almost always focused on her daughter. She was fortunate enough to have her daughter reside with a family member rather than lose custody of her, but in essence, she was one fragile relationship away from losing that precious custody, and that weighed on her like a boulder. I remember one conversation in which Jillian shared, “I’m so worried about my mother. She doesn’t have enough money for gas, her prescriptions, and the heating bill. If she doesn’t get her prescriptions, she will get sick and could end up not being able to take care of my daughter. If she goes to get the prescriptions, she won’t have money for both that and the gas to get there.”

Jillian is but one representation of the near-constant fear that incarcerated mothers experience. If they have a sentence longer than 15 months, it is completely likely their parental rights will be terminated, and most sentences for drug offenses, which are often non-violent crimes, typically carry more than 15 months. Pair this with the glacially slow legal system which leaves women like Jillian in limbo, waiting for their sentences to be assigned all the while knowing the custody of their children is at risk.

If you are both a therapist and parent, the following is likely not difficult to appreciate. In my clinical experience, mothers who lose custody of their children are at risk to reoffend because they lose what is very often their entire sense of purpose. Oftentimes, although women such as Jillian use and sell drugs—which is obviously an unsafe atmosphere in which to raise children—they engage in far less risky behavior than if they were childless. Not uncommonly, the women with whom I have worked in correctional custody have been victims of human trafficking, sometimes even prostituted by their own family members while adolescents. Many of them grew up in poverty, having experienced horrific abuse, multiple pregnancies, school dropout, addiction, and the absence of their own parents, who were often imprisoned.

To highlight the dark hues of this already bleak picture, I remember a client I will call Mary-Beth, who took a five-year sentence rather than accepting probation so that she would have a chance of being able to spend some quantum of time with her mother, who was also incarcerated and would be released within nine months. Mary-Beth had her own daughter at home, but this did not waive her choice to take a prison bid over probation, because she was that entrenched in trying to have an interaction with her mother.

It has been relatively easy for me to see how the patterns of familial and often multigenerational trauma have played out in Mary-Beth’s life, and the lives of other women who have desperately tried to salvage their parental identities and bonds while behind bars. Had Mary-Beth not spent her childhood chasing her mother out of bars, waiting in cars in the dark while her mother turned tricks, or watching her use substances in between prison bids, Mary-Beth might have been able to develop an identity grounded in secure attachment that could have protected her from imprisonment and resulted in a tangible, rather than ephemeral, relationship with her own child. Now as a young woman, she is perpetuating the same scenario she experienced in the past with her own daughter, which inescapably manifests in pathology around abandonment and paves a direct route to addiction high-risk relationships and self-destruction in seemingly futile attempts to fill the void left by disrupted attachments.

***

I learned more than I ever would have thought possible from this clinical work with incarcerated women and mothers. Whenever possible, I work on parenting skills and psychoeducation around attachment theory with these clients so that together, we prioritize maternal and self-care skills they can utilize upon release. The additional work of helping promote mother-child bonds, even from behind bars, is critical in helping them break the vicious cycles that will inevitably undermine the attachment security of future generations. The last I heard, Jillian had completed her probation, maintained a job in the community, and was upholding her parenting responsibilities. She seems to be one of the lucky ones, and the implications for her daughter will hopefully be tenfold. The next chapter in Mary-Beth’s story is yet to be written.

Encouraging Clients to be Preventative

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Stephen Covey, author of The 7 Habits of Highly Effective People, said in his book, 

Look at the word responsibility—“response-ability”—the ability to choose your response. Highly proactive people recognize that responsibility. They do not blame circumstances, conditions, or conditioning for their behavior. Their behavior is a product of their own conscious choice, based on values, rather than a product of their conditions, based on feeling.

Covey is not a psychotherapist, but as a therapist I find it beneficial to take a page out of his playbook. I encourage clients to assume a proactive stance when it comes to the challenges they may face in life. I do this in a sober-minded manner, not sugarcoating the fact that they will indeed face hardships. In my own practice, I’ve found that upon hearing this uncomfortable message, clients find hearing the truth spoken ennobling, even if it hurts. Clients bring an abundance of untapped strength, fortitude, and resilience, which can be accessed and drawn forth in therapy, a fact that motivates me to candidly share with clients that problems only get worse when ignored. My goal is not to be obvious or annoying, but to lovingly embody the role Socrates played, to be the gadfly in the ointment; to assume the role no one wants to play, the bearer of bad, but truthful, news.

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Out of a sense of compassion, I ask my clients to directly face those ignorable “what-ifs.” In the absence of a plan, in the absence of daily health-promoting routines and rituals, what will happen if a client misses too many days of work? What will happen when a client’s spouse finds them drunk again? What will happen when a client forgets to pick their kid up at school once again? What will happen if a client consistently shrugs off opportunities to support their closest friends? Clients may rationalize and answer that yes, they are prepared to face certain contingencies. But when a problem is up close and personal, I’ve witnessed client after client ignore and avoid problems at all costs. Why do clients do this? Despite my best efforts, clients manage to play out the same pattern of avoidance, over and over again. Don’t get me wrong, I understand that clients are scared. To admit their marriage is struggling, to acknowledge their addiction is out of hand, to recognize their imperfect parenting, to confess their social shyness is causing isolation and loneliness, is truly terrifying. Facing a problem comes with the necessity of change, so, it’s easier to pretend like the problem isn’t there. I see this fear manifest in clients in one way or another, but I see it most clearly with couples.

In my experience based on the clients with whom I’ve worked, and in discussion with colleagues, couples tend to engage counseling services six years after the problem has been going on. Six years! That’s a long time to live with a problem. That kind of time allows resentment, bitterness, and hurt to accumulate to the point of no return. Neurologically speaking, allowing a problem to go on like that creates reinforced neural pathways that are hard to rewire. Relationally speaking, permitting a harmful relational pattern to persist unabated leads to irrevocable harm to intimacy, trust, and communication. So what’s the solution? How can I navigate this and motivate my clients to nip a problem in the bud? My way of approaching this issue is to encourage clients to be preventative, to seek a solution when the problem is in its infancy.

For example, couples who proactively work towards solutions before problems have reared their ugly heads make a commitment to attend maintenance sessions with a therapist once every few years or sooner. They do this habitually not because of a crisis, but because they want to make sure they are on the right track. That’s the ideal scenario, but not every client is at that stage. To get my clients thinking along these lines, I ask clients to take a moment and reflect on the fact that they see a dentist every six months for a cleaning. Why should they attend these appointments if they aren’t experiencing any dental problems? If you don’t have a toothache, why go? I usually get a range of answers, but the theme is usually prevention. It takes little effort to understand the benefit of preventing physical issues, but this logic fails to map onto mental health. So I gently nudge my clients to consider the logical contradiction, asking them to be consistent and apply the same logic to mental, emotional, and relational issues.

The alternative to being proactive is being reactive, I explain to clients. Reactivity, as I have observed over the past several years of doing clinical work, is defined as jumping to conclusions, being on the defense, only seeking solutions when problems are reeling out of control. In other words, it’s a bad strategy that doesn’t work, and it’s no way to live your life. I make the case to clients that if they are being reactive, they are only adding to the problem instead of working towards a solution; reactivity compounds problems. It is so much easier to fix a problem before it starts or in its infancy, instead of when it’s lingered, done damage, and been compounded by time and resentment.

I remember working with a mother and son who lived in a small apartment in the rough part of town. Their relationship could be defined as challenging. Mom fought the urge to not feel disappointed, but she felt like everything her son did made her mad. She was angry at him for getting poor grades, hanging out with the wrong crowd, playing too many video games, and getting into fights at school. She found that it was easier to be mad at him than to look at her own behavior and examine the reasons why their relationship had gotten so rocky. Keeping the focus on him kept the focus off her. Deep down, she was terrified to look in the mirror and acknowledge how her past and present actions had affected her son. I cautioned her that if things didn’t change between them, his behavior would likely worsen. I made the case that she had to come to the table and work on herself and the relationship before having any expectation of seeing him shape up. Despite my urging and pleading, I couldn’t convince her to let go of the blame and evaluate her behavior. Over time, the strain on their relationship grew too strong. He decided to move out of his mother’s apartment, drop out of high school and live with a friend whom she felt like was a bad influence. The day he left, they didn’t even say goodbye to each other.

***

So I urge you to encourage your clients to avoid living a life of reactivity and instead, to adopt a proactive, solution-seeking, adaptive, contingency-based, response-ability mindset towards current and future problems. You will find that when they do, they will be happy, and you will feel gratified.

Excerpt from: The 7 habits of highly effective people: Powerful lessons in personal change (25th Anniversary Edition). Rosetta Books.

Healing Wounded Images of Self and God

Posted on by Psychotherapy.net Team

Carl Jung famously reflected that many of his older patients suffered due to disconnection from religion and sought to find or re-establish a spiritual outlook in later life.

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Grace was 103 years old and living in a rest home. She was referred to me for psychotherapy for possible depression. “You know what it’s like to be 103,” Grace said.

“You’ll have to tell me what it’s like,” I responded.

“I don’t know if I’m depressed or not, I just can no longer do all the things I love. I love to read but my eyes are bad, and my fingers can’t hold a book or turn the page,” she said and held up her fingers gnarled by arthritis. “I always did needlework, knitting and crocheting, but look, I can’t do that anymore.” Using her walker to get to the bathroom was a slow and painful excursion for Grace because of her arthritis.

“I do have something I want to tell you, but I don’t want you to think I’m crazy,” Grace said. “I have a vision, it’s the same thing over and over, and it’s not a dream—it happens when I’m awake, like this, sitting up in bed. There is an old man standing in my door, and he slowly shuffles to the foot of the bed, and in a deep voice that sounds like it’s coming from under the earth, he says, ‘We have to get together in the midst of this pain and work it out.’ Well, this same thing keeps happening again and again,” Grace explained.

Grace had earlier referred to her history of religious faith and her current questions. I inquired further about her beliefs and doubts. She had always been a person of faith, yet now she felt inadequate and unlovable because she could no longer be the active and productive person she had previously been. We explored what the visionary experience might mean for her if she considered it in light of that cluster of feelings and thoughts. Perhaps she might come to consider that God was mirroring her current pain and asking to be close to her in its midst, and to allow that, rather than judging and dismissing her worth. This might be the solution to her troubles. With that understanding she suggested, “I think I’ll be okay now, Tom, I don’t have to think I’m no good just because I’m not like I used to be.”

Larry was 74-year-old who had spent the last three years in a nursing home. He was nearing the end of his life and was dreading it. He was born with a deformed hand. He said his father had been alcoholic and abusive. Larry both loved and hated his father. During nearly every psychotherapy session, he made comments about hating God. If his earthly father had been so cruel, how could he trust a heavenly father? Psychologically, he could partly hold onto the affectionate side of his father-conflict by projecting the hurtful side upward.

“But I did see the light one time, Tom,” he said. Larry had been scuba diving, doing restoration work beneath a large ship—and he became stuck, ran out of oxygen, and knew he was about to die. “Suddenly there was a beautiful light all around, and I had never felt better in all my life, and I was loose, and I came to the top.”

“Did that change any of your thoughts about God,” I wondered?

“Aw, no, I still hated God; but I did see the light two more times.” Larry went on to describe two additional near-death experiences, with bright light and peaceful feelings—but he was not able to consciously draw comfort from those experiences as he neared the end of life.

Chris was a 64-year-old resident in a nursing facility, and in one therapy session shared an essay he’d written about mental illness and religious faith. “In our struggle with schizophrenia, we have much to contend with. The many highs and lows, confusions and crises in the life of a schizophrenic. We try medication, psychiatrists, and the like. These work to a degree, but are not something that sustains you or makes you stable. God is good for the mentally ill. The only concern is we have to be careful not to confuse spirituality with our mental illness. Mental illness makes it difficult to believe in God. We are so confused and not sure what to believe anyway with hallucinations and such. God is aware of this and He knows the plight of the mentally ill.”

Ah, but there’s the rub—how to distinguish mental illness from spirituality? Certainly, some persons with a mental illness do confuse the two. So what might be characteristics of a wholesome religious outlook versus psychopathological distortions? The unhelpful and pathological elements may be characterized by fear, anxiety, avoidance, grandiosity, aggression, subjective idiosyncrasy, irrationality, and hatred. Whereas productive and encouraging spiritual viewpoints might include humility, patience, peace, insight, fortitude, and may be conventional, doctrinal, rational, and foster love.

***

I have worked with many thousands of clients over my 40-year career, the great number of whom have passed away. For many of these clients, facing death was always more distressing for those lacking a religious outlook. Many of them, as well as my current clients of all adult ages, have also struggled to endure disability, and/or chronic pain, or past trauma, and sometimes profound loneliness. When asked how they survive, and where they find encouragement, the common response has been—“God.” It has been quite rare for someone to disavow all questions of religious faith; more commonly, these individuals struggle with unexamined doubts and spiritual conflicts associated with past relationship issues. We often hear the phrase “the fog of war,” referring to the challenge of sustaining clarity during moments of danger and chaos. Many of my clients encounter a fog of faith as they grapple with spiritual doubts made worse by illness and isolation.

The unanswered questions and doubts are invariably present and may be withheld if I don’t notice or respond to their indirect emergence. I find that I can aid the conflicted client in their quest for new perspective, for a renewed outlook that might offer them meaning and hope. Faith was regained for Grace when she humbly allowed God’s comfort to overtake her fears of being unlovable due to infirmity. Dozens of my clients have reported near-death experiences, and all of them described spiritual comfort and a dissolution of their fears of dying; all, that is, except for Larry, who had been wounded too deeply and too early in life. Chris had a major mental illness, but also a vibrant religious faith and the wisdom to understand the need to keep each as distinct as possible.

In psychotherapy with these clients, I have followed the lead of the spiritual symptoms, signals, questions, and comments, and helped them to sort through possible distortions in order to create space for a life-affirming and personality-broadening outlook on our shared existential challenges regarding illness, aging, and death.
 

The Challenge of Retirement: Finding Meaning and Self-Esteem in New Ways

Posted on by Psychotherapy.net Team

The Ground Shifts

I retired twice, almost 20 years apart. The first time was the hardest. For almost a year, I missed everything and everybody who was part of my professional world, including the cleaning lady and the postman with whom I had daily chats. Because so much of my identity was tied up with my professional role as a psychologist, I felt totally lost when I left my university position as director of the counseling center. The phone seldom rang, no one seemed to need me, and I was left with a huge hole in my self-esteem. Traveling, while fascinating and worthwhile, couldn’t supply what was missing.

Fortunately, after nearly a year of feeling like I was wandering alone in a desert, I got a phone call from the university asking me to serve as acting dean of students for a year while they conducted a national search for a permanent dean. I accepted gladly and without hesitation. And the following year went by quickly with many challenges and accomplishments. I loved the job! It represented a perfect blend of clinical skill in dealing with students, professors, and college deans, and academic know-how, that is, how to navigate the academic environment.

But the year ended, and I was plunged into retirement once again. This time, however, I was much better prepared. I decided to expand my very small private practice, seeing individuals and couples, and began a twenty-year career working solo in a downtown office in Chicago. Once again, life was fulfilling, but as I began the decade of my 80s, some minor physical difficulties made a second retirement seem wise.

After this second retirement, I began asking myself what I had learned after more than 50 years of clinical practice. I had worked with different ages, races, cultures, sexual orientations, socioeconomic levels, and professions. In the mix of clients over the years were a 9-year-old pickpocket with a wide, girlish grin that lit up her face; a slew of lawyers, a number of whom were suicidal; a circuit court judge with family problems; a few physicians trying to resolve their romantic lives; a beautiful, light-skinned, African-American model who was rejected by her family for not having dark enough skin; a 15-year-old boy who accidentally shot and killed his brother; alcoholics of all kinds, and a politician running for statewide office whose wife accused him of domestic abuse. While such differences in descriptive trappings may seem profound, what stood out for me were their common ingredients.

Among the settings I worked in were mental health clinics, psychiatric hospitals, a home for delinquent girls, medical schools, private practice, and universities. In these diverse places, I performed many different functions, such as teaching, administering tests, directing programs, supervising students, and counseling individuals as well as couples. I worked on the East Coast and the Midwest; in small towns, medium-sized ones, and big cities; in small clinics as well as giant hospitals that stretched over many miles. In all these varied worlds, no matter the differences in local culture, skin color, tattoos, and garments, I found that people are more alike than different.

Besides the obvious physical similarities, I, along with many others, have realized that basically all of us have the same kind of needs, fears, defensive strategies, hopes, and dreams. Over the years, this became clear across all the varied roles I played, whether with administrators, students, colleagues, students, or clients. While everyone has a different viewing lens for perceiving the world that is shaped by unique biological, familial and cultural factors, we are fundamentally the same. We all want to be loved, appreciated, and understood. We want to matter to our friends and family and be special in some way to all those with whom we come in contact. We want to be self-sufficient and competent. We want space and time to be autonomous in pursuit of our own dreams. We want to belong to a group, neighborhood, church/synagogue/mosque, or community—a place of welcome and acknowledgment. All of us want to feel safe in the neighborhoods in which we live and to be reasonably stress-free. We also want some challenge in our lives, that is, some novelty to reduce the boredom of ordinary days. And we want to feel good about ourselves; we want to walk around with our heads held high and a liveliness in our steps.

People everywhere are afraid of the same kinds of things. We are afraid of being assaulted, either physically or verbally. Because both physical and psychological dangers are threatening (one to our lives and the other to our identity), both kinds of peril create fear, tension, and anxiety. Contrary to the old childhood rhyme we used to chant, “Sticks and stones may break my bones, but names will never hurt me,” names, especially the insulting ones, do hurt a lot. So do betrayal, bullying, humiliation, manipulation, and rejection, all of which bruise our fragile sense of self.

We are also afraid of having our inadequacies and our failings brought to light. When we are teased, taunted, or made fun of, our imperfections are made visible for all the world to see. We feel exposed as inadequate in some way and feel vulnerable; we are not as strong, smart or “in control” as we would like. Because vulnerability is scary and psychological assaults hurt, people develop fears about these threats and build self-protective mechanisms to feel safe.

Trying to be safe, we may hide in our rooms or in our heads, lie to ourselves or others, counterattack in person the assaulters or assail their carbon copies, keep others at a distance by obnoxious behavior, or pretend we are very talented, wise, good-looking, or famous. The hiding can be literal, as when a teenager spends all her free time in her room, or symbolic, as when a doctor, lawyer, or engineer keeps his personal self out of sight and remains ensconced in his professional role. Rather than acknowledge hopes, dreams, failings, and inadequacies to close friends and family, the professional recluse relies primarily on his work-related skills to navigate erratically the world of intimacy and relationships. In this manner, he hides from his vulnerability and winds up feeling safe and in control.

Hiding in our heads is a way of viewing the world from a vantage point above the fray. We can think all kinds of negative thoughts there, and nobody is the wiser. In this space in our heads, we are safe from counterattacks and free to be ourselves. Intellectuals, writers, academicians, and other creative souls are often in this group because thinking feels a lot safer to them than feeling. Emotions are often intense, chaotic, and unpredictable, whereas thoughts tend to be logical and manageable.

Other ways of hiding include addiction to computer games. There, ensconced in technology, we avoid the unpredictable world of people by focusing on dragon-slaying and war games. In that way, we maintain a pseudo-connection to others through computer identities that do not risk much vulnerability and yet satisfy our desires to be winning and in control. Addictions of all kinds are reliable hiding places, which often last until physical dysfunction appears on the scene.

Other protective strategies include power-hungry maneuvers such as boasting, bellicose rants, and dictatorial strategies. Braggarts fill the conversational air with their accomplishments in hope that no one will notice how empty they feel. Similarly, the bully and the dictator try to convince their worlds that they are powerful when, underneath it all, they feel helpless and insignificant. Angry, belligerent people who are adept at keeping people away are more comfortable with solitude because closeness to others is fraught with emotional danger. Being betrayed, criticized, disappointed, insulted, and/or rejected are just a few of the perils they try to avoid.

While all the preceding observations have been underscored many times in my clinical and personal worlds and written about elsewhere, several new insights have emerged from my experience, some of which are counter-intuitive. Some are different from those in the psychological literature, and others run counter to the prevailing culture in the US. Since I love to write, I decided to write a book of essays that focused on my clinical experiences and the new understandings gleaned thereof.

Positive Thinking

One of these new insights contradicts the American culture’s focus on the power of positive thinking. In contrast to this popular notion, I think it is safe to say that positive thinking is not always helpful. Platitudes (trite remarks used too often to be interesting or thoughtful) and happy talk do not prepare us for disasters lying just ahead. Every cloud does not have a silver lining, nor is there a pot of gold at the end of every rainbow!

Because the world is filled with all sorts of unhappy events, from disappointments and failures to losses, thinking only positive thoughts is delusional. Trying to maintain a happy face while tragedy engulfs us is unnatural, akin to trying to laugh when our hearts are breaking. Like Pagliacci, the clown who was intent on making others laugh while tears streamed down his cheeks, we shortchange ourselves when we fail to deal with negative events and emotions. For many patients who do not process their negative feelings at the time of a disturbing event, the failure to deal with these emotions may, and often does, lead to symptoms such as anxiety and/or depression. In addition, when positive thinking bypasses the processing of negative events, it can limit problem solving and result in impaired judgment about courses of action.

I have found that whenever there is heartbreak, no matter where it is coming from, the best way of getting through it for most of us is by acknowledging the sadness, disappointment, humiliation, or anger, and then working through it. In a healthy person, the processing of negative feelings goes through phases, much like the waves of emotion that accompany grief, until there is a personal resolution that uniquely fits the person. The problem arises when people get stuck in negativity and can’t move beyond it, which is where positive thinking and therapeutic strategies may prove useful.

Direct Expression of Anger

Another psychological reality that is infrequently articulated in the psychological and popular literature was dramatically conveyed in a few words by a patient. It jarred me when I first heard it. After weeks of catatonic behavior followed by a psychiatric hospitalization, a 40-year-old man intoned, “Madness is better than sadness” as his first words upon recovering. When he was asked what he meant, he responded, “When you’re mad, you can do something, but when you’re sad you can’t do anything at all.”

At this time in our culture when violence permeates the American scene in so many ways—there is video violence, domestic violence, street violence, school violence, and workplace violence—it is difficult to see how madness can be better than sadness. However, what the patient was communicating clearly was that anger is energizing and leads to action, while sadness is immobilizing and induces helplessness. Most of us would prefer to feel alive, in charge of our lives, and full of options, rather than depleted, stuck, and without possibilities. Discerning when and where the direct expression of anger is adaptive and when it is destructive would be beneficial to all of us.

Romantic Love

Another cultural misdirection is our obsession with romantic love. Via scores of dating sites flourishing on the Internet, we run blindly toward the Promised Land of Eternal Love. We buy romantic novels, read manuals devoted to orgasmic ecstasy, and watch sophomoric movies filled with hormone-saturated teenagers groping their way to fulfillment. And yet, all this cultural energy devoted to its arousal and maintenance does not alter the reality that romantic love (sexual feelings and emotional closeness) is ephemeral. Because it is fueled primarily by fantasy, novelty, and emotional arousal at the time it develops, romantic love is almost impossible to sustain. Unless it is replaced by a quieter respect, admiration, affection, or commitment (or has some of those ingredients to start with), romantic love quickly dies, fading away in the light of reality.

Vulnerability

Another idea that has emerged for me over the years is that vulnerable people are easier to relate to than assertive, self-confident ones. Vulnerability is an openness about feelings, successes, failures, strengths, inadequacies as well as hopes and dreams. While our society imbues self-confidence with high status and desirability, and the trait is clearly invaluable, vulnerability is more appealing and more likely to foster intimacy. Vulnerable people are more readily trusted (we know where they’re coming from), nonthreatening, and likable, whereas super-confident individuals earn our respect and admiration. We look up to confident people (they are our role models), but we are less likely to regard them as good friends.

Control

Other new counter-cultural understandings gained over the years include the following: One can’t control reasonably healthy people against their will without their feeling resentful. While punishment and torture work to some degree, they tend to create long-term resentment that manifests itself in sabotage and/or other passive-aggressive tactics. In addition, all of us possess a degree of autonomy that can’t be manipulated under any circumstance.

This powerful realization came from a testing case where I was to administer a battery of tests to a 15-year-old who had accidentally shot and killed his brother. As soon as the young man walked into the testing room, it was obvious that he was in no mood to be evaluated. He sat on the floor with his arms folded across his chest and refused to answer any of my questions. I tried everything I knew to reduce his defensiveness, but nothing worked. So after about 45 minutes, I gave up and started to pack up my testing paraphernalia, saying, “It is clear that I can’t make you talk to me,” as I stood up to leave. At this point, he asked, “What do you want to know?” and became fully cooperative with the evaluation. What changed his mind? Apparently it was his realization that he was in control of cooperating and that I couldn’t make him do anything.

Luck or Chance

Luck or chance have been badly underrated. And yet much of life (genes, parents, family, schoolmates, friends, teachers, roommates, romantic partners, jobs) is a function of timing and chance. Hard work and talent play significant roles in our achievements, but luck or chance is at least as important, if not more so at times. Whether or not we get accepted into our preferred college, get the dream job we always wanted, or win a particular sports event is dramatically affected by the other competitors and the biases of the decision-makers in that situation. Unless we accept that reality, we are likely to take too much credit for our accomplishments and too much blame for our failures, leading either to false pride or undeserved self-depreciation.

Other Insights

Other insights I have had over the years include the idea that healthy narcissism is quite different from the pathological variety. Healthy narcissism embellishes personal achievements with delight and enhances lovability with charm. It provides the joie de vivre—the joy of living—that adds just the right amount of zest to ordinary life. And finally, empathy, the most important of the relationship skills, enables us to relate to others with care and compassion, providing self-esteem enhancement that is deep and durable. It helps us develop friendships and maintain romantic relationships over the long haul.

In all, I am far wiser than I was when I began this journey of enlightenment, although it didn’t begin as such.

Psychotherapists Do Not Cry Here: Hope During the War in Ukraine

Posted on by Psychotherapy.net Team

Alina

Over the last few days, she has slept and eaten very little. She advises her audience to see the bright side of everything. “I just discovered that I have cheekbones,” she says with a sense of unanticipated pleasure. Her voice is otherwise quiet and calm, with slow, thoughtful tones that strike a peaceful chord in me and no doubt the rest of her audience, like a friendly and familiar echo. Her name is Alina, and she is a fellow psychotherapist who works in Ukraine. Though her face reveals neither panic nor despair, there is something more profound and deep about her that hints at fatigue and sorrow, but also of hope.

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Alina webcasts live every day in order to support her people. To support those who need to be in the presence of a kind and compassionate face in the midst of pitch-black darkness. You can almost feel the touch of her cold hands, which she desperately tries to warm by clutching a mug of hot tea. “You need to drink a lot of water, friends, it helps to fight against the stress,” she says, while at the same time listening to the sounds of regular explosions, whose proximity she tries to determine in order to decide whether to rush to the nearest shelter. In her webcast, Alina is “ready to take tender care” of any suffering soul, regardless of nationality or current place of residence. “Please just don’t swear in the chat. Everyone is suffering right now. I understand all of you, but please let’s love and take care of each other,” she says so gently, as if she is gently stroking each one in her audience.

Mikhail

“I don't know what to talk about…,” Mikhail, my own client, says after a long pause. And along with the words, tears that were just moments before frozen within him melt and cascade freely. Yet he cries in complete silence. His face is twisted by pain and horror. But I can see by the position of his neck, shoulders, and arms that something inside of him has been released, opening a space which later may be filled with something other than those tormenting feelings. Three days ago, he found out that his only son had died in Kharkov. From that day, he has known nothing of the simple comforts of sleeping, eating, or any other “normal” part of his previous life. He only knows that his child was killed. “He… was… ki-i-i-illed… killed…” Again, a speechless yet deafening grief which starts my own hands trembling, so I hide them away from the screen. “What would I do if Mikhail was actually sitting right in front of me?” a thorny voice echoes from deep within me. Mikhail blames himself. It was he who left his child in Kharkov several years ago when he moved to Moscow for work. It was he, the father who could not protect his son. It was he who did not die in place of his son.

Long before I became a therapist, my own great-grandmother told me how she had survived the orphanage, World War II, the evacuations, tuberculosis, breast cancer, and her only husband by 50 years. She was the most cheerful and resilient person I have ever known. She always had something to tell me, something to share. However, she almost never talked about the war, only briefly mentioning it. Whenever I cried over some trifle, she would look at me in surprise with her gentle blue eyes and admonish: “Why are you crying? Has a war begun? No. No reason to cry, then, right?” “Okay,” I remember thinking at the age of seven, “should the war start, I’ll cry then to my heart’s content.” That calmed me.

Now I can't cry. During the worst of my life’s upheavals, I have never cried. This has helped in my work. Who needs a tear-stained psychotherapist?

Alina

While Alina's voice sounds more subdued over the following days, there is an increasing power in it. She sniffles but does not cry. Maybe it’s just a cold. Alina will not leave her homeland. Ukraine is her home, this is where her family is with whom she will stay to the end, and “this is not a subject for debate.” Alina promises to go live whenever possible. This is how she chooses to create, or perhaps re-create, the world around her. And there are more and more participants with each of her webcasts, which means the boundaries of her world are getting wider, rather than smaller. This is her contribution, her mission. Over the ensuing days, it seems harder for her to choose words, but they are becoming more precise, and her message is becoming clearer. “Take care of your loved ones, hug them, take care of yourself.” It is amazing how much sense shapes these simple messages. “Do your everyday routine, physical exercise, drink herbal teas.” During one of the live chats, someone asks, “Do you drink tea with or without sugar?” Alina replies, “I drink mine without sugar.” Suddenly, her eyes widen and twinkle as she says, “You know, the most delicious tea is served in trains! There it is served with sugar and lemon. I normally don’t drink tea with sugar, but I just love that one they serve on the trains! You are traveling somewhere far, far away with your tea in tea cup holders…” It is not only the Ukrainian audience that is warmed by the cordial human flame that is Alina. This flame spreads well beyond her Ukrainian audience. By the end of the nearly two-hour webcast, someone who is not from Ukraine suddenly calls in and says, “It is we who should support you, not the other way around.” Alina shrugs it off and sends air kisses.

Mikhail

Again, Mikhail doesn't know what to say. The pauses are the longest we’ve had in our sessions. I hear my heart pounding in anticipation of what he will say. Even through the screen, I seem to be able to hear his heart as well. I follow his chest as he slowly but rhythmically draws in and then out. It seems labored and pained. I know from our work together that he needs a doctor and medicine. But right now, he is here. And I'm here with him. I feel the urgency of helping right here and right now. “And you are,” an inner voice confirms that I am, indeed, already helping. Although I am a cognitive behavioral therapist as a last resort in the most difficult situations, I reach far up my sleeve now and pull out what I believe will be the most useful therapeutic offerings—trance techniques, light hypnosis. Slowly and carefully, I calibrate my voice and tone. I follow his facial expressions, his posture. It is as if I am conducting open-heart surgery. He starts following me. Or perhaps it only seems so to me? No, he is definitely following, his eyes are closed, his lower jaw has slightly slipped down. Good. We go ahead.

That 60-minute session with Mikhail seems to last for weeks. Towards its end, I ask him about his feelings or whether he has anything he wants to say. “When I closed my eyes, I saw his face so clearly, as if he was standing in front of me. I was asking for forgiveness; asking again and again.” At that very moment, Mikhail’s face falls below the sweep of the camera, and he quietly slips away from view. My hands shake, but this time, there is nobody to hide them from. After an instant, I see Mikhail's face again on my screen. He says, “…and you know what? He forgave me, my son forgave me.”

Alina

Alina did not go live today. In the chat, she hurried once again to calm everyone in her audience. “Don't worry, my friends, the connection is acting up. But know this! I believe we will all meet in person in some wonderful place and hug each other.”

Russian Shame

Posted on by Psychotherapy.net Team

The Russian invasion of Ukraine muted me for several days. Shame has a powerful silencing capacity. The words with which to talk about this war come to me in English and not in Russian, my mother tongue.

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I spent the first weekend after the Russian invasion of Ukraine with two Russian friends (things are not that straightforward, one is actually better described as an American Jew and the other as a half-Ukrainian, half-Russian living in France) and one of their children. Their car still has Russian plates, and as they stopped to refuel, an Eastern European truck driver approached them to insult them for being “Russian murderers.” They had to rush away, mostly to avoid scaring the children any further.

As he recounted the incident, my friend was hiding his eyes; his shame was palpable. His pain resonated with me, amplifying my own. Walking in silence on the windy Normandy beach, we looked at the reddish sunset, which evoked for us the cruel bloodshed taking place in Ukraine. In the evening, with a glass of wine around the fireplace, we talked. Before leaving, one of them went out in the night to put white tape above the small Russian flag on his plates. His hands were shaking as he came back.

“Dogili—this is what we have come to,” he kept repeating, his whispering sounding like sobbing.

His young son was incredulous, confused about his father’s meddling with the car plates. He did his best to explain, avoiding his son’s inquisitive eyes.

“I am terrified about him being bullied at school,” he whispered.

When my friends left to return to their lives, shattered by the consequences of this pointless war, the house felt empty. In the silence, the question of the highest dramatic order resounded within me with a sense of great urgency: Who am I in relation to these events?

Even though I left Russia more than two decades ago, in the eclectic construction of my emigrant self, the ‘Russian me’ has been a structural and defining element. Even if other multiple self-narratives have developed over time, sometimes taking precedence over the original simpler version—the ‘me-therapist,’ the ‘me-mother,’ the ‘me-French,’ etc.… Today this foundation pillar of my identity has been undermined, sending my whole self into turmoil.

This is not the first time I have not exactly been proud to be Russian. My original place, like an abusive parent, keeps rocking my sense of self-worth, constantly tainting it with shame.

As a therapist, I do know that the emotional axis of shame and pride is central to the human psyche. I also guess that one of the secrets of Putin’s political success and longevity has been his promise to restore the greatness of Russia, give a sense of national and perhaps personal pride back to Russians—a pride of belonging to a great place. Rebuilding an empire is the easiest narrative trick that a politician can perform- to create and then dangle this alluring psychological carrot before the masses.

The days that followed the beginning of the war sent waves of shock through my life and my therapy practice. Some of my clients are Russian, and they are in disbelief. Some of them have been to street protests, some have just sat in their kitchens until the grayish Moscow morning, drinking and talking with their friends, sharing their confusion, their fear, but mostly trying to cope with their shame.

With their lives wrecked by the dirty war initiated by their motherland, they are wrestling with the immediate questions of survival, not only pragmatic but also psychological.

They will find different ways to cope with their humiliation. Some are leaving Russia in a desperate attempt to escape this feeling. Creating enough geographical distance can alleviate shame temporarily, but it never quite does the trick of entirely canceling it. The shame we were made to feel by our parents has the lingering power to transcend time and space and forever undermine our self-worth. This is what many of my emigrant clients wrestle with.

Russia will remain the pariah of the West and the world for the foreseeable future. We, the Russians living inside and outside of the country, will have to bear the shame of this situation for years to come. We can do very little to turn down the volume of this feeling, no matter how many Ukrainian flags we display on our social media feeds or either publicly or privately in our daily lives.

We will have to learn how to live with this shame, and if we listen to it carefully, we may gain a chance to do better, to learn from the terrible mistake of giving power to a monster, letting him take over our country, and use our language and our history for personal gratification, propaganda, and war.
 

Corrective Emotional Experience Is the Key to Therapeutic Effectiveness

Posted on by Psychotherapy.net Team

During my early training in psychotherapy, I was struggling to understand my role and what to say to patients. A wise supervisor introduced me to the term “corrective emotional experience” and said that once I fully understood its implications, my job would seem a whole lot simpler and I’d have much less trouble finding useful things to say to patients. He taught me that the main and unifying goal of all psychotherapies is to help patients have new and better experiences, both in the sessions and also in the rest of their lives. Such experiences could heal wounds from the past, change perceptions and attitudes in the present, and result in healthier behaviors and virtuous cycles in the future. Virtuous cycles are positive mirror images of the negative vicious cycles that so often grease a slippery downward slope for people with emotional problems. A virtuous cycle starts with a small corrective emotional experience which triggers a chain of other desirable experiences in a continuous cycle of improvement. An example would be where someone afraid of socializing screws up the courage to take a tennis lesson and gets invited to a party, which results in a new friendship, which makes it easier to approach other people socially in a variety of other social relationships, which improves job performance, which results in a raise, which increases confidence, and so on. This advice hit home, stuck with me, and has ever since guided all my clinical work and teaching. Corrective emotional experience is, I think, the best way to understand the mechanism of psychotherapy process and change—and also to integrate the bewildering variety of therapy techniques into one unified and harmonious psychotherapy. The process best explains the process of change as it occurs across all forms of psychotherapy. Sandor Ferenczi introduced this experiential way of viewing psychotherapy change in the 1920s. He was a master clinician who understood and made use of the healing power of the therapeutic relationship. His suggestion, radical at the time, was that emotional experiences in therapy, not intellectual insights, are the real drivers of change. As his student Sandor Rado would put it much later, “Insight alone never cured anything but ignorance.” It’s fair to say that Ferenczi, not Freud, had the most important influence on psychotherapy as it is practiced today. Freud readily admitted that he found clinical work interesting mostly as a research tool, necessary to build and test his theories of mental functioning, but was much less engaged in the human and healing elements of therapy. His patients were often disappointed, describing Freud as talking too much, too abstractly, and too didactically. In 1946, Franz Alexander (another of Ferenczi’s students) named and concisely defined Ferenczi’s theory of change: “The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.” In answering the crucial therapy question of how best to promote corrective emotional experiences, the first insight I have is that psychotherapy sessions are not all created equal. Change tends to occur in leaps, not in small steady increments. I have treated some patients intensely for years—with absolutely no discernable progress. In contrast, I have seen many patients for only fifteen minutes in the emergency room who years later said something along the lines of “you probably don’t remember me, but you said something I’ve never forgotten that changed my life.” This makes every patient contact an adventure, potentially ripe with opportunity, never routine. There is always the possibility of a magic moment in therapy—saying something that promotes a corrective emotional experience and sets off a virtuous cycle. We can’t expect magic moments to happen often, we can’t predict them, we probably won’t even know that they have happened—but we can and should always be alert for the potential and try to create favorable conditions through our relationship with the patient. While the unifying goal of all therapies is, or at least should be, to help patients have corrective emotional experiences, there are many different ways of getting there. Sometimes the corrective emotional experience comes from an insight that clarifies how the past is influencing the present or how unconscious conflicts are causing self-destructive behaviors. Sometimes it comes from changed behavior, such as facing phobic situations instead of avoiding them. Sometimes from testing and correcting cognitive distortions. Sometimes from emotional catharsis. Sometimes from a paradoxical injunction. And sometimes from the simple therapeutic act of validation. These are just to name a few. Corrective emotional experiences are also, of course, constantly happening as part of everyday life—a new friend or love relationship, adopting a pet, beginning an exercise regimen, getting acquainted with nature, a better job, an act of resilience in the face of stress and disappointment, or just about any other positive new experience. Therapy is just a way to increase the odds of having (or noticing) corrective emotional experiences, speeding things up, and triggering virtuous vs. vicious cycles. Too often these days, therapists adhere slavishly to one or another therapy school, and schools compete with one rather than join forces. This guild warfare is bad for psychotherapy, bad for therapists, and, most of all, bad for patients. Every therapist should have eclectic training that provides a full tool kit of techniques that promote corrective emotional experiences. No one school has a monopoly on wisdom or therapeutic power.

Ninety-Five Percent: Preparing to Work with Previously-Incarcerated Clients

Posted on by Psychotherapy.net Team

On the heels of my previous blog about the stigma experienced by previously-incarcerated clients with mental illness, I find myself once again in a reflective state around the idea of re-entry for these challenged and challenging clients. I draw attention to the title of this writing, which reflects the staggering reality that, according to a recent congressional study, 95% of those who become incarcerated will return to the community. Let that sink in for a second. This means that almost everyone who is sent away to a penal institution will be back on the streets. Why, then, haven’t we pushed ourselves to view crime and the “criminal” as less of that individual’s moral failure, and more of a societal one that must be addressed upon their departure from incarceration?

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It is easy to sit in judgment of others, especially those who have transgressed, and it takes only seconds to formulate a first impression of someone. Pair this with the biases and prejudices that incarcerated clients experience, and they leave prison or jail with a complete narrative that may very well not be their own. Clients returning to the world beyond prison gates live with these preconceptions from the moment they interview for a residence and/or job to the moment they seek follow-up services for physical, mental health or substance use treatment. And in my experience, these particular clients know full well that welcome mats, smiling faces, and open arms will not abound upon their release. That being said, unless clinicians acknowledge their own fears and judgmental attitudes towards these clients and fully lean into their own discomfort, the cycle that perpetuates stigmatization and diminishes rather than enhances their successful re-entry will continue to imprison them.

I recently worked with a client I will call Brennan, who has been diagnosed with a serious mental illness as well as a substance use disorder. Brennan is intelligent, resourceful, and sociable, but when taking his psychiatric medications tends to become more reserved, something that I have found occurs frequently with individuals experiencing psychotic or more severe mood disorders. Brennan does not have a lengthy history of incarceration, nor does he demonstrate an antisocial personality which would lead to a callous disregard for others. Instead, Brennan’s psychiatric challenges of late seem to have led him to correctional facilities, which, in turn, has made it difficult for him to re-engage with the world upon release. Recently, upon pursuing post-release community services, Brennan was left in limbo rather than being accepted into the program after he spoke honestly about an interest in smoking marijuana. Although he appropriately utilized the skills we taught him prior to release, Brennan was shamed and unable to successfully reintegrate into the community as he had hoped and, quite frankly, deserved.

As I continue to help facilitate re-entry for my clients and assist them in navigating the confusing labyrinth of providers, I’ve noticed that the doors for treatment do not fly open for them, which makes the struggle to resume or begin a life beyond the walls that much more difficult. Their psychiatric conditions, which often incorporate psychotic features, frequently lead to their presenting with strange or bizarre thought content that is even more evidence to community providers that they should be feared and turned away rather than assisted. One of the most potent interventions I’ve used when preparing these clients for life on the outside has been the process of reality checking and reality check sheets. For individuals with major mental illness, and especially for those who struggle with psychosis, this allows them to speak openly about whatever thoughts enter their minds in a safe space where they can receive supportive, rather than dismissive, feedback and learn that their thoughts do not have to be a source of shame or be given authority over their lives.

A client I will call Kent believed that he was related to a very powerful and influential celebrity. This was a persistent and fixed delusion. He did not typically converse openly about this except for when his paranoia was triggered, which could in turn contribute to erratic and sometimes volatile behavior. However, Kent felt safe with the staff members, who helped him to develop a small list of reality checks on printer paper in his cell. One such note asked him to respond with a “yes” or “no” to the question of whether he had been particularly invested or rigid in this belief on that particular day. He would then communicate his response to staff who could provide reality-based and instructive feedback for him while helping him to monitor himself. This intervention was effective because Kent trusted the clinical team, who always promoted safety as the most important value to the correctional community in which he lived. Kent exemplifies the importance of assisting these clients by providing concrete tools they can use once released and can share with providers on the outside.

***

What I wish for all of us is to continue challenging the status quo. To go outside of our comfort zones and take on the more complicated clients, the ones who keep us on our toes and challenge our clinical minds. I challenge you to push members of other professions, often the individuals we work with to establish services or provide housing, to do the same and, perhaps most importantly, to get more clinicians involved in services such as housing, substance use treatment, or community intervention upon intake. Let us truly meet people where they are on their journeys. There is no “perfect” client, and any client who says and does exactly what is expected of them is probably not getting all of their needs met either. Let’s keep our advocating voices strong and help those who need it the most, as in the case of the client who is trying to forge a life outside of prison walls.

An Existential-Spiritual Journey During COVID-19

Posted on by Psychotherapy.net Team

A Place of Uncertainty

As we approach the second anniversary of the first detection of COVID-19, we are no longer in the acute stages of the pandemic. However, neither do we find ourselves squarely in a post-pandemic world, as new variants continue to evolve and spread rapidly, sparking fear and halting daily life. A heightened sense of self-doubt, vulnerability, and anxiety can occur in this “limbo-like” state, particularly for clients experiencing life-threatening medical conditions. Feeling threatened for prolonged periods may increase both the client’s and therapist’s need for certainty and diminish our ability to tolerate ambiguity. In the case of COVID-19, when safety and normalcy are in question, life’s uncertainties may be harder to endure.

Existential approaches are particularly well-suited for addressing concerns provoked by the COVID-19 pandemic such as encountering the fragility of life and the unpredictable nature of events, as well as uncertainty about when (or if) the pandemic will end. For Yalom, the aim of psychotherapy is to help clients fully experience and accept the existential anxieties associated with the “givens of existence,” including death, isolation, freedom, and meaninglessness. As a result of facing death, individuals may experience a sense of urgency to revise life priorities that can lead to improved meaning.

Existential therapists generally suggest that anxiety and existential guilt need to be experienced in an open and honest manner and, when directly encountered, can become a source of vitality, creativity, and purpose. Rollo May and Paul Tillich believed that courage and determination are fostered when anxiety, adversity, and life’s dilemmas are faced. In other words, when we accept our limitations, we also commit ourselves to living fully.

Victor Frankl’s recent series of posthumously published papers does this by shifting emphasis away from the question of “What can one expect from life?” to “What does life expect from us?” Thus, he suggests that it is life itself that asks questions about meaning. While we may feel challenged and forced to face discomfort when we ask ourselves what life expects from us, French philosopher Gabriel Marcel posited that such pain and suffering offer the only pathway to real insight and spiritual growth. Perhaps through these challenging questions that place uncertainty, obstacles, and suffering before us, we discover our meaning and purpose.

Clinical Vignette

The clinical vignette presented below highlights the challenges of how a therapist-client dyad worked through their mutual feelings of “not knowing” and uncertainty by processing their own existential anxieties and fears. A series of dreams of the client and therapist, as well as the use of creativity as a spiritual intervention, are described to demonstrate the complexity, practicality, and depth of the existential approach. In particular, the vignette highlights how dream interpretation can be used in enhancing problem-solving and conflict resolution, mastering trauma, exploring unknown possibilities and paths not chosen in life, wish fulfillment, compensation, communication with the therapist, and integration of self.

Initial Phase: An Exploration of Death and Social Anxiety in the Context of COVID-19

Steven is a 63-year-old man who presented for individual psychotherapy approximately six months after the resection of a non-malignant brain tumor. He experienced one generalized tonic-clonic seizure immediately after his tumor resection, which had a significant impact on his social and emotional functioning.

In terms of constitution, Steven had always been shy and sensitive. He had maintained a group of close friends since high school. Although he never married, he had had two long-term relationships since graduating from college. At the time of his surgery, he had been retired for two years from his career as a special education teacher and had reportedly been adjusting well to his life transition. Steven valued his level of independence, intellectual curiosity, and work ethic. His numerous interests included photography, hiking, reading history, and political activism. After the onset of his neurological condition, however, he became quite withdrawn and fearful about leaving his apartment. Although his seizures were well controlled with medication, the onset of his condition and the implied risks amplified his social anxieties and fear of death. Whenever he did leave his apartment, he felt self-conscious about his word-finding difficulty and occasional stutter, which exacerbated his fear of being ridiculed and shamed. After experiencing months of social isolation and increasing depression, he reached out for therapy at the encouragement of his physician and close friends. He hoped to regain self-confidence, be able to connect with old friends, and resume his recreational interests.

Steven’s comments about his own mortality were interspersed throughout the early sessions and were delivered in an intellectualized and affectively neutral manner. He recalled his experience of waking up from surgery and having a seizure in a vivid but emotionally detached manner, leaving me feeling highly anxious. I felt that he would have been frightened and overwhelmed if this had happened to him. These sessions felt more as if Steven was reporting about his life, rather than experiencing his life.

Given the news of the spread of COVID-19 in New York City during his third month of therapy, Steven agreed to continue sessions via telehealth. On top of the feelings of death and social anxiety and uncertainty secondary to his brain tumor and seizures, he felt the virus was exacerbating his lack of control over his life. Steven had a mindset that his medical condition and COVID were unsolvable problems leaving him trapped in his apartment with no escape.

In the first few telehealth sessions, there was a noticeable shift in Steven’s mood, focus, and communication style. Where previously he would speak at length about his negative interactions with the public in the local supermarket or in the elevator of his building in a detached fashion, his conversation in the context of the pandemic became more emotionally laden, his mood palpably more depressed, and his focus turned inward. While he had already worked through diminished control over his health and restrictions imposed by his physician and medications, COVID-19 surfaced additional fears of brain cancer and not being able to get help if he were to have another seizure.

The threat of COVID-19 increased the reality of his mortality due to his medical condition, and he could no longer speak about it indifferently. Instead, this emotional intensity filled the content of his thoughts and treatment sessions such that he grew more removed from the people and activities that had filled his time with meaning, purpose, and pleasure before his brain tumor. His increased level of avoidance, which had started after his surgery and was exacerbated by COVID-19, further impacted his sense of identity and agency in the world. For instance, Steven expressed that he was afraid of dying alone and nobody finding him. He did not have any religious affiliation but felt that he was a spiritual person when walking in nature or helping others who were vulnerable.

In the second month of treatment, Steven had reported a dream where he “was traversing over a deep canyon. As [he] cautiously walked across a wide rope with railings, it swayed back and forth. [He] saw a dark, shiny mountain across the cavern, but the rope was not attached to the mountain. [He] was unable to look down and felt paralyzed to take an additional step forward. [He] tried to scream out for help, but no words came out.” He woke up sweating and frightened. In session, Steven was asked to tell the dream in the present tense to promote a sense of presence and agency. When asked about the predominant feelings he had in the dream, Steven responded that he was overwhelmed with the anxiety of and fear of falling into the cavern that had no bottom. When asked how he would want the dream to end, he responded by wanting the rope to continue to the mountain so that he could feel safe with his feet firmly on the ground.

During the next few months of therapy, questions that had been previously effective with helping other clients with medical conditions and high levels of anxiety to gain a sense of meaning or agency (e.g., “What are some things that you can control now?” “What are your feelings of fear and anxiety trying to teach you?” and “What do you feel most passionate about in your life?”) were dismissed as unhelpful. Steven emphatically stated that he needed definitive answers to the questions that preoccupied his entire day, such as “Will my tumor grow back and become cancerous?” “If I exert myself through exercise or go to social events with my friends, will I get COVID or a seizure and die?” and “Is the government deliberately giving us misinformation regarding COVID-19?” I felt increasingly anxious and was unable to give a clear answer to any of these questions. As Steven’s therapist, my own experience of “not knowing” was overwhelming, since we were both experiencing our own feelings of anxiety, fear, and uncertainty about getting or spreading the virus. Steven tended to repetitively ask questions with no clear answers and would spend hours searching through social media sites for elucidation. Over time, he noted that the therapy was not helpful, even indicating that he felt more frustrated and withdrawn in both his sessions and his personal life.

Middle Phase: A Shift in the Therapist’s Approach

After consulting with several colleagues, I decided to focus on active listening, patience, tolerating silence, and providing space for Steven to find the words for his feelings. The decision to shift my therapeutic style with Steven was motivated in part by my experience of feeling alone in the room and that my words were not being heard; any interpretations or interventions offered were readily dismissed, as though batted away with a tennis racket. My reactions were further complicated by the difficulty of picking up nonverbal cues on the Zoom telecommunication platform. Ultimately, my countertransference reactions yielded a deeper appreciation for Steven’s emotional life, including his profound sense of isolation, powerlessness, and feeling invisible in the world. I was then able to provide Steven with titrated reflections of this loneliness and helplessness, contextualized within the uncertainty of the pandemic and his medical condition.

Shortly after I shared this particular self-disclosure and processed his reactions, I experienced a dream where “I was dragging a dead body of a man in a trash bag down a busy avenue in Manhattan. The bag was heavy, and it took a great effort to pull the bag toward Macy’s on 34th Street. I struggled to pull the bag toward the holiday window at Macy’s when the dream ended.” I understood the dream to be an indication that I was trying too hard and doing too much of the therapeutic work, and that Steven needed to take more responsibility and ownership of the course of the treatment. I also wondered about the meaning of the Macy’s holiday window scenes of families celebrating together, children playing, and religious scenes, and whether some creativity or spirituality needed to be part of the therapy in order to bring Steven to live more fully again.

This internal shift in my perspective led to a new phase in treatment where Steven was able to gradually mourn his loss of identity, direction, and purpose in life related to his medical condition and COVID-19. We began to explore his regrets in life. Steven was able to recall that he had always wanted to be a professional photographer but had not had the confidence to pursue this wish. He had always wanted to have children but felt that his career in special education partially fulfilled this desire. Shortly after, Steven recalled a dream where “[he] was in his parent’s country house in [his] room looking at a wall of his photographs from one of [his] high school classes. [He] noticed the subtleties of lightness and darkness in the scenes of Manhattan and started to experience a sense of pride and accomplishment. At that moment, [he] overheard [his] parents and other relatives laughing in another room, and [he] felt a sense of humiliation and shame that they were making fun of [his] photographs.” He awoke feeling a sense of hope about his creative abilities and a sense that he now had the time to act on it. He also felt that he did not trust his desires when he was younger and was more concerned about what others would say about his artistic ability. When asked of his associations to the dream, Steven mentioned that the night before he had watched a film of someone who spent years walking every street in the five boroughs of New York. Steven regretfully said that he wished he had the courage and confidence to pursue his deeply-buried artistic dreams.

Working Though Phase: The Use of Creativity as a Spiritual Intervention

After a period of medical improvement, including being seizure-free, Steven started going out of his apartment a few days a week to take black and white photographs in Central Park. During the early morning hours, he experienced a sense of awe, wonder, and adventure in not knowing where his walks would lead in the park. He took black and white pictures of statues, lights filtering through leaves on the trees, animals resting in the zoo, and a formation of geese flying over a pond. Steven experienced a greater sense of freedom, calm, and centeredness during these occasions. His rediscovered artistic passions, which resulted in increased flexibility and confidence in taking risks in other aspects of his life, including contacting friends and colleagues with whom he had lost contact. These photographs activated something on a deeper level in Steven and enabled sharing these photographs with his older friends. He initiated contact with his former school and volunteered to teach photography in a small group setting, which provided a sense of purpose and direction in life.

As Steven’s level of anxiety and medical symptoms improved, he was able to shift his focus from internal preoccupations with not knowing what his future would be like to existential concepts of meaning, values, and priorities. He thought more about his future, making peace with external things that he did not have control over. Steven shifted his position from the passenger seat to taking a more active approach in life. He became curious about how he wanted to lead his life and pursue his social and recreational interests. I facilitated this process by open-ended questions, such as “What has sustained you in dealing with your medical issues?” “Where do you think you found your strength?” and “If you were to imagine your life one year from now, looking back on how you dealt with your medical recovery, what would you think about how you handled things?” In addition, I asked, “If you had not had your neurological condition, would you be dealing with the pandemic any differently (and vice versa)?”

Steven realized that when he began treatment he had been feeling sorry for himself and angry at the unfairness and injustice of having a medical condition after being a good person who devoted his life to helping others. He realized that he was fearful of taking risks and failing, and that he had more to give to others despite his limitations. Steven acknowledged the importance of his friendships and of continuing to develop his personal values and traits. He gradually came to realize his own power to choose how he wanted to view and respond to life’s major challenges. Furthermore, he started to become aware of ways in which his medical condition had made him stronger, including being able to face his mortality and tolerating not knowing and uncertainty. He was eventually able to acknowledge that his courage, determination, and creativity enabled him to cope with his multiple challenges and that he had more to live for.

Concluding Thoughts

Existential approaches are uniquely suited to address prominent themes in the COVID-19 pandemic, including anxiety surrounding death, uncertainty, isolation, and vulnerability. Existential therapy provides an important opportunity for clients and their therapists together to face these challenges and discover meaning throughout. Through the process, they are able to live life with greater intention, purpose, self-reflection, and presence, to accept and learn from feelings of not knowing, uncertainty, and anxiety, and to value the benefits of choosing one’s attitude toward adversity.

This case vignette highlights the benefits for both the client and therapist in experiencing, accepting, and learning from feelings of uncertainty. Asking open-ended questions about Steven’s dreams, values, attitudes, and meaning in life enabled him to be more curious and flexible. Incorporating creativity as a spiritual intervention provided an opportunity for a heightened degree of engagement, self-reflection, intensity, hope, and passion. In a parallel manner, my therapeutic shift to slowing down the pace and focusing on the process, tolerating moments of silence, utilizing countertransference reactions, and reflecting on his and my own dreams enabled me to let go of the need to appear as an expert with all of the answers and be more of a “fellow traveler.”

There are moments when clients need their therapists to feel the depths of their powerlessness, loss, vulnerability, and despair in order to find and describe their feelings and to feel understood and emotionally held. There are healing moments when the most important gift that we bring to another person is the silence within us, the kind that is a source of peace, acceptance, and allows the transitional space to be.