Author: Psychotherapy.net Team

Listening for Meaning in the Voices Nursing Home Clients Hear

Posted on by Psychotherapy.net Team

Several years ago, I worked with a lovely lady in her early seventies who resided in a nursing facility, and who heard the voices of her daughter and son daily. She had been delighted to be a young mother of two children but was ill with bipolar disorder and psychotic features that necessitated repeated psychiatric hospital admissions. Her husband subsequently divorced her, gained custody of the children, and remarried. The children bonded with the stepmother and cut off all contacts with their biological mother. One day I asked her, “If we had a new pill that would eliminate all voices, would you want it or not?” “Oh, no, Tom; then I’d have no contact with my children,” she answered.

Different Kinds of Voices

Over the next few years, I asked that question to hundreds of therapy patients in nursing facilities. I had initially assumed that most persons who hear auditory hallucinations would like to turn them off completely. To my surprise and increasing fascination, the majority, approximately 70–80% of those that I asked said no, they would not take a pill that would erase all voices.

Individuals with whom I’ve worked therapeutically have explained that there is indeed a negative aspect of the voices, usually involving insulting and hurtful remarks, but there is also a positive aspect—something that was pleasing, and they would not want to do without. For each person, the positive element was different, and was personally meaningful. “Tom, if it wasn’t for the voices, I’d be very lonely,” said a woman in her fifties with schizophrenia.

“I’d have no one to talk to if it weren’t for the voices,” said a male patient.

“I don’t really talk back to them, but I like them, and I listen to them; and it’s better than talking with people,” said a 73-year-old man with schizophrenia.

“I guess it’s a side benefit of schizophrenia: I can hear the voices of my dead relatives,” said a male patient.

“The good voices I think of as the children, and the bad voices are the adults; I’d just feel terrible if I stopped hearing from the children; they cheer me up,” said a different female patient.

“It’s easier talking to the voices than to people,” a man said.

Some believe they gain special knowledge from voices. “How else would I know what’s going on?” one man asked. “I read people’s minds; I can tell what they’re thinking because I can hear it.”

Some patients, though, do wish to eliminate all auditory hallucinations, and their psychiatric medications do offer symptomatic relief. Some patients tell me that they used to hear voices, but no longer do because of their medication.

Some individuals with whom I’ve worked have achieved insights through psychotherapy that helped them understand and manage the symptoms. I worked with a 74-year-old woman who had more than a 50-year experience of schizophrenia. She knew the name of the condition yet could not recall ever being educated about the symptoms of the illness. She believed that she had super hearing and could hear persons in different rooms saying nasty things about her. Often, she would yell out when passing by the nurse’s desk—because of hearing the nurse making insulting remarks about her. After months of therapeutic conversations about voices as symptoms of schizophrenia, she greeted me one morning by saying, “Guess what happened today, Tom? I was walking past the nurse’s area, and I heard them talking bad about me, and I realized; I’m hearing it, but they are not saying it!”

Troubled Journeys

Multiple factors might cause or contribute to one’s hearing an auditory hallucination—they can be associated with neurologic conditions, seizures, autism, bereavement, medication effects, drug effects, trauma and dissociation, borderline personality disorder, dementia, and/or postpartum psychosis. But for persons with a diagnosed psychiatric condition who hear voices, there may often be a pattern of additional, related life experiences that can further limit social functioning and productive activities.

Many patients who speak with me in psychotherapy about the voices they hear also report early-education learning difficulties, special education classes, and a growing sense in childhood of being different, with estrangement from peers and few childhood friends—and, therefore, reduced opportunities to develop and refine social relationship and communication skills.

Autistic elements are commonly identified in schizophrenic illnesses. Learning disabilities, likewise, are commonly associated with schizophrenic illness. Autistic features, learning disabilities, and mental illnesses can contribute to social estrangement and reduced development of adaptive social communication skills.

Affected persons may withdraw into substitute communications with voices, and that can in turn contribute to worsening of symptoms of depression—as can be manifested in the menace of some perceived voices—and to progressive depths of withdrawal, thereby adding to paranoid distrust of others.

My clinical experience suggests that many patients rely on an imaginary companionship through the voices and would like to minimize or eliminate only the malignant (the derogatory, or depression-reflective) voices. Yet other persons report significant relief when their experiences of hearing voices have been quelled by medication. If those persons had been asked prior to remission of auditory hallucinations/delusions (AH/D) symptoms, might they, too, have said they would prefer to retain the voices? I believe that relief from symptoms would better serve an individual than a pseudo-accommodation to them.

The Gifts of Therapy

I think there is a vital need for new and more effective medications, and for optimum application of presently available medications, along with psychotherapy and psychosocial interventions that can be applied by staff persons in the nursing facility.

Sometimes one learns in unexpected ways that a patient is experiencing hallucinations. I worked with a 48-year-old man with a diagnosis of bipolar disorder and no known experience of hallucinations or other psychotic symptoms. He often complained of pain and argued with staff persons. He was making vague remarks about something bothering him one day, and among other questions, I asked if he ever heard voices in his ears, anticipating he would say no. He surprised me by saying, “Not in my ears, I hear voices in the mattress; I hear the voices of the dead people who died on the mattress before I started using it. That’s why I don’t sleep at night.” The physical frailty that brought him to the facility for nursing care and rehab triggered underlying fears of dying.

Images in dreams typically hold specific and personal meanings that can be identified through sensitive personal conversation, and awareness of those meanings can improve a person’s understanding and coping with internal experiences. Hallucinations and delusions likewise contain personalized meanings and tend to provide protective psychological functions. Symptoms can be remarkably clever psychic creations that help balance an imbalanced psyche.

Many persons who don’t have a mental illness might entertain glorious daydreams of special accomplishments. Some persons with a psychiatric diagnosis develop grand delusions that protect against feelings of shame and disappointment over inadequacies. A 54-year-old man with schizophasia and thought disorders due to schizophrenia who found it difficult to communicate in ordinary ways with others once told me he had written the lyrics for many of the major rock bands.

Sometimes a patient will openly discuss their hallucinations during therapy yet deny having them when questioned by other care providers. “That was a red flag for me,” a 54-year-old female patient said about an initial conversation with a psychiatric consultant asking assessment questions. “I didn’t know who he was, and he was asking these personal questions, so I hardly said anything.”

Some patients say they do not report their internal (symptomatic) experiences, such as hearing voices, to other care providers because “they might not believe me,” “they might think I’m crazy,” “they might just think it’s not true,” “they might make fun of me,” or “they might send me to the hospital.”

I explain that in psychotherapy we are looking for the true personal meaning of the experience, so that they might better understand and manage those experiences—and, for persons hearing voices associated with dissociative conditions, so that they might better integrate the meaning of the perceptions. In therapy we talk about the difference between objective reality and subjective reality, so that the person might feel less perplexed and afraid, and more willing to discuss and examine their experiences.

The Other Side of the Sun

I met for weekly psychotherapy for two years with a 53-year-old man with schizophrenia who told me one morning, “I just got back to earth. For the last 30 years I was living on a planet on the other side of the sun.” He was upset because the staff had laughed and told him it was not true when he told them earlier that morning about his experience. I spoke with him about things that are true as shared realities and things that are true as psychological experiences that have symbolic personal meaning. We spoke of ways he wanted to fit in and get along with others, yet how that might be difficult and how he might sometimes feel far away from others. So far that it would be like being on a different planet; and how good it feels when one starts to feel better, and back down to earth, and better able to connect with people. This conversation helped him to speak more directly about the alienation he sometimes feels because of his illness.

In psychotherapy, some patients argue that the brain is not capable of creating convincing experiences that are not real. The following remarks represent a composite of conversational points from sessions with a few patients.

Therapist: Have you ever awakened from a dream and thought, wow, that dream was so real!

Patient: Yeah.

Therapist: And where did the dream come from?

Patient: Okay, it came from the brain, I see.

Therapist: Have you heard of someone taking LSD?

Patient: Yeah.

Therapist: What happened during the “trip?”

Patient: Oh, yeah; they heard things and saw stuff, and maybe went to another world.

Therapist: Those seemingly real experiences were caused by a chemical that triggered an imbalance of other brain chemicals.

Patient: My psychiatrist said my illness was a chemical imbalance in the brain.

Therapist: And psychiatric medications work to correct imbalances of brain chemicals.

Patient: Oh, so brain chemicals can make you hear and see things that are not there, except in your brain.

Therapist: Do you hear a high-pitched ringing sound?

Patient: No.

Therapist: I do, because I have a condition called Tinnitus. The ringing is not coming from outside of me, but from inside, because of a medical condition. It is subjectively real, because only I hear it. It would be objectively real if we both heard it at the same time.

Patient: Okay, so some things can be real for me on the inside, but not real between you and me; I guess that’s like mental illness.

Asking the Right Questions

Assessment questions using clinical terminology might trigger anxiety and reluctance to acknowledge internal perceptions and beliefs. “Do you hear auditory hallucinations?” might trigger a denial, yet asking “Do you hear voices or receive communications that are pleasant, unpleasant, both or neither?” might initiate conversation about one’s experiences. Asking if one feels paranoid might stir resistance, yet asking “Is it sometimes frightening or confusing to deal with people?” might lead to conversation about the thing’s others do that cause fear or mistrust.

What do auditory hallucinations compensate for? What do they replace? Do internal or out loud conversations with these voices represent a form of self-treatment for the patient? What type of adaptive skill training might address those needs?

Turning to the literature does not always result in answers to these enigmatic questions. I believe that additional research is needed to:

  • Improve awareness of the incidence of AH/D amongst persons with psychiatric diagnoses residing in nursing facilities
  • Identify how many patients have achieved remission of AH/D resulting from psychiatric medication
  • Determine how many persons experience auditory hallucinations without delusions
  • Identify the percentage of patients preferring to retain rather than eliminate AH/D
  • Elicit examples of personal meanings of AH/D
  • Develop educational guidelines to assist Activities Department staffers, including occupational and physical therapists, to teach and practice adaptive social communication skills
  • Gather ideas/suggestions from patients on how professionals might inquire about symptoms without causing shame or triggering denials

***

I have been and continue to be deeply moved by the trust and disclosures offered to me by the many vulnerable persons with whom I have been privileged to work. I ache with hopes that we find new ways to quiet their symptoms, relieve their shame, and help them deepen their willingness and capacity for ordinary social communications.

Grief, The Dismissed Yet Common Experience

Posted on by Psychotherapy.net Team

When I mention grief and loss to my clients, I see their eyes widen with concern. Some will quickly offer, “Oh but wait, no one close to me has died.”

One day it hit me, everyday grief is not normalized nor validated in society. We are so quick to acknowledge the death of someone but not quick enough to acknowledge ended relationships, loss of a job, divorces, loss of finances, loss of friendships, miscarriages, loss of identity, expectations, aging, or retirement.

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As I continue to advance my knowledge and practice in grief, I realize it’s not that grief is not acknowledged, but that instead many—clinicians likely included—don’t fully appreciate its innumerable forms, both great and “seemingly” small, especially, perhaps, if they have not directly experienced it. Recently, this awareness hit me when a client in my grief group expressed with sadness, “I don’t think I belong here.” This person had joined the group after losing their eyesight, while others were in attendance due to losing someone from either suicide or homicide.

I remember feeling the urge to tear up, hearing someone who was experiencing a huge loss invalidate their own pain. In that moment I realized just how dismissed the common experience of grief and loss truly is.

I then offered the client a list of commonly experienced feelings including sadness, anger, confusion, heaviness, pain, disbelief, fear, numbness. They answered, “Yes, I've felt every single one of those.” I then explained to the client that grief is not a “one size fits all” type of experience. It is unique to every individual, not linear. Nor are there rules to grieving, which often make it seem complicated. Some clients simply don’t have a vocabulary that extends to emotions, so providing a list such as this one has been helpful in my work with grieving clients.

It was my goal to help this client understand that grief is a reaction to loss, which explains why they not only belong here in the group, but they also belong in their grief. The truth is, grief does not have to be recognized by others to be validated.

As time went on and the group members became closer, the “who/what” of their grief no longer mattered because they eventually started to bond over the “why.” They began to realize that their pain was the same. Sure, they were all there for different reasons, but their tears looked the same, and their voids felt similar. Eventually, they found comfort and healing within each other’s experiences and words.

After realizing that grief has no face, just different cases, my client no longer felt as if they didn’t belong. Their differences are what made the group feel full. They provided support and balance for each other. The group became a safe space to feel their grief that was either dismissed by themselves, society, or by those around them. Dismissed not because it did not matter, but because it was simply not understood or spoken about.

This client felt that they didn’t belong because the discussion of grief had been shoved under the table for far too long. Discussions around or about grief can be easily dismissed because they are heavy and can be scary. Yet it is something that can’t or at least shouldn’t be avoided. All will someday experience loss, and grief will inevitably follow. Working with grieving clients has taught me that opening a space in clinical conversations can and has helped my clients feel normal, something that loss takes from them. I always say, “Awareness can lead to understanding, and understanding can lead to healing.”

I then ask the next question, “Do clients dismiss grief out of fear that if they talk about it, the pain attached to it becomes real or too much of a burden to bear?” No one likes feeling sadness, pain, anger, and irritation, but ignoring these feelings doesn’t make them go away. If anything, dismissing them will only make them come back harder. The sadness they feel isn’t there for no reason. It’s there because what they are experiencing is part of being human.

If I were to have dismissed my client’s pain and referred them to a colleague, who knows what their grief would have morphed into—it would have likely expanded to include loss-of-clinician. Dismissing the client’s grief would not have made their eyesight come back, nor would it have made the emotional pain they felt lessened or disappear. Yes, this client’s loss differed from others in the group, but if we crossed out “loss of eyesight” and had that same client explain the feelings of loss they were experiencing, we would see that the “who/what” attached to our losses doesn't make them more or less painful. Yet the “who/what” attached to our support system can increase chances of healing and acceptance.

***

It is my hope that one day no one will say, “My loss does not belong here,” but until that day, I will welcome all losses and forms of grief into my therapy group and in conversations with my clients. I will open similar doors to these experiences in my own life.

Battling Stigma: Serving Previously-Incarcerated Clients in the Community

Posted on by Psychotherapy.net Team

Another week has ended. I am feeling those familiar pangs of disappointment—the kind that make me shake my fists and yell to the sky as I continue to battle decades and layers of systemic challenges outside of my control. I’ve watched my team work tirelessly to find yet another needle in a haystack which itself seems to be on fire. From a systemic standpoint, I work with arguably one of the most difficult-to-place populations—those with a history of incarceration and major mental illness. To be clear, this is not the fault of any of the clients I serve, but clearly a societal issue characterized by a continued and seemingly unrelenting stigmatization of its incarcerated citizens with mental health needs. It’s an ugly truth, but that doesn’t change that it needs to be confronted.

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Ned (not his real name) is a man with a complex case history, not unusual to corrections. He is dually-diagnosed and no stranger to the criminal justice system. His supports are extremely limited, and he, not unlike most of his peers, feels that he has a real sense of community and care in the mental health unit at our facility. Ned once said something that profoundly impacted the staff who work with him. It was a typical day of patient care when Ned walked into the room full of clinicians and told the team members how simultaneously sad but wonderful it was that he felt so at home and cared for inside the correctional facility. This was not an easy win with Ned—it took much time and consistency in his relationship with the staff and unit to really feel that he was and is looked after.

Ned is an exceptionally charismatic and humorous individual who deserves the opportunity to have a life outside of the correctional system, no matter how well cared for he feels there. He is someone who responds to redirection and is the epitome of how and why Rogerian therapy can be so impactful, despite its many detractors. Building rapport and a strong therapeutic alliance with Ned has allowed the team members to assist him in moving forward in his life and to spend less time in the justice system than he may have without such extensive support.

The disappointing aspect of all this is that the community mental health system does not know how to respond to Ned. He deserves competent and caring outpatient mental health care, access to substance use treatment, and opportunities for vocational rehabilitation. He has many strengths and is much more likely to stay connected to providers if he feels they are genuinely invested in his well-being. However, despite all of his strengths, he requires a lot of contact with staff members Living in the time of COVID-19 has only made it more challenging for community providers to stay fully staffed and for resources to be obtainable; as a result, the patience that Ned deserves from community caregivers may not be as plentiful. Ned was removed from a community placement twice within the last year, and typically within a very short amount of time. Any time a community setting doesn’t work out, it’s hard to not let the disappointment set in because we are so genuinely invested in the outcomes and well-being of those we serve.

We live in a nation that incarcerates more individuals per capita than any other developed nation, which means that many of us and our clinical colleagues have had professional, or perhaps even personal contact with someone who has been incarcerated. Yet despite this fact, I have found that there is so much fear in the field of human services when it comes to working with previously-incarcerated individuals with mental health needs. Time and time again, the job of finding placements for these individuals has proven to be excruciating. Community providers often want assurance that these individuals aren’t too psychiatrically sick or require resources beyond their capability or willingness to provide. There may even be the implicit fear that previously-incarcerated clients, especially those with a history of mental illness, may be violent and/or physically dangerous. And these are but a few of the barriers for placement and treatment once these individuals are released from prison.

To be fair, we are living in the time of a pandemic, and staffing and resources in the human service world are at an all-time low. Closures are happening left and right, and the competition for resources has intensified. I appreciate the gravity of this, but the fact is that we were struggling with this long before the pandemic began. Deinstitutionalization had a direct impact on the criminal justice system, leading prisons and jails to become the largest providers of mental health in the nation. John F. Kennedy had the right idea with the Community Mental Health Act in 1963—unfortunately, America has never had the infrastructure to support the aftermath of deinstitutionalization in community settings. Pair this with the time of the pandemic, and people with mental health needs are becoming psychiatrically sicker and for longer periods of time, which has immense consequences on their long-term prognosis.

The weight of this has often felt crushing to me and my clinical colleagues in corrections. Agencies need to be equipped to provide treatment to individuals like Ned who have been incarcerated and also live with major mental illness. People reintegrating into society from prison or jail may need more assistance to get on their feet and figure out the fast-moving world that they were removed from and to which they are returning. Yes, individuals with major mental illness may require more staff time and patience. Yes, as those providers, we should step up to the plate and meet this challenge head-on. Furthermore, as clinical providers, we cannot expect marginalized people who often have become very adept at pushing others away or having people ignore them or reject them to instantly acclimate to new surroundings and not need anything from us.

***

So why do I write all this? I write this because I’m betting there are other correctional social workers and clinicians out there who feel the weight of this just like I do. Society has an interesting way of tucking away those it sees as “undesirable” and then looking away, assuming either that these individuals will not reintegrate into society or somehow magically will. These individuals will of course be walking down our streets with us, they may live next door, or they may stand behind us at the pharmacy. If we know people who end up incarcerated will return back into society, why are we not providing them access to services? If services continue to screen for those who are “high-functioning” and “less needy,” then we are truly perpetuating stigma and preventing people like Ned from having the opportunities that they not only deserve, but are fully capable of having. A friend of mine once told me, “We’re all just walking each other home.” I hope community, psychiatric, and correctional providers can work together to make this journey better for our fellow walkers.

Setbacks in Psychotherapy

Posted on by Psychotherapy.net Team

Introduction

When I was in graduate school learning about psychotherapy, I read a lot about how to do therapy, but I found myself yearning to see clinicians doing the work as models to emulate or reject. Now that I am a university professor training graduate students in clinical psychology, I expose my students to as many clinical video recording demos as I reasonably can. In my first-year interview and psychotherapy courses and in my second-year practicum, my grad students watch hours of clinicians doing psychotherapy. In turn, they seem to really benefit from watching the work and seeing the full range of styles, techniques, and theoretical approaches. We all agree that seeing clinicians in video demonstrations makes our readings on assessment and psychotherapy come to life as we appreciate and critique excerpts from my library of videos. Like me, they find it helpful to see models of how this kind of work is done. Moreover, they also have a yearning—like I had in graduate school—to actually see work that does not go well, in order to discern how clinicians react and recover when there are setbacks in the course of psychotherapy.

To this end, as the creator of the Collaborative Assessment and Management of Suicidality (CAMS), an evidence-based framework for effectively engaging and treating suicidal risk, I can now satisfy and promote my early yearnings to see and understand what to do when faced with a clinical setback. However, this particular article is not about extolling the virtues of CAMS or its extensive supportive evidence base (including nine published clinical trials, five published randomized controlled trials, and a rigorous and convincing meta-analysis of nine CAMS trials). Rather, my emphasis here is focused on an aspect of a training video that has been offered for several years by our training company, CAMS-care, LLC.

The Setback Session

Over the course of my career, I have routinely done live roleplay demonstrations, recruiting someone out of the audience to roleplay a case they know well. Obviously as an unscripted and spontaneous demonstration, it always puts a bit of pressure on me to “perform” with a variety of different roleplay “clients” that I encountered. There have been many times over the years when a volunteer audience member plays an especially difficult or provocative case, and everyone then gets to watch me squirm and struggle—just like what happens in real life! Beyond my early yearnings to see clinical demonstrations, I also wanted to see demonstrations of things not going perfectly as well—just as in real life. Overwhelmingly, most clinicians at my workshops have appreciated these live roleplay demonstrations and my taking the risk to demo techniques even when they do not go perfectly. It follows that when CAMS-care moved to scale up our training of CAMS, we shot a 12-session role play video in a studio with a former grad student—now colleague—named Dr. Kevin Crowley, who played a difficult client he saw during his VA internship.

Over two days in the studio, we shot unscripted segments of the first session of CAMS, portions of the second session, a latter interim session, a rather provocative setback session (where the patient has a major suicidal crisis), and the final outcome disposition session of CAMS. This online course has proven to be quite popular and has held up quite well over the years since we shot it. It has now been viewed by thousands of clinical providers being trained in CAMS around the world. Moreover, we know from an unpublished doctoral dissertation project defended last year that this three-hour online course has a notable and meaningful impact on clinicians learning to use CAMS within our integrated training model.

But, getting to the point of this article, what has been most popular—and contentious—about this online course has been Session 9, the “setback session.” I would say overall that 80-90% of those we train praise, appreciate, and feel quite positively about the setback. In contrast, there is a small minority who emphatically do not like the setback demo and share critical comments, with some even feeling offended by it! In any case, the setback session evokes a lot of strong reactions. I have often reflected on why this might be.

The online course provides overview portions of me talking about the model, but most of the course features various demo excerpts of Sessions 1-12, depicting a successful course of CAMS-guided care. My “client” Kevin plays a tricky case—he behaves peculiarly and is extremely wary of being in therapy at all. What emerges is a significant trauma history and a lifelong preoccupation with suicide. More to the point, he does not generally trust people, as he has experienced extensive interpersonal betrayal, one of his “drivers” of suicide (in CAMS parlance) and thus a major focus of his treatment. After making steady clinical progress, depicted in the video training over the first eight sessions, Kevin comes into the ninth session of CAMS angry and belligerent after a series of disappointments since his previous session that evoked an acute suicidal crisis. Clearly upset, Kevin immediately goes on the attack, accusing me of “lying” to him, “letting him down,” and “not having his back.” At first, I patiently hear his accusations but gently observe that he did not follow his CAMS Stabilization Plan, which involves engaging in predetermined coping strategies and ultimately contacting me on my cell phone. But as he repeatedly accuses me of lying to him and betraying him, I became increasingly angry myself. As my voice raises, I point out that he did not even give me the chance to have his back—a critical therapeutic issue within his suicide-focused treatment.

There is an awkward pause in a kind of “gotcha” moment, and his head drops in shame as he sees that we are experiencing a re-creation of a dynamic that he has experienced repeatedly. Seeing this clear shame response, I immediately drop and soften my voice, regroup, and apologize and endeavor to clarify the therapeutic moment: that we can do this differently and it could be a corrective experience! The session quickly settles down, eye contact is regained, and we both discuss and learn about what did and did not happen. I also quote my research mentor, Marsha Linehan, who famously would say in such situations, “The patient never fails the treatment, only the treatment fails the patient!” I have to work hard to move Kevin from a position of embarrassment and shame following this contentious exchange. By the end of the session, we clearly do come back together with smiles and an obviously increased bond for having weathered the intensity of our intense exchange. In our final outcome-disposition session (Session 12), when asked what made the difference, without hesitation Kevin notes the breakthrough in Session 9 and the insights gained in that setback session.

Takeaways

So what exactly are viewers reacting to when they see our setback demo? Many say they like how real it is and that my anger shows how much I care. Others are relieved to see an expert lose their cool because it has happened to them, and still others appreciate my recovery and reasserting of the model in a therapeutic manner. Detractors of the setback are not happy with my getting angry at the patient and raising my voice and shaming the client. There are sometimes comments about my being a privileged white male who is asserting my power in a paternalistic way. There are some native cultures in Australia and the United States who find my approach offensive towards a vulnerable client. My UK colleague and friend Dr. Zaffer Iqbal reviewed the setback in isolation (not having seen the previous sessions) and noted, “Oh, the Brits will never go for that!” Incidentally, while we have heard some negative feedback from our UK colleagues, the overall take has been quite positive (also, seeing the setback within the context of a demo of a full course of care is very important). Still others object to my personalizing the crisis and focusing on Kevin’s not calling me on my cell—and notably many clinicians are not comfortable sharing their personal cell phone number. And some say it is never okay to let the client see the clinician get upset.

Recently for suicide prevention month (September 2020), our training company posted a new video on our website of the same setback session, with Dr. Crowley reprising his role of Kevin. But this time the clinician is Dr. Blaire Ehret, who is a VA Staff Psychologist (Dr. Ehret got her Ph.D. at Catholic U and worked in my lab and is now a CAMS-care consultant). The goal was to show that within this same provocative session, a different clinician could handle the same situation quite differently and still adhere to the CAMS model. Dr. Ehret did an outstanding job; she never once lost her cool. She was empathic to Kevin’s anger and validated his feelings of betrayal with no particular pushback. Kevin the client eventually comes around and responds to her earnest appeals to look more closely at what has happened. I watched it and marveled at how reactive I still felt towards Kevin’s pointed attacks of the clinician, and I appreciated her composure and patience. We have received very positive feedback about this redo of the setback session, and it shows there is more than one way to do this kind of work and the model still prevails in both versions. And unlike my version, it is hard to imagine anyone being offended by the way Dr. Ehret does the same session!

So what is the point? The setback clearly evokes a lot in those who see it. Do I regret having reacted so strongly in the original rendition? Yeah, a bit; I wish I had not raised my voice quite as much as I did. But then again, no, because it is me—warts and all—and who among us is perfect at doing this? I certainly know that I am not perfect! How about you? What is plain to me is that being real, earnest, honest, and responsible matters a lot. My reaction was real, my attempts to apologize were earnest and honest, and I calmed down and recovered. I gently pushed to achieve a therapeutic breakthrough, and, in the end, I think I was quite responsible, owning my imperfection but still endeavoring to achieve a “teachable moment” which my client ultimately appreciated as the turning point within this demo of using CAMS.

*****

Who among us is perfect at doing something as complex as psychotherapy? Is it better to train by showing relative perfection, or is it better to be real in showing a setback and then recovering? Clearly, I favor the latter. But I respect those who disagree and have strong opinions otherwise. Perhaps it is useful to reflect on the evolution of psychoanalysis during the 20th century. Early analysts saw clinicians’ reactions (like becoming emotional) as countertransference and evidence of poor training (i.e., time to go back into analysis to rid oneself of such reactions). Then there was a notable shift as drive theory psychoanalysis split off into various relational models (e.g., the British School of Object Relations and Self Psychology).

I am a fan of these relational models, particularly as they relate to the evolving notion of countertransference, as increasingly such reactions have been seen as data about the client. What the client evokes in the therapist can be helpfully used to directly inform and shape interventions. Rather than being admonished as an imperfect clinician in need of further psychoanalysis, the relational models emphasize using the clinician’s own reactions as a valuable part of the therapeutic exchange. Perhaps not surprisingly, I love Kohut’s argument that invariably there will always be empathic failures; the key is how one handles such failures in order to create a therapeutic moment. Believe me, such a view is music to the ears of beginning clinicians. And for my part, I want the people I train to see that while all of us are imperfect, there are appropriate ways to work within our imperfections for therapeutic good. Should beginning clinicians and even seasoned clinicians actually see a setback and consider the range of ways of responding? There is no doubt in my mind. And until I finally master being perfect, I will continue to show struggles in my trainings and how such struggles can ultimately be made into therapeutic gold!

Melting Fear with Love

Posted on by Psychotherapy.net Team

Walking up the back stairs, I heard someone yelling and cursing loudly. I pressed the red button releasing the door lock and came onto the third-floor unit. The fire of her fury had burnt out rapidly, and a 32-year-old young woman—I’ll call her Gwen—now sat hunched and sobbing in the nook at the end of the hallway. I thought if I spoke or approached too closely she would dismiss me, so I sat quietly 10 feet away. Her breathing slowed, she sighed and looked questioningly at me. I introduced myself and my role as a therapist, and she began to tell me of her frustrations: with her medical problems, her mood shifts associated with bipolar disorder, and feeling trapped in a nursing home with people ordering her around.

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During her stay, Gwen had many similar fiery outbursts aimed at authority figures, and weekly conversations with me in which she spoke of being trapped and tormented as a child in foster care. She felt furious with her biological mother for abandonment, and with her abusers. As a child, her proficiency with math was a saving grace for Gwen, and her most keen desire was to teach young children about the delights of mathematical thinking. Gwen had been burned by betrayal as a child, and suffered inflammatory medical problems and destabilizing bursts of inflamed emotions that limited her progress in pursuit of her goals of a stable life and a teaching job. She loved being a teacher of young children and wanted to stabilize her physical and mental wellness so she might obtain an apartment and a return to work.

Yet Gwen could easily erupt in dragon’s breath fury when frustrated or challenged or limited by an authority figure. We talked of how her suffering as a child was unjust, and how her feelings of anger were understandable, yet how the heat, hammer, and anvil of her anger needed to be forged into steel-strength skills for successful adult functioning.

Watching the movie Frozen with our grandchildren, I was reminded of Gwen, and reflected further on the emotional themes she and the fictional character Elsa had played out in their lives. Each an orphan with a gift, overwhelmed by circumstances and emotional reactions to them and fleeing into unhelpful and alienating defenses—either with ice or fire—and as yet unable to assume full adult responsibility until brought home by love.

***

In the movie Frozen, the initially playful child, Elsa, has been endowed with special powers over the piercingly beautiful yet dangerous elements of winter.

In Norway, the setting for the movie, the freezing powers of winter exert tremendous influence over the lives of the Norwegians. It seems only natural to mythically imagine reversing the dynamic and exerting unique and personal control over cold, ice, and snow.

Elsa is not only endowed from birth with ice magic, but she is also likewise enlisted from birth to inherit grand royal authority as the Queen. Yet with a lack of parental or adult guidance or guardianship, she is left unprepared to understand or to cope with either form of power. With no guiding principles or instruction, she can only rely on her increasingly troubled and difficult-to- control emotions for direction.

In her journey from fear towards love, Elsa magically conjures two characters: Olaf and the Snow Monster, which represent differing elements of her character and of her reactions to the overwhelming circumstances enveloping her. Olaf represents the playful joy of Elsa’s childhood with her younger sister Anna, and the Snow Monster embodies the ferocious defensiveness Elsa has developed as a coping strategy.

Elsa learned only fear and cover-up as ways of managing her special gift. Added to that were the burdens of unresolved grieving over the deaths of her parents and her misguided estrangement from Anna. Under the additional burden of authority as a newly crowned queen, Elsa fails and flees; from the sister she ostensibly wants to protect—even when Elsa knows that Anna is actively endangered by a conniving scoundrel—and as well from her responsibility for the needs of the people she is destined to rule.

Elsa experiences an initial, albeit illusory, euphoric sense of release—which is anything but genuine freedom—as she isolates herself ever further inside a grand though chilling fantasy of solace through solitude.

Elsa, sadly, is not—at least not yet—a heroic figure. She never risks herself for the sake of another. Elsa is a tragically lonesome figure who withdraws from others into an ever-deepening coldness. Elsa even rejects her sister after Anna has come to call her back to family and community and responsibility.

The real heroine of the movie is Anna, who remains hopeful even while enduring a childhood of rejection and imposed isolation. Anna always believes the best about her older sister Elsa, and Anna departs immediately, and on her own, to find and rescue the sister who has run away.

Anna awakens love and heroism in the character Kristoff. It is their budding love for each other, along with the vestiges of Elsa’s hope and joy in the figure of Olaf, which prepares the way for Anna to give of herself to the end in a successful attempt to save Elsa through an act of true love.

***

Two years after my initial encounters with Gwen, I had the opportunity to work again with her in a different nursing facility after she experienced another medical flare-up. This time, her attitude and outlook were far more mature and optimistic than when we first met, yet she still struggled with unstable medical and emotional distress. She was considering the short-term goal of moving in with a family—a lady and her two young adult daughters—under a foster family care program. One morning she was crying heavily when I came to her room. Gwen said, “I know it’s different, it’s not the same as foster care when I was a kid, but it reminds me of that.”

The host family was patient and kind and invited her six times to their home, so she might gradually consider the option of living with them, without any rush to decide. Gwen reflected with me on each contact she’d had with the potential host family—what they said and did, and how kind they had been and how hard it was for her to trust that it might turn out well. However, she also felt reassured to learn that the host family would hold no authority over her, and that she would be free to move on from their home to her own when it became available. She could live in a house with a friendly family—with ordinary routines and with full opportunities and encouragement to pursue her dreams.

Here finally was a chance for the stability she yearned for without the need of flame-throwing defenses. For me, Frozen was the perfect illustration of the challenges of coping with losses and misfortunes and injustices, while learning to love and care for others and to responsibly develop one’s particular gifts. As a psychotherapist, I was able to draw from the riches of mythology, fairy tales, literature, and cinema to elicit analogies and insights to formulate broader understanding of the trials encountered by my client.

Two weeks after moving in with that family, Gwen returned in triumph to the nursing facility to share her relief and satisfaction. The gentle and loving support of the host family helped to melt her dreadful fear and allowed her to enjoy the ordinary, yet for her rare pleasures of family life.

Anger and Powerlessness in the Era of COVID: Changing the Narrative

Posted on by Psychotherapy.net Team

Anger seems ubiquitous in our society, a pandemic, perhaps, if not an epidemic. Our clients come to us angry about a great many things, and have a right to be angry about many, if not most of them. Furthermore, while anger is usually thought of as a dangerous, uncomfortable, or even “negative” emotion, it can actually be very healthy—an emotion that alerts them to the fact that they might be in danger—that things are not okay. That a boundary has been crossed. That they are not safe or someone else isn’t. Anger can provide our clients with important information—that action needs to be taken to make things right or to create safety.

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That said, just like any emotion, while the initial feeling of anger might be justified, our clients’ understanding of the feeling, and the narrative that accompanies it, might not be. In other words, feelings are never wrong, but interpretations or narratives about them (and what to do about it) often are.

To give a simple and common example, a patient of mine, Jonathan, has struggled mightily with road rage. If he was driving and another driver made a dangerous move in front of him and nearly caused an accident—or even simply made a move he considered to be “inconsiderate” of him—he often felt a surge of adrenaline, experienced initially as fear and then as anger. Here his anger was telling him—in some cases rightfully—that the person made a dangerous choice that was not safe for him.

However, as we slowed down and analyzed his reactions and looked into the narratives he created around these incidents, we learned that there were layers of interpretations. The first was obvious and caused anger from feeling unsafe: that the other driver was being unsafe or not considering other drivers. But Jonathan was also creating a second narrative with that anger: he was interpreting the other driver’s behavior to mean that they didn’t care about him or, worse, that they were recklessly disregarding his safety on purpose. It is this second narrative that would cause him to become even angrier and lash out at the driver in some way that would lead to intimidation or unsafe behavior by him or both parties.

In our work together, Jonathan became able to suspend his second narrative and hold the possibility that it could have simply been that the person wasn’t paying as close attention as they should have at that moment—something that happens to almost all of us. Or that they were rushing to the hospital because of a medical emergency and paying less attention to safety in the interest of speed. Or perhaps something flew into their eye, and they were temporarily blinded. Or maybe even that people’s definition of consideration was different than his, and that was okay. In time, he was able to understand that he didn’t actually have the information that would allow him to attribute motive or intent to the other driver.

Allowing his anger to create that second narrative might have made him feel good or righteous at that moment, but ultimately it wasn’t based on fact and, more importantly, it frequently led to less safety rather than more. Most often, the reason he created that second level of the narrative was because of rage’s closest companion: powerlessness.

When hurt, our clients’ safety has typically been threatened, or a boundary has been crossed. It is not just anger that they feel, it is powerlessness. They feel out of control. Someone, or some group, has made a choice or choices that had an effect on them (or people they cared about, or the planet), and they hadn’t been consulted. The choice was made without them.

This points to an experience that is deeply uncomfortable and yet an undeniable fact of life: our clients don’t always get to choose how things go, even when it is painful for them. They come to recognize that to a degree, powerlessness is part of life.

This fact of the human experience is so difficult to accept. And it’s especially difficult to accept for clients who were traumatized as children—they were taught that powerlessness brings victimization and pain, so they feel terrified of being powerless again. This was certainly true in the case of Jonathan, who was severely abused as a child. Experiences of powerlessness would trigger that childhood trauma, and he would respond with rage and actions that instantly created a feeling—for a moment at least—that he could feel safe through feeling powerful, even if it was at the expense of the comfort of others (or ultimately even his and their safety).

But even among those who were treated well as children, our clients would all so much rather feel in control of their lives. Make no mistake—they should feel empowered to do all that they can and make the best of the life that they have. But the hard truth is that their power is limited. For some more than for others, but no amount of money or status will create immunity from powerlessness. If it rains when we are out for a walk, we will all get wet. Anyone could get cancer. Bullets won’t bounce off any of our flesh. If the global climate catastrophe in front of us continues, none of us will survive.

And so it is with COVID. Our clients feel deeply powerless when faced with the virus that is circulating the globe and wiping out millions of people in its wake. They come to understand, slowly in some cases, that they are all, to a greater or lesser extent, dependent on everyone else in order to create safety for themselves—in essence, as individuals they are powerless to stop it. This profound powerlessness is deeply uncomfortable and, along with the anger that naturally comes from feeling unsafe, many of our clients have coped with that by creating a second level of narrative to try to regain a sense of power.

Helen is an elderly patient in her late seventies whose husband of over fifty years had a kidney transplant several years ago due to a genetic disorder that caused kidney failure. Because of the transplant, he is on daily, lifetime immunosuppressants so his body doesn’t reject the kidney. Unfortunately, these immunosuppressants also make it impossible for his body to effectively fight off illness or respond to a vaccine in a way that would create immunity from COVID-19. Given his age and compromised immune system, he would in all likelihood die from COVID were he to contract it.

Helen and her husband are still full of energy, creative, and sharp of mind. They want to visit their children and grandchildren, travel, volunteer, and spend time with their friends. Instead, they are forced to be extra cautious and conservative in their actions and activities, reducing their world to one that is much smaller and less fulfilling than they would like. They feel trapped at home. When Helen reads on the news that people in her community are choosing not to get vaccinated because it’s their “right” or “COVID isn’t as bad as the hype” or “the government can’t tell them what to do,” she is deeply enraged. She talks bitterly about how they are “selfish” or “uneducated” and that perhaps dying from COVID as a result of their actions “is what they deserve.”

Helen is feeling enraged at the people who aren’t getting vaccinated or wearing masks. Some would argue justifiably so—their actions are denying her and her husband safety and dramatically affecting their lives. However, by attributing a lack of empathy, lack of intelligence, or malicious intent to those people, Helen is adding a second narrative to counteract her feelings of powerlessness about the situation.

Thus, whether our clients are calling the unvaccinated “stupid” or they are protesting mandatory vaccines or mask mandates, purchasing medicines not advised by the medical community, or grasping on to conspiracy ideology in order to feel more empowered by having “insider” information, these actions, amongst so many others, are ways in which Helen and others in similar or related circumstances are reacting to an experience of powerlessness and anger.

***

Anger and powerlessness are understandable under the circumstances described above in the cases of Jonathan and Helen, but their reactions, like most of those my clients experience, end up being destructive to self and others. As a therapist, I have found it useful to help my clients understand their feelings and then hold the discomfort of their powerlessness while letting the anger move through them. It has also been very helpful for me to guide them in avoiding the creation of secondary narratives, through which they attempt to grasp feelings of empowerment through frantic and unhealthy action that only serve to feed their rage. Instead, I encourage them to remain as safe as possible in this COVID era, while living with the uncomfortable feelings that powerlessness often brings.

The Day My Life Turned Upside Down

Posted on by Psychotherapy.net Team

The call came at 5:45 in the morning from an unknown number in a familiar area code, an auspicious beginning to any day. An emergency room nurse was calling to inform me that my twenty-six-year-old son had been in an accident and had arrived at the hospital unconscious with a traumatic brain injury. He was nearly 2000 miles away and his prognosis was unclear.

I was due to see my first patient on Zoom in a little over an hour and had a full day scheduled. As panic set in, I literally started walking in circles and I knew that, “COVID be damned,” I was getting on a plane as soon as I could to be with him. I also knew that I could not take care of anyone else at that moment. I was channeling all of my energy to will him back to health.

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For someone who is a planner, I have a professional will as well as a personal will, disability insurance, and life insurance. I was thoroughly unprepared to have my life upended so suddenly. I have maintained a solo psychotherapy practice for more than thirty years, and I’ve always managed my own schedule. There have been days when I woke up ill or had a sick child which required last-minute cancellations, but typically my absences were thought-out and scheduled. This was different. I quickly realized I was incapable of determining what next steps needed to be taken at that moment.

Operating on instinct and adrenaline, I called a close friend who offered to contact everyone on my schedule for that day. This was a godsend, because I knew I was unable to speak to anyone at that moment with any semblance of professional decorum. She also canceled the next day’s appointments, which gave me through the weekend to figure out what I would need going forward.

Just as I longed to have someone reassure me that my son would make a full recovery, I found myself wishing I had been better prepared for such an emergency. No one wants to have a dress rehearsal for trauma, but feeling so out of my depth only added to my distress.

Ironically, because of COVID-19, I had been working remotely for over a year and a half, which meant I had all my patients’ contact information on hand. In the past it would have been in my office and inaccessible to me from afar. Having up-to-date patient contact information readily available made it possible for me to draft an email to all my patients. Before writing to my patients, I called a colleague and asked her to cover my practice for me. In the email, I informed my patients that due to a family emergency I was taking a leave of absence from my practice for the month of July. I included contact information for my colleague in case they had an emergency. I promised to be back in touch by the end of the month with an update regarding when I might be able to resume work. In the email I tried to walk the line between providing sufficient but limited information about my son’s accident. Since I didn’t trust my ability to communicate clearly, I asked my colleague to proofread my email and kept her in the loop of what information my patients had.

Traumatic events rip the Band-Aid off our belief that we are in control of our lives. Without this protective layer it can be hard to regulate emotions. At other times when there was stress in my personal life, work often offered a respite from these concerns. But this time was different. Living out of a hurriedly-packed suitcase in an unfamiliar city and spending long hours at the hospital each day was exhausting. Although my son’s prognosis improved, the timeline for traumatic brain injuries is not clear cut. In the early days of my son’s hospital stay, I was consumed with fear and anxiety for his well-being and future. Both my husband (who went on FMLA for the month of July) and I were riding the waves of our son’s recovery and setbacks, unsure of when we could return home and resume our life.

Having been immersed in a pandemic for over a year was a good lesson that plans need to be held delicately and that caveats are the rule, not the exception. As we spoke with the medical personnel about discharge plans for my son and the possibility of his returning home with us, I began to do a self-assessment about my capacity to work.

Therapists are not interchangeable, and the particulars of each case are privy only to those in the relationship. This puts additional pressure on clinicians to return to work. When I am on vacation, thoughts of various patients enter my mind. Often, I have found those periods to bring fresh insights into my work. But this was far from a vacation, and I had no bandwidth to think about my patients. This was one measure I used to assess whether or not I thought I was ready to work. The first time I found myself on a walk with thoughts of a patient entering my awareness, I took that as a sign of my own road to recovery.

Fortunately, my son improved more quickly than anyone predicted, and we were able to bring him home with us. Despite his favorable outcome, the remnants of this traumatic event left me emotionally raw.

As promised in my first email, I sent another email to all my patients at the end of July. I updated them about my son’s progress and my decision to return to work at the beginning of August. As a way to check in and allow each of them to ask questions without using their clinical hour, I decided that I would call each of them before scheduling a session. I wasn’t able to talk easily about my son’s condition, and I was afraid of getting overwhelmed with my own emotions during their clinical hour. I scheduled four phone calls a day with time in between each one. After a month, or more in some cases, since our last appointment, I didn’t think it was fair to use their time with me to update them on my situation.

As with any significant interruption in a therapy relationship, each patient handled the break differently. One patient said, “I know in the back of my mind that you’re a mother, but I never think about you that way. I was so worried for you because I know I couldn’t bear to lose one of my kids.” Other patients were afraid I might never come back to work and felt selfish for having this concern. A few patients decided not to resume sessions, reporting that the month away had given them an opportunity to decide that they were doing well. I wasn’t surprised by this reaction and tried to process it with each one to bring closure. Two patients gave birth during the month I was away, and both spoke about how differently they reacted to my situation because of their new role as a mother. All of my patients expressed concern for me and appreciation for our connection. I found this especially meaningful at a time when I was questioning so much about the vagaries of life.

Initially there were some bumps in the road as I returned to work. Some patients struggled to share their concerns without feeling self-conscious. They compared their situations to mine and felt foolish to be upset over seemingly trivial matters. This is a common concern in therapy and one I have encountered many times over the years. As I struggled with managing my own anxiety, I was afraid I wasn’t projecting my usual self-assured presence to my patients. A few colleagues of mine have had to navigate more difficult life events, such as sudden deaths and personal medical crises while continuing to work, so I reached out to some of them for support and guidance.

To take care of myself, I started back to work slowly, spacing out sessions when possible. Not surprisingly I was exhausted at the end of each day, yet I found sleep hard to come by. Three weeks after returning to work, I took a previously planned vacation. This further disruption to my practice was admittedly quite difficult for some of my patients, but it felt crucial for my own well-being. During my two weeks off, I noted all the ways a vacation felt so different from an emergency leave, and I returned to work in September more refreshed. This additional break had an unexpected outcome in that it allowed my patients to express a wider range of feelings about my absence. As one patient said, tongue in cheek, “You won’t be doing that again for a long time!” She was in the middle of a painful divorce, and the timing of my absences was especially hard for her. She could express her feelings after my vacation, but not when I returned from my leave.

Modeling self-care is different from talking about it. As therapists, we know “actions speak louder than words,” but often we communicate “do as I say, not as I do.” I thought back to all the times I’ve encouraged patients to take a leave from work or make other life changes to support their own mental health. I could sense how carefully some of my patients were watching to see if I was truly okay. For those who are invested in keeping me on a pedestal, the illusion of my perfect life was shattered, and this was an uncomfortable intrusion into the transference. For others, knowing that something bad had happened to me helped them trust that I could actually understand their pain. Still others expressed an increase in their fear that if I wasn’t safe from harm, then no one could protect them. Processing this variety of responses while tending to my own anxiety was challenging.

***

Throughout my career, there have been stories from my life that I occasionally share with patients as points of illustration or connection. One day I hope I will be able to draw from this recent traumatic experience in a similar way, but for now it is still too raw. As we near the sixth month mark from the accident, the timeframe given by the medical professionals for the fractures to fully heal, all indications are that my son will make a full recovery. I am truly grateful for this outcome, but tears are still close to the surface for me. It takes time to integrate such a life-changing experience, but with support from others I trust I, too, will heal.

Being a psychologist is one of my life’s greatest pleasures. It gives me a sense of purpose and allows me to engage fully with other people. Relying on myself for so many years in private practice comes naturally to me, but this recent experience was my wake-up call that I need to be better prepared to make sure my patients can be cared for in the event that I can’t do it by myself.

Then My Christianity Kicked In

Posted on by Psychotherapy.net Team

My father told me that his grandmother practiced Santeria by wearing amulets and skirts of various colors and surrounding herself with stones in order to honor the various deities. She also made herbal remedies. I remember him explaining to me that this practice was no different from other religious traditions, that it was not witchcraft, did not hurt others, and was deeply spiritual. He believed that it was looked down upon because of its origins in slavery and false association with witchcraft.

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However, I grew up mostly with my mother’s side of the family, in which everyone is (was) actively involved in the Christian faith. I, too, practiced Christianity for many years, although not as devoutly as they did. My family actively distanced itself from those who practiced Santeria. While they acknowledged it as a religion, they even more deeply believed that it was about hurting others, did not honor God in the way that Christians do, was equivalent to witchcraft, and sought to lead followers down a path of misery and suffering. My family also believed that according to Santeria, we bring spirits with us when we die, which for them was the equivalent of demonic possession.

Recently, while interning as a counseling trainee at a local Hospice facility, these two religious pathways intersected most dramatically for me. I had stopped by the room of one of our residents, a middle-aged Cuban woman who had recently suffered a stroke and whose life had been cut short by cerebral arteriosclerosis. She would soon be leaving behind two sisters and two daughters.

As I stood in the doorway to her room, about to knock, I noticed her stones, crystals, and spirit dolls, material staples of Santeria practice. While I know people who practice the religion, I have never had, nor taken, the opportunity to speak with them about it. While the religious adornments in her room were not what I would call “extreme,” I was immediately uncomfortable. I remember thinking, “Oh, wow, what do I do now? and “Why does she have this around,” and “I don’t want to touch these things.” In looking back at that moment, I worried that my lack of experience with and knowledge of the practices of Santeria might taint my interactions with this woman.

It was at that moment that my Christianity kicked in. All those negative messages I had heard over the years about Santeria swirled in my head as I stood there unable, or perhaps unwilling, to enter. I felt caught between the competing pulls of my rigid, conservative Christian religious upbringing and my desire to enter the patient’s space and in some way be helpful. It was like trying to simultaneously focus on two discordant melodies, and not being able to clearly hear either. I realized that I was there to help this woman, to be present and open to “her,” but felt guilty for somehow betraying the values of my family. My Christianity had never been put to this kind of test.

While I so wanted to help ease her burden of impending death, I also felt guilty for not being able in the moment to fully put aside the biases I had been exposed to regarding Santeria. I remember telling myself to stay open-minded, but was painfully aware of feeling that I wasn’t going to be able to help her at all. I took a deep breath and entered her room, trying as best I could to free myself from the gravitational pull of that doorway and my inherited beliefs. I really had no choice but to push forward, at least for the moment. I knew as I entered the room that I would have to revisit this painful moment of conflict if I was to become the therapist I hoped someday to be.

When I later spoke with the patient’s daughters and sisters, each of them kind and compassionate, I realized that they, too, were having difficulty, but not for the same reasons I was. They were struggling to come to terms with the impending loss of their loved one rather than with her religious practices. I worked hard to focus on their pain so that I could be there for them as they were attempting to be there for my patient.

During that first meeting with the patient and her family, I had difficulty freeing my gaze from the dolls and scent of Florida water perfume, said to bring peace, luck, and fortune. We did not discuss Santeria—that was my issue, although I probably could’ve asked how Santeria played a role in their lives and that of my patient. They shared that my patient was the one who had been responsible for bringing most of her family from Cuba and how she was this larger-than-life person. This small but deeply significant piece of family history helped me almost instantly to see my patient as someone larger than the small, frail woman who just happened to practice a faith so different from the one in which I had been raised.

Subsequent family meetings focused on their efforts to accept the impending physical loss of their loved one and how they were attempting to build a support system around one of my patient’s daughters who was in the grips of addiction. They, like every other family in Hospice, irrespective of religious practice, were trying to come together. When my patient finally passed, they were saddened but relieved that she was no longer in pain.

I have not historically viewed myself as a closed-minded person, but in retrospect see how my faith, my religion, came with blinders. I won’t soon forget that initial feeling of discomfort when I stood in that doorway, caught between two different worlds and self-focused. My biases were laid bare that day, and thankfully, I was able to hold them in check just long enough to be of use to that dying woman. I now realize that moments of growth and self-awareness are not always accompanied by good feelings. I am, however, willing to learn, and I am taking the opportunity to better understand Santeria, and what it means to take a giant step away from certain aspects of my family history without feeling diminished or disconnected. It helps that in this my second-to-last semester of graduate studies that I am enrolled in a diversity course and am trying to be a better version of myself, so that the next time I stand in an uncomfortable doorway, I will walk inside with a lighter step.

Confessions of a Student Counsellor

Posted on by Psychotherapy.net Team

Both Sides Now

At the time of this writing, I have one semester to go before completing my Master of Counselling degree, and I am sixty-five hours into the one hundred required hours of counselling contact hours of my student placement. I am still unsure as to who has received the lion’s share of therapy during these sixty-five hours, my clients or me?

This has not been my first exposure to the rudiments of counselling, however—I had some years of experience in addictions counselling and case management and no shortage of support work in various fields to ease me into the relative displacement of a professional counselling placement. At forty-seven years of age, I have undergone many transitions and life experiences.

Nevertheless, the Masters has been quite a proficient primer and prodder of the all-too-many things I didn’t (and still don’t) know about counselling practice, and of the myriad of things that I need to know in order to provide effective and ethical therapy for a range of concerns and to a broad demographic.

Having had experience in various counselling settings—and being quite familiar with both sides of the counsellor’s chair—together with the fact that I consider myself an avid collector of knowledge, particularly in this field, I still felt a strange cognitive dissonance of both excited preparedness and complete inadequacy to the task at hand at the commencement of my placement. But that was then. At sixty-five hours in, I am a worldly veteran!

The first thing that stood out to me about my placement experience was how pretty much every session turned into a countertransference case study from my ethics class, except that I was the subject. I knew about countertransference. I had studied it. Experienced it. Was consciously aware of it. Prepared, I thought. But I never really had that meta-cognition before that one develops, both while counselling and in the post-session self-flagellation…ahem, reflective practice.

Almost every session seemed like a mirroring of the personal life struggles I had faced, parallel processes of my current situations, relatables that were bone deep. The client I was sitting with was recounting the very relationship issues I had struggled with. Of course I was batting for him! My heart was filled with sympathy, my responses were, albeit textbook, empathetic, while my mind was firing off mostly Andrew-shaped responses ready for delivery. Often, I would catch myself before essentially counselling myself instead of my client. Sometimes I was too late and would realise, embarrassingly, later that day or week. More often than not, in supervision. Or because of past supervisions.

Or I could be sitting in front of the horrifying ghost of my mother-self. That is, this particularly triggering, discomforting, and disquieting quality that my mother possessed which I painfully one day realised I had inherited, now (mostly) exorcised out of me (thank you therapists circa 2000-2004, 2008-2009, 2012-2013 and 2020-2021; you know who you are). Noticing the life force draining from my being, I would sometimes sit across from the ghost-client in a sorrowful-seething state of frustration, compassion, bewilderment, intrigue, and hopelessness. I could swing between feeling annoyed and way out of my depths to such misguided compassion that I would feel the urge to take them home and care for them.

Going it Alone

Something I knew before but re-experienced in a fresh new light during my placement is that a significant part of learning to be a counsellor is essentially done alone. There is generally no direct supervision. There is no one in the room to monitor the minutiae of one’s work. There is no direct feedback loop. It is not as if your supervisor has a document to proofread. There is no material structure to assess for imperfections or to correct. No one is surveying clients at the end of sessions to establish trainee performance. No one is there to say, “Hmmm, maybe when you froze for a minute and a half with silence…” or “Perhaps Texas Hold ’em Poker isn’t the most appropriate game to play in a session with a six-year-old…” Of course, there are opportunities to be observed by colleagues and supervisors or to record sessions and review them. But this is limited in its scope and practicability. And daunting as hell! Or as daunting as having my own personal therapy sessions broadcast to the world, perhaps. Being utterly exposed. Vulnerable.

Sitting with clients who have just expressed something, there are a plethora of potential responses in any given moment of a therapy session. Sometimes they flow readily and easily. At other times they feel forced. And in some cases, when a response hasn’t felt right, an also potential plethora of self-reflective doubt and questioning can follow: “Did I say the right thing?”; “How am I going with this client? Doesn’t seem to be any progress being made”; “What is the correct intervention to use here?”; “They have been coming for three sessions now, why won’t they volunteer something… anything?!” Being left to one’s own devices (well, me to mine) can leave one unsure at times about particular interventions to use, ways of progressing through impasse, whether or not to refer, whether I am beyond my professional competence, and one’s capacity to be a counsellor, which can undermine self-trust and even self-worth.

And then at other times, when I am feeling in my flow, when I have recognised counselling greatness in myself—you know, when a client has expressed eternal gratitude or you witness a breakthrough or an insight emerges—then I can quite easily develop that very shiny, bulletproof sheen of self-satisfaction and self-congratulation, feeling like the king of the counselling castle! Either polarity can be both misguided and unhelpful to me, I have discovered, and, left alone with such musings, can be a potentially missed opportunity to see beyond my own perspectives and to develop my practice.

Thank goodness we are not completely alone during this, at times, trial by fire. Having practicing colleagues around is such a comforting and valuable scaffold of support. I am fortunate to be doing my placement in a medium-size clinic providing both psychology and counselling services, so there are usually at least a few others to talk to or debrief to if needed. I am aware, however, that others’ placements are more isolated and devoid of such support, and I have witnessed the emotional and psychological strain that this can take. I am very grateful to be developing in the kind of environment where I feel supported and not alone. Hmmmm, maybe there’s a market for a Tinder-like app for counsellors in isolation?

I think there is a limit, however, to how far collegial support can go. There are certainly limits to my own (and I am guessing other humans’) capacity to expose oneself in the workplace. Especially as an up-and-coming trainee counsellor, wanting to exude competence and confidence at every opportunity (I am willing to admit that could just be me, but I suspect not). Clinical supervision during my counselling placement has been a great support and I think the site of my most focussed learning during this Masters and certainly during my placement. I am fortunate to have both group and individual clinical supervision. They are both supportive, instructive and provide opportunities to develop and learn from others’ practice. I have found that it is in individual supervision, however, that I have the greatest opportunity to be vulnerable and to shed light on the more shadowy areas of my practice. It feels a bit safer than group supervision and I like its structure, containment, consistency, and predictability.

Maybe Not Completely

I am fortunate that I was paired with an external clinical supervisor by my university placement team whom I like and respect, but, most importantly, with whom I feel safe. Safe to say (almost) anything to. Safe to expose my insecurities and doubts to, to be able to tell them what I did and said in a session, for example, without any debilitating apprehension. They provide safety and security in calling me out when needed, ensuring I understand my limits and blind spots. Kind of like a parent’s love in providing firm and consistent boundaries to an overly exuberant child. They encourage me and validate me, sharing their own stumbles and falls. But the catch is, as I recognised a while ago, I must be willing to be vulnerable and uncomfortable and wrong, again and again, to gain the most from this. I must be willing to be a beginner again and again and again if I am to grow and develop as a person and as a therapist. But this is hard to do at times. For fear of judgement (self and other), feeling inadequate and for (the generally unfounded) fear of finding out that maybe I am not cut out for this profession. The most satisfying, albeit challenging, learning I have experienced during this placement, and the Masters too, has been exposing myself in supervision.

Like when I reluctantly discussed a client I had seen once whom I suspected to be beyond my scope of competence. Reluctant because I was personally and professionally very curious and they claimed they weren’t in a position to engage in costly treatment options and so I really wanted to keep working with them. And I suspected that if I spoke about them in supervision (and to my line manager) that they would advise referral. But I did. And it was right. And I referred. It was frustrating and challenging, but a great experience to have in the sandpit. And I incidentally had reflected to me my potential for a hero complex. Ouch! But yes, probably accurate. Or when I spoke about how I responded to an awkward situation with a child client and their mother, suspecting I didn’t handle it very well and wanting input. And then getting feedback that challenged as well as expanded me, reinforcing that I really do not know what I do not know as well as not knowing what I do know, too. These things can sting for a bit, but I am a better counsellor for it.

Just like when I have been in therapy myself, the more I am willing to be vulnerable and uncomfortable and reveal those shadowy parts of myself, so too in my counselling role (especially as a trainee), the more I allow this, the more space I make within myself to expand. I make the space for learning and growth and development and career and life satisfaction and ideally to be a more effective therapist and, of course, to do no harm.

***

I recall a brief conversation I had with a university lecturer this year, a seasoned counselling psychologist and academic. I was reflecting on the challenges of not knowing it all and bemoaning if I would ever feel competent as a counsellor. Their response was heartening to me, then and now. They related to this feeling, stating that they still occasionally felt this way. But they also knew that they are a damn good therapist and a valuable resource for their clients. Nice.

Countering Client Hostility with Radical Candor

Posted on by Psychotherapy.net Team

“No offense, but I don't need self-awareness,” said Michelle. “That's not what I'm paying you for.” After a brief pause for emphasis, she proceeded. “I am not telling you how to do your job, but I need tools!” she demanded forcefully with a pen and notepad in her hand.

Michelle was self-referred after receiving multiple messages from friends and family that she was “difficult to deal with” and that she did not know how to “empathize” with others.

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Caught off guard, I sat silently and nodded. At that moment I felt powerless and ineffective. I also noticed my abdomen brace, as if preparing for a fight. I thought I had been doing well by actively listening to my client and helping her to feel understood. She had a gift for verbosity, which made it almost impossible for me to get a word in. By the end of the first session, however, I felt an impulse to refer her out. I even recall mentioning to her that I would find a list of providers who conducted strict CBT, as it appeared she would benefit from the structure. However, something in me then uttered out, “Let’s try my way first and if, after a few sessions you aren’t happy, I can provide you with some referrals.” I don’t know if I was slightly intrigued by the challenge or that I knew it would be difficult for Michelle to receive treatment elsewhere.

While Michelle’s intensity continued session after session, I began noticing patterns. The session would begin with some pleasantries, move seamlessly into an onslaught of reprobation, and then conclude with a slight glimmer of hope. I had never experienced anything like this.

She would admonish me for the session by saying that “it’s only me talking”—despite not allowing me to speak—and demanding that “in one of these sessions, I am going to need you to do most of the talking.” Further, she compared being in counseling to being in a “hospital” (the first time I had heard this reference).

“Don’t enact your rage on her,” said my own therapist, after I vented extensively about my exasperating and confusing sessions with Michelle. In my therapy, I would go on ad nauseum about how I wanted her to drop out of treatment. I even mentioned how I had dreams of Michelle being much larger than me and picking me up and repeatedly slamming me down. My therapist cleverly pointed out that being with Michelle felt like a rollercoaster ride (I am terrified of roller coasters). My therapist also helped me to realize that despite my criticism and Michelle’s seeming intractable intensity and displeasure with me and our work, she kept returning.

I persisted and became more optimistic over time as I noticed Michelle becoming easier to deal with, which I disclosed to her. She dismissed my praise by stating that I was lying and that the positive reinforcement was incentivized by the fact that she was paying me. I reminded her of how she had been telling me that her family noticed positive changes as well.

One of the strategies that seemed to be effective with Michelle—in addition to the basic attending skills—was my authenticity and self-disclosure. For instance, I disclosed the fact that working with her felt like entering a boxing match, and how I experienced her attitude as an attempt to push me away—even my dream about the rollercoaster.

With regard to payment, Michelle had mentioned the transactional nature of our relationship numerous times. For instance, she once accused me of using her to pay my phone bills. I wanted to be gentle but honest. “You think this is really about the money?”—pausing while Michelle nodded affirmatively—“I lose $700 per month by working with you, not including if you skip a session.” I noticed Michelle smiling. After inquiring about how she experienced my disclosure, Michelle mentioned that this was “good to hear” and inquired further about why I continued to see her at a reduced rate. This led me to mention that based on the way she initially presented herself, it would have been very difficult for her to find another therapist (she also had complained about struggling to find one in the past) and that it would cost her a lot more money for treatment that might not have been as effective (i.e., brief CBT as opposed to more ongoing relationship focused work).

***

Michelle still has moments that make it painful for me to work with her, but I do consider our work to be successful. She is recently much more likely to notice her maladaptive behavior in the moment. She often praises me for her progress, but I do not think I deserve it. I was simply the first person in her life whom she couldn’t push away. I was also honest about how her behavior affected me without discarding her.

I believe that we can do good work with most—if not all—clients if we are willing to travel with them despite their efforts to avoid meaningful connection. I also know that honesty is the best policy when it comes to engaging people who are resistant. Sitting with the discomfort that hostile clients like Michelle can stimulate and being the one person that stands by their side has often resulted in positive change for these clients—and for me.