Author: Psychotherapy.net Team

Psychocardiology: Psychotherapists Helping Cardiac Patients

Posted on by Psychotherapy.net Team

According to the Centers for Disease Control, one person in the U.S. dies every 36 seconds from cardiovascular disease (CVD). And heart disease is the leading cause of death for men and women of most racial and ethnic groups.

Obviously, this is a huge challenge for cardiologists. But cardiologists aren’t the only ones working to slow the encroachment of these deadly diseases. The psychotherapy community is also getting involved through a field known as psychocardiology. Researchers in this area are interested in understanding how psychological factors, such as depression, anxiety, stress disorders and substance abuse, contribute to CVD and vice versa.
 

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For example, a study in the European Heart Journal by Sripal Bangalore and colleagues found that individuals with a history of CVD are more likely to experience symptoms of depression than those without such a history. Conversely, the risk of developing CVD increases by as much as 65% in individuals with depression. And in those who are already being treated for heart diseases, psychological problems can cause further complications. All of this suggests a deep, bi-directional connection between the heart and the brain.

Let’s consider what therapists need to know to put this information into practice.

What we Know About the Brain-Heart Connection

We’re only just beginning to understand the deep connection between the heart and the brain. We know, for instance, that psychological stress can put extra strain on our hearts. When our bodies are in “flight-or-flight” mode, our blood pressure increases and our brains release adrenaline, along with other chemicals that can cause our hearts to spasm.

Although these physiological changes can help us survive immediate threats to our lives, when we spend most of our time in “flight-or-flight” mode, as is the case with most of our patients, the odds of developing heart disease greatly increase. In fact, one large scale study by Salim Yusuf and his team which involved 25,000 participants in 52 countries, found that psychological factors accounted for about 30% of heart attacks and strokes.

One explanation for the increase here is that stress hormones can cause damage to our hearts when constantly released into our bloodstreams over long periods of time. Additionally, mental stress increases inflammation of the brain and the heart, which can also lead to further complications.

The Need for New Interventions

Stress Management
Armed with the information above, many psychocardiologists are focused on stress management. The hope here is that cardiac patients who learn how to better manage stress through behavioral change will not only improve their symptoms of depression, but will also see improvements in their heart symptoms.

Such findings suggest that stress management training administered by therapists and psychologists would be beneficial for every cardiac rehabilitation patient. And when compared to the cost of other interventions, like angioplasty or bypass surgery, stress management is quite cost efficient.

Improved Quality of Life
Other psychocardiologists look for ways to improve quality of life. Yes, many heart patients end up with depression after surgery or other medical treatment for cardiovascular disease. And yes, depressed people often don't exercise, eat well, or take their medications. But there may also be physiological connections between CVD and depression.

Because we know that cognitive behavioral therapy combined with talk therapy can effectively reduce depression and anxiety, there is reason to believe these interventions can also reduce levels of stress hormones, decrease elevated heart rates, and calm hyper-active responses to physical stressors.

Challenges Remain
Unfortunately, while acceptance of psychocardiology is growing among the medical community, there are still challenges. For one thing, it’s difficult to get insurance companies to pay for any cardiac rehabilitation, let alone adding a psychological component. And with hospital stays getting shorter in the U.S., there’s little hope for inpatient rehabilitation and outpatient rehabilitation tends to focus on physical therapy, since insurance refuses to pay for other services.

However, none of the above has to get in the way of therapists’ treating their own patients, inquiring about heart disease symptoms, and making them aware of the heart-brain connection. Additionally, we all need to look for ways to treat the whole patient and to partner with cardiologists or other clinicians to ensure that our patients receive the best care possible.

Case Application

Jeffrey, a 48-year-old male with symptoms of depression, was referred to my office by his cardiologist for an evaluation. Jeffrey presented with both anxiety and depressive symptoms. His symptoms of depression had been present for nine months. Jeffrey was an avid cyclist who had recently suffered a myocardial infarction (MI) that required a cardiac catheterization, medication management and a cardiac rehabilitation program. Even though Jeffrey recovered from the MI, it left him with damage to his heart muscle, and he was advised by his cardiologist to continue to exercise but that he must also “slow it down.” This meant that Jeffrey could no longer ride with his buddies, something he used to look forward to all week long, since they rode at a level that would cause too much strain on his heart.

Even though Jeffrey was given clearance by his cardiologist to ride again, over the past nine months he had been struggling to get started. Jeffrey was becoming increasingly anxious that riding would put too much strain on his heart and possibly cause another cardiac event to occur. He worried about what would happen to his wife and two children if he had another MI and did not survive. He would ruminate over the possibility of never being able to keep up with his cycling buddies, a group that he had been riding with for over ten years.

The worry was starting to negatively impact Jeffrey. He now had low energy during the day, no motivation to exercise or join his family and friends in weekend activities, difficulty concentrating at work, poor sleep, weight gain, and feeling “down” on most days.
After taking Jeffrey’s medical and psychological history, I explained the mind-body connection, the concept of psychocardiology, and the comorbidity between psychiatric disorders and heart diseases. I also explained the bi-directional relationship between the heart and mind and how his heart problems were negatively impacting his mental health state, and that by working with him to help his mood, he would feel better physically.

To alleviate some of his anxiety and to highlight his body–mind connection, I incorporated breathing exercises and other relaxation techniques, such as guided imagery and body scanning to reduce stress and muscle tension. Body scanning is like meditation; it enabled Jeffrey to get in touch with his physical symptoms and their meaning. Jeffrey started to realize that cycling was a coping mechanism that he used to alleviate his anxiety and that now he needed to discover new methods. He identified his all-or-nothing thinking, e.g., “If I cannot ride my bicycle a certain way, I would consider myself a failure.” In sessions we addressed how this rigid thinking made it difficult to recover when something unexpected occurs.

CBT exercises helped Jeffrey explain the link between cognitions (beliefs that he would never be able to keep up with his riding buddies) and emotions (fear, failure) and safety (he may have another MI and not survive this time). Cognitive restructuring helped to identify old and new stressors, understand what response they trigger, and find alternative responses. During sessions, Jeffrey identified and processed the negative feelings that surfaced during his forced time away from riding. To increase self-confidence and reduce anxiety, measurable, realistic, performance-based goals were developed and monitored in each session.

***

Jeffrey’s unexpected cardiac event resulted in an immediate imbalance and disruption to his life. The inability for him to continue cycling was devastating and hindered his recovery process and negatively impacted his mental health. Jeffrey’s deeper understanding of the role psychological well-being played in his physical functioning resulted in greater motivation to work on his mental and physical health. The collaboration between two specialties, cardiology and mental health, enabled Jeffrey to have his psychological and physical needs managed simultaneously.
 

Exploring Our Client’s Multiverse

Posted on by Psychotherapy.net Team

Whether you ascribe to Jung’s theory of archetypal selves or follow Richard Schwartz’s Internal Family System’s (IFS) theory of parts, clinicians likely agree that the human consciousness contains multitudes. Consciousness—collective or otherwise—is multifaceted. IFS or the clinical practice of inviting a client’s different parts to engage in both internal and external change can offer something to even those clients who report a life free of both pathos and pain.

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For clients who make meaning of their lives through stories, we prefer to call this work Internal Fandom Systems (IFans). We have used the power of fanfiction to make IFS more inviting to our pop culture-fan clients, and still appreciate the canon that Schwartz created. We made this change to help our story-loving clients become curious about the wide cast of characters who inhabit their inner world. Inviting clients to notice and then engage with these different parts of themselves can be the beginning of a mythic adventure. But how do we get clients to notice the different parts that exist within them?

First, we engage the client in a brief psycho-education dialogue explaining the theory behind parts. For clients who are particularly interested in psychodynamic theory, we take a heaping spoonful out of the collective unconscious and explain the ways that the work of other great thinkers both paved the road for and are consistent with IFS. Once the logic of parts starts to become clear, we invite the client to get curious about the parts of themselves that are currently present. This differs from our standard Therapeutic Fanfiction approach in two important ways:

We are using fandom characters to help the client get to know an aspect of their own personality rather than using fandom characters and archetypes to help a client build competency and/or skills to meet an external challenge, and

Rather than learning to access the power of a fandom character in the greater collective unconscious, we are helping clients to get to know the characters of their personal unconscious. In IFans, the client learns about their own multi-verse rather than channeling a character or learning a skill from fandom.

As the client describes different thoughts, feelings, and sensations, we begin to get curious with them about the identity of a particular part. Clients often come up with fandom characters on their own, but when they struggle to describe the part, we might ask them if there is a character or fandom object that matches with the part they are currently noticing. If a client continues to struggle, we might offer a fandom character or archetype that comes to mind for us.

In a recent session with a client, I (Larisa) offered, “It sounds like this part is really worried about you but communicates in almost a condescending tone. It’s making me think of Tony Stark from the Marvel Cinematic Universe.” While the client agreed that Tony is someone who shows he cares through quips and snarks, they reported that this didn’t feel quite like their part. In this case, the client ended up choosing a different fandom character. But sharing the character that came to my own mind helped the client continue to sit with what felt most authentic to them, ultimately leading to the character who resonated most with this part—Sam Wilson, once the Falcon and now Captain America. In Therapeutic Fanfiction, the next step would have been for me to ask the client to share the skills, values, or attributes of Sam Wilson that appealed most to them. Then, we would get specific about which aspect of Sam might be able to help them face their current external challenge. But in this scenario, my goal was to help the client practice listening to their parts. Their Sam Wilson part turned out to be a protector, who was working to keep the client’s adult consciousness or Self away from the part we would eventually come to know as the Winter Solider, i.e., the shadow side of their Bucky Barnes part.

Just as in IFS proper, when using the Therapeutic Fanfiction lens of Internal Fandom Systems, clinicians help ensure that both client and therapist are getting curious about different parts, avoiding the blending of Self and other parts that can sometimes occur. As Sam observes to Bucky, “You have to stop letting other people tell you who you are.” Of course, Sam is correct. It isn’t our job as therapists to tell our clients who they are. It is our job to help them learn how to listen to their parts, to support them in learning who they are at present, and then to get curious about who they’d like to become.

Therapeutic Reflections of a Former Gang Member

Posted on by Psychotherapy.net Team

A Special Niche

“What population do you work with?” is a question that often induces mild anxiety in me. It seems like a convenient excuse for therapists to exclude groups that they don’t enjoy working with. As an example, I have heard several clinicians state that they refuse to treat people with personality disorders. While we have a right to choose (no one wants to be miserable at work), I think this attitude alienates those who may need our help most.

“Blasphemy!,” you might cry out, “We can’t be everything to everyone.” I understand. However, I got into this profession to help people. I try my best to accept people unless I believe I am unable to help from an ethical standpoint. There is something to be said about advanced training for more complex disorders. Even so, I believe that the therapeutic alliance is what matters most.

To tackle my resistance to the above question, I took a deeper look at my work over the past few years and came to realize that there is no specific population I focus on. Between private practice and a local outpatient clinic, I see clients ranging in age from five to 82 who have disorders across the mental health spectrum. If I were forced into choosing a specialty, however, it would be gang-affiliated children. I have been working with self-reported gang members since 2017, and even co-founded a clinical think tank to address their mental health needs.

Despite running the think tank and conducting individual psychotherapy with this population, I don’t consider it a niche. Instead, I view it as working with children who struggle with a wide variety of mental health challenges—especially trauma. However, admittedly, there is a part of me that may be failing to fully “claim” this population because of its associated stigma. Therapists often mention “I don’t work with those people,” or “that’s not my cup of tea,” when I share my work in this area. I also sometimes get reactions from them that appear to fetishize violence. It causes me to feel alone and ashamed.

While working with gang members may not sound appealing, it has been very meaningful for me. I credit my work with these clients as the reason for most of my clinical competency. Working with children is not easy in its own right, but working with children who are marginalized due to their gang status poses an even greater challenge. Another layer of complexity is that I, too, identify as a former gang member.

I Was a Gang Member

There is a common assumption that I might have more in common with these clients than other therapists. Sometimes this is the case, but often it is not. In fact, very few of my clients are aware of my former status. Though I am a big proponent of self-disclosure when it is useful, I rarely feel the need to disclose. The main reason is that most of what they bring to sessions are age-appropriate stressors just like other children’s: video games, struggles with parents, relationship issues. Their gang membership often comes up more as a cultural identity than an area of focus. Perhaps there could also be a small part of me that does not consider myself a “real” gang-member. After all, you can’t Google what I was a part of, and it neither made the news nor even extended very far beyond my local neighborhood.

Nevertheless, my past affiliation as a member (and leader) helps me to understand some of the nuanced challenges that these children face. I have experienced them myself. There are systemic barriers that are next to impossible to overcome, such as racism, oppression, and self-hate. My clients also share complicated feelings that they grapple with, such as feeling unwanted, constant fear, and pressure. Further, there is often confusion about who they really are.

At school I was viewed as a “nice” and “honest” child who showed respect to adults and completed assignments on time. I also had a side of me that could be aggressive and intimidating when I wanted to be. Was I the aggressive kid that some of my friends knew me as? Was I the nice child that aimed to please all of his teachers? This schism resulted in frustration about who I was and how I presented myself to different groups of people. My clients struggle with the same plight.

As I reflect on my personal experience in working with gang-affiliated clients, I often feel conflicted. I am cognizant of the ugly side of being in a gang. I am also aware of some of its benefits. This may sound distorted, but there are some strong emotional needs that are met from being gang-affiliated. For instance, I have not been able to replicate the sense of nurturance that I felt from knowing that there were multiple people willing to stand up for me at any given moment. My clients experience something similar.

I also learned leadership skills that I would later use to lead multiple organizations in the future. For example, there are ways to utilize your tone of voice to get almost any message across. I also learned the power of “the look”—a way of looking at people that makes them feel like they are the only person that matters in that moment. I would be negligent if I did not highlight some of these positive attributes. One of my clients recently told me that he watches for how people “squinch their eyes” to get a sense of who they are as a person. It took me back to my past as well.

The conflict continues. Do I act as a salesman who cleverly convinces these children to desist from gangs? The media and law enforcement would certainly suggest it. I know this is inappropriate. Gangs have been around forever, and they aren’t going anywhere; they also aren’t only present in urban neighborhoods. I know that my clients would stop trusting me if I tried to dissuade them. A break in trust could result in their losing a connection with the one person who “gets” them.

Instead, I utilize my unique skill set to help promote prosocial behaviors. For instance, I can convey that I am on their side. While I personally have not been able to replicate the sense of nurturance I felt while gang-involved, I try to help these particular clients realize that they can receive nurturance and loyalty outside of their gang. I offer a sense that I am willing to take on some of their emotional burden as we collaborate to figure things out together. I can read body language to get a sense of how I am affecting them. I can utilize self-disclosure in a manner that brings me closer to them.

The big question is, does it work?

I can only use my own experience and those of the clinicians in our think tank (it is next to impossible to find therapists that positively affirm that they work with these children). If we are using the metric of “getting kids out of gangs,” then no. However, when considering helping these children to open up, look at their lives more critically, and feel accepted in a society that is intolerant of them, then yes.

Some of the things I have heard recently from my clients are: “You’re one of two people that I feel like I can talk to,” “Talking to you eases my pain,” and even “I love you.” This is significant, considering that most of my gang-affiliated clients are impacted by stereotypical masculinity.

The Case of Jay

Jay is a thirteen-year old African American boy who struggles with symptoms associated with ADHD and Oppositional Defiant Disorder. Up until this point, he has been living with his mother and two siblings. However, due to his “attitude” and problematic interactions with his older sister, he was recently sent to live with his godmother, who lives nearby. He is engaged in school but has been declining academically. Some of his interests include playing basketball and internet gaming. While Jay has a difficult time opening up to people and is very easily agitated, he comes across as bored, disengaged, and angry.

I began working with Jay in 2018. During the first session, he sat slumped in his chair and sucked his teeth for most of the time (I later learned that Jay had a long list of therapists he didn’t like). Jay was described in the notes I received as “non-communicative” and “guarded.”

At the time of that first meeting, I was freshly out of graduate school and desperate to do a good job. “How are you?” I asked. Jay gave me a look of exasperation and continued staring off into space. Uncomfortable with silence, I proceeded to introduce myself and explained that I had been assigned to work with him (dumb move, but it helped to ease some of my anxiety). Jay didn’t budge.

This went on for the majority of the first session and the next. Anything I asked was either dismissed with one-word responses or ignored entirely. Somewhat desperate, I decided to do something unorthodox towards the end of the second session. I noticed he had been wearing some trendy sneakers that matched the rest of his outfit.

If I was going to get anywhere with this client, I had to relate with him. The only issue was that I had an unwritten, self-imposed, rule that I didn’t want to sound like some kind of camp counselor (I had some insecurities about being called a “counselor,” as it can easily be confused with a non-clinical role). I was there to be a clinician. I told myself, “Forget it!” (replace “forget” with an expletive) and went with my gut.

“I see you like to get fresh,” I noted while nodding my head and pointing at his sneakers. Something interesting happened.

“You like my drip?” (slang for nice outfit), Jay replied with a slight smile, and gave me a handshake. It was progress. I felt like a fool. Why hadn’t I tried this earlier?

Fast forward a bit. Although subsequent sessions remained generally anti-climactic, Jay did begin arriving to them a little earlier. Nothing dramatic occurred, and to an outsider, it may have appeared like wasted time. Jay insisted on telling me about the latest games he had been playing and eventually started challenging me to play him as well.

Once I felt like a strong rapport had been developed, I casually asked Jay why he thought he was in counseling. He revealed that he had been in counseling for several years before and that his family did not “like” him. He mentioned his perception of how he was disciplined more harshly than his other siblings.

Now we were getting somewhere. As time went on, the sessions oscillated between video games and minor disclosures about how upset he was with his family. “I don’t care” was one of Jay’s favorite responses.

One day I asked him to draw a picture of his family. It was not a specific intervention. I just knew, by this point, that it was one of the activities that younger kids enjoyed doing. The drawing looked like a few beetles, with his mother being slightly larger than the rest. He took the picture home with him without saying anything further.

During the following session, Jay revealed how drawing the picture helped him to realize how much he did care about his family. I was annoyed. Really? After all the sophisticated interventions I learned in graduate school, this is what stuck? I was happy with the small progress but was distressed by how random the occurrence seemed to be. Was this something that could be replicated with other clients? I soon learned that this was not necessarily the case; every client was different. Jay helped me to learn that.

A big milestone for us occurred when Jay asked if he could visit with me twice weekly at the clinic. This was not possible due to insurance restrictions, but it suggested that I had been doing something right. He became much more talkative about his life and what mattered to him.

It was not a miracle. Over time, Jay continued working well with me, but he also developed habits such as daily marijuana usage and decreased engagement in school. His mother also complained about his being “influenced” by the wrong crowd. He was no longer fighting with his older sister, but he also was not actively speaking to her either.

I could relate with his feelings of being excluded by most peers but included by other teens in his neighborhood. I told him this. Jay continued working with me as he realized I was not much different from him. I “got” him.

No Fairy-Tale Ending

This case does not have a fairy-tale ending. Due to scheduling conflicts, Jay was no longer able to work with me. Admittedly, he mentioned also becoming tired with counseling, as he had been working with therapists since he was ten. I respected it.

Jay mentioned that though he no longer wanted to continue therapy, he refused to work with anyone else (his mother was insistent upon his staying). One of the things he mentioned during our last few sessions was “you helped me control my anger,” and “now I know how to ignore people” in lieu of lashing out.

As I reflect on my work with Jay, I realized that most of what I learned in graduate school did not help me connect with him. He appreciated me for being real, being on his side (when the world—including other therapists—seemed to be against him) and disclosing parts of my life when it was relevant (i.e., the fact that I often felt unwanted in many social settings as a teen).

Further, and most importantly, I approached him as a child (now teenager) before a gang member.

I am still apprehensive when asked what population I work with. However, it is getting easier, as I remind myself of the gifts that these clients have brought to me as a clinician. My work with gang-affiliated clients has made me a much stronger clinician. I know what it is like to connect with “treatment-resistant” people. That has made me much better at connecting with clients overall.

The Pregnant Correctional Practitioner: Challenges and Benefits

Posted on by Psychotherapy.net Team

In my previous blog, I addressed my own personal growth and development that occurred during my time as a clinical social worker specializing in the area of correctional mental health. Working in a correctional environment has taught me valuable lessons about compassion and empathy, who I am, and how to sit with others who are attempting to heal in the long shadow of the darkest moments of their lives. My own experience of having been twice pregnant while working in this capacity has deepened my appreciation of the human condition.

We clinicians know full well how demanding graduate and post-graduate training are, and how these demands don’t simply stop while we are moving forward professionally. And this includes family-building. However, despite the fact that 83% of social workers identify as female, the topic of pregnancy and how clients respond to a pregnant clinician is rarely discussed in the confines of a classroom. As a result, most clinicians who experience pregnancy will out of necessity learn how to navigate these 40-plus weeks in an on-the-job-training fashion.

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Having to navigate pregnancy as a professional was challenging in its own right. Both my experience and research have suggested that women often experience far fewer advancement opportunities as a result of preconceived and outdated notions about their ability to simultaneously manage their professional and family lives. This concern often occupied my thoughts as I wondered what my professional life would look like after my children were born. These thoughts and concerns were often unwelcome add-ons to the actual physical challenges that occurred during and after pregnancy, including nausea, extreme fatigue, and decreased reliance on caffeine to provide that occasional boost. I often experienced periods of heightened anxiety with regard to my baby’s fetal growth and health. As my body changed, revealing the undeniable reality of pregnancy, my body was on greater and greater display, which made for an interesting addition to the already demanding emotional and physical nature of my correctional work.

Deciding how to respond to curious clients was always a challenge for me. This was brought into bold relief when working with those clients who, because of separation from their own families, experienced grief and deep feelings of sadness and loss. Sometimes that grief was profoundly complicated in younger clients who faced the prospects of never becoming parents due to extended prison sentences. Others, whose incarceration followed child abuse, frequently faced the possibility of never seeing their children again. As a clinician, this was always difficult to witness while I was, at the same time, navigating my own journey toward childbirth and parenthood.

My first pregnancy occurred while I was working in a women’s correctional facility. The experience was interesting, albeit complicated. I had just transitioned from working in a men’s facility and all of my rapport building in the women’s facility was done while I was pregnant. Working in this environment, I was constantly in the presence of women who had lost custody of their children, been at odds with their children due to chronic incarceration and substance use, killed their children, miscarried after a violent interaction with a male counterpart, were themselves pregnant, had given up their children for adoption, and/or had stillbirths. The questions were never-ending regarding where I was in my pregnancy, how I was feeling, and what it was or would be like to be a parent. My growing belly was always the elephant in the room, and quite honestly, practically a constant reminder for these women of what they had lost.

I worked with several women who were due around similar time frames to myself. One of the women, we will call her Melody, looked at me one day and said something that put this into perspective for me. She angrily lamented, “I can’t even look at you, it’s not fair! You’ll get to keep your baby, and I will have to give my baby up as soon as I’m ready to leave the hospital!” Before this comment, I didn’t realize how significantly impactful my own pregnancy was on the relationship I had with Melody and others in similar situations.

Fast forward to my second pregnancy, in which I was back working with incarcerated men. There were fewer questions, but the stares were more frequent and the outlandish comments about my reproductive choices would fly frequently. Since I had my two children 22 months apart, there were a few times I was asked about what I wanted for a family size—“Do you want a big family?” Or, “Are you just going to be one of those people who pops a lot of kids out?”

However, despite the loaded commentary, both the men and women I worked with showed a lot of compassion during my pregnancies. Despite the pain that this pregnancy evoked in them, particularly around their own losses and desires to themselves be parents, the clients always took care to make sure I was safe from harm and didn’t do any heavy lifting, and they were extremely understanding if I had to leave early for an appointment and their schedule was changed.
                                                                ***
Ultimately, my experiences as a pregnant practitioner have taught me more about empathy and the depths of a parent’s love. They have also taught me about the trauma and tragedy that abound when pregnancy and parenting intersect with unmanageable circumstances, restricted choices, and limited resources. Working clinically while pregnant has taught me how to sit with discomfort and the pain that life offers, which ultimately has made me a more compassionate, empathetic, and astute social worker. I encourage pregnant practitioners, regardless of whether they work in corrections or elsewhere, to lean into the experience so that they can develop as yet undiscovered skills and qualities.

Fellow Therapists: Do You Work With Sex Offenders?

Posted on by Psychotherapy.net Team

I have had a career-long commitment, or understanding, primarily with myself, but also with insurance companies, that I choose to not work with child-abusers. It is not that I can’t see redemptive possibilities. It is just that I know I have a strong bias and am not willing to forge a pathway to empathy for those who molest children. It is a boundary I set when deciding whom and who not to treat. My thoughts about this dilemma came to the forefront very recently.

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Yesterday, a man who had been on my therapy waiting list finally arrived at my office. On his intake he noted a recent breakup with his girlfriend of several months. He stated he experienced depression and needed help to “get over the relationship.” It was only in session that the rest of his concerns emerged. At the beginning of their relationship, he told her that he had been married and had several children, but lost custody of them in the divorce. At that time, he was in deep financial trouble, having lost his then recently-purchased home, cars, and his wife to her drug addiction. Nevertheless, the Department of Children and Families (DCF) had determined that neither he nor his ex-wife were capable of raising their children, who were subsequently placed into foster care.

The divorce and subsequent foster placement of the children occurred several years prior to my meeting with him. Several of the children had since reached the age of majority. For a seemingly inexplicable reason, the foster parent who later became the adoptive parent of several of the children took it upon herself to contact my client’s girlfriend (I have no idea how she learned about her) in order to warn her that my client had been accused by his then young daughter of inappropriately touching her. True? Not true?

My client vehemently denied that this ever happened and maintains that position to date. According to him, there had been no legal proceedings, and instead, four hours of reported verbal assault by the local police. He was then purportedly presented with paperwork which he signed without reading. Why? As it turned out, he could not read. He only recently discovered that the paperwork was an affirmation of his guilt, precipitating removal of his contact privileges with his children. The most important sentence, that he could not read and was not read to him, was that he was (and possibly still is) forbidden to be around all children under a certain age. He was later told by his ex-wife that he had been placed on the state Registry of Sex Offenders. Boundary alert! But there was something about this man that compelled me to search a bit deeper.

It was easy for me to confirm that he had never been placed on that Registry through a simple request form and a phone call to the state. But what about the other accusations? I suggested he engage an attorney to find out whatever he could from the DCF offices in his state. As stated, he and his wife had been deemed unfit and the children were placed in foster care, from which they were eventually adopted. He has not seen these children since.

If he was and still is a concerned parent, I wondered why would he not have fought this and tried for all these years to see his children? He did admit that one of his older children had recently contacted him and said that the child abuse was a fiction delivered to DCF by his mother, no doubt out of anger and rooted in her addiction. This child, now an adult, refuses to make a legal statement.

As it turns out, DCF initially denied him access to any of the historical paperwork, reportedly stating that it was too late that they could not find electronic versions of it. As the children were no longer “his,” no documents could or would be turned over to him. Nevertheless, his newly-retained attorney persisted and indicated that there was indeed a document my client is not aware of indicating only that in saying goodbye to his children he was “observed hugging his daughter tightly.” This seemed appropriate to me, as he was saying goodbye to her for an indeterminable length of time. As per the attorney’s suggestion, I have not disclosed the existence of the document to my client. There may be more information forthcoming, and while I trust my intuition and am fairly accurate in “reading” my clients, I would be profoundly sad to learn that these accusations of child abuse against this man are true. It will be up to his attorney to share any “new” findings of legal significance. For now, my client is very relieved to know that he is not listed on his state’s offender registry.

Given that he has recently lost another relationship, I believe that my job at this point is to help this man try and understand why that relationship ended and to move forward if possible. His only response in this context thus far is that he just feels more broken. In light of my long-term and deeply-held conviction to not treat child abusers, I question whether I am comfortable treating him. Or, I wonder, am I too far in right now to bow out should more information come forth indicating that the charges of child abuse were indeed valid? As a parent, I intellectually appreciate how the trauma and drama of those events converged in a legal mess for this naïve, then-illiterate man who struggles to date, but am disturbed by his seeming inability or lack of initiative to have fought for custody and have found a way to hold on to his children.

***
 

As a therapist, I have asked myself new questions about how to set professional boundaries as to who I do and do not choose to treat. Do I believe everyone deserves a second chance? No—not when it comes to abusing a child. But this is not a matter of another shot at life. This is partly a story of a man who carries with him the stigma of assuming he was listed as a sex offender in the state for all these years. That was simply not true. A victim of a vicious ex-wife, a potentially inept police team, the inability to read, and the lack of good legal counsel at the time, conspired to trap this man, holding him hostage for wrongs not committed. Had he been found to be an abuser, DCF would have reported him to the state and he would have been on their list. That was never the case. And what about when these boundary lines become blurred? How do I (re)define my role in order to help a client like this one to establish new goals in the center of a complicated and lingering legal morass that may never be resolved? I have decided, at least for now, to continue to meet with him. But what if information does indeed emerge that implicates him? Do I search for redemption or reestablish my professional boundaries? I do not have that answer, at least at this moment in time.
 

Gratitude and Grit

Posted on by Psychotherapy.net Team

What can we, as therapists, use in our work with clients to promote positive mental, emotional, physical, relational, and spiritual health? This can sometimes be a frustrating pursuit, as those who come to us for help often carry confusing and contradictory messages regarding what they need to become more resilient and improve their overall well-being. In my therapeutic work, I have found that many clients already do things in their daily lives in the hope of staying or becoming healthier. I have often noticed that one of the most beneficial things I can do is to build on two qualities that my clients already have within them—gratitude and grit.

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Gratitude
Many of us have been taught from our early days from grandparents, elders, or other teachers that part of living well includes paying attention to what we are grateful for in life. Taking time to notice, name, and express gratitude has now become a studied phenomenon as well, with results showing that there can be many positive impacts:
Reduction in stress, depression, and hopelessness
Improved sleep and overall mood
Increased sense of motivation and agency in life
Expanded sense of positive self-esteem
Improved relationships and greater appreciation of others
Deepened sense of spirituality
Increased creativity and openness
Increased hopefulness

I often use this wisdom in my work with clients to encourage them to cultivate a positive outlook and take time to really notice, absorb, and express gratitude, thereby deepening an important state in mind and body. The benefit of this can be readily apparent—as is often evident in my conversations with one client, Casey, a single parent managing her own mental health challenges and navigating layers of stressors from physical health challenges, difficult family relationships and the exhaustion of raising a lively child on her own. It would be easy to focus on the problems in Casey’s life, and the daily distress. Casey, however, has a natural tendency to flip the conversation to the positive, and to notice what she loves about life and the “blessings” she counts as numerous and abundant. Casey has taught me more about gratitude than I have read in any book, as she visibly changes in front of me in our counselling sessions when her smile breaks out and the mood in the whole room shifts.

However, one catch is that gratitude is notably fleeting. Although it is readily accessible for Casey, gratitude is also easy to lose hold of. Her attention can move quickly to focus more on what is stressful in her life. Her natural survival instincts push her back toward watching out for what worries her, and problems resurface and grab her attention. Indeed, a session with Casey is often a bit like a two-step dance—smiles and laughter one moment, and just a few minutes later, tears and waves of anxiety. Casey has also taught me the importance of tools for managing this shift.

Which brings me to the other quality that has been helpful for Casey to cultivate: grit.

Grit
What do people rely on to get through a tough day? What behaviors, supports, or messages does a client reach for to help them continue to show up and carry on? Each person will have patterns of coping—in how they think, collaborate, or sustain themselves when facing challenges. One word for this quality, supported by the research of Angela Duckworth, is grit. Each person’s grit will look different, and everyone may use it to different degrees. Duckworth’s research, as well as what I have witnessed in clients, supports that when people are able to tap into their grit, the benefits include:
Increased ability to persevere
Expanded response and ability to adapt to challenges
Persistence to face fears
Growth in self-esteem and confidence
Increased hopefulness
Development of a growth mindset
Increased likelihood of achieving positive change
Long-term success and satisfaction

Grit is fueled by what matters to a person—do they have particular goals they’re pursuing? What do they care about and feel passion for?

When I sit with Casey through these waves of emotions as she shares the experiences in her life, this theme is apparent. Her intense emotional responses to all her life also demonstrates her incredible passion and tenacity for living well. Casey can become overwhelmed with helplessness at times, but connects back to her grit by remembering why things matter to her, and particularly what she hopes to pass on to her son. I’ve seen her pull herself up time and time again, landing solidly back in gratitude.

The more aware she is of her purpose and passion, the grittier she will become!

Building on Grit and Gratitude
In some ways, these two qualities can seem somewhat contradictory. Gratitude requires people to pause, relinquish any push for change, and shift to noticing the positive things that are already in their lives and relationships. Grit, on the other hand, allows people to keep moving, to notice and confront what might be challenging or feel negative in their lives, propelling them into more adaptable change.

I think there is an interesting and symbiotic relationship between these two qualities. When I have a hard time accessing gratitude, it’s my grit that I rely on to cope with a challenging situation. When I feel depleted and far from gritty, pausing to connect with gratitude refuels my hope and energy for perseverance.

What is encouraging to me about the benefit of both these qualities is how accessible they can be. Just as Casey naturally seems to have them both at the ready, I’ve come to appreciate how it’s possible for others to be intentional in turning toward each of these states to deepen their connection to them.

Here are some steps I have found helpful to encourage clients to use to be able to access more of the benefits of their grit and gratitude:
Observe it. Take a moment to name one thing you are grateful for and one thing that helps you persevere.
Express it. Journal, write it down, or say it out loud to yourself or a friend. Draw it, sing it, or build or sculpt it. Making it a bit more tangible in some ways will deepen its meaning and help you absorb the benefits.
Practice it. Choose a way to regularly practice the first two steps. The more regularly we dip into gratitude and grit with intention, the deeper the patterns and habits that bring us to connect more openly and regularly in line with these qualities.
***
I’ve come to believe deeply that taking a small amount of time to consistently notice what already matters can greatly increase mental, emotional, physical, relational, and spiritual well-being. Encouraging my clients to notice what they are grateful for and what they find challenging allows them to tap into this powerful tension between gratitude and grit—building on one helps fuel and nurture the other. In the end, I believe well-being and relationships will be strengthened by tapping into these inherent qualities. 

A Man, A Car, and a Metaphor

Posted on by Psychotherapy.net Team

John was a warrior in every sense, long-returned from a battle that most had forgotten. But John remembered, in all ways a soldier can—in slow motion. Every skirmish, every battle, and every slight upon his not-so-triumphant return from a not-very-popular war left its indelible mark on his body, his spirit, his life. Most of all, John’s body kept the score, tallied in sleepless nights, unyielding fits of agitation, anger, and sadness, and unsuccessful alcohol-laden attempts to subdue his demons.
 

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I met John during the practicum semester of my doctoral training at a local VA outpatient center. John didn’t say much, which was both a relief and source of frustration. Looking back, I’m not sure what I could have offered, but I believed that I should have been able to connect better. Afterall, I was young, energetic, and optimistic. He was just the opposite—haggard, tired, and deeply worn. Yet, he came to every type of therapy group we offered, showing up in every imaginable weather condition in his 1964 Chevy Impala.

Back then, I didn’t appreciate the metaphor because I was too caught up in trying to figure John out from a literal perspective. Had I known then what I know now, I would have spent my time with John hanging out and chatting in and about his car, rather than trying to break through or ply my nascent clinical skills.

That white Chevy Impala, ironic in this case given the swiftness, beauty and agility of its namesake, was what car enthusiasts would call a “beater.” Simply, a “beater” is an older, high-mileage car with more than its share of dings, dents, and duct tape that still works. It gets from here to there without splash, without head-turning (except perhaps for the noise and smell it leaves in its wake). It is a utilitarian object.

Beaters work…until they don’t, at which point they are typically too costly for the owner to repair. And therein lay the metaphor which I wish in retrospect I could have appreciated. For that car was the mechanical and aesthetic embodiment of this enigmatic war veteran. John, like his Impala, had been patched together and just kept running, until they didn’t.

Halfway through my practicum, we learned that John and his car died within days of each other. And you can only imagine the theories and rumors that spread as quickly as a car fire. Was it suicide following the demise of his trusty metal steed? Did he go first, and the car had the metaphysical prescience to call it quits soon after? Did they go together? Was it a suicide pact between old friends? In hindsight, we never found out, but John and his Impala certainly left us wondering, and created a poignant metaphor that I carry with me and that forms the template for my interest in client metaphors.

***

My own steel and iron metaphor turns 50 this month. I know, who celebrates the birthdays of their cars, let alone someone who identifies as a parent, university professor, clinical psychologist, and purported adult? Well, I do, and I hail my 1972 Volvo 1800E, born a half-century ago in Sweden, soon after transported to the U.S., and raised by its foster owner for a decade before finding its way to Tom, its previous forever-parent of 35 years. Tom loved the car for personal reasons that I never did discover but had lost his passion after the passing of his daughter. Two subsequent strokes made it virtually impossible for Tom to get into the car, let alone work under its hood or dashboard (which requires Houdini-like contortionist skills).

I had seen my first 1800 at age 7, when after chasing a ball into the street (perhaps a tad impulsive of me) I found myself face to face with what appeared to that sci-fi-fed child to be a spaceship. Flash forward 60 years to that boy grown to manhood who now stands before his own spaceship with the same sense of marvel and admiration for this beautiful object. And therein lies my metaphor.

While getting into and out of my car reminds me that I am no longer that nimble 20-year-old (or even 40, 50, or 60-year-old, for that matter), I am young and dashing when we are in motion together (or at least so I delude myself). We (or more likely it) turn heads, draw curious questions and leave people wondering, “Hey what is that thing?” Together, we are enigmatic, mysterious and interesting, perhaps just a little bit sexy, but most definitely ageless. There is always a glitch du jour around the corner to remind me that aging is messy and sweaty, and both mechanical and organic maintenance require diligent effort that has dividends in a sense of vitality and efficacy. And to add to its appeal, both metaphoric and literal, I recently brought my 1800 to its first European classic car show and enjoyed the social aspect of that gathering of fellow automotive metaphorists.

***

So today I think of John, the man, the car, the metaphor, and I thank him, as I do all clients whose lives are sometimes more poignantly appreciated in metaphoric rather than literal terms.

In the Same Leaky Boat: Being a Parent and Therapist

Posted on by Psychotherapy.net Team

I have some new career goals that have been taking a great deal of my attention and time lately. They’re exciting, but intense and demanding. I also have two little ones tugging at my clothes at all times. Sometimes I feel split in a million directions with my time, my attention, and my emotional and physical energy. I wonder why I’m working so hard and why it never feels like it’s enough (and feel that it’s all my fault). For what? Where did I get these ideas of what it means to be a successful parent and a productive therapist/business owner? And why do I feel so alone in all of it?

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When I’m reviewing my photo reel on my phone at the end of a day (a modern habit any parent will attest to doing), an unconscious smile on my face as I scroll through my kids’ smiling goofy faces and chubby limbs, I often feel content, relieved to some degree. I made it through another day.

But I also feel guilty and like I’m falling short, sad that I’m always hurried and tired. I feel worried that I’m not soaking up the time with my small kids thoroughly enough, whatever that means. “They grow so fast!” we’re often told, as if that’s a helpful thing to hear when we're already crushed under the weight of perfectionism, guilt, a barrage of unrealistic goals and expectations, financial burdens our parents were not saddled with, and a list of other maddening external constraints.

I know my clients feel this, too. I work with many new parents and I think frequently about how best to support these clients—the ones with babies and toddlers, who feel barely human, disconnected from themselves, like they’re forever flailing, convinced they’re failing at everything.

Caroline, for example, is a client I’ve been seeing since the spring of 2020. It took a pandemic for her to feel justified in reaching out for help. When we first started working together, her baby was four months old. She had recently left her job (after a brief return following a mere eight weeks of maternity leave) to stay home with her daughter. She’d like to work again, to connect with aspects of her identity that feel distant right now, but the cost of childcare is nearly equivalent to her former salary. Additionally, she found that her workplace was too inflexible about scheduling and not supportive of pumping.

Caroline has no family nearby, and the pandemic pushed her further into introversion and isolation. She has no real “tribe” or community of other parents with which to commiserate, share information, or get her out of the house. She scrolls Instagram and feels inadequate when she sees the slim bodies of celebrity and influencer moms, the perfect plates of cut up fruit and toast for babies, the inventive sensory activities, the families out in the world doing fun things, the informative posts from child psychologists, or the quotes from other mothers that are meant to be inspiring but just reinforce her sense of failure and defeat.

She spirals into panic when she thinks something might be wrong with her daughter’s development or health. She feels responsible for carrying the weight of all of the researching and decision-making regarding various aspects of care for the baby. Her husband doesn’t see or appreciate the mental labor and intense pressure she puts on herself to make sure their daughter is fed, clothed, entertained, and developing appropriately. Their relationship has suffered significantly.

Caroline feels beaten down and trapped. All the days bleed together, and there’s nothing she really looks forward to. She loves her baby and feels connected and attuned to her but is not enjoying motherhood in the way she had hoped, which makes her feel tremendously guilty.

Sometimes we’ll be in session and all of a sudden, the baby appears, finishing up a nursing session I didn’t even know was occurring off screen. Caroline will stroke her daughter’s back while she gazes off exhaustedly and says, “No one prepared me. No one told me how hard this would be.”

We’re in this boat together, me and my clients. It has a ton of holes, and we’re constantly exhausting ourselves scooping out water with our feeble buckets and trying to keep ourselves afloat. But the truth is we didn’t build this boat. We also didn’t break it.

The more I work with clients like Caroline and go through my own experiences balancing work and life with small children (an intense phase I’m aware will be over before I know it—I don’t need the reminder), the more convinced I am that our self-blame and the pressures we put on ourselves are absurdly misplaced.

When I take the time to question the metrics I use to evaluate myself and their origins, I start to see the cracks in a society that by design provides little support to parents (mothers especially) in the workplace and beyond, reinforces impossible standards through social comparison, and isolates us from support and community (to say nothing of the deeply problematic inequities baked into all of it). We are not doing anything wrong. The system itself is broken.

And recognizing this, making this mental shift of externalizing some of the perceived failure I experience, allows me to be a bit kinder and more realistic with myself. The more that I acknowledge how broken the system is, the more I can comfortably eschew its standards.

When I’m with clients like Caroline, struggling in similar ways with expecting too much of themselves and feeling the pressure to do everything (and do it “right”) and to enjoy every second of parenthood, I can invite them to examine the larger context of these expectations. I can affirm and normalize slowing down, practicing acceptance, and embracing rest and self-compassion as an act of defiance and empowerment.

We have done enough. We are doing enough. Let’s just float for a bit.

Costumed Authenticity: Building Trust in LGBTQ+ Telehealth

Posted on by Psychotherapy.net Team

He was the kind of client who liked to sneak in jokes to relieve his own anxiety. A deflector. The kind of client who is openly gay, but emotionally closed. In telehealth sessions he rarely looked at the camera, or even the screen. His thoughts were off in the distance. He had a lot to say, but it was going unsaid. Or, more accurately, he had a lot to share, but it wasn’t being verbalized.

Social camouflage can be a powerful survival mechanism. While it can lead to compartmentalizing social identities, it’s important to value a client’s need for safety. In fact, if there’s anything I’ve learned from my LGBTQ+ clients, it’s how multifaceted identities open up progressively through tiers of trust. Codeswitching is common, as is reserving whole aspects of personal identity for those who actually appreciate it. This can make it hard to trust anyone, especially a mental health professional.

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Even amongst the LGBTQ+ community there is no guarantee of acceptance, requiring camouflage just as much within the rainbow as outside of it. Pansexuals and omnisexuals may tell people they’re bi because it’s more commonly understood and socially accepted, just as bisexuals may tell people they’re gay. Genderqueer, genderfluid, and agender people may generalize themselves as queer or nonbinary rather than get into the specifics of their actual identity. Likewise, there are many nuanced facets to being a transgender person, but there’s no chance of talking about that with someone who’s unfamiliar with even the most basic Trans 101 terms. Yes, a client may talk about their sexuality or gender identity with a therapist, but at what level is the conversation? Tier one? Tier two? Tier ten?

In the back of my mind, I found myself relating to his bemused smile and his coy silence. But how could I, as his counselor, create enough safety in a telehealth session for him to share more of his unspoken authenticity? Or, at the very least, another side of himself?

I’ll be the first to say that telehealth has more than a few problems, yet having a small window into the client’s home is a game changer. I’ve had some clients proudly take me on a video tour of their house, and others who actively hid their home environment. Getting to see someone’s sanctum of comfort, or playground of self-expression, is an honor that should not be taken lightly. Yet when a client doesn’t know how to talk about themselves, a little curiosity about their external environment can go a long way.

In the background of his bedroom was a sewing mannequin. When I asked if he sewed, he laughed and said he was better with a hot glue gun. Then, when I asked what he’d been working on, there was a second of hesitation. A second of hope, mottled with the fear of rejection. The natural prelude to authenticity.

No, he wasn’t a Drag Queen. He was a Drag Cosplayer, who spent a small fortune every year transforming himself into sci-fi and fantasy characters to attend massive conventions. And he walked a fine line, in heels no less. He didn’t fit in with Drag Ball Culture, and he was sure most Queens would call him a nerd. On the flip side, not every conventioneer appreciates a cross-dressing cosplayer. Here was courage and shame in the same costume. Here was cognitive dissonance. He kept all his social media accounts private but had hundreds of people take pictures with him at every event. He was an anonymous celebrity.

This disclosure segued into a conversation about his favorite anime characters and, most importantly, why they were his favorite. People are drawn to certain fandoms for key archetypal reasons, because they resonate with a specific character, or universe, or story arc. Fortunately, I happened to grow up in the height of America’s anime revival, so I recognized not only his characters, but also his attention to detail. After that, I was updated on the status of his latest costume for the next two months. It turned out he had a soft spot for manic female antiheroes who are vibrant, loud, and completely over the top.

It takes time to build rapport. As therapists, we are outsiders, approaching each tier of privacy like a gate. It’s not enough to say friend or foe. For this client, I had to not only know the password to be let in, but I also had to speak the language. It’s because of this that I encourage therapists to take an active interest in their client’s media. Dive into their music scene, or favorite book series, or television show, or movie fandom, or video game community, because there you will learn a hidden language.

So I asked him if, in our next telehealth session, he would be willing to show up in character, and he laughed, and cringed, and said he’d have to think about it.

My next session was with Haruko Haruhara, from the spastic anime masterpiece FLCL.

My next session was with my client’s shadow, imagination, and feminine inspiration, and this time, they looked right into the camera.

A Walk in the Park

Posted on by Psychotherapy.net Team

It seemed like any other day, nothing too challenging, I hoped—a walk in the park. Well actually, it was a jog in the park, my favorite place to run…woods, roots, rocks, mud, water. It was just enough of a challenge for this aging body. As I launched (actually lurched) forward for my run, I caught a fleeting glimpse of a couple trying to cajole their young child into a nature walk. “What a nice thing to do with a child,” I thought as I rounded the first bend. But apparently this child had a different view on the situation, because within seconds, he was screaming his displeasure at the top of his lungs, while his powerless mother offered all sorts of appeasements before landing on, “Alright then, I guess I am going to take you home and put you to sleep.” Her way of throwing in the towel and expressing perhaps her sense of powerlessness.

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Within less than a quarter mile, I had that Swiss Family Robinson fully assessed and the child thoroughly diagnosed. I was quite proud of myself. “What a masterful clinician,” thought I. Even in spite of the fact that I have largely retired from clinical practice and play therapy, I still had it.
Well, the jog ended; I had made it through yet another humbling reminder of my age but figured, “A little (understatement) joint pain, inflammation and blanket of mosquito bites are a small price to pay for the privilege of making it through another run through the wild.”

As I turned the corner of the park’s field station, who did I see standing before the opening and closing door of the elevator, proudly pushing buttons, but young Robinson, or the howler monkey I had heard upon entering the woods. But he wasn’t howling and instead was fully engaged, if not enthralled, by the mechanism of the elevator apparatus, or perhaps the power he wielded over the beast by pushing the button. His parents were doing their best to patiently indulge him in his fascination while trying, once again, to rein him in. “Two more times, and then you can take one ride in the elevator, and it will be time to go home,” they offered the boy, who paid absolutely no attention to them.

As you might imagine, I couldn’t restrain my inner-clinician, who had already channeled Virginia Axline, and said to the boy, “You really like that elevator,” upon which he took my hand to lead me into the mechanical maw of this beast he had tamed- although that might have been my projection, not his. “Ah, taking the hand of a complete stranger,” now that is diagnostically important, so my unsolicited assessment deepened. I gently released his tender but firm little grip and stepped back as he continued, unabated, his elevator play. I believe that in that moment, mom was embarrassed and quickly apologized for her child, something that in retrospect I believe she was accustomed to doing.

I piped up, “I could tell from his screaming a bit ago that he didn’t want to walk in the woods, but he sure likes playing with the elevator.” Mom and dad were on board with this unfolding in-situ play therapy session and said to me, “You sure seem to know a lot about kids, do you have grandchildren?” Ouch!!!!!

I felt like saying, “Hey, young people, don’t you see this sweat on my body…I have just vanquished the wilderness trail with my blinding speed and god-like endurance” (I probably ran a mile), but decided to restrain myself. We turned our attention back to elevator-boy, who was now jumping with glee and flapping his hands, trying to verbalize his enthusiasm in words, clearly a challenging developmental task for this sweet, sweet little boy, whose only failing that day was his choice to endlessly engage with this predictable machinery rather spend a minute walking in the muddy, bug infested, woody and sensorially-overwhelming uncertainty of the woods his parents so wanted him to enjoy.

My parting words to the young couple was not affirmation of the obvious diagnosis, but something along the lines of, “It’s so wonderful that you encourage his fascination with the elevator….encouraging any fascination in a child is a good thing.”

Perhaps they were saying something equivalent to “Who was that masked man?” as I hobbled away, or at least that’s what I hoped. And while part of me wanted to turn back around and ask if they’d had their child assessed for autism, I didn’t think that level of intrusion was necessary or appropriate. I was pretty sure that I was in the ballpark on my assessment, but I wasn’t there, or being asked, to render a professional opinion. Maybe it was enough that this “elder-seeming” man they met in the park was kind to them and their child.