“Name it to tame it” has become a popular phrase among parents and those working with children. It denotes the principle that we can help emotionally overwhelmed children feel better by helping them put their feelings into words. Daniel Siegel provides an example of this principle. Bella, a nine-year-old girl, watched the toilet overflow after flushing it, “and the experience of watching the water rise and pour onto the floor left her unwilling (and practically unable) to flush the toilet afterward.” Her father later sat down with her and encouraged her to tell the story, allowing “her to tell as much of the story as she could,” and helping her “to fill in the details, including the lingering fear she had felt about flushing since that experience. After recalling the story several times, Bella’s tears lessened and eventually went away.” Putting these experiences into words, Siegel writes, “allows us to understand ourselves and our world by using both our left and right hemispheres together. To tell a story that makes sense, the left brain must put things in order, using words and logic. The right brain contributes to bodily sensations, raw emotions, and personal memories, so we can see the whole picture and communicate our experience.”
Author: Psychotherapy.net Team
The Silent Therapist: Teddy Bear Therapy with Adults
Alex is a tall, thin, 86-year-old former psychotherapist now living in a nursing home, and walking with a walker. He experiences mild anxiety and depression associated with adjustment to his advanced stage of life development, and he experiences mild cognitive issues. I meet with him for life review therapy.
The Importance of Everyday Objects
Alex loves music and theater, and he wrote and performed in plays, in addition to practicing and teaching psychotherapy. He had studied in a Catholic Seminary yet decided against becoming a priest. He has a teddy bear named TJ in his room with a scarf around its neck knitted by his daughter. Alex was given TJ many years earlier, and for 30 years TJ served as his co-therapist.
“I gave presentations at maybe 75 conferences with at least 75 participants each time, and I always brought TJ with me,” Alex said. “I would approach the podium and introduce myself. The audience members were probably wondering what was going on with this guy holding a teddy bear. ‘This is my partner TJ. He doesn’t have a lot to say, but he would be glad to meet some of you while I am speaking.’ Always, someone would raise their hand and ask to hold TJ.
“While I was speaking, I would notice one person tap the shoulder of the one holding TJ, and pretty soon he would be handed along, person to person. When I was wrapping up and asking if there were any questions, one or more hands would shoot up, and someone would say, ‘We haven’t had a chance yet to hold TJ.’ The experience of TJ being at the meeting would create a warm sense of camaraderie, and people always spoke to me afterwards to remark on the special experience it had been for them,” Alex said.
In his private practice, Alex had TJ placed in a chair next to his in the office. “Clients would walk in and say, ‘What’s up with the bear?’ ‘Oh, this is TJ. He just likes to listen; he doesn’t say too much; you can hold him if you’d like to get to know him better.’ Some who scoffed at TJ the first time, might return the next time and just pick him up and hold him without saying anything. “TJ was like a doorway to feelings and thoughts that clients might not get to for a long while if I had only used language. It was always remarkable to me the things that people remembered and talked about because they were holding TJ,” said Alex.
He added; “With my students or clients, they look at me, and they see their projection on me. But when they look at TJ, they see into themselves; a part of their self they have not been in touch with, or for a long time, and they sometimes don’t know what to do with it.”
“TJ helped me have a tangible connection to the child in me, and helped me evoke that in others,” Alex said. He added, “TJ represents innocence, and there are not so many ways in therapy, or in society, for an adult to access their innocence — and I don’t only mean childhood innocence, but a sort of opening to wonder and mystery and spirit — because if those things aren’t present in therapy, what are we doing,” Alex asked?
***
Teddy bear therapy has been around for many decades, yet mostly used in work with children. Alex found clever and effective ways to incorporate TJ into his teaching and therapy practice. At a time when he feels saddened by the need to adapt to a slower and less productive period, life review therapy validates Alex’s notable accomplishments and restores his positive sense of self-worth and makes room for his mischievous and warm-hearted sense of fun, which is where TJ comes into play. Questions for Reflection and Discussion What are your personal and professional impressions of the author’s work with this patient? How might you have addressed the patient’s relationship with TJ’s similarly? Differently? How have you made use of inanimate objects in your clinical work?A Day in the Life of a Very Old Therapist
The day had not started well. I woke at 3:00 a.m. with leg cramps that wouldn’t go away. I quietly got out of bed, careful not to disturb my wife, Marilyn, sleeping deeply next to me. To relieve the pain, I took a hot shower until it turned lukewarm, then dried myself and returned to bed. The heat had soothed my muscles, and the cramps had subsided somewhat. I tried hard to go back to sleep. But when it comes to sleep, “trying hard” is always doomed to failure. Insomnia has been my kryptonite for decades. I had been tapering down my use of sleeping pills, reluctantly, as my doctor suspected they were accelerating my memory loss. I tried some breathing exercises. Time after time I inhaled, whispering “calm,” and exhaled, whispering “ease,” a meditation practice I’d learned years ago. But it was to no avail—the slight calming brought on by the utterance of “ease” soon morphed into anxiety, another old nemesis. I shifted my attention and focused on counting my breaths. A couple of minutes later I realized I had forgotten about counting and my ever-restless mind had wandered elsewhere. A year earlier Marilyn had been diagnosed with multiple myeloma, an insidious cancer of the blood plasma. She was in the midst of a series of chemotherapy treatments, which had yet to result in any significant improvement. Her warmth and the sound of her breathing were so familiar, my beloved bedmate for many decades. But now something new had joined us, this sinister illness, doing battle within her. I was pleased to see her resting peacefully that night and gently traced the lines of her face in the dim light. We’d been together, inseparable, since middle school. Now I spent the majority of my days worrying about her and trying to enjoy the time we still had together. Nights I spent worrying about a life without her. How would I pass the time? With whom would I share my thoughts? What loneliness awaited me? Noticing that my mind had strayed so thoroughly, I gave up the idea of getting back to sleep. I checked the clock and noted, to my surprise, that it was already 6:00 a.m. Somehow, when I wasn’t paying attention, I must have nodded off for a couple of hours.
Jerry: What’s Not to Like?!
After breakfast, I looked at my schedule. I had only two appointments that day. The first was a termination, the final session with Jerry, a patient whom I’d been seeing for one year. Jerry was a successful lawyer in his 40s who had come to therapy seeking answers after his girlfriend of two years had left him, the third in a string of failed relationships. “I can’t see why,” he’d said during our first meeting. “I’ve got a great house, a great job, tons of money. What’s not to like? I mean look at me.” He’d gestured at the well-tailored, clearly expensive suit he was wearing. Jerry was not what you’d call warm or reassuring. He was demanding, and often critical. He groused about my fee, suggested I get a better gardener to tend the plants along the walkway to my office, and, once inside, disparaged the artwork on the walls. He had come to me, he told me repeatedly during our first few meetings, because he’d heard I was the best, and he deserved the best. This was soon accompanied by a look of disappointment in his eyes that I hadn’t swiftly cured him of his troubles. Clearly, that look said I wasn’t the best after all. And yet, over time, we’d had success. What had worked? We had two important factors going for us. First, Jerry was highly motivated to make change in his life. Despite his prickly exterior he realized that he was in some way contributing to his relationship problems, and he was eager to put in whatever work was needed to address this. I had to slow him down, let him breathe, and see that part of the problem was the immense demands he placed on himself and me to magically “fix” him. “Imagine being your girlfriend for a few minutes,” I suggested. “What if you weren’t ‘the best,’ if your garden path weren’t expertly tended, if you didn’t look perfect on Jerry’s arm? Would Jerry love you and support you nonetheless?” “I doubt it,” he said. “Instead he would criticize you constantly, and you’d end up feeling crappy about yourself and your relationship. And . . . ?” I left the question hanging in the air. Jerry considered for a moment. “And you probably wouldn’t stick around,” he said finally. This realization, that being demanding and often unkind severely impacted his relationships, clicked for him. He could see the role he was playing and started to change. In the weeks that followed, he set about in earnest to improve. He began to catch himself whenever he was overly critical of me and whenever he complained that others in his life were inadequate. He took more responsibility for the way people, especially potential romantic partners, responded to him. And he set about curbing his sharp tongue. Jerry’s fierce drive to change himself was essential to the progress he made, but it was not something I could control. I could influence another factor, however: the powerful relationship he and I developed. From the beginning, Jerry had tested me: Why wasn’t my taste in art better? Where was my fancy car? Why hadn’t I been able to fix him all the way yet? Through all these barbs, I’d stayed in there with him. I’d been empathetic and warm, and also willing to push back when it seemed a challenge would do him some good. Gradually he softened up and stopped competing with me. As our relationship grew, his bristles felt less like attacks and more like witty, playful jabs that I could parry or call him out on. Little by little we built a strong connection, a “therapeutic alliance” as we call it in the field. This alliance, building it and using it, is the most important factor in my therapeutic approach. In what now seem like countless lectures, and numerous writings, I’ve stated that “it is the relationship that heals.” What drives change is not a worksheet that the patient fills out, a brilliant question the therapist poses, or a behavioral change the patient must chart daily. In my approach to therapy the honest connection between the therapist and the patient is the medium through which we discover, learn, change, and heal. Jerry and I had made excellent progress using that relationship over the course of the year we had together. He became friendlier, and when he occasionally still snapped at me with a disapproving comment, I would point it out. He learned to apologize and then, bit by bit, catch himself before saying something acerbic, and often, quite endearingly, replace such comments with attempts at compliments: “The lemon trees beside the path are looking much better this week” or, “You know, that statue of Buddha on your bookshelf is actually more interesting that I thought.” I looked forward to our weekly meetings and would be sad to say goodbye when today’s session ended at 11:50. But, for reasons that will become clear, we had agreed upon a one-year time frame at the beginning of his therapy. He had certainly made the most of it, and we were both hopeful that his future relationships, romantic and otherwise, would be richer and more satisfying.Born of Necessity: One-Session Therapy
The second session on my schedule that day would be very different. It was with a woman named Susan, whom I planned to see only once. Only once!? How could I do anything resembling effective therapy in a single session? And why would I want to try? To explain, I need to rewind my timeline a bit to provide context. About five years before this, when I was in my early eighties, I noticed that my memory was starting to fail. I had always been a bit forgetful, misplacing my appointment book, glasses, or car keys with regularity. This was something different. I began to encounter people I recognized, only to have their names elude me. Occasionally I’d stop in the middle of a sentence, stuck searching for a familiar word. And, more and more frequently, I would lose track of the characters in movies Marilyn and I were watching. As this progressed, I began to think that, perhaps, I was no longer able to offer the long-term therapy I had for nearly 60 years. Instead of open-ended therapy that sometimes lasted three or four years, I decided to set a 12-month time limit, agreed upon in advance, for all new patients, hence my agreement with Jerry. I approached this new framework with some sense of loss, as it represented a major shift in my work, one derived from necessity, not desire. But soon curiosity, and my wish to continue being helpful, won out. Ultimately, I found this to be an agreeable solution. If I chose my patients carefully, I was almost always able to offer a great deal during our year’s work together. With some patients, in fact, there was an increased sense of urgency, and thus motivation, thanks to the time limitation. This had worked well, both for me and for my patients, for the last five years. Then around the time I was 87, I started to find I was more and more reliant on the summaries I recorded after each session to remember the details of my patients and that, even with these notes in hand, their faces and problems occasionally seemed alien. I was faltering, and I began to question the value of the care I was able to provide. I felt I still had much to offer, but it was clear that I could not, in good conscience, engage in ongoing work with patients, even limited to one year. And yet, and yet . . . the thought of no longer practicing was dizzying. Sharing with my patients, aiding them through their darkest thoughts, and joining them on journeys of discovery—for the majority of my life this had been my daily work and my calling. Who would I be, if not a psychotherapist? Truth be told I was angry and deeply frightened. I was not ready to feel this old, this useless. The thought of leaving therapy behind felt like resigning myself to rapid decline, followed soon after by my inevitable death. I pondered this dilemma. I had to put my patients’ needs first, so doing long-term therapy was out. But after so many decades of practice and research, I knew I had developed levels of insight and expertise that were rare, and still potent. Plus, I felt the personal need to continue contributing in some way. How could I offer something—enough to be helpful to patients, enough to keep myself engaged in the world—while also not endangering anyone? I came up with an unconventional idea. Perhaps I could meet with people for one-time, one-hour, consultations. During that hour I would offer everything I could—insight, guidance, a warm accepting presence—and then, if appropriate, refer them to a colleague who seemed well attuned to their particular challenges for ongoing treatment. The idea of such short-course therapy was profoundly foreign to me. I have always seen therapy as a longer-term endeavor—not the endless years of old-school psychoanalysis, but often several years, long enough to help patients search for better understanding of themselves and make meaningful change in their lives. The question of how I might be effective in single sessions could be an interesting experiment, if nothing else. For some time after coming up with this idea I vacillated between skepticism—Was this just a way of forestalling my own decline rather than offering anything truly beneficial to the patients?—and excitement—I knew I had skills honed to an uncommon degree and had been helpful to many, many struggling people, which undoubtedly had some value. I took the time to stare carefully at my own feelings. It was possible my pride would resist accepting this lessened importance. And yet I knew that, at some point, I would need to accept my decline and pass the torch fully to the next generations. I honestly did not know what this experiment would yield, which itself was intriguing. Thus, I began a new adventure of short therapeutic encounters, and investigation of what might be most helpful in a far briefer time frame for creating change than I had ever before conceived as effective. I announced my retirement from ongoing therapy, and my offer of these single-hour consultations—either in person in my Palo Alto office, or online—on my Facebook page. Within hours, requests for appointments started to pour in, far more than I’d expected. They came from all over the world, English-speaking countries of course, but also many other places, too—Turkey, Greece, Israel, Germany—as Zoom had collapsed the barrier of space. And they came from people in many stages, and to some extent many walks, of life. This single-session format, I quickly realized, would allow me to work with many people I had never been able to reach otherwise, people for whom ongoing therapy with me was prohibitively expensive. It was clear this would be a very interesting shift from the relatively traditional private practice I’d led from the lovely Spanish-style cottage in our backyard over the previous 20 years, and for decades before that working in the psychiatry department at Stanford University. Would it be effective for the patients? Would it feel satisfying for me? Only time would tell. It would certainly be new, and at my age, newness was nothing to scoff at. This, then, was how I found myself on that particular morning contemplating my first single-session consultation with Susan. I was excited yet concerned. I am not always filled with second-guessing, but after a restless night spent with my darker thoughts about Marilyn’s failing body and my own weakening mind, I had my doubts. How much good would I be able to do, really, in these short encounters? I had several things going in my favor, I reminded myself. First, my particular therapeutic approach has always been heavily focused on using what I refer to as the here and now. By this I mean that the interactions the patient and I have in the moment are the essential tools of change. Whatever problematic tendencies a patient has—their insecurities, their neuroses, the things they do that get in the way of their relationships with others—these are all likely to show up in the therapy sessions, through their interactions with me. Jerry, who had to have the best therapist, is an excellent example. Even though he came to me for help, and thus presumably began our work with a positive opinion of me, he constantly criticized me in many ways. Time and again I brought his awareness to this tendency. At first, he attributed the comments to my inadequacies, that I was overly sensitive and jealous of his financial success. But little by little Jerry began to see that he behaved this way elsewhere in his life as well, and that it impacted his relationships, and his happiness. This here-and-now approach is largely ahistorical, meaning that it does not rely a great deal on patients’ personal histories. Rather than spend great amounts of time digging through patients’ backstories, time which I would not have in these single sessions, I focus on the present, tuning in closely to every word and gesture they offer, as well as those that they omit. I was confident this approach would allow us to get into the serious work quickly. It also had the great benefit of dove-tailing nicely with the limited capacities of my faltering mind: remembering the past was increasing challenging, and recalling copious details about each patient was beyond me. But being present right here and right now, I could do very well. A second thing I had going for me was that nearly all of the people who requested consultations had some knowledge of me in advance. Over six decades I have written many books, including influential textbooks for student therapists, philosophical novels, and books of stories like this one that aim to demystify the process of therapy. Through these I have had the good fortune to become a well-known figure in the field, and most of the people who had requested consultations thus far had mentioned reading at least one of my books. It was clear from most of their emails that they saw me as having some amount of wisdom and power. I took this with more than a few grains of salt, knowing that we all sometimes seek reassurance from silver-haired elders. In fact, there was a small voice inside me, adolescent and rebellious, that wanted to shout out “I’m not that old yet!” and cancel this whole undertaking. But for the most part I was happy to play the role of guru on the mountaintop, realizing that I might be able to use the wisdom with which people imbued me and leverage that power to help them change.Susan: Trying Out My New Strategy
Such was my state of mind as I settled into the chair in my office and opened a Zoom window to speak with Susan, a 50-year-old schoolteacher from Oregon who was deeply depressed. We quickly greeted each other, and I explained that I would only be able to see her one time, as noted in the Facebook posting, and that I hoped to be as helpful as possible. It felt very strange saying all of this, and I think I was laying out the groundwork as much for myself as for her. She nodded, then launched into her tragic story. Two years ago, at about 10:00 on a Thursday night, she had opened the refrigerator and noticed that the large cherry pie she’d made was nearly gone. She had planned to serve it the following evening to close friends who were coming over for dinner, but now it was reduced to a sliver of crust oozing deep red filling. What had happened to the pie? It was no mystery: no doubt Peter, her husband, must have eaten it. It wouldn’t have been the first time. “That gluttonous slob!” she exclaimed, bursting into tears. The fate of her cherry pie was too much. The last straw. She had to be at work until 5:30 the next day, an hour before her dinner guests would arrive. She would barely have enough time to get dressed and set the table, let alone bake another pie. The disrespect! Brimming with anger, she’d stomped upstairs and confronted her husband, who was already in bed. They argued for 10 minutes. Tempers and voices rose. He told her he had always been the main support for the family (not true! she protested) and that he’d eat any pie he damn well pleased. She retorted that he was an obese hog who was going to gorge himself to death. He told her to sleep on the couch and pushed her out of the bedroom, slamming and locking the door. “Fine,” she yelled. “The last thing in the world I want to do is to share the bed with a selfish glutton.” The next morning, her hard knocks on the bedroom door and loud calls to her husband were returned with silence. Finally, she and her two daughters broke into the room to find him lifeless in bed. They called emergency services, and when the medics arrived, they declared he had been dead for several hours. When police officers arrived, they sealed off the house and searched every room. Susan and her daughters were interviewed at length—clearly the police were considering the possibility of foul play, going so far as to infer that the pie might have been some sort of weapon. “How awful,” I said. “And how much have you recovered from your husband’s death?” “I’d say zero,” Susan replied. “No recovery. None at all. Perhaps I’m getting worse. I miss him so much, and I am racked with guilt about what I said to him that last night. And I’m also mad at him for leaving me. I cry all the time and now I’m the one who can’t stop eating and I’ve gained 60 pounds. I saw a psychiatrist here recently and he said that I was, in some way, identifying with my husband. What help was that? I’ve developed terrible skin problems and I can’t stop scratching myself. I can barely sleep, and when I do, I keep dreaming of Peter. When my daughters leave for college in a month, I’ll eat by myself in restaurants and people will look at me and, I’m sure, pity the dumpy fat woman eating all alone.” She caught her breath loudly, perhaps holding back tears. “That’s it, Dr. Yalom, I’ve unloaded on you. That’s everything. I don’t know what else to say.” She slumped back in her chair. “You know, Susan, I’ve worked a lot with women who have lost their husbands and your account of what you’re going through is not unfamiliar to me. Let me ask you something. You say your husband died over two years ago. Can you compare your condition now with a year ago? Is it different? Is it less painful?” “No. Just the opposite. That’s what torments me; I think of him more and more, and when I’m alone in the house I’m terrified of being sad and lonely forever. Damnit. It’s not fair.” “Grief always lessens, but it takes time. Usually, the course of grief goes through a predictable cycle. It’s most keen the first year when you experience the first birthday, the first Christmas or New Year’s Eve, without your spouse. But then, as time passes, the pain lessens. And later, when you go through the cycle of the special days for the second time, it becomes markedly less painful. But that isn’t happening for you. Something’s blocking you and I have a hunch it’s related to your anger.” Susan nodded vigorously and I asked, “Can you put that nod into words?” “I have no words for it, but I feel you’re right. It’s confusing. I’ll be drowning in sadness and then, suddenly, all I feel is intense anger.” “Let’s focus there, on your anger,” I said. “Just let your mind go there and for just a couple of minutes please share your thoughts with me. In other words, think out loud.” She looked puzzled and shook her head. “I don’t know how to start.” “It might be easiest to start at the beginning. Think out loud about your very first encounter with anger.” “Anger . . . anger. The first time I felt anger was with my first breath—at my birth.” “Keep going, Susan.” “There was anger when I was born. My mother’s anger. I remember her saying time and time again that she wanted a boy and if I had been a boy, she would have stopped there. She just wanted one child, and it wasn’t me. She let me know about it over and over.” “So you spent some of your early childhood hearing about how your birth, your very existence, inconvenienced her?” “Oh God, yes, she made me feel it all the time. Damn her for that!” “And your father?” “Worse. Sometimes even worse. His favorite joke, which he never tired of telling, was that the nurse made a mistake when I was born and brought the family the afterbirth instead of the baby.” “Ouch. Oh, Susan, how dreadful to have your father joke you’re not a person, that you’re a placenta.” “He thought that was such a funny joke. And my mother agreed. I’ll be honest with you. I know it’s unnatural, but I hated them. Both of them. My father especially. He wouldn’t pay for my college. He wanted me to work as a secretary in his store instead. So, I left home early and had to work my way through school.” She paused, letting these deep emotions swirl through her. After a moment, while she was still in that open tender place, I pushed her to go deeper. “And the anger toward your husband? Tell me about that.” “It wasn’t like my anger toward my father. Certainly not at first. I met Peter after I left home, when I was in college. We were sweethearts and he was good to me. His parents were well off, and he always had money. Whenever I was strapped, he’d help pay my rent or buy groceries. And I’d never had that kind of help or affection before. “Peter’s father was a politician and wanted him to follow in his footprints. Peter had the charisma—he could be incredibly charming and fun. But he was lazy, a poor student who gambled whenever he could, and eventually flunked out of school. He became a guard at a local bank, a job his father got him. He never made enough to support us or, if he did, he secretly gambled it away. Either way, he made it clear that I always had to work. I never took time off, except three-month maternity leaves when I had our daughters. I could never become myself, never be the kind of mother I wanted to be for my girls. Instead, I worked, worked hard. And you know what? Just a few days before he died, he told me he’d gotten too heavy to be a bank guard, and they’d moved him to office work, which meant a pay cut. He said it wasn’t a big deal, and I got so mad at him because he didn’t even care about his health. And probably I would have to find a second job to pay our bills.” “I hear lots of anger rumbling, Susan,” I said. “A husband who never recognized all the work you did, who never valued your needs and wants. A cruel father who saw you as either a problem or a punch line. And a callous mother who never wanted you, never offered love. Now they are all gone— mother, father, husband—all gone. And a good bit of your life has gone by as well. Oh, Susan, no wonder you’re angry. Who in your situation wouldn’t be enraged? I know I would be.” She nodded as I spoke. “How does it feel to hear me say that, Susan?” “Hard. Right. But hard.” “I want to take a moment to look at all you’ve accomplished in spite of them: two loving children, a valuable teaching career, and so much more. You’ve done so well, Susan.” She swallowed, taking that in. “I haven’t really been able to talk to anyone about this,” she said. “Everyone wants to remember Peter as a good person, remember us as a good couple. No one wants to talk about the darker side.” “Thank you for sharing it with me. Your anger is only human. Yet I suspect it presents a big problem. We feel we should never speak ill of the dead, that it’s wrong or somehow disrespectful. Does this ring true for you?” She nodded, tearing up. “Well, I disagree. Anyone in your situation, with the experiences you’ve lived, would have the angry feelings you’re experiencing. You’re judging yourself far too severely.” Susan was sobbing now, and I waited for her to calm down and breathe. “I don’t know what to do, how to stop it,” she said finally. “I’d like to remember so many other things about our life together. I really did love him. But now I’m just so mad.” “I suspect that as you accept your anger, accept that it is appropriate and you have good reason for it, those other memories will return. But it will take time.” “Maybe.” She nodded. “I hope so.” Then, in my most solemn voice, I continued. “Susan, I’ve listened carefully to everything that you’ve told me, taken it all in and pondered it carefully. I want you to know that I pronounce you innocent. Please hear that: I pronounce you innocent! You deserve a good life. You’ve worked hard, you’ve been a good mother, a good wife, and you deserve some happiness now.” She smiled through her tears, and I finished the session with a keen sense of having been helpful. I gave her the name of a therapist with whom she might continue. Clearly this old man still has something to offer, I thought on reviewing our meeting! I received a follow-up email from her a couple of weeks later which confirmed this. She thanked me for helping her, writing:I won’t forget the moment when you said something like “apparently your mother and your father were not good parents, but even so you’ve done extremely well in life . . . I admire you for that.” You gave me a warm feeling of being seen and respected and supported at the same time. Also your pronouncing me innocent. I will never forget that remark, and the smile on your face as you said it. I will keep the sound of your voice in my mind and my heart.
Thinking about it later that night, I felt this was one of my best therapy hours ever. I resolved to keep offering these unusual one-hour sessions, to see whom I could help and to glean as much as I could from the process. Equally important, I would share what I learned. Earlier, speaking of my desire to help patients, I left out the other major aspect of my professional life, that of teacher. Most of my work as a writer has been in the service of teaching young therapists and others practicing, or entering, therapy. Furthermore, many of my thoughts have gone against the grain, countering major trends in the field. While psychiatry has increasingly pushed medication as the solution to mental illness, I have championed human connection; while psychotherapists have increasingly been taught approaches that aim at symptom reduction, like cognitive behavioral therapy or solution-focused therapy, I have embraced curiosity and deep personal exploration. This dedication to sharing what I’ve learned has always been a powerful force driving me forward, and I began to feel that impulse again when thinking of Susan and imagining many rich brief encounters ahead of me. I would undertake this project not only to help those who seek consultation and to remain engaged myself, but also to pass on what I learn. Full book available here. From the book HOUR OF THE HEART by Irvin D. Yalom and Benjamin Yalom. Published on December 10, 2024 by Harper, an imprint of HarperCollins Publishers. Reprinted with permission.Finding Healing Through Art: A Case Study in Art Therapy
Art Therapy is a powerful form of psychotherapy that uses creative expression to help individuals explore emotions, process trauma, and find pathways to healing. Unlike traditional talk therapy, Art Therapy offers a non-verbal outlet, allowing clients to express feelings that may be difficult to articulate. By tapping into the subconscious, art can reveal hidden emotions, facilitating self-discovery and growth. In this case study, I’ll explore how art therapy transformed the life of Julia, a young woman struggling with anxiety and self-doubt.
Julia’s Journey to Art Therapy
Julia, a 28-year-old woman, came to therapy seeking help for anxiety. She described herself as “constantly on edge,” plagued by feelings of inadequacy and fear of judgment. She had tried various coping mechanisms, but none provided lasting relief. When talk therapy didn’t yield the progress she hoped for, Julia decided to explore art therapy as an alternative. Although Julia had no formal art background, she had always been creative. As a child, she enjoyed drawing and painting but had abandoned these hobbies as her responsibilities grew. During our initial session, Julia was open but hesitant. She expressed concerns about her lack of artistic skill, unsure if she could convey her feelings through art. I reassured her that Art Therapy wasn’t about creating “good” art, but rather, about expressing oneself freely and authentically. Together, we embarked on a journey to explore her inner world through colors, shapes, and symbols.Session One: Laying the Foundation
To ease Julia into the process, I introduced her to a simple exercise called “Art for Emotion.” She was given a set of colored pencils and paper, and I asked her to draw how she felt at that moment. Julia chose dark, muted colors—black, gray, and navy. She created a swirling, chaotic pattern, which she described as a “storm” in her mind. This storm, she said, represented the anxiety that constantly loomed over her, making it difficult to focus and connect with others. As we discussed the drawing, Julia began to open up about the ways anxiety affected her life. She described feeling as though she were “drowning” in her responsibilities and unable to meet her own high standards. She admitted that she was often overly critical of herself, which only fueled her feelings of inadequacy. Together, we explored how these swirling emotions manifested in her daily life, from her job to her relationships.Session Two: Exploring Symbols
In the second session, I introduced Julia to clay. Working with clay allows clients to engage with tactile sensations, which can be grounding and soothing. I encouraged her to create a symbol that represented her anxiety. After some thought, she molded the clay into a small, tightly-wound spiral. The spiral, she explained, was a representation of her tendency to overthink and get trapped in cycles of self-doubt. As we discussed her creation, Julia had an insight: she often felt like she was “spiraling” out of control when faced with uncertainty. By externalizing this feeling through clay, she was able to examine it more objectively. We talked about how anxiety is a natural response, but when it becomes too intense, it can feel like being caught in a relentless loop. Julia began to see her anxiety not as a personal failing, but as a reaction to stressors in her environment.Session Three: Redefining the Self
By the third session, Julia seemed more comfortable with the process. She was starting to embrace the therapeutic benefits of creative expression, and her initial reluctance had faded. This time, I suggested a self-portrait exercise, asking her to draw herself as she currently saw herself. Julia spent a long time working on this piece. When she was finished, she showed me a drawing of a woman standing on a cliff, looking out over a vast, empty sea. The woman appeared small and vulnerable, dwarfed by the landscape. Julia described the scene as representing her feelings of isolation and uncertainty. The cliff, she explained, symbolized the constant pressure she felt to maintain control and avoid falling into despair. Through this self-portrait, Julia was able to articulate her fear of failure and the pressure to keep up appearances. She expressed how exhausting it was to always be “on guard” and how much she longed for peace. In our discussion, we explored the symbolism of the cliff and the sea. Julia admitted that the sea, while initially representing emptiness, also held a sense of possibility. She recognized that the vastness of the ocean could symbolize potential rather than just fear. This shift in perspective marked a significant turning point. For the first time, Julia began to see her anxiety not as an insurmountable obstacle, but as something she could navigate and overcome.Session Four: Reclaiming Inner Strength
By this session, Julia had begun to show a marked improvement. She appeared more relaxed, and there was a newfound sense of confidence in her demeanor. For this session, I introduced a collage exercise. Julia was provided with magazines, scissors, glue, and a canvas. I asked her to create a collage that represented her ideal self—a version of herself free from anxiety and self-doubt. Julia took her time with this exercise, carefully selecting images that resonated with her. Her final piece was vibrant, filled with images of nature, people laughing, and symbols of strength like lions and mountains. She explained that the collage represented the qualities she wished to embody: resilience, joy, and courage. We discussed each element of the collage, and Julia shared how creating it made her feel empowered. By envisioning her ideal self, she began to see her potential beyond the limitations of her anxiety. She acknowledged that while she might always face challenges, she could choose how to respond to them. This realization helped Julia redefine her relationship with anxiety, no longer seeing it as a defining characteristic, but as one part of her broader experience.Session Five: Reflecting and Moving Forward
In our final session, Julia and I revisited her earlier pieces. We discussed her journey through the Art Therapy process, from the initial storm of emotions to the empowered collage. Julia reflected on how far she had come, expressing gratitude for the opportunity to explore her feelings in such a unique and transformative way. She described how the process helped her develop a greater sense of self-compassion, allowing her to accept her imperfections without judgment. Through art therapy, Julia found a new way to manage her relationship with anxiety, one that didn’t involve fighting or suppressing her emotions. Instead, she learned to embrace her feelings, understanding that they were a natural part of her experience. She left therapy with a renewed sense of self, ready to face the challenges ahead with resilience and creativity.***
Art Therapy offers a unique path to healing, one that goes beyond words and taps into the power of the creative mind. For Julia, the process of expressing herself through art provided insights that traditional talk therapy hadn’t been able to access. By working with symbols, colors, and textures, Julia was able to confront her anxiety in a safe and supportive environment, ultimately reclaiming her inner strength. Her journey is a testament to the transformative power of art and the human spirit’s capacity for growth and healing. [Editor’s Note: Please see our interview with Judith Rubin, Bringing (Art) Therapy to Life: An Interview with Judith Rubin, the preeminent pioneer in the field of Art Therapy.]Reasons Why Safety Precedes Forgiveness for Survivors of Abuse
When your offender(s) can’t harm you now or in the future, you are safe. Can you forgive them? Like with all aspects of trauma recovery, the answer is not a simple yes or no. Safety isn’t just about the reality of you being safe, but how safe you feel. You might be safe but not feel safe. This is a common experience, as trauma hinders the ability to assess one’s safety accurately. Trauma tells us that we are not safe even when we are. Feeling is just as crucial in trauma recovery as being because these two experiences are often indistinguishable; for us, not feeling safe feels the same as actually not being safe. After World War II ended, forgiveness advocates might have said to Wiesenthal, “You’re safe now. You’ve survived. The Nazis cannot harm you. You should now be able to forgive.” Yet if Wiesenthal experienced trauma and did not feel safe for years after he was liberated, that would have been impossible. Survivors must both be and feel safe before they can genuinely forgive.
Forgiveness Without Safety Harms Survivors
“He’s a monster. He beat me and locked me in my room for days,” Charlie shared during an Alcoholics Anonymous (AA) meeting. “I can’t think about him without feeling angry.” Charlie began using alcohol at age 10 to cope with their stepfather’s emotional and physical abuse. By age 20, they were hospitalized for alcohol poisoning twice and had been arrested for disorderly conduct, as well as for driving under the influence—multiple times. At age 22, Charlie got sober, embraced their identity as nonbinary, and began attending AA meetings daily. AA helped Charlie to understand their trauma and use of alcohol as a coping mechanism, but the forgiveness advocates associated with AA nearly destroyed their recovery. “You need to forgive him,” was the message from Charlie’s AA group members. “If you don’t forgive, you’ll relapse, and if you relapse, you’ll die,” said Charlie’s AA sponsor. The AA group and the sponsor encouraged Charlie to forgive their stepfather by spending time with him. It did not matter to them that the stepfather continued to emotionally abuse Charlie; he often called them “a freak,” “a drunk,” and “a cunt.” The group encouraged Charlie to ignore these harmful words and approach him with compassion and empathy. Charlie followed this advice and spent more time with their stepfather, expressing compassion and empathy in the hopes that this would ignite forgiveness, which they were told would help them recover from trauma and addiction. Instead, this exposure invited further trauma as their stepfather continued to abuse them emotionally and physically, resulting in Charlie needing to be hospitalized with a broken leg and ribs after their stepfather pushed them down a flight of stairs. The AA group’s recommendation to forgive caused Charlie to place themself in unsafe situations, which led to retraumatization. As a result, Charlie stopped attending AA meetings, ended communication with their sponsor, and relapsed days later. Attempting to forgive without safety threatened Charlie’s survival. Some survivors have even been killed due to pressure to forgive their offender(s), which made them feel as if they needed to continue to participate in unsafe relationships. Psychologist Mona Gustafson Affinito writes, “Workers in the field of domestic abuse, for example, are familiar with victims returning to their abusers because they have been advised to ‘forgive’ the perpetrator. Physical and emotional injury, child abuse, and death of both victims and abusers have resulted.” Those who advocate for forgiveness should be aware that their recommendations might contribute to the deaths of survivors who are not safe. “How many battered women, for example, have returned to their batterers for more (and perhaps fatal) abuse because some counselor advised them to keep trying to save the marriage out of love and forgiveness?” asked philosopher Jeffrie G. Murphy. “I do not know what the answer to this question is, but I am worried that the boosters for universal forgiveness may not give ample thought to such issues.” Unfortunately, however, many laypeople and clinicians pressure, encourage, or recommend forgiveness to survivors without considering their safety. Regarding the risks of forgiving when one is not safe, practitioners of forgiveness therapy say that it’s not forgiveness that’s the problem, it’s reconciliation. They argue that reconciliation is to blame when forgiveness occurs without safety. “The argument seems to imply that forgiving is a way for the offender to keep a sinister control over the forgiver. If forgiving led automatically to reconciliation, then the argument would have weight,” write Enright and Fitzgibbons. They clarify their reframe with an example: “Suppose Alice forgives a husband who continues his pattern of abuse. Is she not now open to even deeper abuse? If she misunderstands forgiveness and confuses it with reconciliation, then, yes, she is open to further and dangerous abuse.” Many confuse forgiveness with reconciliation. People rarely know or communicate the distinction between these two concepts, and this mistake can cause harm. Practitioners of forgiveness therapy must be aware that though forgiveness is not reconciliation, forgiveness can lead to reconciliation, which may jeopardize a survivor’s safety. Therefore, all clinicians must provide survivors with psychoeducation regarding the difference between forgiveness and reconciliation and consistently assess the safety of survivors pursuing forgiveness. But at the end of the day, a debate over semantics doesn’t hold much weight when a recommendation to forgive could lead to a survivor’s death. When forgiveness is dangerous, it should not be a part of recovery. Of course, forgiveness without safety does not always lead to death. However, it can still harm in other ways. Forgiveness can encourage repeat offenses rather than deter them, giving the offender(s) the opportunity and incentive to continue their abusive behavior. Psychologist James K. McNulty conducted a study that found that the tendency to forgive correlated with continued psychological and physical aggression in marriage. He found that spouses who were more forgiving experienced greater psychological and physical aggression in their marriages over the first four years when compared to less forgiving spouses, who reported declines in psychological and physical aggression. McNulty expressed concern about how forgiveness can negatively impact relationships, writing that “the tendency to express forgiveness may lead offenders to feel free to offend again by removing unwanted consequences for their behavior (e.g., anger, criticism, rejection, loneliness) that would otherwise discourage reoffending.” Consequences are needed in relationships, but forgiveness can insulate offenders from the consequences of their actions, causing them to reoffend. During the first month of Charlie’s trauma therapy with me, they told me about their experience with their AA group and how their insistence on forgiveness had harmed them by encouraging them to reengage in an unsafe relationship with their stepfather. This prompted me to suggest, “What if you choose a new group that could better meet your needs?” “I can do that?” Charlie asked, surprised. “Why not?” I responded. “Your old AA group was no longer helpful. Why not see if another community could be more beneficial to you at this stage in your recovery?” Charlie hit the ground running, and within two weeks, they found a new AA group and a new sponsor who considered safety, not forgiveness, the top priority. This group asked Charlie questions such as “What do you need to stay sober?” “What works for you?” and “Do you want to forgive him?” Charlie felt accepted by this group, and as a result, they continued participating in AA, which became vital to their recovery. Months later, Charlie decided to estrange themself from their stepfather, which their AA sponsor, the group, and I supported, as Charlie reported that this estrangement was what they needed to feel safe. One year later, they received their one-year AA sobriety coin and have since continued to make considerable gains in their trauma recovery. You need to be and feel safe before you can forgive. If you are currently not safe, you cannot focus on forgiveness. You may be safe but do not feel safe, so forgiveness is currently out of reach for you as well. You may have never felt safe, and the experience of thriving feels foreign. However, it is entirely possible for you to both be and feel safe. The human brain prioritizes survival, but once this priority is met by reestablishing safety, the brain can refocus on thriving (recovery and possibly forgiveness).Feeling Safe Enough
People often assume that certain types of traumatic experiences (physical or sexual abuse, combat exposure) are more impactful than others (financial, emotional, or spiritual abuse, abandonment, or neglect). Yet, studies indicate that children who experience emotional abuse and neglect develop the same or worse mental health issues as children who experience physical and sexual abuse. Therefore, we cannot assume that one type of traumatic event will have a more or less significant impact on a survivor than another. What’s more, response to trauma is highly dependent on the individual. [edtiquote:we cannot assume that one type of traumatic event will have a more or less significant impact on a survivor than another]I’ve worked with siblings who were close in age and lived in the same home throughout their childhoods, with the same abusive parents. These siblings never have the same experiences or the same trauma responses. They are always different. Comparing your traumatic experience with another’s doesn’t make sense; if trauma were a competition, every survivor would be a winner. All traumatic experiences are significant and valid, and so all types of safety are essential. If you are currently safe but don’t feel safe, you can begin to establish a sense of safety by accepting that all forms of felt safety are necessary. For instance, physical safety is not more or less essential than emotional safety. They are equally important. In the case of the former, you may need to feel that you are not in physical danger, and that the offender(s) or things that cause you harm cannot reach you. For the latter, the feeling of emotional safety might come when you are in an environment in which you can be honest about your emotions without feeling manipulated or invalidated. There is not one form of felt safety that should receive more or less attention or be taken more or less seriously. Every type of safety is essential in your recovery, especially since survivors often report lacking many different forms of safety. It’s common for survivors to report feeling physically, sexually, emotionally, financially, and relationally unsafe. Financial safety is a common theme in trauma recovery, which may be surprising. However, when you take a moment to think about it, it makes a lot of sense that this is so important. In most societies, financial security creates and sustains many other types of safety. Those with financial security can use their resources to support and promote their physical, sexual, spiritual, and emotional safety. Those without financial security are often the most vulnerable to experiencing trauma, less likely to be able to escape their offender(s), and less likely to receive treatment. In addition, those who do not feel financially safe often feel unsafe in other ways. For example, some survivors living in the United States do not feel physically safe because they cannot afford medical treatment if they become ill or experience an accident. Some clinicians believe that you will never feel safe until you are fully engaged in the recovery process. In this view, it is impossible to reestablish safety at the beginning of recovery. Instead, these clinicians promote intense emotional processing interventions, such as forgiveness, before you feel safe or are able to tolerate processing, believing that safety will be reestablished along the way. This line of thinking only makes sense if one believes in the existence of perfect safety, a sense of security that never wavers during the pursuit of recovery. It assumes that once safety is achieved, it never goes away, and thus, the intense recovery process can continue uninterrupted. As nice as this would be, it’s not how recovery from trauma works. Some days you might feel safer than others, and the circumstances of your life can change to bring you closer to or further away from the unsafe situations or relationships you seek to avoid. There is always the possibility of a step back in recovery, and that’s okay. It’s a normal part of recovery. No one feels safe all the time, not even people who haven’t suffered trauma. Safety cannot be a byproduct of recovery, something that happens once you start working. It must be the enduring foundation, and to lay such groundwork, the clinician must work with the survivor to establish safety before anything else. The truth is that recovery comes with safety, not the other way around. Perfect safety is unobtainable, but feeling safe enough is possible. Events and experiences can and will threaten your safety. If you’ve ever had a pet, you’ve probably seen this play out. For instance, imagine your cat is asleep on your lap. Suddenly, the cat jumps up, looks at the corner of the room, and freezes. The cat’s hackles are raised, as if static electricity has made their fur stand up. The cat is in survival mode; they heard something that caused them to feel unsafe. Then, after a few moments, the cat lays back down on your lap and falls asleep. The cat has reestablished a sense of safety and now feels safe enough to refocus on thriving (napping in the open). All organisms have moments of feeling safe (focused on thriving) and moments of feeling unsafe (focused on survival). They go back and forth, course-correcting as they go. The goal for survivors is not to reestablish perfect safety; that is impossible, and they never had it in the first place (none of us do). The goal is to reestablish actual safety and a felt sense of safety, which promotes your survival and makes you feel safe enough to focus on thriving. As you progress in recovery, your clinicians hope to see you become more resilient as your sense of safety increases. Reflections for Survivors Survivors who question the importance of their safety can ask themselves the following:- Am I safe? If not, can I prioritize reestablishing safety?
- Am I feeling unsafe? If so, can I prioritize reestablishing safety?
- Do I feel physically, emotionally, sexually, relationally, spiritually, or financially unsafe? Do I feel any other type of unsafety?
- Do I know what I need to support my actual safety and feelings of safety? If so, can I communicate these needs to my clinicians and those in my support system?
- Can I prioritize my need to feel safe enough over my participation in intense emotional processing interventions such as forgiveness?
- Do I believe my client’s safety is vital in their ability to progress in recovery?
- Have I assessed my client for all forms of safety (physical, emotional, sexual, relational, spiritual, financial, etc.)? Am I continuing to assess their safety at all stages of their recovery?
- Does my client always feel unsafe, or are these feelings triggered by something or someone?
- Am I helping my client reestablish both actual and feelings of safety?
- Am I prioritizing my client’s sense of feeling safe enough before introducing processed-based interventions such as forgiveness?
A Unique Mental Health Conference That Supports People With DID
Stationed safely behind my exhibit table at the annual Healing Together conference in Orlando, I observed the attendees milling about the hall. Their dress ran the gamut from business attire to resort wear, to outfits that seemed like Halloween costumes. Some were dressed as children, with ribbons, sparkles, young-style dresses, and fanciful headgear. Others looked like animals of one sort or another. A few pushed carts filled with stuffies or were with emotional service dogs. The weekend-long meeting, then in its 12th year, had just begun, and people were congregating at the snack and non-alcoholic beverage bar. Watching them greet one another enthusiastically, I surmised most were returnees. It was 2022, my first year at the conference, and I knew no one. The outfits disconcerted me most. I understood that they were an expression of dissociative identity disorder (DID), formerly called multiple personality disorder—the focus of the meeting—but I had never seen such an unabashed display, even in support groups.
Inside the DID Support Network
The conference is sponsored by An Infinite Mind, a nonprofit that aims to increase awareness of and education about DID for three constituencies: people who have DID, their supporters (family and friends), and professionals (clinicians and researchers). The hope is that greater understanding of the condition will counter myths and stigma, enable people living with DID to navigate their lives and treatment more effectively, and broaden clinicians’ skills and knowledge. Most medical conferences that offer Continuing Education Units (CEUs) invite presentations from professionals only. The board of An Infinite Mind invites them from all three cohorts, believing each can learn from the others. As someone living with DID—now 82, I was misdiagnosed as schizophrenic in my 20s and didn’t learn I had DID until my 40s—I was there to give a talk about my experiences and to promote my memoir, Losing the Atmosphere.
Having spent decades trying to hide my neurodivergence—necessary for my dual careers as a librarian and an I.T. systems analyst—I was uncomfortable the entire weekend, though I went through all the proper motions: I spoke with people who stopped at my table, sold books, and gave my talk. In the weeks following the meeting, I tried to make sense of my reaction. In a way, I was like a dog acclimated to living with humans suddenly finding itself in a field of dogs. But where an actual dog would have joyously connected with its fellow creatures, I didn’t dare mingle. Like the legendary sailors who tied themselves to the mast so they wouldn’t succumb to Lorelai’s song, I remained tethered to my exhibit table. Yet something about the meeting drew me back the following year. I was a little more relaxed then, but it wasn’t until my third year, 2024, that I felt completely at ease, able to fully absorb the power of the conference. I would later learn that my timeframe was not uncommon.
A few hours before the 2024 doors officially opened, I entered the exhibit hall with my cart of books and handouts and began looking around for a table with my name on it.
“Hi, Vivian! Welcome!”
I turned. “Hi, Jaime!” I said to the founder of An Infinite Mind and the mastermind behind the Healing Together conference.
“Can I give you a hug?” she asked. My hesitation must have been obvious. “An elbow bump?”
We bumped.
She inquired about my train trip from New York, then said, “I know you don’t like crowds, so I put you at the end, near the crafts corner.”
“Thanks.”
She remembered. I was pleased. My first two years were during the Covid pandemic, and I worried about getting sick.
A pre-school special education teacher, Jaime Pollack received several misdiagnoses, including schizophrenia, before she learned, in 2005, that she had DID. Her search for information about it led her to meet other people with the condition, and, in 2007, to start a peer-led support group. She soon realized they shared similar challenges, chief among them the lack of accurate information. There was an abundance of books and journal articles for clinicians and scientists but little for people who had DID—about what it felt like, how to manage day-to-day situations, how to find appropriate treatment. Believing she could be of more help filling this void, Jaime changed focus and started An Infinite Mind.
“This is our biggest conference ever,” she said now, pride in her voice. “Would you believe we’re 400 in person and 300 online? From 26 countries! There’s even a group here from Australia!”
“Wow!”
“And people say DID is rare!”
As I made my way to my table, I felt an inner calm, despite being nervous about my talk the next day. I had come home.
My exhibit set up, I walked around to see what else was on display and to greet people I knew from previous years. There were a few other memoirs, various therapy practices from around the country, a short educational film about DID, workbooks to help you get in touch with your internal parts, DID-themed crafts, a DID writing program, artwork and jewelry created by people with DID, and more.
When the doors opened, the familiar Disney-like parade filled the hall, but now I saw it as a glorious celebration. At Healing Together, you didn’t have to keep your inside selves hidden if you didn’t want to. If your body was 60 but you felt 8, here you could be 8. If a part of you was nonhuman, perhaps an animal, here you could be that animal. And if you were conservatively dressed, as I was, that was OK, too.
Yet this was a serious conference. My presentation would be one of more than 40 that weekend, a mixture of those based on lived experience and those based on science. A sampling:
- What One Therapist Wishes She Had Known Seven Years Ago about Treating Clients Who Live with DID
- One Body, Multiple Eating Disorders
- Healing from Toxic Shame
- So, You’re in a Relationship with Someone Who Dissociates. What now?
- PTSD and DID: Physiological Adaptation in Response to Trauma.
- When Your Therapist Is Your Whole World (This was my talk, about becoming dependent on my therapist as a step toward healing, then eventually moving on, with my therapist still important but no longer my whole world.)
All three cohorts were welcome to attend any of the presentations. The only cohort-specific events were the optional lunchtime chat-and-chews. There were four groups:
- People living with dissociation and dissociative identities
- Supporters of people living with dissociation and dissociative identities
- Therapists with dissociation and dissociative identities
- Therapists who treat dissociation and dissociative identities
These get-togethers took place simultaneously, so if you identified as belonging to more than one group—there are professionals and supporters who dissociate—you had to choose.
When the first Healing Together conference, held in 2011, was in its planning stages, clinicians discouraged Jaime from going through with it. Bringing together many people with DID could create an unstable situation, they said. Jaime and the board of An Infinite Mind board didn’t agree. Largely plurals themselves, they understood the issues and knew how to address them.
DID is usually caused by ongoing childhood trauma at the hands of someone the child knows well. The trauma can be physical, sexual, emotional, or spiritual. It can be neglect or unpredictable behavior on the part of a caregiver. (For me, it was a combination of physical and emotional trauma and my parents’ unpredictable behavior.)
Some traumatized children wall off knowledge of the trauma and the feelings associated with it. The resulting lack of awareness allows them to live seemingly normal lives. The splitting is not intentional. It kicks in automatically, a kind of psychic immune system, shielding the child from emotions like pain, anger, terror, shame, and feeling betrayed that would otherwise overwhelm. The child’s internal system may have multiple splits, with each walled-off part, or alter, playing a different role in protecting her. The parts may be of varying ages and sexes; some may be aware of the others, some may not.
This dissociation serves a purpose while the trauma is still ongoing. It becomes problematic when the child grows up, moves away, and is no longer being traumatized. Dividedness is not necessary for the adult’s survival, but her alters, stuck in the past, don’t know that. They are much like the Japanese holdout soldiers who hid in the jungle, ready to fight, long after World War II ended.
The board of An Infinite Mind understood the dynamics of dissociation and switching, particularly the effect of triggers, which can “wake up” alters holding disturbing memories. This is similar to veterans with PTSD who hear a car backfire and react as if they are on the battlefield. The alter who surfaces in response to a trigger may not know what year it is or where they are. What the person with DID most needs when this happens is to become grounded. This means knowing that they are in the safe present, not the unsafe past.
Some ways to facilitate grounding are walking a labyrinth, doing crafts, journaling, and activating the five senses: taste, sight, touch, smell, and sound. The following notice appears on the first page of the 2024 Healing Together agenda:
Throughout the conference, you can visit our calming and grounding area when you need a break. There are art activities, a quiet space, sensory items, and a walking labyrinth.
Creating a Safe Space
The conference is made into a safe space in other ways, too. The exhibit hall, presentation rooms, and grounding areas are accessible only to those who have registered. No random guest in the hotel complex can wander in. Each presenter is instructed to begin their talk by announcing that it’s OK for attendees to walk out. Confidentiality is stressed. Most presentations are recorded; a few are not, because the presenters asked that they not be. The recordings are available for several weeks after the conference ends, so people can listen to sessions they did not get to attend or re-listen to others. Attendees are on their honor not to share the recordings with anyone who was not at the conference.
One effect of the safe-space bubble is that people with DID, whether dressed conservatively or conspicuously, get a taste of what it feels like to be neurotypical. We can converse in our native language. “We flew in yesterday” is DID-speak for “I flew in yesterday.” We can mention “littles,” and it is understood we are referring to the child parts inside us. We can talk about a particular alter having “body-time,” and everyone knows it means that alter was “out,” or “fronting,” i.e., that was the alter interacting with the world at that moment.
Like Brigadoon, the mythical Scottish village that comes to life one day every 100 years, Healing Together is a place where, for one weekend a year, people with DID get to be mainstream. It’s the attendees who don’t have DID who feel “other.” More than a few people who stopped at my table felt the need to justify their presence by saying, “I don’t have DID, but my daughter does…,” or “I don’t have DID, but I’m a therapist…,” or “I don’t have DID, but I’m buying the book for…”
People living with DID have many hurdles to navigate. One is the diagnosis itself. A fair number of clinicians, believing the condition is rarer than it is, don’t recognize it when they see it—outside of this meeting, people with DID do not generally “dress up.” Someone with DID spends an average of seven years in the mental health system before receiving the correct diagnosis. (For me, it was 30 years.) In fact, DID affects between 1-1.5% of the population. For comparison, schizophrenia affects 0.25-0.64%, and autism 2.8%.
Another hurdle is finding a therapist. DID is about creating internal silos. Therapy involves breaking down the silo walls so information and feelings, however painful, can be shared among alters. Not many therapists are experienced in doing this difficult and lengthy work. (The search for a therapist with DID expertise took me six years, bringing me into my 50s.)
Still another hurdle is stigma, in large part generated by sensational media portrayals of DID. Among many examples are the 2003 mystery/thriller Identity and the 2016 horror/thriller Split. A physician I once consulted for digestive problems changed from cordial to fearful when he found out I had DID. First, he asked me to wait outside while he made a phone call. Then his receptionist said I could go home, and the doctor would mail me his recommendations. I subsequently sent him an article about DID I had written for New York Magazine, along with a note explaining that people with DID were no more apt to commit violent crimes than anyone in the general population. He apologized by mail, saying my article taught him a lot, but I chose not to see him again.
At Healing Together, people with DID, regardless of how we are dressed, have ordinary conversations, attend meetings, and participate in Q&A sessions as if we are just regular people, which we are. By the end of the weekend, it struck me that I hardly noticed the outfits anymore. And if I closed my eyes when I was talking to someone, I wouldn’t have known whether they were a person with DID, a supporter, or a professional, unless they chose to tell me, or unless they used plural pronouns while referring to themselves.
Though I could have used the grounding area during my first two years, I was too overwhelmed by the conference to seek it out. But in 2024, when my pre-talk nervousness escalated, I made my way to the crafts table. I didn’t know what I was going to draw until I saw a flower appear on the paper that was the hallmark of six-year-old Emily, one of my alters. Feeling calmer, I made another and posted both above my table.
I wasn’t happy with my talk. My pacing was off, and I had to skip the middle and jump to the end to stay within the time frame. Ordinarily, I would have found it hard to hold my head up afterward, yet I continued to be buoyed by the conference and enjoy interacting with the attendees. It wasn’t until the train ride back to New York, with 24 hours of rolling landscape as a buffer between Healing Together and the “real” world, that I understood why.
***
I consider myself mostly healed—I have reached the stage of “functional multiplicity,” where my DID does not interfere with my having a full and satisfying life in the non-multiple world—but I had never before experienced an environment where I didn’t feel at all different from other people. It was also an environment where, despite my talk, I felt I mattered. Several times during the weekend, people told me they heard me speak in prior years, or had read my book, or had given a copy to their therapist. A feeling common in people with DID is that we are inherently less than, or not as worthy as, “regular” people. In me, that feeling is often buried so deep I am not aware of it. But for the entire weekend, I felt easy in my body in a way I hadn’t known was possible, as if a burden I didn’t know I was carrying had been lifted. Gazing at the trees whizzing by my window, I realized the burden was shame.
Healing Together is a space where those of us with DID can think of ourselves as having dissociative identities. Full stop. The word “disorder” has no place in the description, being inappropriate for the remarkably creative way our psyches shielded us from the effects of trauma. It is a serious meeting with a generous sprinkling of light moments. My favorite from 2024: When introducing the keynote speaker, Jaime asked attendees to raise their hands if they had dissociative identities. Many hands went up. “So, there’s actually a lot more people in this room than are in this room,” she said to laughter and applause.
I look forward to hearing her introduce the 2025 keynote.
***
My table in the exhibit hall of the Healing Together conference
The two flowers I drew at the crafts table.
Editor’s Note: An excerpt from Vivian Conan’s Losing the Atmosphere can be found on Psychotherapy.net.
Spilling Over Modernity’s Borders and Boundaries: A Decolonial Story About Alzheimer’s, Family, and Migration
“¿De dónde eres?” My friend’s 9-year-old niece asked me shortly after we were introduced to each other during Christmas. This was in Bogotá last year at my high school friend’s place. She sat next to me, leaning slightly toward me. Her question seemed fueled by a kind of curiosity that two strangers at times share when wanting to rush through the unfamiliar and quickly find a common place from where to discuss matters of much greater importance, like her Christmas presents. It must have been around 15 years since my high school friend and I last knew about each other’s lives. Various life circumstances might have contributed to vanishing from each other’s lives—including living in two different countries—until whenever the day was going to come for us to meet again and pick up our friendship right from where we left off to catch up on whatever many years in between.
My eyes shot open and met her curiosity, sensing all over my body the shock of her question. Did she unwittingly render me foreign to and within my homeland? I wondered.
“Pues de aquí. De Bogotá. Rola 100%!” I said to her, stating what for me was the obvious.
“Es que hablas diferente.” She further explained.
“¿Y tu?” Le pregunté,” pretending to ignore the state of my body, and attempting to reciprocate an interest in our origins.
“De acá.” Me respondió, while organizing her Christmas presents for their exhibit.
My friend overheard our conversation. On the way to the kitchen, she provided some context to resolve her niece’s confusion and to create mine.
“Ella es de aca pero hace mucho que no vive aquí por eso habla así.” my friend explained with the tone of certainty of an irrefutable conclusion.
“Así cómo ???” I yelled in horror; but she had now gotten lost far back in the kitchen as the Christmas host.
Like many, I became well acquainted with the origin question as an immigrant, hence actual foreigner to the sociopolitical and material history of my host country, the United States (U.S.); as well as with the experiences of those who although were born in the United States are inadvertently or intentionally rendered foreign in their homeland by others. This is, when informed by discriminatory singular and monolingual principles about nationals and foreigners from a land. Having left Colombia as an adult, in the U.S. the socio, geo, and body-political history of Latin America/Abya Yala I carry, materializes not only in my accent but in my interactional manners, phenotype, epidermis, and knowledges, which intertwined with local racializing practices, continuously mark the well or ill intended curiosities of the inquirers, nationals or immigrants alike, about their assumptions about my foreign origins. Regardless of their intent, in foreign soil, I share my origins with my chest filled with air, trying out a new sense of pride in the diaspora evoked by its nostalgia, not quite reaching patriotism but maybe darn close to it, if I were to speculate on what incarnated patriotism would be like:
“From Colombia.” I usually respond to that question and sometimes I point at my wrist when I wear its colors.
Re-entering: From Here and From There Migration Experience
During the last couple of years, I have been spending more and more time in Bogotá than I ever have since the early 2000’s when I left. My mother’s health and increasing loss of memory called for it. Although no doctor would diagnose her with Alzheimer’s in her late 80s, that was the family’s narrative about that part of my mom’s life and our relationship with her still to this day. Her four daughters were no longer living in Colombia. My three sisters and I migrated to the U.S. at different times during our adult lives, for different reasons that required no explanation. Mom and dad raised us during the Colombian armed conflict, intensified by the international drug war and the U.S. intervention.
In a country living and enduring the ongoing wounds of war, poverty, and state neglect, as it is the case for many countries living through long-standing conflicts around the world, as I recalled, for many Colombians across various socio-political circumstances, since birth, the idea of leaving Colombia becomes part of what it means to live in Colombia, aspiring for refuge elsewhere. Violence humiliates the homeland and elevates the non-realizable promises of foreign land. Those of us who realized the idea of leaving Colombia represent the 6% of the population who currently live outside of the country—primarily in the U.S., Spain, and Venezuela. According to the Migration Policy Institute, Colombians are the largest group of South American immigrants in the U.S., representing 2% of U.S. immigrants. Colombian migration to the U.S. has increased three times as fast, from 144,000 Colombians in 1980 to 855,000 in 2022.
During our lives in the U.S., mom would come to visit for various periods of time, visiting with each one of us across states. My dad traveled once, which was more than enough contact with U.S. soil for him, given his politics. We would stay in contact through daily emails or texts, otherwise. Also, from time to time, I would travel to Bogotá for a long weekend or so for a visit. Before migrating, and all throughout the Covid pandemic, my oldest sister lived with and cared for mom in Bogotá until the impending heart-wrenching decision finally came knocking at the door to meet the four of us face to face.
The emotional intensity, and dedicated care my sister and her children had been providing mom with for the last few years had proven to be no longer sustainable for either of them. Con cabeza fría, we had to make the overdue decision, even against mom’s wishes that she no longer remembered. Mom needed to be relocated to a specialized nursing home for her proper care. She had outlived friends and close relatives. My father died back in 2008, and we heard that mom’s last living sibling, the oldest, Alberto, was still alive but bedridden in deteriorating health conditions. He died not too long after mom moved to the nursing facility.
My relatively advantageous immigrant conditions afforded me alternatives that only so many immigrants in the U.S. have in similar circumstances, with aging parents still living back in our home-countries. I began traveling to Bogotá regularly during the last year before mom died, spending months at a time with her while working remotely. My sisters would visit when able. Daily, morning and afternoon, raining or not, I would walk back and forth to visit mom at the nursing place in the north area of Bogotá from the small place nearby I rented during my stays. I would pick up on my way some kind of dessert for my mom’s sweet tooth that memory loss had forgotten to forget. I became very well acquainted with mom’s co-living folks and their visiting families; and also the nurses, aids, physical therapists, and cooking and cleaning staff, majority women, to the extent that exceptions for their visiting hours became the new visiting hours. It was through their lives—the only people I had close contact with at that point in Bogotá—that I re-entered a sense of living a life in Bogotá, although still having more than one foot in my immigrant life in the U.S., to which I remained virtually connected through a laptop.
Through life at the nursing home, I reintegrated myself to the familiar tensions of the Colombia Nation-State’ s sociopolitical heartbeat, revealing along the signs of the 24 years that have passed and have transformed both the country and my politics in the diaspora. The tensions were palpable. On the one hand, the advantageous circumstances of the families who could afford their relatives to live there were visible. And, on the other, so were the injurious sociopolitical conditions and longstanding neglect by the Nation-State toward the lives of the people working there. Although responsible for the care of the facility’s residents, they had to do so while undergoing living conditions that seemed to cry out in state neglect. This was one of the other jobs they needed for their survival and the survival of their family.
Some of their children were being educated under precarious conditions in public schools. Evictions from their home were more tangible month after month. The impeccable makeup of some of the women working in the kitchen kept hidden the marks of patriarchy’s hands from the night before, some of which was documented in futile police reports as well as in her self-defense fingernails imprinted on his skin. Their clothes served as curtains behind which their bruised bodies were concealed, while their bones would heal from their forceful impact against the wall, or the push down the stairs. Their children were their witnesses. According to the Colombian newspaper, El Pais, between May of 2023 and 2024, 149.017 family violence incidents and 630 femicides were reported in the country. Limping, the women would arrive on time at the nursing home after a 3-hours-long commute from the south of Bogotá to care for my mom with the best of dispositions possible. Story after story, the nostalgic Nation-State Colombia of the diaspora that I was so proudly holding tight to, wearing it on my wrist, and expanding my chest, started to melt throughout my body, transpiring through my skin, forming a polluted stream of outrage that took off running through la Avenida 19, running all the red lights, turning toward la Autopista Norte, eventually merging with Bogotá River, considered one of the most contaminated rivers in the world, according to WSP.
My relationship with mom that year was not exempt from a sort of re-entering experience. It was similar to how my re-entering to a life in Bogotá was. On occasion, mom would seem as if she could see in my face sort of a familial resemblance but not quite family. I was beginning to feel that way about everyday life in Bogotá although not linked to a matter of memory but migration. I recognized aspects of what I remembered was my homeland out of the unrecognizable features of the obvious changes since I left. I was able to discern some things but not others with my renewed borderland eyes as a Colombiana inmigrante en the U.S.
My life from when I lived in Colombia during the late 1900s met with my life as an immigrant living in the U.S. since the beginning of the 2000s only to discover they had already met over two decades ago and have become inseparable since. My memories from Colombia were never left behind. On the contrary, they carried me through the making of a new life in a new land. After all, we can’t separate ourselves from the history that makes us. I have been living both lives simultaneously, through a multiplicity unfolding either in Colombia or the U.S.
A sense of foreignness within the familiar, and a sense of familiarity within the foreign helped me discern the experience of dwelling in the borderlands, which my friend and her niece also brought out in the open during Christmas, when I reconnected with them months after mom died on March 29, 2023. The borderlands became a point for reflection on what it was bringing forth—difference—to ultimately transcend modernity’s definition of difference as fracturing borders or boundaries since the conquest of the Americas—the colonial difference. Walter Mignolo has written extensively on this topic.
The colonial difference refers to a hierarchy of separation (for control purposes) through the development of borders or boundaries that create races, cultures, Nation-States, identities, languages, genders, etc. Modernity’s colonial difference fractures the bones of the communal into hierarchical separate pieces whereby those lower in the hierarchy can be thrown down the stairs or against the walls of separation that it created. Thus, my friend nieces’ question about my origins, became a recognition of difference stemming from my 24 years in the diaspora crawling up my Colombian accent to renew it within a sense of plurality. My renewed accent marks a difference that does not have to be of borders, exclusion, fracture, or separation, but of relationality and connection out of what it means to live relationally, or in more than one world simultaneously.
I have heard many stories, mostly from Mexican, Chicanxs, Mexican-American, or Texanes, about their experiences when returning to their homelands in the Nation-State of México. They shared being made to feel that they do not belong on either side of the border: “not from here, not from there,” “ni de aquí, ni de allá [neither from here nor there].” I understand this to be a symptom of modernity’s logic of criminalization by difference and punishment when crossing the border. Anything that does not represent nationalism on either side of the border, thus promotes monolinguality, monoculturality, or singularity, is destitute and criminalized. On the contrary, from the borderlands of my experience, I am thinking about immigration interrogating the borders while being interrogated; thus, opening at the same time possibilities to rethink the fracturing premise of separation modernity promotes into being “from here AND from there, simultaneously, thus relationally.” This revised premise eases my body when facing the origin question by Colombians in Colombia.
Rendering the Familiar Unfamiliar: Radical Listening
More often than not, mom did not know exactly who I was, or when and where we may have met at some point in our lives. Only a couple of times, she recognized me as her youngest daughter, “marce,” as she used to call me. Although she never forgot her name, Gloria, she did not know where she was nor recognized her own image in the mirror. Sometimes I was her youngest sister, and other times, she would address me as her nurse or aid. When I would rub her hands, the touch would call her to reposition her hands and to start giving me instructions on how she wanted her nails done that day. When I would pass my fingers through her hair, sometimes she would address me as her hairdresser, or quite firmly in a tone I did not recognize, she would push my hand away demanding that I do not touch and mess her hair.
As much as mom did not remember that I was her daughter, I did not always fully recognize mom in the body and interactions of the 89-year-old woman living in the nursing home—except during her brief inconfundibles momentos [unmistakable moments] of humor here and there. This was not surprising to me, having learned about similar yet different stories from folks from various backgrounds with parents living with Alzheimer’s or dementia, not only in my therapy work. My family was now living through those stories but creating our own. Our story is also likely to be my story about possibly inheriting from mom a life with Alzheimer’s yet to manifest, at least as far as my memory can tell thus far.
Although not surprising, witnessing mom’s increasing experiences of discomfort, suffering, and loss of conversational abilities was at times hard. Yet, unexpectedly, under such unfortunate circumstances, not being remembered by mom at times opened alternative relational possibilities. But it required radical listening to recognize these as possibilities and through the rather overwhelming presence of Alzheimer’s. I have learned radical listening from various perspectives that I carried with me every day to the nursing home during my visits. These include perspectives on borders, memory, history, and aesthetics shaped by my lived experiences as a bilingual immigrant, my understanding of Narrative Therapy in English as a family therapist, and mostly by my engagement with the decolonial project from Abya Yala y el Caribe in Spanish and Spanglish as a member of the civil political society. These are perspectives that have shaped not only my family therapy work but my life as I write here.
Cognitively speaking, Alzheimer’s configured mom and I as strangers, no longer family. We became foreigners to one another. Most interestingly, however, it rendered us foreigners to modernity’s concept of the family. As an immigrant, working and living in community with immigrants in the U.S., questioning, revising, expanding, or delinking from the westernized idea of family has not been uncommon. Migration is a context for the necessary renegotiation of our ties and kinships within the context of voluntary or involuntary separation, and deportation. For example, during the current administration in the Nation-State of the U.S., during the last four years, nearly 4.4 million people have been deported to more than 170 countries according to the Migration Policy Institute.
Mom and I became foreigners to the western idea of the family settled and promoted in Colombia, and many other parts of the world, through Catholicism, heteronormativity, patriarchy, capitalism, and their institutionalization of relationships. As one of mom’s four non-adopted or non-in vitro children, our half a century-long enfleshed relationship was governed in great part by humanized fracturing assumptions of reproduction, motherhood, productivity, and gendered relationships founded on who gave birth and who was birthed to constitute a family. Thus, oddly, Alzheimer’s liberated us, not from accountability for all the headaches I caused mom over the years, rather, from thinking ourselves, and listening to each other, through the institutionalization of boundary-based relationships, its imposed social expectations, and Nation-State’s laws whereby the western family has been instituted as some sort of a social mandate. If I were to take a guess, these sort of institutionalized human laws and western concept of the family might be the sort of conundrums that would make la Pachamama, Madre Tierra, shake the earth. Mom’s forgotten aspirations for my life and my sisters’, which included growing up to become Colombian mothers, with good husbands, and decent, healthy, economically independent (from men), and hard-working women, were no longer shaping our relationship.
Deinstitutionalized by the unfortunate circumstances of Alzheimer’s, thus no longer being a Colombian mother and a Colombian daughter in the modern sense, we learned each other and cared for each other otherwise, sometimes minute by minute. The fracturing logic of the family boundaries planted by modernity was removed. Thus, I understood care to be instead about honoring the relationship with the person I owed my existence to in so many ways in addition to giving birth to me. As a family therapist, I am attentive to what the global and western concept of family imposes on relationships in an exploration of what sort of relationships are possible otherwise or in addition to.
My relationship with mom was unpredictable and in constant movement. It was to be discovered by dwelling in the moment of its expression. We had to discover who we were, a cada momento (every moment), according to the memories invoked and received as they came, no matter what. Was I the hairdresser, the woman who does her nails, her sister, one of my sisters, her nurse, or any other character out of my mom’s history? I could not arrive at the nursing home with certainty of who I was, but with clarity of where my existence—and my sisters’— came from. I became someone only through the act of being with mom and our memories, some of which we invoked together.
We connected through the ever-changing moment of the circumstances that brought to life some of the memories of what we were made of. The circumstances I am referring to were for the most part sensorial. The senses evoked sparkles of memories, interconnected with other memories, both hers and mine. The taste of the daily desserts, my touch, the temperature of my hand over hers, the boleros we listened to, the noise from the novelas on the TV we stared at, pictures of her younger life, the colors and textures of my clothes, my gray hairs, the co-living folks’ speech or appearance, the birds’ colors and their singing having Bogotá’s traffic as their symphony far in the background, as well as the colors of the flowers around us when we sat outside in the garden evoked memories intertwined. Those memories that have shaped, among other things, our half a century relationship, not only formed our lives but who we were to become moment by moment. I realized I was mom’s sister, por ejemplo, only in the brief moment that she saw me as her sister. Undoubtedly, we were radical historical and relational beings.
I can’t help to think about how social relationships, including relationships within the context of westernized therapy look like when we are to arrive at the encounter with someone else not with certainty (or doubt of) of who we are as therapists but with clarity about where we come from—as historical beings. This shifts away from the mainstream conceptualization of the therapist as an empty (no history) interventionist, solely performing according to the regulations of the institution and professional Eurocentric theories to be good or effective therapists. As historical therapists, instead, we become available to engage and receive the encounter with another, attending carefully to our histories, intentionalities and how we are shaped by the experience of the encounter. Thus, similar to who I became when visiting mom, who is the therapist is not independent from the encounter with who consults. The therapist becomes a therapist in the encounter with the person who is consulting. This shift requires an initiative to des-institutionalize the therapist, and to foreignize westernized therapy perspectives that situate an ahistorical therapist.
The Sensorial Grammar and Temporality of Memories
As mom’s cognitive abilities continued to deteriorate, it seemed as if for those of us around her, her presence in this world began to disintegrate into oblivion. She was talked about, no longer engaged with, her body moved from one place to the other, and words were put in her mouth, at times necessarily. Her existence was for the most part reduced only to her possibilities, or lack thereof in her present, in the here and now. Although her body was present, the growing absence of thought, reason, and the ability to access frameworks of intelligibility to express ideas in the present moment seemed to cast doubt on her very existence. Hence, if we were to recognize mom’s existence and vivid presence in this world, it required us—decolonially speaking —to overcome modernity’s spatial (here), temporal (now), universal assumptions. It also meant to cast doubt on the overemphasis on cognitive function, (capitalist) productivity, modern storytelling (or framework of intelligibility), and conversational skills as the only ways of being or existing. Then, it became more possible for me to continue to relate to mom, to learn from her, and to be transformed with her.
I came to understand that the sensorial had become the grammar of our communication, through memories. Mom’s life was unfolding through her bits of memories that situated us in their respective temporalities. Although evoked in the present, mom’s slivers of memories were transgressing modernity’s contemporary framework, its universalized linearity—past, present, and its spatial metaphysics that places the present as the monopoly for the principles of what is real and represented as real. She brought me into her life to take part in events that were happening before I was even born. When some of the aides or co-living folks would overhear our conversations at the nursing home, however, it was not uncommon that they would mistakenly “correct” mom’s temporality when instructing her about their (modern) sense of time—the time most of us operate under. They would persist in telling mom what year, place, and person she was, alluding to the calendar present even though it did not match the temporality of her memories. I could see in mom’s face deep concern and confusion by their efforts. She was in complete disbelief and shocked by how wrong and confused they were.
“What are they saying?” She would ask me.
Thus, even as an unborn person, unquestionably I was mom’s companion through the pieces of her history from a time that for folks in the nursing home and in the majority of the Eurocentrically educated world, was not chronologically feasible. Both of us experienced those brief moments often to resolve whatever concerns she may have had, at times involving her parents and siblings—my grandparents, aunts and uncles, all biologically dead—and her childhood home in La Candelaria, in Bogotá’s historic downtown. She worried if we had locked the house after we left, or if we had brought the keys with us, if we had enough time to eat dessert and get home in time before her younger sister, Estella, would get there, or Alberto, her oldest sibling, would pick us up. It seemed as though the sensorial grammar of our communication implicated mom’s entanglement with what decolonial theorist Rolando Vázquez calls a relational idea of time and space that doesn’t have either a geometrical, chronological, linear, or circular understanding of time like modernity marks reality.
I got a sense of the temporality of mom’s memories not by asking mom her age, since she no longer had reference to that kind of time-thinking. Modernity’s temporality—defined by calendar date, clock time, age, or generations—were not determinants for tracking her stories or a reference to time. Instead, it was the people who featured in that memory and its setting that gave me a reference to the time of the events, making them feasible. Her experience in the present was happening through her history—that is, through her memories from a time when her parents were alive, she was living in la casa de La Candelaria with her siblings, and I had not been born. Hence, there were no westernized life span or human developmental theories that would serve as frameworks to interpret her experiences.
Instead, the vegan cheesecake de maracuyá of La Despensa, the bakery around the corner of my rental, would bring to the surface memories that contained mom’s lived experiences with their own temporalities in no specific order. Events would unfold through particular relationships and their settings. Her memories jumped from one moment to the other according to what the cheesecake called for, and I jumped along. Following her memories was more helpful than listening to them from assumed theories of time, stories, and development. I would say, decolonially speaking, that relational time re-dignified mom’s existence that modernity’s capabilities of erasure through its overinflation of cognition, the contemporary idea of time, and the metaphysics of presence had rendered it suspicious. For modernity, Alzheimer’s had placed mom in an evacuated present time—with no history. She was seen as living in an empty time like Walter Benjamin’s because all that counted as a measurable reality was no longer mom’s reality. Thus, on the contrary, from de-modernity, I would say that by radical listening to the plurality of mom’s lived experiences in their own terms that modernity destitutes through erasure, the senses restituted.
Sensorial Invocation
One of the settings or temporal references that would come up quite a bit in mom’s memories was the colonial casa de La Candelaria of my grandparents. It was the house where mom and her siblings were born and raised until she married dad. This was also the house that kept many explanations of the scars still visible in my body—head, knees, and face by roller skating throughout the house from one patio to the other, running up and down, and playing with my sisters on the swing set by the large fig tree in the back patio still standing. Every weekend mom would take us to visit our grandparents. The house was finally sold to an Italian man much later after my grandparents died. He renovated it into a hotel, maintaining its colonial architecture.
Late afternoon on Sundays when Bogotá’s traffic would be more bearable, I would drive mom from the nursing home to la casa de La Candelaria. The first time we got there I was dying of anticipation for the memories and experiences we were about to live together and for what I was going to learn about mom’s history once she would see the house and the colonial neighborhood. I was hoping that seeing the material presence of the house we have visited several times, through her memories, imaginatively, from the nursing home, would call upon a flood of pieces of memories here and there, unleashed from Alzheimer’s and running loose through La Candelaria’s narrow streets, passing through la Catedral Primada were she married dad, right across from the presidential residence, el Palacio de Nariño.
Overjoyed, I would yell out calling and pointing out various landmarks of our shared history through the neighborhood. I had not been there in years! It was extraordinary to be back. To my surprise and quite a bit of disappointment, my persistence in calling upon mom’s memories was futile. The house we had been at through the memories evoked and configured from the sensorial grammar of our relationship was not the material house of la casa de la Calle 11 con 2nda in the year 2023, nor its representation. It existed in a different temporality.
Over a year after mom died, cousins on my dad’s side, my sisters, and I were finally able to arrange a time to meet in Bogotá and drive to my dad’s family farm in Sasaima, one hour away with no traffic, to bury mom’s ashes. She is buried next to my dad’s, my paternal aunt’s, and paternal cousin’s ashes. They are overlooking the mesmerizing landscape of the Andes mountains, surrounded by the farm’s variety of lush vegetation that my dad had a deep connection to. The scars on my body that la Casa de la Candelaria could not explain, the farm in Sasaima could from rolling down the hills, swimming, and barbecuing with my sisters and cousins during the various trips with dad’s family growing up. Unlike the scars of the women working at the nursing home, these were privileged scars of a life from the minority in Colombia also living in the midst of Colombia’s armed conflict. Privileged and all, even so, neither la casa de La Candelaria nor the farm in Sasaima were exempt from becoming sites for violence where kidnappings took place of an aunt and cousins on both sides of the family while I was still living in Colombia.
During our day or weekend trips to the farm growing up, at lunchtime the family would get together and sit around the large dining table to eat what the land offered–herbs, vegetables, and fruits among other foods. We were always served delicious vegetable soup with cilantro. In the diaspora, I have experienced being at that table and sipping soup with cilantro millions of times. Cilantro calls on that memory. In a split of a second, cilantro opens the door for me to enter into that moment although I am on U.S. soil. It brings me to the sensing of the taste of food, the light coming from the wood windows, the touch on my skin of Sasaima’s humidity in the mid 70’s, and the crackling sound of the straw woven mats. I can’t recreate that experience otherwise. I’ve tried. I can see static images but can’t experience the sensation of being there that cilantro brings to life.
Returning to the farm in 2024, I was amazed by being at the same table, eating the food of the land, and soup with cilantro. I couldn’t believe it. It did not take me too long to realize though that it was a different “coming back,” it did not feel the same as the experience of the memory from the diaspora. It was as if the memory linked to cilantro existed in a life with a different temporality, in a parallel reality, yet intimately connected to the material farm. Just like mom’s experience of driving by la casa de La Candelaria in 2023, the vividly sensed farm within my connection to cilantro also belongs to a reality that was embedded in a different temporality, and therefore a different relationality. It is a place I can no longer drive to on my own—no matter the traffic or the day —but I can taste my way to it.
In connection to a decolonial premise, I would say that la casa and the farm exist in memories that do not subscribe to an understanding of modernity’s contemporary, its linear temporality, and notion of reality as presence. Although I would say that our memories surfaced in the present as expressions from a relational time, relationally, not always on our own volition, but under certain circumstances, such as sensorial. According to Vázquez, these memories, like all our memories, live in a plurality that is always moving. Hence, memories are not chained to a particular date or someone’s age in a dead or static past, for example. In that sense, these memories are not representations of the material in the present—mom lived certain moments of her day at La Casa de la Candelaria while being at the nursing home, but could not recognize the material house on Sundays when we drove by.
Our lived experiences live in our memories and grow their own heartbeats, giving us life. We are made of memories, collective memories, with their own lives, sensings, and times. Our existence comes from those memories. Thus, it might be more suitable to say that memories are beside us. They are not deep in history but wide in history, next to us or in front of us, accompanying us, guiding us, and constituting our lives, even though they do not always show up in the present, unless relationally and sensorially called upon.
Like my memories, mom’s seemed to be interacting with other memories, perhaps being that the reason why it was possible for me to join her in a moment in her life when although I had not been born, memories of my aunt, uncles, grandparents and the house better helped me to be there for her and with her. Therefore, although mom’s ability to recall events that took place in the nursing home that morning, an hour ago, or last week kept dwindling, her memories interconnected to mine and our senses kept alive aspects of what she had lived, shaping how she lived, and continue to live through us, her four daughters’ memories and the memories of all she had contact with, perhaps even before she was born.
Her existence spilled over modernity’s placed boundaries of her skin to re-exist via her relational memories in a relational time that has kept her alive after her biological death. Mom got to re-exist, inadvertently putting doubt to and rendering suspicious for me modernity’s persuasive cognitive driven and over inflated perspectives that previously rendered mom’s life doubtful and suspicious, when her life was reduced to be only cognitively spoken about.
Re-existence: Restitution by De-institutionalization
After getting over my disappointment from my mom’s unexpected response to La Candelaria, I chuckled a bit and rolled my eyes while driving back to the nursing home before it got dark. “Really?” I thought. Although I had been experiencing and learning from the ongoing and uncertain movement of my relationship with mom, and attentive to what the unpredictability that each bit of memory would offer to us, my over-a-decade of experiences as a therapist, academic, and researcher—Eurocentrically trained—couldn’t help it but to show up.
I realized that I had begun to identify a pattern of response from mom to “study it” and identify its conditions or context. I tried to generalize it by manufacturing similar conditions for the sustainability of the pattern of response. I wanted to replicate it. In doing so, I was attempting to manipulate mom’s response at my will by driving her to la casa. Ugh! I was guided by my own assumption and best intentions to create a “happy” moment for mom. I am fairly confident in saying that this is somewhat similar to modernity’s logic of knowledge production in therapy.
Based on the therapeutic model’s theory of change—or what the therapist believes (based on research) makes people “happy” (well, stable, healthy, or problem free etc.), interventions are identified with expected outcomes (via research or clinical case examples) to be replicated (mostly to a homogenous population). Such interventions are technified or manualized for easier distribution, consumption, and implementation for others to use with the persuasive generalized promise of delivering an outcome of change to help a-historical people. I am afraid that by doing so, I was imposing a boundary between the subject (investigator) and object (mom) to arrogantly identify sensorial tools for change, to technify and manualize our relationship based on modernity’s arrogance to self-define what is good for others.
Very gladly so, unintentionally perhaps, mom sort of delivered a candid middle finger—not the first nor the second in her life—at my attempts at technifying our relationship. I received her delivery happily. I had re-institutionalized our relationship, losing sight of the possibilities that come from the borderlands, memories and their sensorial grammar, relational time, and defamiliarization from modernity’s logic of erasure.
Mom’s implicit middle finger reconnected me to our lived experiences to sense more clearly what institutional practices do and fracture, like the institutionalization of the land, bodies, relationships, healing, and histories. Thus better discerning deep connections—being from here AND from there—to my home-land, in various relational times, my languages, and relationships with the people I owe my existence to, the food the land offers, the Andes where my parents ashes are spread, la casa and the farm along with their explaining histories, the Bogotá altitude, the strangers in the street, the acquaintances of the bakery around the corner, and the long-time friends and the people they owe their existence to. These are the sort of experiences that contribute to de-institutionalizing my work as a therapist and training therapists, to begin conceptualizing our work first and foremost from the histories that make us.
Author’s Note: I want to thank Jill Freedman & Gene Combs at the Evanston Family Therapy Center and their 2024 training cohort for listening to my reading of an earlier version of this story, which helped me revise it.
Impactful Encounters: The Truth About Therapy in Nursing Homes
What do you imagine it might be like to spend a day doing psychotherapy in a nursing home?
Well, no, it would not be like that.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
In some nursing homes, there are many patients from age 40 to 70, with disabling or sometimes terminal diseases and medical conditions, who might likewise suffer from major mental illnesses, a history of trauma, and/or substance use disorders. And all of this can play out in the social dynamics between clients and sometimes understaffed, overburdened, and maybe inadequately trained caregivers.
Staff persons often turn to behavioral health clinicians with complaints about the “behaviors” of clients. A key part of my work is to help staff persons see how “behaviors” might be trauma reactions, or manifestations of pain, or psychiatric disorders, or medical conditions, or simply responses to the style of approach used by that staff person.
Challenges to Nursing Home Psychotherapist
While I am protecting my clients’ basic confidentiality, as a consultant psychotherapist, I understand that I am not practicing in a vacuum. I am seeking to relieve the symptoms of my clients while helping the staff to better understand and respond to the needs and symptoms conveyed through sometimes troubled and troubling behaviors.The 10 clients I met with on this particular day each had major medical and psychiatric needs, were facing the end of their life, were actively grieving. Many had histories of difficult personal relationships. The clients were all in their 60s and 70s. Many were socially avoidant and isolated, some tended toward paranoia, and were argumentative, while some experienced auditory hallucinations. Nevertheless, and almost to the one, all were lonely, fearful, and frustrated by a loss of control.
I encountered each of these individuals in the vividness and complexity of their situation, tried to help them gain new perspectives on their experiences, better recognize their available choices, and to consider alternate ways of thinking and acting. Therapy can support persons facing the end of life and can help them better appreciate the psychiatric nature of peculiar subjective experiences. It can also widen the focus of attention from their medical condition to their whole self.
Nursing homes provide settings for meaningful, challenging, and beneficial psychotherapy, and I strongly encourage therapists to consider practicing where the need is so greatly concentrated. Look, you are not going to find such dynamic cases in any other setting.
At the end of this day, I got in my car, and I felt tired and drained. But why, I wondered, should I interpret my tiredness as being heavy stress? None of the clients I saw that day would say the encounter had been stressful; they would each say it had been relieving and encouraging. The encounters ended with expressions of thanks, handshakes, and comments about looking forward to the next session.
As I drove home, I could look back in my mind’s eye at each client and see ways I had helped them or eased their burden on that day. Was the work stressful? Sure. But I chose to maintain perspective and balance, and take care of myself, while enjoying a rewarding sense of fatigue from a day’s good work.
Questions for Reflection and Discussion
What is your first reaction to the author’s message about working clinically in a nursing home?
What personal and professional challenges would you anticipate in this setting?
What countertransference reactions might you have in this kind of work?
What Happens Now? Reporting Childhood Sexual Abuse
Isabella’s stomach is tight as she squirms in her chair. She is wringing her sweaty hands and can feel a lump in her throat. She is scared. Isabella swallows hard and then begins to disclose to her school counselor that her stepfather is sexually abusing her.
Childhood Sexual Abuse
Sadly, Isabella is one of many children and adolescents being sexually abused around the world. Childhood sexual abuse (CSA) is a global social epidemic that is overwhelming for all who are connected to it.
The Centers for Disease Control (CDC) estimates that 1 in 4 girls and 1 in 13 boys in the United States will experience child sexual abuse before their 18th birthday. Ninety percent of this occurs at the hands of someone known and trusted by the child or the child’s family. We will follow Isabella’s journey as she moves through the multidisciplinary systems she encounters following her disclosure, which I hope will be helpful to fellow clinicians working with sexually abused children.
The Children’s Advocacy Center
Isabella’s school counselor reports the sexual abuse to the child abuse reporting hotline. This sets the wheels in motion for Child Protective Services (CPS) and law enforcement to intervene. Isabella’s mother is wrought with fear and anxiety when she receives a call from a detective. She was instructed to bring Isabella to the local Children’s Advocacy Center (CAC). As she drives to pick up Isabella from school, she experiences a surreal sense of shock and numbness.
Back in the day, many years ago, disclosures of childhood sexual abuse were met with fragmented investigative responses with children like Isabella participating in multiple interviews. Not only was this potentially traumatizing for the child, but it also resulted in inconsistent findings for various disciplines and poor outcomes for our youth and families. This changed in 1985 with the formation of the first Children’s Advocacy Center (CAC) in Huntsville, Alabama. Uniting law enforcement, criminal justice, child protective services, medical, and mental health services under one roof, the CAC movement revolutionized our response to sexual abuse allegations. Today, the CAC approach is the best practice for multidisciplinary professionals battling child abuse and neglect. The force monitoring and accrediting our CACs is the National Children’s Alliance (NCA) which oversees nearly 1,000 CACs.
Advocacy and Case Management
Upon entering the CAC, Isabella and her mother are greeted by Jordan and Rose. Jordan is a family advocate and case manager for the agency. Rose is a child engagement advocate. Jordan explains that she will be helping Isabella and her family during their time at the CAC and beyond. Rose explains that, as a child engagement advocate, she will be helping prepare and alleviate as many stressors as possible for Isabella today. Despite Jordan and Rose’s friendly demeanor, Isabella is cautious, and her stomach remains just as tight as it was when she disclosed to her counselor.
Isabella and her mother follow Jordan and Rose down the hallway into a clean, tidy room with a couch and toys. Rose notices Isabella’s anxiety and offers some fidgets, coloring sheets, and a snack. Rose showed her a book with pictures and names of the people she will be meeting today and explained the jobs they do at the CAC. Isabella begins to relax.
As previously noted, most perpetrators of child sexual abuse are known to their victims. The CDC estimates the 90% of sex offenders are known to their victims and their victim’s family. In some instances, the perpetrator lives in the home or is the breadwinner for the family. As a result, the aftermath of a disclosure of CSA can leave a family with another crisis. The CAC’s family advocacy team helps to support the non-offending family members as well as the victim. Family advocates are the first to greet victims and their families, and are a consistent presence. They provide advocacy within the multidisciplinary team (MDT), emotional support as victims proceeds through the judicial system, information about client’s case, and assistance with tangible needs such as bills, clothing, food, housing, transportation and other aspects of daily living.
Research shows children fare better throughout the investigative process when they know what to expect. Child engagement advocates attempt to decrease traumatization and alleviate stressors victims may experience while at the CAC through preparing them for what they will be experiencing, using play, and trauma-informed care.
Forensic Interview
While Rose was playing with Isabella, Jordan brought her mom back into the room. After a bit, another lady came into the room and Jordan introduced her colleague, Abby. Rose had shown her a picture of Abby in the book earlier and told her she was a forensic interviewer. Earlier, Rose had explained that “forensic interviewer” was a name for someone who was going to ask Isabella some questions. Abby smiled as she greeted them and asked Isabella to come to the “talking room.”
Isabella felt the knot return to her stomach as she looked first at Rose and then at her mom. She stood and gave her mom a hug before following Abby to the “talking room.” Once in the room, Isabella looked around. There were not any toys in this room. Abby started out by asking Isabella a lot of questions about herself. Isabella’s knot got a little looser as it wasn’t hard or scary to spell her name and talk about her pets. Abby explained to Isabella that only “true” things that happened can be talked about in the talking room. Isabella told Abby about what happened with her stepdad. Abby asked a lot of questions with a lot of details. Isabella felt anxious but she remembered her breaths that Rose taught her. Abby let her take breaks when she needed them. Abby had Isabella draw on a diagram of her body where her stepdad touched her. When they were done in the “talking room,” Isabella went back to the original room where her mom, Jordan, and Rose were waiting.
Forensic interviews (FIs) of children and adolescents provide key evidence to guide investigations and support decisions regarding whether to pursue criminal prosecutions or continue interventions by child protection. Forensic interviews (FIs) may be requested by law enforcement and child protection. Occasionally, the District Attorney’s Office may request an FI. Typically, the FI is scheduled as close to the disclosure as possible. These interviews are done blindly, meaning the highly trained forensic interviewer does not know the details of why the victim has been brought to the CAC. FIs are legally justifiable, fact-finding interviews with a child conducted by specially trained forensic interviewer.
In cases of childhood maltreatment, the overarching goal of a forensic interview is to gather information from a child in a neutral, non-leading way. The purpose of a forensic interview is to minimize the number of times a child must tell their story. Forensic interviewers provide an opportunity for a child to disclose abuse. If abuse is disclosed, the interview is used to gather details about their victimization. CPS and law enforcement observe the interviews to assist in their investigations.
Interviews are recorded to minimize the number of times a victim must detail their trauma and to increase the accuracy of the information provided. The FI is viewed in another room by law enforcement and child protection. Caregivers are not allowed to observe their child’s interview. Although the video recording itself does not substitute for a victim’s testimony in a court of law, it is utilized by the multidisciplinary team as part of the investigation and must meet certain legal criteria. A forensic interviewer is not responsible for proving or disproving an allegation.
Child Protective Services
After the forensic interview, Isabella returns to the room where her mother, Rose, and Jordan are waiting. Her mother has paperwork in her hands and is busy reading and signing forms. Jordan explains the next steps of the process and provides resources that might be helpful for Isabella and her mother. She tells them that an investigator with Child Protective Services (CPS) will be coming to speak with them shortly. Isabella wonders if the CPS worker was one of the people who was watching during her forensic interview.
CPS is responsible for identifying and intervening in cases of childhood abuse or neglect. The overall purpose is to ensure child safety. During the investigative stage, interviews are conducted, pertinent records are reviewed, and a home visit is conducted. As in Isabella’s case, the CPS investigator was present at the CAC during the forensic interview and has information on what Isabella has experienced.
Based on the totality of the investigative information, Child Protective Services makes decisions regarding whether a child may remain in their home or not. In Isabella’s case, the mother is protective. She decided to stay at the home of relatives until the stepfather is out of the home or other housing is obtained. Given that the protective concerns are addressed, the CPS case is closed. This is not always the case.
Some family systems require ongoing services from CPS. For example, if the non-offending caregiver does not believe a child’s disclosure and is not willing or able to protect the child from the alleged offender, CPS may stay involved with the family. They may need to have a child, and their siblings, temporarily placed outside of their home with a relative or a foster home. Given the mandate to preserve families, CPS would have the family members participate in a case plan that will support the eventual reunification of the child with their caregiver. Case plans may include therapy and substance abuse treatment. Each state has their own child protection agency and services may vary from jurisdiction to jurisdiction.
Law Enforcement
As the CPS worker finished the last few questions, a man wearing a suit and tie entered the room. As he gets closer, Isabella realizes he also has a badge and a holster. The man introduces himself and explains that he is a detective with the local police department. He also observed the forensic interview and believes there is enough details to pursue filing a criminal complaint against the stepfather. The detective meets with Isabella’s mom.
Not every disclosure of CSA is investigated by law enforcement. This can occur for a variety of reasons. For example, due to the inherent pressure in cases of CSA, a child may recant their original disclosure and state abuse did not occur. Another example would be instances when the victim was unable to provide specific details or was unable to recall dates.
In cases involving law enforcement, an investigation will ensue to determine if the CSA can be charged criminally. Some investigations are closed due to lack of evidence. If the law enforcement officer believes there is enough evidence to hold the offender criminally culpable, the case will be passed on to the district attorney’s office for consideration for prosecution.
Mental Health Treatment/Therapy
Approximately two weeks later, Isabella’s mother received a phone call from the Client Intake Specialist (CIS) Cheyenne. Cheyenne is from the Clinical Department at the CAC. She let Isabella’s mother know that she received a therapy referral for Isabella from Jordan and wanted to know if mother was interested in services for Isabella. Isabella’s mother expressed interest in services. CIS explored times that would work both for mother and Isabella, as well as assigned a therapist named Jackie. Following the initial intake, Isabella receives ongoing therapy to process and integrate her history of CSA.
Different forms of therapy can be utilized with Isabella post trauma including, Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), Play Therapy, and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Therapists may incorporate expressive media including play, sandtray, kinesthetic movement, and expressive arts (i.e., art, music, dance) into treatment.
The intake session allows the therapist an opportunity to gather psychosocial information to ensure the client receives the best therapeutic services available. Depending on availability and resources, the CAC may also offer services to non-offending family members. In some cases, referrals are made to trauma-informed providers outside of the CAC.
Moving Forward/Conclusion
Isabella completes therapy, and, for the most part, her functioning appears to be developmentally on track. Intermittently, she experiences episodes of posttraumatic distress and receives booster therapy sessions as needed. Isabella testified in the criminal trial against her stepfather. This adds another layer of complexity to her therapy and to her family.
The short- and long-term impact of childhood sexual abuse is well established. Timely and comprehensive interventions are essential to protect children and strengthen families. This includes the multidisciplinary work covered in this article. Cases of CSA are multilayered and complex. The investigatory and therapeutic process may not be as streamlined as it was for Isabella. It is crucial members of the MDT operate in their scope of practice. Additionally, support from the non-offending caregiver and society at large is crucial for the overall welfare of victims.
Analyzing the Intersection of Play and Existential Therapies
Before there was “empirical” support for the use of play in therapy, and long before the discipline was formally established, play’s clinical value was broadly recognized. And the value of play as an important element of human development dates to antiquity. The notion of Homo Ludens (man, the player) captures, at least for me, the idea that play is an intrinsic characteristic of humanity. Interested readers can sample offerings from the International Journal of Play Therapy and the American Journal of Play.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
But I digress! My purpose in writing this essay stems from a friend and fellow clinician’s recent dream about an (as yet perhaps) unwritten book with the title, “Existential Questions Children Would Ask.” It immediately brought me to the mental intersection of play and existentialism, which was only a short distance from the idea of play therapy qua existential therapy (I’ve always wanted to use the word qua in my writing!). Interestingly, and going briefly back to the realm of empiricism, it is child/client-centered play therapy (CCPT) that has received the most empirical support of all modes of play-based treatment.
What about this particular form of Play Therapy has attracted so much clinical attention and held up so well under the bright light of empirical scrutiny? I think it is because this particular form of intervention capitalizes upon and provides fertile clinical space for the expression and core existential concerns and existential practice. But first, a quick look at CCPT.
Child Centered Play Therapy as an Existential Laboratory
Virginia Axline described eight cornerstones of her approach to play therapy, She believed that the therapeutic space for children should be a safe one, grounded in acceptance, warmth, freedom of expression, and patience with and respect for their capacity to make choices and solve problems.If we consider that these core elements of child-centered play therapy align quite nicely with the basic benefits of free, or unstructured play in general, it makes sense that this mode of intervention has historically enjoyed widespread use while also withstanding the harsh and often fickle winds of empirical scrutiny. As such, it is, based on my experience, the ideal existential laboratory, or playground, in which children—of all ages— a can express, address, and work on, and occasionally through some of their deepest concerns that they might not otherwise recognize, acknowledge or talk about. When these children come to us, it is usually at the behest of their teachers and/or parents who can’t quite understand why their child is aggressive, sad, unregulated, or any number of other behaviorally expressed concerns.
Irvin Yalom identified four core existential challenges that clients (and non-clients) experience throughout their lives. For Yalom, freedom, with its promise of limitlessness and choice can also be threatening, as it taps into a fundamental fear of loss of structure and foundation. Isolation, not to be confused with independence or autonomy, is about feeling alone and disconnected from the world of people. When meaning is perceived as a linearly navigated destination rather than a circuitous and often confusing journey, the traveler often wearies, wanders, and worries their whole life. And finally, and in every sense of the word, death as a final frontier, leaves so many clients fearful, un-completed, and regretful. Paraphrasing Yalom, many of us don’t take the loan of life (live fully) for fear of the ultimate payment, which is of course, death.
If we now think of the client- (or child-)centered play therapy as a space created for and with the child that satisfies Axline’s criteria, then that space becomes an existential laboratory in which the client, with the clinician’s agenda-free guidance, is free to explore those four elements of existence.
Exploring the Four Existential Dimensions through Play
Josiah was a young adult who had long struggled with the physical and emotional challenges of a congenital illness that factored heavily into the decisions he had to make as he left adolescence behind. Finally free of the many demands college made of him, he weighed the choices ahead with a sense of gravitas. He wanted a career and a long-term intimate relationship but had so parsed them in his mind that having both seemed impossible.While he wanted the freedom to choose both goals, Josiah believed that pathways to both were distinct and that he could not pursue one until the other was accomplished. The freedom to choose was blocked by the structural mental barrier he created. I asked him to show me the challenge in the sand tray, and his depiction appears in the figure below. Through our play in the sand tray and other creative-expressive media, Josiah took down the invisible barrier he built that separated the two goals he sought along his path to freedom.
.png)
Devon was eight when his parents brought him to me for occasional aggressive behavior towards his younger sister. A strong academic student, sociable child, and typically loving family member, his behavior seemed to change soon after the death of his grandfather. Overcome with grief, Devon’s parents struggled to open family conversations around their deceased patriarch. As a man who had held such a prominent place in the family, the grandfather had literally disappeared from their lives. Devon’s attempts to ask or speak about his grandfather were met with resistance and confusing dismissals. Devon began lashing out at home and at school.
Our play took many forms, but Devon particularly gravitated to an old-fashioned game of marbles, one that he had learned from his grandfather. He set up difficult obstacles and goals for himself as the “shooter,” often becoming frustrated when his shot missed its intended mark. In one particular round of marbles, Devon decided to seek some heavenly inspiration, so to speak. He named his shooting marble, the biggest one on the floor, the “grandfather marble.” Almost at once, his accuracy improved as he moved effortlessly around the floor, skillfully guiding the marbles to their destinations—with the help of his “grandfather marble.” I did not feel the need to literalize the metaphor of the grandfather marble, although Devon began talking about his beloved grandpa. Conversations began to open in the family, and Devon’s aggressive behavior, its roots finally exposed, diminished, and both he and his family began sharing their feelings and stories about their lost loved one.
Micah, age six, was small for her age, and very shy, both at home, but particularly at school where she was occasionally bullied by one of the “bigger kids.” She would often come home crying and began resisting going to school in the morning. Her sleep was also increasingly affected. When she did go to school, she would keep to herself on the playground and rarely initiate conversation or play with others. As much as she wanted to interact, Micah became increasingly isolated. When the parents finally found out the details of the bullying, they took swift action, and changes were made at the school.
As with Devon, Micah’s play took many forms including art and dollhouse play; however, she particularly liked building solid structures out of blocks into which she would hide a particular toy car. The structures were elaborate and impenetrable, and once erected, remained so for the balance of each of our meetings. I did not want to impose my words or thoughts on Micah, but instead gave her the time and space to play through what I thought was the need to build protective enclosures for their small vehicular inhabitants. As we built and rebuilt these bastions, we talked of safety, danger, fear, and courage. And as the bullying stopped, and as weeks of play passed, and with the support of her parents, Micah took down the walls once and for all and freed their inhabitants from their previously protective isolation.
Sianna was soon to leave adolescence behind, hopefully with a greater sense of purpose and self than had characterized her earlier years. She never quite fit in, nor did she seem to want to. Perhaps she did, at a deeper level, but she seemed quite content being alone with her art. Through her drawings, both on paper and her skin, Sianna expressed both frustrations over and wonder about what lay ahead. She had the sense that her purpose lay beyond traditional education, but no clear sense of what that was or would be. While she found art to be a meaningful endeavor, she was not quite sure how to channel it into a sense of purpose.
I enjoyed Sianna’s drawings, which she readily shared as she discussed the challenges of being in this no-person’s-land on the doorstep to whatever would come next. She seemed to lack a coherent sense of self beyond her drawings. I had a wonderful lava lamp in my office during our work together, which was always percolating during our sessions. One day, she brought in this image, which said it all. Finally freed from the inchoate mass of bubbling lava from which it sprang, this little formless creature looked back at its previous entrapment and said, “Thank God, now what!?” That said it all for her, and I felt no need to impose interpretation.
***
Like most other forms of contemporary play therapy, client-centered work carries with it no assumptions other than freedom to express, freedom from judgment, and freedom from scripted technique. As such, clients are encouraged to work on the deeper existential issues related to freedom, isolation, meaning, and of course, death. It doesn’t rush, it doesn’t judge, it doesn't impose, nor does it rely on specific agenda, per se, other than the play therapist’s presence, patience, attention, and caring. These four case snippets and their accompanying images nicely demonstrate that, at least for me, this unhurried form of intervention is in many ways an existential playground.
Questions for Reflection and Discussion
What are your impressions of the author’s connection between CCPT and existential therapy?
What existential concerns have you noticed in the play of your young clients?
How do you address these concerns when they are expressed through play?