Author: Psychotherapy.net Team

The week after George Floyd?s death was significant for me both personally and professionally. Personally, as an African-American father and husband, I wrestled with the potential implications of this and other recent events on me personally, my family, and my community at large. Professionally, as a marriage and family therapist, I prepared myself to be ready to provide emotional support to all my clients, knowing that they differ in their variety of cultural experiences. Interestingly, while I was prepared to support my clients in their various responses, I was not prepared to have to provide emotional support for my professional colleagues as well.

For some of my fellow helping professionals of color, this event was just the latest of many similar social injustices, leading them to wrestle not only with determining how they should respond, but also how much emotional energy they would allow it to have in their lives — believing that it likely wouldn?t be the last such event they would experience. And for other colleagues, while they were aware that they lived in an imperfect world with an imperfect history, this event made the inequalities between their life experiences and that of many others — with whom they differ culturally — more real and personally impacting than it had ever been before. In response to this new-to-them revelation, and with a genuine desire to not let that feeling fade away without making a mark on their lives in some positive way, a trend began — a trend that I call “The Ask.”
“The Ask” refers to the trend that I, and many other professionals of color, experienced after the death of George Floyd, where typical casual greetings were replaced by emotion-filled questions such as, “So, how are you doing?” — except with much more meaning that it previously held.

Asking how someone is doing is a common question among professional colleagues, as it is in nonprofessional life. It is generally a casual greeting, a courteous gesture of respect, and an acknowledgement of the therapist as a person, without an actual expectation of a long discourse in response. This is evident when someone says to their colleague in passing, “Hey, how are you doing?” only to be caught off guard when the colleague stops and offers a long personal answer to the question. The unexpectedness of the response reveals the reality that the original question was intended to be more of a casual greeting than a genuine invitation to share. Interestingly, while mental health professionals are often very good at cultivating vulnerability with their clients, we rarely do the same with our colleagues.

Despite the genuineness of the invitation, therapists of color do not always feel they have the luxury to casually accept the invitation to share vulnerably. This is not due to a desire for secrecy, judgment, or to convey a colleague?s unworthiness to know; but rather because doing so comes with risks that the therapist may or not be willing to take. As such, when it comes to asking therapists of color to share how they are doing as it relates to their personal and emotional struggles influenced by the impact of social injustices on their personal cultural experiences, it is beneficial to consider a few of the risks they might feel in responding to “The Ask.” Here are just a few of those risks, to get you started.

Risk of Polarization: Accepting the invitation to vulnerably share emotional cultural struggles (including past experiences and fears for the future) risks shifting the rapport between colleagues. Oftentimes, prior to “The Ask,” the therapist of color had the luxury of cultivating genuine neutral support from their colleague, regardless of whether the colleagues shared the same cultural experiences or values. They could practice managing their emotional struggles privately and strategically sharing about their own experiences only when doing so was beneficial for risk-free clinical consultation, understanding, and growth. However, if the therapist of color shares that they personally struggle with an experience or value the colleague has contrasting values and beliefs about, it may negatively influence future conversations. And depending on the colleague?s response, both therapists may walk away from the conversation with changed beliefs about and comfortability with each other. For some, this would be considered acceptable and beneficial, as it helps colleagues present their authentic true selves to professional relationships. However, for others, they would prefer the choice of when to take that risk, rather than having the risk thrust upon them.

Risk of Vulnerability: “The Ask” is often a request for someone to be vulnerable in a way that they have not previously been with the person who is asking. It is asking someone to trust that the answer can be received well and will not be used against them. And while it can be easy to take a lack of automatic trust personally, the reason for the caution often precedes the request. Often, previous experiences of vulnerability being rejected, minimized, or abused makes a genuine “Ask” a riskier request than it was intended to be.

Risk of Traumatization: “The Ask” indirectly invites the therapist of color to reexperience something potentially traumatic (whether directly or indirectly). While this may genuinely assist in helping the colleague increase their cultural understanding, the question arises as to whether it was worth the cost to the therapist of color. And while some reasonably conclude that this risk is acceptable because they are asking a mental health professional who is trained to effectively manage these potentially emotionally traumatic experiences, this conclusion minimizes the significant toll such a reexperiencing of trauma takes on mental health professionals who, while trained, are real people with real feelings.
In light of these risks and in order to provide a few helpful considerations regarding how a genuinely interested colleague can show care for therapists of color as individuals, while also seeking to learn from their cultural experiences, I offer the following.

Accept the Unavoidability of Risk. Doing so reduces judgment, shame, and blame in the event of an undesirable outcome such as unintentionally offending the person being asked and straining future professional interactions. While accepting that risks are unavoidable, efforts should be made to show a desire to reduce these risks and potential negative impacts as much as reasonably possible. Sometimes a brief disclaimer before “The Ask” that conveys value and reassures of positive intentions can significantly reduce unspoken tensions. For example, “I know it might be a lot to ask, but it?s not too uncomfortable, can I ask you something about your experiences?”

Ask Humbly. Asking with a sense of respect and value, rather than entitlement, sets a good foundation for the possibility that you can be trusted with the answer. Humility conveys both confidence as well as respect, making it clear that you know that what you are asking for is a vulnerable, voluntary gift the therapist of color can choose to or not to offer.
Accept & Validate Caution. Remember that present caution often has a past origin (that precedes “The Ask”), so instead of interpreting their caution as a personal sign of disrespect, consider what possible experiences they may have had prior to your encounter that may be making it difficult for them to return your genuine inquiry with unfiltered vulnerability. It?s even possible that they may have had a bad experience with someone similar to you in some way, making it unclear whether or not you will behave similarly or whether you will pleasantly surprise them.

Appreciate the Gift. If a professional is willing to share vulnerably despite these and many other personal or professional risks, then show your appreciation for that generous gift by expressing that appreciation verbally. Show that it was worth the risk by putting something you learned into action and sharing such with them. You can also show your appreciation for this gift of risk by not asking for too much too frequently — going back to the well too often can lead to feelings of being taken for granted. If it is unclear how often is too often, or what degree of appreciation is most applicable, initiate a verbal or behavioral offer in which you are comfortable, and follow their lead based on their response.

After spending several therapy sessions navigating “The Ask” with my clients, primarily focused on identifying and meeting their needs and desires for personal growth and understanding rather than my own, I experienced “The Ask” coming from a colleague whom I trusted professionally, but with whom I had not yet been personally vulnerable. Because of a combination of my previously cultivated respect for them professionally and the respectful care exuded by their request, I chose to take the risk and share of my efforts to balance personal and professional cultural experiences during these turbulent times. Although inwardly cautious, I was hopeful that it would be received well. Although the genuine verbal appreciation that I received in response was reassuring, what made the risk most worth it was the acknowledgment that the experiences I shared helped enhance their personal and professional understanding — potentially even helping them to understand experiences their current clients had been sharing about more thoroughly. Knowing that a personal risk could positively impact not only another professional, but also countless clients whom I may never be in a position to support directly, not only helped make that a positive experience, but also increased the likelihood that I might take that risk again in the future.

***
 

In life, both personally and professionally, some things can only be learned through experience, whereas other things we must learn by asking about others? experiences. I encourage you to acknowledge and accept the risks and implications of “The Ask,” including the emotional and relational implications of your genuine curiosity and desire for personal and professional growth. Offer nonjudgmental support if “The Ask” is declined. And express your genuine appreciation for whatever response your colleagues are willing to provide. 

A fellow therapist and I were leaving the local massive business furniture outlet and headed toward my new private practice office with a brand spanking new desk stuffed into the trunk of his trusty 1976 Buick Regal. The desk was sitting on its side, protruding from the trunk and looking like a chimney or perhaps a missile without fins. It might have looked a bit odd, but this mode of transportation was going to save a starving new private practitioner (that would be me) a hefty delivery charge.

This was the easy part. Getting it up several flights of winding stairs ourselves was going to be the real challenge, and to this day, I still have an almost imperceptible spot on one of my fingers briefly smashed in the process to remind me of that glorious event.

As we drove to my new office, he explained that having a large, expensive-looking desk made a therapist appear successful and this would work to my advantage as a placebo, giving clients more confidence in my ability to help. However, while attempting to navigate the Buick with no view out the rear window, my colleague gave me a stern warning, that a desk was merely intended to make the office look stylish, since it played no part in the treatment process.

Now, don’t get me wrong! I was well-aware of his statement that the desk plays no part whatsoever in the treatment process. That fact had been drilled into my head by every professor whose course I had ever taken.

We were taught in no uncertain terms that when you are doing therapy with a client, you are face-to-face, with no desk in the middle. You have a chair, as does the client. However, sitting behind a desk makes you look like some big expert. Not good. Sitting behind a desk contributes to the imbalance of power already inherent in the therapeutic relationship. Here again, not desirable. It makes the helper look more important. You are perceived as being better or special. The explanation we were given depended on the professor, but the bottom line was always the same: get the darn desk out of the helping equation — and get it out now!

If your office has a desk at all, sit beside it or use it as window dressing. But whatever you do, do not sit behind it.

It was quite easy for me to acquiesce, since I had previously done home-based treatment for many years, where the closest thing to a desk was a client’s kitchen table or workbench cluttered with an endless array of flat-head screwdrivers in the garage.

Then came the dawn. One fine day when I was ready to begin a therapy session, my client remarked, “Look, I know this sounds stupid, or maybe a bit old fashioned, but I like it better when you sit behind the desk.”

Rather than hiding behind my notes from grad school or reflecting the statement back, I merely moved behind the desk for old school therapy, and everything seemed to go well.
Since that time, this has occurred maybe 20 or so times over the years. That is not a lot; however, it is certainly enough to take it seriously. Although this request is not the rule, it is in the realm of possibilities.

Looking back, my graduate faculty got it right maybe 95% of the time, but there are clients who do not fit the model. In those instances, although they may be statistically rare, I would say pull up a chair behind the desk rather than trying to pay homage to a mentor from the past textbook author you admired.

One day, when I was recounting my ditch-the-desk experiences with a physician, he noted that it made a lot of sense. He reminded me that for many years, physicians wore lab coats. Then there was a period when the profession thought it would be better to dress in street clothes. Physicians traded in their traditional medical threads for suit coats, sports shirts, silk ties and scarfs, blazers, and, on occasion, yoga pants.

According to the physician I was conversing with, some, though certainly not all patients insisted upon seeing a physician who looked… well… like a physician rather than a dignitary attending a high-ticket fund raiser or somebody gearing up for a sweaty jog in the neighborhood.

Like the counseling client who wants to see you sitting behind the desk, a cadre of patients came forward and said they felt more comfortable having a doctor who dressed like a doctor, complete with a stethoscope and a name tag. Thus, in many instances the doctor’s outfit of yesteryear, like vinyl in the music industry, is making a comeback.

Could conducting therapy from behind the therapy desk be the next big thing? Frankly, I rather doubt it, but it could be worth its weight in gold for helping a select group of clients.

***

Postscript: Dr. Rosenthal’s new book is the Human Services Dictionary 

In 1968, an elementary school teacher named Jane Elliott decided to teach her young students an important lesson: discrimination is arbitrary and hurtful. For those who have not heard of her work or seen the video, she divided the children into groups of blue-eyed and brown-eyed children, each group taking turns experiencing what it was like to be ostracized due to an inherited characteristic. Lesson learned. Of course, it is unconscionable that any group of people should be judged superior or inferior based upon any aspect of their appearance, but we humans have no shortage of ways to diminish our fellow citizens.

The scourge called racism has been dominating the news for weeks now, but never has its impact been far from the consciousness of our fellow citizens of color. And I have little doubt that many therapists are bearing witness to countless tales of shame, disrespect, violence, and fear. Each heartfelt and troubling story is an opportunity for us to gain a deeper understanding of the burden and cost of racism as it is experienced by our clients, day after day, year after year, generation after generation. Important conversations are also happening in these clients’ homes, between spouses, siblings, parents and children. And while many of these conversations likely share similarities, each will be as unique as the DNA of its speakers. I got a glimpse into the power and pathos of such talks during my most recent sessions with my client, “Ed”.

Ed describes himself as a mixed-race child; his mother is black and his father is white. His parents divorced when he was nine years old, and while the children continued to have visits with their father, the mother was the primary caregiver. Both Ed and his sister identify as black. Our last few sessions delved into recent conversations he’d had with his father, children, and sister — raw, bold, and honest communions.

During Ed’s last talk with his father, he was horrified to hear him utter some racist comments. As the father of two self-identified black children, Ed couldn’t fathom how his father could hold any racist views. The father’s response was that throughout the years, he had had “numerous run-ins or altercations with black folks which left a bad taste in his mouth.” This is a perfect example of the danger of generalizing from a few examples to prove the theory. After speaking at great length with Ed about this, the father conceded the cognitive dissonance of his views, but maintained that they were his views nevertheless. Although Ed loves his father, he no longer feels as close to him.

“Very Waspy-looking — pale skin, straight, light blond hair, blue eyes,” was Ed’s description of his wife. Their children, 11 and 13, more closely resemble their mother than their father, and Ed believes “they’ll easily pass for white.” Sitting around the dinner table one evening, he asked the kids what they would say or do if they were socializing with a group of people who were disparaging people of color. Would they speak up and say they were offended because they were mixed-race, or would they laugh it off, as my client said he had done in his youth, to avoid conflict? Had they ever witnessed discrimination in school? Ed realized this was the first time the whole family had sat together to discuss racism and how it might impact each of them. He and his wife now plan to revisit this topic on a regular basis.

Another important talk was the one Ed with his sister, who is married to a dark-skinned black man. Their three sons are as dark-skinned as their father. His sister shared her fears with him, fears echoed by many other parents of black sons both privately and publicly. Will they have the same opportunities as Ed’s “white” children? Will they be subjected to police brutality? Will they be disrespected, spit upon, diminished as people? While this was not a new conversation between the two of them, they both admitted this one had a more urgent tone to it.

Sitting with Ed during these last few sessions, listening to him speak about the different ways discrimination has shaped him and his family, I wished I had thought to bring up the subject of race in our earlier sessions. When I asked myself why I hadn’t, I didn’t like the answer. I was uncomfortable. What if Ed felt my words of support weren’t authentic? What if he realized my knowledge about black culture was lacking? What if I inadvertently said something he construed as racist? Racism appalls me, enrages me, but here I was shying away from broaching this difficult but important subject with the very client who would have benefited from these talks. And all because of a bunch of “what ifs?” I thought about the countless times I would point out to my clients that “what ifs?” keep us from challenging ourselves by confining us within very narrow boundaries, shutting out much of life — both its beauty and ugliness. Now my own “what ifs” were keeping me from fully connecting with my client because I was reluctant to sit with discomfort. But I have vowed to break free of these self-limiting boundaries so that I can more fully support all my clients, especially my clients of color.

As Ed and his sister acknowledged, crushing racism is indeed urgent. Whether insidiously or blatantly, its loathsome tenets debase societies. Perhaps it’s time we brought Jane Elliott’s video out of storage, to be viewed far and wide. Because unlike Jane Elliott’s students, we have yet to learn her lesson that any form of discrimination destroys the soul. 

My patient is angry and ashamed. Another fight with her boyfriend, another book thrown across the room. When the feeling rises up this strongly, she finds it almost impossible not to strike out in action. She does feel better for a moment afterward, until the wave of shame comes over her. She feels trapped, stuck; action and inaction both seem intolerable. “I have to make the feeling go away.”

 My patient and I are doing therapy using the “TEAM” model, developed by David Burns. TEAM is an acronym that stands for T = Testing, E = Empathy, A = Analysis of Resistance, and M = Methods. “Analysis of Resistance,” also called “Agenda Setting,” lets us turn on its head our attitude about painful emotion: instead of seeing negative feelings as the problem, a sign of pathology or disorder, we can reflect on what is positive and important about them. As painful as they are to experience, our anger, guilt, shame, fear and sadness serve as critical signals and motivators, and reflect our deepest held values for ourselves and the world. Something remarkable happens when we shift our attention to notice this.

 My patient and I are exploring a moment in time when she’d become so furious with her boyfriend that she felt an urge to destroy something. They’d been arguing over his not wanting to vacation with her family, and he had just said to her, “Don’t be so dramatic, you need to get ahold of yourself.” Feelings of shame and rage tumbled over each other inside her. She was filled with an urge to hurl the book at him, at the lamp next to the sofa, through the glass of the window. How could such a violent feeling possibly be a good thing? She takes some time with me to recall exactly how she was feeling.

She spoke slowly as she covered the painful terrain, alternating between glancing up at me and covering her eyes with her hands. “I was already hurt and angry that he wouldn’t spend time with my family, and then I felt like I was being condemned for being upset and hurt.” She paused, silent, and shaking. “I felt dismissed, wiped away, worthless.” She looked up at me, her face tight. “And then came rage, and that damn book, and yet and yet another round of shame, rage and shame, over and over.” Her shoulders sagged and she started to cry, shaking her head, “I just want to make the whole mess of feelings go away.”

In TEAM therapy, the analysis of resistance includes “the Magic Button question,” designed to help us see what is positive about our feelings.

“Yeah, I can see why you’d want to zap away those feelings. I’m wondering if we could do a little thought experiment. Let’s imagine you have a magic button, right here on the table next to you, and if you push that button, all of those negative feelings, the rage, and shame and hurt and feelings of worthlessness would be wiped away, with no effort at all. Would you push that button?”

“Of course! In a heartbeat!”

“That makes so much sense to me; but let’s be clear — we’d be saying you’d feel zero of any of these feelings, even though your boyfriend had just made that cutting comment; you wouldn’t react negatively at all. Is that what you’d want?”

She looked at me with a wan smile, “Okay, I guess I see your point, I don't want to be a robot.”

“Yeah, right. I’m actually thinking that your anger, your hurt, your shame — even that feeling of worthlessness — are important and actually positive. Let’s take the hurt and anger, for example. What is positive about those feelings?”

“Huh. I don’t know. I mean, what he said was actually kind of a dick thing to say.”

“I agree — it was kind of insulting, and then dismissive. Would it make sense to feel hurt and angry if someone close to you spoke to you that way?”

“I guess, yeah. I mean, I’d want to stand up for myself.”

“Yeah, like if someone stepped on our toe, you’d want to have awareness of pain?”

“Right, that makes sense, but I’m not sure I’d want to feel so much rage and shame that I felt like hurting him.”

“Probably not — we’ll get to that in a second, but let’s focus on what’s important and positive about your feelings. What does it say about you that you’d get angry if someone isn’t treating you well?”

“Well, that I care about myself.”

“Right, exactly! Can we start writing these down?”

Together, the two of us started to note down what was positive about her negative feelings — that her anger served as a signal that her boyfriend has crossed a boundary and said something hurtful to her, that she cared about herself and doesn’t want to be a doormat.

“But what about that shame feeling and feeling worthless — how can those possibly be good?” she asks me.

“Excellent question — can you think of anything?”

“Well, I guess it shows I’m not shameless,” she says dryly.

We both laugh.

“Ha ha! Yes, right — and what does that mean, to be shameless?”

“Well, someone who is shameless really doesn’t care about their behavior. I felt ashamed because I had lost control, and I wanted to hurt my boyfriend. You know, he can be a dickhead sometimes, but I actually do love him, and I really don't want to hurt him. I don't want to hurt anybody.”

“So, the fact that you felt shame means you cared about your behavior and your impact on others?”

“It was hard to see at that moment, but yeah, I suppose so. I mean, I didn’t throw the book at him, or even at that damn lamp. I just threw it at the wall, away from him.” She put her hand to her forehead and looked up at me sheepishly. “It made a mark on the wall. Actually, it made the third mark on that part of the wall. I guess that’s my book throwing place.”

“Oy!” I commiserate.

“Well, if we get this figured out and I stop throwing books, I can always repaint it,” she smiles. “No, but seriously, I think I’m getting the point here. My anger signaled that he said something hurtful, and then my shame let me know that my anger had gotten out of control and I was in danger of doing something I’d regret. And it’s funny, when I think of my feelings in that way, as carrying an important signal, or a message, I don’t feel as upset.”

“So, you don’t want to shoot the messenger?” I ask.

“Or I should at least read the message first!” she replies, “In a funny way, perhaps one reason I got so upset is because I had stopped listening to what my feelings were trying to tell me, so they had to get really loud for me to hear them. Maybe if I read the message, the messenger won’t become such a beast. How about if I worry less about the messenger, and start listening to the message?” 

All patients are unreliable narrators in that their narratives change as their treatment deepens. Free association, the analysis of dreams and enactments in the transference all affect the patient's understanding and memory of past events. The lapses in memory or affect-laden versions of events are not conscious. However, some patients are not unreliable narrators because of unconscious lapses in memory or understanding — some patients intentionally lie.

I am not talking about sociopaths who do not experience guilt, but rather about patients who lie to preserve their narcissism or to avoid punishment for something they perceive as wrong. Sometimes people lie because they have an intense sense of shame or they have an overly strong superego rather than a weak one.

Children usually begin to tell lies in their preschool years, between the ages of 2-4 years of age. They are imaginative and often fabricate stories as part of playing. Children also lie as a tool to preserve their self-esteem among those who matter to them — parents, friends and teachers. And children also lie to avoid punishment. Lying is a normal part of child development, but when it is treated harshly, the impulse to lie is reinforced and can continue into adulthood.

In some families, lying is encouraged because of a chronically stressful family situation such as alcoholism and/or abuse. If the impulse to lie is pronounced, it can result in the development of a “false self.” In its most pathological form, the false self is set up as real, and everyone thinks that it is the real self. In friendships and work relationships, observers think the false self is the real person.

Persistent lying becomes a maladaptive coping strategy, because covering up a lie is a significant stressor. Since lying is itself stressful, it creates a downward spiral: lying, covering-up, guilt, anxiety, more lying.

My patient Patrick is stuck in a dysfunctional loop that he has been repeating since he was a little boy. He often lies to women to protect them from disappointment or rejection by him, and to protect himself from their angry response. Then he avoids the person he has lied to because he feels guilty. This dynamic gets acted out most frequently in treatment regarding coming to session and paying on time. Almost from the beginning of treatment, he came late to the sessions and paid late. When there was a lull in the session, I brought up the payment of my bill.

“By the way, you have not paid me for last month,” I said.

“Yes, I did. I sent a check to you,” he replied.

“When was that?”

“You think I'm lying to you, don't you?”

“Why would I think that?” I asked.

“I'm furious that you don't believe me,” he said with his jaws tight.

“When did you send the check to me?” I asked calmly.

Silence.

“I…did it this morning before I came here…That's why I came late, because I thought you'd be angry that I hadn't paid you.”

The dynamic began with Patrick’s having anxiety about not paying me on time. Indeed, our agreement was that he give me the check the session after I give him the bill. He knew he did something wrong, but he could not face it. He tried to avoid it by coming late. Then he got angry at me because he projected his own guilt and expected me to be angry at him both for not paying me and for being late. He felt he couldn't deal with my reaction to his transgression, so he regressed to an immature state in which he feared punishment and then coped with the stress by lying.

It has taken many years of analysis to get to the point where Patrick and I can discuss this downward spiral. In the past, each time I uncovered a lie, he responded with narcissistic rage, and it took several sessions to work through. Sometimes, he threatened to quit treatment. Now we can deal with it in a single session. Part of the problem was that I did get angry at him when he was telling me an obvious lie.

“You're angry at me, why don't you admit it?!” he yelled. “What's the point of coming here and talking to you if you are going to get angry?”

“If you don't pay me and then lie about it, I am going to have a negative reaction,” I responded.

“You are not supposed to have an emotional reaction. You're supposed to be a therapist,” he said.

“You mean you can treat me any way you want to, and I'm not supposed to have a reaction?”

“Yes, I think another therapist would be more helpful.”

“So, the problem is not that you haven't paid me and told me that you did. The problem is that I have a reaction to your not telling me the truth?”

“Yes…”

Eventually we developed a more effective way of dealing with it.

“You haven't paid me for last month,” I said toward the end of a session to which he had come late.

“I know. That's why I came late. I expected you to get angry. But you don't seem angry. I know I've done something wrong and then I tried to avoid it by coming late…,” he said.

“What do you make of that?”

“I do something wrong, then I try to avoid the consequence and come late, but that makes it worse,” he said.

“Yes?”

“I provoke you and then I get angry if you get provoked,” he said.

“Yes,” I said.

“The question is: why don't I pay you when you give me the bill?” he said.

“And then what makes it so difficult to own doing something wrong?” I asked.

“I don't know why I don't pay you on time.”

“But that's a separate question from why you need to avoid me or lie to me as a result,” I said.

“Yes, I see, there are two issues.”

***

Patrick and I are getting better at deconstructing these episodes. He has developed an observing ego, and when he comes late, he usually knows he's avoiding something that he's ashamed or guilty about. Together, we scan what's gone on in the recent past to find something he did or didn't do that he feels bad about. Usually he has either overtly lied to me about it or lied by omission. Once we identify what he feels bad about, we are usually able to see a conflict he had/has and identify that as the beginning of the downward spiral.
 

In psychotherapy, clients take us into their homes, literally and figuratively. When they fully engage in the therapeutic relationship, they invite us into their emotional homes, some more than others. They show us the way around and ask for our help because the integrity and stability of their home has been fractured.

Today, with the transition to online therapy, they take us into their homes even more. How often do I sit in a session, like I did with John, who was talking about the lackluster sex in his marriage and, as he did, pulled out a photo of his wife and children? Or Jan, who had just lost her mother and, in deep grief and bereavement, searched for a picture of her parents at their wedding 50 years ago.

Pictures shared in the office via iPhone, iPad, or whatever device that accompanies them, are way more commonplace than ever before. Just the other day, Emily showed me an online picture of what her new home, made of steel drums, will look like.

It is a technologically mediated world, no doubt.

But with COVID-19, we have been given access into our clients’ actual homes. With shelter-in-place, therapy has largely, at least up until now, transitioned to telehealth through video platforms like Zoom, Doxy.me, or Facetime, or for some who can only show us a small bit, by phone.

Much has been written of therapy sessions being interrupted by the family dog or cat, kids in the background or a Grub Hub delivery. For many, these have been moments of new exploration, humor or something in between. How many of us have laughed at the glitches, random incoming texts, or alerts from CNN about the latest stock market plunge or surge. Fortunately, my interruptions have been limited.

Having recently read the New York Times piece by psychotherapist Lori Gottlieb on how the toilet has become the new therapy room and more, I wondered if I had perhaps been too rigid and controlling. I have emailed my clients to assure that they glean the most of our sessions by creating a safe and sacred space for themselves to have our sessions, and even make sure that they have tissues close by just in case we hit on a sensitive spot. I have also asked them to consider taking time before and after sessions to contemplate our work (akin to the drive to and from the therapy office) and that they not just run back to check on the rib roast. That said, not everyone has had privacy; with kids in online learning and the recent work from home status and other family members joining to shelter in place for the period of time, it can become quite challenging for clients to carve out the special space and time that therapy demands.

I have been brought into bedrooms, living rooms, home offices, lanais, cars and even a closet – but not yet a toilet. I have had house tours but have yet to meet other members of the family, with the exceptions of meeting an ex-spouse and a few grown kids.

In these moments, I can’t help but feel as if I am an unintentional intruder into my clients’ personal spaces, although with time and repetition (a therapy phrase), that has softened and I have felt less of a voyeur. Yet with the advent, or should I say the domination, of telehealth, this experience remains new for me. It can be comical watching a client run from room to room in an attempt to find privacy in a closet. This particular client obviously did not receive my preparatory email.

While my reflections over issues of privacy and intrusion are sincere, I am also concerned about the other side of the looking glass, so to speak. What is this experience like for my clients? What do they really see? It’s not just about what we see and experience. We all show up a bit differently as well. I know there are therapists doing sessions from their living rooms, and in some cases a designated bedroom or room with a false background, or even their cars. I have had the opportunity to view the workspaces of colleagues. I am fortunate to have available to me a designated home office, detached somewhat (with separate entrance) from the main house, pretty much (but not failsafe) indestructible to outside forces… no kids, dogs, or random visitors (although the landscapers have made an appearance from time to time). I wonder what our clients see, feel and experience when allowed entry from the virtual waiting room into our personal spaces. This is all curious to me and definitely grist for the mill when we return to (a new) normal.

Entering my clients’ space, having been ‘forcefully’ invited in, has given me a new sense of closeness to them. I wonder what is in the mind of clients who are now given the opportunity to be voyeurs into our lives? What is it like trying to access their emotions and inner states from a car? Given that our playing fields have become levelled (we are both in our homes), how does that affect their relationship with us?

I’m curious. How does the client/therapist relationship change when both have access to the one-way mirror?
 

As we know, the COVID-19 pandemic presents unique challenges to both the client and the therapist. This phased framework for coping with the pandemic was developed by integrating my observations of patterns in client responses with application of developmental and resilience theories and research on the neurobiology of trauma. The framework helped in working with Melissa, a 42-year-old client and single mother of two preteen children.

These phases are presented here in a neat and clean linear fashion, but, the pandemic is anything but! Our clients move in and out of phases based on new and changing information and the complex emotional reactions they must process in response to these changes. Being at an ‘earlier’ phase is not failure. It is simply fact, and we can help clients acknowledge that with awareness and give them the care and support that fits the phase they are in.

Phase I: Shock, which might include a freeze response. In my office in mid-March, we discussed social restrictions and my move to telehealth. She said, “I feel numb… kind of in a daze, like this isn’t real, and I keep forgetting what I’m doing mid-task.” I immediately shifted into somatic based interventions focused on regulation and grounding. I had her feet firmly on the floor, did a ‘sensory count’ orienting exercise looking around the office, and I handed her a weighted blanket to place on her lap.

Phase II: Crisis, when shock wears off and people might move into a ‘fight or flight’ response. Clients sometimes feel enraged, terrified or are in a ‘‘hyper alert’ state of vigilance. When Melissa and I connected for our first telehealth session, she spent several minutes angrily pointing out all the “ways in which no one is handling this.” She told me she was sleeping poorly and found herself scrolling through her phone for hours each day reading news articles and posting on social media. I offered support and reminded her anger and fear were normal responses to an out-of-control situation. We identified boundaries she could set for herself and ways in which she could mentally “take a break” from her pandemic worries and discharge built-up cortisol and adrenaline.

Phase III: Coping, when our resources are marshaled to determine “how we are just gonna get through until this is over.” In coping, people are living and working in ways which significantly overextend them. During the next few weeks as Melissa adjusted to life ‘on lockdown’, she put in long hours trying to make sure her children met every single expectation of their school’s distance learning program. She would then stay up late trying to finish work for her own job in the insurance industry, and frequently would find herself overeating or having “more wine than usual” as a way to numb out the exhaustion she felt. During this time, we addressed Melissa’s feelings of guilt and inadequacy as she tried to “do it all” and found online resources for her to support her children’s learning, and I encouraged her to honestly evaluate how long she felt she could sustain this routine.

Phase IV: Adaptation, which shifts out of coping into an awareness that life changes should be viewed as sustainable and semi-permanent. The focus also slowly moves away from replicating or waiting for pre-pandemic life to return. Clients are able to evaluate, reflect and ask themselves, “What’s working right now?” Melissa began examining, as she put it, “the question of how I want our lives to be for the foreseeable future.” Although she at times moves back into crisis or coping based on current events or new stressors, her sessions now consisted of my supporting her to make decisions which had the goal of balance and sustainability. She adjusted her expectations for online learning, spoke to her supervisor about a temporary reduction in her caseload, started making more time for Zoom calls with friends and recently declared two hours every afternoon as “chill out time” for her and her children to relax, take walks, nap and play together.

It is difficult to be in adaptation without a sense of basic economic security, physical safety and human connection. Melissa had a basic foundation of these experiences which helped her move into adaptation, but the deep systemic inequalities in our country mean many clients will be pushed into the chronic crisis or coping phase. Regardless of what phase they are in, using this framework helped Melissa and I to work together, providing both support and understanding.