Author: Psychotherapy.net Team

How to Create Positive Outcomes in Play Therapy: Following the Child’s Lead

Posted on by Psychotherapy.net Team

I’m an over-preparer. I want to be prepared for whatever happens. Not just in life, but in the therapy room too. I want to be prepared when a client doesn’t have anything to say. I want to pull out that worksheet and be like “No worries! Let’s work towards your therapeutic goals!” (Not in those words, but you know what I mean.) I do come prepared, no doubt, but I think my desire to be prepared can come from a deeper place of needing to feel in control. In a sense, I want to control what happens in the session. I think as therapists we all desire some control within our therapy space. Think about it. We tend to think we know it all; the perfect theory, the perfect worksheet, the perfect intervention for our clients.

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But I often stop long enough to ask myself, “Is this really what my client needs right now?” I think this desire for control can become especially hard to ignore when I work with child clients. This desire for control could be due to many different things such as pressure from parents to “fix my kid” or my assumption that child clients don’t know what they need, and I think I do know what they need. I am the expert after all…right?

But I also have to ask myself what happens if I let go of my assumptions, my agenda, myself, what could happen? What if I listened to that tiny voice in the back of my head saying, “Just go with it”? Letting go of myself and my desire to control was a difficult lesson to learn. However, I discovered that when I did let go, when I did listen to that voice saying, “Just go with it,” incredible things happened. And I learned this all from a 6-year-old boy I’ll call Adam.

What a Therapist Learned from her Young Client

Adam was having some emotional regulation difficulties in his first-grade classroom, so he was referred to me, the school counseling practicum student. As I got to know Adam, I learned that he loved video games. And that was all he would talk about. I was very aware, thanks to the elementary school counselor, of all of the difficulties Adam was having at home. Yet, when I would ask Adam about how home was, he would always say “Good,” and change the subject to…you guessed it…video games.

I tried many different interventions with him including sandtray, creative art, and as a last resort, talk therapy. Nothing worked. I was beginning to get discouraged because I felt that I wasn’t “helping” him, and he was still having the same issues in his classroom. I was not seeing progress.

When I brought this up to my practicum supervisor, she suggested an intervention based on Adam’s love of video games. The intervention was to create a video game controller and to create buttons based around coping skills and his difficulties. Then, the child would use this controller to “control” the therapist. The therapist would follow the child’s instructions and act out the buttons the child was pushing on the controller. This intervention was to give the child “control” of a scenario based around his issues. To my relief, Adam agreed to participate in the activity. However, when I tried to steer him in the direction I thought he needed to go, such as creating buttons based around coping skills and emotional regulation, Adam was quick to turn me down. Instead, he created buttons for running, jumping, fighting, and throwing erupting cupcakes at an invisible perpetrator.  

Throwing erupting cupcakes was not what I had in mind for this intervention. However, there was a voice in the back of my mind saying, “Just go with it.” So, I did…despite my other thoughts saying, “Nope, this isn’t going to work. He’ll never get better if you keep this up.”

But listening to this voice in the back of my mind would become imperative to what happened next.

Before my next session with Adam, the elementary counselor informed me that someone had tried to rob Adam’s home. She said that he had briefly mentioned it to her in passing and she wanted me to know just in case it came up in our next session. Well, during our next session when I asked Adam if he needed to talk about anything, Adam simply said, “Nope,” and continued to eat his lunch. I could feel tears welling up in my eyes. I simply wanted to help Adam, and I could tell there was still some resistance. However, I tamped down my desire to pry and to push and moved on to explain the plan for our session.   

“So, Adam,” I said, “Remember the controller we made together during our last session?” Adam nodded. “Well, we’re going to use it today.” I reviewed the button meanings with Adam and when we were finished, I said, “Okay, here’s what’s going to happen. You’re going to give me a problem and using the controller, you’re going to control me to help me solve the problem.” Adam began jumping up and down excitedly. “So,” I continued, “What’s the problem you want to use?” Now you should know that my idea of the type of problem I wanted Adam to come up with was “A friend beat me at a game” or “I got a bad grade on a test”. I wasn’t prepared for what came out of his mouth next.

Adam thought for a minute and then finally said, “You’re being robbed.” Without thinking, I said, “Well, let’s think of a different problem…maybe one that happens in everyday life.” Adam looked disappointed but started to think. Suddenly, an alarm went off in the back of my head and I realized what Adam was trying to tell me: He knew exactly what he needed; he needed to process the break-in he had experienced. The voice in my head was shouting: “Alicia, JUST GO WITH IT.”  

So, I listened and I pivoted. I said to Adam, “You know what? Yeah, let’s go with that. I’m being robbed.” Adam began jumping up and down excitedly. And then fun ensued. Adam pushed the “jump” button, and I jumped around the room. Adam pushed another button, and I threw erupting cupcakes. I ran and hid, I fought my perpetrator, all the while Adam was jumping up and down and laughing his little head off. Finally, after I was completely exhausted, Adam said, “You did it! You fought him off! He’s gone forever!” With relief, I plopped down in my chair as Adam erupted into applause for my performance.

As I reflect on this session, I notice how close I was to missing what Adam was trying to tell me. I was blinded by my own agenda. I thought I knew what was best for him. But in that session, Adam was trying to process something that was very real and scary in his world. And I almost missed it.  

Since then, I’ve learned to use my intuition and to listen to that little voice in my head saying, “Just go with it,” particularly when it comes to working with children. I listen to the child when I introduce an intervention, and they say “No,” I let them pick up the sandtray to play with because I understand that that is what they may need in the moment. I let them do my interventions in their own way. I allow them to control what happens in the therapeutic space because there’s a good chance that they don’t get that anywhere else.

All I can say is that I’m glad I let go of my agenda and my desire to control during my session with Adam because when I did, healing took place. And I want more of that. I want more than anything to help children process things they don’t understand. I want to be the conduit they use to control what is outside of their control. I want more laughter, more fun, more silliness. And overall, I want more healing to take place in the therapy room. Adam taught me a valuable lesson: To let go of myself and just go with it.  

Questions for Reflection and Discussion

How does the author’s reflections on her play therapy work resonate with you?

What do you appreciate about the author’s clinical work with Adam?

What might you have done differently with this particular child?  

Legendary Psychotherapists Share Their Secrets to Longevity

Posted on by Psychotherapy.net Team

The Pioneers of Psychotherapy Lived Long, Productive Lives

Several years ago, I authored three books and a string of articles featuring contributions and interviews with some of the greatest therapists in the world. At the time, I searched for commonalities that might be relevant. Recently, I revisited those commonalities and noticed one factor, seemingly unrelated to the psychotherapeutic process, that stood out: advanced longevity. This subject seems to be of increasing interest today.

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By examining the experts featured in my books and articles, and adding a few more world-class therapists to the mix, I reached a striking conclusion. Simply put, many of these professionals enjoyed or continue to enjoy extremely long and productive lives. Here are some examples:

  • Albert Ellis lived to be 93 and completed his interview with me at age 89.
  • The father of CBT, Aaron T. Beck, made it to 100.
  • Muriel James, who penned the transactional analysis and gestalt classic Born to Win, lived to 101. For context, only 0.027% of Americans reach 100. Muriel was 86 at the time of our interview.
  • Ray Corsini, editor of Current Psychotherapies and one of the top psychologists of the last 150 years, was 94 when he passed away.
  • Suicide and thanatology expert Ed Schneidman lived to 91. Did you know Edwin Shneidman coined the term “suicidology”?
  • Career counseling guru Richard Nelson Bolles, author of What Color is Your Parachute? the best-selling career choice book of all time, lived to 90.
  • William Glasser, the father of reality therapy with choice theory, died at 89.
  • Viktor Frankl, the creator of logotherapy and a Holocaust survivor, lived to 92.
  • Robert Firestone, the father of voice therapy, was 94 and still active as I wrote this blog, but sadly passed away prior to its publication.
  • Irvin Yalom, an expert in group therapy, humanistic therapy, and death and dying, is 93.  

The Masters Share their Secrets to Longevity

If this phenomenon is the norm, what is responsible? Just what constitutes the magic bullet? Is helping others beneficial for the helper? Is listening and empathy advantageous to human physiology? Is it frequent sitting? (Certainly not according to any expert I have ever heard!) Is it getting up from the therapy chair, simulating an air-squat repetition performed at the beginning and end of each 50-minute hour fountain of youth? Have therapists stumbled onto their own brand of interval training? Could the benefits come from the intellectual stimulation from thinking and analyzing client behaviors?

When I asked Ellis about his secret to remarkable longevity, I jokingly asked if he had the water at his institute spiked with vitamin E or something. I inquired if he was into herbs or cranking out crunches while his clients shared their tales of woe. Was it the REBT thinking that kept him youthful?

Ellis shared that he had good heredity. His mother and her whole family lived into their nineties. His dad lived until age 80 and was one of the earliest to die in his family. Ellis insisted he didn’t use anything special, just worked on his emotional problems and avoided upsetting himself about things. He added that learning new things, helping people, and engaging with music kept him going.

But could the secret lie outside the therapy sessions? Or to put it a different way, could the answer be found in what therapists do when they are not actively engaged in the practice of psychotherapy or after the point in their career where they are no longer seeing clients?

Consider my exchange with Muriel James a while after our interview; when I inquired about whether she was still doing individual and group therapy, she told me she had branched out.

“What do you mean, branched out?” I asked.

She explained that she would get up early surrounded by a cup of java and about 50 history books. (Did she say 50 books? Yes, Howard, she said 50!)

She had discovered, at least at the time, that female history authors were discriminated against and therefore she was writing the texts using a male pseudonym. Talk about practicing what you preach. In my mind Muriel was using Born to Win self-therapy 2.0.

Yes, some luminaries in our field left us too soon, and for the 1000th time, correlation is not causation, but this phenomenon is certainly something to ponder. Just ask any therapist!

Questions for Reflection and Discussion

What are your impressions of the author’s connection between success and longevity?

How do you stay focused and sharp as you age in your clinical career?

Which one of these elder statespeople do you admire and why?  

Michelle Jurkiewicz on Gender-Affirming Psychotherapy with Children, Teens and Families

Posted on by Psychotherapy.net Team
Lawrence Rubin: Thanks so much for joining me today, Michelle. You are a psychotherapist in private practice in Berkeley, where, among other things, you specialize in gender-affirming mental healthcare for children, teens, and their families. Did I get that right? 
Michelle Jurkiewicz: Yes, you did.
LR:
we have the gender affirmative model, and then we have gender-affirming care
What exactly is your gender-affirming model as applied to clinical work with kids and teenagers? What does that mean?
MJ: We have the gender affirmative model, and then we have gender-affirming care. The gender affirmative model is a way of thinking about and understanding gender diversity, which applies to everyone. It’s based on the premise that gender diversity is a normal and healthy human variation, that people have the right to live in the gender that feels most true to them, without criticism and discrimination. And it’s also based on the idea that there’s not a preferred outcome in terms of a young person’s gender, whether that’s transgender or cisgender. There’s not one that’s preferred.

Gender-affirming Mental Health Care with Children and Teens

LR: And you said that’s different than gender-affirming care.
MJ: Gender-affirming care is informed by the gender affirmative model. When we talk about gender-affirming care, especially when you hear about it in the media, it’s often referring to medical care. But gender-affirming care often takes place amongst an interdisciplinary team.

So, if you’re talking about puberty blockers and gender-affirming hormone treatment, then that is something that even as a psychotherapist, you would be working in conjunction with an endocrinologist or pediatrician, likely a social worker. There are various members of the team.

The main way the gender affirmative model works with children and teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are and be who they are, as well as increase what we call gender literacy. In the most basic sense, gender literacy is increasing an understanding of the sociocultural norms of gender roles and stereotypes, and what potential consequences there are if you step outside of those boxes.

We want children to be able to be themselves and explore who they are while also—in age-appropriate ways—making sure that they understand the world that they live in and that not everyone necessarily understands gender diversity.   

LR:
the main way the gender affirmative model works with children and teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are
What is your particular role in that network of professionals that converge in working with a kid or a family around gender and gender transition?
MJ: There’s not as much need to be in contact with young children before puberty unless there’s something else going on. Then, of course, like any child, we would be in touch with pediatricians and other relevant professionals.

But when a child enters puberty, and there is the question or desire for puberty blockers or later for gender-affirming hormone treatment, the gender centers require an assessment from a mental health provider, which they take into consideration. It’s one piece of the whole picture of whether this is the right thing for the child. The psychotherapist’s job in those instances is to share your thoughts about whether, in your professional opinion, that is the best next step for this child and family.   

LR: So, they will take your input, based on your observation and your work with the child and family, into consideration before the team decides, although I imagine it’s ultimately—hierarchically—it is the physician who makes the decision.
MJ: Well, the parents ultimately, but yes.
LR: Is this evaluative process with pre-pubertal clients what you refer to as your holistic evaluation?
MJ: We typically think of the holistic evaluation even prior to that. But in terms of specifically with pubertal kids who are seeking gender-affirming medical care, we’re referring to taking everything that we possibly can into consideration. And that means that we work very closely with parents as well.

So, we’re looking at all aspects of their history. We’re looking at how parents feel about it because it’s important that if this goes forward, we have the parents’ full support.   

LR: While we’ll chat about the family a bit later, I would imagine at this juncture that dealing with parental ambivalence would be an important part of that holistic evaluation.
MJ: I think oftentimes, parental ambivalence is addressed and worked with even prior to this evaluation. 
LR:
the gender affirmative model does not advocate for specific psychological testing
I would hope so. For those psychometrically driven clinicians out there, are there specific inventories or questionnaires, psychological tests, so to speak, that would be part of an evaluation?
MJ: The gender affirmative model does not advocate for specific psychological testing. Prior to the gender affirmative model, the child had to undergo a whole battery of psychological tests. We don’t do that anymore.

There are various screeners and batteries, and things like that that some clinicians use to help them get a child’s gender into focus. I personally am not using those so much because I feel like I’m well-trained and I have a lot of experience, and that, through my conversations with children and their families, I get a very good picture and don't need those batteries.

I will say, though, that I am an advocate for more research in that area. I think there are some people that are working on a more standardized evaluation process, of course. But I have not found that useful in my own work.   

LR: I guess when you’re talking about gender-affirming care, you are already outside of standardized notions. You’re already considering not just the psychological makeup of the child, but the whole ecosystem. To then try to empower some instruments to carry the burden of decision making almost seems antithetical. 
MJ: I agree. I think the tension is around insurance companies.
LR: And then there’s the issue of liability. If the clinician is going to be called into court, psychometrics may be desired, or even demanded. In the course of your typical evaluation, what are you looking for historically, developmentally, in a teenager? In other words, what are some of the markers you are looking for that give you a sense that this child has always been on this path?
MJ: That’s a good question because I think what we’re seeing is shifting, and it used to be that the kids that we were working with came out when they were very tiny, and they maintained that identity until puberty, and then they accessed gender-affirming medical care.

I think now we’re seeing more and more kids come out later, in which case, when we’re looking at their history, we’re not necessarily looking for stereotypes, such as they played with stereotypical toys of the other gender, or they wore clothes of the other gender—although we do gather that information, but it’s not a required piece of their history.

If we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones. Because puberty blockers have not been shown to have long term adverse effects once they’re stopped, that could happen potentially more quickly if a child is in a lot of distress and puberty is right then and there. But that doesn’t mean then that that child would necessarily go on to gender-affirming hormones.

We are looking for some sort of consistency in their identities. We’re developing this pathway in conjunction with medical providers, which requires that the child is, at the same time, learning about the risks and benefits in a developmentally appropriate way. In some ways this is asking them to take on something we don’t typically ask of cisgender kids in terms of their medical care, but it does mean that a lot of times these kids know a lot.   

LR:
if we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones
They’re informed.
MJ: They’re very informed, and that’s a necessary piece of the process.
LR: Why does WPATH (World Professional Association for Transgender Health) recommend that while evaluating these kids, you look for, if not rule out, autism spectrum disorder? What's the link that they think must be examined there?
MJ: If a child is on the spectrum, it does not disqualify them from gender-affirming care. However, what WPATH is addressing, and what I’ve seen in my own practice, is that there is a huge correlation between gender diversity and being on the autism spectrum. The most recent statistic I’ve heard is that about 10 to 12% of gender diverse children are also on the spectrum. That’s huge compared to the regular population of kids.
LR: As a clinician, and perhaps intuitively, what do you think the connection is?
MJ: I don’t know, but my best guess, and the way I think about it as of this moment, is that a necessary piece of being diagnosed on the spectrum has to do with social differences, the way that one reads cues, the way that one responds to others and interacts with others. And so, I wonder if children who are on the spectrum feel less inhibited by social norms around gender, so they have naturally more freed up space to take it up. 
LR: Do you have to sort of screen for, if not rule it out before proceeding with transitioning?
MJ: We don’t inhibit a child from proceeding because they’re on the spectrum. But what we do need to be screening for is the hyper-focusing and rigidity that often accompanies spectrum-related behavior. We need to make sure that that’s not what’s going on with gender.
LR:
here is a huge correlation between gender diversity and being on the autism spectrum
Are there any myths you’ve come across about these gender diverse kids who are searching—and is ‘searching” a good enough word? 
MJ: Gender exploring! I think that there are many myths, and one of the ones that comes to my mind immediately is the idea that kids can’t know their gender if they’re gender diverse. They’re likely to change their minds later, so we should not really be listening too much to what they’re saying. We have to wait a while. I think that’s a big myth.

I think another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender. And that’s a big shift in thinking. That’s something that I am monitoring within myself. Oh, and then there’s the myths of the gender affirmative model, that it’s just a fad or a kid might say they’re transgender because they're trying to fit in with peers, or that being a gender-affirming therapist means that if a kid says they’re transgender, the therapist is going to immediately write a letter and say yes, puberty blockers. Yes, hormones. In reality, these are decisions that are very carefully sorted through and that take time.   

LR:
another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender
Is that second myth related to what you refer to as quieting the gender noise in the clinician’s head?
MJ: We all have a gender. We all grew up with expectations. We all hold biases about gender. And that’s what we think of as gender noise. Gender noise, the myth that I was talking about, was the myth that somehow being cisgender was preferred or more ideal, and that’s just been stated as fact, basically, for as long as we’ve known in Western culture. That’s a more difficult one for some people to really shift around. And even when we shift around it, I think if we’re really not paying attention, it can be easy to slip out of that. This is especially so if I’m not monitoring my countertransference, monitoring my own biases about gender.
LR: Makes me think that gender noise is on one end of the spectrum of therapists’ presence with these kids, and severe unchecked countertransference is all the way at the other end, and there are so many points in between where that noise can impact the therapeutic relationship.
MJ: I want to make one more point about gender noise based on something I’ve noticed in my practice with cisgender people. I’ve had several cisgender male clients who have expressed a lot of stress and even angst around masculinity with questions like, “Am I measuring up?” or “Am I too masculine?” Does that mean they’re aggressive? Just trying to sort out for themselves what it means to be a man and what is okay and not okay. And I would say even that is gender noise.
LR: What is that male bashing concept typically attributed to the dangerousness of hypermasculinity? 
MJ: Oh, toxic masculinity?
LR: Is that what you refer to when you say a cisgender male might come in worrying that they’re just a little too beefed up emotionally? 
MJ: Some of them worry if they’re even doing masculinity correctly. Like, are they masculine enough? There’s such mixed messages out there right now and I don’t know that historically, I have had so many male clients talking about these issues as I have in the last couple of years.
LR:
we all have a gender. We all grew up with expectations. We all hold biases about gender. And that’s what we think of as gender noise
I wonder if the males who come in worrying about their masculinity is more of a function of their education level, their intelligence, their sensitivity, and if they are sensitive to ‘am I being too masculine,’ then that sort of answers its own question.
MJ: Exactly, exactly. And I think the Me Too Movement, along with toxic masculinity, has brought these topics to the forefront.
LR: Not to mention the politicization, but we’ll save that for another conversation. How does gender stress differ from gender dysphoria? 
MJ: It’s a good question. When I think about gender dysphoria, in the most basic sense, it’s the distress that someone feels when their gender identity does not match the gender designated to them at birth. And gender dysphoria, often, but not always, can show up around their body, like, not wanting certain body parts they have, or wishing they had body parts they don’t have. Feeling like their face, or their bone structure, or body shape, or genitals are wrong. The distress is very internal.

You don’t have to be gender dysphoric to experience gender stress. You could feel very comfortable with your gender identity and your body and all of that, but on a regular basis, encounter situations based on your gender that cause stress. For example, if you’re a trans girl, and have to choose between men’s or women’s bathroom, the very process of going to the bathroom can become stressful. That would be gender stress even if you’re okay with who you are, and your body, and everything.  

LR:
when I think about gender dysphoria, in the most basic sense, it’s the distress that someone feels when their gender identity does not match the gender designated to them at birth
How have the gender issues that have been presented in your practice changed over the last 20 years?
MJ: They’ve changed quite a bit! Early on, most of the children that were brought to me around gender were assigned, or designated male at birth and were wanting long hair and to wear dresses and play with dolls, and they were saying that they were girls. Their parents wouldn’t really know what to do at that time. They would have questions like, “Is it bad to let my little boy wear a dress or play with dolls?” or “Do we affirm that and say it’s fine,” or “Do we change pronouns or a name?”

These were little kids that usually ranged in age from 3 to 6. But sometimes they were older, but almost always they were quite young. Early on in this work, I didn’t really ever have a parent bring a child who was designated female at birth when they were little. The way I understood this was that the girl box, so to speak, is a lot bigger than the boy box. It was, and maybe still is okay for little girls to cut their hair short and play with the boys and be good at sports. But it was not seen as okay for a little boy to wear a dress.

Over time, this has shifted. And as I touched on a little bit earlier, while we still see those young kids, they’re not coming to our offices as frequently. I think because parents have more awareness out there and perhaps parents aren’t as worried when the kids are little and they’re going to kind of see what happens and support their kid in the meantime. Parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body.

The other difference that we’re seeing is that kids come out later. I have many families that bring a teenager to me who has come out as transgender, post puberty. We never used to see that, and now we’re seeing it more and more. I see that pretty equally among “designated male” at birth or “designated female” at birth. But when we start to talk about who is showing up for medical treatment, there is a greater number of designated female teens showing up for hormones than there are designated male teens.    

LR:
parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body
Before we shift gears, is there anything else I should ask about the kids?
MJ: Not so much specific questions, but I guess what I would say about the kids themselves is that some of these kids absolutely know who they are. Regardless of how certain or sure they are of their identity, what we know these kids need is family acceptance, and family acceptance does not necessarily mean, “oh, my kid’s trans, so let’s go get hormones.” They need to know that families have their back, and ideally that communities, teachers, churches, have their back and love them no matter who they are.
LR: In your book, you said that if depression and anxiety develop, it’s likely due to negative social responses, so treatment should be aimed at helping and healing the surrounding environment. Are you saying that effective intervention for the child or teen means that the clinician must work with the family?
MJ: We do help the child, too, but I feel like the root of it is not necessarily about their child’s gender as much as it is about the parents’ response to their child’s gender expression. If we think about just anxiety and take away the gender piece when we’re working with an anxious child, we often find that we have to work with the parents as well. You know, there’s something going on at home, or there’s ways the parents can do things differently to help work with us, to help treat the anxiety. We were not just treating that in isolation.

So, in that way, it’s not that big of a leap to think about it as you’re starting with the family. And somebody doesn’t have to be out there being super politically active if that’s not what they want to do. But the way that they are holding gender in mind and interacting in the community, in their own communities, for example, and raising awareness, I think is huge.   

LR: Do you go to the school in the course of working with a particular child and family? Do you go to churches? Do you go to community centers? What is the extent is your work outside of the therapy office?
MJ: I think gender-affirming care is a team effort. We’re lucky here because we have people at UCSF’s Child and Adolescent Gender Center, where there’s an educational specialist. And if the family wants, that person will go with the family to the school and advocate on the child’s behalf.

If the family doesn't want to bring in an educational specialist, I know about creating a gender and educational gender plan. I can offer information to the family if they feel like they can address the school themselves.

That’s basically about having a discussion with administrators about whether there is a safe person for this child to go to if something were to happen. What bathroom is this child going to use? Do they have access to one that feels safe and comfortable to them? Whether teachers are informed or not, whether the kid is out to peers or not, those sorts of things are talked about amongst the adults to create a plan to support the child at school, for example.   

LR:
I  think gender-affirming care is a team effort
So basically, extending the office to include all possible support members to extend the safety of the office into the world that they actually have to live in.
MJ: Exactly.
LR: What about the kids who express gender stress, even gender dysphoria, but don’t want to, or aren’t committed to chemical intervention? 
MJ: We’re seeing this a lot. I think this is one of those myths out there that transgender and gender diverse children and teens necessarily are seeking out medical intervention. Because that’s not true. It’s a subset that wants medical intervention, and even within that subset it has to be determined to be the right next thing for them.

There are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention. They love their bodies the way that they are. And so, there’s that piece, and then in terms of the journey piece like we talked about in the book, is that gender journeys are something we’re all on throughout our life, right!?

Even as a cisgender woman—and being a woman has been an important identity of mine—but how I experienced being a woman, and thought about being a woman, and expressed my femininity or lack thereof at 20 years old is very different than how I do it now in my 40s. So, there can be shifts in how we express gender, experience it, and then there can also be shifts in identities.

That happens over time, and so we don’t think of there ever necessarily being an end point in terms of a gender journey, although there may of course be an end point in therapy when kids are doing well, and they’re not needing that level of support.   

Gender-affirming Work with Families and Beyond

LR: What are some of the clinical challenges that the parents have brought to you, or the families? Because it’s not just parents, it’s also siblings, maybe even the extended family.
MJ: There are so many if we got into specifics! But I’ll start general first. When a child comes out as transgender or gender diverse in some way, it impacts the entire family, especially the family unit living together. And siblings have a range of experiences. Sometimes it’s not an issue, and everything’s fine, but other times, the sibling may go to the same school. This sibling may either feel they are a target, or they may actually experience being a target, like being teased for who their sibling is, or they may fear that that is going to happen, even if perhaps it doesn’t. Siblings might not understand and might need support in even understanding what this means.

However, I think parents struggle more than siblings do, partly because we’re finding that young people just tend to have more flexible minds around gender than us adults. One particularly difficult thing is that every parent has dreams for their children and ideas about who their child is, who their child is going to become. When they realize that there’s an aspect of their child where their gender is something different than they’ve imagined, there has to be a reworking of those dreams and expectations. Oftentimes, there has to be a lot of grieving and mourning for what they thought that they would experience with their child, or what their child would experience in life.

There’s often anxiety for parents about how the world is going to accept their child. They may ask, “Is my child going to be hurt in this world because of who they are?” Then there’s the stress of extended family. I’ve worked with families where things are going really well within the nuclear family, but the thought of telling grandparents feels really dicey out of fear that the grandparents aren’t going to understand.

Or I’ve worked with families who are religious, and their particular church or synagogue is not supportive of gender diversity. This is a community that the family loves and relies on, and they’re having to face the harsh reality that they may need to move out of or disconnect from this community in order to support their children. Or they wonder if there is a way for them to bring education to those communities and to help them to grow and expand to accept their children for who they are. So, it's a lot of pieces that parents are holding.   

LR:
here are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention
What family factors have you experienced that might undermine successful intervention with the child, or do those families simply not come to therapy?
MJ: Rejection is the biggest thing. If parents are absolutely like, “this is not true, it’s not real, I’m not even going to discuss this with you,” that is the worst-case scenario, and we see those children do very poorly. That’s where we’re seeing the highest rates of suicide. The highest rates of runaways. And once these children run away, they’re at greater risk of victimization than their cisgender homeless peers. So, we know that the biggest protective factor is family acceptance.
LR: Are the transgender kids accepted in the broader LGBTQ community, or do you find it depends on the community? 
MJ: It’s actually kind of complicated. In my experience, some older adults or adults in general‚ not young adults, but middle age and older in the LGBT community can be quite non-accepting and surprisingly dismissive that these identities are real, coupled with the belief that it’s sexual orientation and not gender identity.

I would say that we see less of this within the younger members of the LGBT community, like adolescents and young adults. I think there’s still some cases

Embracing Technology in Counseling: Innovative Tools for Enhanced Client Support

Posted on by Psychotherapy.net Team

In recent years, technology has become more pervasive, entering many fields, including, for our purposes, counseling. And for better or worse, it has provided innovative tools that enhance therapeutic experience and offer new, convenient, and accessible avenues for clients to access a variety of mental health supports. From telehealth sessions to digital resources and AI-driven interventions, the possibilities are vast and increasingly accessible.

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The Importance of Technology in Counseling

In the wake of the COVID-19 pandemic, telehealth has emerged as a key instrument for the delivery of mental health services. It offers clients flexibility and accessibility, removing barriers such as geographic distance, transportation issues, or scheduling conflicts. Telehealth platforms allow for face-to-face interaction through video calls, creating a space for meaningful therapeutic engagement. This approach has been particularly beneficial for clients who feel more comfortable in their own homes or who may struggle with anxiety related to in-person meetings.

Email and secure messaging platforms provide an invaluable extension of the counseling relationship. Clients can now send a secure message through a client portal. These tools allow clients to reach out between sessions for support, clarification, or to share progress in a timely and secure manner. This continuous line of communication can help maintain therapeutic momentum and provide timely interventions when needed. However, it's crucial to establish clear boundaries and guidelines around digital communication to ensure both client and counselor well-being.

But the real big one, the humdinger, is artificial intelligence (AI). It is emerging as an asset in the therapeutic process. AI-driven tools can assist in creating personalized therapy homework assignments, offering clients tailored exercises that align with their treatment goals. For instance, AI can suggest cognitive-behavioral strategies, mindfulness exercises, or journaling prompts, providing clients with structured ways to work on their issues outside of sessions.

Moreover, AI can serve as a practice partner for clients working on interpersonal skills. For example, a client preparing to engage in conflict resolution with a spouse might use an AI-powered chatbot to role-play scenarios. This practice can help them build confidence and refine their communication strategies before addressing real-life conflicts. While AI cannot replicate the nuances of human interaction, it offers a safe and controlled environment for clients to experiment and learn.

So, yes, the possibilities might just be endless, but I would like to give you one, real-life, actual example of a client using technology for their benefit.

Technology as a Lifeline for Bipolar Disorder

One case involves a client of mine diagnosed with Bipolar 1 disorder, who used technology to build a support network. Recognizing the importance of communication and preparedness, she created a detailed Google Drive document outlining her mental illness. The document included descriptions of her symptoms, warning signs of a potential episode, and specific suggestions on how her friends and family could support her during difficult times. Additionally, she listed emergency contacts and step-by-step instructions for what to do in a crisis.

This proactive approach has had a hugely positive impact on her life. By sharing the document with her close friends, she empowered them to better understand her condition and respond effectively when needed. This not only provided her with a sense of security but also strengthened her relationships with her support network. The ease of access and the ability to update the document as her needs evolved demonstrated the power of technology in fostering a supportive and informed community around her.

I found this use of technology by my client helpful for a number of reasons. There’s a level of sober self-awareness that a person needs to have if they struggle with Bipolar 1. The nature of the disorder comes with manic highs where sometimes the trigger of an upswing can be identified or even anticipated. But this is not the case for everyone. Sometimes the upswing comes without warning and takes over someone’s life with destructive consequences. If that is the case for one of your clients, planning and brutal honesty is critical.

I am in the habit of saying to clients, “forewarned is forearmed” (I stole this from one of my graduate school professors). Meaning, I want clients to be honest with themselves about how powerful their symptoms can be, and how they are not always in full possession of their mental faculties during the onset of an episode. Therefore, it is imperative they plan for those times. And to primarily focus on preemptively equipping their support network with information and resources on how to support them when they struggle to care for themselves. This wisdom applies itself broadly to clients struggling with a variety of mental health disorders, not just Bipolar 1.

***

There is wisdom in knowing your limitations and preparing for difficult moments. For clients who struggle with chronic, persistent, and severe mental health disorders, they absolutely need a strong support network. I strongly encourage my clients to think about the strength of their support network as a measure of their recovery, maintenance, or long-term wellness plan. And, thanks to technology, fostering and empowering that support network is easier than ever.

Questions for Reflection and Discussion

What challenges have you experienced bringing this level of technology into your practice?

What reservations do you have integrating AI into your clinical practice?

What techniques and methods would you like to learn moving forward?  

Addressing Bullying in the Classroom: Undercover Anti-Bullying Teams

Posted on by Psychotherapy.net Team

“I know I’m weird,” she said slowly, tossing her multi-colored hair around her shoulders as she sat down heavily in the chair in my office, “but I can’t help it!” Tears welled up in her dark eyes, and she shuddered involuntarily. The smell of sweat and fear filled the air in my small room. Her eyes, heavy with cheap mascara looked as if they had withdrawn into her pale, blotchy face. She shifted her long body from side to side. “I feel like a dumb goose,” she sobbed. “I don’t belong in this school or even this world. I know they all hate me.”

I sat back gently to give her space and listened with interest to what she was saying. I had seen her on the school campus many times, usually alone, looking stressed and unhappy, walking quickly from place to place, carrying her heavy school bag and not looking at anyone. Other kids seemed to avoid her and whispered about her as she walked past.

“It’s not fair, I’ve done nothing but be myself, but nobody can accept that. I am starting to think that it’s true what they say. Why do they want me to change? I don’t ask them to change who they are!” she blurted out.

“I don’t belong here,” she reminded me. “I want to stay home and never go to this stupid school.”

She paused for a moment, then she said, “But I hate home as well, I don’t belong there either, my parents are losers and never get out of bed. I don’t know what to do. I really hate my life.”

The sound of her pain seemed to hang like a sword in the air. I was stunned by this stream of painful emotions that surged like a tornado in my room.

“No,” she said emphatically, “It’s not fair because I have done nothing.”

“Would you mind if I asked you some questions about what’s been happening?” I asked. “I’ve seen something like this before,” I added, “and I have some ideas about what we can do.” She shifted slightly in the chair, her long legs looking for a place to hide and her sobs began to slow down. She shrugged her shoulders and said, “I guess…Go ahead then.”

I paused again for a brief moment, then I asked gently, “Where does this kind of thing happen most?”

“It’s everywhere but mostly in my classes. It’s the story of my life. They gang up on me and shut me out deliberately and they talk about me behind my back. I can’t take much more of it,” she said. “They bully me and make me feel stupid. One kid even made up a song about me. Everyone laughed, even my so-called friends,” she said with disdain.

She lifted her head slightly and looked out at me from under her tousled hair. I handed her a tissue and she dotted the black lines of mascara that had made streaky tracks on her face. I had been carefully listening for a way to talk about what she had been experiencing and I had a number of choices including “bullying,” “ganging up,” “shutting me out deliberately,” “talking about me behind my back,” “making me feel stupid,” but I chose “bullying” because it seemed to sum up all the other things she had been going through and it was, after all, a description that she had chosen.  

“Is it bullying that you’ve been the target of?” I asked. When I used this word, she looked up at me and her face winced at the sound of the word. I felt that I had struck a chord with her.

“Yes, it’s bullying plain and simple,” she said sadly.

“I would like to tell you my ideas about how we can get rid of it, would you like to hear them?” I ventured. “It may take a few minutes and if there is something you don’t understand, please ask me. Is that alright?”

She didn’t answer, and looked bored, but I persevered.  

Planning an Undercover Anti-Bullying Team

“I have seen problems like this one and even some worse ones solved with ‘Undercover Anti-bullying Teams,’” I continued. “They are a group of students from your class that we select together, and they come up with a plan to eliminate the bullying. Once they find out how much the bullying is affecting people, they usually are happy to do whatever they can to bring some happiness back into the class. It’s my guess that they are looking for a chance to do something right. I think they know about the bullying but don’t know what to do about it. They hate it as much as you do.”

“Yeah, sometimes some kids have stuck up for me and the bullying has stopped, but it doesn’t last. I wish they could keep it up because that’s when I think they accept me.”

I paused for a moment, thinking about what she had just said. I could see that there had been moments when there was no bullying, that there had been exceptions to the story that she was telling me.

“On your team,” I continued, “must be the two kids who are the biggest bullies together with four others who are kids that the teachers and other students look up to.”

She looked startled when I mentioned the bullies being on the team.

“That’ll never work,” she said, “Why should they want to help me when all they do is bully me?”

“Well for one thing, they are outnumbered,” I smiled, “and the other more important reason is that, in my experience, sometimes even the bullies get sick of bullying, but they don’t know what else to do. They almost think that’s who they are. For some reason, they like to think that they know how everyone should be and when they come across someone who they think is different, they try to get them to be like them! That’s the part I am still trying to figure out, why they think they should do that.

“I’ve found through doing this Team idea for over 50 times now, that once they are introduced to a better way and the other kids on the team get behind the plan, they always seem to change the way that they speak and act, and in some teams, they have become the leaders of the team! In many cases, the bullies have become friends of the ones they had been bullying, but we don’t expect them to.”

“It could work….” she said cautiously. “50 times? How many failures have you had?” she cheekily asked, and I thought I detected the hint of a smile.

“I know it sounds ridiculous, but there have been no failures. Every team has been successful in eliminating bullying, and what’s more,” I said with pride, “it hasn’t returned!

“There are two other important parts to this way of dealing with ‘bullying’.” I continued. “Firstly, the teachers of your classes are told what has been happening to you in their class and that an ‘undercover anti-bullying team’ has been set up to eliminate it. They are usually quite surprised, and some teachers have even told me that I’m mistaken. They say that there is no bullying in their class! Just goes to show how clever kids are. The kids who bully certainly don’t want the teachers to know about it.”

“The teachers are told the names of the team members including those doing the bullying, but without mentioning the names of the students who are doing it. They are invited to make suggestions about who they think should be on the team. Sometimes we add their names as well, but most often you will know the ones best suited to help you. It’s not just your friends, but ones who you think could really make a difference. So now the teachers know about what was previously kept hidden from them. They become like extra team members!

“Secondly, when you are sure that the bullying has gone for good, the team members receive a certificate of recognition from the Principal and a canteen voucher from the school. We have a special ceremony in my office where we hand out the certificates to the team. We talked about how the team went and what they have done and what they can keep doing to make this school safe from bullying. Sometimes the Principal hands out the certificate, sometimes the dean, and sometimes teachers and even parents will come to show their appreciation. Sometimes, the ex-victim likes to give out the certificates!” Like I said, I’ve done this over 50 times now and it has worked every time.”

“I guess…” she said tentatively. “It’s better than nothing being done which is how it’s always been.”

“Once the team is set up,” I continued, “They make a plan that details how they are going to make the changes. I don’t tell them what to do, it’s better if it comes from them.”

“Then I wait a couple of days for the team to begin their plan and the next step is to call you out of class, and we talk about what has changed and what remains to be changed. I write all this down on my form. Then I call the whole team together and I share with them what you have told me. We talk about the same things that I talk about with you, such as: How is the plan going? Should they add to the plan? Is it enough? Have they been able to stick to the plan? What have they noticed about your reactions to their efforts? Have other kids said anything? Have they been able to keep it undercover? Etc.

“You don’t have to meet the team or do anything special, but it does help if you recognize the efforts the team is making. I also ask your teachers to tell me what changes they have noticed, and I share these observations with the team and with you each time we meet. We keep going with this process until you decide that the bullying is over. In most cases it takes at least a couple of weeks for the changes to become permanent, but I am sure you agree that’s not much compared to how long this has been going on for.”

She was starting to show some real interest by now. She brushed back her hair and stood up and looked at her eyes in my mirror. She used the tissue I had given her earlier to dab the corners of her eyes. She is quite tall, I thought, as she stood beside me.

“Well, to get this started I need to carefully write down the story of the bullying. This will be what I read to the team. Then we select the team members and then I email your teachers to let them know what we are doing. The next day, I call the team members from classes where they will not be obvious and give them their instructions.”

“One more thing,” she interrupted me, “why is this ‘undercover?’”  

“I was hoping you would ask that,” I said. “As I explained earlier, I have found that when people feel that they have been caught out bullying, they are more than likely to blame the person they think has exposed them. Then they try to get revenge on that person, and it usually makes things worse. If they are invited to solve the problem of bullying without being exposed as the bullies, they respond positively. It’s a way of protecting you from retaliation. They become part of the solution, whereas before they were part of the problem. It gives them a fresh chance to do what is the right thing to do. Punishment never works in cases like this.”

“Also, the other students who have been observing the bullying and have done nothing to stop it usually feel ashamed of their inaction. By being anonymous, they also get a chance to make the changes they have wanted to do without it being a big deal.”

“But the main thing though, is that this kind of bullying survives because it is undercover or under the radar. Teachers rarely see it. We must use the same kinds of tricks against it, and who better to do it than students themselves? It is a job that no teachers or other adults can do; it’s going to need some special strategies to expose it and to get rid of it.”

I paused for a while to let all this information be absorbed by her. She seemed to understand what I was saying.

“What I have noticed happening with these teams, is that sometimes the friends of the team members notice the changes and ask if they can be on the team. It’s often hard for the team members to keep it a secret because they enjoy the new job and things in the classroom change pretty quickly. I believe that the kids who bully are not bullies by nature. Often, they don’t even realize they are bullying. They think they are having a joke. Hardly ever do they think that bullying is their only job in life.  

“Are you ready now to tell me your most recent experience of bullying?” I enquired as I took out the forms I use to record her story.

“Well,” she began, “It’s been going on for most of my life. It wasn’t as bad at primary school, but it’s gotten much worse as I’ve gotten older.”

This is what she told me. I carefully recorded her own words, checking every now and then to make sure I had written down exactly what she said.

“Well, in social studies, we had to get into groups around tables and I was late to class because of my rowing training. The only place left was right by the door where no one was and everyone who was around were saying things like ‘goosey girl,’ ‘loner,’ and ‘O.T.L.’ (Only the Lonely) and stuff and laughing so the teacher couldn’t hear. I was sitting by myself, and it made me feel horrible, like I was dead meat.

“Another time last week was when I walked into the library, a group of the boys were lined up against the wall on both sides and they were yelling stuff at me and saying stuff to me. They were calling me names and saying that I made up an account on Facebook just to have friends and stuff and why did I bother coming to this school because nobody wants me here. A while ago in P.E (Physical Education), we had to get into groups, and nobody wanted to be in my group. The leaders put me in a group, and they were all going, ‘why do we have to have her in our group and stuff?’ This kind of thing happens to me a lot when we have to get into groups.”

I wrote it down as she spoke, checking with her to make sure I heard her clearly. Then I asked her how this incidents affected her and made her think and feel.

“I feel like I can’t cope, and I want to be able to relax like everyone else. It’s OK for them but they don’t realize what they are causing me because I don’t get any support at home. I don’t feel at home even at home. It makes me want to run away. Sometimes I want to leave but I can’t. Sometimes I want to leave and never come back. I hate coming to school early for rowing because kids are saying horrible things and stuff but if I am late, everyone draws attention to it. They look at me and act in a shaming way. It makes me hate school. I used to love school and now when I wake up, I just want to lie there and not move. I hate it so much. Sometimes I wish I was not even alive.”

I let that powerful expression of her emotions hang in the air. I had heard similar stories many times but each of these moments are so moving, so important. Following the questions on my form, I gently asked her, “Ideally, how would you like things to be?”

She paused for a while and looked at me. My guess was that it was hard for her to relive those painful moments, but this question seemed to shift her thoughts.

“Well, I want to feel comfortable here to relax and forget about everything else, to be comfortable at school. I want to be able to say what I feel, not being scared of everything I say and do. I don’t want to be bullied anymore. I want to have friends, good friends that I can trust and not laugh at me or put me down. I feel like I must defend myself to show that they are not hurting me,” she added.

“Thanks for letting me write it all down,” I said. “Can I read it all back to you to make sure that I have got it down correctly? Remember that this is the story I will read out to the Undercover Anti-bullying Team once they are assembled.” She nodded her head. I read the story to her just as she had told it to me. She listened carefully to my reading of her story and looked sad. “Are you OK with me reading this out to the Team like that?” I asked.

“I hope this works,” she said, “and that they don’t use it as a reason to bully me more,” she said with a worried look on her face.

“You know, in all the Teams I have run, that has never happened. Most times the team is shocked to hear the story and is ashamed that it has got to this stage. In some cases, students have cried when I have read their story out. One time, the bully confessed! It was him that eventually became the leader of the team.”

She seemed reassured by this, and I said to her, “Now we must select the Team before I let the teachers know about it. Let’s look at your class list and we can go through each student one-by-one and you can tell me what you know about them and we can select the Team.” I printed off the list and we discussed each student. I explained that apart from the two students who were responsible for the most bullying, the other four people would be students that the rest of the class and teachers looked up to. Students with status in the eyes of their peers. I recorded these names on my form.

Once the composition of the team was decided, I thanked her for her bravery in coming forward with this and I sent her back to her class.

Building the Anti-Bullying Team

Then I sent this email to her teachers:

Hi Teachers,

Candice has told me a story about some bullying of the continual teasing, name calling, mocking family, excluding from group work type, what others might think as “low level,” but to her its big and causing her to switch off school. Together we think that an Undercover Team might work well to eliminate the bullying.

She has selected:

Michelle, Josephus, Mario, Alayah, Yanet and Carlos as students she wants to support her. Remember that in this group are the two “worst” bullies. Considering what you know about these students and others in the class, can you suggest any others that may be more suitable?

If you think this is a good team to go about doing anti-bullying work, don’t reply. If you have any suggestions, please let me know asap as I need to call the team together tomorrow.

There is nothing extra you need to do but it would help if you notice the activities of the team and feed your observations back to me by email. I will pass them on during the monitoring process. You may decide to take some actions yourself with the class, but please do not let the existence of the team be known to the class.

On the side of a bullying free school, Mike.  

Sending such an email to the teachers is a risky business and I have only recently begun to do that. It is my belief that this undercover bullying needs to be exposed, and the widest audience possible recruited, to eliminate it. By informing teachers about activities that have been happening in the lives of their students, they become part of the Team and become more aware of the relational climate in their classes. Knowing what I know about each teacher, I predicted a variety of responses.

1.Dear Mike

Thank you for the email regarding the bullying of Candice. I was quite surprised to read this because I thought she was doing very well. Are you sure you have the right person? I struggled to detect the two worst bullies though. Except for Mario who makes the occasional smart comment to everyone, not just Candice, they all seem to be nice kids. I won’t allow any negativity in my class though and it is important for me that kids feel safe enough to learn.

It must be pretty low level as you say because I haven’t seen much of it. Still, I will take your word for it and keep my eyes open for the positive actions of the team members. She has selected a good Team because the ones she has chosen are students that I think have leadership potential. Who are the bullies again?

I will keep you posted, George.

2.Mike

I thought as much! She is strange and the kids find it hard to accept her. She should get her hair cut and not put so much make up on. She mucks around quite a bit and draws attention to herself. She doesn’t do much work in my class and is absent a lot. She doesn’t make it easy for herself though as she sometimes says some pretty harsh stuff back to them. I wonder if she deliberately excludes herself from whole class activities.

She does need to harden up and not be so sensitive.

I will keep my eyes open for any kids who might be acting differently towards her, but I can’t see them making much of a difference.

Most of these kids on her “Team” are pretty hard workers when they want to be so I wouldn’t make any changes.

Andrea

3.Dear Mike

This is clever! I have seen this kind of thing in my last school but it was more obvious. The counsellor took the kids who were bullying aside and had a talk with them. There was a small change but it didn’t really last because my guess is that they did it for the counsellor, not because it was the right thing to do.

As you know, I do my best to have the best environment for learning. Happiness is important to me, and I want my kids to have fun learning. But if any one kid is unhappy in any way, I want to know about it.

I will call a class circle tomorrow and we will all talk about how we can make our relationships the best that they could be. I will not draw attention to Candice but talk about good relationships in general.

In agreement with you about having a bully free school, Jenny.  

I was predicting a more unsupportive response from one teacher who I knew wouldn’t email me but would talk to me face to face.

I was sitting in the staffroom with my friends during morning break when he came over to me. The room was filled with colleagues drinking coffee and enjoying the respite from teaching. There were lots of warm conversations around tables and some people had gone outside to enjoy the early summer sun.

“Can I talk to you?” he asked.

I knew what this would be about and I steeled myself for what I knew was going to be a difficult conversation. “Could we go somewhere else and discuss this outside?” I asked.

We found a quieter corner of the courtyard and he started telling me his ideas.

“I am not happy about this ‘Undercover Team’ in my class,” he said. “It’s bollocks. I won’t tolerate bullying. I have high standards. If I knew who they were, I would make them stand up in front of the class and apologize to everyone for what they are doing. Then I would give them a detention or lines, and I would ring their parents and tell them what they are doing.

“Going soft on these bullies is a waste of time,” he continued. “They need to be held accountable for what they are doing and be punished. That’s how it was in my day, and I haven’t changed my opinion.”

I struggled to find a way to address his concerns.

“Kids in my class don’t dare bully each other. If I catch them, they know what to expect. If it was my kid who was bullied, I would want those kids excluded from school.”

I took a deep breath and tried to be calm.

“I know that this is not how you might do things, " I said, “but I have found over many years that when kids are punished, especially for bullying, they will somehow try to get their revenge back on the person that has told on them. If they don’t, then they will get their friends to. It always makes things worse. Besides, they spend time thinking about revenge and then they don’t learn. In my experience, students who are bullied don’t want the bullies to be exposed or punished. They just want it to stop.

“We both want the same thing, for kids to learn and to treat each other well. I am not asking you to change anything in any way, but just see if you can notice when the students on the team are doing positive things to support Candice.

“There may not be bullying while the students are in your lessons,” I explained, “but if all teachers can be on the lookout for any kind of unpleasantness, then our school is going to be a much happier and purposeful place, wouldn’t you agree?”

“Well, I’d be surprised if it was going on in my class, but I will keep an eye out for Candice as I do anyway.”

“Thanks for telling me about your concerns,” I added and went back with a pounding heart to my friends.

The Anti-bullying Team Convenes

Two days later I called up the team members. They shuffled into my office looking anxious and worried. I suspected that although they were classmates, they were not friends. They looked at each other suspiciously and began to ask why they were called out of class.

“Welcome,” I smiled and said as they looked uncomfortably for a chair to sit on. “You must be wondering why you have been called out of class and I will tell you why in just a moment and you may be surprised. But you may not be as well.

“Yesterday, one of your classmates told me a sad story of bullying in your class. I made sure she didn’t mention any names because as I explained to her before she started, the best way to eliminate bullying is for everyone to work together. Sometimes people get caught up in bullying and want to change because they know it’s wrong and they would not like it if it was done to them. Sometimes, people don’t even know that they are bullying and just think they are having fun. Other times, people see and hear the bullying and don’t know what to do about it. Many times, it seems as if even friends are in on it”.

“Who is it?” one student said. “Why us?” another said.

The room went silent, and some students began shifting nervously in their seats. I let the silence sit for a while and then I continued, “She has personally selected you as the students best able to eliminate the bullying. Not only that, but your teachers have endorsed her selection and are going to do what they can (without exposing the team) to make their classrooms safe from bullying. If you agree to be on the team, and when you have eliminated the bullying for good, you will receive a Principal’s Award in recognition of your anti-bullying activities and a canteen voucher from the school at a little ceremony to celebrate your success. He could even present it to you if you like,” I added cheekily.

“The important thing about this is that it is undercover. Nobody would know of your existence but myself, your teachers, the Principal, and of course the student who has been bullied. You can tell your parents if you like as I am sure they will be proud of your selection in this really important matter.”

They laughed uncomfortably and looked at each other sideways.

“I am going to read out the story and then I will tell you who it is and ask you if you would like to be involved. Are you ready to hear her story?” I asked.

“Yes,” they all nodded in agreement.

“I think I know who you are talking about,” one of the boys ventured.

“I will read the story exactly as she told me. I have added nothing and taken nothing out. You may know of the incidents she describes, and you may have seen it differently, but this is her story; this is how it is for her,” I added. “I am telling you in this way because I want the focus to be on the bullying, not so much on who was involved. You will notice that she doesn’t name anyone. That is not important to me. No one is being blamed or singled out.”

“This is her story,” and I read out her story, including how it made her feel and think.

There was silence as I read Candice’s story to the group, and some students said quietly, “that must be horrible.”

“I think I know who it is,” one boy said. “I didn’t know she felt like that. That’s sad.”

When I mentioned her name, I noticed looks of surprise on the faces of some students. Some were clearly embarrassed, but all the students listened without interruption to her tale.

“Would you all like to be on her undercover team?” I asked.

They all said they would be, including the ones she has identified privately as the two worst bullies.

“What do you want us to do?” Josephus asked.

“We make up a plan. I call it our ‘five point plan.’ On it, we list simple ideas that will turn things around for her. Who would like to start?”

I went over to the whiteboard with my marker in my hand. “If the same things were happening to you, what would you like people to do?” I asked.

“Offer her help when she needs it and offer for her to come into our group. I will do that,” Alayah said.

“That’s great!” I exclaimed.

“I could remind her that she doesn’t need to go ‘all stupid’ in a gentle way. I will do that because I think she will listen to me,” Michelle said.

“Stick up for her when people tease her,” said one boy and the others all nodded in agreement. “Would you all like to sign up for that?” I aske

Successful Use of Haleys Strategic Model of Family Therapy

Posted on by Psychotherapy.net Team

As a marriage and family therapist, I often find myself drawn to the road less traveled. In a field dominated by well-known approaches like Cognitive Behavioral Therapy and psychodynamic therapy, I’ve discovered the beauty and power of a model that, while rarely discussed in contemporary literature, possesses a distinctiveness that sets it apart: Haley’s Strategic Model.

Challenging the Traditional Model of Therapy

At first glance, this approach might seem unconventional, even daring. Its directive nature challenges the traditional therapeutic stance of non-directiveness, opting instead for a proactive, solution-focused approach. This alone makes it a rarity in today’s therapy landscape. But it’s precisely this departure from the norm that makes it so intriguing and, in my experience, incredibly effective. This therapeutic method stands out for its bold departure from traditional therapeutic approaches as it challenges the status quo of non-directiveness and passive exploration. Numerous clients shared with me the allure of a solution-focused approach, which they did not think was possible given the passive exploration they had come to expect from psychotherapy. What truly sets this model apart is its emphasis on strategic interventions. Rather than probing into the depths of past traumas or exploring abstract concepts, this model is all about pinpointing the problem, devising a plan of action, and executing it with precision. It’s like a finely crafted puzzle, where each intervention is strategically placed to unlock the path to change. But make no mistake — this approach isn’t for everyone. It takes a certain type of therapist, one who isn’t afraid to roll up their sleeves and dive headfirst into the complexities of family dynamics. It requires a keen eye for patterns, an intuitive understanding of systems, and a willingness to challenge conventional wisdom. More importantly, it takes a deep sense of empathy and compassion. Despite its directive nature, Haley’s model is rooted in collaboration and understanding. It’s about meeting clients where they are, acknowledging their struggles, and empowering them to take control of their own narratives. Using this therapeutic method isn’t just about following a set of techniques; it’s about embodying a mindset — a mindset that sees problems not as obstacles, but as opportunities for growth and transformation. It’s about embracing the uncommon, the unconventional, and the uncharted territory. In this model, two key techniques stand out: strategic interventions and paradoxical techniques, each serving as powerful tools in the therapist’s toolkit. So, what does it take to steer the ship in Haley’s Strategic Model? Effective implementation hinges on a blend of qualities and skills that go beyond the traditional therapist toolkit. Patience, creativity, and adaptability are essential, as is a keen understanding of family dynamics and systems theory. Being able to think on your feet and pivot strategies as needed is crucial, especially when faced with complex and ever-changing family dynamics. Balancing the directive nature of Haley’s approach with collaboration and empathy requires finesse. While strategic interventions are at the core of the model, it’s equally important to create a safe and supportive environment where clients feel heard and understood. I’ve found that taking the time to build rapport and establish trust lays the foundation for successful therapy. It’s about finding the delicate balance between guiding clients toward change and empowering them to take ownership of their journey.

Clinical Application of Haley’s Model

Strategic interventions are precisely targeted actions designed to disrupt dysfunctional patterns and facilitate change within the family system. I recall a client, let’s call her Sarah, who sought therapy for her strained relationship with her teenage daughter. Sarah felt overwhelmed by her daughter’s rebellious behavior and constant defiance. During our sessions, I introduced a strategic intervention by prescribing a specific communication exercise for Sarah and her daughter to complete together. This task aimed to improve their communication skills and foster a sense of understanding and connection. As they engaged in the exercise, Sarah and her daughter began to open up to each other in ways they hadn’t before, leading to a breakthrough in their relationship dynamics. Paradoxical techniques, on the other hand, are seemingly counterintuitive strategies used to evoke change by embracing resistance or amplifying symptoms. In another case, a couple, let’s call them Mark and Lisa, sought therapy for their constant arguing and power struggles. Despite their initial reluctance, I introduced a paradoxical technique by prescribing a “fight schedule” where they were only allowed to argue at certain times of the day. This approach initially seemed absurd to Mark and Lisa, but as they adhered to the schedule, they began to realize the futility of their constant arguing and started to communicate more effectively outside of their designated “fight times.” Of course, navigating the directive approach isn’t without its challenges. Resistance from clients can arise, whether it’s skepticism about the effectiveness of strategic interventions or discomfort with the idea of change. In these moments, patience and perseverance are key. I’ve learned to approach resistance with curiosity rather than confrontation, exploring the underlying fears or concerns that may be driving it. One striking example of overcoming resistance involved a young boy, let’s call him Max, who was brought to therapy due to behavioral issues and defiance at school. Max had a history of pushing back against authority figures and was initially resistant to the idea of therapy. He viewed it as just another attempt by adults to control him. Instead of adopting a traditional authoritarian approach, I decided to honor Max’s self-determination and autonomy. I engaged him in collaborative discussions, allowing him to voice his opinions and preferences. Together, we set goals for therapy that aligned with Max’s interests and values, empowering him to take an active role in his own treatment. As therapy progressed, I introduced strategic interventions tailored to Max’s unique needs and preferences. For example, instead of prescribing specific behaviors for Max to follow, I invited him to brainstorm alternative solutions and encouraged him to take ownership of his choices. Over time, I witnessed a remarkable shift in Max’s attitude towards therapy. His resistance softened, and he became more open to exploring new perspectives and strategies for managing his behavior. By honoring Max’s self-determination and empowering him to be an active participant in his therapy, we were able to achieve meaningful progress and foster a sense of agency and empowerment within him.

***

From its directive nature and emphasis on brief interventions to its strategic focus on systemic change, Haley’s model has provided me with a refreshing alternative to traditional therapy approaches. By harnessing the power of strategic interventions and paradoxical techniques, I have been able to navigate complex family dynamics with precision and creativity, fostering meaningful change and empowering my clients to lead more fulfilling lives. While a bit intimidating earlier on in my career, I have enjoyed, and my clients have benefitted from embracing the innovative and the unconventional and daring to explore new horizons in my practice. With this therapeutic method as my guide, and of course, my clients’ willingness to trust me and enter into new territory with me, new opportunities for growth and transformation have revealed themselves. Questions for Reflection and Discussion In what ways have you traveled unfamiliar roads as a therapist? What model of family therapy works best for you and why? What do you find most rewarding and challenging in doing family therapy?

Managing Post-Election Despair in Therapy: A Clinician’s Conundrum

Posted on by Psychotherapy.net Team

Managing Therapist Post-Election Despair in Session

I consider myself a liberal Democrat, living in a blue pocket of a red state. As a licensed MFT (Marriage and Family Therapist), I also identify as female, white, middle class, and heterosexual. Like many Americans, I stayed up all night to watch the presidential election result come in. My grief and devastation, along with my fears and anxieties about the future, made sleep elusive. After a mere two hours, it was time to get up, resume my role as therapist, and try to figure out how to work with clients on their concerns about this. I had spent weeks working with clients on election anxiety. But this day was different: it is unusual to be experiencing something so distressing that your clients may also be simultaneously experiencing.

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Typically, I manage my self-of-the-therapist by practicing self-care and working on it outside of a clinical setting. But, on this day, I was going to have to find a way to work with clients on concerns I had barely begun to process myself. Should I even go see clients when feeling such sadness and despair? What could I possibly say to alleviate anxieties they might have about deportation, eliminating the education system, reproductive rights, etc.? How would I respond to real concerns that they could lose their healthcare or Medicare under this new administration, thereby losing access to their therapy services? How could I reframe people’s concerns, when I could not think of anything positive about the future? I had rarely felt less like going into work.

9:00 AM. Couple therapy session, mid 30s, White heterosexual couple, liberal Democrats. Both expressed their anger, frustration, and powerlessness about the results. They described their frantic research to determine if they should move their family to another country. I began the session listening, validating, and empathizing. However, our discussion soon shifted to all the ways that the election discussion between them paralleled other dynamics we have been addressing in therapy.  

How did his high anxiety and spiraling thought process relate to her role of staying strong, presenting the calm facts to the children, and managing his anxiety? What messages do they want to give to their children about their election response? What would need to happen for them to take his idea of moving internationally and make that a reality? What is their biggest fear? We ended the session with the couple pondering how they might take their powerlessness and turn it into activism by volunteering to help turn the electorate around in two years.

10:00 AM. Couple therapy session, mid 40s, heterosexual Latino couple, she identifies as Democrat, he identifies as Republican. They began the session with their intense argument about the results. She described him as smug and being a “sore winner;” he described her as bitter and naïve for thinking the outcome would be anything else. Using Gottman’s ideas of the 4 horsemen of the apocalypse, we explored how their interactions with each other reflected these problematic patterns. How did these character attributions relate to their negative affect? How did they display defensiveness, contempt, and criticism? How was their interaction about the election different than their other interactions? How could we shift this discussion on value differences to a more respectful one? How do they manage their perceived differences in values?

11:00 AM. Individual therapy session, male, White, Jewish, mid 60s, presenting problem of anxiety. He entered therapy agitated and began to pace the floor. Due to the nice weather, I suggested that maybe we do something different today and take a walk in the park. He agreed. We walked and explored his anxiety: What would happen with Israel? What if he loses his Medicare and senior benefits? How would he cope with this level of uncertainty? What if his young daughter had an unwanted pregnancy? He ended the session with his own suggestion of avoiding any more election coverage and how taking a break from social media would probably help him the most right now.   

12:00 PM. Individual therapy session, African American female, early 50s, presenting problem of grief. She focused on her anger towards voters and her fear that the results were a result of racism and sexism. She expressed concern for her transgender son and what changes might affect him. What would her deceased mother have said to help ease her fears? What other losses do these results bring up for her? What personal experiences has she had with racism and sexism that this is evoking for her?  

1:00 PM. Individual therapy session, early 20s, White man, unsure party affiliation, presenting problem of depression. This was the only session of the day where the election was not discussed, and we had a session much like previous ones. It could have occurred on any other day.

2:00 PM. Couple therapy session, early 50s, White, Jewish, Republican. They began the session talking about how happy they were about the election results and their shared optimism for what the future holds. They described how they bonded over their relief that Israel policy would likely be beneficial. Using Solution Focused Therapy, I focused on these moments of exceptions: what was different about their shared experience last night? How could we expand upon what was working between them last night? When else have they been able to connect like that?

3:00 PM. Individual session, African American female, late 20s, Independent, presenting problem of co-parenting challenges with her ex-husband. She shared how disappointed she was in the results and was struggling to make sense of them. For the first time today, a client asked me directly, “What was your response to these results? Make it make sense for me!” What do I self-disclose and how much? What could I say that is genuine, brief, and helpful to our relationship? I paused and said, “Yes, I was very disappointed also. The way that I make sense of it is that I think that most people want similar basic things: to be financially stable/not stressed about money and want the best for the people they love.

“People in this election took different paths to what and who they think will give them and their family the best outcome on these measures. It is easy to look at this and see all the ways that the path they chose might not actually do that for them. We can’t control what happens from here, so my personal challenge is to figure out how to cope with it and manage my own fears around what could happen.” She was satisfied with my response, and the session moved on.

***


4:00 PM. I am exhausted. I complete my notes and head home. Today was a difficult day, but I am proud that I was able to self-disclose appropriately, take election talk that could be viewed as “venting” and weave it into therapeutic work, and find a way to work effectively with a topic that I am still processing. I am confident that this will not be the last time I face such a challenge.   

Questions for Thought and Discussion

In what ways do you resonate with the author?

How have you addressed election/political/emotionally laden issues like politics with clients?

To what extent would you have self-disclosed as did the author? Differently or at all?  

How Do You Maintain Compassion and Respect for Your Clients?

Posted on by Psychotherapy.net Team

Compassion is the basis of morality.
—Arthur Schopenhauer, The Basis of Morality  

Should you have to treat people who have assaulted or murdered others? What about working with clients who hold hateful beliefs or taboo fantasies or act in ways that directly contradict your moral standards? What if they’re blatantly sexist, racist, homophobic, or transphobic? How do you know what your role is when you feel disgusted or angry or upset by how a client lives their life?

All humans are unquestionably shaped by their values. No matter how much you try to embrace your open mind, some implicit biases are inescapable. Everyone has preconceived criteria for which behaviors feel acceptable or unacceptable.

Therapists often work with people the rest of society often belittles, misunderstands, and ostracizes. When a client sees only the bad in themselves, you reach in and find all the good. You hold a light in a place that can feel so dark.

But what if you don’t like the client? What if you not only disagree with their values but find their personality annoying or obnoxious? What if some or all of their mannerisms irritate or upset you? What if you find yourself feeling agitated during your work together?

Let’s slow down here. We invite you to spend a moment thinking about a value you hate. Hate is a heavy word; we chose it because it triggers strong emotions. For example, maybe you hate self-centeredness or people acting like they know everything. Now imagine you have been assigned to work with a client who holds or embodies these specific traits. They show no interest in changing, but they’re in a state of distress, they need help, and you have the expertise to help them.

Could you do the work? Could you genuinely support this client, find their goodness, and be on their team? In everything you do with them, could you commit to caring about their well-being?

Feelings of dislike exist on a large spectrum. Unfortunately, you may not be prepared to manage it when it happens. Negative countertransference arises when we experience conscious or unconscious negative reactions toward a client. Despite the word negative, these feelings are not good, bad, right, or wrong. But we must be mindful of how they can affect treatment. Acting out as a result of negative countertransference can include:

  • Rejecting your client
  • Offering unsolicited advice
  • Avoiding certain topics because they make you feel uncomfortable or unsafe
  • Openly disapproving of your client’s choices
  • Withdrawing from emotional connection
  • Being defensive or dismissive of your client’s feedback
  • Demonstrating inconsistent boundaries throughout treatment
  • Trying to overcompensate for your dislike by being overly agreeable or passive
  • Prematurely abandoning a client due to your own frustration or hostility

Negative countertransference sometimes happens when a client inadvertently knocks at unresolved parts of your own life. Maybe their anger reminds you of your father’s anger, and you have a contentious relationship with him. Maybe their passivity speaks to your own difficulty asserting yourself, and you resent having to be the strong communicator in the relationship. Perhaps you’re an unpaid intern and aren’t sure if you can make rent this month and your wealthy client is lamenting about their next real estate venture. Because you are a human and not a robot, it would make sense if you felt agitated by these circumstances.

There are no bad clients. But some clients may feel bad for you. In addition to unpacking personal reactions in therapy and supervision, here are some guidelines for managing your emotions and offering helpful and ethical care to your clients. We explore them in more depth in the subsequent sections.

Managing Your Emotions in Therapy

Leaning deeply into unconditional respect: Deliberately choosing to respect your clients for who they are, where they are, and what they bring to you

Deliberately searching for the good: Intentionally finding and holding on to your clients’ strengths and virtues

Embracing empathy as a nonnegotiable: Prioritizing a warm, empathic approach with your clients regardless of your similarities or differences

People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, “Soften the orange a bit on the right-hand corner.” I don’t try to control a sunset. I watch with awe as it unfolds. —Carl Rogers, A Way of Being 

Respecting clients means fully accepting them for who they are and where they came from. It entails honoring where they stand in their current journeys.

Respect moves into valuing autonomy. Clients have the right to live their own lives and make their own choices. You can have your opinion, but you do not live in your client’s body, reside in their home or community, or manage their relationships. Respect is the prerequisite for unconditional love. And love can be such a rich part of therapy, even if you don’t identify with loving your clients in the specific sense of that word. Respect is also a catalyst for helping you release rigid expectations about how a client should think or behave. This opens deep space for curiosity and connection.

Respecting clients does not mean condoning problematic behavior. We’re not advocating clients harming others or themselves. We absolutely want to see people make optimal choices in their lives.

However, respect means seeking to connect with the context and motive driving someone’s behavior. As a species, each person’s way of being is influenced by so many factors, including their culture, geography, upbringing, family influence, neurobiology, trauma, and genetics. It is especially important to remember this when working with clients you find challenging.

Respect can get muddled if you struggle with believing your clients owe you something. For example, therapists sometimes believe that clients owe them:

  • Complete honesty
  • A desire to do deep work
  • The belief that therapy is a worthwhile investment
  • Motivation for growth
  • Insight into their current needs or problems
  • A full understanding of therapeutic boundaries
  • A willingness to integrate feedback
  • Socially acceptable behavior
  • Measurable progress

Having some parameters for treatment is reasonable. You are hired to support your clients to achieve specific mental health treatment goals. This work should adhere to certain protocols; deviating too far from the basic structure of therapy can create problems. However, treatment in the real world does not exist in a predictable cut-and-paste formula. Clients come to therapy with unique personalities, unmet needs, and distinct behavioral patterns. Many arrive in a state of crisis when other resources have proven to be unreliable or unavailable. If they are mandated to therapy, they might resent having to meet with you altogether. In almost all cases, clients are juggling numerous stressors, and they want relief from their distress.

Respect helps therapists mitigate the risk of inappropriately generalizing or stereotyping clients. For example, let’s say you conduct an intake with someone who discloses a horrible experience they had with another therapist in the past. They express their anger toward the healthcare system and tell you they have doubts that you can help them. Some therapists would flag this client for being “too difficult,” or even, “treatment resistant.”

Respect means you give the client the benefit of the doubt. You listen to what they have to say about those past experiences. You care about their pain, and you emphasize that you care about that pain because you value their wellness.

As a therapist, respect means you hold the CHAIR (consistency, hope, attunement, impact, and repair) model as much as possible. You strive to convey a positively consistent presence for your clients. You find and hold on to hope for change in every way you can. You seek to attune to their emotions and needs. You look for opportunities to impact them and help them experience their world differently. And if and when conflict occurs, you take the lead in repairing that discourse.

Respect also means truly owning what lies in your locus of control. This, too, is covered by CHAIR. Ultimately, you can control the knowledge you obtain, the therapeutic actions you take, and the presence you exude. You control the boundaries you set, how you advocate on behalf of your clients, the referrals you provide, and the way you acknowledge making a mistake. Depending on your specific workplace setting, you may also control many logistics, including your fees, documentation protocol, after-hours contact, intake paperwork, and the arrangement of furniture in your office.

In reality, however, you can do everything you’re clinically supposed to do, and you still can’t control your client’s reactions. You aren’t in charge of deciding whether you have rapport. You can’t fix whether a client’s partner loves them or whether their boss perceives them to be incompetent. You can never control what a client does or does not do within the context of therapy itself.

The good news is that the more you can respect your clients, the more meaningful this work feels. This is because when you have a foundation of respect, you can lean more deeply into the caring part of this work.

We believe it’s impossible to care too much about a client. To care is to be invested in someone’s well-being. When you care, your heart and soul come into this work. It is one of the most beautiful traits you can bring to clients. As for us, we care about our clients immensely and wholeheartedly. We also have no qualms about telling them we care. We want them to know they are worthy of being cherished because they are. Holding this privilege gives our work such vitality.

Caring is not the same as enabling, overextending, or breaking therapeutic boundaries, however. Those specific actions often come from a place of caring, but they might speak more to unchecked countertransference when therapists lose professional objectivity and presence.

Caring lends a hand to respect, allowing you to detach your compassion and tenderness from expectations. Within this state of respect, you genuinely want what feels best to your clients without defaulting to an assumption that you know what’s best for them. You can value rapport and connection without ever demanding it. Most of all, you can and should care without conditions.

From this lens of respect, therapists can trust how the process of therapy organically unfolds. The freedom lies in the flexibility. It is the balance of accepting clients for exactly who they are while holding on to the hope that change can always happen.

Therapy, from this framework, bursts with possibilities. Embracing radical curiosity sets the stage for holding unconditional positive regard for your clients.

You won’t agree with or like every client you work with, but respect means trying to understand that most everyone is doing the best they can in a given situation. People want to secure their survival. Clients seek to avoid pain, even when that means hurting themselves or others.

How You Cultivate Deep Respect for Clients

Prioritize curiosity at its utmost capacity: What past circumstances led this client to make the choices they made? How, in every moment, are they seeking to minimize pain? Which behaviors have become solutions to temporarily cope with distress? Who hurt them and created those unhealed wounds in the first place? How are they trying to do the best they can with what they have?

Check in with yourself when you think a client owes you something: Be mindful of the tendency to assume your client inherently owes you something. If you find yourself struggling with this, ask yourself, Why do I find this so important? If you’re struggling to let go of this expectation, practice saying to yourself, How can I meet this client exactly where they are? 

Focus more on what you owe your clients: You owe consistency, hope, attunement, impact, and repair. You can’t control how your clients respond to what you offer. Leaning into your locus of control may help release the demands you feel toward clients or the treatment itself.

Pay attention to your countertransference: Countertransference is not good, bad, right, or wrong. It exists and can’t be avoided. But you can be mindful of how you orient treatment when it arises. Remember that your client, even if they remind you of someone or something you dislike, is a whole person with a distinct personality. Remind yourself often of this aspect of therapy.

Commit to neutralizing your values within therapy: In your personal life, you are entitled to orient yourself in ways that honor your values. But your job as a therapist is to show up and support your clients with respect, compassion, and professionalism.

Allow yourself to care tremendously: You are allowed to care about your clients. You are allowed to have feelings of protectiveness, adoration, warmth, delight, and closeness with the people you work with. Deep care, of course, should not justify consistently breaking therapeutic boundaries.

Have a plan if you simply cannot set your negative reactions aside: Sometimes this happens. You may not be able to work with certain clients because their content is too triggering to you. This does not make you a bad therapist. However, it’s in your client’s best ethical interests to refer them to a provider who can competently treat them. If this isn’t possible, focus on getting quality supervision, consultation, and/or personal therapy to address your issues.

Deliberately Searching for the Good in Clients

As therapists, we are called to search for the good, even when the good feels buried or insignificant compared with other traits we see in our clients.

It is also imperative to remember that no value is unanimous. As the philosopher Friedrich Nietzsche said in his book Beyond Good and Evil, “There is no such thing as moral phenomena, but only a moral interpretation of phenomena.” Humans have decided on some parameters of good and evil, but a choice that feels boundlessly immoral to one person may be entirely warranted to someone else.

If you assume a stance of moral superiority, you risk operating from a “me-versus-you” mindset. This mindset can create competition, and competition erodes the fabric of the relationship you’re trying to build. If you aren’t on the same team, you unknowingly risk becoming opponents. You may feel irritated, offended, and riled by your client. Your client may feel judged, condescended to, or unsupported. You both are apt to move into defense stances—and this defensiveness may prevent the crucial scaffolding of emotional intimacy from developing.

Your work as a therapist means signing up to care about people who think and act differently than you do. Biases are inevitable, but you must be able to examine inward and dismantle feelings of superiority. You are not a savior. You are not the all-knowing expert. You have simply been invited into a sliver of your client’s life. You owe it to them to witness their pain and understand the gravity of their life story.

Searching for the good means assuming a stance of giving clients the benefit of the doubt. This becomes especially important when working with clients who feel challenging. When you can pause and drop into a client’s pain, when you can land into the rawest feelings and deepest wounds, you soften. There are many ways for therapists to soften, but it happens when the therapist can truly land and sit with someone else’s emotions, no matter how big, heavy, or confusing they are.

Softening is the catalyst for opening. Opening emotion, opening trust, and opening connection. Everyone needs a soft place to land, and you have the opportunity to create this place for your clients. Not all will take you up on it. But many will.

Your expertise isn’t what makes therapy meaningful. Your courage to move beyond societal constraints and listen to another person is part of your impact. It’s a deliberate choice. But in our judgmental world, you are privileged to make this choice every session.

It is tempting to find out what is wrong with your clients. The reward of this work comes from uncovering what is wholly good.

Embracing Empathy as a Nonnegotiable

Empathy refers to the capacity for relating and sharing feelings with another person. It means being able to sense what someone might be experiencing and hold space for that experience. When someone feels empathic, they feel warm, and people tend to be drawn to the energy of warm people.

What person comes to mind when you think of the word warmth? It may or may not be a therapist, but it’s certainly someone who feels highly approachable and friendly.

Those who exude warmth demonstrate how much they care about people, and this care is felt through their words and actions. They tend to be optimistic without being overly positive. They remember details and they understand pain. They know how to hold emotions without overreacting or underreacting. You want to be around them because they feel safe, and that safety feels good.

Some people mistake empathic therapists for naive therapists. This, however, is rarely the case. Truly holding empathy without constraints means understanding and making space for all the mistrust, skepticism, and shame that people who walk into therapy carry.

Instead of condemning or withdrawing from those barriers, empathic therapists simply make space without any pressure or judgment. They respect the client’s defenses for their necessary function. Empathy is patient, and empathy doesn’t have an agenda.

We encourage therapists to self-assess their empathy by ranking themselves on a scale from 1 to 5 for each of the statements listed below:

1 = almost never

2 = rarely

3 = sometimes

4 = often

5 = almost always

1. I seek to understand a client’s pain deeply.
2. I consider the context of why someone might think or act in a certain way.
3. I can imagine what life feels like in my client’s shoes.
4. I am told I am a great listener.
5. I am told I am warm or kind.
6. I consider myself to be exceptionally compassionate.
7.When I think about my most difficult clients, I would rank myself as having an extraordinary amount of empathy for them.
8. I do not expect people to change on my behalf.
9. I am patient with relapses, regressions, and setbacks.
10. I believe I can genuinely sit with another person’s emotions well.

You want to strive for a score of 40 or more. If it’s lower than that, consider deliberately practicing more empathy in your work or asking for help if you are struggling with a particularly challenging client. Like any muscle, our capacity for empathy needs to be worked out regularly to build strength. But the stronger it is, the more you will connect with your clients and respect them for exactly who they are.

Guidelines for Softening and Finding the Good

Imagine your client’s younger self: Your client’s present self is a product of millions of interactions and experiences. The “challenging” clients are often the ones who have experienced extreme hardship earlier in their lives. When you can drop into noticing their younger state, you will likely find it easier to hold empathy. For instance, instead of solely seeing a client as an angry, self-righteous man, you can also see the part of him who is a fearful and helpless little boy.

Look past diagnoses and symptoms: Diagnoses are theories that summarize a given set of presenting behaviors. Even if you accept a diagnosis, everything is subject to scrutiny and change as humanity evolves. It is imperative to push past limiting thoughts such as believing that someone with panic disorder or someone with schizophrenia automatically behaves a certain way. Diagnosing can be a helpful starting point, a tool, but it is never an end point. It does not paint the full picture of who someone is, what they struggle with, and what they need to move forward.

Practice more mindfulness: Slow down in session. Be more deliberate with how you listen and understand your client. If it’s helpful, consider entering a potentially challenging session with the intention, I will look for what’s wonderful in this person. When this notion is your compass, you seek to find strength and goodness.

Remember, everyone is trying to survive: This stance can’t be emphasized enough. Recognizing this truth is not the same as condoning any specific behavior. Rather, it offers an understanding of why people develop certain patterns, no matter how destructive.

Prioritize empathy: Although empathy is often taught as a preliminary skill in graduate school, it’s not a pervasive trait among all therapists. If you struggle with experiencing or manifesting empathy, focus on what might be in the way and, over time, prioritize implementing more empathy in your work.

Reflecting on Domestic Violence: How One Therapist Made a Difference

Posted on by Psychotherapy.net Team

I loved my work in community mental health, but I hated office politics—the best way to avoid them was to spend as much time outside the building as possible. I accomplished this for over 10 years by providing in-home services.

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Making a Mental Health Impact in the Community

My very favorite program under the in-home umbrella was referred to as “Mother House.” It was a joint program between a Christian based church that wanted to make a difference in the community and the child & family team of the community mental health center (CMHC) where I worked.

The church owned and maintained a four plex, two-bedroom apartment building, the purpose of which was to provide safe shelter for women with children leaving domestic violence relationships. To qualify for the housing, they required the mother and a child to have a diagnosable mental illness and to be receiving treatment for that illness. They asked the CMHC and particularly the child/family services program to provide mental health treatment.

The CMHC where I worked was very traditional in their orientation to service programs; separating adult services from services for children. An adult parent needing mental health services was seen in the adult division, while the child was seen in children’s services. Never the two should meet. “It can’t be done” they said. “One therapist cannot work with both adult and child service programs at the same time.”

By that point in my career, I had worked in every type of mental health program you could imagine—inpatient, outpatient, day treatment, rehab, adult and child case management, and crisis intervention. By then I was the senior clinician in the agency. I was a perfect fit and said, “Watch how it can be done.”  

Making a Domestic Violence Shelter Work

Over the course of the project, I had anywhere from four mothers, and 8 to 11 children of all ages in treatment under one roof at any time. Mothers were occasionally asked to leave the program when they could not honor the rules. One parent and one child in treatment and no men were permitted to live in the building. I had the independence to do whatever I needed to do keep them functioning; grocery shopping, bill paying, doctor’s appointments, school meetings, and therapy.

I loved the constant challenge and the variety of individual, family, or group therapy. I loved the unplanned picnics, holidays, water balloon fights, family feuds, wars with the neighbors, and the continual challenges of keeping men from moving in on the women. I did not care for the police calls. When the police did come, they sent four squad cars and for hours they screwed up what I could have settled in 30 minutes. Things ran far more smoothly when I was in the building.

One of my first families was a mother with a severe mental illness who had lost or given up custody of her four children. The first to come home was her 13-year-old daughter, Wendy. She came home angry, defiant, and rebellious. She had a lot to be angry about and a right to be angry. She was not a bad child, just an angry one. I did not think therapy was successful for her, but she had her anger to keep her going.   

The mother had to leave the program after the fourth child came home because the apartment was not big enough. We lost touch clinically but through sources in the system, I continued to hear of what was happening in the mother’s life and those of her children.

Fast forward to 2021. The picture of a young woman came through my Facebook page, and although the last name was different than I remembered it when working with the mother and four children, I knew it was Wendy. That 13-year-old girl, now in her thirties, was married, a mother, and looking to connect. I responded to her, and she replied. While she had created that post over two years before, we decided to meet at a local restaurant—she, her mother, and me.

When I arrived, she greeted me as soon as I walked through the door, jumping up from the table to wrap me in a big warm hug before I could even sit down. She did not bring her mother because she wanted to let me know personally and privately that she was sorry for the horrible way she treated me while they were living in the apartment. “I was so angry.” I respond, “You were, but you had a lot to be angry about.”

Wendy shared her story, and what a story it was! She had experienced her share of struggles and challenges, several of which I had heard through my mental health grapevine. She was happily married to a good man and together they had a huge family of “his, mine, and ours.” She had turned out to be a wonderful mother, and a loving and caring daughter to her mother.

***

I subsequently reconnected with Wendy’s mother with whom I met occasionally for lunch. Surprisingly, she recalled that her time at Mother House with her four children, and when she later came home with them, was one of the best times of her life. She said, “We were all like family in that building and you were part of the Family!”

Questions for Reflection and Discussion

What are your impressions of the Mother House project?

What challenges might you experience working with this population?

How might you have worked differently with Wendy under similar circumstances?    

Using Four-Legged Friends as Metaphors in Therapy

Posted on by Psychotherapy.net Team

The Clinical Challenges of Adoption

As an adoptive parent and psychologist, I’ve long been drawn to all clinical aspects of the adoption process. I began this part of my journey with my wife, who, as an adoption social worker, referred home studies to me. A home study is basically a psychosocial evaluation of the prospective adoptive parents with recommendations about their “readiness” or “fitness” to adopt. Through those many intimate visits with clients, who, for a variety of reasons ranging from infertility to choice, I learned of the frustrations, despair, and hope that accompanied the decision to raise another person’s child.

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The home studies laid the foundation of the post-adoption placements with those new parents who were fortunate enough to meet the often-stringent requirements for domestic adoption, and even more demanding requirements that accompanied adopting a child from another country. While those visits were often accompanied by the joys of new parenthood, they also came with a myriad of unanswered and unanswerable questions about what lay beyond the luster of that new status. From those visits, I learned of the many challenges that new parents faced, peppered in with the often-irrepressible joy they experienced.

From the child, especially when I was privileged to work with them in therapy, I witnessed firsthand the “primal wound” that Verrier described as a core dynamic in adoption. For as much as is gained by an adopted child, so too have they experienced loss, even when that loss was necessitated by birthparent neglect, abuse, and/or abandonment. I even had the opportunity to work with those birth parents before and after placement, where the experiences of grief and loss were clearly on display.

The Therapeutic Value of a Puppy

I remember 8-year-old Amber and her 4-year-old brother Asher, siblings who had spent most of their childhoods in various foster placements following removal from their biological parents due to severe neglect. My work with them began right around the time that their out-of-state adoption was being finalized, so I knew that my time with them would be short. Since they were, in every sense of the word, fellow travelers, I met with them together in play therapy, themes which revolved around family life.

I was able to loosely track the chronology of changes they had experienced in their short lives through their dollhouse and sandtray play. What stood out the most was the issue of loss, impermanence, and change, issues that were always at the forefront of their lived experiences. One of our sessions revolved around planting a small tree in front of the office. Metaphoric and literal conversations about growth, hope, and vitality were plentiful. Gardening and nature-based metaphors are among my favorites in therapy, made even more so when I have been able to literally get my hands dirty with clients.

And then the day of our last session came. Amber and Asher would be traveling the next day for what would hopefully be their permanent placement. I was very anxious. What could I possibly offer them in those last minutes of our short-lived relationship? What could I say that could even be mildly reassuring?

As I drove up to the office (and I promise that I am not making this up), there was a puppy sitting on the doorstep—very young, very lost, and thankfully, very affectionate. I knew at once what shape the final therapy session would take as I quickly scooped up this little lost creature and brought it inside.

The children came only moments after I got settled, so I thought it would be a good idea to include them in the welcoming of this puppy—water, a soft towel to lay on, and some of the resident cat’s kibble. We had to manage with what we had on hand, but no one, especially the puppy, complained. Asher and Amber fell instantly for the dog, taking turns gently holding it, assuring it that it was safe and loved, and that it would be cared for. We talked about fear, hope, loss, adoption, and forever homes that day, and we never used any of these words. This furry, four-legged metaphor was all we needed to help launch these children on the next leg of their own journey.

***

Take whatever lessons you’d like or need from this story into your own clinical work, whether it be with children, adults, or any of your clients that have been lost and seek welcomed rest stops along their own journeys.

Questions for Thought and Discussion

What have you found to be some of the greatest challenges in working with adopted clients?

What are your impressions of the author’s approach to this case?

How have you used metaphors in therapy?