Author: Psychotherapy.net Team

Trusting Her Voices: Trusting My Own

Posted on by Psychotherapy.net Team

There was something different about this seven-year-old who at such a tender age had already lost her father. And if that adversity was not enough, Christine was struggling to fit in and keep up. Yet, there was something about this lost and lonely girl, some palpable sense I had of her resilience. After a psychoeducational evaluation, carefully chosen recommendations, and consultation with her mother, it would be 15 years before I next saw this girl. She was now a woman who was, perhaps not unsurprisingly, still struggling to fit in and keep up, this time with a far-less accepting college crowd and the rigors of an academic curriculum that was really of little interest to her.

I was immediately struck by how she was at the same time both young for her age and an old soul- isolated, enigmatic. In her “backpack of wonders,” as I silently called it, she had a number of amulets drawn from characters of popular culture; wore T-shirts advertising her fascination with or perhaps identification with popular teen icons, and soon revealed to me that she had learned to populate the empty rooms of her life with what she called her ‘All-Girls Group.’ “Voices in her head, damn!”, I thought to myself. Could I have so badly wanted to see that struggling child in the most benign light all those years ago, denying the possibility of early onset schizophrenia? A rising sense of panic muddled my thoughts. Critical, self-questioning voices.

What to do? Query her mother more deeply? Do a thorough psychological evaluation? Refer her immediately to a psychiatrist? Consider the possibility of hospitalization? These were the voices in my head, and while I did not ignore them, I addressed each of them, ruled out immediate danger, and opened myself to Christine’s inner world. In the process, I got to know Laura, a “real” young woman who chronicled her lifelong battle with cystic fibrosis in the book Breathing for a Living. I met Lisa, the take-no-prisoners character from Susanna Kaysen's Girl, Interrupted. And after being granted membership as the “only boy” in Christine’s exclusive private club, went to work with her, following her lead, suspending my voices, getting to know hers, and following her lead in trying to plot a therapeutic path for us and for her.

That phase of therapy ended abruptly following a surgical procedure for Christine and loss of the family dog, which I imagine were very destabilizing for her. I later found out that she had joined the Army. “Of all places to go… They will eat her alive.” When she arrived several years later to reconnect and reinitiate our work, I found out that Christine’s group had abandoned her to the military thinking it the wrong decision. But with some creative re-framing, she accepted the notion that her support team thought the Army would be an important test for her and that she had to go it alone.

And, as to be expected, Christine experienced considerable adversity during her short stay with Uncle Sam-a belligerent drill instructor, unaccepting platoon-mates, brutal physical rigors and loneliness Broken and alone, Christine hobbled back into her life and somehow her “girls” found her, flocked to her side, lifted her on their backs and marched her back to school…and life. Along the way, their numbers increased to include a few new select members, this time a few male figures- all strong, all supportive, all with stories of survival and resilience, just what she needed.

Christine finished her college degree, tried a few different jobs in the computer field, and as of this writing, was still searching for the very same things she was looking for when I first met her as a child. I see her whenever she calls, trust that she is never alone, and long since separated myself out from the voices in my head that did not trust the voices in hers. I don’t believe that Christine ever dis-trusted her voices – that was me, although I never showed it to her. I think I was only able to accept hers when I was finally able to subdue my own.
 

The One Thing a Therapist Should Never Say to a Client

Posted on by Psychotherapy.net Team

As a graduate student I was given the old stand-by assignment: seek out an accomplished therapist and interview him or her. Since my overwhelming desire in life was to become a private practice therapist myself, I didn't envision this as just an assignment, but rather an exciting adventure. I was going to put my whole heart and soul into it.

Since I wanted to pick a person of note, I spoke to a cadre of folks in the field, including my esteemed professors, and decided on a therapist I’ll call Mindy. She seemed to be a real therapist's therapist. A large private practice? You bet. A superb reputation? Affirmative. A mental health conference presenter? Check. She even ran workshops around the globe in remote countries I had never heard of. This was going to be great.

Mindy’s administrative assistant was kind enough to set me up with the necessary appointment and it was off to the races. Her office was in the high-rent district in a city about 130 miles away from my hometown in St. Louis, but I knew the long drive was well worth it. As the elevator to her office sped from floor to floor, I glanced in the mirror to check my hair a couple times. Okay, maybe it was more like a dozen or more times, but keep in mind I wanted to come off as a serious future professional. Maybe we would be working together in the same practice one day. Yes indeed, I had high hopes.

Mindy was dressed in a muumuu that made her look like she might be playing a part opposite Elvis the classic Blue Hawaii.

I had imagined I might see a couch or a rosewood desk with spit-shined brass handles, but that was hardly the case. She motioned for me to have a seat while she sat down in an antique rocking chair.
We were separated by an unusually large sheet of paper like one might use in a lecture for a flip chart. But the paper was on the floor. Hmm, what was that about?

Before I could get my first question in which was something like "Did you know you wanted to become a therapist as a child?", she began firing questions at me.

I was way too timid at the time to ask this exalted expert what in the world was going on here, so I answered perhaps five or six questions. As I spoke, she would lean forward in her rocker and scribble something on the massive sheet of paper on the floor using a King Kong- sized marker.

Wait a moment. We weren't here to therapize me, or were we?

After just minutes, I tried to talk and she said, "Howard stop. I know exactly what your problem is."
Wait, I didn't know we were talking about my problems.

"I know you came here to interview me for your graduate class, but we need to deal with some much more important issues. You are just like me. You have severe anger problems and you are a quitter. Yes, a quitter. I am sorry to say you will never finish your master's degree. I'm going to set you up for a few sessions of individual as well as group psychotherapy. You still won't ever get your master's degree, but I can help you in other ways."

Had this merely been a bad dream we could have analyzed it, but it wasn't. I hadn't recalled saying anything even remotely related to anger and certainly nothing about giving up on graduate school. For gosh sakes, it was the number one thing in my life at the time.

Now fast forward to the present. I did an internet search and low and behold I discovered that Mindy never finished her degree. But wait. It gets even more interesting. Since she was attending a doctorate in psychology program where the master's was not conferred until you completed the doctorate, to this day she still possesses just a bachelor's degree in psychology. She was only allowed to practice back in the day when I saw here because licensing had not yet been enacted in our state.

So, what's the take home message? Well, I believe the behaviorist, hypnosis expert, and assertiveness training pioneer Andrew Salter (a famous therapist himself with just a bachelor's degree) nailed it when he gave the best definition I have ever heard of reaction formation: "You think you are looking out a window, but you are really looking in a mirror."

The worst thing a therapist can do? Well it is as simple as looking in a mirror while convincing yourself you are gazing out the window and making a pernicious statement about why the person sitting in front of the desk, or rocker will never be able to do something.

Oh, and by the way, Mindy, if you happen to be reading this blog and decide to email me to express your anger or discontent, just for the record, it's Dr. Rosenthal now.
 

The Modular View of the Mind

Posted on by Psychotherapy.net Team

My earlier blog post suggested that the human organism contains multiple selves in the same way that your cell phone contains multiple apps. I now want to link that metaphor to an actual therapeutic model known as Internal Family Systems that I have found useful in my clinical practice and then discuss its application with one of my clients.

IFS is predicated on a modular theory of the human mind. The human mind consists of modules (apps on a cell phone), discrete mental models that interact with each other to produce our experience of aliveness. You might consider the idea that we have mental models of parenting, careerism, friendship, family, as well as more philosophical mental models such as the meaning of life or our role and purpose in the universe. These mental models operate within discrete modules that are activated depending on the circumstance the individual encounters. One’s behavior (the manifesting of the “self”) hinges on the module that takes precedence within the human mind at any moment. The full range of our inner life reflects the complex interplay of these modules which is neither haphazard nor random. They function interactively and synergistically as a system. That’s why the IFS model uses systems theory—how parts interact to create the whole—to underpin the way psychotherapy is done. Human distress is often productively seen as the breakdown of a system—namely, the breakdown in the way modules within the psyche interact.

IFS envisions a tripartite system. That system consists of the Manager, the Exiles, and the Firefighter. The Manager module is the most familiar, for it is that version of the self that tries to exert control. When we say to ourselves, hey, let’s keep it together, we are trying to activate the managerial self. When we present our best selves to the public, we are giving priority to the managerial self (the managerial self is a kind of public-relations self). The Manager is the module in the psyche that promotes order and combats chaos and disorder. The Manager module vigilantly stands guard against the Exile module which contains the unwanted aspects of ourselves (the pain, the shame, the trauma that accumulates over the course of a life). When the managerial module fails to quell the upsurge of the exiles sequestered in the exile module, the “self” behaves in maladaptive ways. We often call that falling apart, or having a meltdown, or losing our cool. Enter the Firefighter module. This module is allied with the Manager module since it, too, exists to keep the exiles sequestered within the human psyche. The firefighters are aroused into action when the managerial self finds itself unable to quell the upsurge of the exiles. You could look upon a person who resorts to alcohol or drugs to numb the pain of trauma as one who has unleashed the firefighters upon the escaping exiles. The managerial self would prefer to shepherd the exiles (the pain of the trauma) back into the recesses of consciousness; but when it cannot do so, the firefighters spring into action, which is experienced as the irresistible urge to get high. Firefighters aren’t concerned with what’s optimal. Firefighters douse the fire.

It is the interplay of these three modules that inform an IFS practitioner. But I want to be clear that the IFS tripartite system isn’t the sum total of the modular view of the mind. Quite the contrary. It is the specific therapeutic application of it. The modular view of the mind is better understood as a philosophical model of the human organism, where the notion of the unitary “Self” is seen as an illusion. The upshot is that suffering arises from a disharmony among the various modules within the psyche, a kind of fragmentation of the mind. Mental and emotional health—equanimity, inner peace, self-command—reflects psychic integration. The healthy person is an integrated person (a person with integrity).

The therapeutic project of achieving integration is collaborative, non-pathologizing, and above all, ongoing. It was quite useful for me in working with Phil, a client struggling with alcohol abuse, who came to me because his estranged wife gave him an ultimatum—therapy or divorce. He said his wife thinks he needs “anger management lessons.” He admitted sometimes going “semi-postal” –a characterization that alarmed me but that he shrugged off as flippant—and wanted to “fix that, you know.” I didn’t “know,” which is why the first session explored Phil’s motivation with the hope that the Managerial-self could fully explain what “fix[ing] that” would look like. The second and third sessions brought to light the subtleties in his Managerial module. What sorts of perceived chaos was Phil seeking to avert? What kind of inner monologue preceded and followed an outburst? Why is his managerial self so ineffectual? The fourth session attempted an exploration of Phil’s exiles, but he disavowed having any (“I’ve never been abused.” “Seen bad things but not like I’ve been to war or anything like that.”). The fourth session; however, was far from a bust. He offhandedly admitted that whiskey with a dab of Coke help him “cool out.” He said he only goes “semi-postal” when he hasn’t had a drink in the last twenty-four hours.

“Ah, there’s his Firefighter module in action,” I thought.

Once we got beyond the Managerial module, things got interesting. Anger-management therapy transmogrified into substance-abuse counseling, which ultimately turned into something quite dramatic. That story, too involved for this blog, will be presented soon as a full-length article.

Stay tuned!

In Praise of the Life of a Psychotherapist

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“Clients often ask me how I can stand listening to them drone, whine or complain.” Just yesterday someone said, “I’ll bet you need a stiff drink after listening to this stuff all day”. I can safely say after nearly 25 years in practice that I have never had this day that they seem to imagine—a long, tedious day of listening to self-pity and self-absorption. Particularly lately, what I feel is mostly gratitude. Somehow, I get to do this: come to work to listen to the stories of the intimate lives of others, to know and to love the hard-fought struggles of their lives, and to share and assist in their journeys toward healing, growth, and transformation. And what I have been thinking about a lot lately is how those journeys have in turn shaped my own journey in myriad positive ways. I know I am far from alone in my experience, and that my grateful thoughts could not begin to be comprehensive, but I think it is useful for us as psychotherapists in what is often a beleaguered world to remind ourselves of the many personal and psychological benefits of our chosen path, such as emotional maturity, unlimited opportunity for continuing education, learning about love, practicing mindfulness and self-awareness, accepting failure, and fostering resilience.

Emotional Maturity

For me, much of this feeling of gratitude is a happy by-product of maturity. When I was younger, I was so afraid of not being enough, or of doing something wrong, or of not being liked, that it was harder for me to stay focused on the great gift of being able to do this kind of work. As I have aged and grown in confidence, the energy I used to expend fussing about my own probable inadequacy no longer draws as much from my other resources. I am able much more easily to make myself fully available to another without such a weighty anchor of self-doubt and self-consciousness. Another reason for gratitude: I managed to find myself in one of the few fields of work where a few gray hairs and wrinkles, and the maturity that hopefully comes with them, is a benefit.

In turn, maturity seems also to be a by-product of the work. I have often thought that one of the reasons therapists are so often drawn to various forms of meditation is that mindfulness is an intrinsic aspect of the work of psychotherapy. Years of practice in itself create a habit of focused attention that is a growth-promoting emotional self-discipline. There is self-surrender in entering a session that I have come to welcome wholeheartedly. It is not as though I have ever completely and perfectly stayed attuned and present for every moment, but like mindfulness meditation, I and all of us who do this wander in our minds, draw ourselves back, wonder about the wandering—and return. Unless the stress of my own personal day is truly overwhelming, “listening to others helps me to move into a mindful space and draws me out of myself”. The constant practice of moving into this mode of being no matter how tired or irritated or stressed or sad I may be is a daily workout that leaves me stronger, more flexible, and more resilient in all aspects of my life.

Unlimited Continuing Education

Learning as a psychotherapist is a lifelong project. In seeking ways to help clients, I read and consult and attend workshops and, in the process, learn about myself and understand myself and them better. Often when a client is exploring an issue or attempting to create change it challenges me—because I want to feel my own integrity with them—to push to grow equally. I cannot suggest assertiveness without finding it within myself, ask clients to trust their own authority without trusting mine, or ask clients to challenge their own fears and avoidances without challenging my own. So many of my clients are or are learning to be brave, loving, compassionate, and skilled, among many other gifts, and I am grateful for the opportunity to share in and learn from their growth.

To give a recent example, I have been working with a woman who has been trying to cope with a serious illness, recent job loss, and a disintegrating marriage to a husband who is psychologically unravelling and will likely end up in prison, all while trying to keep life stable and sane for two small children. In the last few weeks, her home went into foreclosure and she had to get a restraining order against her husband. She came into a recent session not surprisingly sad and overwhelmed, but in the context of our conversation mentioned that she had gotten a journal so she could keep a daily record of all the things she is grateful for. She is worried with all that is happening in her life that her perception will become distorted if she doesn’t make an active effort to recall what is good and positive. Having never faced the kind of comprehensive disaster she is now confronting, I truly don’t know how well I would marshal my psychological and spiritual resources to meet it, but I know her example has added to whatever resources I will bring to bear to cope with whatever inevitable hurts arrive in my life. I hope I will be able to remember that in the face of enormous losses and challenges, it was clear to her that she needed to focus on successes, however small, on moments of beauty, and gestures of kindness and generosity. I am grateful that in a context where I am supposed to be the guide, I am also so often guided.

Love

As therapists, we are rightfully cautious about how we think about love in our work, but “I have come to feel that love is inevitably a part of any authentic caring relationship”, and therefore an inevitable part of most therapy. Love of course is a big word and can be used to describe a lot of different relationships, from one we have with chocolate to one we have with a lifetime companion. I mean the non-possessive, boundaried love that is often created within the unique intimacy of the therapy relationship.

Recently I participated in an exercise in meditation class that I believe is relatively common but was completely new and unexpected to me. We class members were led, eyes closed, to sit in two rows of chairs facing each other. When we opened our eyes, we were asked to look into the eyes of the person across from us with all the love and understanding in our hearts and to imagine that this face across from us was the face of the divine here on earth. I gazed into the beautiful brown eyes of the middle-aged man across from me, a total stranger recently arrived in the US from India, and saw myself reflected in them. Both of us teared up as we grasped each other’s sweaty hands. We were totally unknown to each other, but for those moments, intensely close. It was far from a perfectly transcendent moment—it is uncomfortable to stare at length into the eyes of a stranger, and I found myself worrying about the unattractiveness of my blotchy, tearstained face, or if he wanted me to let go of the hand I was inexplicably clutching like a lifeline—but I was powerfully moved, and shocked by my sense of recognition and awe. We were asked to close our eyes again and shifted our seats before opening our eyes to another, a different stranger, to whom we were to open our hearts in love and share that deep, long and reciprocal gaze. The message was a yogic one, about the divine that dwells in all of us if we choose to see it, but it also made me think about love in therapy, and how this exercise resembles in many ways what we do in our offices day and in and day out.

We ask another person to open themselves up, to sustain our gaze, and to trust that we will see them as gently and with as much acceptance as we can. When we add compassion, empathy, understanding, patience, respect—all the things we strive for in our stance as professionals—we also, at some level, will feel love. And I find that this makes me, on good days, look at the world and myself more gently, with more forgiveness. This is a lesson I want to learn, again and again—more so now, in a world that seems increasingly focused on hate and division.

Speaking about a therapist’s experience of love creates a lot of anxiety—I am a little anxious trying to write about it, knowing as I do the chorus of objections and concerns that arise about boundary violations or crossings if the love we experience is not managed safely or professionally. I have seen from the front row how love in a therapy relationship can be abused—I have clients who have had sex with prior therapists, been subject to other sorts of boundary crossings (too much information about the therapist’s personal life, coffee at Starbucks, stock tips, or non-standard payment arrangements to name a few), or have been bullied into behavioral changes that support the therapist’s ego and self-esteem rather than the client’s goals—and I am well aware the effects of even the smallest of these boundary violations are devastating to clients. Because love is such a charged and complicated word, I do not use it with clients, but not saying it does not mean I don’t feel it or have the need to make sense of the experience of it clinically, personally, and spiritually. And I believe that the non-possessive, boundaried intimacy of therapy relationships has taught me much about love, and I am a better human for practicing loving others in this way.

Mindfulness and Self-Awareness

For most of us, the most comfortable and familiar way to think about love or any other emotional experience centered on the dynamic relationship between therapist and client is as a transference/countertransference phenomenon. That involves a certain exercise in mindfulness, a capacity to be open and aware of one’s own experience and to think about and feel how that experience is a communication from and about the client—often a disowned or unmet need—and consider how to use that information in a healing, compassionate way. It is also an exercise in self-awareness, because our slates are not blank, and we have our own unruly psyches to manage. The experience of love (or hate, or any other emotion), however it is manifested, becomes an opportunity to feel without acting, to explore different narrative possibilities and feel them out for their truth and consistency or self-delusion and wishfulness, just to name a few possibilities. There is no real way to be fully engaged without feeling, but as therapists we learn to watch the feeling as we feel it. This capacity for mindful self-awareness is perhaps the Rosetta Stone of positive emotional functioning, the skill we try to teach our clients in every session, and the skill that determines our success in helping them heal. It has also, of course, made me happier and more effective in all my relationships.

Accepting Failure and Protecting Resilience

It is unpleasant to fail, and I don’t enjoy it, but my work as a therapist has given me a ton of practice, and I have learned to accept failures more gracefully, with less unproductive self-criticism and more and more balanced self-examination. I have gotten it wrong more times and in more ways than I can possibly count. Every day, every session. Today, eager to make my own point, I dragged a client who was really hurting onto a small tangent because of a thought that was interesting to me, but not at all his direction or focus. I stumbled back to really listening to him, but the diversion created a small but avoidable need for repair and re-attunement. And that was a good session, on a good day! “But constant practice helps me to keep my balance, not get overly focused on mistakes, and move on to attend to things that are really important.”

Often as therapists we focus on issues of burnout or secondary trauma, and certainly these issues are real, especially in settings where therapists have limited control or access to support. I am inclined to believe that much of the possible psychic damage is not about the actual work we do, but the environment we do it in. If we see too many patients, fail to maintain reasonable boundaries, do not have adequate opportunities for supervision or consultation, try to meet unreasonable expectations or fail to care for ourselves psychologically outside of sessions, we will suffer in our work—both in our ability to do it well and in our own psyches. Without these boundaries, we cannot foster and protect our own resilience. But in the presence of control and support, we sometimes forget to emphasize in much of our dialogue about life as a psychotherapist how very fortunate we are as therapists to be able to engage in work that is entirely about finding meaning and healing through relationship.

In Conclusion

I also feel a little bit of guilt about my good fortune. I am spoiled. People are hurt at all levels of society, but I am not in the trenches, and I deal less than many with the horribly complicating factors of socioeconomic stress. And those other huge structural issues—such as racism, sexism, and homophobia—are somewhat blunted for my largely educated and economically stable clients. I have a group practice with colleagues I love and respect, and whose intellectual and clinical growth has interwoven with mine for over almost 20 years. “It would be churlish not to be grateful for such fertile soil in which to grow.”

We are all aware of the downsides of our vocation: the pay is not great; although we have a lot of freedom, those of us in private practice do not have the practical benefits many professionals take for granted, such as sick or vacation days, or health insurance that is less than astronomical; we tend to be made fun of in the popular culture; we have limited job security; the importance of our work is undervalued, misunderstood, or misrepresented by many; if you do the work well, you will be no stranger to self-doubt and uncertainty; you have to metabolize a lot of ugly stuff; and new acquaintances tend to become uneasy when you tell them what you do, just to name a few. But the world is not rich with opportunities to make a living in ways that feel intellectually and morally coherent and also promote emotional health and growth. It is a life of service in many respects, but also a life of service to the self, an opportunity to try to do good and to try to be good. That is a lot to be grateful for. 

Finding Playfulness in the Seriousness

Posted on by Psychotherapy.net Team

I have recently seen videos of social experiments that encouraged adults to find time to play. In one such video, a hopscotch board was drawn on a city street and over the course of the next ten hours of the 1,058 people who walked by, only 129 stopped, if but momentarily, to engage in the playful distraction.

In another video, a man and his friends set up a large ball pit in an urban space to see if adults would take a moment for themselves. He asked people walking by if they were too busy to have fun. Immediate responses focused on the need to return to work – all work, no play. However, several people decided to seize the moment to dive in. A man wearing a perfectly pressed suit threw his briefcase into the pit moments before jumping in. The joy that exuded from those playful moments was priceless.

I am a play therapist, so am fortunate to play for a living. Through play therapy, children can externalize, process, master their struggles and tame inner demons through a variety of expressive mediums. Sessions transform from battles to caring for babies, playing sports, building worlds in the sand, making and eating full course meals, watching puppet shows, drawing, painting, blowing bubbles, and much more. With play, the possibilities are only limited by one’s imagination. It is truly a privilege to see the healing power of play first hand and to make time to experience play myself.

I would guess a vast majority of adults believe that play is primarily reserved for children. Life is stressful and there are a plethora of serious tasks and obligations that we must save our energy for instead of goofing off and spending time playing. Many of us are inundated with a full caseload, meetings, case management, consultation groups or supervision, continuing education, family obligations, and other side projects. We simply do not have time to stop and play hopscotch or jump in the ball pit. It does not mean that we do not want to; there is just not enough time in the day.

Being a psychotherapist is an immensely rewarding, and at times challenging and emotionally draining job. Being a container for so many hurting humans takes its toll on mind and body. We need self-care more than we allow for ourselves. We need to remember that we cannot give so much to so many and very little to ourselves. We must be gentle with ourselves and find time to rest, relax, and replenish.

When was the last time you allowed yourself to be completely immersed in your imagination and fully experience that moment? How can you make more time for playful self-care? When an obligation needs to be removed from our schedules, why is self-care is often the first to go? Because we convince ourselves that we cannot possibly sacrifice anything else on our schedule. As the Zen proverb states, “You should sit in meditation for twenty minutes every day – unless you’re too busy. Then you should sit for an hour.” This gentle self-care reminder is applicable to time spent playing as well. Foster more moments of joy, laughter, happiness and the liberation play can bring in your lives. The next time we contemplate if we have time in our day to playfully tend to our minds and bodies because we are too jam-packed, we must remind ourselves that these are the moments that we need these experiences the most.
 

Why the Therapist

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My family, like any other, has its ups and downs, especially now as we are free-falling somewhere in the middle of Monica McGoldrick’s stage of ‘launching children and moving on’. I’m not exactly sure if our children just aren't on the same launch schedule as my wife and I, or if we have simply failed to supply them with sufficient psychological propellant for their tanks.

In any event, a recent episode in our family’s unfolding narrative culminated with my wife, a social worker by training, texting our seed-sowing, soon-to-be 20-year-old ‘emerging-adult’ daughter a poignant, incisive and heartfelt text. Fearful that her venturing forth would leave family and friends behind, it read simply, “it’s much easier to ignore people and cut them off, than working at repairing relationships.”

Brilliant, I thought. My wife was quite proud, and I of her, for providing our child with yet another foundation stone in the launch pad from which she could eventually free herself from the massive gravitational pull of planet parent (not sure of why the intergalactic metaphors here, but it probably has something to do with encounters with alien life forms- our young-adult children).

We both eagerly awaited our daughter’s response, certain that it would be replete with affection and gratitude for sound advice. What my wife got back was, “Is that a dad quote?!” REALLY, is that a dad quote?!?! Was this a not-so-cryptic attempt to marginalize and diminish my wife? A backhanded insult at me for offering yet another of my unsolicited and perhaps patronizing pieces of parenting?

Mind you, I am a PhD clinical psychologist, with ABPP certification in child and adolescent psychology and a registered play therapist-supervisor. I have street cred with kids, teens and families. People pay me cash money, and those whose lives I have touched seem grateful, at least many of them do.

Which finally brings us around to the mixed metaphor title of this blog post. Parenting is rocky on any planet. And to paraphrase the great Sylvester Stallone from his movie Rocky Balboa, “life ain’t all sunshine and rainbows…it’s a mean and nasty place, and will drop you to your knees.”

So, getting back to the idea of therapists offering advice to their not-so-receptive children. The proverb says, that ‘the cobbler’s children always need new shoes,’ a popular example of the notion of vocational irony. A deep inspection finds this saying has several implications. If the cobbler was really good at his job, his kids wouldn’t need to go barefoot. Or perhaps it means that the cobbler is so busy cobbling for others, that his own children go without. But did anyone ever stop to think that the cobbler’s kids just don’t want to wear their father’s cobbled creations? Maybe the kicks (teen slang for shoes, I am told) are cooler in the cobblery down the street. Or maybe they would rather make their own shoes!

And maybe psychotherapists everywhere, especially those that dare to work with teens and their families, can take a lesson from this humble cobbler of young psyches. Keep your cobbling separate from your parenting, or you might end up with holes in the soles of your relationships. 

On Holding Your Tongue

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We therapists have all been guilty of this one: holding forth when we should really be letting our client have the floor. I recall many cringe-worthy moments as a nervous new therapist, going as far as talking to my clients about the theory behind what they were experiencing, convinced they would be as fascinated by this as I was. Fortunately, I was empathic enough to pick up on their blank stares and restrain myself.

I am currently in the process of doing a qualitative study on the common factors in working with dreams. This is relevant because of what I’m finding in the data around dream interpretation. In short, don’t do it! What modern dreamwork methods suggest is that even if you have a jaw-droppingly brilliant sense of what your client’s dream is about… don't, especially if you have something amazing to say, the best thing to do is keep it to yourself!

Why hold back? There are a few good reasons. First, because we may not actually be right. Dreams are multi-faceted and only the dreamer really knows what they are about. My wonderful interpretation may fit the images tidily and still not have any relationship to the client’s dream. Also, I’ve found that if my take on the dream is not a fit, my less assertive clients will do their best to see my point of view and contort their dream into the Procrustean bed I’ve made for them.

Another reason to hold back my brilliance? This is the main reason: because if I don’t, I rob the client of their own thrill of discovery, the excitement that comes when they unlock the meaning of the dream for themselves. Not only will the client’s interpretation be better-timed because the realization comes when they are clearly ready to have it, but also, the insight or experiential shifts made in the process will stick because they are the dreamer’s own and there is strong emotion attached to their discovery.

Despite what I just wrote, on occasion, if I feel I really must offer my pearls of wisdom about a dream, I have learned to do so tentatively, and back off immediately if I get that telltale blank stare. I may be right, and the timing may be wrong. Or I may be way off base. Either way, the best interpretation is the one that comes from the client. After all, I don’t want them to walk away from therapy thinking, “Wow my therapist is so smart, how can I manage without her?” Rather better is when they walk away with a sense of mastery and confidence about their own ability to read into their dreams and their life.

That said, good dreamwork like good therapy, should be highly collaborative. We all tend to have huge blind spots around the images that come in our dreams; so playful and respectful curiosity can help guide the dreamer to find their way through the complexity of their dream world. You can also use a device from the dream interview method that suggests you play really dumb and ask the dreamer to explain their dream images as if you are from another planet. The words they use for me-from-Mars often give a sense of how the image may be a metaphor for something in their life-and what they say is never predictable. If they dream about a dog and I say, “I’m from Mars, what’s a dog?” the answers could range wildly: from a dangerous beast with big teeth to my best and most loyal friend.

In the common factors research into dreamwork, of the 14 dreamwork methods I analysed, only psychoanalysis still advocates for interpretation by the dreamworker. All the rest advise strictly against it and suggest instead to encourage the dreamer to engage with their dream experientially and allow the dreamer’s sense of what the dream means to emerge. When I’ve had the self-discipline to do that, so often I have been amazed by the creativity and insight from my clients, and the unexpected places they went with their dream images, that I’m glad I held my tongue. 

Shame Part 2: Shame Proneness

Posted on by Psychotherapy.net Team

Megan came into session and sat down. Her eyes wandered around my face, but didn’t meet mine when she said, “I did it again. I went back to him.”

“Tell me,” I said, leaning forward.

“I’m a – a loser. I can’t stay away from him even though he’s bad for me.”

Megan had come into therapy after failing to sever ties with her most recent boyfriend, Tim, a man who repeatedly left her feeling emotionally abandoned and worthless. She reported a history of tumultuous intimate relationships that consistently left her feeling lonely and dissatisfied.

Tim was no different. Every time he dismissed her or invalidated her, it tore a little more of her heart out. Worse yet, it confirmed her inner fear: She was worthless and no one would ever, could ever love her. Trying to repair fractures to her self-esteem, she would search for the next man to love her, only to find herself in another relationship where she felt dismissed and worthless.

This isn’t unusual. It’s certainly a story I’ve heard variations of many times as a psychotherapist. Megan, who was thirty-five years old, reported that she had been going through this cycle since she was a teenager. She felt hopeless that she would ever find the stable, loving relationship she so wanted. I felt it as soon as we started our work together. Shame.

In my last blog post, I discussed the shame that entered the room in early sessions, when patients began exposing themselves. Megan’s shame was more complicated. Normal shame is transient, but for Megan, her inclination was to experience shame in all ambiguous situations. This proclivity has been assigned various names. I like to call it shame-proneness, which is the term June Price Tangney, one of the leaders in research on moral affects, (shame and guilt), named it.

When Megan came into situations that naturally elicited self-assessment, her emotional response would be feeling bad, small, defective. Self-esteem is a cognitive evaluation of the self; shame, on the other hand, is an affect, and therefore, permeates the entire self, spilling into every crack of someone’s being, coloring all their experience-darkly.

On some level, Megan believed that she deserved poor treatment from men, causing a repetition of the very pattern she was trying to stop. No matter how hard she tried to find a different outcome, she was always confronted with the same feelings of shame. Thus, the narrative – I am bad – that she desperately wanted to change, perpetuated itself.

Megan explained that she went back to Tim during the week when he promised it would be different, only to be left again. This was the fifth time she went back only to be left.

“He threw me out.” Tears trickled down her cheeks. “See, I’m weak. I’m a failure at everything. I’m never going to find what I want. It’s me.”

Her feeling bad about herself in the Tim situation pervaded other aspects of her life. That is, she felt bad all around, not just in relations to Tim.

I knew I had to help her see how her self-perception created a type of self-fulling prophecy. So, I reminded her of what we had been working on. “Remember what we talked about?” I often use psycho-education with patients, even when I’m working more psychoanalytically as I usually do with a shame-prone patient. I don’t find that keeping the nuances of therapeutic work undisclosed helps, especially for patients who feel so exposed already. It’s like throwing them outside in the cold without a coat, alone.

Megan and I had discussed shame. She knew that it tied back to early experiences of emotional neglect and abuse, where she unfortunately heard messages that she was bad and wouldn’t be anything different, ever.

“I remember, that just makes me feel worse. I should know better by now,” she whispered. This is where shame is so tricky; it’s very hard to intervene without evoking more shame.

I addressed her experience in the room. “We knew it would be hard not to go back if he called. Intellectual insight comes before the emotional connections that make change easier. You are working very hard to undo a narrative that took years to build. It takes time.” I leaned forward, again. “Remember, what we talked about last session, during the break from Tim.”

“Yes, I’ve – gosh, I can’t believe I forgot.” She pulled out her phone and showed me a schedule of all the workouts she had done the last week. Megan had been very athletic. I encouraged her to go back to exercising.

I wanted her to feel her strength and resilience. I wanted her to find her value in her activities. One of the most effective ways to help people combat these shame narratives is to help them access and activate their natural strengths, the parts of them that weren’t fostered, because no one acknowledged them when they were younger.

It’s our job as clinicians to discover these natural endowments and cultivate them for all of our patients. Shame-prone patients need more help figuring out what they are and more time to develop motivation.
Megan smiled as she showed me what she had accomplished that week. I saw pride glowing in her eyes. I observed it with her. “What are feeling?”

“I feel good.”

I smiled, thinking that we had found a space for Megan that was shame free. “What’s it like to feel good?”

“It’s something I knew I wanted to feel, but I could never quite find.”

“Now that you know what it feels like, it will start to get a little easier. Be hopeful.”

“I am.”

*Megan is an amalgamate of patients suffering from shame-proneness.
 

Shame Part 1: Walls are Fears Disguised as Safety

Posted on by Psychotherapy.net Team

The wind blew in strong gusts, howling and shaking the windows. Tracey pulled her cardigan tighter, then rubbed her arms with her hands. “I hate strong wind. It feels like the walls are going to come down.”

Interesting, I thought, we’re getting closer. This described exactly what was happening in the room.
Tracey and I had been working together for four months but had barely scratched the surface. She discussed work-related stressors and dating. She would go into detail about the many men she dated, but she never described her feelings. I wanted to know more about her inner life, but I felt her guardedness. She had a wall up. And I had to respect it.

Walls are fears disguised as safety.

But why are they there in the first place? When patients come in, but have trouble disclosing, this is the question.

We call it defensive structure or defensive mechanisms or resistance, this wall. We have words, but one I rarely hear that is significant, is shame. My dissertation topic involved a thorough analysis of shame and I have continued my research. Every time I’ve presented on the topic, students and established clinicians alike ask the same question: “Why aren’t we having classes on shame?” It’s important.

Shame is the deepest and most painful affect, as it involves an evaluation of the entire self. Whereas guilt assesses what we do- “I shouldn’t have done that”, for example; shame evaluates the entire self: “I shouldn’t be that.” Guilt says, “what I did is bad.” Shame says, “I am bad.” Shame pervades our sense of self – entirely.
Shame also involves the real or imagined perception of another. It’s the reason why infants and toddlers will run around nude without feeling exposed. They haven’t reached the developmental stage where they recognize themselves in the eyes of others.

The essence of psychotherapy requires that patients come in and reveal their innermost self, layers of secrets, elaborate fantasies. We are asking them to tell us the very thoughts and feelings that are usually hidden, because we don’t want others to see. Shame inevitably arises as the bricks come down and the patient feels exposed.

For patients like Tracey who have never been in psychotherapy before, this is often even more difficult. Additionally, unresolved shame creates more psychotherapeutic challenges. Unresolved shame (which I will discuss in the next blog), develops when injuries to the self occur over and over; any type of emotional abuse will leave people with some unresolved shame, which is woven into the very fabric of their identity.
In a lecture I had given some time ago, a psychodynamic student asked if I thought it was our own shame that made us avoid discussions of shame. I hope not. We need to afford patients the luxury of a safe room, where we are sensitive and cognizant of the shame that naturally arises as disclosure increases.

I had to help Tracey feel safe enough to slowly remove the bricks she felt were loosening. I went with the metaphor. “What do you imagine would happen if the walls came down?”

“I dunno.” She crossed her arms tighter.

“Are you feeling that right now, like the walls are coming down?”

She diverted eye contact, picking at a string on her shirt. “I don’t want you to think I’m crazy. I feel crazy sometimes.”

I leaned forward. “I know this is hard. Everyone that comes in here feels like their thoughts are crazy. I have thoughts sometimes that others might think were crazy. It’s normal.”

She looked back at me. “You do? But you’re a doctor.”

“We all have ideas and thoughts and fantasies that feel bad or scare us sometimes.” Small self-disclosures to normalize the situation and show patients that we are also vulnerable to emotions helps ease shame-ridden angst. Also, keeping the dyad collaborative instead of hierarchal reduces shame.

“I have thoughts like that all the time.” She placed her hands over her face. “There are things that I’ve never told anyone before. I know I should tell you, but it’s very hard.”

“I know it is. Maybe we can start with what you’re afraid I will think.”

“OK,” she said with a small smile. I felt a few bricks had come down as I acknowledged her shame. I knew that the more we discussed her fear, the safer she would feel to explore what was behind the wall. It would be two bricks down, one back up, but at least we were finally at a start.

*Tracey is an amalgamated example of patients during early sessions struggling with shame. 

Teen Heroes with Feet of Clay: The Dilemma of a Pop-Culture Psychotherapist

Posted on by Psychotherapy.net Team

Recently scanning the Internet, I was dismayed although sadly not particularly surprised by the glaring headline which read “Demi Lovato rushed to hospital for possible overdose.” My first response was “damn, poor kid!”

The next flurry of thoughts closely paralleled my own varied life roles. The father in me remembered my kids’ shock upon learning that this same celebrity, former Disney actor/singer used to cut herself. The pop-culture author in me reflected on the writing I’ve done around superheroes who are often deeply flawed characters. Finally, the teen therapist in me wondered once again how to bring the stories of popular culture icons like Demi Lovato into the therapy room. As examples of the challenges and pitfalls of high achievement and celebrity? As cautionary tales to those who would model their lives and mold their dreams in the images of superstars? Or simply as examples of people more alike than different from them, who struggle to regulate anxiety, depression and the accompanying demons by using, cutting and killing themselves.

Heroes abound in popular culture, exceeded only by those who have fallen hard and as such are in no short supply. As I watch the 2018 Tour de France, I remember Lance Armstrong’s substance-enhanced fall from grace. As I read more deeply into the life of Demi Lovato, I think about Justin Bieber’s near-death automobile escapades, Britney Spears’ seemingly unending brush with the dark side and the terrible fate that Heath Ledger, aka the Joker met; not to mention the myriad music legends whose lives were cut short by their own hands- Kurt Cobain, Whitney Houston, Michael Jackson and the artist who will forever be known as Prince.

Just today, a soon-to-be twenty-year-old asked me (in my professorial role) a poignant question about adolescent identity formation. A question she would like to have asked her developmental psychology professor, I believe she was reflecting on her own journey to personality coherence on the road to adulthood. We concluded together that there are many influences that shape who we are and who we become during our formative years, not the least among which are popular culture figures both great and small, evolved and base, and those who succeed and ultimately who fail…terribly.

In his book, Breaking through to Teens: Psychotherapy for the New Adolescence, Ron Taffel encourages all those who work with teens to be familiar with popular culture and its many and often strange inhabitants. He challenges clinicians to regularly assess their PCIQ, or popular culture IQ. As a therapist who specializes with children and teens, I couldn’t agree more strongly. I worked with a troubled seven-year-old who had been alternately diagnosed with ADHD, oppositional defiant disorder and conduct disturbance. He taught me about the struggles Japanese anime character Naruto faced, and in so doing provided me key insights to helping him. And it was the tortured relationship between Darth Vader and Luke Skywalker that assisted me in my work with a depressed and alienated adopted pre-teen. Each of these pop-culture characters, regardless of their fictional origins, struggled in very real ways.

So, the next time you have the opportunity of working with a child or teen who identifies with a figure of popular culture–whether fictional or non, elevated or fallen; be prepared to explore the meaning of that identification, whether positive or negative. And be prepared, as I have learned, to sit patiently at the intersection of that client’s and their hero’s relationship in order to gain a deeper understanding of your young client as they wrestle to make sense of themselves, the world around them and the characters within it. Lessons abound.