Author: Psychotherapy.net Team

Bare: Psychotherapy Stripped

Posted on by Psychotherapy.net Team

Editor's Note: The following is an excerpt taken from Bare: Psychotherapy Stripped, by Jacqueline Simon Gunn, published by University Professors Press © 2014 and reprinted by permission of the publisher.

I think Dostoevsky was right, that every human being must have a point at which he stands against the culture, where he says, this is me and the damned world can go to hell.
—Rollo May

Please Don’t Let It Be Her

“Jacquie? Is that you?”

Oh no, please don’t let it be her. The voice came from behind me.

But of course it was, the slightly nasal, overly enunciated voice always unmistakable. My body tightened. Of all the people to run into — in Bloomingdale’s, no less — while looking the way I did: sweaty, smelly, and disheveled. Served me right for doing my training run, then squeezing in an errand before showering, while convincing myself I could manage to escape notice of someone I knew. The Big Apple may be big, but it is not that big.

“Jacquie? Jacquie.”

Her voice doesn’t sound close. Maybe if I move fast enough, I can get lost amongst the shoppers. But then I heard the distinct sound of hurried heels clacking on the tiled floor, and
before I could slip into the crowd, a hand touched my shoulder.

“Jacqueline!”

I bolstered my spirits, and turned to face the inevitable. Maybe it’s time I bring this relationship to a close.

Tess was my newest patient. I had just earned my psychologist’s license a few months prior to our first meeting, and subsequently accepted a full-time staff position at the Karen Horney Clinic. I had already been employed at the clinic for two and a half years, first as an intern and then as a post-doc fellow, so when they offered me the position — nearly nine years ago now — the decision to accept it wasn’t difficult. I could continue with my current patients while I received some additional supervision, all providing me with the ability to slowly transition into private practice.

A colleague who had been working with Tess for nearly two years referred her to me. Another client would pack my schedule, as I was carrying a nineteen-patient caseload at the time, so I initially felt hesitant to take on a new client. After extensive consideration, I agreed. “I wholeheartedly believed I was ready to push myself professionally.”

How could I have known what would happen or the effect she would have on me?

My colleague had to prematurely terminate her work with Tess because she and her husband were moving out of state. At my request, she gave me only a small amount of background information; I am not a fan of learning about a new patient second-hand. I have found it more beneficial to be exposed to patients’ narrative directly from them. The referring therapist did tell me that Tess was 61 years old, suffered from chronic depression, and having an inordinately hard time with the aging process.

She added, “You’ll be a good match.” When I wondered why, she responded, “Tess needs a tolerant, warm and empathetic therapist. I think you’ll work well together.”

I was not finding that to be the case.

Appearances

When Tess came in for our initial meeting, I immediately noticed her striking appearance. She was quite attractive, small framed and perfectly made up. What I found most significant was her choice of attire; dressed impeccably, she reminded me of someone clothed for a night at the theater. Though curious about the façade she put on display for the world, it was much too soon for such a personal inquiry, so I held my thoughts and associations in abeyance to be brought up later in therapy.

Within just the first moments of session, however, I managed to ostensibly muck things up. I called her Contessa. Tess does not like to be called Contessa, which I soon discovered. And her displeasure spoke to that fact through her terse reaction. “It’s Tess.”

Though my colleague had referred to her as Tess, I noted in her file that her given name was Contessa. Nicknames can be a highly personal experience, and I did not want to presume familiarity too soon. So I called her Contessa. But I knew better. I should have asked her outright what she preferred to be called. Just like a nickname can be personal, so too can a given name be a source of anxiety, as well as a seedbed of myriad emotional triggers.

“Tess, I’m sorry. I didn’t realize you dislike Contessa.”

“I hate Contessa. It’s a family name. And it reminds me of someone who’s ancient and stodgy.”

And just like that, with tightened lips appearing like she’d just sucked on a sour candy; she folded her arms in a resolute stand against distasteful nomenclature.

“Really? I think Contessa is a beautiful and rare name. It evokes such elegance.”

“Nonsense.” She dismissed my opinion with a wave of her hand and flutter of eyelashes. “Now, Tess. That’s fun and youthful. Tess is a model’s name.” Her eyes twinkled when she said that, encouraging me to make the leap, to associate her with models. And honestly, though I am normally savvy enough to avoid that slippery slope, she did carry herself like one. And that is exactly where my thoughts landed. I bet she could’ve been a model in her day. I wonder if she was.

As the session moved along, Tess began describing her long history of depressive episodes, her numerous hospitalizations, and her propensity to isolate from others. I had so many questions for Tess, but I wanted to allow her the liberty to express herself without interruption during this first session. Some clinicians prefer to perform an extensive intake evaluation during the first few sessions, in order to collect adequate background information. I find this sort of structured interview interferes with the patient’s process of describing personal information, so I allowed Tess to tell me her story while I listened attentively with compassion and empathy.

I learned in the first session that Tess lost both of her parents at a young age; she lost her mother first when Tess was 17, and then her father when she was 24. I felt a twinge of pain as she revealed this; it was only the first session and I already could feel the heaviness, the burden she was carrying, and I felt sad as I listened. She was also married for ten years, from 36 years old until 46 — when her husband, who was having an affair during the last year of their marriage, left her for another woman.

Now 15 years later, she still had not recovered from this. I began to notice through her narrative that she blamed herself for the numerous hardships she endured in her relationships — and this was only the beginning. “Throughout our treatment together, I would hear many heart-wrenching stories from her past”, as well as experience and bear witness to her suffering resulting from some serious and frightening occurrences that happened during our course of therapy.

As I listened, I also wondered about her feelings surrounding the termination with her previous therapist. I found it significant that she didn’t bring this up. In my experience, premature termination most often brings up mixed emotions for our patients: abandonment, anger, betrayal, loss. Why wasn’t Tess bringing this into the room? We were near the close of our session when I realized this — too late to bring it up now — so I made a mental note to inquire about this at our next session.

With only five minutes left, Tess began to inquire about me. How old was I? Was I married? (She did not see a ring and assumed that I was not.) Did I want children? When questions such as these come up at the end of a session, it is always difficult to negotiate how to respond.

Early in My Training

Early in my training, I almost never answered patients’ personal inquiries. I was trained from a classical psychoanalytic perspective. Residing under this particular model of psychotherapy, personal disclosures are looked down upon and are thought to have a negative impact on the evolving of transference — the response of the patient to the therapist, both conscious and unconscious. This level of neutrality never felt quite right to me; it truly felt inauthentic, but I was still in training and didn’t have the confidence yet to feel comfortable following my intuition. My own way of working, which at times involves personal disclosures, evolved slowly over the years.

Though it was not official at the time, I considered Tess my first private practice client, so I wanted to display a sense of confidence and maturity that I believed I should possess. It was more for me than anyone else, really. I had counseled countless patients prior to Tess, so I was confident about my abilities; however, since I was not yet seasoned, I floundered when she riddled me with personal questions. Tess challenged almost every aspect of the delicate balance that I eventually learned was a key factor in using self-disclosure as a therapeutic technique. In psychotherapy, as in life, experience is often the best teacher. Well, Tess, she was akin to a full-time professor.

I felt anxious; I did not know Tess well enough yet to have a real understanding of what these questions, and my choice of whether or not to respond, meant to her. I acknowledged her inquisitiveness and replied with what I hoped embodied an empathetic tone, “We can talk about these questions at our next session.” What an unoriginal answer. I quickly berated myself, but I really needed to understand her better before I could make a decision about how to handle these quite personal inquiries. By the time she left the session, I was exhausted. I also felt the urge to cry. I really needed to think about what was going on for me; these feelings obviously communicated something quite essential about our dyad.

I would find out soon enough.

A few nights later I had the most unnerving dream. I arrived at an important psychoanalytic conference, preparing to present on self-disclosure in the treatment setting. I walked in, my flowing mint-green dress billowing with each step. My most favorite frock. I felt confident. All eyes were on me. The dress had done its job.

And then my gaze swept across the room. The crowd milled about clad in black (mostly suits), their formal outfits a stark contrast to my lustrous gown! Sudden discomfort settled in. My skin burned from embarrassment.

I woke up drenched in sweat. Even in the dream, I remember thinking, “What a curious dream.” And despite its obvious disconnect from reality, I couldn’t shake the residual uneasy feeling. Quelling all the thoughts spinning around in my mind — I know this dream, there is something so familiar about it — I attempted to set aside my strong desire to self-analyze, and instead prepared to leave for my office with a lucid mind.

Flowing Mint Green Dress

While still trying to distract myself from ruminating about the meaning of my dream, I ruffled through my closet deciding what to wear. And there it hung: my flowing mint green dress. I shuffled past it, searching for the right outfit for Tess — For Tess? Why for Tess? — but my eyes repeatedly returned to the green dress. What an odd juxtaposition. I usually wear my most professional clothes when seeing a new patient (partly to set them at ease, partly to establish professional boundaries), yet here I stand, still trying to divert my attention away from the green dress that hung in my closet before me, hindering my ability to avoid the dream and to find some “appropriate” clothes to wear. My experience that morning, after only one meeting with Tess, already began to mirror the difficult relational dynamic that would infiltrate our journey together.

Tess came to our second session flawlessly dressed and made up. Again, images of my flowing mint-green dress distracted me. However, this time I associated thoughts of the dress to the feeling I had when observing Tess’s attire; she looked lovely, but over-dressed for a therapy session. This time I observed her posture and cadence as she walked in. It was incongruent with her impeccable makeup and high fashion. She walked with her head down and back slouched, a remarkable difference from her model-like stature of the previous session. I associated her demeanor with someone who was just beaten up.

She slumped into the chair.

“I’m boring, right? I have nothing in my life except my dog.” She frowned and averted her eyes.

“Boring?” On the contrary, you’re absolutely fascinating. “It actually seems that you have quite a bit to talk about. Where is this feeling coming from?” It was then that she began to tell me about what I eventually dubbed “Her Fall from Glory.”

Tess had been a well-recognized author and editor; she and her former husband actually met while she was working as an editor of a reputable magazine. She also published a book about her personal experience battling and overcoming breast cancer when she was 49 years old. Before her breast cancer, which eventually led to her losing her breast (she made sure to add that she had an implant), she had many friends, an exciting social life and a loving partner who stood by her through her year-and-a-half ordeal.

““I was beautiful, so beautiful; I had many men. Many.” Her pain permeated every word.” “Now men don’t even look at me when I walk down the street.” She sighed, heavy and long. “See? I have nothing.”

Now this is a telling statement!

“Nothing.” She repeated, overly enunciating it, drawing out, then punctuating, each syllable — each sound — with the kind of attention to detail one might find in a pillow embroidery.

My mind raced with all the different paths of inquiry she left open for me to explore, but the amount of information she generously offered so overwhelmed me that the session ended before I realized it, leaving me no opportunity to explore any of her story or encourage her to elaborate. I did want to give her something to leave with. This is vital to the therapeutic process — giving the patient a part of you by acknowledging what they have shared and offering some empathetic insight.

“You’re a fascinating woman, Tess, and I have so many questions for you.” I noticed her curious expression. “You’ve been through so many hardships.”

“Interesting? Really?” Her remark took a sad turn. “But I have nothing now, Jacqueline. You’re young. Don’t wind up like me.” Is that a little envy in her tone? Or was it hostility? And she just glossed over my comment about her hardships? She gathered her belongings, moving with slow sadness, and left looking even more broken-down than she did when she came in. Again, I felt like crying. And again, I forgot to ask about her experience terminating with the previous therapist.

Tess began therapy with me on a twice-weekly basis. I typically prefer to understand a patient’s internal dynamics and interpersonal style before increasing the frequency beyond once per week. What one might think would be helpful for a patient — added stability, consistency and containment — may be too much for them in the early stages of the treatment. But since Tess was seeing her previous therapist twice a week during their second year of treatment, we collaboratively decided to keep this therapeutic frame. As I thought about Tess after our second meeting, I sensed that twice-weekly sessions were ideal for her, but I did wonder if it might become a bit overwhelming for me.

The content of her narrative — losing her parents at a young age, cancer, divorce — as well as the feelings being evoked while sitting with her, already felt overpowering. “During the first month of treatment with Tess, she spoke endlessly about her “Fall from Glory.”” I sensed that she felt shame about where she was in her life now; in order to sit with me and expose her current situation; she desperately needed and wanted me to know who she was prior to her “fall.” I would later understand that this “fall” happened as a result of losing her breast, coupled with her almost complete emphasis on her outward appearance as defining her. For Tess, I came to understand relatively early in our treatment, outward appearance was all she believed she had to offer; it was who she was. This was at the core of all her issues and eventually established a quite frustrating dynamic between us.

Having conceptualized her dynamics early on, I decided that my therapeutic position should be to listen attentively to who she was prior to her breast cancer. I believed it would help her feel less shame when, in later sessions, I would be encouraging her to focus on where her life was in the present. Through this active listening, I gathered a lot of background information; although I did notice that when I tried to explore her early childhood experiences, particularly her relationships with her parents, Tess met me with harsh resistance. Okay, so I guess this is important. Though I made a mental note, I didn’t push her; this was obviously an area of great devastation for Tess. We would get to this material at some point, but definitely not yet. She had other, more pertinent, news to share with me.

“Everyone cheats.” This came out of her mouth with the nonchalance of someone placing a dinner order. She wasn’t making an observation solely about the men in her life because “everyone” included Tess. During her ten-year marriage, she confessed to multiple liaisons with other men. For some reason — likely having to do with my sense that she thrived on external validation of her desirability and worthiness from men — this information didn’t surprise me in the least; but it piqued my curiosity.

“Tell me more about this?” And she did. She went on to describe the many sexual partners she had through her twenties and thirties. In fact, all her friends had extra-marital affairs and, she reiterated, cheating was merely a part of marriage. I experienced a visceral reaction as she provided this information. How strange to hear those words come from this 61 year old woman sitting across from me.

“I pondered why I felt strange learning about Tess’s clandestine liaisons.” I don’t get it. I’ve heard countless stories like hers, especially from all those sex workers I’ve counseled who have repeatedly described having sex without any emotional connection. I guess this Tess, the Tess-Post-Fall-From-Glory, is not the same woman who enjoyed those extra-marital affairs. This Tess is depressed and broken. I found it difficult to imagine her with the sexual prowess she described, of being a woman who ostensibly detached emotion from many of her sexual experiences and enjoyed sex for the pure physical pleasure it offered. It was clear that she did; that is, before she came to see her body as deformed.

One of the men she had an affair with, Barry, was the man she eventually developed an ongoing and quite serious relationship with after her divorce. She described Barry as “the love of her life” and the man who stuck by her during her fight against her breast cancer. He eventually left her for another woman once her battle with cancer was over and she was healthy again. When Barry informed her a few months later that he was married to this other woman, Tess described feeling abandoned and devastated. This, too, added to her “Fall from Glory.” Tess was 51 when this relationship ended.

“I haven’t been with another man since.” Tess broke eye contact with me. She focused on the floor and kept her gaze there.

Interesting. Men make up such an integral part of her life. She thrives on their attention and affections. That’s a long time to keep yourself alone.

The Healer that is Hurting

Posted on by Psychotherapy.net Team

Life’s a beach, or so I’m told. Paradoxically, death may draw many apt analogies from this image.

This summer, my work was humming along to the tune of vibrant pulsing music, much like a beloved beach getaway. My client load, lightened by family vacations, left breezy spaces in my schedule for unpacking course development and writing projects that had been tucked away for a while and for unfolding new ideas I had been eager to examine in the full light of day.

The sun shone brightly down as I played with the projects like beach volleyballs in the ocean, keeping each in the air with my respective co-teachers and co-authors until they skidded across the water before me with large splashes of inspiration, ready to be passed, set, and attacked in turn with greater intention.

And then, I woke up one morning this week to an email informing me that a buddy of mine who has been battling brain cancer for more than a year is now in end-of-life care. In cruel and rapid succession, thirty minutes later, I learned by telephone that my mother-in-law died peacefully in her sleep the night before, after her own two-year fight against cancer. Despite the battles my loved ones had been fighting, the news of these events was both sudden and unexpected, like going for that ball in the water and falling off the sandbar that I didn’t even know I was on into the depths of the ocean, scrambling to find solid footing again.

Anticipatory grief was launched from the American side, where my buddy is from, and was amplified by the full force of the shipwreck of my mother-in-law’s passing on the Swiss side, where I now live. It has been two and a half years since my last family loss, my maternal grandfather, my last grandparent. I remember that it hurt to lose him – an enormous, ocean-sized bucket full – but I had forgotten how ravaging grief feels in the moment it is felt. Until now.

Grief is often described as coming in waves. I had forgotten how bone crushing and soul squelching the break of those tsunami-sized waves feels until I received news of these recent events. Gasping. Sobbing. Roaring. Crashing. Crushing. Overtaking. Undertowing.

The former lifeguard in me recognized the drowning person’s combat, wordless and writhing under the weight of the wave of grief, struggling to keep her head above water, breathing in fits and spurts. Time is different in that space and place, seemingly at a standstill in the struggle to get to the surface, to figure out which way is up again. Until grief, finally deciding to subside… leaves the body limp and devoid of form or feeling, like seaweed tossed upon the shore both as an afterthought and as a reminder of the power of the wave that has (temporarily) receded.

I am still on this sober beach, lying on the sand in the ebb of the tide in the interim between my mother-in-law’s death and burial, her demise and our ceremonial remembrance of her. I am experiencing the void of losing her and the unbearable anticipation of the loss that I know is still coming – the next hard wave that will hit when I want to pick up the phone after work to pass the commute home in her company – only to realize that I will never be able to do that again. I am also in anguish about what I cannot see coming – how I will react to the funeral rites I will experience for the first time as a family member in Switzerland. I have attended funerals here before, but not for someone within my family.

Despite my full integration into this Swiss society I’ve called home for over a decade, the subtle differences in rites and rituals here contrast from those of my home Appalachian culture and signal my otherness, and aloneness, to me. Certain differences in the timing of things and in how the ceremony is performed are culturally and painfully dreadful to me, like skidding against hard rocks at the bottom of a crashing wave without choice or conceivable resistance to the process.

Thus, documenting my feelings, resonances, and imaged analogies while I am still in the throes of fresh grief will serve to remind me, the healer that is hurting, that it is important to let people feel what they feel, to ask them to describe their resonances in whichever directions their sensations take them, to explore what grief and loss mean to them and how it is expressed in their culture(s), and to bear witness to their pain and struggle without trying to fix what is ultimately unfixable.

I will sit with my pain and accept it as the old acquaintance it is, letting it accompany me on this voyage to the beach and home again in the full consciousness that the length of this journey is unknown and impressible. I will also bear in mind that, at some point, I will not remember it as vividly as I feel it in this moment, and I will try to take some small comfort in that. I will eventually be able to feel the warmth of the sun again, despite its continued shining. And, when I sit as a counselor with grieving families, I will not soon forget – and will never minimize – the impact of the roaring waves of grief that cover them until their seas eventually calm again, even if just temporarily.

A Barbie in Paris

Posted on by Psychotherapy.net Team

Barbie girls do not visit my therapy room that often.

This one was from a Fashionista kind – perfectly blond and dressed up for a lunch in town with her equally well-groomed girlfriends on stilettos.

This is the unkind thought that crossed my mind as I opened the door and greeted her. I felt bad; a spark of shame made me smile a bit more broadly to her than I would usually do. How could I reduce this person to a soulless doll? Nadia (no, she was not called Barbie) was probably suffering – otherwise why would she be here?

She was a Russian-American living in Paris. Her parents had immigrated to Texas when she was eleven; and this is where she had grown up – she stressed at the very beginning of our session. She felt American and preferred to speak English with me, if I did not mind. I did not.
Her English was perfect indeed, with a subtle Southern twist.

Ignorant of my inner thoughts about her, she sat down, crossed her long legs and kicked off:

– I hate everything here.

This was a rather unusual beginning. My American clients are typically fascinated about Paris, though, sometimes, this initial idealization turns into disillusionment or frustration about the French administration or widespread snobbiness.

– Everything?
– Yes, I hate French people, I hate French food…
– Is there anything you might like about Paris?
– Nope.


She sounded certain; the frozen frown on her perfect face confirmed this commitment to disgust. I believed her feeling. She looked fed up with trying to fit into a place she did not belong to.

The only reason Nadia was still living in France was her French boyfriend.

At first she had found the idea of following this Frenchman to Paris rather appealing. Her Texan girlfriends were finding it exciting, they could not hide their envy. This sat well with her – she was into fashion, and Paris was the place. She could picture herself working for one of the luxury brands, wearing a Chanel jacket and some fine jewelry…

Who was this man? How did he connect with her? What did he appreciate in her apart from her looks?
I did not get much out of her: he was rational, well-organized and made good money.

Is it ever possible to love someone and completely dislike the culture this person belongs to? Having loved France and a French man for twenty years, I naturally doubted that, but Nadia’s story was different: they had met in her step-motherland, the US, and her knowledge about France was limited to Hollywood movies and her mother’s dream to visit Paris, an impossible fantasy during Soviet times.

But Nadia was not interested in philosophical questions. She made it clear – she just wanted me to tell her that “her feeling was normal” and would pass with time: should she stay and give France another chance, or return home? She was desperately homesick.

Was this place rejecting her? Probably. This had been my first reaction after all – Paris is not to welcoming Barbie girls – its well-known lights can be disappointing and lack the promised glamour. My own Frenchness, acquired through hard work, had rejected the way she was exhibiting herself.

She stubbornly rebuked my attempts to enquire into her relationship with her original home, Russia. She did not have much recollection from her first years of life there, and had never given it much thought. She insisted on being happily American. Could it be that her current exposure to another strong culture was threatening her American identity?

Working on this is possible in long-term therapy and can be painful at times. I suggested that, as long as she was ready to commit.
Nadia was resisting taking any responsibility for the flaws in her relationship with France, she just could not do anything else than hating the country, the people, or the food here.

After going in circles for an hour, we did not manage to move an inch beyond this initial point. I sat there in front of her, moving closer to the realization that I could not help her without her cooperation.

When I finally closed the door behind her, I felt exhausted and relieved. My guess was that she would not be coming back. I felt used by her, and as result mildly ashamed.

Shame is a tricky but always informative feeling.
What was it about? Maybe this shame was something Nadia was experiencing deep down under her tight red top, under her perfectly tanned skin?

Reflecting on our session, based on the very little she had shared with me about her past, I could imagine the young Russian girl brought by her parents to a new and probably alienating place. She had mentioned that the first year had been hard – children at school mocking her for her wrong clothes and wobbly English. But she was a tough kid, and soon enough she had joined the group of the ‘popular girls’. This had come with a cost – losing weight and learning how to play totally new and strange sports among other things …

Thinking about this teenager dealing with her new immigrant condition that she had not chosen, I could finally feel some compassion.
Here in Paris, the adult Nadia was certainly feeling as inadequate as the younger Nadia during her first years in America. The fact that this time she was the one making the choice to move did not make it any easier.

My intuition was proven right – Nadia never came back, neither did she follow up on our unique encounter. This happens rarely, and every time it does I am left with more uneasy questions than answers. Did I fail her somehow? Should I have done something differently or was I simply not the right therapist for her?
Even now as I am writing about Nadia, I feel an uneasy feeling, a mild embarrassment about failing to connect with her, to feel for her more in the moment. Had I been able to connect with the young Russian girl, ridden by the feeling of being too different from other truly American kids, would it have gone any differently? Perhaps her Barbie-like façade was the only way she had found at the time to fit in, to belong. How desperate she would have been to fit in to adapt her own personality to this caricature of a perfectly American girl. Had she played with foreign-looking Barbie dolls as a little girl back in her native Russia?

Most probably I will never find answers to these questions, and as any other therapist, I had to learn how to deal with such frustrations and uncertainties – they are part of my job.

I hope that one day Nadia is safe enough to get in touch with her shame about her imperfect origins. After all, she chose to contact me – a Russian become French, rather than one of the many American psychotherapists in Paris. Maybe a well-hidden part of her wanted to connect with her ‘shameful’ roots; but for now this part was too small and too insecure. I had to accept that and hope that in the future she will give therapy another chance…
 

What Do a Mango Tree and Child Therapy Have in Common?

Posted on by Psychotherapy.net Team

I am from Brooklyn. While a tree might have grown there for someone else, it certainly did not do so for me. A few shrubs here and there, some weeds poking up in the cement cracks perhaps, but nothing more verdant than that. I was thrilled, upon moving to my current home in Florida to have a mango tree on my property.

Everything I ever needed to know about therapy I’ve learned from that mango tree…but more about that in a bit. Each year like clockwork, the tree blooms, fruits, sheds and ultimately yields. And each year like clockwork, I worry that for a variety of reasons, it will not actualize its mission. And each harvest season, I must remind myself that this magnificent living thing has its own rhythm, its own wisdom and needs me there simply as a witness, unassuming caretaker and gentle guide.

In similar cyclical fashion, right around this time for the last two years, I received a call from Jamie’s parents. “Hi Larry”, says Tom, Jamie’s dad, “Jamie just finished 4th grade and asked to see you; he misses you.” Tom went on to describe how his creative, playful and precociously intelligent and self-aware child had flourished and evolved despite the challenging climate of public school. Now, a rising fifth-grader, Jamie was again expressing anxiety over leaving the familiar landscape of fourth grade.

I first met Jamie when a mere sprig of a second-grader, who at the time was nervous at home and at school, fearful of making mistakes, prone to clashes with his parents and the occasional classmate as well as very sensitive to criticism. Our therapeutic play was at his pleasure, not my design, as I believed a client-centered approach best fit his growing needs. I trusted that through his drawing, role-plays, arts-and-crafting as well as popular culture-based story telling that he would play out exactly what he needed to express; and that my non-directive feedback would provide whatever additional insight he might have needed.

It was now two and-a-half years later, and there stood Jamie in the middle of my therapeutic playroom, surveying all the possibilities before him. Without flinching, he quickly went to work; reminding the bobo doll who was boss, animating a group of hand puppets in lively conversation about fears, worries and confidence, and finally turning to me saying “I’m done, let’s go talk to my parents about why they brought me here.”

And so it was! This little mango tree named Jamie told me exactly what he wanted and needed, reminding me of my role and its limitations while imparting a simple lesson that applies to mango trees and child therapy alike. Trust in their wisdom, potential to grow and ability to tell you exactly what they need. The measure of the bounty will be its own reward.  

Burning Out After Jumping In: Reflections From the F

Posted on by Psychotherapy.net Team

Some days, I question why I became a social worker. Other days, I wonder why I chose to work at an inpatient psychiatric facility for the past two years of my life. Coincidentally, these last two years were my first years in the field post graduate school. The reason I find myself working at an inpatient facility is a much less dynamic mystery—I was hired straight out of grad school by the hospital I did my first-year internship with. I remember it vividly. I was nearing graduation with a mountain of student loan debt, armed with an Ivy League education and ambition to help others. Secretly, I was crippled with anxiety about exiting the comfort that being in school provided. So, like most people, I jumped at the first job I was offered. Mystery solved.

However, wondering why I became a clinician is a recurring thought. Sometimes I find myself pondering the motivation behind my entire career path. On other more hectic days, I gravitate towards the more stress-fueled variety of that question: Why the (expletive) did I choose to dedicate my life to helping others who, more often than not, don’t want my help?! Why am I swimming in debt to provide services to patients who would rather do literally anything than attend my groups?

It occurred to me recently—can this be burnout so early in my chosen career? Is it possible to be burned out after two years of practice? Apparently so. Okay, so, we’ve established that I’m burned out. The question now evolves to—what do I do about it? I engage in self-care daily. I have a beautiful horse that I ride as much as possible; I have a wonderful husband who supports me in every way; I journal; I participate in mindfulness; I play with my dogs, I don’t take work home with me. But, on the worst, most chaotic days—that’s not enough.

If I’ve learned anything from my years on this planet—what’s right for one is not right for others. I don’t presume to have the answers for anyone but myself. Though, I know I’m not the first to wonder if it’s too late for a career change because I just can’t take anymore (just a side note—I’ve investigated essentially every profession that does not deal with other living human beings). So, I’m not sure if this is the “right” approach, but here’s what I’ve determined: burnout is eased by the days that a patient says, “thank you.” Okay, that’s ridiculously simple and people are rolling their eyes thinking, “Yeah, someone says thank you and then all your stress and compassion fatigue just vanishes?” Definitely not.

But, today a patient walked into my office. Uninvited… sure!, but “come on in” I said! He said to me, “When I first got here, you made me nervous because you are a smart woman. But, I have to tell you that I’ve learned so much from your groups. You have a heart of gold and have helped me more than you know.” This person then proceeded to recite ideas that were shared in my groups and was applying them to his particular situation. He illustrated how certain topics helped him in specific ways throughout his admission. I won’t pretend that this interaction erased the layers upon layers of burnout hovering over me like an aggravating, stress filled cloud. But, I can say with confidence that this conversation reminded me why I became a social worker. This five-minute discussion is the answer to the recurring question: why did I enter this field?

Burnout remains a mystery to me. I know I haven’t introduced an unfamiliar idea into the narrative around this subject. Though, if you’re anything like me, and you feel like you’re doing as much self-care as one human can possibly do yet continue to feel dread as you pull into the parking lot at work—then gratitude is the sprinkle of motivation essential to putting the car in park and carrying on with the day. And maybe it is just enough to keep me moving forward into this new and strangely rewarding career.
 

The Acronymization of Psychotherapy and Mental Illness

Posted on by Psychotherapy.net Team

According to the New York State Office of Mental Health (I randomly chose New York because it is my birthplace), an acronym is a “pronounceable word formed from each of the first letters of a descriptive phrase or by combining the initial letters or parts of words from the phrase.” Actually, this definition was news to me because what I’m really referring to in this blog is an “initialism”, which according to dictionary.com, is “a set of initials representing a name, organization, or the like, with each letter pronounced separately.”

Oh hell, what’s in a definition anyway and what does this even have to do with psychotherapy, or mental health for that matter? Let’s PTC…. pause to consider. Sorry, I couldn’t help myself.

Psychotherapy acronyms such as EFT (Emotionally Focused Therapy), ACT (Acceptance and Commitment Therapy) and REBT (Rational Emotive Behavior Therapy) share a certain mellifluence. They roll gently from our tongue and offer no mystery to the audience, who instantly knows exactly what complex forms of treatment they represent. Psychotherapy initialisms such as DBT (Dialectical Behavior Therapy), CBT (Cognitive Behavior Therapy) and CCPT (Client Centered Play Therapy) are a bit harsher on the oral musculature, but like their grammatical half-cousins leave no one wondering about the nature of the clinical intervention.

Psychopathology acronyms like SAD (Seasonal Affective Disorder), GAD (Generalized Anxiety Disorder) and ADD (Attention Deficit Disorder) leave us with the comforting knowledge that we have adequately captured the complexity of psychopathology with a catchy shortcut. In parallel, psychopathology intialisms such as OCD (Obsessive Compulsive Disorder, BPD (Borderline Personality Disorder) and PTSD (Post Traumatic Stress Disorder), while a mouthful in their own right, equally assure us that we “know” the person who sits before us in the consulting room.

I understand the essential reason for acronyms and initialisms in place of their parent terms. They are lexical placeholders; stand-ins for their meatier counterparts that ease communication between diagnosticians and psychotherapists. They are helpers. Or are they?

I think that these otherwise well-intentioned substitutes rather than simplifying, actually obscure, obfuscate and trivialize both psychotherapy and those struggling with psychiatric disorders. Instead of conveying meaning, they commodify the human experience and trivialize psychotherapy. They scientize and sanitize the pain and complexity of human suffering while creating the illusion that the complex and often unpredictable dance of psychotherapy is easily measured and fully understood. These reified and abbreviated pseudonyms, these shallow masks of meaning mis-cast light rather than illuminate, hide rather than reveal and hurt more than they help us to understand.

The solution in my not-so-humble opinion. Call them like they are. JSN! Just say no to acronyms and intialisms and resist the downward pull of simplification and commercialization in the place of understanding and compassion.  

When Your Client Dreams about You

Posted on by Psychotherapy.net Team

Things were not all good between my client and me, but I had no idea. She showed up promptly and consistently, seemed to like me, at times even told me how much the therapy was helping her. Yet she often seemed uncomfortable, preferring to fill the session with detailed accounts of her life rather than engage in the directly experiential way I like to invite. My role became that of a witness, a compassionate listener for sure, but rather a passive one. I thought, okay, this is our dance-step.

Then she brought the following dream: I was cleaning her house and had done rather a cursory job of it. The house was still so incredibly unkempt she had rolled up her sleeves and was tackling the lion’s share of the job herself. Later I show up with a flashlight and am opening up rooms she never visits, illuminating darkened corners.

The metaphors here are pretty darn obvious, so I won’t belabor them. If we read the dream as a commentary on the therapeutic relationship, I am clearly getting a mixed review – leaving her to clean up her own house because I’ve done such a bad job of it, but also encouraging her to look into areas (inside herself or in her life) that she would otherwise not visit.

What I love about this example is that the dream becomes the vehicle for the client to comment on the therapy process in a way that she would never have done otherwise. I try hard to level the playing field, be open and immediate with my clients, invitational, friendly, casual – in all ways endeavor to make the therapy relationship feel safe enough for clients to say anything. But often it’s only through dreams that I hear truly honest commentary on the things that don’t sit right with them about my job as their therapist.

This argument for listening to dreams extends further. In my personal experience as a client, I have found dreams open up avenues I would otherwise not walk down. The unflinching honesty of dreams at times makes me cringe – they are like that good friend who will tell you when you have spinach in your teeth or have behaved badly.

The most profound therapy session of my life was precipitated by a dream. I was born very premature and in the germ-phobic mid-60s, so I was kept sealed off in an incubator, touched only as needed for the first six weeks of my life. I had another near-death experience as an adolescent, when, convinced I was invincible, dove under a waterfall and then got carried deep underwater by the powerful current, nearly drowning before I resurfaced.

I had a powerfully scary dream that wove these two events together, and because I was seeing a Jungian analyst at the time, naturally I brought the dream to our session. We revisited the dream material, re-entered the dream, sketched it… but all this did was underscore the profound sense of aloneness contained in the dream. Then my therapist asked me to re-enact a part of the dream where I reach out and no one is there. In that moment, he grabbed my outstretched hand firmly and looked me right in the eye, reaching back across the years to provide a firm supportive presence to that lonely baby and that teenager. It was so unexpected it sent a kind of shock wave through my body.

This profound moment had ripple effects that ultimately shifted my sense of self and relationship. Yet I would not have brought the topic up had I not had that dream. I have now been working with dreams, my own and those of others, for more than 20 years. Sadly in that time, I have seen dreamwork fall out of fashion. I am hoping the examples offered here show that dreamwork is not just some quaint antiquated practice but one that has current relevance: we all dream about things that are deeply authentic and that are too often left out of the therapeutic conversation.

Imagine You Are a Smart Phone

Posted on by Psychotherapy.net Team

Think of yourself as a smartphone—i-Phone, Android, doesn’t matter which. Push that thought to
its limit and see where it takes you. It might alter the way you experience the feeling of being
alive. And it might open up new paths in therapy.

Properly speaking, a smartphone is not strictly a phone. Rather, it is a device containing numerous
apps, a tool with multi-variant potentiality. Tap on the Facebook icon and the device becomes a
social-media tool; tap on the Gmail icon and it serves as an email-exchange tool; tap on Google
and it’s a search engine; tap on the phone icon and only then does it become what its name
suggests—a phone.

Consider now the human organism—you as a biological being, you in your pre-conscious state,
you before you think your thoughts about who you are, you before you occupy a role. You are in
that pre-somebody state, a bundle of potentiality, a device with uploaded apps. Tap on your
“therapist icon” and you inhabit the role of therapist. You become a certain kind of person, one
who engages with others and the world in a certain confined way. You operate in therapist-mode.
You take on an identity in the same way that a smartphone takes on an identity when an icon is
activated. Tap on your “spouse icon,” your “parent icon,” your “let’s-go-drinking icon” and you
inhabit the role of . . . . well, you get the point. You, the human organism, like the device we call
“a smartphone,” has no unitary identity.

To put it in grandiose terms, the Self is an illusion. There exist only ephemeral, highly contingent
selves within the human organism. Your identity is a function of whatever “app” has been
activated. Indeed, even your reductionist thoughts about yourself—I am this or that—is itself a
function of a certain app icon that has been activated. The implications of this are far-reaching
and profound.

A person highly prone to anger, you might say, is a human organism with a very large “anger-app
icon” on the home page, easily and frequently activated. One who is rarely aroused to anger has a
“small anger-app icon”—all human beings come equipped with an “anger app”—that is situated
far from the home page. You could say that your identifiable personality features—your
somebody-ness—are the readily accessible app icons on your home page.

Here’s the upshot for you to consider, so far as therapy is concerned. In many ways, therapy is an
enterprise of reconfiguring the app icons on a home page. Certain large icons on a home page
may not be the kind of apps a person wants to be easily activated (anger app, jealousy app,
addiction app, etc.). Therapy facilitates the shrinkage of those icons and the removal of them from
the home page. Therapy can also facilitate the placement of sought-after icons onto the home
page. This form of therapy engages with a client as a person without a unifying essence.

Therapy becomes an exploration of apps occupying space on a person’s homepage and a discovery of
long-neglected, even forgotten, apps lying dormant several swipes away from that home page.
Therapy under this paradigm diminishes the impulse to diagnose. To tag a person with a
diagnosis—say, as bipolar or borderline—is to risk engaging with that person as having a
unifying, definable identity. It is akin to treating a smartphone as strictly a phone, or a social-
media tool or an email-retrieval tool or so on.

Are there therapy paradigms that suit this I-am-a-smartphone mindset? In my next two blog posts,
I will investigate two paradigms as possible instantiations of this mindset: Internal Family
Systems and Buddhist-inspired therapies (e.g., mindfulness-based therapies).

Why Therapists Choose Online Therapy for Themselves

Posted on by Psychotherapy.net Team

More and more fellow therapists contact me to seek online therapy (through video-conferencing) for themselves. They come from various places – rural areas or large cities, and from different continents.

What are the reasons explaining this choice?

In a survey that I ran this year with online therapy users about their rationale for choosing this setting, several practitioners happened to be among the responders. One of the reasons they named was that they already knew socially all the good local therapists. This is particularly true for smaller towns and rural areas, but it also often becomes the case after a few years of practice in larger cities.

Another reason is the broadened choice of practitioners. Therapists make sophisticated clients: they usually know what they are looking for, and want a particular approach that may not be available locally. With online therapy, the options are almost endless.

For trainees, having access to a long list of online therapists makes things more affordable, especially for those training in places like New York, California, or London, where the rates of therapists are higher.

Additionally, more and more therapists move frequently to another state, city, or even country. Mobility naturally brings people to online therapy, because when they move they don’t necessarily want to discontinue treatment and start over with a new therapist

My own experience actually combined both – mobility and training needs. When I reached out to an online therapist I was in training, with personal therapy hours to accumulate for my professional accreditation. Simultaneously, I was facing an international move, and it was causing me a great deal of emotional turmoil. It was not my first expatriation, but this time it was hitting me hard – I was feeling uprooted against my will, immensely angry at the circumstances and literally sick with anxiety. I was relocating to a country where I did not speak the language well enough to reach out to a local therapist. A therapist online, with face-to-face sessions via videoconferencing, seemed like a reasonably good option. It turned out to be a bold choice that worked for me.

Beyond these practicalities there is a subtler psychological reason: the feeling of shame.

Marie Adams discusses therapists’ mental health in The Myth Of The Untroubled Therapist: there is a tacit expectation for us, as therapists, to be “all sorted.” But ironically enough, we are not immune to the shame associated with mental health struggles.

Reaching out to a therapist who comes from a different cultural background and lives thousands of miles away can help us overcome the “shame barrier.” Many of my clients acknowledge that online therapy allowed them to jump into it, overcoming the very natural feeling of shame associated with the exposure that any therapy requires.

Among my online clients, therapists make a very inspiring bunch. Negotiating this particular type of peer therapeutic relationship presents its own fascinating challenges. The enhanced face-to-face experience offered by the screen enables intimacy for therapists who often find it uncomfortable to be in the client’s chair or, in this case, on the other side of the screen.

The online option may also foster cross-cultural exchanges beyond borders: there is no better way of satisfying our curiosity about how colleagues work in a different culture. I remember my own excitement as I first reached out to a therapist across the Atlantic.

As with everything new, the very idea of a therapy that is not in one single room but rather through video-conferencing can be associated with some risk-taking. I hear cautious or even suspicious remarks, mainly from therapists who have not yet tried this new way of making therapy happen. This being said, are we not expecting our clients to take risks daily, venturing into new territories? Therapy, by its very nature, is about risk taking, and as our world changes we have to adapt, and possibly take on the role of explorers ourselves. 

How To Help Your Clients Undo What They Haven’t Yet Done

Posted on by Psychotherapy.net Team

Once, a man who was recently released from prison told his counselor how enraged he was that he just had his wallet stolen from him. This man was visibly angry as he described having $450 dollars in that stolen wallet; and to make things worse, he had a strong suspicion who stole it. He told the counselor that he was going to seek out the thief, get his money back, and kill him. The counselor did not flinch, judge, or panic when the man told him he would seek out and kill the thief. Instead, he asked the former prisoner how long he’d been incarcerated. “I was down for 8 years, and I just got out,” the man replied.

The counselor asked, “Did you like your time in prison?”

“What?” replied the man angrily.

"Did you like spending time in prison?" the counselor repeated in honestly inquisitive voice.

The man then stared angrily and directly into the counselor's eyes and asked, “Did you ever spend time in prison?”

“No,” said the counselor.

“I didn’t think so,” said the man angrily, and he looked away shaking his head in disgust.

The counselor prodded further, again, genuinely inquisitively, “Let me ask you: In all that time in prison, were there ever moments when you wanted to get out?”

The former inmate seemed to get even angrier at this question, “What’s wrong with you?” he asked. “Of course I wanted to get out! I wanted to get out every single day!”

Unfazed by this man’s anger, the counselor asked, “How badly did you want to get out?”

The man, now visibly more agitated and enraged, stared down the counselor intensely and said, “I wanted to get out every second of every day!”

And the counselor asked, “What would you have done to get out?”

And the man, still staring through the counselor, replied sharply, “Anything.”

“Anything?” asked the counselor, matching the man’s eye contact and in a firm voice of his own.

“I would have done anything!” said the former inmate, stepping aggressively toward the counselor.

The counselor looked piercingly but compassionately back into the eyes of the angry man without flinching and finally asked, “Would you have paid $450?”

The man stopped. He got it. He understood. The counselor's words moved through him. He realized that if he would have killed the man who stole his $450, he would have ended up in prison (this time probably for life), and while he was in prison, he would have “done anything to get out,” certainly including paying $450 – and his anger left. He thanked the counselor and walked away.

Now, this is a true story, and the client was mine, and because it’s a true story, you probably want to know the rest of what happened, so I’ll tell you. The man, the former inmate, he was calm enough after talking to me that he went home and went to sleep instead of seeking out the man he believed to be the thief who stole his money. In the morning when he awoke, he said a thankful prayer that he didn’t go after that man and end up in prison. In fact, he even imagined that he paid the amount that was stolen from him and was now free. He felt so good knowing that he resisted acting on impulse for the first time in such a long time, that he decided to make another good decision and clean his room as soon as he got out of bed. To his grateful surprise, not long into his picking up the pile of clothes off the floor of his room, he found his wallet – and the $450.

The question you can ask your clients is this: How much would you pay to undo impulsive decisions you've not yet made? Would you be willing to pay the price of self-control? In the safety of your counseling office, it's often helpful to play out your clients' most impulsive thoughts without the slightest bit of judgment. The more you can play out future scenarios, impulsive decisions, realistic consequences, and what your clients would be willing to do to go back and "undo" something that they haven't even technically done yet, the more you can expand their consciousness and move them from the impulsive, emotional center of their brain to the higher-level thinking center that will help them make more effective decisions.

It's never too late to undo what hasn't yet been done.