Author: Psychotherapy.net Team

Cancer and The Secret

Posted on by Psychotherapy.net Team

Rhonda Byrne’s metaphysical book and DVD, both titled The Secret, have challenged the consciousness of millions worldwide. The film has reportedly helped many people improve their lives by sharing a “secret,” the metaphysical law of attraction. Essentially, this law states that what we think and feel will directly determine what we attract and thus experience, putting us each in control of manifesting the reality we wish to create.

Stay Positive

Two practices described in The Secret include working with a vision board and keeping a gratitude journal. To make a vision board, the individual must become conscious, clear, and specific about what he or she wishes to manifest. Once this is clear, the person creates a collage by drawing, painting, or cutting out magazine pictures that represent these desired realities and then posts them onto a bulletin board. The vision board is kept in a place where the individual will look at it daily. The individual thinks about these realities and actually imagines himself having these things/people/experiences for a few minutes each day. John Assaraf, a successful entrepreneur featured in The Secret, describes his personal experience with vision boards in an interview with Larry King.

A gratitude journal is a daily practice focused on recognizing and consciously experiencing the positive and wonderful things one already has. A common practice is to list five or ten things at the end of each day that you are or were grateful for that day. Theoretically, gratitude, like any positive feeling, attracts more positive feelings, things, thoughts, and experiences. Both of these practices train a person to imagine, thinking about, feel, and focus on the positive things—either those that the person already has or those that they wish to create.

These tools are useful practices. However, I feel that the film overemphasizes the need to be positive.

This shiny-happy-people approach can be problematic for individuals facing loss, depression, and physical illnesses like cancer.

Is there not a night-side to life? The Secret’s segment on cancer, especially, may give an oversimplified message.

In the film The Secret, a breast cancer survivor details how she defeated her cancer without radiation or chemotherapy. She explains that she healed herself with the law of attraction: by thinking positive thoughts, watching funny movies, and telling herself multiple times throughout the day that she was healing. As a cancer survivor, myself, I have to admit that the watching-funny-movies bit put me off; it seemed a bit ridiculous as a cancer treatment. But I got the point: she did whatever she could to keep her spirit up and stress level down. From health psychology and psychoneuroimmunology, we know that stress is counterproductive to healing. But “is it reasonable to believe that we have to be positive at all times in order to heal?”

Do our thoughts actually create physical reality? If I believe that my life is a product of circumstance, largely outside of my control, and that all that I have created now is all that I will ever create in the future, I will likely mope through each day creating more of the same. We’ve all seen this in ourselves, friends and clients. If, however, I subscribe to the law of attraction and believe that I can create anything I wish by feeling good and thinking positive thoughts, I will perhaps engage with life more fully, set clear goals and work to create the things I wish to experience. Such a strategy can be life changing, and not too far off from some positive psychology and cognitive-behavioral interventions. I begin to feel hopeful and empowered. I continue practicing positive thinking, writing in my gratitude journal, visualizing what I wish to achieve. By the law of attraction, I begin attracting more and more of these positive thoughts, feelings, health, objects, people, and circumstances into my life. Wow! Things are really looking up!

Downward Spiral

The problem, however, surfaces when I wake up one day and just can’t get myself into a positive frame of mind. The pressure mounts, especially if I believe the implied corollary to The Secret’s hopeful message: that negative thoughts will send my life promptly into a negative spiral, attracting more and more undesirable things. In an effort to be positive, I may try to deny what I am truly feeling. I begin to feel frustrated, stagnant and confused; soon I am in a tailspin.

The danger of The Secret’s message for cancer patients, in particular, is that they might begin to feel that they are now to blame for their illness and that their thoughts are solely responsible for their healing. “I probably caused my cancer by being so negative. I now have to watch all my thoughts and feelings if I want to heal.” Cancer patients may begin to feel a need to be positive at all times, since negative thoughts and feelings will only create more of the same, presumably exacerbating the disease. This style of thought is reminiscent of the cancer personality research and Temosho’s type C personality, which received criticisms from patients for the same reasons. Cancer patients felt an added sense of guilt and blame on top of fighting for their lives.

Let’s take the hypothetical example of Sally, who is in breast cancer treatment and has begun using the law of attraction, visualizing herself as a beautiful, healthy, powerful young woman. Each day, she envisions herself leaving the cancer center for the last time, never to return. She imagines herself inspiring others to make the same positive changes in their lives and has been feeling great! Her CT scans are improving, she hasn’t been sick from the chemotherapy, and she has been meeting more positive people and experiencing scenarios that she imagined. She practices her visualizations and focused desires each morning, and spends time being grateful for the wonderful things in her life. Sally has really benefited from her new metaphysical practices.

Today, however, she’s feeling very sick; she is tired, angry, worried, and anxious, and she doesn’t know why. Sally begins to worry that her negative state of mind is going to make her sicker and ruin everything she has worked for. Sally begins to think, “If I’m not thinking positive thoughts, my cancer is going to grow. Oh my god, I can’t feel happy right now; I am going to die.” “Soon, she is feeling even worse than she did when she woke up because she feels bad that she is feeling bad!” I call this a “mind f*@%,” and yes, that’s a clinical term. It can spiral down pretty quickly. Sally, without other tools in her toolbox, becomes despondent and confused. She feels powerless, perhaps even more powerless than she felt pre-Secret.

Another metaphysical law not discussed in The Secret is the law of rhythm. This law simply highlights that there are both ups and downs in life. “The tide of the ocean goes out and it comes back in. No one is maniacally happy and positive all the time.” There is a flow to being human, and that includes times of reverie, reflection and even sadness.

Finding the Rhythm

This catch-22 is often the place where people get stuck. A colleague said to me one day,”Have you heard of The Secret? What a load of crap! I have more people coming into my office upset about this thing. You can’t just be positive all the time; you have to work on your issues.” Unlike my colleague, a hardcore psychoanalyst, I do not agree that The Secret is a load of crap; I believe the philosophies are empowering and useful. But as a therapist, I agree that it is indeed necessary to welcome times of sadness or reflection wherein we might work on some “issues.” It’s unreasonable to expect to feel happy, positive and powerful all the time. There is a flow to life: sometimes we are down, other times we are up. There are days when issues are going to grab hold, unpleasant things are going to happen, and we are going to feel bad, sad, mad, and even helpless; we’re human. Rather than try to suppress these difficult thoughts and feelings, it is useful to become aware of what they are about, especially if they seem to come up over and over again.

For the most part, our hypothetical cancer patient Sally is on the right track. She should continue to focus on what she truly desires and work to make that a reality. Life is a beautiful creative process, but also sometimes a process of unraveling. Sometimes, like Sally, we are down, and that just is. “These downtimes are a necessary part of life. We must be willing to be with that aspect of our experience, too—maybe even feel grateful for it.” On second thought, gratitude might be pushing it.

We would all like to avoid stress, pain, and sorrow and live forever carefree in the land of positive thoughts and feelings. The reality, however, is that these “negative” elements are pieces of human existence. Navigating bad feeling states with a bit of acceptance and curiosity will make the journey less painful. Training and experience tell me that emotions shift only when they are fully heard. There is no getting around this piece, and that is no secret.

References

Byrne, R. (2006). The Secret. New York: Atria Books.

Holland, J., & Lewis, S. (2000). The human side of cancer: Living with hope, coping with uncertainty. New York: HarperCollins.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002). Psychoneuroimmunology: Psychological influences on immune function and health. Journal of Consulting and Clinical Psychology. Special Issue: Behavioral medicine and clinical health psychology, 70(3), 537-547.

Kiecolt-Glaser, J. K. (1985). Psychosocial enhancement of immunocompetence in a geriatric population. Health Psychology, 4(1), 25-41.

Kiecolt-Glaser, J. K. (1984). Psychosocial modifiers of immunocompetence in medical students. Psychosomatic medicine, 46(1), 7-14.

Simonton, C. O., Simonton, S., & Creighton, J. L. (1978). Getting well again. New York: Bantam Books.

Temoshok, & Dreher (1992) The type C connection: The behavioral links to cancer and your health. New York: Random.

Food for the Soul

Posted on by Psychotherapy.net Team

A Call and Response to Feed My Soul

It is easy to know when the body needs food: our stomach growls, our energy level drops, or that "time of day" creeps around. But how do we know when our soul needs food? Do we take more vacations internally? Do we wish or want to be somewhere else? Are we available to hear the hunger call from the soul, and if we hear it, how do we respond as psychotherapists? How do psychotherapists feed their souls?

Do we go on a retreat, meditate, vision quest, make a pilgrimage, snorkel, travel, read, garden, or just unplug the phone and computer and stay home in the solace of our own bedroom? What satisfies one will not necessarily satisfy another. It reminds me of ordering a meal with a friend and then asking, "Where did you find that on the menu?" Not that I especially wanted what she ordered, but I did not even see it.

What continually calls to me the loudest is what I have come to know as my soul call. Listening to the call is the essential ingredient. Sometimes, the call comes several times before I respond. I imagine that the soul leaves messages on my inner answering machine. Russia started calling to my soul about four years ago. Jim Bugental asked me to help train some Russian psychologists who were coming to California for a few weeks. It was a challenge that I met with enthusiasm.

Inside, I held a deep curiosity about Russians. Since childhood, I had viewed them as a mystery. Russia was also a scary place for me as a child—a place full of people who had the power to scare me into the basement of my school, make me cover my head, and pray their bomb would not fall on my school.

There was never a bomb dropped. Instead, my curiosity was engaged. Who were these people my parents and other adults feared so much? That nagging question began to be answered during this training. I engaged in many conversations with the Russians as their teacher in various classrooms and over coffee. It was clear we had many things in common. They were very gracious people and extended an open invitation for me to visit their country. The Russians were no longer a mystery, but individuals, with concerns very similar to my own: children, education, health, money, growing old, losing, gaining, and all the other multiple facets of the human condition.

It felt good to have a general invitation, but I remember clearly saying I had no interest in going to Moscow; perhaps I would like to go to St. Petersburg to see the Hermitage, the great art museum. There was really no depth to my response. I was surprised at my reaction, because travel has always fed my soul. I enjoyed the students very much, but felt no great internal push to pursue going to Russia at that time. However, a message had been left on my inner answering machine, to be retrieved in time.

Several years passed and Bugental gave me another invitation. This time it was to teach existential-humanistic psychotherapy in Russia. Now my reaction was completely different. Meeting this opportunity appealed to me. This time I answered yes to going to Russia.

Why was I open? There, from inside, a real push had manifested, a yes. How could I know what this yes was about? Was it an ego call or a soul call? Where was this yes coming from in me? Since there was little money and little recognition involved, the inner pushing did not have the feeling of an ego call.

What is a soul call? The calling is uniquely expressed in many traditions, such as the Buddhist's dharma (duty) and the Greek's daemon. I have come to respect that for each of us the call and the response is unique. There are many ways of responding to a soul call. The need to satisfy physical hunger is present daily in each of us. The push to satisfy soul hunger seems to be more evident in times of loss, life crises, conscious searching, or "wake-up calls" (at the least expected times). Such unexpected calls can happen as a child darts in front of our running car and we slam on the brakes. Several of these calls in one day usually trigger self-reflection. Is there a message in these events? If so, what is it? What do I need to look at and attend to?

Life circumstances might be comfortable or paradoxically chaotic, when a soul call comes. The Russian invitation came at a time of comfort in my life. It was a wake up-call for me—an invitation to move out of my comfort zone, to seek nourishment for my soul in a foreign land. I knew pilgrimages as a deep form of nourishment for my soul. I had been a pilgrim to the East: India, Turkey, and European countries. Now everything in me said yes to Russia. There was a subtle feeling to the yes, as if a hint were being whispered into my ear. I felt deeply excited.

A Call to Adventure

Joseph Campbell wrote in The Hero with a Thousand Faces that the hero's journey begins with the call to adventure: "The call rings up the curtain, always, on a mystery of transfiguration—a rite, or moment, of spiritual passage, which, when complete, amounts to a dying and a birth." Was this journey to Russia a hero's journey? Other psychotherapists had certainly made this journey. Were their journeys rites of spiritual passage? I had no idea at the time. Many months later, I knew this journey was definitely a spiritual feast for me. This call to adventure called upon all the stuff I am made of and more. Everything I taught, I lived.


Moscow River

The first leg of the journey required my becoming adept at the great nineties voyager, electronic mail. Everything was arranged by e-mail. The fabric of trust and responsibility was being woven through this electronic medium. There was only one vital piece missing: what did my colleagues in Moscow look like? We had not met in person. I did not think about this human fact until I got off the plane and found no one there to meet me. I quickly reassured myself. I remembered sending a video of myself. They should be able to recognize me. The fact remained that no one was there to meet me.

I began to feed my fears by reminding myself of the ruble crisis. Then my mind would quickly switch to reassurance. I had received no e-mail telling me not to come. The voice of fear would come for more food. I would feed it with excellent morsels. Maybe the e-mail had failed. It certainly wouldn't be the first time. I could even go a step further and say this whole journey was stupid.

I was at the point of mental exhaustion when a striking blonde woman emerged from the crowd. She looked at me and said in clear English, "Seminar, seminar?" "Oh yes, yes, seminar," I gleefully responded. We politely shook hands. The truth was that I restrained myself from embracing my apparent rescuer. Needless to say, I had no clue of the fears yet to manifest to my waking consciousness.

In broken English, I was introduced to a gentleman who I understood was the professor who had been e-mailing me. We laughed about our e-mail. In very broken English, they asked where the other person was. I explained with the help of my fingers that there was only one, never two. We proceeded to the sidewalk with my luggage. I was then informed that the seminar started that night. I remembered that this was not what we had arranged, but let this communication pass as the language barrier seemed impossible in my tired state. First, they would take me to my hotel. As the door to the car opened, I communicated as clearly as possible that in the last e-mail, we had confirmed my staying with the professor and his family. They confirmed this was absolutely not true as I stepped back from the car. The woman then said in very clear English, "Football seminar!"

I responded, "Psychology seminar!"

All communication stopped as they rushed back inside the terminal. As I stood on the sidewalk with my luggage and looked inside the distant terminal, I had no clue about what was to come next. I could not help but laugh as I thought of missing my son's football game that day. And yes, if I had come for the football seminar, I might actually get some fame and money. My journey was definitely not one for the ego. At this point, I would need some heavy reliance on my soul.

It was certainly an existential moment. What were my choices? I decided to return to the terminal and wait by my arrival gate. As I pulled my bag, I looked into the terminal. For the first time, I had the very sharp awareness that the area I was walking into was filled primarily with men. There were very few women. The voice of fear came up. What am I doing here? This time a layer of courage and determination that I knew I could depend upon emerged over the fear. I had come to know this part of myself in many other circumstances in my life. I knew I would be fine. I could meet this situation with quiet resolution.


(L. to R.) Dr. Myrtle Heery,
Dr. Anatolii Naminach,
Dr. Elena Korablini in Moscow

Within minutes after I got to the gate, another blonde woman arrived, and said to me, "Seminar?"
This time I responded, "Psychology seminar?"
She smiled and immediately hugged me. I felt a physical relief for both of us as we stood for a few seconds longer in our shared hug. In excellent English she said, "Myrtle, welcome to Moscow. I am so sorry we are late. There was a terrible traffic problem."
The story of my arrival would be told and retold in Russia and America. It would be a central thread in my adventure. In so many ways, all of the human emotions that needed to come out of me did during this airport experience. My fears, doubts, mistrusts, excitement, humor, and hopes were all present. My ability to make choices, to take responsibility, and to recognize the limits of my situation were all present. The knowns and unknowns were present. My capacity to fully live the present moment was supported by a deep reverence and trust for life. I had answered my soul's call.

How are we to build a new humanity? Reverence for life. Existence depends more on reverence for life than the law and the prophets. Reverence for life comprises the whole ethic of love in its deepest and highest sense. It is the source of constant renewal for the individual and for mankind.


Dr. Anatolii and Larissa Naminach

Reverence for Life

The seminar in Moscow was held in a spacious, light-filled room across from a monastery, where tourists regularly step out of large tourist buses to visit. In the monastery across the street time was marked with prayer and chanting by the monks, while our time was marked with psychological exercises searching the inner worlds of the participants. In each environment—the monastery and the seminar room—there was an atmosphere of reverence for life. The pilgrimage to the monastery brought to my mind my pilgrimage to Russia—my search for meaning in my life. In this moment of great unknowns in Russia, I, along with the other participants in the seminar, was searching for meaning. Both the monastery and the seminar held a simultaneous unspoken hope, a reverence and caring for human life.

The ruble was crashing and there we sat faithfully searching. I had read in the American newspapers how there was an atmosphere of great fear and insecurity in Russia.

No one knew what would happen next. In spite of the uncertain economic moment, we had a full house and participants came dressed in their finest, ready to take part. I wondered if the same seminar would even fill given a similar economic scenario in America. Dr. Naminach, my host in Moscow, and his staff were organized, caring, and eager to learn. Bugental's book, The Search for Authenticity, had just been published in Russian and was available at the seminar. There was an air of excitement.


Colleagues in Moscow

The participants seemed fully capable of holding the dichotomy of outer economic insecurity and exploring their subjective inner lives in the moment. Their presence and eagerness to explore their subjective worlds moved me. I found myself humbled by the courage, intensity, humor, love, and genuine goodwill of the individuals who organized and attended my seminar. As my eyes scanned the audience, I had the experience of looking into many souls; language was not a problem. The first day, a delightful man named Deema translated for me. He had translated for Carl Rogers and Virginia Satir when they came to Moscow in the '80s. I felt both honored and humbled as he reminded me they both died about a year after he translated for them. This delightful man reminded my ego that in his previous experience, fame had been quickly followed by death, lest my ego become too puffed up with importance. He had a twinkle in his eye as he mentioned the fact of death. We laughed about the possibility of my death and settled quickly into a very somber recognition of the reality of my death, his death, and everyone's death—a topic not easily mentioned in my country. Humor marked with serious intent became a familiar paradoxical theme while I was in Russia. The Russians had the gift of taking a very serious matter such as death, throwing it up in the air with laughter, and letting it fall to the earth with all the gravity of life.

The work of mobilizing concern for what truly matters for the individual—an essential part of the therapeutic hour in my private practice in the U.S.—was not an issue in Russia. These were already in place due to the difficulties of daily survival. The elements that did need addressing were choicefulness and responsibility. To begin to see choices was difficult, but taking on the responsibility of a choice seemed monumental for the Russians. This underlying theme was palpable.

There were, of course, the usual human problems of relationships, children, work,


Russian Orthodox Church
St. Petersburg
betrayals, losses, aging, isolation, and death. Nothing on the surface seemed new, yet I knew I was definitely someplace and somewhere new. I grew up in a democracy where external freedoms have been abundant all my life. These external freedoms were a vastly new world construct to these people, and their inner selves were grappling with new systems of being in their world.

There was the long history of Stalin, Lenin, and of communism. These external systems had led the individual. Like it or not, the government told you what, when, and where to be and do. Now people had the freedom to choose, or did they? What I immediately found was that people were hesitant to take on the awesome responsibility of their lives. Now they were eager, but so many obstacles were lurking. I did what Bugental refers to as a live demonstration of our work. A volunteer from the participants would sit with me for 15 to 20 minutes and work on a concern in front of the group with me. This is not "hot seat" work from Gestalt therapy. The Russians were very familiar with gestalt work and wanted to know if this demonstration would be the same. I shared that it was not. In fact, it could be a cold seat, if that was how the participant wanted to use his or her time. The choice is made in the moment. It is a time of genuine presence for both the therapist and the volunteer. Of course, there is an element of being on stage, but I have done this so frequently that I know from experience that the audience very quickly melts and the work in front of me becomes enlivened in the moment.

I referred frequently to Bugental's forthcoming book, Psychotherapy Isn't What You Think, which I helped edit. In response to the live demonstration, the participants said it was not what they had thought it would be. These demonstrations seemed to help the participants help each other later working in pairs. The focus of the work is the moment. Psychotherapy is the lived moment, not history-taking and interpreting. In the demonstrations I continually brought each person into the moment. Sometimes I would access the moment by bringing awareness to physical gestures or citing a here-and-now emotion present in the volunteer. A simple example was my comment on one volunteer's laughter when she was with me. The awareness of that moment drew her into the next paradoxical emotion of sadness. She was eager and ready to search inside herself. Her searching took her through many emotions, images, and a decision to take action on a very difficult relationship. Another volunteer became acutely aware of crying from only one eye, a characteristic that she slowly chose to change. The ability to let both of her eyes cry echoed her need to let all of herself be present in the moment. It was frightening, yet she was able to make this courageous step in front of many people.


St. Petersburg Colleagues

Engraved on the Soul

In St. Petersburg, Dr. Korablini and her staff also proved wonderful hosts, fulfilling my dream of a visit to the Hermitage. The seminars followed a similar structure to those in Moscow and the accompanying excitement was also present. While working with me, one volunteer participant placed her hands in prayer position in silence for several minutes. I broke the silence by commenting that her hands were in prayer position. She nodded yes and continued. Raising her head and hands still in prayer position to the ceiling, she openly wept. I had no idea what she was weeping about, but the entire group, including myself, wept with her. It was a moment I will forever treasure. There were no words, just the physical gesture of prayer and tears streaming down her face. Much later, after the group came back from the depths of our individual souls, we accessed our spirits and flew together in the absolute delight of our unspoken experience. Perhaps, as James Hillman says, the soul is in the depths of our being while the spirit flies. We moved as a group through the depths of healing without words. The volunteer then told us she felt she could continue with the very difficult tasks confronting her life. This "soul holding" had enlivened her to be herself, to live her life with all she had available to her.

Soon after this experience I returned home, to my family, my private practice, garden, music, and dog. I sometimes see this woman's face and the faces in the group weeping together etched in my memory as I trim my roses, listen to my clients, or watch my child's soccer game. The tears have been engraved on my soul.

This article was originally published in the Journal of Humanistic Psychology, Vol. 42, #3, Summer 2002, 89-101. Reprinted with permission.

Where’s the Bear?

Posted on by Psychotherapy.net Team

In an early chapter in my general psychology textbook's discussion of behavior, it said, "I see a bear; therefore I run." That seemed sort of obvious to me. The next line went on —"I run; therefore I see a bear." The more I thought about that, the less I got it. So I asked my professor. He said that it was probably the most important thing I would ever learn in psychology and that I should think about it until I understood. It's taken many years but he was right. It's an enormously important metaphor. Let me show you how it works.

“If you act frightened, you'll soon find something to be frightened of.” 

Acting As If

Mary and John were considering divorce. Her trip through menopause had coincided with the end of his career and they quarreled about everything. The content of their bickering wasn't as important as the tone. "You're wrong," was the first response out of either of them. Each of them saw the other as critical and demeaning. Even after many sessions of therapy, they continued to demean each other.

On a Tuesday at their regular appointment, I asked them to act "as though" they liked each other a lot. They looked at me as though I was crazy. "I'm serious," I said. "Move your chairs closer together and hold hands while we talk. After you leave here, go for an ice cream cone and look at each other with soft, loving eyes as you lick your sweets. I'd like you to keep that kind of pretending up until you come back here on Friday."

"But," Mary protested, "that's like lying."

"Yup," I said. "It's called acting."

On Friday, they came in laughing at a private joke. The animosity was gone and they were excited. "Maybe there is hope for us," said John. "I'd just about given up. Why did pretending work?"

"If you act frightened, you'll soon find something to be frightened of," I replied. "If you act angry like you and Mary were, you turn each other into enemies."

Finding Something to Fear

Another application of this metaphor is what happened after 9-11. We were frightened and the enemy was, for the time being, unknown and unseen. When people feel afraid, they tend to look for something to explain their feelings, seeing an enemy or danger around every turn. Anything to somehow justify the fear, even when there is no bear. Wars are begun over such things.

This is the same principle we put to use upon walking into a scary situation: taking a deep breath, standing tall, holding our heads high. Often, if we do this, our anxiety vanishes and we find there is no "bear" there.

When a Patient Dies . . . Should the Therapist Attend the Funeral?

Posted on by Psychotherapy.net Team

Unless we are treating medically ill or very elderly patients, we’re not likely to think of our patients as being at imminent risk of death, at least not while they are under our care. Patients leave therapy for any number of reasons, but few clinicians are prepared for the possibility that termination would take place because a patient has died. I had been worried about Jim* for months, urging him to see a physician for his deteriorating health, particularly his strained breathing. The fact that Jim was similar to me in age (early fifties) made the issue all the more personal for me. When I began seeing Jim as a psychotherapy patient some nine years earlier, our expectation was that we would meet for only a few months. Jim had grown increasingly concerned about troubles in his marriage, and he wanted to figure out what he was doing wrong. The story that unfolded during the subsequent years was tragic in so many ways. Oddly, as matters got worse in Jim’s life, the alliance between the two of us got stronger.

When I received the phone call from Peggy, one of Jim’s friends, I sensed that I should rush to the hospital. The fact that Jim had actually, finally, gone for medical help led me to believe that he must have been in desperate pain. As I arrived at his bedside, he gave me a wry smile, so common in our exchanges, so much like the amused look that he would give in our sessions when he said something completely outlandish about the state of affairs in our world or our town. It was evident to me that Jim was at the threshold of death, a hunch confirmed by the nurse who entered the room during our chat.

During dinner at home that evening Peggy called from the hospital to tell me that Jim had passed away. I excused myself from the table, and went to my study where I reflected with deep sadness about the loss of such a precious person. “A bit surprised by the depth of my grief, I felt caught off guard as I tried to discern the reasons that Jim had affected me so deeply.” I reflected with fondness on the years of our work together, but also questioned what I might have done to help him obtain medical help before the point at which his body began to surrender. Over the course of Jim’s nine-year therapy, Jim brought me some of the most difficult issues I had encountered in three decades of clinical work.

Soon after Jim had started therapy, his wife asked him for a divorce, causing him to become depressed and neglectful of his physical well-being. Jim began to drink heavily in his desperate attempts to alleviate the incapacitating emotions with which he struggled on a daily basis. In time, he lost his job as a salesman because of his increasing unreliability. Without work, Jim then was left without insurance coverage. His financial picture worsened on a daily basis, and he eventually became destitute as he found it necessary to allocate his minimal savings to cover the expenses of a protracted divorce and custody battle. As Jim’s psychological, financial, and medical problems intensified, I found myself juggling several roles in my work with him. In psychotherapy, we focused on his emotional well-being, with particular attention to his worsening problem with alcoholism. Although Jim was responsive to therapeutic work focusing on abstinence, he periodically relapsed in response to stressors in his life. In the financial realm, Jim was able to turn to close friends to help him procure the basics of life, but he had nothing more than what was needed to sustain himself.

As for his deteriorating medical condition, I helped Jim connect with a public health nurse who agreed to consult with him as well as facilitate the process by which he could obtain basic medical care for critical physical conditions. As the months and years flew by, Jim was looking sicker and sicker each time I saw him. In one medical consultation the nurse became deeply concerned about Jim’s strained breathing, and insisted that he proceed with her immediately to the emergency room so that he could be admitted to the hospital. The end would come only two days later, leaving me no time to process impending death with Jim, or for that matter gather my own thoughts in anticipation of the loss.

Responding to a patient’s death

Although I had seen hundreds of patients over the years, and had supervised or consulted on thousands of cases, I had not yet dealt with the death of one of my patients. I had no script but I had many questions. Should I attend the funeral? How will I identify myself? Do I send a sympathy card or flowers to Jim’s sister? If I attend the funeral, how should I interact with his son, or with his ex-wife who would probably accompany their son to the funeral? Jim’s ex-wife and I had met once, at the very beginning of my work with Jim, to discuss their marriage; presumably, she would remember me. Certainly, she had heard quite a bit about my involvement over the course of the nine years, particularly in the form of the reports I had written relevant to the custody evaluations. In addition to the pragmatic concerns, what about the emotional issues? How would I process my own grief? With whom could I consult to deal with my questions, my concerns, my sadness?

I was also unprepared for the ethical issues that emerged. When Peggy called to inform me of his passing, she said that she hoped that she and I would have the opportunity to process our feelings about Jim, and our reaction to the loss. On several occasions Jim had given me permission to speak with Peggy regarding my concerns about him. Jim knew that she and I shared a commitment to his well-being. However, would it be ethical to disclose anything about my therapeutic work with Jim? I thought not, although I did feel that it was permissible to concur with statements about what an impressive man Jim was, and how he had touched each of our lives.

The ethical quandaries continued when I received a call from Jim’s sister, who phoned to thank me for all that I had done for Jim and to invite me to the funeral, saying that she knew it would mean so very much to Jim if I were present. She had known that Jim had been unable to pay for his sessions during the past several years, and expressed her deep appreciation for my kindness in continuing to see her brother. Although she offered to pay his debt, I explained that I couldn’t accept the offer. I was well aware of the fact that his sister had minimal financial resources, and that there would certainly be no estate in Jim’s name.

Should I go?

Should I attend the funeral? How could I not go? After reflecting on the words of Jim’s sister about how much it would mean to him, the decision became clear that I should be present at the celebration of Jim’s life. As I pulled up in front of the stately church, I fretted about when I should enter and where I should sit. I sat inconspicuously in the middle of the congregation, attending to the eulogies, and quietly grieving the loss of such a special man. Following the ceremony, Jim was buried in an adjacent cemetery while additional prayers were read. To exit the burial area it was necessary to pass through a receiving line consisting of Jim’s sister, his son, and his ex-wife, all three of whom were aware of who I was and the nature of my relationship with Jim. I offered the customary expression of sympathy, all the while feeling constricted in terms of what or how much I could say.

Somehow I expected that the story of my relationship with Jim would not end on the day of his funeral. I anticipated a call from his sister, another from Peggy, perhaps from his ex-wife, and possibly from his son. I was relieved that I wasn’t contacted by any of these individuals, or anyone else for that matter. In the years since his passing, I’ve wondered why I had even anticipated such a contact. At the risk of sounding egocentric, I had come to realize that Jim’s son, his friend Peggy, and I—his psychotherapist—were the most important people in Jim’s life. Wouldn’t family members, or close friends, want to extend condolences to me? Obviously, such a wish had more to do with my needs than with the reality of the situation. However important the therapist may be, in the eyes of others, the therapist may or may not be all that different from the accountant, or even the auto mechanic, for that matter.

Many people might wonder why a therapist would experience grief at the loss of a patient. Unlike a planned termination with a long-term patient, Jim’s death left me feeling a sadness for a life cut short, frustration about clinical work abruptly terminated, and an aching feeling of emptiness resulting from the loss of someone I cherished. To process my grief, in the week following the funeral I turned to a colleague who guided me through a cathartic discussion about my reaction to the death of this special patient. “We spoke about the grief evoked by the death of Jim, and also about the reactivation of grief associated with previous losses of significant people in my life.” Specifically, I found myself becoming stirred by thoughts and memories pertaining to the death of my parents. In so many ways, memories of being nurtured by caring parents as a child evoked associations regarding the ways in which Jim relied on me for help, support, and kindness. The cycle of life and death continued.

Honoring . . . grieving

There’s no question in my mind that adhering to the highest standards of ethical and professional behavior is essential, irrespective of the situation. My patient’s privacy must be protected, dead or alive; the secrets I hold must go with me to my grave. At the same time, I cherish the wonderful relationships I have had with many of my patients. Just as I have become a compelling voice in their lives, they have also become part of me. Out of respect for this valued alliance, we need to grieve. We need to find ethically informed ways to participate in the rites of death and the process of mourning.

There are, however, circumstances in which attending a deceased patient’s funeral may not be appropriate. Many patients are not as open about being in therapy as Jim, who had talked to me often about his discussions of our clinical work with his sister, his friend, his son, and even his ex-wife. However, for patients who are secretive about their therapy, the presence of the clinician at a funeral, especially a small gathering, might be problematic because mourners might infer or ask about the relationship with the deceased. Risking such a confidentiality breach must be avoided, necessitating that the clinician grieve in private rather than at the funeral. Or, had there been ongoing legal problems or animosity involving relatives and significant others, the presence of the therapist at the funeral might be provocative, and therefore inadvisable. If and when such events recur, I will again consider the dilemmas, seek out consultation, and strive to make choices that are ethically and clinically grounded, yet informed by caring attitudes.

“I feel at peace regarding my choice to attend Jim’s funeral. I know that I would have felt terrible pangs had I chosen to stay away due to a rigid, unfeeling worry about professional boundaries.” The decision was less complicated due to the fact that Jim was so open about his therapy under my care, and also by the fact that the funeral was well publicized and drew a large crowd. I was touched by the fact that several people came up to me to say, “You must be the Richard” whom Jim so often mentioned. If I had not been a known character in the play, I still would have attended, but with the demeanor of a saddened distant acquaintance at a large ceremonial gathering, rather than as a person in whom Jim had invested the stories of his life.

I also felt that I had benefited in many ways by my relationship with Jim through the positive energy, the intelligent dialogue, and the profound humanity he brought to each of our interactions. Jim left me with intangible gifts that continue to enrich me professionally and personally in many ways. Honoring Jim, and grieving with others who cared deeply about him, felt important and right.

* Note: All names have been altered to pseudonyms.

Lowering Fees in Hard Times: The Meaning Behind the Money

Posted on by Psychotherapy.net Team
These days therapists are hearing about the bad state of the economy not only from the news, but also from their clients. And many of us have been affected ourselves by the economy in one way or another. In discussing how world financial events affect therapists with a group of colleagues recently, up came the topic of priorities, money and how we help both our clients and our practices prosper.
 
The topic of fees and money in our work is central and worthy, as well as rich with possibilities for understanding much about our clients, how they communicate, what they need and fear, and how they deal with change. But of the many facets to the discussion of money and therapy, the subject of “how we therapists view therapy and the meaning behind the money is most compelling.”
 

Raising Questions

As practitioners we must wrestle with several ideas and feelings all at once. First, what exactly is our creed? We are supposed to be helpful, but what is really helpful when it comes to setting and maintaining fees, particularly in times of financial hardship? Many therapists intuitively feel that we should be generous, even at our own expense. So how do we unscramble all the pieces to make good clinical decisions and take good care of ourselves and our practices?
 
Is therapy a luxury? Is it a necessity? Who decides this and how? Some therapists tell me that they feel guilty charging any fee when clients are having a difficult time financially. Others have shared with me that they are having difficulty paying the fee for their own therapy and supervision.
 
How involved ought we be in a client's decision to begin or continue treatment? Should we encourage clients to stay? Is that too "sales-y"? Do we slide our fee? (Does the massage therapist or physician?) Do we really believe in what we do? Is it possible that coming to therapy actually helps people prosper? And make more money? Why are we hesitant to conduct business as usual?
 
I certainly don't think we should encourage clients to come to treatment that they cannot afford. But I am asking us to consider what "afford" means. What is our work worth to us and why? And what is it worth to our clients?

The Worth of Therapy

Many clinicians believe that therapy is an investment. If we help people to take care of their inner world the way they take care of their outer world, the payoff in emotional well being is well worth the money. But success in our business is not always concretely measurable. In fact, how clients value therapy, use what they have learned and acknowledge the benefits varies greatly from person to person, and is quite subjective. It is sometimes up to the therapist to hold onto the idea that the treatment is valuable and worth the effort.
I think we must be clear about what our work is worth, and confident about the legitimacy of our fee, even when we decide to lower it. We need to be watchful of our own anxiety when we respond to a fee problem. Lots of therapists are actually confused about what the fee is for exactly. “Do we charge for our time, our analytic ear, our guidance, our expertise, our ability to endure and stay with difficult feelings?” It depends on who you ask. Some therapists may even feel relieved by charging a lower fee. They link their own self-worth, value and effectiveness to appeasing the client in this moment of stress. A lower fee feels like less pressure to push for change, and more freedom to just be with the client, which is, in many cases, the best intervention anyway. Ironically, we tend not to recognize the legitimacy of empathic listening alone as valuable and fee-worthy. Some of us operate under the idea that we need to be masters of theory or savvy interventionists in order to earn our keep. Do we underestimate the value of providing a good ear and the healing power of helping clients to talk openly and be understood?
 
Many of us could use a bit of help unpacking our own money issues, and may squirm at the thought of negotiating a fee. But discussing fees is not as tedious as many of us might think. Simple questions such as, "Should I consider changing the fee?" "How might it feel if the fee were lower?" or "How is it going with your finances and paying the fee? Let's talk about that" can help get a good dialogue started. And there may be a difference between the therapist suggesting a lower fee and the client asking for one. If we sense that money is what is in the way of someone continuing therapy—the resistance to it—then we may choose to inquire about it like any other matter in therapy.
 
One therapist I know asks her clients what they have in mind to pay. She also asks how frequently they would like to come. She is committed to consulting with clients about their ideas and wishes, especially when it's about the therapy itself. She likes to model a "feel free to say everything" way of working. Her touch is light, curious and exploratory. And oftentimes money is not really the issue at all, but rather a conversation starter, or a way for the client to communicate to us that something is off kilter in the therapy. Perhaps we have said something wrong, or hit the wrong note with a client. Many clients don't know how to tell us this directly. We cannot understand unless we explore it a bit. “I am reminded of a line from Woody Allen's Manhattan, when he said to his ex-wife, "My analyst warned me about you. But you were so beautiful I got a new analyst."”
 
So there is much to be gained by talking things over in sessions with our clients. Oftentimes money concerns are a perfect way to hear more about what a client needs, how they feel taken care of, what their parents did with money and what effect that has had on them. We may miss the boat on some good work if we merely chalk up financial problems to the economy and leave it at that.
 
When we lower a fee, we are sending emotional messages to the client. What, then, are these messages? Are they always what we intend?
 
“Possible Answers”Sometimes, of course, a duck is a duck. Someone loses a job, or does not have the means to afford a higher fee. But I have seen many different solutions to these would-be obstacles to treatment. Some people come less often; some have to take a break for a while. Some do shorter sessions. One therapist I know does online counseling, and since it's more convenient for her, she feels she can charge less. Some therapists do reduce fees when the need is clear, and with the understanding that when things get better the fee will be returned to its regular status. Others save a few sliding-scale slots as part of their overall caseload and reserve them for a population they feel most needs it, such as young adults or single parents. There are many possible answers, but I think we have a better chance of landing on the best ones when we are conscious of the unconscious and allow for some good discussion all around.
 

The Importance of Communication

In some cases, suggesting or agreeing to lowering the fee may be communicating the idea that we agree that things are indeed pretty bad for the client, and they won't get better—that they are poor and perhaps helpless to figure out how to figure out their money situation. We may be sending a message of despair, not of understanding and support. Other clients may feel loved or cared for, but for some it may signal that we don't value the work, or value the client. Not always, but we can't be sure unless we really talk it through.
 
One therapist shared with me that after she lowered the fee, the client stopped coming. After several attempts to reach her, the client finally called back and said that she felt guilty and embarrassed paying so little and so decided not to come. It can work the other way as well. A lower fee may leave us resenting the client, particularly if it has not been thought through enough.
 
Some therapists like the feeling that they are being supportive or practical, loving even, when they are negotiating a fee. And it may be true, since being so is the heart of much of what we do as psychotherapists. Many of us, particularly from social work or social welfare backgrounds, have the idea that we must offer up at least some of our services as charity. This is a worthy ethic of the helping professions and our practices. However, should it be done habitually to the point where we have difficulty meeting our own obligations or goals? Not so fast, I think. Our relationships with clients are important. Our time with them is sacrosanct. We work hard with concentrated effort and dedicated time. We are not (well, I don't think so) merely the mani or the pedi that could be done at home.
 
Can we suggest that clients look at things this way, too? Dare we question the priority that therapy holds in their budgets? Or suggest giving up something in order to pay our fee? Should we question their leisure plans, hobbies or choices? Should we help them to view therapy as an investment in their marriage, financial recovery or success in life? “Do we really believe this is a luxury item or a vital part of our clients' well being?”
 

Therapist Attitudes, Beliefs and Fears

And what about our fear of losing clients, of financial insecurity, or of ineffectiveness? It's difficult enough to have your own business and have your paycheck change from week to week. To have to bring in business concerns on top of doing therapeutic work adds to the pressure. How much do we know about our own worries and the effect they have on our decision making when it comes to fees? Some clinicians think they must slide to keep business.
 
People don't negotiate fees with the grocery store, cable company or the gas station. Most doctors and dentists don't negotiate either, though a friend of mine who is struggling financially told me that her doctor told her to keep her co-pay and not pay it. My friend felt very loved by this, and loving toward the doctor.
 
And a lot of lawyers I know do pro bono work, or barter. We can make this part of our work too, but should it really be our only way of thinking about our work? Why is it that many therapists' default thinking goes to the value being less rather than more? Or maybe it should be as one therapist I know says, like taxes. The more you make, the more you pay.
 
Some of us are jaded or heartened by our experiences with our own therapy. If we have felt understood, helped, and have made progress, we may tend to value therapy more. If we have had a less than fulfilling therapy experience, or have unresolved issues with our therapist, we may tend to transfer those feelings into our practice. “Many therapists model their practice after their own therapist, especially those of us who learn largely by emotional experiences and modeling.”
 

Conclusion

Everybody prospers when we give ourselves permission to talk out our ideas to an open ear, and to study what's operating underneath. We do not have to act quickly. I think sometimes we want to resolve things fast. It's hard to stay with uncertain, uneasy feelings, and we so humanly go for the good feeling. But I think we miss out on a lot of important information when we do this, not to mention the opportunity to model patience, curiosity, tolerance for bearing some discomfort, and the value of talking, consulting, and understanding something more fully. Even in our business, we sometimes forget we can benefit from studying even, maybe especially, the basics.
 
Many therapists do try to make treatment available and manageable for clients as long as they themselves can afford to. And many of us sort out the facts from the feelings and make decisions based on what we figure to be best clinically. But money has so much meaning, and when we don't take at least a few minutes to be curious about what that meaning is to us and our clients, we may be short-changing everyone.
 
We need to know where we are coming from, and to unpack what's influencing our choices when we are working toward the best solutions in difficult financial times. It is key for our own self-care, the well being of our clients, the work, and even the economy.

Words Against the Void: Poems by an Existential Psychologist

Posted on by Psychotherapy.net Team

EMPIRICALLY VALIDATED PSYCHOTHERAPY

What works in psychotherapy?
That's far beyond the likes of me. 
I've only practiced fifty years, 
and still am plagued by doubts and fears. 
I muddle on and try my best
to aid my clients in their quest 

for ways of being more alive,
somehow in spite of all to thrive.
I wish I knew the right technique
to give them more of what they seek.
The mystery of change persists
unsolved by dogged scientists.
I hope that they will soon impart
quick ways to heal a broken heart.
My efforts stagger, balk, and lurch
unguided by precise research
to tell me how to ease life's pains,
and thus flawed intuition reigns.
Pray science soon will guarantee
sure cures for human misery,
but meanwhile I'll do what I can
without a validated plan.

FREEDOM vs. DETERMINISM

Just reacting? Freely striving?
Blindly driven? Wisely driving? Who's the rider? Who's the horse? 
Who's in charge? Who charts the course? 
Sort your data, choose your theory, 
Argue concepts 'til you're weary.
Psychologize until you die—
While we argue, life goes by.

ALTERNATIVE

Most of your waking life
will be spent, one way or another,
worrying about your worth as a person.
Why don't you just make something up,
and right off the bat
be done with the whole problem?
There must be better things to do 
than fret about your relative merit

in the universe.
You could, for example,
blow clouds around the sky
to the delight of small children.


DECADE OF THE DREAM

The recent Decade of the Brain
I found was much too great a strain.
It burned mine out, and I am left
quite mindless and of hope bereft.
Now comes the Decade of the Gene,
a slogan that I find obscene.
I wish there were some persons still
who'd help me my frail dreams fulfill.
We need a Decade of the Dream
in which bright rays of hope would beam
down on our sordid human plight
and fill us with some healing light

SISYPHUS REDUX

This rock, this mountain, this man,
this futile perseverance—
what use is such a myth?
Sisyphus gets nowhere,
gravity always wins.
Go ahead, if you wish—
imagine him happy
with or without anti-depressants.
You might as well imagine
the rock is ecstatic
bouncing down the slope, defiant.
So is this struggle any use to us?
We are in it, and outside it.
We view it, and have attitudes.
We are not rocks, not mountains,
not sure we are Sisyphus.
We read the story,
see him sweat,
dodge the rock,
respect the mountain,
climb up to stand on Sisyphus's shoulders
and peer beyond, beyond.

You can read more of Tom's poems in his book, Words Against the Void: Poems by an Existential Psychologist, available at Amazon.com.

Existential Poems

Posted on by Psychotherapy.net Team

Managed Care

Provide, provide some balm to ease our pain, bestow on us an angel's healing grace, an ample dose of Camus or Coltrane, an antidote to stop our lemming's race.
 
What's covered and what claims will be denied? Lear's madness now infects the entire race. Prescribe a cure to save the old man's pride, dispense a drug to save us from disgrace.

What medicine will cool our feverish brow? What X-rays show us where our souls are cracked? What treatment plan will clearly tell us how to find at last the love we've always lacked?

Third party payors tightly hold the purse, and terror grips us in our restless sleep. Who knows what charges they will reimburse? Salvation on this earth does not come cheap.

Tight economic limits rule the day, the bureaucrats will ascertain the price of rescuing we sheep who've gone astray, and short-term therapy must now suffice.

Be generous, while you contain the cost—Life's harder than we ever realized. We're floundering, our ark is nearly lost—Be merciful, if that is authorized.

Psychology

As I came into consciousness there was a war where millions died, and even when frail peace broke out life's anguish left me horrified.

I worked in mental hospitals, construction jobs and factories; I traveled where the war had been and contemplated tragedies.


Perplexed by what I'd seen of life, appalled by so much misery, I sought to understand the cause and thought I'd try psychology.

I hoped I'd find some people there who cared about the human soul, but learned instead it was our job to do "prediction and control."

And sure enough, some governments have found psychologists can aid in customizing torture skills, a job for which they're amply paid.

Not all psychology, thank God, is used for purposes so cruel, but much of what it's all about is tailored to a basic rule:

Whatever does in fact exist exists in some precise amount, and so our task is to devise precision tools with which to count.

Away with fuzzy-minded thought, away with sloppy sentiment—Pure science is the one true faith; the goal of life is measurement.

Do I belong in such a field? Can such a field put up with me? When questions such as these grow grim for refuge I try poetry.
 

Empirically Validated Psychotherapy

What works in psychotherapy? That's far beyond the likes of me. I've only practiced fifty years, and still am plagued by doubts and fears.

I muddle on and try my best to aid my clients in their quest for ways of being more alive, somehow in spite of all to thrive.

I wish I knew the right technique to give them more of what they seek. The mystery of change persists unsolved by dogged scientists.

I hope that they will soon impart quick ways to heal a broken heart. My efforts stagger, balk, and lurch unguided by precise research to tell me how to ease life's pains, and thus flawed intuition reigns.

Pray science soon will guarantee sure cures for human misery, but meanwhile I'll do what I can without a validated plan.

Acrophobia

"You've got to jump off cliffs all the time and build your wings on the way down." — Ray Bradbury
 
Never having bravely jumped, I must admit that I am stumped. I don't know how to build a wing and am afraid of everything. I'd panic, shriek, and tremble if I found myself atop a cliff. I'd quiver, quake, and quickly run, 'cause that's not my idea of fun. At least I do not make a fuss like that pretentious Icarus. I'm cowardly confessing that I live my life down where it's flat, admitting with a mournful sigh, I'm terrified of getting high.

9/11 One Year Later: A Psychotherapist Reflects on His Experiences at Ground Zero

Posted on by Psychotherapy.net Team
As we pass the one year anniversary of the terrorist attacks of September 11, 2001, Americans are reflecting on the toll this event has taken on our collective consciousness. Due in large part to the power of the media to magnify this spectacle to epic proportions, it is arguably the most traumatizing event in post-modern times. As mental health professionals, we can witness the reverberations of 9/11 from a unique vantage point. Although clients in my private practice have rarely cited the terrorist attacks as a presenting problem, there was clearly a great deal of thought and energy devoted to reassessing priorities and choices. In the first month following the attacks, it was impossible for me to conduct a psychotherapy session without acknowledging the tragedy. My clients and I had a rare opportunity to share moments of mutual empathy that deviated from the usual limits of the therapeutic relationship.
 
Despite this, my professional activities felt inadequate in addressing my own need to do something more in response to 9/11. When a colleague told me of her positive experience as a Red Cross disaster mental health volunteer, and the need for assistance with the relief effort in New York City, I felt drawn, compelled, to join. After completing the orientation and training classes provided by the Red Cross, I found myself reconnecting with the idealism and passion that first attracted me to human service.
 

Arriving in Manhattan

I arrived in New York on 12/19/01 ready to do my part. I completed the necessary in-processing at headquarters and took a cab to the hotel room provided by the Red Cross in midtown Manhattan. Negotiating subways, cabs, and crosswalks was challenging at first, but I was soon able to pick up a bagel and coffee and make it to the downtown A-train without being late to my destination.
 
Getting to know the city firsthand helped me appreciate the changes that had occurred since 9/11. I was told that in the aftermath of the disaster, New Yorkers became more open than usual, with some people actually talking to strangers on the subway. Those I encountered were genuinely appreciative of the volunteers from out of town, expressing an uncharacteristic sense of their vulnerability, and need for assistance. The 9/11 attacks made us all painfully aware of the limits of our technological infrastructure, and the fragility of our human bonds.
 
I was assigned to a huge tent next to the 16-acre pit at Ground Zero, which served as a respite center for the firefighters, police officers, and other workers. This site was staffed round the clock, and I worked the 4pm to midnight shift in the dining area where the recovery workers took their breaks. Our duties at Ground Zero consisted of circulating around the tent, striking up conversations, and offering support and information. Interactions with the workers ran the gamut, from chitchat about upcoming football games, to personal discussions of the search for missing friends. About half of the contacts were interested in talking about the recovery work, but far fewer were willing and able to express feelings about the disaster.
 

How Ground Zero Stretched the Therapeutic Role

It became clear early on that the workers were making a great effort to suppress their emotions in order to carry out their difficult tasks. Almost all of the workers had lost at least one friend or colleague in the World Trade Center. In this intensely chaotic yet controlled environment, the appropriate role of mental health volunteers was to engage Ground Zero workers in a delicate dance between small talk and existential validation. It felt as if we were there primarily to bear witness to the experiences of the Ground Zero workers, as they endured 12-hour shifts recovering human remains, struggling to keep their exhaustion and grief from interfering with the mission.
 
Balancing this unconventional therapeutic role, alternating between schmoozing and debriefing, proved to be terribly fatiguing at first. It was a stretch from the more evocative style of my mental health practice. At times, I felt as if I was carrying the unexpressed grief of the recovery workers back to my hotel room every night as I searched myself for the empathic response to their ordeal. Processing my experiences on a daily basis with other disaster mental health volunteers rewarded me with the awareness that our mere presence at Ground Zero was our greatest contribution to the workers there. “We weren't expected to have any words of wisdom… and nobody did.”
 
Some of my disaster mental health colleagues in New York worked with family members of victims who were openly grieving and verbalizing their experiences. My assignment at Ground Zero was quite the opposite; in fact, it may have been the location in Manhattan where one was least likely to witness the venting of feelings.
 

Herculean Efforts and Unexpressed Sorrow

Being present in this hallowed ground, with the sound of heavy equipment, and the smell of combustion and decomposition ever present, was a trying task for everyone there. The Herculean effort of the recovery workers, to postpone their natural emotional response, was both impressive and poignant. A group of firefighters sat at a table, laughing and joking about some trivial issue, after hours of raking through the piles of debris in search of missing colleagues. One police officer, who led his cadaver dog into the pit to assist in the locating of bodies, told me of the difficulty of suppressing the horrible images he encountered when he returned home to his wife and children. A fire captain solemnly acknowledged to me that, even after three months, the recovery workers were driven by the desperate hope that, somewhere in the six-acre pit, a living soul was waiting to be rescued.
 
Among the recovery workers there was a continuum of emotional expressiveness which appeared inversely proportional to the individual's proximity to the disaster. That is, the closer the worker was to Ground Zero, the less emotional expression was evident. In general, the firefighters were the most guarded and difficult to approach. I am not sure why, but they did suffer the largest overall loss in their ranks (close to 10%). The various police officers were more receptive to interactions with the disaster mental health workers. Perhaps the most approachable and, ironically, underserved group of workers at Ground Zero were the ironworkers, welders, heavy equipment operators, drivers, engineers, and other construction workers who were contracted to clear the site. Unlike the police and firefighters, these workers had no professional preparation for working around human remains. Add to this the reality that many of these men and women had worked nearly every day since 9/11, without break either by their own choice, or by virtue of the critical nature of their skills, and it is becomes clear that they represent a segment of victims of the WTC disaster that warrant closer attention.
 
I had never felt such a heaviness of unexpressed sorrow, though it resonated deeply with my own personal family losses prior to 9/11. My evocative skills were not useful at Ground Zero… I felt burdened, at times, with the violence and trauma that was ever-present yet still mostly unprocessed. Over my two weeks in lower Manhattan, my PTSD response took the form of sleeplessness and fatigue. Yet, too, I was surprised at the absence of nightmares that I had expected would occur. Perhaps the daytime witnessing of horrors made such nightmares superfluous.
 

Leaving Manhattan… Returning Home

The practical function of the disaster mental health professional at Ground Zero was as a vessel, or conduit of pain to facilitate the recovery work; I knew that I would have to carry my share of it home with me.
 
The Red Cross cautioned the volunteers that when we returned home people would ask about our experiences. They suggested that we would find it difficult or impossible to convey our true feelings and experiences to those who had not been there. That was indeed an understatement! Even here, in writing this account, do I find it so hard, so inexplicably difficult to express my experiences fully.
 
As the days and weeks passed, I felt more and more as if I had walked away from a battleground—with all the grief, psychic numbing, and survivor guilt that goes with such trauma. Indeed, I had walked away from a battleground—it was not "just a feeling." I had crossed the line between observer and participant, and no professional objectivity would suffice. My mental health colleagues and anyone else who ventured close to the unprecedented injury and destruction of the 9/11 attacks knows of what I speak. “This ineffable experience is captured best, not in any words, no matter how well expressed, but in the silent glances between workers, the hugs of those that care, the hope of those who courageously carry on in spite of loss and despair.”
 
Despite the routine debriefings provided by the Red Cross, I left New York with more than a lifetime's worth of intense images and sensations. I intuitively knew that my disaster mental health experience would be life-changing, but I did not know exactly how.
 
At first my clinical practice felt boring in contrast to what I had witnessed in New York.I felt different, as if I had expanded, or gained access to parts of my own life that I had not seen before. At first my clinical practice felt boring in contrast to what I had witnessed in New York. I found myself reaching to find the relevance in the complaints of the worried well, which suddenly felt terribly trivial. My style shifted, temporarily, to a less patient, more emphatic "let's get on with it" tempo. I soon became aware that I was unwittingly projecting my need for catharsis onto my clients. This awareness was the first step in beginning to understand what all this meant to me. I too, needed to know and understand my feelings, to express and share my fears and sorrows, and take the risk at experiencing catharsis in my own life.
 
Opportunities to share my disaster mental health experience, both publicly and privately, have given perspective to my images of Ground Zero, and grounding to my emotions. I feel more vitally connected to my soul and less attached to old assumptions. My work has settled into a serenely energized stance. Now, when I am sitting with my clients, I feel that we are more in touch with each other's humanity than before-or rather, more than I had previously allowed.
 
At Ground Zero, my instincts were all I had to work with; they have since become my most valuable therapeutic resource.