You might notice that I use some unusual language constructions as we talk. My use of language reflects some particular understandings that I think are important therapeutically. For example, I speak of “the person who is dying” rather than “the dying person” to acknowledge that people are more than the illness they live with. They are more than the problems they live with. As a narrative therapist, I think identity descriptions are important as they influence how we think of ourselves, what we think might be possible for us, and then how we might respond. The identity of “dying person” can limit how the person sees themselves and then influence how they might respond and act.
At first, the family were shy and hesitant to talk. But as they warmed up, they started to tell some really funny farming stories, which were brilliant. One was about how the man fell out of the tractor and just lay there because he couldn't stand up but had insisted that he go on working. And these men started to laugh as they were sharing these stories from their lives, and then one of them said to me, “Oh, I thought you counselors were meant to make us cry, not laugh.” It was quite delightful. Talking about such stories not only can nurture the relationship with someone after they have died, but they can also make it grow. The written stories we co-create therefore often reflect not just how a person has died but what might endure from the relationship family members have had with them. For example, the published story called “A Small Hope,” which illustrated how a therapeutic conversation brought forward some beautiful memories two young children had of their father, and then how they were developed into legacy stories they could carry with them throughout their lives.
If I'm looking back on conversations, say, in a transcript, it gives me the chance to really look closely at my questions and to think, “How could I have asked them better? What work is that question doing? Has it been helpful?” That constant examination and thinking about questions has really allowed me to be a lot more intentional and be more skillful in my questioning. At the same time, I think my listening has changed. I'm always listening for the beauty in people's lives, the stories, the nested stories within whatever we're talking about. Just the other night, someone was talking to me about accompanying a family member who was dying and said, “You know, the job of the family is to deeply love,” and it just really struck me. I heard that clearly and in a way, perhaps, that I wouldn't have prior to doing all this writing.
One cultural idea that springs to mind is the idea that death is a bad thing to be fought. If you have a curable illness or apply this idea to your experience in particular ways it can be very useful. However, for many people living with an incurable illness, the idea of a fight can start to become unhelpful. It might lead to them fighting the illness at any cost, for example, forgoing quality of life in pursuit of more and more treatments to avoid dying. Or it may position them as either winning or losing a battle, which can be a very unhelpful and limited description for someone who is dying.
Part of my role is to create a space for people to reflect on how they are going about living with the illness and approaching death so they can examine whether they are doing it in ways that fit with their values and what matters to them.
I've illustrated therapeutic conversation with people who have taken up a fighting stance against an illness with different consequences in some of my papers. For example, in the first story that I ever wrote, I met with a man who refused to acknowledge he was dying and was fighting by continuing to work rather than spending time with his family, and that didn't fit with his values. For him, the meaning of fighting his incurable cancer was not abandoning his wife, and he decided to have some enormous experimental surgeries. It was a really important thing for him to do. A fighting stance can work for someone. I can think of another person who had a really traumatic childhood, as did his wife. They had found each other at a young age, and it had been a very happy relationship. And for him, the meaning of fighting his incurable cancer by having some enormous experimental surgery was not abandoning her. It was a really important thing for him to do. The cultural idea of fighting can be both unhelpful and helpful. Dominant ideas aren’t usually good or bad in themselves. However, if they are guiding a person’s life, are unexamined, and don’t fit with their values, they can be problematic. It's more important how particular cultural ideas are applied, the way that they affect people’s relationships with themselves and their experiences, and the meaning they hold as a way of approaching death.
Another dominant Western idea that can have unintended consequences is the message that we should be positive. In fact, Carla Willig describes the pressure to be positive as a cultural imperative in Western societies. At the end of life, the idea that we must be positive can shut down talk of our mortality and of suffering leaving people alone in their experience. Part of what I do is to listen and be present for stories that are often silenced. They may be experiences of suffering or fears about dying for example. There are few relationships where people can speak of such things. The idea we “must be positive” affects health professionals, family, and friends as well. It may have family members and visitors trying to cheer people up rather than acknowledging what a person is going through. So, at times, it can be a very persuasive and unhelpful idea.
There are many cultural discourses that can cause people distress when they are approaching death. The idea that relationships end with death, and we have to “move on” rather than that relationships continue beyond death. And then there are some of the individualistic discourses; Western discourses such as “the reason that I've got cancer is because I didn't eat right, exercise enough,” and so on, right? People are often made to feel they are to blame and individually responsible for the bad things that have happened in their lives even when they are societal issues. Those are just a few examples. I find Narrative Therapy helpful in untangling ideas so that the people I meet with can examine them more closely.
Hope is an experience that I commonly examine with the people I meet with. Hope can mean many things to many different people, and I can't assume that I know the meaning of it in a particular person’s life. I might ask, “What does hope mean for you?” There’s an example of such a conversation about hope and the questioning I might use in the story “A Small Hope.”
I think Narrative Therapy really lends itself to assisting people at the end of life to reflect on the cultural ideas that are shaping their experience and then choose and think about how they want to go about the end of their lives.
I, for instance, can think of a person I saw who didn't feel that his life was worth living because he thought he was a burden to others. When I met him, one of the things I noticed was that despite this man being unused to living with other people and describing himself as a bit of a hermit, the carers kept coming into the room. I asked him about this and the relationships with the carers and discovered he actually learned all about their families and the countries that they'd come from.
I discovered that he was someone who was deeply respectful of others and who was able to get on and make the people around him feel really good about themselves. And through exploring this, we were able to expand his possibilities by bringing forth identities of him as a person whom others liked, as someone who cared about other people and so on. I guess we were able to bring forth a sense of living meaningfully for him. The identity we brought forward of him as someone who could give to others and make them feel valued was really helpful in starting to push the idea that he was a burden out the back door.
I was once asked to see a man who was living with a number of very serious conditions. He was refusing to speak about his dying even though he was in the last few weeks of his life, and was insisting on having resuscitation even though it would be hopeless and at the same time very traumatic for his family. He was self-medicating to the point where there was real concern that he might accidentally kill himself and wouldn’t discuss his future care needs. It had come to a critical point, especially for his family. When any of our staff tried to speak with them about any of these matters, he became angry. After an incident where he shouted at one of our doctors, I was asked to go out and see him.
I went out and met him and his wife, and as is common practice for me, I began by asking him about himself and his life aside from the illness. As we discussed who and what was important to him, I was listening for Aristotelian virtues that he had expressed in the way he went about his life. I learned that he dearly loved his family. They were incredibly important to him, and he was very concerned about their well-being. I learned that he was a really considerate employer who knew all about the families of his employees. He personally bought them Christmas presents. He was a very kind man. And I also learned, in his early life, that he was a courageous person. He was an adventurer. He had been involved as a bystander in a very violent and frightening incident and had behaved with incredible compassion and courage. So, these are identities that I sought to bring forward through inquiry as I hoped that they might be helpful to him.
After nearly an hour, he said to me suddenly, “Sasha, you've got it.” And I said, “Oh, may I ask what is it that you think I've got?” And he said, “You get why I want to live. You get why I don't want to die. You will be my death philosopher, and I will talk about dying with you.” We were then able to talk about his dying and how resuscitation would be hopeless and traumatic for his family to witness. Remember, family really mattered to him, and that value was very present in the conversation. We were able to talk about his hopes in taking the medication, that it was harmful, and also about what he might want for the end of his life. I don't think it was just that he felt seen and heard, which was so important, but also that he was able to access parts of himself that he needed to have those conversations. The conversation and the two we had following this one allowed us to plan for him to have a dignified peaceful death with his family nurtured as well.
I might be talking with a person about what their fears are about dying. What part of dying are they most frightened of? Just recently, I was talking with someone about her deep shame at the thought of other people seeing her naked body. Another was frightened about incontinence, and how would she maintain her dignity? These people are worthy of my every respect, and when they're able to share some of those fears or losses, it's the gift, and it's a gift to be honored, I think.
When I was learning all of this in the ‘80s, family therapy, thinking systemically, wasn't necessarily the usual way of thinking. Whereas, again, for Māori, thinking systemically, meeting as a group and working things out, was, again, a practice that they had done for 1,000 years. And I think the other thing is that the way that they mourn is, in my mind, very enlightened. For example, a tangi or tangihanga, which is a funeral, takes place over days rather than in an hour, giving meaningful time for connecting and expressions of grief. Such a practice has influenced the time my family and many others give to mourning. And I believe that New Zealanders touch their dead more than any other culture in the world, and perhaps this is part of the legacy and influence of Māori. I feel I’ve benefited from the influence of Māori processes.
Posted in Approach, Death and Dying, Families, Family Therapy, Narrative Therapy, Population, Therapeutic Issue
Navigating Client Loneliness in the Digital Age with Therapy
I’ve noticed a striking paradox in today’s digitally connected world: loneliness persists despite the abundance of online connections. Many of my clients grapple with profound feelings of isolation, shedding light on the intricate relationship between technology and loneliness. As digital interactions increasingly shape our social landscape, it has become important for me to delve into the possible underlying connection between loneliness and digital habits of my clients. By examining this paradox, I have been better able to support them in navigating the challenges of modern connectivity while fostering their interpersonal connections and well-being.
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Nurturing Non-Digital Relationships through Therapy
Social media and messaging platforms often create a superficial sense of connectivity, where likes and comments substitute for meaningful face-to-face interactions. Moreover, the pressure to maintain a curated online presence can amplify feelings of inadequacy and isolation. Excessive screen time and reliance on digital communication can hinder the development of deep, authentic relationships, ultimately contributing to a sense of loneliness and isolation. Understanding these detrimental effects of hyper-connectivity on social well-being has been crucial for me as a clinician working with clients who have been impacted in this way.
I’ve come to realize that while virtual communities offer a semblance of connection and support, they often pale in comparison to the richness of genuine, in-person relationships. Online interactions lack the depth and intimacy of face-to-face encounters, leading to a sense of emotional emptiness. Additionally, the curated nature of online personas can create a distorted perception of others, fostering feelings of inadequacy and isolation. Excessive reliance on virtual interactions can thus contribute to anxiety and depression.
In my clinical work, I’ve witnessed the pervasive influence of the fear of missing out (FOMO). This hyperconnected lifestyle often leads to a sense of emptiness and disconnection from the world around them. However, amidst the frenzy of digital connectivity, the concept of the joy of missing out (JOMO) offers a refreshing perspective. By consciously choosing to disconnect from digital distractions, my clients can potentially create spaces for meaningful real-life and interpersonal experiences. I have strived to promote awareness of these concepts and to empower my clients to prioritize meaningful off-screen/offline connections.
Case Applications
I recall working with Sarah, a 32-year-old marketing executive, who presented with profound loneliness despite her extensive online network. Spending hours each day immersed in social media and messaging apps, Sarah sought validation through digital interactions. However, despite the illusion of constant connection, she felt increasingly isolated from genuine human interaction. Through therapy, I remember supporting Sarah as she acknowledged the detrimental effects of hyper-connectivity on her social well-being.
Sarah’s treatment plan focused on dismantling her curated online presence, moderating her excessive screen time, and reducing her reliance on digital communication. Together, we explored alternative ways for her to nurture meaningful relationships offline. I emphasized the importance of face-to-face encounters and encouraged Sarah to connect with a limited group of friends in real-life settings.
In a similar manner, I supported Michael, a 28-year-old Latino construction worker, who experienced feelings of emptiness and isolation despite his active participation in online communities. Raised in a tight-knit community, Michael valued deep, meaningful relationships rooted in face-to-face interactions. However, his demanding work schedule limited his social opportunities, leading him to seek connection through virtual means. In therapy, I recall reflecting on Michael’s cultural values and exploring strategies for fostering authentic relationships offline.
Recognizing the importance of developing culturally relevant social skills to navigate interpersonal interactions, I suggested incorporating extended family members into Michael’s treatment plan. We discussed the idea of using role-playing exercises with his relatives to simulate real-life scenarios and practice social interactions within a familiar cultural context. By engaging with his extended family in these role-playing sessions, Michael gained confidence in initiating conversations and building rapport with others while staying true to his cultural heritage. These sessions provided Michael with valuable opportunities to develop his social skills in culturally relevant contexts, ultimately empowering him to forge deeper connections within his community.
***
Technology presents a double-edged sword in the fight against loneliness. While it offers innovative solutions for connection, it also poses challenges, contributing to the erosion of traditional social structures. By promoting digital interventions that prioritize authentic connection and well-being, I hope fellow clinicians can empower their clients to navigate the complexities of loneliness in this complex digital age.
Questions for Reflection and Discussion
What is your opinion on the author’s view of technology and loneliness?
What has your clinical experience been with clients who have chosen digital over live connection?
In what ways does the author’s position resonate with you personally?
Facing the Fear of Flying Together: Reconsidering Exposure Therapy
Beyond Resistance to Exposure Therapy
Exposure therapy for anxiety and related problems gets a bad rap. It is often seen as mechanistic, simplistic, unimaginative, and even cruel. The suggestions that “coaches” or AI could do as good if not a better job with exposure treatment, compared to well-trained therapists, only reinforce these beliefs. This contrasts with the treatment outcome research studies that show it as one of the most effective approaches in psychotherapy.
During my early years of practicing in a CBT-focused clinical psychology program, we were taught and expected to use exposure therapy. Soon, I found that I was not looking forward to the sessions that included exposure, and I abstained from volunteering to take on new clients whose presenting problems indicated that they could benefit from exposure therapy. I viscerally understood why studies have also shown that a majority of therapists, even those who identify as cognitive behavioral, shy away from exposure therapy.
My supervisor was certain that my and my classmates’ feelings were related to what he believed was at the core of the exposure underutilization: Therapists are, by and large, very empathetic people and thus we hate “making” our clients suffer. If we only realized that a compassionate approach sometimes requires short-term pain toward long-term gain, it would lead to an exposure therapy renaissance — or so he believed.
His contention resonated with me. I certainly was concerned when witnessing my teen client’s face turn pale and eyes water while touching the floor, doorknob, and trash can in our clinic bathroom while engaging in exposures for contamination fears. And I deeply felt the anguish of a middle-aged mother trembling as she held a knife and recounted the obsessive fears of hurting her daughter. But very few worthwhile things come easily, without pain attached to them. With my supervisor’s help, I started paying attention to the uncomfortable emotions and physical sensations that were coming up for me during exposures and worked on accepting them in the service of helping my clients.
It was a long journey, but I slowly improved, vowing that the avoidance of my distress was not going to be the reason for the avoidance of exposure therapy. This was my way of bucking the trend — much more pronounced these days — in which therapists lean into validating, complimenting, and colluding with clients’ defenses at the expense of challenging, probing, and having difficult conversations with them. A majority of therapists I know have become very good at accepting clients and being liked by them, but not great at actually helping them change in meaningful ways. But exposure therapy is far from the only approach that can be challenging to do and can lead to heightened distress in the short-term. I would argue these conditions are true for any good therapy.
Another observation my supervisor made was that many therapists were afraid of “pushing clients too far,” potentially leading to crying, hyperventilating, or even decompensating. “First,” he stated impatiently, with a hint of agitation, “no client will decompensate because of heightened anxiety — this fear only mirrors unfounded fears that clients often have, and it needs to be dispelled through psychoeducation.” He then assured us that we would become better at knowing how quickly to go up the exposure hierarchy (constructed at the beginning of treatment to guide exposures) with experience. Over time, he insisted, good therapists get a sense what the optimal dose of exposures is. Like Goldilocks, we learn that it needs to be strong enough to cause significant anxiety, but not too overwhelming to paralyze the client. That was, in his view, the art of exposure therapy.
Over the years, I did become proficient in the practice of exposure therapy, even penning a Washington Post article extolling its virtues. I have witnessed the transformation of people’s lives with the help of imaginal, in-vivo, virtual reality, and interoceptive exposures. And, yet, I have felt that by focusing on doing the exposures, we are missing crucial elements that could help more clients decide to take the leap and keep them engaged until they improve.
Most people are deeply ambivalent about change, especially the change that requires hard work and invites distress. When some realize that anxiety is contracting or even ruining their life, but they are not sure how to muster the courage to do something about it, internal (and sometimes external) conflicts ensue. Leveraging the therapeutic relationship to work with clients on these conflicts and on finding a way to integrate the parts of themselves pulling them in different directions is at the heart of what I do. In this process, my clients and I have come face-to-face with what it means to be human — to struggle with uncertainty, isolation, death, and the search for meaning. As Irvin Yalom suggested, all our fears emanate from trying to deal with these givens of the human condition.
Flying with Rick: A Case Study
“I don’t think I can get on that plane, I’m sorry,” said my client as we lined up to embark on a flight to Charlotte. He exited the queue and started walking away from the gate. When I saw him slowing down and stopping about 100 feet away, still facing away from me, I gave him a few minutes and then approached.
His face was contorted with fear and apprehension. I was concerned that he felt he needed to fly to be a “good client,” despite multiple discussions we had about him taking the pilot seat in his exposure therapy journey.
“I’m not going to ask you to get on the plane,” I said. “This is your choice.”
Rick had contacted me a few months before and said he was in his late 20s, suffering from flying phobia. In our initial meeting, I explained how I practice Cognitive Behavior Therapy (CBT) with an existential slant. We discussed what our work might look like, including the exposure therapy part, in which one gradually confronts one’s fears. “So, you’ll fly with me?” asked Rick, with a nervous half-smile. “If need be?”
I hesitated uncharacteristically. Being a nervous flyer myself had never stopped me from visiting my family overseas, traveling, or doing exposure therapy with previous clients. But abstaining from flying during the pandemic had increased my apprehension. Still, how could I expect my clients to face their fears if I was not prepared to do the same? “Of course!” I said, before I could change my mind. I wanted to model the courage that is one of my strongest-held values.
We first explored Rick’s history. He’d been uncomfortable in planes for as long as he could remember. His mother was a very nervous flyer, so Rick’s family rarely flew. When they did, his mom looked petrified and once even dug her nails into his skin during turbulence. So, he came to his flying anxiety by both nature and nurture. As an adult, Rick continued to avoid flying, and the less he did it, the more afraid he became. He still felt tremendous guilt about bailing the night before the flight that was supposed to take him to his best friend’s wedding.
Then, just before the pandemic, Rick was offered a dream job. Although it required frequent air travel, he decided it was too good a career opportunity to pass up. “I figured this would be exactly the kind of push I needed to get over my fear of flying,” he said. But the pandemic curtailed his new team’s travel, and Rick got few opportunities to fly. Later, when the U.S. reopened, he needed to be ready to fly anytime. He endured a business flight to Colorado with the help of Xanax but felt so miserable before the trip and after the medicine wore off, that he realized he needed to seek therapy.
We started by watching videos depicting a wide variety of flights, including turbulent ones, followed by vividly visualizing flying scenarios. I guided him to engage his imagination, focusing on all aspects of the experience, as if he were in a movie. When the imaginary exposures raised Rick’s anxiety, we practiced “sitting with” the anxious thoughts, feelings, and physical sensations. For example, I asked him to mindfully scan his body to notice where the uncomfortable sensations were showing up. Rick described his throat drying up and chest constricting, and he learned to allow them to be as they are, without judgment or suppression.
We also practiced observing the stream of anxious thoughts and imagining “placing” them on, for example, leaves in a stream or clouds in the sky — thus letting them continuously come and go. We discussed how this acceptance approach works best in the long run. We also practiced several breathing and muscle-relaxation techniques to be used only occasionally when anxiety becomes paralyzing. I warned Rick against using these “quick fix” techniques habitually, as they could become another kind of counterproductive avoidance. After a few months, Rick said he wanted to try “the real thing.”
At the airport, Rick blurted out, “I really, really want to do this, but I think I’m getting a panic attack!”
“Let’s breathe together like we’ve practiced,” I said. “Inhale for four, hold for four, exhale for eight though the nose…And repeat.”
Soon, Rick appeared more resolute and started heading back toward the gate. As I walked beside him, I felt my own anxiety bubbling up, but I kept a calm demeanor. Just before joining the line of boarding passengers, Rick stopped again. “It’s like I want to go, but some invisible hand is not letting me,” he said.
It seemed like he still was not accepting his ambivalence. How much easier it is for all of us to externalize what we don’t like about ourselves!
“Perhaps the hand is also a part of you,” I said. “There seem to be two parts of you.”
“Yes, it does feel like that.”
“What is each one saying?”
“One says, ‘You can do this, you’re strong, you’re not going to let the fear boss you around.’ And the other says, ‘You’ll faint or have a stroke if you get on that plane. If the plane doesn’t crash first. This is too much for you to handle!’” he said.
I waited, curious to see what he’d do with these two parts.
Rick asked for reassurance: “But it’s not going to crash, right?”
“Neither of us has a crystal ball,” I said with a slight smile, because Rick had been emphatic about his disdain for anything superstitious or new-agey.
He smiled back before his face turned solemn.
“I see more emotions coming up for you,” I said.
“A lot of irritation. Frustration with myself that I can’t be the person I want to be, that I am torn between these parts.”
“Is either part helping you expand or contract? Makes you larger or shrinks your world?”
“The first one makes me larger, but how do I make that one win?”
“It’s not about winning or losing. Only you know which one you’ll choose to listen to,” I said softly.
“I’m choosing to listen to the brave Rick, but the other part is still there…” his voice trailed off.
“That anxious Rick might always be a part of you. Can we just take him along for the ride?”
The gate attendant announced the last call for passengers heading to Charlotte. My stomach began to ache. We might never get on this flight, I thought with mixed feelings. A part of me felt disappointed with my ineffectiveness as a therapist. And another part was relieved that I might be spared flying today. It was then that I decided that self-disclosure might be helpful to get us past this impasse — after all, we were in this together.
“The truth is, I’m not a fan of flying either, especially after a long hiatus. I haven’t flown since the pandemic began, and my hands are sweating.” I turned my palms around for him to see. “But I don’t want to look back on my life with regret for not taking a chance, the regret that I so often hear from my elderly clients.”
Encouraged by the look of grateful surprise that flashed across Rick’s face, I continued. “Imagine sitting with your grandkids on your 80th birthday. What would you like to tell them about how you approached this short and precious life?”
Rick’s eyes brimmed with tears. He rushed toward the attendant, but quickly turned around. “You’re coming?” he asked.
I followed him swiftly, letting my legs carry me and my anxiety. I was thankful he led us to the plane.
Once in the air, Rick was surprised that he was not as anxious as he thought he’d be. “Anticipatory anxiety is always the worst,” I said. When the plane started to shake and both of us noticed our anxiety rising, we practiced the acceptance strategies. The majority of the flight was smooth, and each of us enjoyed a soda and flipped through a magazine. On our descent, the plane shook slightly and moved from side to side as we went through a thick layer of stormy clouds. Rick’s face turned pale and he murmured, “What now?”
“You know what to do,” I said.
Rick led us though some breathing exercises, and as his body relaxed a bit, he joked pointing out the window: “I am working hard to put my catastrophic thoughts onto these dark clouds!”
When we touched down, Rick turned toward me and mouthed, “Thank you.”
Now it was my turn to tear up. “Thank you. It was my honor to join you on this journey,” I said.
***
I was grateful that we were able to find strength in vulnerability and face the fear together. When we own all parts of ourselves, we can come to terms with the existential givens in unison. Approaching each therapeutic encounter as an opportunity to delve into the fundamental challenges of human existence, we enable our clients to grow stronger in the face of life’s uncertainties. Rather than offering them absolute solutions aimed at minimizing their anxiety, we can join them in embracing the existential realities, along with the unease these bring. And confronting the core realities of our existence is essential for leading rich and purposeful lives.
Exposure therapy is not about conquering anxiety but about finding a way to live authentically despite it. Instead of being technocratic cheerleaders, therapists using exposure have an opportunity to accompany clients on some of the scariest and most profound literal or figurative quests of their lives and witness the transformation that happens when we stop avoiding what matters.
“Have you decided how you’re coming back to D.C.?” I asked Rick as we exited the plane.
“I’m going to fly by myself!” he said with a smile. “And bring nervous Rick along.”
Questions for thought and discussion
What were your impressions about this therapist’s approach to exposure therapy?
In what way or ways do you think the client benefited from her intervention?
In what ways have you found exposure therapy to be useful in your practice? Not useful?
Creating a Safe Therapeutic Space for All Feelings
Yesterday, after a long silence, my client suddenly asked me, “did I offend you?”
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Where did that come from, I thought to myself. She had historically been so agreeable — almost too agreeable. I often wished she would occasionally say something offensive. I let these thoughts percolate as I considered how to proceed. I am trained to think twice before answering a question directly. Questions are fodder for the therapeutic process. I decided to delve deeper by responding with a few questions of my own. “How would you know if you did? What would it mean to you if I felt hurt? Have other people suggested that you’ve been offensive to them?”
A Therapist’s Secret Wish
I don’t let her know about my secret wish that she offer something offensive about me. Afterall, this was her process and I want to be careful not to project my feelings onto her, lest she become disagreeable to fulfill my aspirations for her instead of her own. That would defeat the entire purpose. Despite my success at navigating the conversation, my desire to be the recipient of a nasty comment did not abate. Perhaps I sound like a masochist who enjoys reveling in the psychological pain of being insulted. You might be thinking, is this a repetition compulsion? She should’ve gone to therapy to face her traumas not become a therapist to reenact them. Or maybe others would call me a martyr who sacrifices her own need for respect to keep her clients happy with her. She sounds Codependent. Is she in this for the right reasons? You might wonder.
I definitely do not have a penchant for pain. When someone insults me, I do not like the way it feels. Despite my best efforts to hold them back, my eyes often fill with tears in response to even a minor slight. Like most humans, I protect myself valiantly when I feel judged or criticized. Were I, in actuality, to be a martyr for the sake of keeping my clients happy, it would actually be pretty devastating to hear negative feedback. It would mean they weren’t happy with me. Wouldn’t that defeat the entire purpose of the sacrifice?
Here’s the thing; I’m no masochist and I’m definitely not a martyr. However, I am invested in my clients. I believe that for my clients to heal, they need a space where they are free to say and be whatever and whoever they want — including offensive. I might be a sensitive person, however, when I’m in my therapist role, my feelings are only welcome if they are in service of the client. If they aren’t, I set them aside to work through later.
In my experience, clients don’t come to therapy to be rude or offensive, especially toward the therapist. They certainly don’t want to be perceived as an ingrate by someone whose job definition is to help them. They are often ashamed of their selfishness and deny it, not only in the therapy room, but in their lives. But here’s a little secret; if they leave part of themselves outside, then part of them won’t heal. For therapy to work, they need to give voice to all their thoughts and feelings, especially their most shameful ones.
As a therapist, it is my responsibility to make space for the repressed voices of my clients. Good therapy grants permission to express what, outside of therapy, might be labeled socially inappropriate. Lack of this permission can reinforce ineffective patterns of repressing feelings and increasing shame.
The therapeutic challenge comes when, in instances such as this one, my own feelings are at stake. It’s relatively simple to support a client when their complaints are about “other things.” However, when their pain might be related to me, even if I had no intention to hurt them and despite the feeling that they are nitpicking, I feel obligated to face the Herculean task of supporting them just the same. Indeed, this selfless endeavor may be the most important and impactful act of therapy. If I can respond to an insult with curiosity, receive negative feedback without defensiveness, and authentically validate the valid, then I am giving my clients full permission to shamelessly express themselves. I cannot think of a better way to convey unconditional acceptance. But don’t get me wrong, I’m not giving permission for people to act how they please. Actions need boundaries. However, in therapy, I believe that words don’t and that words shouldn’t, even if and when those words are offensive.
***
So, as I think again about yesterday, I hope I can find a way to convey this message, “no, dear client, you didn’t offend me, but I hope that one day you feel strong enough to take that risk. And when you do, I will not abandon or reject you. Instead, I will be honored that this vulnerable and precious part is finally brave enough to join us in session.”
Questions for Reflection and Discussion
In what ways is the therapist’s attitude in this essay similar or dissimilar from your own?
How do you address situations where your client offends you?
In what clinical circumstances might you NOT address a client’s offensive behavior?
Reflections on Clinical Techniques for Working with Loss
In the “helping profession,” it is easy to talk about how we handled our successes, but seldom do we openly speak about the failures, the ones who got away. The people who leave treatment and don’t come back, or the ones who take their own life. How do you reconcile this?
Losing Clients in Therapy
I remember sitting in a training group run by one of my mentors — the topic was treatment failures. He said clients come and go, and that few therapists get through their career without experiencing the death of a client.
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The Ones Who Come and Go or Don’t Come Back
Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.
On the Death of a Coworker
At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.
Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.
Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.
On the Death of Clients
True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.
The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.
In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.
The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.
I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.
The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.
I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!
Questions for Reflection and Discussion
How have you dealt personally and professionally with losing clients?
How might you have avoided a particular client’s unexpected departure from therapy?
What are your thoughts about attending a client’s or their family member’s funeral?
Gardening Narratives and Storyliving Ones Life
“Terra de encanto amor e sol
Não falo inglês nem espanhol
Quem te conhece não esquece
meu Brasil é com S”
–– Brasil com S, João Gilberto
I’m Adriana Müller (AM) and I live in the Abya Yala region, in the territory known by the native peoples as Pindorama but named on maps as Brazil. It is an area of 3.287.597 square miles (over 8 million square kilometres) filled with an exuberant nature and a wide variety of flora, fauna, and geography, ranging from the Amazon rainforest to the gaucho pampas, passing through the hinterland (known as ‘sertão’) and the wetlands (known as ‘pantanal’). It is a region that has always been inhabited by people who know the seasons and have mastered the art of land care. It is a territory that, over the centuries, has received people from every continent, coming through a number of means and for different reasons. Brazilian people are the mixture of all these stories that can be revealed in our cultural way of being cheerful, outgoing, interactive, greeting friends with hugs and kisses — and the ever-present cup of coffee. Our people love football and carnival, take for granted different kinds of faith and beliefs, use plenty of metaphors while speaking and we live with passion. Brazilian folks are creative, they care about the others and know how to cook using everything the earth yields. Brazilians are helpful and have healing strategies for almost every problem. We know what resistance means, and we usually show it by singing and dancing our love and pain in various tones and rhythms. Brazilian people find ways to weather the weather and survive through life challenges, always making a point to value and honour our legacy.
This article is a tribute to all this cultural heritage. It is about a work I have developed on Narrative Therapy, in particular the use of narrative metaphors. The central topic to be presented here is gardening. Here in Brazil, there are some metaphorical expressions that highlight our connection to the land: we say that someone who is down to earth and is not easily deceived is a “pé no chão” (they have their feet on the ground), and the traditional samba is known as “samba raiz” (root samba). Whoever has “one inch of land” has a place to live and all those who were born here are “children of the land.”
It is from the land that we derive our livelihood, and, throughout Brazil, people know how to clear the land, cut the furrows, sow the seeds, and harvest the crops. In the Tupi language, people born in the territory known today as Espírito Santo are called “capixabas,” which means ‘land ready for planting.’ That's where I live — in the capixabas’ land. Because of my personal experiences in planting as well as in gardening, I started some therapeutic conversations rooted in the metaphor of the garden. The idea is to intertwine the principles of narrative therapy and four moments in the process of tending a garden, inviting clients to view their lives through the glasses of the following metaphors: 1) pulling out the weeds; 2) choosing the good seeds; 3) ‘hopefying’ like a farmer and 4) celebrating the harvest. The process involves therapeutic documents such as letters or poems, the relational development of meanings and encouraging clients to understand their personal agency through the metaphor of gardening.
The Magic of the Narrative Therapeutic Encounter
According to narrative therapy, our life has a multiplicity of events that can be grouped in a certain temporal sequence, generating a narrative on a specific topic. We are not predefined nor fixed beings. On the contrary, in each one of us, stories are waiting for the right moment to come to light and reveal their power. And each story is activated through questions, resonances with other people’s stories, and present connections to past experiences. In short, it can happen in various ways, but always as an invitation to access, connect, and chain the events. As Paulo Freire said, “Pieces of time that, in fact, were in me since when I lived them, waiting for another time, which might not even have come as they came, when they could lengthen in the composition of the larger plot.” (1)
Hence, this text is about aligning some moments that happened in my life story while meeting some clients — and how the images and resonances of these consultations generated metaphors and poetry.
Usually, people seek therapy when they are facing problems that limit their sense of competence, their capacity for agency, and their perception of themselves as a person of value. In short, when the story reveals more about the problem than about the person. In such moments, a narrative-based therapist seeks to rescue the beauty and dignity of life, through questions, paths and processes that give prominence to information that contributes to the creation of a good story (2).
According to my personal communication with David Epston, questions guide the conversation: trivial questions lead to trivial answers, boring questions build boring narratives and poetic questions are seeds of poetic stories. And he introduces a new kind of question — the ones with ‘Duendes’. Those questions come from the heart and bring into the conversation “the spirit of narrative therapy full of enthusiasm, irreverence, improvisation, imagination, righteous indignation at injustice, solidarity with those who suffer, collective creativity, fascination with the magic and mystery that reside at the heart of everyday life”, among others (3). An invitation to look at life with wonderfulness (4) — which Paulo Freire (5) would call the ‘beautifulness’ of life and relationships — finding ways to stop emphasising problem-saturated stories and start portraying versions that reveal people’s preferred identity.
Externalizing conversations (6), in which people name the problems and perceive themselves as separate from them, contribute to the necessary distancing so that preferred stories can be accessed. In this process, thinking about the effects of the problems in contrast to personal goals gives the person some space to see themselves as separate from the problems, and also to reconnect themselves to what La Taille (7) calls the ‘ethical view’. For me, this ethical view poses the questions “what life is worth living?” and, consequently, “who should I be to live that life?” The search for these answers leads the person to strive to be a person who deserves to live such a desirable life. Therefore, their actions are aligned with values, beliefs, principles, skills, competencies, goals, purposes, among other aspects that are their strength when facing life’s challenges and dilemmas.
Such aspects are part of the history of the person; therefore, they happen in a socio-historical environment and involve others. They also take place within what Freyre calls ‘tribio time’ – ‘tri’ for three, and ‘bio’, for life. It is an existential time that for him, is never only past, neither only present, nor only future, but all three simultaneously combined.” It is an intersection of past, present and future that evokes as well as prophesies, and in which survival and anticipation are intertwined.
La Taille also says that ethical answers about one’s life guide us to moral questions about “how should I live?” — a question that involves actions and its individual and collective consequences. In a similar way, Freire also tells us about the dialectical unity action-reflection necessary for the development of a critical consciousness that constitutes the way of being and/or transforming the world. Such concepts are very close to what Michael White called personal agency, which he described as “a sense of being able to regulate one’s own life, to intervene in one’s life to affect its course according to one’s intentions, and to do this in ways that are shaped by one’s knowledge of life and skills of living.”
In this context, re-authoring conversations which involve connecting the landscape of action (account of events) and identity (perception of meanings), seek to reveal the potentialities always present in the story and the agency of the person. In addition, re-membering conversations seek to connect us to significant people and the mutual contribution to the sense of being a person of value. Knowing that we are part of a network of affections that constitutes us and in which we actively participate by giving and receiving — and, thus, developing meaning — is important in building the notion of oneself as a person of value.
While the therapeutic meetings take place, each conversation reveals precious details that the therapist writes down or keeps in mind. Later on, such words can be given back to people as documents that ‘rescue the said from the saying of it’ (8) and can help highlight stories that reveal their preferred identities. Usually, I write documents as poetry — which can become song lyrics, as in the Rhythms of Life methodology (9) — as Rubem Alves used to say: “Words only make sense if they help us to better see the world. We learn words to improve our eyes.”
But how do we know which words are to be rescued and, later on, be delivered to those who said them? Grandesso (10) helps us:
If any lighthouse or compass to guide the journey in the field of meaning could be available, it would come more from the reactions of our body, responding more to the poetic forms of the words that touch us, than from any previous knowledge. (…) What (the therapist) can offer for that moment, are not his/her explanations or his/her theoretical knowledge, but his/her understandings in the form of reflections coming from words and images that arise from generous listening.
That is how the narrative metaphor helps throughout the therapeutic process, reminding us of White’s warning (11) about our ethical responsibility in the development of meaning, since it “powerfully shapes the training activities of the I and the relationship in which we engage under the name of therapeutic practice.” The narrative process is always respectful and seeks to position the client as an expert, therefore, a metaphor never arises before the meeting, but, during its flow. Each metaphor represents the harmony of the therapeutic context and is always a symbolic, figurative, and poetic invitation for the person to leave what is known and familiar to go towards what is possible to know.
Such scaffolding conversations, which White elaborated based on Vygotsky’s writings, are very similar to what Freire called the achievement of the “untested-feasibility”: one that is not yet, therefore is unprecedented, but whose originality lies within viable possibilities. Paro, Ventura, & Silva (13) show that, according to this Brazilian educator and philosopher, we face, individually or collectively, concrete, challenging and historical obstacles and forms of oppression, that impose themselves as if there is no way out — and which Freire calls ‘limit-situations’. We do not accept or receive such ‘limit-situations’ passively, but rather, we seek to overcome them through ‘limit-acts’. As we take distance from the ‘limit-situations’, the ‘background-awareness’[3] can emerge. The ‘background-awareness’ is something that cannot and should not remain as it is, therefore, what needs to be faced, discussed and overcome. The ‘limit-situations’, when detached from reality, can be objectified and understood as ‘issues-problems’. So, we begin “to dream of another possible world, something that does not yet exist, but may exist through the articulated action of its subjects, as an ontological need for the transformation of our individual and social reality (…), the ‘untested-feasibility’” (14).
Creativity, joy, hope, eyes that see ‘beautifulness’, freedom, dialogue… are ingredients that make the difference in a therapeutic encounter that aims at the ‘untested-feasibility’. The magic of the therapeutic encounter creates the possibility for each one to write and live their life in an unprecedented way and, creatively, to begin the ‘storyliving’ of their own life.
My Storyliving with Gardens
One year after graduating in Psychology, I moved, for professional and family reasons, to the city of Venda Nova do Imigrante, in the countryside of the state of Espírito Santo. We lived there for 10 years in a condominium on a farm. This experience soon gave birth to the idea of creating a Sustainable Development NGO — the CDS Guaçu-Virá [3]. This whole experience, both in contact with the land and the country people as well as with ecology and preservation professionals, taught me a lot about nature and its cycles, its diversity and its peculiarities. This life experience revealed the importance of our relationship with this living organism on which we inhabit and taught me precious knowledges ‘from the root’: the ones incorporated through daily experiences, for real, and in continuous partnership with Nature. For example: how can we have potable water to drink and cook? Firstly, by recovering the water springs in the woods, planting trees that could help renew the springs — or, as we used to say: “planting water.” Secondly, taking care of every tree like a precious asset until the fountain was back to life. From then on, so long ago, it still supplies 15 houses, one factory and three lakes. Through this and other praxis, day after day, for 10 years, nature taught me about Life and living.
So, when I came back to the capital city, Vitória, all these threads of knowledge and experiences were intertwined with my life. I found myself surrounded by plants and realized that the more attention I paid to them, the more they flourished. Nature always responds and, even living in an apartment, my care for them would return as buds, blossoms, birds, butterflies, and bees. Suddenly I realized I could have the farm atmosphere right in the middle of the city. As mentioned by Reis (15), gardening and other activities that involve caring for and contemplating flowers and ornamental plants, whether in the external or internal environment, generate a sense of well-being by stimulating the senses through luminosity, colours, sounds, aromas, textures and shapes, in addition to activating the aesthetic sense. Therefore, they can be important allies for the preservation and recovery of health and well-being.
When I started using the metaphor of the garden in consultations, I noticed that the enchantment was as fast as nature’s response. There is something inside that, in a special way, connects us to the idea of a garden: being a gardener, being a seed, being a flower bud, understanding the phases of a garden. There are many possibilities for applying this metaphor, and all of them invite us to beautiful narratives of agency, of developing meaning and finding resources to deal with life’s challenges. The metaphor of the garden is an invitation to rescue each one’s connection to nature. Next, you will find the metaphor of Gardening and two stories. I hope these shared ideas can contribute to nature’s power of enchantment and poetry that activate creativity. Let’s sow narrative ideas!
Gardening Narratives
“Vai o bicho homem, fruto da semente, (memória)
Renascer da própria força, própria luz e fé. (memória)
Entender que tudo é nosso, sempre esteve em nós, (história)
Somos a semente, ato, mente e voz. (magia)”
(Redescobrir – Gonzaguinha) [4]
According to White & Epston (16), “the narrative mode of thought (…) is characterised by good stories that gain credence through their lifelikeness.” Good stories have a great number of metaphorical images that organize the telling and help build a positive sense of being. If you have ever taken care of a garden — either a small one in pots or a large one over lawns — you can identify four moments of this work: pulling out the weeds, choosing the good seeds, waiting for sprouting and being happy with the result. Let me share with you the metaphor and its connections to narrative therapy.
1. Pulling out the weeds or invasive plants
Every garden has weeds that show up as unwanted guests. Dealing with them requires some specific skills: knowing how to tell plants and weeds apart, understanding the effects of these invasive plants on the flora, and establishing an action plan to better lay the garden out. This stage is the well-known narrative ‘externalization conversation’ in which we invite the clients to name the problem (weed), to check the effects of the problem on their life, to evaluate such effects and to set a plan of action to recover their life (the garden) from the consequences of the problems. In Freirian terms, we can say that this is the ‘background-awareness’ stage.
A garden full of weeds is like a story saturated with problems: it loses its strength, vigour and beauty, not because it lacks these characteristics, but because all its energy is being used to maintain the problem. That is why it is important to help people to recover their notion of personal agency through action-reflection, that will help them elaborate and put into practice their abilities to storyliving as the protagonist of the plot.
Some questions (metaphorical or not) that can help in this moment are:
Questions about the effect of the problem:
What have I been feeling / thinking?
What has been bothering me?
How does this ‘weed’ disturb me? Is it a mistletoe that suffocates me? Is it a kind of weed that traps and hurts me? Is it a weed that competes with me for water and nutrients?
Questions about the plan of action:
How do I want my garden to be?
What do I want to see blooming in my garden?
What are the main potentials of my garden?
What should I do to make this dream-garden come true?
Who can help me with this task?
What are my skills and abilities to deal with this challenge?
When can I start working in this garden?
These reflections detach the person from the problem and help to start a process to connect the person to the preferred version of his/her story — the garden each one dreams of.
2. Choosing the best seeds
While speaking about gardens and gardeners, Rubem Alves (17) invites us to the following reflection:
What comes first? The garden or the gardener? It’s the gardener. If there is a gardener, sooner or later a garden will appear. But if there is a garden without a gardener, sooner or later it will disappear. What is a gardener? A person whose mind is full of gardens. What makes a garden is what the gardener has in mind. What makes a nation is the sum total of the thoughts of those who are a part of it.
After removing the weeds, the disturbed but cleared soil is ready to receive the seeds. And, if the garden is in the gardener’s mind, it is time to help by choosing the best seeds: those aspects of life that the person holds precious, considers important and wants to keep updated. What s/he wants to plant and see growing and what activates the sense of beautifulness and wonderfulness.
In addition to the questions of the ethical and moral landscapes, arises the notion, “how do I want my garden to be?” What should I do to make it that way? What kind of gardener must I become to help this garden grow? — there are other questions that also contribute to this development, as they open the possibility for the sense of agency, values and wonderfulness:
What seeds do I choose to plant?
What do I admire and consider important to be present in the garden of my life?
What is beautiful and special about me that I want to see blossom?
What aspects of my life do I value?
What matters in my life?
Who helps me in this planting?
What did these persons teach me? And what do I teach them?
What is special and unique about this garden?
Through these reflections, people connect to what they hold precious, and their favorite story grows stronger in meaning, shape, colour and scent. The garden is coming to life.
3.'Hopefying’ like a farmer
One thing that has always impressed me in my experience living on the farm is the wisdom of the farmers. Planting is an art and, as such, it requires very specific skills, including what I usually call the ‘farmer’s hopefying.’ Firstly, the farmers let the land rest after harvesting, and, after that, they start working on it. From sunrise to sunset, they spend the day ploughing, balancing the soil nutrients, watering, planting the next crop. Tirelessly, they keep on watering that soil already sown, but still with no sign of life or success. Every farmer needs to believe in the work done and in the power of the seed — they need to believe in the ‘untested-feasibility’. They need to hopefy. They need to be “neither only patient nor only impatient, but, as Freire says, patiently impatient”.
Achieving the ‘untested-feasibility’ involves hopefying. But make no mistake: hopefy is an energetic attitude, a way of positioning yourself in life, and not a mere linguistic pun. There is the ‘hope’ from the verb to wait for. This ‘hope’ keeps us passive, static, waiting for something to happen or for someone to do something. And there is the hope as in ‘hopefying.’ To hopefy puts us in an active, dynamic position. In Freire’s words: “To hopefy is to get up, to go for it, to build, to hopefy is not to give up! To hopefy is to move forward, to join with others to do otherwise…”.
Everything we plant in life has its own time to come into being. While this time passes by, let’s remember to hopefy as the farmer does. During the consultation, that is the moment I usually write and hand over poetry to the ‘gardeners’.
4. Celebrating the harvest
Picturing the field producing and harvesting is as important as preparing the soil, planting the best seeds and knowing how to hopefy. Celebrating this moment means recognizing the strength within the whole process. In Freire’s words, “Joy does not come only when one finds something, but it is part of the search process. Teaching and learning cannot happen outside the search, outside the beautifulness and joy.” As an educator, Freire talks about the process of ‘teaching and learning’ which, in this text, is metaphorically called ‘sowing and harvesting’ — and which, as such, applies to the most different processes in life.
The harvest unfolds the power of wonderfulness — the beautifulness’ unveiled. They are the foundation for the preferred story: the one that reveals the preferred identity of the person. Realizing that one is capable of transforming soils previously taken over by weeds into gardens full of beautifulness reveals the ability each one has, as individuals and collectively, to sow dreams and reap realities.
Now the time has come to present two stories of therapeutic meetings in which the metaphor of Gardening Narratives were used. It is important to say that both stories were authorised to be published and that, for privacy, the names were omitted or modified. I would also want to point out that, like in any process, nothing follows the rules by the book. The fluidity and organization required in a written text are not found in the same way in the dynamics of interactions, which are mostly based on simultaneity, dynamic responsiveness, and constant reorganization. In Freire’s words. “An event, a fact, a deed, a gesture of anger or love, a poem, a canvas, a song, a book never has a single reason behind it. (…) That’s why I was always much more interested in understanding the process in which and how things happen than the product itself.” Therefore, you are invited to understand the process, while I keep hopefying the essence of Gardening Narratives presented in these stories comes to life beyond the didactic sequences just shown.
First Story: Once I Met a Gardener
She arrived at the office with tears in her eyes and a story of suffering to tell. There, in front of me, another woman reporting about when she discovered her husband’s betrayal, about the effort she made to forgive him, and to give them a second chance. At that time, they were two. Time passed, the wound healed, and the couple dreamed of being three. Pregnancy came as a gift, and on the day she delivered her child, she made up her mind to put all that bad story behind her. She wanted to be reborn as a mother and as a new woman. It was time for a renewed family to come into being. Along with the baby, there came forgiveness. And she cried for joy.
She went home, breastfed, took care of herself, and felt whole. She felt that there was attention and care from the couple to the baby, and she was sure that this was the family she had always dreamed of. Nevertheless, a few months later, she discovered that the betrayal was not a shadow of the past, but the harsh reality of the present. That was when she came to my office, and I learned about this story combining pain and hope.
Michael White taught us that we are outside witnesses to the stories we are told. This is not trivial, and it requires responsibility both in listening generously and in responding to what we hear. He presents us with a four-step map to navigate this unfamiliar therapeutic conversation terrain, calling our attention to each expression that strikes us during the telling of the narrative, the image it brings to our minds, the resonance of it with our life and where it takes us. That day, while hearing those stories, several images — real and metaphorical ones — came to my mind. I heard them as a woman, as a wife, as a mother. I felt them as a storm, as lightning, as devastation. I took them as birth, as life, as forgiveness. Eventually, she wiped her tears, looked at me and waited for my words.
Inside me, this phrase echoed: “I feel devastated.” The image came naturally: a raked-up garden, holes everywhere. And the resonance took me back to the time when I lived on the farm and dedicated myself to the garden at home. There I made beds with colourful flowers and medicinal plants. Bordering the lot, I planted a hedge of calliandra (Calliandra brevipes), with their blooming fragrant flowers forecasting rainy days. Throughout the garden, I planted fruit trees to feed the birds, yellow trumpet flowers (Handroanthus albus) and a jambo tree (Syzygium jambos) to have a beautiful colourful rug with the fallen flowers, and a tree for each baby I had. In my garden, I planted trees, dreams, and stories.
But, in the same garden, there were weeds — lots of them! And they taught me a powerful lesson: weeds are easier to remove when they are still sprouting. One can do it with one’s bare hands. But, once they are grown and rooted, one will need a hoe and some strength. All this work breaks the soil, leaving holes all over and it harms the garden’s beauty. That was the image evoked and shared — a damaged garden. But this experience with weeds taught me we can either look at the holes and at the ugliness of the garden or we can see the loose weedless soil as a terrain for new seeds. All these memories were shared with her. “Does it make sense to you?” I asked. She said yes, and we started talking about how to till a revolved garden.
This metaphor came back a number of times throughout the meetings and conversations. Through the reauthoring conversation, she connected the landscape of action to the landscape of identity, going back and forth in time, talking about what really mattered in her life, the people who contributed to her being who she was, her dreams and projects, her skills and competences, her values and principles. While listening to these stories, a new image emerged: a living and loving garden. Then I realized she was gardening narratives.
Firstly, she strengthened herself. She reconnected herself to everything she valued and cared for. She recharted her routine including things she likes and reviving her sense of religion. She realized her ability to move forward, and she appreciated the ‘beautifulness’ of her life. Step by step, she sowed new seeds in her garden.
Then, she hopefied for a new stage: togetherness. Not to re-live the past, like in a never-ending circle, but to live a spiral-present that provided something new and more rewarding. So, she decided to invite her husband to come around and learn about her ‘garden.’ This hopefying moment enclosed the wish to till the best asset of her garden: her family. She felt inside a growing power to take herself as an agent and a sower of possible futures — of ‘untested-
How In-Person Sessions Create Space for Clients Unspeakable Truths
Many of us have not gone back to in-person sessions even though the Covid epidemic has passed. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on long business trips or had some other compelling reason that made them unable to come in person. But beginning in March 2020 my practice transformed — all phone (or in a few cases video) sessions. After two years of living in my “weekend” house, I sold my office in New York and accepted the fact that my practice was going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.
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Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.
John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.
A Revealing Therapeutic Interchange
[Therapist’s thoughts]: I am aware that Sharon’s crotch is in full view. She does this often when she is wearing a skirt. I am trying not to look at her crotch while she is talking to me, but I have the impression that she is not wearing underpants. I think to myself that perhaps she is just wearing dark underpants. I start to question myself. Am I really seeing her genitals? Yes, I am. How should I handle it? If I ignore her exposing herself to me, I will be doing what her mother did — acting as if she is not a female with genitals. On the other hand, I know that however I say it to her, she will be mortified and furious at me. In the past, I felt the mortification would be too much for her, but this time I feel this is much more directly sexual than her sitting this way in the past.
“Are you aware of how you're sitting?” I asked.
Sharon immediately put her knees together.
“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”
“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”
“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”
“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”
“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”
“You mean it doesn’t matter if your crotch is exposed or not?” I asked.
“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”
“You mean you feel like there’s nothing between your legs?”
“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”
“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”
“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”
“You didn’t offend me. But I think exposing yourself is a way of telling me something.”
“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”
“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”
“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”
“What about underpants?”
“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”
“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”
“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”
[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]
[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]
“You mean your mother was masturbating in front of you,” I said.
“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”
[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]
***
Sharon’s traumatic childhood experience would not have been unearthed if I was talking to her on the telephone or video (which is face-to-face). On the phone or on video, she would not have been able to engender in me the same confusion, self-doubt, anxiety, and denial that she experienced as a child; she would not have been able to communicate the unspeakable truth. Telephone sessions may be useful for many patients, but for those who enact rather than verbalize their early experiences, it is not optimal.
Questions for Thought and Discussion
What are your impressions about this author’s clinical approach with this client?
Might you have done or said something different under these circumstances?
How do you address uncomfortable situations like these in your practice?
Existential-Spiritual Techniques for Fostering a Healthy Perspective on Aging
Introduction: The Existential-Spiritual Model
The case vignette that I will share presents the application of an Existential-Spiritual model of coping when working with patients experiencing the natural inevitability of aging and the “normal” responses associated with it. The integrated model includes six intervention practices: self-compassion and mindfulness, discovering meaning in life, prayer, creativity, expressing gratitude, and being open to a sense of awe. Existentialism poses universal questions and concerns, while spirituality provides space to process grief and loss and create meaning in life (1). The aims of spirituality include having compassion for others’ pain and suffering, advocating for social justice, and gaining awareness of and learning from the tragic dimensions of existence, thereby enhancing an appreciation for and valuing of life. This case of Jonathan highlights how dreams can be a valuable resource in gaining a deeper understanding of an individual’s attempts to deal with their existential and spiritual challenges, as well as finding passion and purpose in life (2).
Initial Phase: Processing Unprocessed Grief and Loss
Jonathan is a 68-year-old male who entered individual psychotherapy for the first time. He reported that he has been married for 40 years and has a married adult daughter and two grandchildren, ages 8 and 12, who live nearby. He had retired just one year prior to the pandemic. Jonathan, who majored in English literature, pursued a law degree for financial stability and a personal value of and commitment to social justice. After law school, he worked in his father’s medical supply business to support his father’s declining health due to numerous medical problems and an early death from diabetes at age 56.
Jonathan expressed concerns of feeling “empty inside” and experienced lack of direction, meaning, and purpose in life since his mother died approximately five years ago, just six months after his retirement. He reported feeling numb and indifferent over the wars in Ukraine and Gaza/Israel, and the intensified polarization of political discourse he observed during his extensive time watching cable news. Given his commitment to social justice, these feelings were different for him. In addition, a close friend had died early on in the pandemic, but he was unable to visit him in the hospital or attend his funeral due to COVID-19 safety restrictions.
Jonathan wanted to work with a psychotherapist experienced in Existential-Humanistic approaches based on his longstanding interest in the existential writings of Tolstoy, Sartre, and Camus. During his initial psychotherapy session, Jonathan reported a disturbing dream from the night before. He was in a building with a male colleague and his own daughter trying to find a pool. His colleague pointed to some skin lesions on Jonathan’s body; one had rows of 20 elevated dots that looked like shingles. There was another area that had been festering for some time. He was preoccupied by his skin condition in the dream and when he looked up, his colleague and daughter were no longer there.
Jonathan frantically searched the building asking for help in finding his colleague, daughter, and the pool. He recalled walking into an office with an elderly woman who was volunteering in the building. She was unable to provide any guidance as to his colleague’s or daughter’s whereabouts. Jonathan felt anxious about missing out on seeing them and the opportunity to swim. He woke up feeling worried and not knowing what to do.
I used several existential approaches, including Jonathan telling the dream in the present tense to develop a sense of presence and agency. I asked him what he thought the dream meant and inquired about his main feelings in the dream. Jonathan responded that he felt that something was missing in his life and “life was passing me by.” Jonathan associated the dream skin lesions with his mother’s fatal skin melanoma. He also described the colleague in the dream as confident and adventuresome, much like his recently deceased friend. I wondered if the dream reflected Jonathan’s hope that his therapy would help reduce his anxiety, but also his fear of what his treatment would uncover.
When asked to elaborate on the circumstances of his mother’s death, Jonathan expressed that she had been living in an assistive living facility in Florida for three years with a full-time aide. He then expressed guilt that he only visited her a few times a year due to his busy work schedule. He said he felt emotionally overwhelmed being with her as she did not recognize him during his last few visits, and she needed everything repeated numerous times. Jonathan said he was actually relieved when she passed away but felt ashamed for having these feelings and did not share them with anyone.
To further his sense of agency, I asked Jonathan, “What is the existential message that can be taken from the dream?” He responded, “I need to stop avoiding making a medical appointment with my dermatologist because I am scared of what it could be” and that he might be paying a price for not processing his numerous losses. I then asked Jonathan, “If you could continue the dream, how would you want it to end?” After struggling with an answer, he said he missed seeing his colleague at work, swimming, and spending time with his daughter and grandchildren.
The initial phase of psychotherapy focused on his unprocessed grief and loss over his mother’s and close friend’s deaths, reflecting on the impact of the COVID-19 pandemic, and clarifying his values. He expressed resentment that he and his wife, who were eagerly looking forward to his retirement, were unable to fulfill longstanding travel plans to Asia, South America, and Alaska during the pandemic. Jonathan felt it unfair that he had sacrificed being a lawyer to help run his father’s medical supply business, and that he historically had placed others’ needs above his own.
He felt that it was unfair that these losses happened to him now, just as he was on the verge of finally pursuing his own dreams. He also felt that his mother’s and friend’s deaths, as well as the social isolation during COVID-19, were disruptions of the life “he was supposed to have,” rather than inevitable parts of anyone’s life. He wondered if he was being punished for not being compassionate and supportive of his mother at the end of her life. I suggested using self-compassion statements to soften some of the self-critical attitudes, such as how he should have grieved his mother’s passing.
Jonathan and I explored how his sense of guilt, regret, and shame over his mother’s death had drained his coping skills and flexibility to deal with his mourning process. We discussed how some of his basic assumptions of the world — such as “The world is fair,” “bad things should not happen to good people,” and “there is a reason for everything that happens,” — were shattered and left him “drifting at sea without a paddle,” not knowing what to do. We explored how these feelings were similar to how he felt at the end of his initial dream and how these factors may have impacted — and could continue to impact — his ability to mourn and grieve. Jonathan gradually was able to acknowledge, but not accept, that the world is unfair and unpredictable, and that random events can happen to good people.
I asked Jonathan to describe in more detail his last visit with his mother. He recalled her sitting up in bed requiring her full-time aide to feed her pureed food. She was staring out the window as if she was already in a different place. Jonathan said she was there physically, but in some ways she had died psychologically. I suggested that he was experiencing an ambiguous loss, making it challenging to start grieving her passing because she was still there physically. He tried to imagine what she might have been experiencing looking out of the window, and he wondered if she was scared of dying and being forgotten by others.
The next session included recalling positive memories of his mother — what kind of person she was before her Alzheimer disease diagnosis, and what values she lived by. He brought in photographs including her wedding picture and one where she was holding his daughter when she was an infant. His mother’s eyes in the second picture conveyed a warm, loving glow, which was comforting to Jonathan. He also recalled how she went back to school to become an elementary school teacher when Jonathan and his younger sister were in high school, and how much he enjoyed hearing stories about her work. He realized that his mother was more than his memory of what she was like at the end of her life.
Jonathan also discussed how his best friend, Michael, passed away three months into the pandemic. They had become best friends in 8th grade, and even though his friend moved out West after college, they maintained regular contact, including yearly visits. Michael was adventurous, loved hiking and fishing in the Pacific Northwest, and enjoyed talking to strangers. I suggested to Jonathan that the colleague from his initial dream might symbolize this friend, perhaps indicating a desire to emulate his confidence and adventurous spirit.
Jonathan fondly recalled that the conversations he had with his friend always had the quality of picking up right where they left off. His beloved friend Michael, a social worker, always provided a listening ear and would ask challenging, but supportive questions. He was non-judgmental and helped Jonathan with various struggles. When asked what he missed most about his friend, he replied, “I could talk about anything without feeling judged, and he treated everyone with respect, always seeing the best in others.” When asked what Michael would say to him now in terms of how he should handle all his losses, he replied, “Just savor the preciousness of each moment, don’t take anything for granted, and take some risks.”
On top of these two significant losses, Jonathan felt that the pandemic was a very isolating and frustrating experience. His retirement dreams were put on hold, leading him into several unhealthy patterns, such as excessively, or perhaps obsessively watching cable news, growing more irritable with others, and being intolerant of conversations with friends and family members with opposing political viewpoints. His main pleasures during the pandemic were his weekly Zoom meeting with his daughter’s family, reading, and taking daily walks.
I asked open-ended questions at this time, including: “What sustained you during the pandemic?” “What did you learn about yourself?” and, “Where did you find the strength?” Jonathan felt that his longstanding interest in Buddhism and the Jewish value of healing the world (tikkun olam) provided a sense of stability. Specifically, Buddhism stressed the importance of not getting too attached to things, the importance of just “being” and accepting things as they are. Although these beliefs provided some degree of intellectual comfort, they did not have a major impact on his actions or his self-confidence.
In order to provide Jonathan with a deeper foundation and sense of direction, I asked Jonathan to describe his core values, which he identified as supporting his family, treating others equally and with respect, and pursuing excellence in whatever he did. Since his retirement, he felt that part of his identity had been lost even though his career was never in line with his values of social justice and being a lawyer, leaving him lacking passion and direction. He was encouraged to explore if these values were still effective and whether he needed to reconsider refining them in some way. Jonathan was gradually able to realize that although he did not need to financially support his daughter and grandchildren, he could model for them how to handle adversity and aging in a graceful way, as well as find other ways to channel his need to treat others equally and with respect. I stressed that values are not fixed in nature but can be created. At this point in therapy, he was also encouraged to practice mindfulness exercises and self-compassion to increase his level of self-reflectiveness, to be less judgmental of his struggles, and to recognize that his feelings are transient.
Middle Phase: Establishing a New Sense of Self Through Existential Approaches
Four months into treatment, Jonathan reported a vivid dream where he was walking in New York City trying to get to a meeting in his office on the East Side. He was waiting with a group of people in a building near Central Park. Some of the people were taking too long so he decided to leave to make it to the 3:00 meeting. He was trying to find a cab, but they were all full. He walked down an area in midtown that was sectioned off with small houses that one would typically see in the suburbs. One of the buildings had a large window where he saw a group of people relaxing and socializing.
Jonathan realized he had to get to the office, so he finally got into a cab and saw he only had a $10 bill to pay for the short trip to the office. The traffic was slow, so he decided to get out of the cab to walk the remaining distance. There were long, winding, hilly sidewalks that are not typical of the city, and he realized that he was on the opposite side of Manhattan from his office. He sensed he would miss his meeting as he saw trains passing by near the Hudson River. He then found himself walking down a long, beautifully constructed road with tall, shady trees leaving the city through a tunnel. He woke up feeling that he wanted to stay in the city and that going through the tunnel was potentially dangerous.
Jonathan felt the dream meant that he was struggling to find a new path in life, that he had lost a core part of his identity in his retirement, and that he lacked a sense of community. Like in the Robert Frost poem, The Road Not Taken, he feared making the wrong choice, reminiscent of his decision not to pursue his dream of becoming a lawyer. He was asked to visualize what it would be like going through the tunnel. Jonathan imagined it would be dark, claustrophobic, and scary to walk on the narrow sidewalk with a guardrail with all the cars driving by fast. He felt that he would eventually be able to get to the other side, but it would take a great deal of effort and time. He was asked to imagine what it would be like if he went further into the tunnel to the other side.
Jonathan struggled but was eventually able to say that he wished his parents and best friend were on the other side to greet him, saying how proud they were of him and the sacrifices he made for his family. He cried and realized that he had taken them for granted when they were alive. I acknowledged Jonathan’s determination, courage, and perseverance despite his anxiety and that the dream reflected his progress in therapy. At the end of the session, I asked him to think about if he was currently taking anything else for granted in his life. The following session, he mentioned that he felt gratitude that his family was healthy, that he had a few close friends, and that he could still give to others and pass on his knowledge and insights to his grandchildren. I then suggested that at the end of each day he write down what he was grateful for.
Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values
In the subsequent sessions, I asked a number of open-ended questions to further work through Jonathan’s grief and mourning including, “Are there any ways you can honor your parents and friend by living out the values and causes they believed in?” Jonathan felt that his parents were generous in giving to those less fortunate, and that his mother had volunteered in a pediatric clinic at a local hospital after her retirement. Jonathan was also determined to honor his friend’s life for the years he did not get to experience by being more adventurous and taking more chances, including planning a trip with his entire family out west to a national park. He felt that identifying these values and living them out would be a way of honoring their memory and remaining close to them even after they passed.
Jonathan returned to the next session visibly shaken by an encounter at a supermarket the day before. He noticed a homeless man desperately wanting some food. The people in line were rude and impatient with him, avoiding eye contact as if they felt disgust at his condition and shame for looking away. Jonathan quickly went to the cashier and offered to pay. Jonathan’s and the man’s eyes met, and Jonathan felt that this was something his parents would have done without any recognition for it. He felt that this small moment of compassion was a way of honoring his parents’ values. He eventually decided that he wanted to volunteer in a nearby soup kitchen one day a week and to tutor local elementary school children in reading and writing.
The final stage of psychotherapy included a number of significant events and choices. Jonathan took a trip with his entire family to Yosemite National Park. While looking at the Sequoia trees with his family, he felt a deep sense of connection to his friend, Michael, and a feeling of awe in being in a place so vast and mysterious. He subsequently began to pray more consistently, to be more courageous and adventurous like his friend, gradually releasing his fears of the unknown and uncontrollable. Jonathan appreciated that although someone dies, the relationship does not end and can continue to evolve (3).
Upon return from his trip, Jonathan reported a dream where he was walking a tall winding staircase at a water amusement park. He recalled looking down and realized that he could seriously hurt himself if he fell. Despite his anxiety, he kept on walking up and was securely placed in a luge headfirst while lying on his back. He felt scared and excited about what it would feel like going fast down the waterslide. Jonathan woke up feeling energized and proud of his courage like he did on his recent trip with his family.
Jonathan began to read and write poetry, which he shared with his grandchildren. The poems reflected themes of savoring the moment, particularly in nature and while listening to music, avoiding getting lost in trivial complaints, and expressing gratitude for what one has. Jonathan felt that his creative writing was the beginning seeds of his own legacy.
As the psychotherapy concluded, Jonathan acknowledged how his parents’ and friend’s values and personal qualities had a significant impact on his life and that he shared these values of promoting the growth and well-being of the next generation. Generativity became a new core value that provided a sense of purpose and meaning in his life (Buechler, 2019).
Concluding Thoughts: What is Psychological Health When Working with Older Adults?
The case vignette highlights the benefits of integrating existential and spiritual interventions when working with older patients. Jonathan needed to gradually process his unresolved guilt, regret, and shame regarding his mother’s and friend’s deaths before he could fully experience joy, vitality, and meaning in life once again. His mourning process was further consolidated by honoring his parents’ and friend’s values, the causes they believed in and how their good qualities had changed him for the better (4). He recognized that he shared these same values, which was fulfilling for him in maintaining a deep connection to them even when they were no longer physically present. Jonathan was able to acknowledge the legacy he received from his parents and began to integrate the value of generativity in his life.
The theme of giving to others less fortunate become a unifying thread in his life narrative. While he could not prevent or slow down the inevitable tragedies in life and the regrets over past choices, the thread provided a meaningful foundation and compass in navigating new, turbulent challenges in life. When reflecting on his treatment, Jonathan recalled that his brief interaction with the stranger in the supermarket may have impacted the person’s life, and Jonathan experienced a sense of their shared humanity.
From a meaning-centered psychotherapy lens, Jonathan not only acknowledged the historical meaning of continuing his parents’ values and legacy, but also started creating and experiencing other sources of meaning in life (e.g., experiencing connection and awe in Yosemite (experiential) and deciding to embark on more adventures and being courageous in creating new experience himself (creative source of meaning)). Jonathan’s experience of awe enabled him to deepen his awareness of life’s fragility, resiliency, and sense of wonder (5). His involvement in reading and writing poetry facilitated a change in his attitude and perspective on life. His daily practice of mindfulness provided a safe space to observe his thoughts and feelings in a nonjudgmental and self-compassionate manner, while practicing gratitude increased his appreciation for the gifts of life and the legacy of those who passed before him. Prayer facilitated his ability to let go of his need to control life and provided a sense of safety in letting go of his fear of the unknown (6).
Jonathan’s journey highlights that psychotherapy with an older adult can bring “a heightened existential awareness…a new appreciation of the preciousness of life… (and the ability) to trivialize the trivialities” (7). At this development stage, there is a degree of comfort, meaning, and purpose that one’s actions, deeds, and values can have a known or unknown rippling effect on one’s family and others (8).
Questions for Thought and Discussion
What are your impressions about an existential-spiritual approach to therapy?
In what ways was this author effective in working with Jonathan?
Might you have worked differently with this particular client?
References
(1,6) Gordon, R. M., Groth, T., Choi, E., Galley, J., Marcantuono, J., & Kulzer, R (2023b). An Existential-Spiritual model for coping during and after COVID-19. Spirituality and Clinical Practice. Published online: December 11, 2023.
(2) Gordon, R. M. & Groth, T. D. (2023a). Relational and existential supervision and therapy for adolescents with life-threatening illness. Journal of Infant, Child, and Adolescent Psychotherapy, 22(4), 311-322.
(3) Buechler, S. (2019). Psychoanalytic approaches to problems in living. Routledge.
(4) Kessler, D. (2019). Finding meaning: The sixth stage of grief. Scribner.
(5) Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. Paragon House.
(7) Yalom, I. D. (1996). Lying on the couch. Basic Books.
(8) Yalom, I. D. (2008). Staring at the Sun: Overcoming the terror of death. Jossey-Bass.
Postmodern Play Therapy: Helping a Child Overcome their “Trouble Energy”
When I was deeply entrenched in research, writing, and play therapy practice that incorporated superheroes, I learned about the importance of the origin story — the backstory narrative. It is no different in the context of this article, which is about what I call “postmodern play,” a term I use to describe play-based interventions rooted in Narrative Therapy. As a brief but related aside, I had just finished a book on the use of superheroes in counseling and play therapy when I was contacted by MSNBC to come on air to discuss what they, NOT I, called Superhero Therapy. When I sat excitedly in front of my television that night to watch myself, I noticed a chyron beneath my image that said, “The APA does not endorse Superhero Therapy.” Fifteen minutes of infamy, I guess.
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Ironically, I had never used the term, “Superhero Therapy” in my writing, nor did I profess my clinical work with superheroes to be evidence based. And so, it is here! The APA will never endorse postmodern play, nor will it ever attain evidenced-based status. And I aspire to neither.
But, as Irvin Yalom suggested in his Gift of Therapy, nonvalidated therapies are not (necessarily) invalidated therapies. So it has been for me, and postmodern play. In my child therapy work, particularly involving play, I have noticed that positive changes in the child’s world, both inside and outside of the therapy space, could often be explained by some of the core principles of Narrative Therapy, one of the postmodern approaches to therapy — which also includes Brief Solution-Focused Therapy. These core principles included a(n):
- Strength-based orientation rather than one based on deficiency
- Focus on the child as an agent of change
- Externalization of the problem
- Collaborative orientation to treatment that includes parents and teachers
- Author-editor relationship between therapist and child
- Future orientation that draws upon past successes
- Articulation of preferred identity through storying
- Personalization of outcome measures
- Understanding that children have islands of competence
Channeling Trouble Energy in Play Therapy
As an example, I recall 8-year-old Liam, who came with his parents for help with “his” problems of stealing food, his mother’s jewelry, and temper tantrums — exclusively at home when he was confronted with his misdeeds. Born in Asia, Liam was adopted in early infancy and seemed to be progressing nicely through his developmental journey. But something was happening that was giving rise to this relatively new spate of behavioral problems. During the intake, the parents and I wondered together if the racial/cultural difference between him and his parents was contributing to an emergent and distressing sense of “otherness” — they rarely, if ever, discussed the adoption, Liam’s origin story. We wondered if he was trying to process the loss inherent in the adoptive process, stealing as a way of filling a gap. We wondered if the marital tension between them was creating a bed of unrest and insecurity for Liam. We wondered!
When Liam came to my office the following week, I was met by a very poised, articulate, and interesting child whose vigorously shaking leg suggested that deeper currents of emotions ran just below the surface of this very seemingly contained boy. Drawn in by that current, I wondered aloud about the “energy” in his leg, and asked in what other parts of his body does he sometimes feel such energy. He played right along and said how sometimes that energy goes to his stomach, and sometimes arms, and together, we called it “body energy.” We explored this body energy when it started and whether he liked it, whether it got in the way sometimes and what he typically did with it once it appeared.
From there we launched into a conversation of other possible types of energy that he had, and as I asked him to describe some of his interests, which included history and origami, I asked him if he could label that energy, to which he responded, “art energy and learning energy.” A bit later in the conversation, when our conversation turned to the concerns his parents had around his stealing and angry outbursts, he quite spontaneously came up with the notion of “trouble energy.” I asked him to pick a colored piece of Play-Doh and show me how big trouble energy could be in his life, and he offered an apple-sized ball of Play-Doh in his little hands. That was the sum total of our intake and treatment plan.
The clinical work in the following weeks consisted of:
- Play therapy with Liam using the sandtray to act out play out scenes of family separations and reunions
- Playful conversations about trouble energy in his life, and what he wanted to do with it and its influence
- Liam sharing his vast knowledge of world history and “trying” to teach me origami
- Discussing simple behavioral methods for the parents to use when Liam expressed anger and took things
- Collaboration with his teacher around additional sensitivity to his needs, and
- Occasional family drawing time during which Liam and his parents expressed themselves freely.
- Referral of Liam’s parents to a marital counselor which they happily agreed to.
I never doubted that Liam was content with allowing trouble energy to rule his life, and I always had confidence that his parents and teacher could and would work together to support him and bring out the best in him. As a tip of my hat to readers who might be wondering, “well, what was your outcome measure(s),” I offer the following which is Liam’s depiction of trouble energy at the time of our last session at right, in contrast to trouble energy at the beginning of our work, at left.
I also offer the words of David Nylund, speaking at the Pan Pacific Brief Therapy Conference in Japan in 2001, regarding outcome measures in a postmodern, narrative play therapy context. He said, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person is able to reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”
***
My work with Liam and his family was complete, satisfactory to all involved. His tantrums subsided, the family re-visited and openly discussed the story of his adoption, and his feelings about it, and the stealing ended. I trust that my description of the work adequately captures the core principles and methods of what I call postmodern play therapy. Chyrons not withstanding!
Questions for Reflection and Discussion
What are your impressions of this author’s work with Liam?
In what ways have you found narrative therapy to be helpful?
What about this approach do you find interesting? Helpful?
Psychodynamic Therapies: How Did We Get Here & Where Are We Going?
I just finished reading Our Time Is Up, a wonderful combination of novel and memoir authored by the talented psychoanalyst and writer, Roberta Satow. Dr. Satow has created the most vivid description I’ve ever read of what real psychotherapy actually feels like — from the very different perspectives of the patient, the therapist, the supervisor, and the trainee. Most books on psychotherapy either miss its elusive magic or overplay its drama — this one has perfect pitch and puts you right there in the room.
Throughout my career, doing psychodynamic psychotherapy was always the part of my week I most enjoyed. Satow’s book both recalled many fond memories and inspired me to pull together what will likely be my final thoughts on what is wonderful about dynamic psychotherapy, and what are its limitations.
Psychodynamic Therapy’s Checkered Past
I’ll start with the checkered past — especially paying tribute to Sandor Ferenczi, the master clinician who was the underappreciated father of psychodynamic therapies. Next, I’ll evaluate the much reduced, but still crucial, role of dynamic techniques among the current chaotic and bewildering array of therapies. Finally, I’ll try to predict the future — what is the best-case final fate of psychodynamic therapies?
[Full disclosure] I graduated from Columbia University’s Psychoanalytic Center and taught its Freud course for 10 years. But I never was much of a fan of 4/5 times a week, on the couch, traditional, regressive psychoanalysis — regarding it as unnecessary and impractical for almost all patients and wasteful of resources better allocated to once a week, sitting up, long- or short-term dynamic therapies. While best at psychodynamic therapy, I also learned and integrated cognitive, behavioral, interpersonal, and family approaches. I think Freud was greatly overvalued in his own time and is greatly undervalued in ours — and I equally oppose blind Freud worshipers and blind Freud haters.
Freud: Great Model Builder, Lousy Clinician
Having invented psychoanalysis (in collaboration with his mentor, Joseph Breuer, and their shared patient, Berthe Pappenheim), Freud divided it into three separate endeavors: 1) research tool; 2) model of the mind; 3) clinical treatment.
Psychoanalysis as a research tool was at the outset enormously exciting — uncovering basic aspects of human nature that informed not only psychology, but also the study of myth, anthropology, sociology, art, and literature. But most new insights into the unconscious were made early on, and nothing really novel has emerged from the couch since Freud’s death.
Much more enduring has been the psychoanalytic model of the mind. Here Freud sat on Darwin’s shoulders — applying Darwin’s revolutionary, but generalized, discoveries in evolutionary psychology to the specifics of human behavior and symptom generation.
Freud borrowed from Darwin three crucial insights: 1) human mental functioning is just as derivative from our primate ancestors as is our bodily morphology; 2) much of our behavior derives from inborn motivations that reside outside our conscious awareness; and 3) these have been shaped by natural and sexual selection.
Freud filled in Darwin’s general outline with exquisitely detailed and specific analyses of the form and content of the unconscious and how one’s past experiences powerfully influence current hehavior. Freud’s model of the mind contained some bad (but then plausible) guesses which are the source of current ridicule — but the main concepts hold up extremely well and remain important in understanding people and treating them.
Freud never claimed to be a great therapist, or even to having much interest in psychoanalysis as a clinical art. He saw himself much more as an adventurer using psychoanalysis as a research tool in the scientific exploration of how the human mind works — awake and in dreams. Descriptions by Freud’s patients describe him as highly intellectual and patriarchic in his approach, using the therapeutic encounter to formulate and test his theories of how the unconscious works.
Ferenczi: Master Clinician
Sandor Ferenczi, Freud’s student & analysand, was the great clinician of early psychoanalysis and by far the most powerful influence in how psychodynamic therapies have since evolved and are practiced today. He was responsible for defining its healing qualities, introducing many major innovations, and adapting esoteric psychoanalytic theory to real world practice.
Here’s a summary of Ferenczi’s clinical contributions:
Therapeutic Alliance: Ferenczi emphasized the importance of negotiating a strong collaborative relationship with the patient, established on more equal terms, characterized by shared goals, and with mutually agreed upon roles and division of labor.
Interpersonal/Relational Therapy: Ferenczi was much more alive than Freud to the power of the healing relationship and the importance of establishing a strong affective bond with the patient. As his student, Sandor Rado, put it, “Insight never cured anything but ignorance.” The relationship is more curative than specific interpretations, however brilliant or accurate they may be.
Empathy: Ferenczi regarded therapist empathy as an essential tool in promoting change. Sharing feelings and feeling understood facilitates change as much as does gaining specific insights.
Here-and-Now: Freud mainly used psychoanalysis as a research tool to determine how past experiences shaped the unconscious and influenced current behavior. Ferenczi did this too, but also brought more focus to the triggers of present problems and how best to solve them.
Therapist Activity: Freud aspired to (but never really achieved) being a passive “blank screen” upon which patients could project their fantasies. Ferenczi was much more active and real in the sessions.
Patient Activity: Patients don’t get better just through free association and the insights gained in the therapy sessions — they must also widen their experiences and get out of repeated behavioral ruts. What happens between sessions is at least as important as what happens within sessions.
Corrective Emotional Experience: This was best stated by Ferenczi’s student, Franz Alexander, who said, “The patient, to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.”
Psychodynamic Therapy: Regressive psychoanalysis was originally a great research tool but has never been a practical treatment — it is way too resource wasteful, suitable only for pretty healthy patients, and risks creating excessive dependence and hiding in the treatment. Ferenczi’s innovations allowed psychodynamic theory and technique to be flexibly applied in less intensive, but very effective, sitting-up psychodynamic therapies occurring usually once a week.
Time-limited Focused Therapy: Ferenczi and Rank realized that long-term therapies were too intense and inefficient to treat the many people who needed help. They developed a remarkably useful brief dynamic therapy (currently much underutilized) that focuses only on understanding and changing the most pressing presenting conflict.
Self- Disclosure: Ferenczi was not shy about revealing information about himself if this would further the relationship or provide a useful model for the patient.
Role of Childhood Traumas: Freud’s first theory of neurosis attributed it exclusively to early childhood sexual traumas. But he abruptly and completely abandoned this causal theory in the early 1890s because such childhood sexual experiences were so commonly reported by his patients. Freud then assumed the reported experiences existed only in fantasy, rather than having actually occurred in reality. Ferenczi had the more balanced view that real childhood traumas do sometimes play a contributory, but not exclusive, role in producing adult symptoms and that they are not exclusively sexual.
Treating More Difficult Patients: Many classic psychoanalysts were often so picky about selecting patients that only the people who didn’t really need treatment would qualify for it. Ferenczi adapted psychodynamic understanding and techniques so that they could be usefully applied to the more severely ill.
In summary, Ferenczi, not Freud, was the clinical father of psychodynamic psychotherapy and his innovations shaped how it is still practiced today.
Psychodynamic Therapy’s Current Status
My previous essay; Psychotherapy Status Report offered a report card on the current status of psychotherapy. It nicely provided context for the more specific question of where psychodynamic therapies fit in. The short answer is that all psychotherapy practice is fragmented and chaotic — and that psychodynamic training and practice add to the confusion.
There is little integration among the more than 50 different named forms of psychotherapy. These are often seen as competing; most trainees receive instruction in just one narrowly focused method and many practicing clinicians identify with just one form of therapy. “CBT” is the most popular brand name, followed by “psychodynamic,” and “trauma-informed” which is becoming increasingly popular. There is also an age and gender disparity. Older therapists are more likely to identify with psychodynamic; younger with CBT; women with trauma-informed.
Training in psychodynamic psychotherapy is also chaotic. There are hundreds of different programs varying greatly in theoretical model, prerequisites, intensity, techniques, and accreditation. At one extreme are the traditional psychoanalytic institutes which are more selective, require many years of intense didactic and clinical training, often still use of the couch, and require personal analysis. At the other extreme, there are now psychodynamic training programs that are open to all and, remarkably enough, completely online.
There is very little research on psychodynamic psychotherapy because it does not conform easily to standardized clinical trial research designs and only a handful of its practitioners are research trained. The few scattered research studies suggest that psychodynamic therapies are equal in efficacy to better studied psychotherapies.
Dynamic therapy is gradually declining in influence. Most psychiatric residency programs now provide little or no training in psychodynamic therapies — even though such training is still often desired and sought after by some residents. Young therapists in other disciplines are less and less likely to be trained in dynamic techniques. And insurance companies are less likely to fund dynamic as opposed to other techniques that are less intense and better studied. The average age of dynamic therapists is rising, and its cultural relevance is diminishing. The future does not seem bright.
Future Directions
Will Psychodynamic Therapy Continue as a Separate Profession?
I hope not. Psychodynamic therapy was always my favorite technique, but only if combined with cognitive behavioral, interpersonal, and family techniques. Similarly, the training programs I created were based on the integration of psychotherapies, not their separation into separate silos.
I have long felt that psychoanalysis is too important to be left to the psychoanalysts. They have maintained an unfortunate rigidity in technique and teaching; have been resistant to innovation; and missed opportunities to expand their purview and influence. Their biggest mistake was rejecting Aaron Beck’s CBT. Beck was a trained analyst who originally conceptualized his innovations as an expansion of psychodynamic techniques, not a replacement. Had the psychoanalysts been wise, they would have embraced CBT as an extension, rather than rejecting it as a competitor. I don’t think that psychodynamic therapies should be taught in institutes that specialize in it. Similarly, I don’t think that “CBT” or “DBT” or any of the other 50 alphabet denoted therapies should be taught or practiced as a separate discipline distinct from other psychotherapies.
Instead, I think psychotherapy should be considered a unified therapy which includes within it a wide variety of techniques. And training programs should no longer brand themselves narrowly. Narrowly trained therapists become hammers looking for nails, rather than flexibly responding to patient need. Psychodynamic techniques should be highly valued because they are very valuable- but they should be valued as a component of psychotherapy, not as a separate specialty.
Will Psychodynamic Therapists Be Replaced by Computers?
I’ve written an entire blog on the history of computers delivering psychotherapy: their current role and their future potential. Bottom Line — there is nothing humans do that computers won’t eventually do better.
One small consolation is that computers will have more trouble and take longer replacing psychodynamic therapists than almost any other type of professional. More than most human endeavors, uncovering someone’s unconscious motivations and facilitating corrective emotional experiences are intuitive and inferential processes that don’t easily lend themselves to the number-crunching powers of machine learning. But given enough data and enough time, even these most human of skills may be mastered by artificial intelligence.
Should this pessimistic prediction discourage people from entering the field? I think not at all. First off, psychodynamic psychotherapy is a better hedge against computer replacement than almost any other career choice. But more important, doing psychodynamic psychotherapy is one of the most rewarding ways of spending one’s time on earth. You have the immense satisfaction of understanding and helping others, with the valuable added bonus of learning from your patients how to become a better person.
***
Which brings us back to where we started. Roberta Satow’s book is a great introduction for new psychotherapists and a great refresher for experienced ones. No manual of psychotherapy, and no textbook, can ever capture the special healing ambiance of the therapist/patient relationship. Only the lived experience of someone who has been a patient, been a therapist, been a supervisor, been a trainee — and can write really well — can bring therapy alive in a way that inspires and educates.
Questions for Thought and Discussion
In what ways do you concur or disagree with the author’s assessment of dynamic psychotherapy?
Would you consider training in psychodynamic therapy?
What kind of client would you refer to an analytic therapist and why?
Navigating Client Loneliness in the Digital Age with Therapy
I’ve noticed a striking paradox in today’s digitally connected world: loneliness persists despite the abundance of online connections. Many of my clients grapple with profound feelings of isolation, shedding light on the intricate relationship between technology and loneliness. As digital interactions increasingly shape our social landscape, it has become important for me to delve into the possible underlying connection between loneliness and digital habits of my clients. By examining this paradox, I have been better able to support them in navigating the challenges of modern connectivity while fostering their interpersonal connections and well-being.
Nurturing Non-Digital Relationships through Therapy
Social media and messaging platforms often create a superficial sense of connectivity, where likes and comments substitute for meaningful face-to-face interactions. Moreover, the pressure to maintain a curated online presence can amplify feelings of inadequacy and isolation. Excessive screen time and reliance on digital communication can hinder the development of deep, authentic relationships, ultimately contributing to a sense of loneliness and isolation. Understanding these detrimental effects of hyper-connectivity on social well-being has been crucial for me as a clinician working with clients who have been impacted in this way.I’ve come to realize that while virtual communities offer a semblance of connection and support, they often pale in comparison to the richness of genuine, in-person relationships. Online interactions lack the depth and intimacy of face-to-face encounters, leading to a sense of emotional emptiness. Additionally, the curated nature of online personas can create a distorted perception of others, fostering feelings of inadequacy and isolation. Excessive reliance on virtual interactions can thus contribute to anxiety and depression.
In my clinical work, I’ve witnessed the pervasive influence of the fear of missing out (FOMO). This hyperconnected lifestyle often leads to a sense of emptiness and disconnection from the world around them. However, amidst the frenzy of digital connectivity, the concept of the joy of missing out (JOMO) offers a refreshing perspective. By consciously choosing to disconnect from digital distractions, my clients can potentially create spaces for meaningful real-life and interpersonal experiences. I have strived to promote awareness of these concepts and to empower my clients to prioritize meaningful off-screen/offline connections.
Case Applications
I recall working with Sarah, a 32-year-old marketing executive, who presented with profound loneliness despite her extensive online network. Spending hours each day immersed in social media and messaging apps, Sarah sought validation through digital interactions. However, despite the illusion of constant connection, she felt increasingly isolated from genuine human interaction. Through therapy, I remember supporting Sarah as she acknowledged the detrimental effects of hyper-connectivity on her social well-being.
Sarah’s treatment plan focused on dismantling her curated online presence, moderating her excessive screen time, and reducing her reliance on digital communication. Together, we explored alternative ways for her to nurture meaningful relationships offline. I emphasized the importance of face-to-face encounters and encouraged Sarah to connect with a limited group of friends in real-life settings.
In a similar manner, I supported Michael, a 28-year-old Latino construction worker, who experienced feelings of emptiness and isolation despite his active participation in online communities. Raised in a tight-knit community, Michael valued deep, meaningful relationships rooted in face-to-face interactions. However, his demanding work schedule limited his social opportunities, leading him to seek connection through virtual means. In therapy, I recall reflecting on Michael’s cultural values and exploring strategies for fostering authentic relationships offline.
Recognizing the importance of developing culturally relevant social skills to navigate interpersonal interactions, I suggested incorporating extended family members into Michael’s treatment plan. We discussed the idea of using role-playing exercises with his relatives to simulate real-life scenarios and practice social interactions within a familiar cultural context. By engaging with his extended family in these role-playing sessions, Michael gained confidence in initiating conversations and building rapport with others while staying true to his cultural heritage. These sessions provided Michael with valuable opportunities to develop his social skills in culturally relevant contexts, ultimately empowering him to forge deeper connections within his community.
***
Technology presents a double-edged sword in the fight against loneliness. While it offers innovative solutions for connection, it also poses challenges, contributing to the erosion of traditional social structures. By promoting digital interventions that prioritize authentic connection and well-being, I hope fellow clinicians can empower their clients to navigate the complexities of loneliness in this complex digital age.Questions for Reflection and Discussion
What is your opinion on the author’s view of technology and loneliness?
What has your clinical experience been with clients who have chosen digital over live connection?
In what ways does the author’s position resonate with you personally?
Facing the Fear of Flying Together: Reconsidering Exposure Therapy
Beyond Resistance to Exposure Therapy
Exposure therapy for anxiety and related problems gets a bad rap. It is often seen as mechanistic, simplistic, unimaginative, and even cruel. The suggestions that “coaches” or AI could do as good if not a better job with exposure treatment, compared to well-trained therapists, only reinforce these beliefs. This contrasts with the treatment outcome research studies that show it as one of the most effective approaches in psychotherapy.
During my early years of practicing in a CBT-focused clinical psychology program, we were taught and expected to use exposure therapy. Soon, I found that I was not looking forward to the sessions that included exposure, and I abstained from volunteering to take on new clients whose presenting problems indicated that they could benefit from exposure therapy. I viscerally understood why studies have also shown that a majority of therapists, even those who identify as cognitive behavioral, shy away from exposure therapy.
My supervisor was certain that my and my classmates’ feelings were related to what he believed was at the core of the exposure underutilization: Therapists are, by and large, very empathetic people and thus we hate “making” our clients suffer. If we only realized that a compassionate approach sometimes requires short-term pain toward long-term gain, it would lead to an exposure therapy renaissance — or so he believed.
His contention resonated with me. I certainly was concerned when witnessing my teen client’s face turn pale and eyes water while touching the floor, doorknob, and trash can in our clinic bathroom while engaging in exposures for contamination fears. And I deeply felt the anguish of a middle-aged mother trembling as she held a knife and recounted the obsessive fears of hurting her daughter. But very few worthwhile things come easily, without pain attached to them. With my supervisor’s help, I started paying attention to the uncomfortable emotions and physical sensations that were coming up for me during exposures and worked on accepting them in the service of helping my clients.
It was a long journey, but I slowly improved, vowing that the avoidance of my distress was not going to be the reason for the avoidance of exposure therapy. This was my way of bucking the trend — much more pronounced these days — in which therapists lean into validating, complimenting, and colluding with clients’ defenses at the expense of challenging, probing, and having difficult conversations with them. A majority of therapists I know have become very good at accepting clients and being liked by them, but not great at actually helping them change in meaningful ways. But exposure therapy is far from the only approach that can be challenging to do and can lead to heightened distress in the short-term. I would argue these conditions are true for any good therapy.
Another observation my supervisor made was that many therapists were afraid of “pushing clients too far,” potentially leading to crying, hyperventilating, or even decompensating. “First,” he stated impatiently, with a hint of agitation, “no client will decompensate because of heightened anxiety — this fear only mirrors unfounded fears that clients often have, and it needs to be dispelled through psychoeducation.” He then assured us that we would become better at knowing how quickly to go up the exposure hierarchy (constructed at the beginning of treatment to guide exposures) with experience. Over time, he insisted, good therapists get a sense what the optimal dose of exposures is. Like Goldilocks, we learn that it needs to be strong enough to cause significant anxiety, but not too overwhelming to paralyze the client. That was, in his view, the art of exposure therapy.
Over the years, I did become proficient in the practice of exposure therapy, even penning a Washington Post article extolling its virtues. I have witnessed the transformation of people’s lives with the help of imaginal, in-vivo, virtual reality, and interoceptive exposures. And, yet, I have felt that by focusing on doing the exposures, we are missing crucial elements that could help more clients decide to take the leap and keep them engaged until they improve.
Most people are deeply ambivalent about change, especially the change that requires hard work and invites distress. When some realize that anxiety is contracting or even ruining their life, but they are not sure how to muster the courage to do something about it, internal (and sometimes external) conflicts ensue. Leveraging the therapeutic relationship to work with clients on these conflicts and on finding a way to integrate the parts of themselves pulling them in different directions is at the heart of what I do. In this process, my clients and I have come face-to-face with what it means to be human — to struggle with uncertainty, isolation, death, and the search for meaning. As Irvin Yalom suggested, all our fears emanate from trying to deal with these givens of the human condition.
Flying with Rick: A Case Study
“I don’t think I can get on that plane, I’m sorry,” said my client as we lined up to embark on a flight to Charlotte. He exited the queue and started walking away from the gate. When I saw him slowing down and stopping about 100 feet away, still facing away from me, I gave him a few minutes and then approached.
His face was contorted with fear and apprehension. I was concerned that he felt he needed to fly to be a “good client,” despite multiple discussions we had about him taking the pilot seat in his exposure therapy journey.
“I’m not going to ask you to get on the plane,” I said. “This is your choice.”
Rick had contacted me a few months before and said he was in his late 20s, suffering from flying phobia. In our initial meeting, I explained how I practice Cognitive Behavior Therapy (CBT) with an existential slant. We discussed what our work might look like, including the exposure therapy part, in which one gradually confronts one’s fears. “So, you’ll fly with me?” asked Rick, with a nervous half-smile. “If need be?”
I hesitated uncharacteristically. Being a nervous flyer myself had never stopped me from visiting my family overseas, traveling, or doing exposure therapy with previous clients. But abstaining from flying during the pandemic had increased my apprehension. Still, how could I expect my clients to face their fears if I was not prepared to do the same? “Of course!” I said, before I could change my mind. I wanted to model the courage that is one of my strongest-held values.
We first explored Rick’s history. He’d been uncomfortable in planes for as long as he could remember. His mother was a very nervous flyer, so Rick’s family rarely flew. When they did, his mom looked petrified and once even dug her nails into his skin during turbulence. So, he came to his flying anxiety by both nature and nurture. As an adult, Rick continued to avoid flying, and the less he did it, the more afraid he became. He still felt tremendous guilt about bailing the night before the flight that was supposed to take him to his best friend’s wedding.
Then, just before the pandemic, Rick was offered a dream job. Although it required frequent air travel, he decided it was too good a career opportunity to pass up. “I figured this would be exactly the kind of push I needed to get over my fear of flying,” he said. But the pandemic curtailed his new team’s travel, and Rick got few opportunities to fly. Later, when the U.S. reopened, he needed to be ready to fly anytime. He endured a business flight to Colorado with the help of Xanax but felt so miserable before the trip and after the medicine wore off, that he realized he needed to seek therapy.
We started by watching videos depicting a wide variety of flights, including turbulent ones, followed by vividly visualizing flying scenarios. I guided him to engage his imagination, focusing on all aspects of the experience, as if he were in a movie. When the imaginary exposures raised Rick’s anxiety, we practiced “sitting with” the anxious thoughts, feelings, and physical sensations. For example, I asked him to mindfully scan his body to notice where the uncomfortable sensations were showing up. Rick described his throat drying up and chest constricting, and he learned to allow them to be as they are, without judgment or suppression.
We also practiced observing the stream of anxious thoughts and imagining “placing” them on, for example, leaves in a stream or clouds in the sky — thus letting them continuously come and go. We discussed how this acceptance approach works best in the long run. We also practiced several breathing and muscle-relaxation techniques to be used only occasionally when anxiety becomes paralyzing. I warned Rick against using these “quick fix” techniques habitually, as they could become another kind of counterproductive avoidance. After a few months, Rick said he wanted to try “the real thing.”
At the airport, Rick blurted out, “I really, really want to do this, but I think I’m getting a panic attack!”
“Let’s breathe together like we’ve practiced,” I said. “Inhale for four, hold for four, exhale for eight though the nose…And repeat.”
Soon, Rick appeared more resolute and started heading back toward the gate. As I walked beside him, I felt my own anxiety bubbling up, but I kept a calm demeanor. Just before joining the line of boarding passengers, Rick stopped again. “It’s like I want to go, but some invisible hand is not letting me,” he said.
It seemed like he still was not accepting his ambivalence. How much easier it is for all of us to externalize what we don’t like about ourselves!
“Perhaps the hand is also a part of you,” I said. “There seem to be two parts of you.”
“Yes, it does feel like that.”
“What is each one saying?”
“One says, ‘You can do this, you’re strong, you’re not going to let the fear boss you around.’ And the other says, ‘You’ll faint or have a stroke if you get on that plane. If the plane doesn’t crash first. This is too much for you to handle!’” he said.
I waited, curious to see what he’d do with these two parts.
Rick asked for reassurance: “But it’s not going to crash, right?”
“Neither of us has a crystal ball,” I said with a slight smile, because Rick had been emphatic about his disdain for anything superstitious or new-agey.
He smiled back before his face turned solemn.
“I see more emotions coming up for you,” I said.
“A lot of irritation. Frustration with myself that I can’t be the person I want to be, that I am torn between these parts.”
“Is either part helping you expand or contract? Makes you larger or shrinks your world?”
“The first one makes me larger, but how do I make that one win?”
“It’s not about winning or losing. Only you know which one you’ll choose to listen to,” I said softly.
“I’m choosing to listen to the brave Rick, but the other part is still there…” his voice trailed off.
“That anxious Rick might always be a part of you. Can we just take him along for the ride?”
The gate attendant announced the last call for passengers heading to Charlotte. My stomach began to ache. We might never get on this flight, I thought with mixed feelings. A part of me felt disappointed with my ineffectiveness as a therapist. And another part was relieved that I might be spared flying today. It was then that I decided that self-disclosure might be helpful to get us past this impasse — after all, we were in this together.
“The truth is, I’m not a fan of flying either, especially after a long hiatus. I haven’t flown since the pandemic began, and my hands are sweating.” I turned my palms around for him to see. “But I don’t want to look back on my life with regret for not taking a chance, the regret that I so often hear from my elderly clients.”
Encouraged by the look of grateful surprise that flashed across Rick’s face, I continued. “Imagine sitting with your grandkids on your 80th birthday. What would you like to tell them about how you approached this short and precious life?”
Rick’s eyes brimmed with tears. He rushed toward the attendant, but quickly turned around. “You’re coming?” he asked.
I followed him swiftly, letting my legs carry me and my anxiety. I was thankful he led us to the plane.
Once in the air, Rick was surprised that he was not as anxious as he thought he’d be. “Anticipatory anxiety is always the worst,” I said. When the plane started to shake and both of us noticed our anxiety rising, we practiced the acceptance strategies. The majority of the flight was smooth, and each of us enjoyed a soda and flipped through a magazine. On our descent, the plane shook slightly and moved from side to side as we went through a thick layer of stormy clouds. Rick’s face turned pale and he murmured, “What now?”
“You know what to do,” I said.
Rick led us though some breathing exercises, and as his body relaxed a bit, he joked pointing out the window: “I am working hard to put my catastrophic thoughts onto these dark clouds!”
When we touched down, Rick turned toward me and mouthed, “Thank you.”
Now it was my turn to tear up. “Thank you. It was my honor to join you on this journey,” I said.
***
I was grateful that we were able to find strength in vulnerability and face the fear together. When we own all parts of ourselves, we can come to terms with the existential givens in unison. Approaching each therapeutic encounter as an opportunity to delve into the fundamental challenges of human existence, we enable our clients to grow stronger in the face of life’s uncertainties. Rather than offering them absolute solutions aimed at minimizing their anxiety, we can join them in embracing the existential realities, along with the unease these bring. And confronting the core realities of our existence is essential for leading rich and purposeful lives.
Exposure therapy is not about conquering anxiety but about finding a way to live authentically despite it. Instead of being technocratic cheerleaders, therapists using exposure have an opportunity to accompany clients on some of the scariest and most profound literal or figurative quests of their lives and witness the transformation that happens when we stop avoiding what matters.
“Have you decided how you’re coming back to D.C.?” I asked Rick as we exited the plane.
“I’m going to fly by myself!” he said with a smile. “And bring nervous Rick along.”
Questions for thought and discussion
What were your impressions about this therapist’s approach to exposure therapy?
In what way or ways do you think the client benefited from her intervention?
In what ways have you found exposure therapy to be useful in your practice? Not useful?
Creating a Safe Therapeutic Space for All Feelings
Yesterday, after a long silence, my client suddenly asked me, “did I offend you?”
A Therapist’s Secret Wish
I don’t let her know about my secret wish that she offer something offensive about me. Afterall, this was her process and I want to be careful not to project my feelings onto her, lest she become disagreeable to fulfill my aspirations for her instead of her own. That would defeat the entire purpose. Despite my success at navigating the conversation, my desire to be the recipient of a nasty comment did not abate. Perhaps I sound like a masochist who enjoys reveling in the psychological pain of being insulted. You might be thinking, is this a repetition compulsion? She should’ve gone to therapy to face her traumas not become a therapist to reenact them. Or maybe others would call me a martyr who sacrifices her own need for respect to keep her clients happy with her. She sounds Codependent. Is she in this for the right reasons? You might wonder.I definitely do not have a penchant for pain. When someone insults me, I do not like the way it feels. Despite my best efforts to hold them back, my eyes often fill with tears in response to even a minor slight. Like most humans, I protect myself valiantly when I feel judged or criticized. Were I, in actuality, to be a martyr for the sake of keeping my clients happy, it would actually be pretty devastating to hear negative feedback. It would mean they weren’t happy with me. Wouldn’t that defeat the entire purpose of the sacrifice?
Here’s the thing; I’m no masochist and I’m definitely not a martyr. However, I am invested in my clients. I believe that for my clients to heal, they need a space where they are free to say and be whatever and whoever they want — including offensive. I might be a sensitive person, however, when I’m in my therapist role, my feelings are only welcome if they are in service of the client. If they aren’t, I set them aside to work through later.
In my experience, clients don’t come to therapy to be rude or offensive, especially toward the therapist. They certainly don’t want to be perceived as an ingrate by someone whose job definition is to help them. They are often ashamed of their selfishness and deny it, not only in the therapy room, but in their lives. But here’s a little secret; if they leave part of themselves outside, then part of them won’t heal. For therapy to work, they need to give voice to all their thoughts and feelings, especially their most shameful ones.
As a therapist, it is my responsibility to make space for the repressed voices of my clients. Good therapy grants permission to express what, outside of therapy, might be labeled socially inappropriate. Lack of this permission can reinforce ineffective patterns of repressing feelings and increasing shame.
The therapeutic challenge comes when, in instances such as this one, my own feelings are at stake. It’s relatively simple to support a client when their complaints are about “other things.” However, when their pain might be related to me, even if I had no intention to hurt them and despite the feeling that they are nitpicking, I feel obligated to face the Herculean task of supporting them just the same. Indeed, this selfless endeavor may be the most important and impactful act of therapy. If I can respond to an insult with curiosity, receive negative feedback without defensiveness, and authentically validate the valid, then I am giving my clients full permission to shamelessly express themselves. I cannot think of a better way to convey unconditional acceptance. But don’t get me wrong, I’m not giving permission for people to act how they please. Actions need boundaries. However, in therapy, I believe that words don’t and that words shouldn’t, even if and when those words are offensive.
***
So, as I think again about yesterday, I hope I can find a way to convey this message, “no, dear client, you didn’t offend me, but I hope that one day you feel strong enough to take that risk. And when you do, I will not abandon or reject you. Instead, I will be honored that this vulnerable and precious part is finally brave enough to join us in session.”
Questions for Reflection and Discussion
In what ways is the therapist’s attitude in this essay similar or dissimilar from your own?
How do you address situations where your client offends you?
In what clinical circumstances might you NOT address a client’s offensive behavior?
Reflections on Clinical Techniques for Working with Loss
In the “helping profession,” it is easy to talk about how we handled our successes, but seldom do we openly speak about the failures, the ones who got away. The people who leave treatment and don’t come back, or the ones who take their own life. How do you reconcile this?
Losing Clients in Therapy
I remember sitting in a training group run by one of my mentors — the topic was treatment failures. He said clients come and go, and that few therapists get through their career without experiencing the death of a client.The Ones Who Come and Go or Don’t Come Back
Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.
On the Death of a Coworker
At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.
Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.
Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.
On the Death of Clients
True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.
The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.
In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.
The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.
I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.
The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.
I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!
Questions for Reflection and Discussion
How have you dealt personally and professionally with losing clients?
How might you have avoided a particular client’s unexpected departure from therapy?
What are your thoughts about attending a client’s or their family member’s funeral?
Gardening Narratives and Storyliving Ones Life
“Terra de encanto amor e sol
Não falo inglês nem espanhol
Quem te conhece não esquece
meu Brasil é com S”
–– Brasil com S, João Gilberto
I’m Adriana Müller (AM) and I live in the Abya Yala region, in the territory known by the native peoples as Pindorama but named on maps as Brazil. It is an area of 3.287.597 square miles (over 8 million square kilometres) filled with an exuberant nature and a wide variety of flora, fauna, and geography, ranging from the Amazon rainforest to the gaucho pampas, passing through the hinterland (known as ‘sertão’) and the wetlands (known as ‘pantanal’). It is a region that has always been inhabited by people who know the seasons and have mastered the art of land care. It is a territory that, over the centuries, has received people from every continent, coming through a number of means and for different reasons. Brazilian people are the mixture of all these stories that can be revealed in our cultural way of being cheerful, outgoing, interactive, greeting friends with hugs and kisses — and the ever-present cup of coffee. Our people love football and carnival, take for granted different kinds of faith and beliefs, use plenty of metaphors while speaking and we live with passion. Brazilian folks are creative, they care about the others and know how to cook using everything the earth yields. Brazilians are helpful and have healing strategies for almost every problem. We know what resistance means, and we usually show it by singing and dancing our love and pain in various tones and rhythms. Brazilian people find ways to weather the weather and survive through life challenges, always making a point to value and honour our legacy.
This article is a tribute to all this cultural heritage. It is about a work I have developed on Narrative Therapy, in particular the use of narrative metaphors. The central topic to be presented here is gardening. Here in Brazil, there are some metaphorical expressions that highlight our connection to the land: we say that someone who is down to earth and is not easily deceived is a “pé no chão” (they have their feet on the ground), and the traditional samba is known as “samba raiz” (root samba). Whoever has “one inch of land” has a place to live and all those who were born here are “children of the land.”
It is from the land that we derive our livelihood, and, throughout Brazil, people know how to clear the land, cut the furrows, sow the seeds, and harvest the crops. In the Tupi language, people born in the territory known today as Espírito Santo are called “capixabas,” which means ‘land ready for planting.’ That's where I live — in the capixabas’ land. Because of my personal experiences in planting as well as in gardening, I started some therapeutic conversations rooted in the metaphor of the garden. The idea is to intertwine the principles of narrative therapy and four moments in the process of tending a garden, inviting clients to view their lives through the glasses of the following metaphors: 1) pulling out the weeds; 2) choosing the good seeds; 3) ‘hopefying’ like a farmer and 4) celebrating the harvest. The process involves therapeutic documents such as letters or poems, the relational development of meanings and encouraging clients to understand their personal agency through the metaphor of gardening.
The Magic of the Narrative Therapeutic Encounter
According to narrative therapy, our life has a multiplicity of events that can be grouped in a certain temporal sequence, generating a narrative on a specific topic. We are not predefined nor fixed beings. On the contrary, in each one of us, stories are waiting for the right moment to come to light and reveal their power. And each story is activated through questions, resonances with other people’s stories, and present connections to past experiences. In short, it can happen in various ways, but always as an invitation to access, connect, and chain the events. As Paulo Freire said, “Pieces of time that, in fact, were in me since when I lived them, waiting for another time, which might not even have come as they came, when they could lengthen in the composition of the larger plot.” (1)Hence, this text is about aligning some moments that happened in my life story while meeting some clients — and how the images and resonances of these consultations generated metaphors and poetry.
Usually, people seek therapy when they are facing problems that limit their sense of competence, their capacity for agency, and their perception of themselves as a person of value. In short, when the story reveals more about the problem than about the person. In such moments, a narrative-based therapist seeks to rescue the beauty and dignity of life, through questions, paths and processes that give prominence to information that contributes to the creation of a good story (2).
According to my personal communication with David Epston, questions guide the conversation: trivial questions lead to trivial answers, boring questions build boring narratives and poetic questions are seeds of poetic stories. And he introduces a new kind of question — the ones with ‘Duendes’. Those questions come from the heart and bring into the conversation “the spirit of narrative therapy full of enthusiasm, irreverence, improvisation, imagination, righteous indignation at injustice, solidarity with those who suffer, collective creativity, fascination with the magic and mystery that reside at the heart of everyday life”, among others (3). An invitation to look at life with wonderfulness (4) — which Paulo Freire (5) would call the ‘beautifulness’ of life and relationships — finding ways to stop emphasising problem-saturated stories and start portraying versions that reveal people’s preferred identity.
Externalizing conversations (6), in which people name the problems and perceive themselves as separate from them, contribute to the necessary distancing so that preferred stories can be accessed. In this process, thinking about the effects of the problems in contrast to personal goals gives the person some space to see themselves as separate from the problems, and also to reconnect themselves to what La Taille (7) calls the ‘ethical view’. For me, this ethical view poses the questions “what life is worth living?” and, consequently, “who should I be to live that life?” The search for these answers leads the person to strive to be a person who deserves to live such a desirable life. Therefore, their actions are aligned with values, beliefs, principles, skills, competencies, goals, purposes, among other aspects that are their strength when facing life’s challenges and dilemmas.
Such aspects are part of the history of the person; therefore, they happen in a socio-historical environment and involve others. They also take place within what Freyre calls ‘tribio time’ – ‘tri’ for three, and ‘bio’, for life. It is an existential time that for him, is never only past, neither only present, nor only future, but all three simultaneously combined.” It is an intersection of past, present and future that evokes as well as prophesies, and in which survival and anticipation are intertwined.
La Taille also says that ethical answers about one’s life guide us to moral questions about “how should I live?” — a question that involves actions and its individual and collective consequences. In a similar way, Freire also tells us about the dialectical unity action-reflection necessary for the development of a critical consciousness that constitutes the way of being and/or transforming the world. Such concepts are very close to what Michael White called personal agency, which he described as “a sense of being able to regulate one’s own life, to intervene in one’s life to affect its course according to one’s intentions, and to do this in ways that are shaped by one’s knowledge of life and skills of living.”
In this context, re-authoring conversations which involve connecting the landscape of action (account of events) and identity (perception of meanings), seek to reveal the potentialities always present in the story and the agency of the person. In addition, re-membering conversations seek to connect us to significant people and the mutual contribution to the sense of being a person of value. Knowing that we are part of a network of affections that constitutes us and in which we actively participate by giving and receiving — and, thus, developing meaning — is important in building the notion of oneself as a person of value.
While the therapeutic meetings take place, each conversation reveals precious details that the therapist writes down or keeps in mind. Later on, such words can be given back to people as documents that ‘rescue the said from the saying of it’ (8) and can help highlight stories that reveal their preferred identities. Usually, I write documents as poetry — which can become song lyrics, as in the Rhythms of Life methodology (9) — as Rubem Alves used to say: “Words only make sense if they help us to better see the world. We learn words to improve our eyes.”
But how do we know which words are to be rescued and, later on, be delivered to those who said them? Grandesso (10) helps us:
If any lighthouse or compass to guide the journey in the field of meaning could be available, it would come more from the reactions of our body, responding more to the poetic forms of the words that touch us, than from any previous knowledge. (…) What (the therapist) can offer for that moment, are not his/her explanations or his/her theoretical knowledge, but his/her understandings in the form of reflections coming from words and images that arise from generous listening.
That is how the narrative metaphor helps throughout the therapeutic process, reminding us of White’s warning (11) about our ethical responsibility in the development of meaning, since it “powerfully shapes the training activities of the I and the relationship in which we engage under the name of therapeutic practice.” The narrative process is always respectful and seeks to position the client as an expert, therefore, a metaphor never arises before the meeting, but, during its flow. Each metaphor represents the harmony of the therapeutic context and is always a symbolic, figurative, and poetic invitation for the person to leave what is known and familiar to go towards what is possible to know.
Such scaffolding conversations, which White elaborated based on Vygotsky’s writings, are very similar to what Freire called the achievement of the “untested-feasibility”: one that is not yet, therefore is unprecedented, but whose originality lies within viable possibilities. Paro, Ventura, & Silva (13) show that, according to this Brazilian educator and philosopher, we face, individually or collectively, concrete, challenging and historical obstacles and forms of oppression, that impose themselves as if there is no way out — and which Freire calls ‘limit-situations’. We do not accept or receive such ‘limit-situations’ passively, but rather, we seek to overcome them through ‘limit-acts’. As we take distance from the ‘limit-situations’, the ‘background-awareness’[3] can emerge. The ‘background-awareness’ is something that cannot and should not remain as it is, therefore, what needs to be faced, discussed and overcome. The ‘limit-situations’, when detached from reality, can be objectified and understood as ‘issues-problems’. So, we begin “to dream of another possible world, something that does not yet exist, but may exist through the articulated action of its subjects, as an ontological need for the transformation of our individual and social reality (…), the ‘untested-feasibility’” (14).
Creativity, joy, hope, eyes that see ‘beautifulness’, freedom, dialogue… are ingredients that make the difference in a therapeutic encounter that aims at the ‘untested-feasibility’. The magic of the therapeutic encounter creates the possibility for each one to write and live their life in an unprecedented way and, creatively, to begin the ‘storyliving’ of their own life.
My Storyliving with Gardens
One year after graduating in Psychology, I moved, for professional and family reasons, to the city of Venda Nova do Imigrante, in the countryside of the state of Espírito Santo. We lived there for 10 years in a condominium on a farm. This experience soon gave birth to the idea of creating a Sustainable Development NGO — the CDS Guaçu-Virá [3]. This whole experience, both in contact with the land and the country people as well as with ecology and preservation professionals, taught me a lot about nature and its cycles, its diversity and its peculiarities. This life experience revealed the importance of our relationship with this living organism on which we inhabit and taught me precious knowledges ‘from the root’: the ones incorporated through daily experiences, for real, and in continuous partnership with Nature. For example: how can we have potable water to drink and cook? Firstly, by recovering the water springs in the woods, planting trees that could help renew the springs — or, as we used to say: “planting water.” Secondly, taking care of every tree like a precious asset until the fountain was back to life. From then on, so long ago, it still supplies 15 houses, one factory and three lakes. Through this and other praxis, day after day, for 10 years, nature taught me about Life and living.
So, when I came back to the capital city, Vitória, all these threads of knowledge and experiences were intertwined with my life. I found myself surrounded by plants and realized that the more attention I paid to them, the more they flourished. Nature always responds and, even living in an apartment, my care for them would return as buds, blossoms, birds, butterflies, and bees. Suddenly I realized I could have the farm atmosphere right in the middle of the city. As mentioned by Reis (15), gardening and other activities that involve caring for and contemplating flowers and ornamental plants, whether in the external or internal environment, generate a sense of well-being by stimulating the senses through luminosity, colours, sounds, aromas, textures and shapes, in addition to activating the aesthetic sense. Therefore, they can be important allies for the preservation and recovery of health and well-being.
When I started using the metaphor of the garden in consultations, I noticed that the enchantment was as fast as nature’s response. There is something inside that, in a special way, connects us to the idea of a garden: being a gardener, being a seed, being a flower bud, understanding the phases of a garden. There are many possibilities for applying this metaphor, and all of them invite us to beautiful narratives of agency, of developing meaning and finding resources to deal with life’s challenges. The metaphor of the garden is an invitation to rescue each one’s connection to nature. Next, you will find the metaphor of Gardening and two stories. I hope these shared ideas can contribute to nature’s power of enchantment and poetry that activate creativity. Let’s sow narrative ideas!
Gardening Narratives
“Vai o bicho homem, fruto da semente, (memória)
Renascer da própria força, própria luz e fé. (memória)
Entender que tudo é nosso, sempre esteve em nós, (história)
Somos a semente, ato, mente e voz. (magia)”
(Redescobrir – Gonzaguinha) [4]
According to White & Epston (16), “the narrative mode of thought (…) is characterised by good stories that gain credence through their lifelikeness.” Good stories have a great number of metaphorical images that organize the telling and help build a positive sense of being. If you have ever taken care of a garden — either a small one in pots or a large one over lawns — you can identify four moments of this work: pulling out the weeds, choosing the good seeds, waiting for sprouting and being happy with the result. Let me share with you the metaphor and its connections to narrative therapy.
1. Pulling out the weeds or invasive plants
Every garden has weeds that show up as unwanted guests. Dealing with them requires some specific skills: knowing how to tell plants and weeds apart, understanding the effects of these invasive plants on the flora, and establishing an action plan to better lay the garden out. This stage is the well-known narrative ‘externalization conversation’ in which we invite the clients to name the problem (weed), to check the effects of the problem on their life, to evaluate such effects and to set a plan of action to recover their life (the garden) from the consequences of the problems. In Freirian terms, we can say that this is the ‘background-awareness’ stage.
A garden full of weeds is like a story saturated with problems: it loses its strength, vigour and beauty, not because it lacks these characteristics, but because all its energy is being used to maintain the problem. That is why it is important to help people to recover their notion of personal agency through action-reflection, that will help them elaborate and put into practice their abilities to storyliving as the protagonist of the plot.
Some questions (metaphorical or not) that can help in this moment are:
Questions about the effect of the problem:
What have I been feeling / thinking?
What has been bothering me?
How does this ‘weed’ disturb me? Is it a mistletoe that suffocates me? Is it a kind of weed that traps and hurts me? Is it a weed that competes with me for water and nutrients?
Questions about the plan of action:
How do I want my garden to be?
What do I want to see blooming in my garden?
What are the main potentials of my garden?
What should I do to make this dream-garden come true?
Who can help me with this task?
What are my skills and abilities to deal with this challenge?
When can I start working in this garden?
These reflections detach the person from the problem and help to start a process to connect the person to the preferred version of his/her story — the garden each one dreams of.
2. Choosing the best seeds
While speaking about gardens and gardeners, Rubem Alves (17) invites us to the following reflection:
What comes first? The garden or the gardener? It’s the gardener. If there is a gardener, sooner or later a garden will appear. But if there is a garden without a gardener, sooner or later it will disappear. What is a gardener? A person whose mind is full of gardens. What makes a garden is what the gardener has in mind. What makes a nation is the sum total of the thoughts of those who are a part of it.
After removing the weeds, the disturbed but cleared soil is ready to receive the seeds. And, if the garden is in the gardener’s mind, it is time to help by choosing the best seeds: those aspects of life that the person holds precious, considers important and wants to keep updated. What s/he wants to plant and see growing and what activates the sense of beautifulness and wonderfulness.
In addition to the questions of the ethical and moral landscapes, arises the notion, “how do I want my garden to be?” What should I do to make it that way? What kind of gardener must I become to help this garden grow? — there are other questions that also contribute to this development, as they open the possibility for the sense of agency, values and wonderfulness:
What seeds do I choose to plant?
What do I admire and consider important to be present in the garden of my life?
What is beautiful and special about me that I want to see blossom?
What aspects of my life do I value?
What matters in my life?
Who helps me in this planting?
What did these persons teach me? And what do I teach them?
What is special and unique about this garden?
Through these reflections, people connect to what they hold precious, and their favorite story grows stronger in meaning, shape, colour and scent. The garden is coming to life.
3.'Hopefying’ like a farmer
One thing that has always impressed me in my experience living on the farm is the wisdom of the farmers. Planting is an art and, as such, it requires very specific skills, including what I usually call the ‘farmer’s hopefying.’ Firstly, the farmers let the land rest after harvesting, and, after that, they start working on it. From sunrise to sunset, they spend the day ploughing, balancing the soil nutrients, watering, planting the next crop. Tirelessly, they keep on watering that soil already sown, but still with no sign of life or success. Every farmer needs to believe in the work done and in the power of the seed — they need to believe in the ‘untested-feasibility’. They need to hopefy. They need to be “neither only patient nor only impatient, but, as Freire says, patiently impatient”.
Achieving the ‘untested-feasibility’ involves hopefying. But make no mistake: hopefy is an energetic attitude, a way of positioning yourself in life, and not a mere linguistic pun. There is the ‘hope’ from the verb to wait for. This ‘hope’ keeps us passive, static, waiting for something to happen or for someone to do something. And there is the hope as in ‘hopefying.’ To hopefy puts us in an active, dynamic position. In Freire’s words: “To hopefy is to get up, to go for it, to build, to hopefy is not to give up! To hopefy is to move forward, to join with others to do otherwise…”.
Everything we plant in life has its own time to come into being. While this time passes by, let’s remember to hopefy as the farmer does. During the consultation, that is the moment I usually write and hand over poetry to the ‘gardeners’.
4. Celebrating the harvest
Picturing the field producing and harvesting is as important as preparing the soil, planting the best seeds and knowing how to hopefy. Celebrating this moment means recognizing the strength within the whole process. In Freire’s words, “Joy does not come only when one finds something, but it is part of the search process. Teaching and learning cannot happen outside the search, outside the beautifulness and joy.” As an educator, Freire talks about the process of ‘teaching and learning’ which, in this text, is metaphorically called ‘sowing and harvesting’ — and which, as such, applies to the most different processes in life.
The harvest unfolds the power of wonderfulness — the beautifulness’ unveiled. They are the foundation for the preferred story: the one that reveals the preferred identity of the person. Realizing that one is capable of transforming soils previously taken over by weeds into gardens full of beautifulness reveals the ability each one has, as individuals and collectively, to sow dreams and reap realities.
Now the time has come to present two stories of therapeutic meetings in which the metaphor of Gardening Narratives were used. It is important to say that both stories were authorised to be published and that, for privacy, the names were omitted or modified. I would also want to point out that, like in any process, nothing follows the rules by the book. The fluidity and organization required in a written text are not found in the same way in the dynamics of interactions, which are mostly based on simultaneity, dynamic responsiveness, and constant reorganization. In Freire’s words. “An event, a fact, a deed, a gesture of anger or love, a poem, a canvas, a song, a book never has a single reason behind it. (…) That’s why I was always much more interested in understanding the process in which and how things happen than the product itself.” Therefore, you are invited to understand the process, while I keep hopefying the essence of Gardening Narratives presented in these stories comes to life beyond the didactic sequences just shown.
First Story: Once I Met a Gardener
She arrived at the office with tears in her eyes and a story of suffering to tell. There, in front of me, another woman reporting about when she discovered her husband’s betrayal, about the effort she made to forgive him, and to give them a second chance. At that time, they were two. Time passed, the wound healed, and the couple dreamed of being three. Pregnancy came as a gift, and on the day she delivered her child, she made up her mind to put all that bad story behind her. She wanted to be reborn as a mother and as a new woman. It was time for a renewed family to come into being. Along with the baby, there came forgiveness. And she cried for joy.She went home, breastfed, took care of herself, and felt whole. She felt that there was attention and care from the couple to the baby, and she was sure that this was the family she had always dreamed of. Nevertheless, a few months later, she discovered that the betrayal was not a shadow of the past, but the harsh reality of the present. That was when she came to my office, and I learned about this story combining pain and hope.
Michael White taught us that we are outside witnesses to the stories we are told. This is not trivial, and it requires responsibility both in listening generously and in responding to what we hear. He presents us with a four-step map to navigate this unfamiliar therapeutic conversation terrain, calling our attention to each expression that strikes us during the telling of the narrative, the image it brings to our minds, the resonance of it with our life and where it takes us. That day, while hearing those stories, several images — real and metaphorical ones — came to my mind. I heard them as a woman, as a wife, as a mother. I felt them as a storm, as lightning, as devastation. I took them as birth, as life, as forgiveness. Eventually, she wiped her tears, looked at me and waited for my words.
Inside me, this phrase echoed: “I feel devastated.” The image came naturally: a raked-up garden, holes everywhere. And the resonance took me back to the time when I lived on the farm and dedicated myself to the garden at home. There I made beds with colourful flowers and medicinal plants. Bordering the lot, I planted a hedge of calliandra (Calliandra brevipes), with their blooming fragrant flowers forecasting rainy days. Throughout the garden, I planted fruit trees to feed the birds, yellow trumpet flowers (Handroanthus albus) and a jambo tree (Syzygium jambos) to have a beautiful colourful rug with the fallen flowers, and a tree for each baby I had. In my garden, I planted trees, dreams, and stories.
But, in the same garden, there were weeds — lots of them! And they taught me a powerful lesson: weeds are easier to remove when they are still sprouting. One can do it with one’s bare hands. But, once they are grown and rooted, one will need a hoe and some strength. All this work breaks the soil, leaving holes all over and it harms the garden’s beauty. That was the image evoked and shared — a damaged garden. But this experience with weeds taught me we can either look at the holes and at the ugliness of the garden or we can see the loose weedless soil as a terrain for new seeds. All these memories were shared with her. “Does it make sense to you?” I asked. She said yes, and we started talking about how to till a revolved garden.
This metaphor came back a number of times throughout the meetings and conversations. Through the reauthoring conversation, she connected the landscape of action to the landscape of identity, going back and forth in time, talking about what really mattered in her life, the people who contributed to her being who she was, her dreams and projects, her skills and competences, her values and principles. While listening to these stories, a new image emerged: a living and loving garden. Then I realized she was gardening narratives.
Firstly, she strengthened herself. She reconnected herself to everything she valued and cared for. She recharted her routine including things she likes and reviving her sense of religion. She realized her ability to move forward, and she appreciated the ‘beautifulness’ of her life. Step by step, she sowed new seeds in her garden.
Then, she hopefied for a new stage: togetherness. Not to re-live the past, like in a never-ending circle, but to live a spiral-present that provided something new and more rewarding. So, she decided to invite her husband to come around and learn about her ‘garden.’ This hopefying moment enclosed the wish to till the best asset of her garden: her family. She felt inside a growing power to take herself as an agent and a sower of possible futures — of ‘untested-
How In-Person Sessions Create Space for Clients Unspeakable Truths
Many of us have not gone back to in-person sessions even though the Covid epidemic has passed. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on long business trips or had some other compelling reason that made them unable to come in person. But beginning in March 2020 my practice transformed — all phone (or in a few cases video) sessions. After two years of living in my “weekend” house, I sold my office in New York and accepted the fact that my practice was going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.
Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.
John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.
A Revealing Therapeutic Interchange
[Therapist’s thoughts]: I am aware that Sharon’s crotch is in full view. She does this often when she is wearing a skirt. I am trying not to look at her crotch while she is talking to me, but I have the impression that she is not wearing underpants. I think to myself that perhaps she is just wearing dark underpants. I start to question myself. Am I really seeing her genitals? Yes, I am. How should I handle it? If I ignore her exposing herself to me, I will be doing what her mother did — acting as if she is not a female with genitals. On the other hand, I know that however I say it to her, she will be mortified and furious at me. In the past, I felt the mortification would be too much for her, but this time I feel this is much more directly sexual than her sitting this way in the past.
“Are you aware of how you're sitting?” I asked.
Sharon immediately put her knees together.
“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”
“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”
“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”
“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”
“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”
“You mean it doesn’t matter if your crotch is exposed or not?” I asked.
“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”
“You mean you feel like there’s nothing between your legs?”
“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”
“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”
“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”
“You didn’t offend me. But I think exposing yourself is a way of telling me something.”
“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”
“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”
“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”
“What about underpants?”
“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”
“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”
“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”
[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]
[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]
“You mean your mother was masturbating in front of you,” I said.
“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”
[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]
***
Sharon’s traumatic childhood experience would not have been unearthed if I was talking to her on the telephone or video (which is face-to-face). On the phone or on video, she would not have been able to engender in me the same confusion, self-doubt, anxiety, and denial that she experienced as a child; she would not have been able to communicate the unspeakable truth. Telephone sessions may be useful for many patients, but for those who enact rather than verbalize their early experiences, it is not optimal.
Questions for Thought and Discussion
What are your impressions about this author’s clinical approach with this client?
Might you have done or said something different under these circumstances?
How do you address uncomfortable situations like these in your practice?
Existential-Spiritual Techniques for Fostering a Healthy Perspective on Aging
Introduction: The Existential-Spiritual Model
The case vignette that I will share presents the application of an Existential-Spiritual model of coping when working with patients experiencing the natural inevitability of aging and the “normal” responses associated with it. The integrated model includes six intervention practices: self-compassion and mindfulness, discovering meaning in life, prayer, creativity, expressing gratitude, and being open to a sense of awe. Existentialism poses universal questions and concerns, while spirituality provides space to process grief and loss and create meaning in life (1). The aims of spirituality include having compassion for others’ pain and suffering, advocating for social justice, and gaining awareness of and learning from the tragic dimensions of existence, thereby enhancing an appreciation for and valuing of life. This case of Jonathan highlights how dreams can be a valuable resource in gaining a deeper understanding of an individual’s attempts to deal with their existential and spiritual challenges, as well as finding passion and purpose in life (2).
Initial Phase: Processing Unprocessed Grief and Loss
Jonathan is a 68-year-old male who entered individual psychotherapy for the first time. He reported that he has been married for 40 years and has a married adult daughter and two grandchildren, ages 8 and 12, who live nearby. He had retired just one year prior to the pandemic. Jonathan, who majored in English literature, pursued a law degree for financial stability and a personal value of and commitment to social justice. After law school, he worked in his father’s medical supply business to support his father’s declining health due to numerous medical problems and an early death from diabetes at age 56.
Jonathan expressed concerns of feeling “empty inside” and experienced lack of direction, meaning, and purpose in life since his mother died approximately five years ago, just six months after his retirement. He reported feeling numb and indifferent over the wars in Ukraine and Gaza/Israel, and the intensified polarization of political discourse he observed during his extensive time watching cable news. Given his commitment to social justice, these feelings were different for him. In addition, a close friend had died early on in the pandemic, but he was unable to visit him in the hospital or attend his funeral due to COVID-19 safety restrictions.
Jonathan wanted to work with a psychotherapist experienced in Existential-Humanistic approaches based on his longstanding interest in the existential writings of Tolstoy, Sartre, and Camus. During his initial psychotherapy session, Jonathan reported a disturbing dream from the night before. He was in a building with a male colleague and his own daughter trying to find a pool. His colleague pointed to some skin lesions on Jonathan’s body; one had rows of 20 elevated dots that looked like shingles. There was another area that had been festering for some time. He was preoccupied by his skin condition in the dream and when he looked up, his colleague and daughter were no longer there.
Jonathan frantically searched the building asking for help in finding his colleague, daughter, and the pool. He recalled walking into an office with an elderly woman who was volunteering in the building. She was unable to provide any guidance as to his colleague’s or daughter’s whereabouts. Jonathan felt anxious about missing out on seeing them and the opportunity to swim. He woke up feeling worried and not knowing what to do.
I used several existential approaches, including Jonathan telling the dream in the present tense to develop a sense of presence and agency. I asked him what he thought the dream meant and inquired about his main feelings in the dream. Jonathan responded that he felt that something was missing in his life and “life was passing me by.” Jonathan associated the dream skin lesions with his mother’s fatal skin melanoma. He also described the colleague in the dream as confident and adventuresome, much like his recently deceased friend. I wondered if the dream reflected Jonathan’s hope that his therapy would help reduce his anxiety, but also his fear of what his treatment would uncover.
When asked to elaborate on the circumstances of his mother’s death, Jonathan expressed that she had been living in an assistive living facility in Florida for three years with a full-time aide. He then expressed guilt that he only visited her a few times a year due to his busy work schedule. He said he felt emotionally overwhelmed being with her as she did not recognize him during his last few visits, and she needed everything repeated numerous times. Jonathan said he was actually relieved when she passed away but felt ashamed for having these feelings and did not share them with anyone.
To further his sense of agency, I asked Jonathan, “What is the existential message that can be taken from the dream?” He responded, “I need to stop avoiding making a medical appointment with my dermatologist because I am scared of what it could be” and that he might be paying a price for not processing his numerous losses. I then asked Jonathan, “If you could continue the dream, how would you want it to end?” After struggling with an answer, he said he missed seeing his colleague at work, swimming, and spending time with his daughter and grandchildren.
The initial phase of psychotherapy focused on his unprocessed grief and loss over his mother’s and close friend’s deaths, reflecting on the impact of the COVID-19 pandemic, and clarifying his values. He expressed resentment that he and his wife, who were eagerly looking forward to his retirement, were unable to fulfill longstanding travel plans to Asia, South America, and Alaska during the pandemic. Jonathan felt it unfair that he had sacrificed being a lawyer to help run his father’s medical supply business, and that he historically had placed others’ needs above his own.
He felt that it was unfair that these losses happened to him now, just as he was on the verge of finally pursuing his own dreams. He also felt that his mother’s and friend’s deaths, as well as the social isolation during COVID-19, were disruptions of the life “he was supposed to have,” rather than inevitable parts of anyone’s life. He wondered if he was being punished for not being compassionate and supportive of his mother at the end of her life. I suggested using self-compassion statements to soften some of the self-critical attitudes, such as how he should have grieved his mother’s passing.
Jonathan and I explored how his sense of guilt, regret, and shame over his mother’s death had drained his coping skills and flexibility to deal with his mourning process. We discussed how some of his basic assumptions of the world — such as “The world is fair,” “bad things should not happen to good people,” and “there is a reason for everything that happens,” — were shattered and left him “drifting at sea without a paddle,” not knowing what to do. We explored how these feelings were similar to how he felt at the end of his initial dream and how these factors may have impacted — and could continue to impact — his ability to mourn and grieve. Jonathan gradually was able to acknowledge, but not accept, that the world is unfair and unpredictable, and that random events can happen to good people.
I asked Jonathan to describe in more detail his last visit with his mother. He recalled her sitting up in bed requiring her full-time aide to feed her pureed food. She was staring out the window as if she was already in a different place. Jonathan said she was there physically, but in some ways she had died psychologically. I suggested that he was experiencing an ambiguous loss, making it challenging to start grieving her passing because she was still there physically. He tried to imagine what she might have been experiencing looking out of the window, and he wondered if she was scared of dying and being forgotten by others.
The next session included recalling positive memories of his mother — what kind of person she was before her Alzheimer disease diagnosis, and what values she lived by. He brought in photographs including her wedding picture and one where she was holding his daughter when she was an infant. His mother’s eyes in the second picture conveyed a warm, loving glow, which was comforting to Jonathan. He also recalled how she went back to school to become an elementary school teacher when Jonathan and his younger sister were in high school, and how much he enjoyed hearing stories about her work. He realized that his mother was more than his memory of what she was like at the end of her life.
Jonathan also discussed how his best friend, Michael, passed away three months into the pandemic. They had become best friends in 8th grade, and even though his friend moved out West after college, they maintained regular contact, including yearly visits. Michael was adventurous, loved hiking and fishing in the Pacific Northwest, and enjoyed talking to strangers. I suggested to Jonathan that the colleague from his initial dream might symbolize this friend, perhaps indicating a desire to emulate his confidence and adventurous spirit.
Jonathan fondly recalled that the conversations he had with his friend always had the quality of picking up right where they left off. His beloved friend Michael, a social worker, always provided a listening ear and would ask challenging, but supportive questions. He was non-judgmental and helped Jonathan with various struggles. When asked what he missed most about his friend, he replied, “I could talk about anything without feeling judged, and he treated everyone with respect, always seeing the best in others.” When asked what Michael would say to him now in terms of how he should handle all his losses, he replied, “Just savor the preciousness of each moment, don’t take anything for granted, and take some risks.”
On top of these two significant losses, Jonathan felt that the pandemic was a very isolating and frustrating experience. His retirement dreams were put on hold, leading him into several unhealthy patterns, such as excessively, or perhaps obsessively watching cable news, growing more irritable with others, and being intolerant of conversations with friends and family members with opposing political viewpoints. His main pleasures during the pandemic were his weekly Zoom meeting with his daughter’s family, reading, and taking daily walks.
I asked open-ended questions at this time, including: “What sustained you during the pandemic?” “What did you learn about yourself?” and, “Where did you find the strength?” Jonathan felt that his longstanding interest in Buddhism and the Jewish value of healing the world (tikkun olam) provided a sense of stability. Specifically, Buddhism stressed the importance of not getting too attached to things, the importance of just “being” and accepting things as they are. Although these beliefs provided some degree of intellectual comfort, they did not have a major impact on his actions or his self-confidence.
In order to provide Jonathan with a deeper foundation and sense of direction, I asked Jonathan to describe his core values, which he identified as supporting his family, treating others equally and with respect, and pursuing excellence in whatever he did. Since his retirement, he felt that part of his identity had been lost even though his career was never in line with his values of social justice and being a lawyer, leaving him lacking passion and direction. He was encouraged to explore if these values were still effective and whether he needed to reconsider refining them in some way. Jonathan was gradually able to realize that although he did not need to financially support his daughter and grandchildren, he could model for them how to handle adversity and aging in a graceful way, as well as find other ways to channel his need to treat others equally and with respect. I stressed that values are not fixed in nature but can be created. At this point in therapy, he was also encouraged to practice mindfulness exercises and self-compassion to increase his level of self-reflectiveness, to be less judgmental of his struggles, and to recognize that his feelings are transient.
Middle Phase: Establishing a New Sense of Self Through Existential Approaches
Four months into treatment, Jonathan reported a vivid dream where he was walking in New York City trying to get to a meeting in his office on the East Side. He was waiting with a group of people in a building near Central Park. Some of the people were taking too long so he decided to leave to make it to the 3:00 meeting. He was trying to find a cab, but they were all full. He walked down an area in midtown that was sectioned off with small houses that one would typically see in the suburbs. One of the buildings had a large window where he saw a group of people relaxing and socializing.
Jonathan realized he had to get to the office, so he finally got into a cab and saw he only had a $10 bill to pay for the short trip to the office. The traffic was slow, so he decided to get out of the cab to walk the remaining distance. There were long, winding, hilly sidewalks that are not typical of the city, and he realized that he was on the opposite side of Manhattan from his office. He sensed he would miss his meeting as he saw trains passing by near the Hudson River. He then found himself walking down a long, beautifully constructed road with tall, shady trees leaving the city through a tunnel. He woke up feeling that he wanted to stay in the city and that going through the tunnel was potentially dangerous.
Jonathan felt the dream meant that he was struggling to find a new path in life, that he had lost a core part of his identity in his retirement, and that he lacked a sense of community. Like in the Robert Frost poem, The Road Not Taken, he feared making the wrong choice, reminiscent of his decision not to pursue his dream of becoming a lawyer. He was asked to visualize what it would be like going through the tunnel. Jonathan imagined it would be dark, claustrophobic, and scary to walk on the narrow sidewalk with a guardrail with all the cars driving by fast. He felt that he would eventually be able to get to the other side, but it would take a great deal of effort and time. He was asked to imagine what it would be like if he went further into the tunnel to the other side.
Jonathan struggled but was eventually able to say that he wished his parents and best friend were on the other side to greet him, saying how proud they were of him and the sacrifices he made for his family. He cried and realized that he had taken them for granted when they were alive. I acknowledged Jonathan’s determination, courage, and perseverance despite his anxiety and that the dream reflected his progress in therapy. At the end of the session, I asked him to think about if he was currently taking anything else for granted in his life. The following session, he mentioned that he felt gratitude that his family was healthy, that he had a few close friends, and that he could still give to others and pass on his knowledge and insights to his grandchildren. I then suggested that at the end of each day he write down what he was grateful for.
Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values
In the subsequent sessions, I asked a number of open-ended questions to further work through Jonathan’s grief and mourning including, “Are there any ways you can honor your parents and friend by living out the values and causes they believed in?” Jonathan felt that his parents were generous in giving to those less fortunate, and that his mother had volunteered in a pediatric clinic at a local hospital after her retirement. Jonathan was also determined to honor his friend’s life for the years he did not get to experience by being more adventurous and taking more chances, including planning a trip with his entire family out west to a national park. He felt that identifying these values and living them out would be a way of honoring their memory and remaining close to them even after they passed.
Jonathan returned to the next session visibly shaken by an encounter at a supermarket the day before. He noticed a homeless man desperately wanting some food. The people in line were rude and impatient with him, avoiding eye contact as if they felt disgust at his condition and shame for looking away. Jonathan quickly went to the cashier and offered to pay. Jonathan’s and the man’s eyes met, and Jonathan felt that this was something his parents would have done without any recognition for it. He felt that this small moment of compassion was a way of honoring his parents’ values. He eventually decided that he wanted to volunteer in a nearby soup kitchen one day a week and to tutor local elementary school children in reading and writing.
The final stage of psychotherapy included a number of significant events and choices. Jonathan took a trip with his entire family to Yosemite National Park. While looking at the Sequoia trees with his family, he felt a deep sense of connection to his friend, Michael, and a feeling of awe in being in a place so vast and mysterious. He subsequently began to pray more consistently, to be more courageous and adventurous like his friend, gradually releasing his fears of the unknown and uncontrollable. Jonathan appreciated that although someone dies, the relationship does not end and can continue to evolve (3).
Upon return from his trip, Jonathan reported a dream where he was walking a tall winding staircase at a water amusement park. He recalled looking down and realized that he could seriously hurt himself if he fell. Despite his anxiety, he kept on walking up and was securely placed in a luge headfirst while lying on his back. He felt scared and excited about what it would feel like going fast down the waterslide. Jonathan woke up feeling energized and proud of his courage like he did on his recent trip with his family.
Jonathan began to read and write poetry, which he shared with his grandchildren. The poems reflected themes of savoring the moment, particularly in nature and while listening to music, avoiding getting lost in trivial complaints, and expressing gratitude for what one has. Jonathan felt that his creative writing was the beginning seeds of his own legacy.
As the psychotherapy concluded, Jonathan acknowledged how his parents’ and friend’s values and personal qualities had a significant impact on his life and that he shared these values of promoting the growth and well-being of the next generation. Generativity became a new core value that provided a sense of purpose and meaning in his life (Buechler, 2019).
Concluding Thoughts: What is Psychological Health When Working with Older Adults?
The case vignette highlights the benefits of integrating existential and spiritual interventions when working with older patients. Jonathan needed to gradually process his unresolved guilt, regret, and shame regarding his mother’s and friend’s deaths before he could fully experience joy, vitality, and meaning in life once again. His mourning process was further consolidated by honoring his parents’ and friend’s values, the causes they believed in and how their good qualities had changed him for the better (4). He recognized that he shared these same values, which was fulfilling for him in maintaining a deep connection to them even when they were no longer physically present. Jonathan was able to acknowledge the legacy he received from his parents and began to integrate the value of generativity in his life.
The theme of giving to others less fortunate become a unifying thread in his life narrative. While he could not prevent or slow down the inevitable tragedies in life and the regrets over past choices, the thread provided a meaningful foundation and compass in navigating new, turbulent challenges in life. When reflecting on his treatment, Jonathan recalled that his brief interaction with the stranger in the supermarket may have impacted the person’s life, and Jonathan experienced a sense of their shared humanity.
From a meaning-centered psychotherapy lens, Jonathan not only acknowledged the historical meaning of continuing his parents’ values and legacy, but also started creating and experiencing other sources of meaning in life (e.g., experiencing connection and awe in Yosemite (experiential) and deciding to embark on more adventures and being courageous in creating new experience himself (creative source of meaning)). Jonathan’s experience of awe enabled him to deepen his awareness of life’s fragility, resiliency, and sense of wonder (5). His involvement in reading and writing poetry facilitated a change in his attitude and perspective on life. His daily practice of mindfulness provided a safe space to observe his thoughts and feelings in a nonjudgmental and self-compassionate manner, while practicing gratitude increased his appreciation for the gifts of life and the legacy of those who passed before him. Prayer facilitated his ability to let go of his need to control life and provided a sense of safety in letting go of his fear of the unknown (6).
Jonathan’s journey highlights that psychotherapy with an older adult can bring “a heightened existential awareness…a new appreciation of the preciousness of life… (and the ability) to trivialize the trivialities” (7). At this development stage, there is a degree of comfort, meaning, and purpose that one’s actions, deeds, and values can have a known or unknown rippling effect on one’s family and others (8).
Questions for Thought and Discussion
What are your impressions about an existential-spiritual approach to therapy?
In what ways was this author effective in working with Jonathan?
Might you have worked differently with this particular client?
References
(1,6) Gordon, R. M., Groth, T., Choi, E., Galley, J., Marcantuono, J., & Kulzer, R (2023b). An Existential-Spiritual model for coping during and after COVID-19. Spirituality and Clinical Practice. Published online: December 11, 2023.
(2) Gordon, R. M. & Groth, T. D. (2023a). Relational and existential supervision and therapy for adolescents with life-threatening illness. Journal of Infant, Child, and Adolescent Psychotherapy, 22(4), 311-322.
(3) Buechler, S. (2019). Psychoanalytic approaches to problems in living. Routledge.
(4) Kessler, D. (2019). Finding meaning: The sixth stage of grief. Scribner.
(5) Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. Paragon House.
(7) Yalom, I. D. (1996). Lying on the couch. Basic Books.
(8) Yalom, I. D. (2008). Staring at the Sun: Overcoming the terror of death. Jossey-Bass.
Postmodern Play Therapy: Helping a Child Overcome their “Trouble Energy”
When I was deeply entrenched in research, writing, and play therapy practice that incorporated superheroes, I learned about the importance of the origin story — the backstory narrative. It is no different in the context of this article, which is about what I call “postmodern play,” a term I use to describe play-based interventions rooted in Narrative Therapy. As a brief but related aside, I had just finished a book on the use of superheroes in counseling and play therapy when I was contacted by MSNBC to come on air to discuss what they, NOT I, called Superhero Therapy. When I sat excitedly in front of my television that night to watch myself, I noticed a chyron beneath my image that said, “The APA does not endorse Superhero Therapy.” Fifteen minutes of infamy, I guess.
Ironically, I had never used the term, “Superhero Therapy” in my writing, nor did I profess my clinical work with superheroes to be evidence based. And so, it is here! The APA will never endorse postmodern play, nor will it ever attain evidenced-based status. And I aspire to neither.
But, as Irvin Yalom suggested in his Gift of Therapy, nonvalidated therapies are not (necessarily) invalidated therapies. So it has been for me, and postmodern play. In my child therapy work, particularly involving play, I have noticed that positive changes in the child’s world, both inside and outside of the therapy space, could often be explained by some of the core principles of Narrative Therapy, one of the postmodern approaches to therapy — which also includes Brief Solution-Focused Therapy. These core principles included a(n):
- Strength-based orientation rather than one based on deficiency
- Focus on the child as an agent of change
- Externalization of the problem
- Collaborative orientation to treatment that includes parents and teachers
- Author-editor relationship between therapist and child
- Future orientation that draws upon past successes
- Articulation of preferred identity through storying
- Personalization of outcome measures
- Understanding that children have islands of competence
Channeling Trouble Energy in Play Therapy
As an example, I recall 8-year-old Liam, who came with his parents for help with “his” problems of stealing food, his mother’s jewelry, and temper tantrums — exclusively at home when he was confronted with his misdeeds. Born in Asia, Liam was adopted in early infancy and seemed to be progressing nicely through his developmental journey. But something was happening that was giving rise to this relatively new spate of behavioral problems. During the intake, the parents and I wondered together if the racial/cultural difference between him and his parents was contributing to an emergent and distressing sense of “otherness” — they rarely, if ever, discussed the adoption, Liam’s origin story. We wondered if he was trying to process the loss inherent in the adoptive process, stealing as a way of filling a gap. We wondered if the marital tension between them was creating a bed of unrest and insecurity for Liam. We wondered!
When Liam came to my office the following week, I was met by a very poised, articulate, and interesting child whose vigorously shaking leg suggested that deeper currents of emotions ran just below the surface of this very seemingly contained boy. Drawn in by that current, I wondered aloud about the “energy” in his leg, and asked in what other parts of his body does he sometimes feel such energy. He played right along and said how sometimes that energy goes to his stomach, and sometimes arms, and together, we called it “body energy.” We explored this body energy when it started and whether he liked it, whether it got in the way sometimes and what he typically did with it once it appeared.
From there we launched into a conversation of other possible types of energy that he had, and as I asked him to describe some of his interests, which included history and origami, I asked him if he could label that energy, to which he responded, “art energy and learning energy.” A bit later in the conversation, when our conversation turned to the concerns his parents had around his stealing and angry outbursts, he quite spontaneously came up with the notion of “trouble energy.” I asked him to pick a colored piece of Play-Doh and show me how big trouble energy could be in his life, and he offered an apple-sized ball of Play-Doh in his little hands. That was the sum total of our intake and treatment plan.
The clinical work in the following weeks consisted of:
- Play therapy with Liam using the sandtray to act out play out scenes of family separations and reunions
- Playful conversations about trouble energy in his life, and what he wanted to do with it and its influence
- Liam sharing his vast knowledge of world history and “trying” to teach me origami
- Discussing simple behavioral methods for the parents to use when Liam expressed anger and took things
- Collaboration with his teacher around additional sensitivity to his needs, and
- Occasional family drawing time during which Liam and his parents expressed themselves freely.
- Referral of Liam’s parents to a marital counselor which they happily agreed to.
I never doubted that Liam was content with allowing trouble energy to rule his life, and I always had confidence that his parents and teacher could and would work together to support him and bring out the best in him. As a tip of my hat to readers who might be wondering, “well, what was your outcome measure(s),” I offer the following which is Liam’s depiction of trouble energy at the time of our last session at right, in contrast to trouble energy at the beginning of our work, at left.
I also offer the words of David Nylund, speaking at the Pan Pacific Brief Therapy Conference in Japan in 2001, regarding outcome measures in a postmodern, narrative play therapy context. He said, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person is able to reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”
***
My work with Liam and his family was complete, satisfactory to all involved. His tantrums subsided, the family re-visited and openly discussed the story of his adoption, and his feelings about it, and the stealing ended. I trust that my description of the work adequately captures the core principles and methods of what I call postmodern play therapy. Chyrons not withstanding!
Questions for Reflection and Discussion
What are your impressions of this author’s work with Liam?
In what ways have you found narrative therapy to be helpful?
What about this approach do you find interesting? Helpful?
Psychodynamic Therapies: How Did We Get Here & Where Are We Going?
I just finished reading Our Time Is Up, a wonderful combination of novel and memoir authored by the talented psychoanalyst and writer, Roberta Satow. Dr. Satow has created the most vivid description I’ve ever read of what real psychotherapy actually feels like — from the very different perspectives of the patient, the therapist, the supervisor, and the trainee. Most books on psychotherapy either miss its elusive magic or overplay its drama — this one has perfect pitch and puts you right there in the room.
Throughout my career, doing psychodynamic psychotherapy was always the part of my week I most enjoyed. Satow’s book both recalled many fond memories and inspired me to pull together what will likely be my final thoughts on what is wonderful about dynamic psychotherapy, and what are its limitations.
Psychodynamic Therapy’s Checkered Past
I’ll start with the checkered past — especially paying tribute to Sandor Ferenczi, the master clinician who was the underappreciated father of psychodynamic therapies. Next, I’ll evaluate the much reduced, but still crucial, role of dynamic techniques among the current chaotic and bewildering array of therapies. Finally, I’ll try to predict the future — what is the best-case final fate of psychodynamic therapies?
[Full disclosure] I graduated from Columbia University’s Psychoanalytic Center and taught its Freud course for 10 years. But I never was much of a fan of 4/5 times a week, on the couch, traditional, regressive psychoanalysis — regarding it as unnecessary and impractical for almost all patients and wasteful of resources better allocated to once a week, sitting up, long- or short-term dynamic therapies. While best at psychodynamic therapy, I also learned and integrated cognitive, behavioral, interpersonal, and family approaches. I think Freud was greatly overvalued in his own time and is greatly undervalued in ours — and I equally oppose blind Freud worshipers and blind Freud haters.
Freud: Great Model Builder, Lousy Clinician
Having invented psychoanalysis (in collaboration with his mentor, Joseph Breuer, and their shared patient, Berthe Pappenheim), Freud divided it into three separate endeavors: 1) research tool; 2) model of the mind; 3) clinical treatment.
Psychoanalysis as a research tool was at the outset enormously exciting — uncovering basic aspects of human nature that informed not only psychology, but also the study of myth, anthropology, sociology, art, and literature. But most new insights into the unconscious were made early on, and nothing really novel has emerged from the couch since Freud’s death.
Much more enduring has been the psychoanalytic model of the mind. Here Freud sat on Darwin’s shoulders — applying Darwin’s revolutionary, but generalized, discoveries in evolutionary psychology to the specifics of human behavior and symptom generation.
Freud borrowed from Darwin three crucial insights: 1) human mental functioning is just as derivative from our primate ancestors as is our bodily morphology; 2) much of our behavior derives from inborn motivations that reside outside our conscious awareness; and 3) these have been shaped by natural and sexual selection.
Freud filled in Darwin’s general outline with exquisitely detailed and specific analyses of the form and content of the unconscious and how one’s past experiences powerfully influence current hehavior. Freud’s model of the mind contained some bad (but then plausible) guesses which are the source of current ridicule — but the main concepts hold up extremely well and remain important in understanding people and treating them.
Freud never claimed to be a great therapist, or even to having much interest in psychoanalysis as a clinical art. He saw himself much more as an adventurer using psychoanalysis as a research tool in the scientific exploration of how the human mind works — awake and in dreams. Descriptions by Freud’s patients describe him as highly intellectual and patriarchic in his approach, using the therapeutic encounter to formulate and test his theories of how the unconscious works.
Ferenczi: Master Clinician
Sandor Ferenczi, Freud’s student & analysand, was the great clinician of early psychoanalysis and by far the most powerful influence in how psychodynamic therapies have since evolved and are practiced today. He was responsible for defining its healing qualities, introducing many major innovations, and adapting esoteric psychoanalytic theory to real world practice.
Here’s a summary of Ferenczi’s clinical contributions:
Therapeutic Alliance: Ferenczi emphasized the importance of negotiating a strong collaborative relationship with the patient, established on more equal terms, characterized by shared goals, and with mutually agreed upon roles and division of labor.
Interpersonal/Relational Therapy: Ferenczi was much more alive than Freud to the power of the healing relationship and the importance of establishing a strong affective bond with the patient. As his student, Sandor Rado, put it, “Insight never cured anything but ignorance.” The relationship is more curative than specific interpretations, however brilliant or accurate they may be.
Empathy: Ferenczi regarded therapist empathy as an essential tool in promoting change. Sharing feelings and feeling understood facilitates change as much as does gaining specific insights.
Here-and-Now: Freud mainly used psychoanalysis as a research tool to determine how past experiences shaped the unconscious and influenced current behavior. Ferenczi did this too, but also brought more focus to the triggers of present problems and how best to solve them.
Therapist Activity: Freud aspired to (but never really achieved) being a passive “blank screen” upon which patients could project their fantasies. Ferenczi was much more active and real in the sessions.
Patient Activity: Patients don’t get better just through free association and the insights gained in the therapy sessions — they must also widen their experiences and get out of repeated behavioral ruts. What happens between sessions is at least as important as what happens within sessions.
Corrective Emotional Experience: This was best stated by Ferenczi’s student, Franz Alexander, who said, “The patient, to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.”
Psychodynamic Therapy: Regressive psychoanalysis was originally a great research tool but has never been a practical treatment — it is way too resource wasteful, suitable only for pretty healthy patients, and risks creating excessive dependence and hiding in the treatment. Ferenczi’s innovations allowed psychodynamic theory and technique to be flexibly applied in less intensive, but very effective, sitting-up psychodynamic therapies occurring usually once a week.
Time-limited Focused Therapy: Ferenczi and Rank realized that long-term therapies were too intense and inefficient to treat the many people who needed help. They developed a remarkably useful brief dynamic therapy (currently much underutilized) that focuses only on understanding and changing the most pressing presenting conflict.
Self- Disclosure: Ferenczi was not shy about revealing information about himself if this would further the relationship or provide a useful model for the patient.
Role of Childhood Traumas: Freud’s first theory of neurosis attributed it exclusively to early childhood sexual traumas. But he abruptly and completely abandoned this causal theory in the early 1890s because such childhood sexual experiences were so commonly reported by his patients. Freud then assumed the reported experiences existed only in fantasy, rather than having actually occurred in reality. Ferenczi had the more balanced view that real childhood traumas do sometimes play a contributory, but not exclusive, role in producing adult symptoms and that they are not exclusively sexual.
Treating More Difficult Patients: Many classic psychoanalysts were often so picky about selecting patients that only the people who didn’t really need treatment would qualify for it. Ferenczi adapted psychodynamic understanding and techniques so that they could be usefully applied to the more severely ill.
In summary, Ferenczi, not Freud, was the clinical father of psychodynamic psychotherapy and his innovations shaped how it is still practiced today.
Psychodynamic Therapy’s Current Status
My previous essay; Psychotherapy Status Report offered a report card on the current status of psychotherapy. It nicely provided context for the more specific question of where psychodynamic therapies fit in. The short answer is that all psychotherapy practice is fragmented and chaotic — and that psychodynamic training and practice add to the confusion.
There is little integration among the more than 50 different named forms of psychotherapy. These are often seen as competing; most trainees receive instruction in just one narrowly focused method and many practicing clinicians identify with just one form of therapy. “CBT” is the most popular brand name, followed by “psychodynamic,” and “trauma-informed” which is becoming increasingly popular. There is also an age and gender disparity. Older therapists are more likely to identify with psychodynamic; younger with CBT; women with trauma-informed.
Training in psychodynamic psychotherapy is also chaotic. There are hundreds of different programs varying greatly in theoretical model, prerequisites, intensity, techniques, and accreditation. At one extreme are the traditional psychoanalytic institutes which are more selective, require many years of intense didactic and clinical training, often still use of the couch, and require personal analysis. At the other extreme, there are now psychodynamic training programs that are open to all and, remarkably enough, completely online.
There is very little research on psychodynamic psychotherapy because it does not conform easily to standardized clinical trial research designs and only a handful of its practitioners are research trained. The few scattered research studies suggest that psychodynamic therapies are equal in efficacy to better studied psychotherapies.
Dynamic therapy is gradually declining in influence. Most psychiatric residency programs now provide little or no training in psychodynamic therapies — even though such training is still often desired and sought after by some residents. Young therapists in other disciplines are less and less likely to be trained in dynamic techniques. And insurance companies are less likely to fund dynamic as opposed to other techniques that are less intense and better studied. The average age of dynamic therapists is rising, and its cultural relevance is diminishing. The future does not seem bright.
Future Directions
Will Psychodynamic Therapy Continue as a Separate Profession?
I hope not. Psychodynamic therapy was always my favorite technique, but only if combined with cognitive behavioral, interpersonal, and family techniques. Similarly, the training programs I created were based on the integration of psychotherapies, not their separation into separate silos.
I have long felt that psychoanalysis is too important to be left to the psychoanalysts. They have maintained an unfortunate rigidity in technique and teaching; have been resistant to innovation; and missed opportunities to expand their purview and influence. Their biggest mistake was rejecting Aaron Beck’s CBT. Beck was a trained analyst who originally conceptualized his innovations as an expansion of psychodynamic techniques, not a replacement. Had the psychoanalysts been wise, they would have embraced CBT as an extension, rather than rejecting it as a competitor. I don’t think that psychodynamic therapies should be taught in institutes that specialize in it. Similarly, I don’t think that “CBT” or “DBT” or any of the other 50 alphabet denoted therapies should be taught or practiced as a separate discipline distinct from other psychotherapies.
Instead, I think psychotherapy should be considered a unified therapy which includes within it a wide variety of techniques. And training programs should no longer brand themselves narrowly. Narrowly trained therapists become hammers looking for nails, rather than flexibly responding to patient need. Psychodynamic techniques should be highly valued because they are very valuable- but they should be valued as a component of psychotherapy, not as a separate specialty.
Will Psychodynamic Therapists Be Replaced by Computers?
I’ve written an entire blog on the history of computers delivering psychotherapy: their current role and their future potential. Bottom Line — there is nothing humans do that computers won’t eventually do better.
One small consolation is that computers will have more trouble and take longer replacing psychodynamic therapists than almost any other type of professional. More than most human endeavors, uncovering someone’s unconscious motivations and facilitating corrective emotional experiences are intuitive and inferential processes that don’t easily lend themselves to the number-crunching powers of machine learning. But given enough data and enough time, even these most human of skills may be mastered by artificial intelligence.
Should this pessimistic prediction discourage people from entering the field? I think not at all. First off, psychodynamic psychotherapy is a better hedge against computer replacement than almost any other career choice. But more important, doing psychodynamic psychotherapy is one of the most rewarding ways of spending one’s time on earth. You have the immense satisfaction of understanding and helping others, with the valuable added bonus of learning from your patients how to become a better person.
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Which brings us back to where we started. Roberta Satow’s book is a great introduction for new psychotherapists and a great refresher for experienced ones. No manual of psychotherapy, and no textbook, can ever capture the special healing ambiance of the therapist/patient relationship. Only the lived experience of someone who has been a patient, been a therapist, been a supervisor, been a trainee — and can write really well — can bring therapy alive in a way that inspires and educates.
Questions for Thought and Discussion
In what ways do you concur or disagree with the author’s assessment of dynamic psychotherapy?
Would you consider training in psychodynamic therapy?
What kind of client would you refer to an analytic therapist and why?