Category: Family Systems

Josh Coleman on the Roadmap to Healing Family Estrangement

Posted on by Psychotherapy.net Team
Lawrence Rubin: I’m here today with Joshua Coleman, a psychologist in private practice in the San Francisco Bay area, and a senior fellow with the Council on Contemporary Families. He’s the author of numerous articles and book chapters, and has written four books, the most recent of which is The Rules of Estrangement. Welcome, Josh.
Joshua Coleman: Thank you for having me. Pleasure to be here.

The Face of Family Estrangement

LR: I’ll just jump out of the gate by asking you, why do you describe estrangement within families as an epidemic?
JC: Well, there’s a variety of reasons for that. One is, and I don’t know about you in your practice, but in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangement. Another reason comes from a recent survey by Rin Reszek at Ohio State, who found that 27% of fathers are currently estranged from a child. That’s a new statistic. While we haven’t really been tracking these statistics, non-marital childbirth is also a big cause of estrangement, which is 40% currently compared to 5% in 1960.Divorce is also a very big pathway to estrangement, especially in the wake of more liberalized divorce laws. When you look at the effect of divorce on families once there’s been a divorce, the likelihood of a later estrangement goes way up. This is especially so when you add social media as an amplifier, our cultural emphasis on individualism, influencers talking about the value of going ‘no contact’ after the divorce, and family conflict around politics, especially in the recent election. All these point to a rise in family estrangement, particularly parental.
LR: in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangementI know the there is a historical rise in divorce. Is there a parallel rise in estrangement with the rising divorce rate?
JC: I don’t think it’s a 1 to 1 relationship, but I think both occur in the culture of individualism, which prioritizes personal happiness, personal growth, protection and mental health. Prior to the 1960s, people would get married to be happy, but more often for financial security, particularly for women as a place to have children. But today, people get married or divorced based on whether that relationship is in line with their ideals for happiness and mental health and the like.The relationships between parents and adult children are constituted in a very similar way, people don’t stay in touch or close to their parents unless it’s in line with their ideals for happiness and mental health. It’s what the British sociologist Anthony Giddens calls pure relationships. Those are relationships that became purely constituted on the basis of whether or not they were inline with that person’s ambitions for happiness and identity. So, it’s a parallel process. I don’t think it’s completely dependent on divorce because there’s many pathways to estrangement.
LR: if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still marriedWhy is estrangement so different from other problematic family dynamics?
JC: Because of how disruptive it is to the adult parent and because of the cataclysmic nature of event and its consequences for the rest of the family. Once there’s an estrangement, it isn’t just between that adult child and that parent. It also can cause one set of siblings, or one sibling, to ally with the parent, another with the adult child. Typically, if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still married. So, it’s really a cataclysmic event in the whole family system.
LR: In your clinical experience, are there identifiable risk patterns for the eventuality of estrangement?
JC: Divorce is a huge risk, especially when it is accompanied by parental alienation, where one parent poisons a child against the other parent. Untrained or poorly trained therapists sort of assume that every problem in adulthood that can be traced back to a traumatic childhood experience. There seems to be no shortage of those therapists who think everything that is problematic in adulthood is due to some kind of family dysfunction or trauma.Another pathway to estrangement is when the adult child married somebody who’s troubled and says, “choose them or me.” Mental illness in the adult child is also potentially destructive. And last, when parents have been doing something much more psychologically destructive over the years, certain adult children just don’t know any other way to feel separate from the parent beyond cutting them off.
LR: Before we move forward, can you give us a clear definition of estrangement?
JC:  It’s when there is little to no contact. If we’re just thinking of the parent-adult child relationship where there’s little to no contact, and underlying is some kind of, complaint or disruption in the relationship, the adult child is typically the one initiating the estrangement. They determine that it’s better for them not to be in contact with the parent or to grossly limit the contact. Maybe they send a holiday card or something, otherwise they have no contact with their parent.
LR: t’s a complete cut off.
JC: Complete cut off, or a nearly complete cut off. Exactly.
LR: the adult child may not be as motivated to solve the problem as the parent isAnd is the focus of your clinical work mostly on estrangement between adult children and their parents?
JC: Typically, because they’re the ones who are reaching out to me. Occasionally, I’ll have siblings reach out to me, but more typically it’s the parents who are estranged. From their perspective, they’re the ones who are in much more pain. The adult child may have cut off the parent because of their pain, but by the time the parent reaches me, the adult child has concluded that it is in their best interest to estrange their parent. So, the adult child may not be as motivated to solve the problem as the parent is.
LR: Do you have estranged grandparents reaching out to you?
JC: Yeah, and a lot of grandparents say, ‘look, I could probably tolerate estrangement from my child, but not from my grandchildren.’ This feels intolerable, particularly for those who have been actively involved with their grandchildren, as many of these grandparents have been.
LR: This “grandparent alienation syndrome” must be particularly tormenting for them. Have you experienced different cultural manifestations of estrangement?
JC: The data from the largest study, which was by Rin Reczek at Ohio State, found that, for example, Black mothers were the least likely to be estranged. White fathers are the most likely to be estranged. Latino mothers are also less likely to be estranged than White mothers. Fathers in general are very much at risk for estrangement regardless of race.There’s relatively low estrangement in Latin American families as well as Asian American families. And similarly, within Asia, we assume that there’s not a lot of estrangement because the culture of filial obligation is still quite active. So, estrangement tends to predominate in those countries and cultures, like ours, that have high rates of individualism and preoccupation with one’s own happiness and mental health.

Detachment Brokers

LR: That’s interesting. So, there’s a parallel between estrangement and the value particular cultures place on either individualism or commutarianism.
JC: Exactly. Some are much more communitarian, emphasizing the well-being of the family and the group, while others are much more individualistic, like we are here. The sociologist Amy Charlotte calls American individualism ‘adversarial individualism,’ which is the idea that you become an individual through an adversarial relationship with your parent, or you rebel against that. But not all cultures have that kind of adversarial positioning as the way that you become an adult.
LR: You had mentioned earlier that some therapists can actually make things worse.
JC: I think that all therapists want to do good, but some simply don’t think through all of the factors. We have to not only think about the person in the room, but also the related people, because estrangement is a cataclysmic event that affects many beyond the person sitting in front of you. Grandchildren are involved and get cut out from their grandparents’ lives. Siblings typically get divided into those who support the estrangements and those who don’t. It’s also very hard on marriages. It’s easy to get sidetracked into focusing on the mental health of the adult child who is cutting off their parent(s) in the name of self-care and self-protection. We have a rich language in our culture around individualism, but a poverty of language that’s oriented around interconnectedness, interdependence, and care.It’s easy to pathologize someone’s feelings of guilt or responsibility for a parent that may just be a part of their own humanity. By giving them the language and moral permission to cut off a parent without doing due diligence on whether or not that parent really is as hopeless as their client is making them to be, contributes to this kind of atomization.Therapists can contribute to the tearing apart of the fabric of the American family, acting as accelerants to that process. We become what the sociologist Allison Pugh calls detachment brokers in her book, Tumbleweed Society. When we support clients’ absolute need or desire to estrange their parents due to their need for happiness and personal growth, we help them detach from the feelings of obligation, duty, responsibility that prior generations just assumed one should have.

LR: Do you ever encourage or facilitate estrangement as a solution?
JC: The same way that I would never lead the charge into divorce with a couple with minor children because of the long-term consequences, I wouldn’t charge ahead with estrangement either. But I do try to help the person to do their due diligence on the parent. Let’s say the parent who is completely unrepentant and constantly shames the adult child about their sexuality, their identity, who they’ve married, or what their career is every time that adult child is around the parent. It’s sort of hard for me to ethically say, “give them a chance!”But I do think it’s our responsibility to ask them: what other relationships will be impacted if you decide to go no contact, is there some way to sort of have some kind of a relationship where you are protected from their influence, or why don’t we think about why is it so hard on you? A newly reconciled adult child recently suggested to me that, ‘if the adult child is insisting that your parents are the ones that need to change to have a relationship, maybe you’re the one that needs to change.’ I liked that because I don’t think everybody has to stay involved with their parents.I do think parents have a moral obligation to address their children’s complaints and empathize with them and take responsibility. Just like the adult children have a moral obligation to give their parents a chance. I work with parents every day who are suicidal or sobbing in my office, and that really gives you a different view of this.
LR: I imagine the most deeply wounded adult children are the most difficult ones to work with around reconciliation. Can countertransference enter the clinical frame at that juncture?
JC: There have been a few occasions where the adult child was so self-righteous and contemptuous of the parent, despite the parent’s willingness to make amends for their so-called crimes––which were more on the misdemeanor side than the felony side––they remained unforgiving. Even when the parent showed empathy and took responsibility in the ways that I insist that parents do, the adult child remained in this very censorious, self-righteous, lecturing place.There haven’t been very many times when I felt provoked on the parent’s behalf, but there have been a couple times where the adult child was earnest, open and vulnerable, and the parent was not willing to do some basic things at the request of the adult child, like accepting basic limits. The parent was insistent. I just felt like you can’t have it both ways. I remember thinking, ‘You can want to have your child to be in contact with you, but you’re going to have to accept the limits that your child is setting, otherwise, I can’t really encourage your child to stay in contact with you in the way that you want me to.’ The transference is worked on both sides of the equation.

A Roadmap for Change

LR: Is there a roadmap for healing estrangement as you suggest in your book?
JC: Typically, if the parent has reached out to me for the reasons I was just saying, the roadmap begins with taking responsibility and the willingness to make amends. I ask that they try to find the kernel, if not the bushel of truth in their child’s complaints. They can’t use guilt or influence or pressure in the way that maybe their own parents might have used with them, and they can’t explain away their behavior. They have to show some dedication to reconciling. It must come with some sincerity. The challenging part for parents is often that they can’t really identify with what they’re being accused of, particularly since emotional abuse is the most common reason for these estrangements.A lot of parents say, ‘wow, emotional abuse, I would have killed for your childhood.’ The threshold for what gets labeled as emotional abuse is much lower for the adult child than it is for the parents. So, a lot of the roadmap for the parent is just accepting that difference and learning how to understand why the adult child is labeling it as such and not really debating it with them or complaining about it. Instead, that roadmap includes a way to empathize with that and understand that those are the most key aspects.
LR: What about when the road to reconciliation has been damaged by physical/sexual abuse?
JC: You have to go there if you have any chance of healing the relationship. If a parent is lucky enough to get an adult child in the room after that child being a victim of more serious traumas on the parents part, the parent has to be willing to sit there and face all the ways that they have failed their child and how much they hurt and wounded them.And it’s not an easy thing to do, typically, because hurt people hurt people. There is high likelihood that the parent who did the traumatizing was traumatized themselves, but if anything is going to happen, it’s going to be because the parent can take responsibility and do a deeper dive and not sweep it under the rug. And that’s very hard work, especially for the adult child who must expose themselves.
LR: Would you work with the adult child separately from the parent and then together by collaborating with all the players in the same room?
JC: Typically, I will meet with each side separately because I want to see what the obstacles are, what each person’s narrative is, assuming that I think everybody’s ready to go forward, I’ll bring everyone together. I usually don’t keep them separate for more than one session, but not everybody is ready to go forward at the same time. If I think that people are sort of ready to engage, then I’ll do a session separately and then everybody together. I tell parents that this is not marriage therapy. The therapy is around helping the adult child feel like their parent is willing to respect their boundaries and accept versions of their narrative sufficiently that they feel more cared about and understood. It’s not going to be as much about the parent getting to explain their reasons or decisions, at least not early into the therapy. If therapy goes on long enough, and people are healthy enough to have that conversation, then it can happen. But it doesn’t always.
LR: What do you consider to be a successful outcome, and at what point do you say that’s enough for now?
JC: I think when they’ve all had enough time outside of therapy, and they were able, to debrief if there was conflict, and if I feel confident that they have the tools to walk them themselves through the conflict and resolve it. I try to help each person set realistic goals and let them know that they are going to make mistakes going forward. The goal isn’t to be perfect, but instead to communicate around feelings and taking each other’s perspectives so all members feel safe and skilled enough to overcome whatever conflict arises. I don’t want anyone feeling discouraged and helpless.
LR: What protective factors do you look for when working with estrangement? The glimmers of hope that you search for with your therapeutic flashlight?
JC: The biggest one is a capacity for self-reflection on the part of both the parents and the adult children. In the parent, I look for a willingness to take responsibility, the capacity for non-defensiveness, vulnerability, and tolerance for hearing their child(ren)’s complaints without being completely undone. For the adult child, I look for acknowledgment that what they’ve done is difficult for the parent, and that their own issues might have contributed to their decision to estrange them.I look for an adult child to say things like, ‘I acknowledge that I was a really tough kid to raise,’ ‘I’ve been a tough as an adult,’ ‘I can give as well as I get,’ or ‘I know that I have an anger issue.’ Those help me, as the therapist, to feel like, ‘okay, you’re not just here to blame and shame the others.’ It’s about a willingness and ability to come to a shared reality, which is important for these dynamics.
LR: At what point might you suggest stopping with a client?
JC: I’ll keep working with people as long as they want to get somewhere. I don’t usually fire clients. But, for example, if I have an adult child who is just insisting that their parent has to change, and it’s clear to me that the parent has changed as much as they’re going to, my goal would be helping them shift towards radical acceptance, rather than to keep beating their head against the wall. And similarly with a parent, if their adult child is just not willing to reconcile, then it isn’t useful for the parent just to keep trying and banging their head against the reconciliation wall either.
LR: Recognizing not only your own limitations, but those that the family system brings to you.
JC: Exactly! I think an important part of our work is to help people to radically accept what they can’t change and influence. As painful as that is to reckon with.
LR: What does radical acceptance mean in this context?
JC: The term came from Marsha Linehan who developed Dialectical Behavior Therapy. It’s not sort of a soft acceptance, but instead a deep dive that you have to do. She has a great quote that says, ‘the pathway out of hell is your misery.’ It’s a great quote because you must first acknowledge that you’re miserable and accept it and maybe not even hope for change. But it does mean you have to acknowledge that you’re currently in hell. And unless you can really accept that reality, nothing good is going to come of it. The other saying that I like that comes from mindfulness or Buddhism is that pain plus struggle equals suffering. That the more you fight against the pain, the more you’re going to suffer. So, I think those are useful concepts.
LR: In this context, at what point does grief and loss work enter the clinical frame?
JC: Grief work is really part of it. Even if I can’t facilitate a reconciliation, it is important helping parents to feel like, ‘yeah, I think you’ve turned over every stone here.’ At that point, it is important to help them accept it and focus more on their own happiness and well-being, and on other relationships. This would include working on self-compassion while mourning the loss of the relationship that may never be.
LR: In closing, Josh, can someone who’s trained in individual therapy do this kind of work?
JC: If you are an individual therapist, you can’t just sort of suddenly start doing couples therapy. You have to have some facility at keeping two subjectivities in your mind at the same time. You know, being able to, to speak to both people in a way that shows that you’re neutral, even when you’re temporarily siding with one person over the other. I think it’s important to have a sociological framework for this part. You also need to set your own limits and boundaries. Doing family work is a very different sort of orientation and requires a unique skill set.
LR: On that note, I’ll say thanks. Josh, I appreciate the time.
JC: It was my pleasure, Lawrence.
*******
Joshua Coleman, PhD, is a psychologist in private practice in the San Francisco Bay Area and a Senior Fellow with the Council on Contemporary Families, a non-partisan organization of leading sociologists, historians, psychologists and demographers dedicated to providing the press and public with the latest research and best practice findings about American families. He is the author of numerous articles and chapters and has written four books: The Rules of Estrangement (Random House); The Marriage Makeover: Finding Happiness in Imperfect Harmony (St. Martin’s Press); The Lazy Husband: How to Get Men to Do More Parenting and Housework (St. Martin’s Press); When Parents Hurt: Compassionate Strategies When You and Your Grown Child Don’t Get Along (HarperCollins). His website is www.drjoshuacoleman.com/.

Rick Miller on the Clinical Challenges of Working with Gay Sons, Mothers, and Families

Posted on by Psychotherapy.net Team

Gay Sons and Their Mothers

Lawrence Rubin (LR): You may be known to our readers as the founder of Gay Sons and Mothers. But they may not be familiar with how extensively you’ve been trained and how long you've been practicing as a psychotherapist with a personal interest in working with gay men and their mothers. 

Rick Miller (RM): I'm a gay man who grew up really appreciating the bond and love of my mother. And, in hindsight, as an adult, what it meant for me was that I got to be myself. She didn't necessarily know that I was gay, or maybe she did, but she never forced me to do anything differently than what I did.

And growing up in a world in the 1960s where it was prescribed, this is what boys do, having a mom who let me be me — and we did a lot of things together — was pretty miraculous. I hear so many stories about people growing up whose parents abused them or forced them to do things differently.

I wrote a book several years ago for clinicians about doing hypnosis with gay men. I thought it would be relevant to do the research or to seek out research about gay men and their mothers. I looked at the literature about gay men and their mothers to include in the book. You'd think this a cliché topic and that there would be way too much information to use. I couldn't find anything! I thought, I’ll write an article about this, and it ended up turning into video interviews. And from there, I started a nonprofit called Gay Sons and Mothers.

We are educating the public about the special bond between mothers and their gay sons and how she contributes to his sense of well-being in the world. It's a multicultural story that looks at strength, at disappointment, and is a very emotional topic.   

LR: So, even before you and your mother had a conversation about being gay and you knew, you had no particular concern over sharing it with your mom. You didn’t worry how she would take it, how you'd be perceived, how you'd be treated. You were just free from the start to be you. 

RM: Well, I was free to be me, but I didn't come out to them — meaning my parents, my mother and my father — until I was 21. So, it was interesting that I had the freedom to be me, but I didn't feel 100 percent free to be me because I waited longer to come out than I probably needed to in hindsight. Today, many kids are coming out at a much younger age to their parents. Of course, the world is very different.

LR: If you intuitively felt accepted by your mom and weren’t censored or limited in any way from being you — you haven't talked about your dad — why do you think it took you as long as it did to become public about it? 

RM: Well, so, it was the early 80s. So, AIDS was hitting the press big time, and I suppose on one level, I was protecting her or them from thinking that something would happen to me, which, knock on wood, did not happen. I was afraid that I'd be rejected, and, not to sound callous, they were paying for my graduate school education, and I just made a mental note in my mind I was going to wait until I finished school to come out, which is so stupid. 

Knowing my parents, of course, they wouldn't have done anything differently. It took them a while to come around, a month or so, which I thought was horrible at the time. But I look back and I think that my parents had to go through their own grieving when I came out to them. Of course, they knew I was gay long before I came out, but hearing it was definitive. And it took them a short time to acclimate and appreciate it. I was incensed at the time. And, often, I say to children and to parents, it's okay to grieve.

LR: Incensed about? 

RM: They were not 100 percent supportive the second I came out to them. And the first thing my father did when I came out was to become a little weepy saying, “the world is unfair, and I'm worried about what that will mean for you.” I took it as supportive, for sure. And then he kind of changed the tune for a bit, and that is when things turned ugly, and again that lasted a few weeks and then everything turned around. 

LR: Smooth sailing with your parents and especially your mom ever since. 

RM: Yep. And I had a partner that I was moving in with at the time. So, what I did, which I shouldn't have done, was when I came out to them, I told them that I was moving in with the person they knew as my friend all at once, so that threw them a little bit. 

LR: Overload! Going back to the second part of the earlier question about your foundation; how do you think clinicians can benefit from awareness of it? 

RM: There's so much inherent in the videos that we share through Gay Sons and Mothers. It's not only about the relationship between a mother and a son, but that part in and of itself is so affirming. Clinicians can watch stories of sons and their mothers and appreciate what it is being gay. And it's not only mother in these interviews. Families are talked about. Extended families are talked about. Culture and religion are addressed in these videos.

So, there's a lot there, and, when mothers are struggling with their kids, I send them videos from Gay Sons and Mothers. On our website, there's a link to our Instagram page. We have a YouTube page. Sons watch. Most people — therapists included — watch these videos and have a deep emotional resonance around the issue of being included, being loved, being supported, being rejected. It's hard not to feel something when you're watching videos pertaining to these themes.   

LR: A connection. How would you respond to a therapist or to a non-therapist who’s visited your site and says, “Yeah, well, what about gay sons and their fathers?” 

RM: There's way more information in the literature about gay sons and their fathers than there is about gay sons and their mothers. And if there hadn't been any with fathers, I would have pursued that, as well. I grew up with a great relationship with my mother. I had the fame of saying to my siblings, “Mommy likes me best.” It carried me through. So, it seems completely perfect that that would be the focus of my work.  

Historically, mothers in the 1970s — or even earlier in the psychiatric and the medical field — mothers were blamed for making their sons gay. And, so, with the lack of literature out there, what's missing is that mothers have the power to raise sons who are mentally healthy, just from being a good enough mother. And, so, that premise is so important to me that I've focused exclusively on mothers and sons.

The issue of fathers and extended family is embedded in the work anyway. So, this project, Gay Sons and Mothers, is inclusive of the entire family. And we're also expanding beyond just gay sons and mothers. We're talking about trans children and all sorts of things. 

Intersecting Identities

LR: How has your advocacy and clinical work been informed by your own personal evolution? 

RM: Oh, gosh, that's such a big question, but I think I can get there. I came out in 1983 — I was already a clinical social worker. In the 1980s, AIDS was emerging, and gay men were dying in big cities, and people were afraid. Homophobia was on the rise because people were afraid of catching AIDS. I was working in the AIDS field, doing volunteer work at this time, and I started working with the gay community from the start.

Boston, where I lived, was a progressive place. So, I was known in Boston as being an out gay male therapist. I mean, there was no web at that time, but anyone who knew me would know that I was gay. But I was also practicing in a very conservative place, Boston, Massachusetts, very hierarchical, very psychodynamic. So, in the professional world that wasn't the world of AIDS, I worked in a hospital. I kept a very low profile, and I felt like I didn't fit in the hierarchy of psychiatrists, psychologists, social workers.   

I'm a social worker, and looking back at my evolution and my history, I wish I had put myself out there more because the contributions that I'm now making to the field in the last ten years as a writer, as a teacher, as someone who's done Gay Sons and Mothers, if I had the confidence to do some of this earlier, I would have done more research focusing on gay men, on gay men and their mothers, gay families. And I think I could have made a bigger contribution to the field.

What happened for me is I started my private practice in the mid 80s, and I switched to full-time private practice. So, I left the hospital. I left the agency where I was doing AIDS work, and basically, I hid in my office with the door closed for decades. And I was very successful in private practice, in part because of my clinical skills, in part because of my personality, and I got to hide.

Once I wrote my first book and I started teaching about working with gay men, I could no longer hide. And, at the time, I was probably 52 years old — 10 years ago. And I'm really glad it happened, but it forced me beyond a comfort level that was really important and good for me, and I wish I did that sooner.  

LR: So, you came out of the closet before you came out of the office. I can see that your personal story could be used as an exemplar, not only for gay therapists, but for gay men, whether still not out or out. I would imagine that you don't impose your story on others. But by living it and being genuine, as you've always struck me, you are an unintended role model.

RM: Well, thank you for saying that, and it served me very well in my practice. I grew up in an upper-middle-class family with well-being and mental health and good physical health. And, to me, that's how everyone lived in the world, and that is so not the case. And so, as a gay man who had a sense of self, who worked with gay men, I served as a role model to other gay men, to all my clients really but specifically to other gay men who didn't have the good fortune that I did or didn't have the personality that I did.  

So, my being outgoing was a very good clinical skill, and, fortunately, in my early 20s, I was in therapy with a therapist who was gay, who had a very good sense of himself, who had a great sense of humor, and who allowed me in the process of therapy to love myself. If I had chosen one of those uptight, analytical therapists in Boston instead, I don't know where I would be right now.

When I was looking for a therapist, I was given the name of eight different people. Back in 1983, I was calling their answering machines. On some, I was hanging up because I was frightened by them. Others shamed me through their tone, and thank God, I didn't work with them. 

Clinical Challenges of Working with Gay Men (and their Mothers)

LR: What are some of the clinical challenges you've found in working with gay sons and their mothers? 

RM: Long before I ever knew I'd be working with gay men and their mothers, I had a gay male client who was really struggling with confidence. He grew up in the projects outside of Boston, and his father left the family, and deprivation was a big part of his upbringing. So, one day, for whatever reason, I had his mother join him in a session and it was like the heavens opened up.  

I understood him so much more, and the bond and the strength of their relationship was amazing. It helped so much in the clinical work. He was a catalyst that led to this project, Gay Sons and Mothers. Every now and then, I'd have another mother and son together, but it wasn't why they were in therapy. Once I started working on this project, various people consulted with me, families for help with their families. For some, in the field of psychotherapy, for others, through the nonprofit where, for free, I just consult with people and help them along.  

What's been interesting is one mother and son that I'm working with right now in therapy are enmeshed with each other, and they're seeing me every two weeks. On certain days, it feels like couples therapy and I really have to work with them to detangle and let go of their expectations with each other. And, so, this is a divorced mom with an only child who's gay, and they expect each other to meet needs that goes well beyond what they should be for a mother and a son.

This isn't the case in all circumstances, but I think it's a great example of how it can be a bit of a burden on both ends to have this close bond that goes kind of way too far on both ends.   

LR: So, enmeshment is one of the challenges. I imagine acceptance is another. 

RM: So many gay men are way too careful, and they're not coming out to their families as soon as they might, or they give absolutely no details about their private lives to their families who really want more from them. So, that is another challenge, that in being careful, even once they come out, being careful continues to be their MO, even when they don't need to be, and people want more from them. They want to hear more details about their day-to-day lives or what they struggle with, or are they in a relationship with someone?

LR: And I wonder if these particular men are so cautious and close to the chest with their families, if they're even more so outside of the home. 

RM: Correct. I'm working with a bunch of men in their 50s, let's say in their 60s, who came out in an era where it wasn't okay to be gay. And even though it's fine now and they have jobs where they are out, they, without even realizing it, are kind of slipping into modes of privacy and protecting themselves because it's a habit that's been with them through their life.

LR: I was going to ask you a little bit later about working with elderly gay men. But this seems like a good point to interject the question of, “what are some of the clinical challenges in working with elderly gay men whose mothers, I imagine, have long passed?”

RM: The most significant challenge is that they grew up in an era where they couldn't be out, where it wasn't safe, and many older men were kind of forced indirectly or even directly to live conventional lives and got married and had children without even questioning the freedom of living life as a gay man.

I had a great-uncle who was gay, and he never came out to my family. When I came out to my parents, they said, “Well, Paul has lived a good life. So, we know that you'll live a good life, too.” But this great-uncle, my grandmother's brother, was in his 80s when I came out. And he said to me, “I really appreciate that you have freedom that I didn't have, and I hope that you will keep my secret from your family because I just don't feel comfortable being out there.” 

LR: Well, I wonder if that fear of abandonment, being cast out by remaining family is that much greater to an elderly man?

RM: He had an incredible social network. He lived in Washington and was cryptographer for the CIA because keeping secrets was something that they did well. So, he had the love of a community of people, and my mother, his niece, and us, meaning my mother's children who were generations below him. And he was still worried about our knowing. It was just a pattern that was ingrained for the time with which he was raised. It's that simple.

LR: Can you imagine taking homosexuality, or any significant part of your identity, to the grave?

RM: When he died, my mother and I went to Washington to clean out his house — he saved everything. There was a pile of letters that his gay friends wrote to him in the 1950s and the 1960s about falling in love with men that they met in cruising areas in parks, and how they couldn't tell their spouses and how tortured they were.

We were cleaning out his house with three of his close friends. My mother came to me, without saying anything, handed me the pile of letters, and I read them. And I thought poor Uncle Paul would die if I kept these letters, so I shredded them and threw them out. And it is my biggest regret because in these letters was the reality of gay history lived by all these men.

But, in my desire to be loyal to my great-uncle, I threw them out. And this was maybe three or four years after I had come out. I was still living in a careful way and more worried about loyalties. If I had these letters now, what they would mean? Oh my God.  

LR: What clinical challenges have you experienced working with gay sons of mothers from other cultures, the Caribbean culture, the Asian, the Southeast Asian, or even African, where homosexuality is shunned and punished, sometimes even fatally?  

RM: In these cultures, homophobia is rampant and masculinity and norms around masculinity are such that fathers are not accepting of their gay kids. Religious norms are such that being gay is a sin and these are beliefs that communities buy into without questioning. So, fathers are often emotionally and physically abusive to their sons. Mothers are forced to choose between their husband or their child.

Some mothers choose their husband over their child. I had a guy that I interviewed who was Latino, and his mother said to him, “First comes God, then comes your father, and then comes you.” So, when he came out, they sent him to an aunt's house far away to Texas where he would somehow have a different life for himself. He ended up responding to a personal ad from someone who he didn't know at the time was a human sex trafficker, and he became a victim of human sex trafficking. It's a tragic story, and he's now an advocate for all of this. But his parents kicked him to the curb and still don't accept him. 

LR: Have you worked with men and mothers and their parents from other cultures, where the parents themselves were afraid of being sanctioned, punished, or harmed?

RM: You're saying that with a great degree of sensitivity and attunement. Most situations, that is exactly what the parents are feeling, but they don't recognize that in themselves. What they recognize is what they're supposed to believe, and that's what they've gone along with. I've worked with Mormon families who have rejected their children. I've interviewed a Latino Mormon man whose mother read his journal and packed up his bedroom one night and put all his belongings in the garage and said, “You're not going to live here anymore. What you're doing is a sin.”  

Eventually, they came around and made up years later. These horror stories unfortunately exist. Some families that are less severe than the examples I gave don't let their kids come to family holidays. They insist that they not come out to extended family that there’s all these conditions. There's a woman named Caitlin Ryan who’s done a lot of research through her organization called the Family Acceptance Project. Her work shows that LGBTQ family members can gain acceptance with their children or their siblings through being exposed to other people that give a message that it's okay.

And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.

If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.   

And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.

If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.

LR: I imagine there’s a significant number of these families that don’t make it successfully through therapy with you. This young man is left feeling just as isolated and rejected as before.

RM: Right. Or the young man will stay in therapy and build his own community, but, unfortunately, not with his family, outside of the family and elsewhere. That said, I am a family therapist. I’m a couples therapist. I'm totally optimistic. I never give up on families reuniting. And, last year, I worked with a fundamentalist gay man in his 30s, really successful in his career and in his life. But he didn't come out until his 30s to please his parents. I had three joint sessions with him and his mother, with the hopes of bringing them together. He never thought it would happen.

I met with her alone first, and she was talking about the Bible and blah, blah, blah, blah. They didn't stick with the sessions, and eventually started talking to each other. A couple of months ago, she was potentially diagnosed with cancer, and that's what brought them together more than anything else. And I wish it could have been sooner.

LR: How would you advise straight therapists working with gay men, beyond the standard of “unconditional acceptance?”   

RM: You raise a very important issue about unconditional acceptance, and many well-intentioned straight therapists try way too hard with their gay clients. In my life, socially, I'll go to a party, and they'll say, “Oh, do you live where all the gay people live? And do you know so and so, and so and so, and so, and so?”

LR: Gay Jewish geography.

RM: Exactly, and often I do. But therapists who try to promote unconditional acceptance and convince their clients that they're gay-affirming and then offer, “Oh, I have a neighbor who's gay,” which actually may induce a lack of trust. The best way to promote unconditional acceptance is to simply say, “I’m straight. Are you comfortable working with me? I am accepting, and I've worked with other gay clients. But, please, if you feel any bit of discomfort, let me know. Let's talk about it.” To me, that's unconditional acceptance, and that's more welcoming than doing a sales pitch that ends up sounding like a microaggression more than anything else.

So, my mentor, Jeff Zeig, accepted me for who I was, and he’s a straight man. There was something so profound in that experience for me. Was he the first straight man that accepted me? No, but it was wonderful to have a mentor who didn't care if I was gay, didn't pathologize me, and said, “Write a book about working with gay men, the field is lacking this information.” It was so validating. And so, what he did for me, which all therapists ideally do for their clients, is embrace, love, support, and send me out into the world to be successful.

That is unconditional love, and that is what straight therapists can do for their gay clients. And what I say in the work that I do is you're giving your clients a bigger gift of healing than you would even recognize because your clients are coming into your office with their presenting problem, whatever that happens to be. It may have nothing to do with being gay. And, through the love and the acceptance and the respect that you're showing to them, they're getting additional healing from the experience of being in your office.  

So, frequently, when people want a referral to a therapist who's a gay client, frequently I'll say, “Why don't you work with a non-gay therapist? Because there is extra work that you can have done, as a result.” Some people will do that, some people won't.

LR: I used to think it important to be colorblind, but we must see color to validate the experience of the “other.” that idea. Similarly, one can’t be gay blind, because being blind to that does not suggest acceptance. It suggests walling off and not affirming that person, not accepting that person. So, I imagine that a clinician working with a gay person has to be very cognizant of the stories, the history that this person brings into therapy.

RM: Yes. The words that are coming to my mind are cultural competence. And that's what we need in the field these days. And I, too, did the same that you just described. I worked with an Asian gay man and a Black gay man, and I cringe when I think to myself or I even probably said things aloud that it's not as bad as you perceive it to be, which is absolutely not true.

LR: It’s not affirming.

RM: Right. The best thing that we can do is to hear the experiences that our clients are bringing to our offices and trust that to be true. The other best thing that we can do to become culturally competent is to go to workshops or watch videos like this or read a few books or speak to your gay friends and family members about their experiences to get educated. It's not hard to do. I find that in our field of mental health there are many people who are well-educated and liberal in their thinking, so that they feel like they have all that they need to know.

But their gay clients are testing them indirectly and don't feel safe because they're presenting a norm that may be uncomfortable. The other thing that I found, and I've mentioned this to you before, is that the field in general, of course, is run by metrics and numbers. And the most successful clinicians and teachers in the field have large numbers of followers and huge turnouts to their conferences. When I teach, sometimes I get 20-25, maybe 40 attendees, if I'm lucky, at a big mental health conference. Well, that's not good for the conference.

So, I'm not advancing as I'm teaching about working with LGBTQ people. And there are very few courses offered at huge conferences, which is unfortunate. So, my advice to people who are organizing conferences is to put us in panels with other people, and that way we can kind of gain exposure and educate people.

LR: So, the idea of a gay-affirming therapist is more cliché than anything else I would think because if you're not a person-affirming therapist, you're not going to be a gay-affirming therapist. Am I getting it, right? 

RM: Yeah, yeah. And I mean, interesting. A clinician that's worked a lot with the gay man or the LGBTQ population by nature is gay-affirming. I know through conversations with a person who has worked a lot with the LGBTQ population is gay-affirming, and they've cultivated acceptance and skills that are affirming and comfortable. As a person, are you a gay-affirming person? I'm not asking you that. I know that you are, but I'm asking people who are listening to this. Do you understand what it's like living life as an LGBTQ person in today's world?

And if you're honest with yourself, maybe there are things you don't understand, and there's ways of getting information. If you pretend that you are, you're fooling yourself. People are going to see beyond that.

LR: They’re going to catch up.

RM: So, when you go to therapy, you should be talking about your sexual life. Many gay clients, out of shame, won't even broach the idea of sex with their therapists. Or, when they talk about sex, their therapist winced because they don't believe in open relationships, or they think that gay men are too sexual, and their biases are coming forward. I h

How To Map the Toxic Impact of Social Media on Families in Therapy

Posted on by Psychotherapy.net Team

Learn how to see. Realize that everything connects to everything else

— Leonardo Da Vinci

The internet in the late 1990s was exciting because you could research topics including sports, education, and entertainment and stay in contact with old friends. In retrospect, however, when working with adolescents at a local PHP and IOP, I/we ignored the impact of Myspace and other social media websites that encouraged cutting and suicide. We attributed the increase in behavior to peer influence and the impact of dysfunctional family relationships.

Today, social media’s algorithms and influencers have more of an impact on the family than we are willing to acknowledge. It has been argued that social media’s algorithms entice family members who use social media to spend more time on the app than with their own family or friends. As a clinician who works with families in private practice and schools, it has become increasingly clear to me that social media’s algorithms and influencers often occupy the “empty chair” in the family sessions.

The “Therapeutic” Power of Influencers on Family Systems of Care

It was evident to me while watching the hearings in Washington, DC a year ago that social media companies will not change their algorithms and will not share them for everyone to understand. The Netflix documentary The Social Dilemma had many former social media employees expressing eye-opening concerns. The film revealed how tech companies hire psychologists to make a persuasive algorithm to increase the appeal and use of their apps.

Unfortunately, Congress appears powerless, unwilling, or both, to make changes due to the powerful lobbying groups. Some have said that Congress is waiting for the UK’s Parliament to take the lead in regulating this industry.

Social media makes money by showing images or comments that their algorithms “say” are interesting and encourage consumers to “like,” “comment,” or “share.” Social media companies have also learned the more divisive and inflammatory the post, the more views and money there is to be made.

Well-designed apps continually boost the user’s connection by showing information, comments, or images that they have discovered are of interest. Showing an opposing view or people from a different “virtual tribe” will decrease the views/time spent on the platform and decrease money for the makers of the app. The app creates a virtually closed system that does not allow any “disliked” information or contradictory views.

If different members of a family “like” different apps, or different posts on the same app, each member of the family may conceivably align with a virtual presence against their actual brick-and-mortar kin or friend. As a result, algorithms have the power and potential to intensify the already-present pattern of conflicts within a family system or relational circle. Disconnection, chaos, conflict, and exacerbation of individual and/or family pathology may follow.

Influencers have always been present in our society. For many years, our influencers were teachers, family members, neighbors, friends, supervisors, actors, news anchors, and other people in our community. We would ask our immediate community personal and embarrassing questions. Many times, adolescents and young adults would get personal and difficult questions answered by building up the courage to approach someone face-to-face in their community.

Building up the courage to ask questions taught us how to manage our fear and anxiety. Navigating face-to-face relationships also teaches us how to manage embarrassment, frustration, anger, resentment, and rejection which is an important step in our development. Non-virtual relationships also allow us to feel emotional and physical closeness that is missing in social media/virtual relationships.

Today, our society is teaching the belief that anxiety is a bad thing that needs to be kept at bay. We in the field know that anxiety is not the problem. Arguably, anxiety is a result of the person’s core belief and/or what is going on in a relationship that will not change for the better. Because of this, adolescents and young adults are narrowing their non-virtual relationships because it is the path with the least amount of risk.

When asking intimate or difficult questions face to face, we learn how to manage proximity and closeness in our family and friend groups. We learn who in our family and friend groups has earned the privilege to be asked these intimate questions. We learn who can keep our personal life private and who may have the better answer, which builds friendships and family relationships.

Social media triangulates family and friends to find the immediate answer and connects people to a tribe that challenges them the least. Many believe decreasing their non-virtual relationship decreases their anxiety, but it actually increases their isolation from their community and increases their anxiety when meeting someone face-to-face. Also, virtual relationships give the illusion that all of these important ingredients are present on social media.

Family members are turning to influencers as if they are therapists/experts with answers (good therapy doesn’t give answers.) Or they are turning to politicians that they must blindly follow (good politicians allow debate.) We know the politicians who are at the extreme right or left posting inflammatory statements get the most views.

These influencers are making statements encouraging family members or friends to pick sides, skipping the process of face-to-face discussion with follow-up questions or reflection that occurs in non-virtual relationships. When a person stops exchanging ideas with their family members or friends, it creates a dangerous virtual closed system.

During my training at the Minuchin Center for the Family, I was always asked, “Whose shoulders is the adolescent standing on?” One year, a family I was working with agreed to meet with Dr. Minuchin for a consultation. Dr. Minuchin said to me after the consultation, “You will fail because the system of care erodes the boundaries of the family.” It became evident that each of the six members of the family relied on their own individual therapists to reinforce their view of how everyone else in the family was toxic.

This taught me the importance of understanding the family map in addition to evaluating if different family members were in coalitions with other therapists, social workers, and/or even agencies. It was an important step to understanding the map and identifying where the coalition(s) across generational boundaries occurred with the family and larger system.

In many of the sessions, other families were able to overcome their symptoms once they began to work on their relationships and change their relationships with the systems of care. It was exciting to see when the system of care noticed their triangulation with the family. Other times it was sad to see how systems of care did not see how they were triangulated against family members.

Today, influencers are present in the family session as seen by the virtual coalitions that the member(s) must maintain as if they were their closest friends in order to be a part of their tribe/team.

The Impact of Social Media on Family Relationships

Families are always ahead of the researchers and therapists, but do we listen to the pieces together as therapists? The following are the themes/symptoms families have discussed in my own family therapy sessions as well as those of colleagues in the wider clinical world. Each of these impacts adolescents, and, in turn, how they impact the adults in their home. On both sides of the relational equation, social media has a powerful impact, and not always for the good of individual and shared relationships.

When one or more family members are engaging in excess screen time from two to sometimes more than six hours a day on social media, the research shows there is an increase in symptoms of depression and/or anxiety. If someone has this much daily screentime, they are displacing healthier activities or hobbies such as walking, sleeping, drawing, painting, mindfulness, and gardening, to name but a few. And this displacement impacts the interactions in the family and community by isolating them.

Algorithms encourage constant social competition and comparison, and as such function as social currency between peers and family members. Adolescents typically feel that they are on stage competing to increase their position in the “hierarchy” with peers and/or parents. They continually compare themselves to peers at school and other families.

The algorithms that draw them in make it difficult for them to turn off the social app and get away from the stresses of adolescence. Jockeying for competition and comparing their lives to others may at times backfire, leaving them feeling poignantly and painfully alone. Again, this constant competition and comparison mirrors similar interactions in the family that can contribute to increased anxiety and depression.

The adolescents I’ve worked with discussed how they feel lonely and alone. They feel lonely when they are not supported or perceive they are not supported by family or friends, and feel alone when they have little face-to-face contact with peers like we all experienced during COVID.

The two-dimensional views people experience when using Zoom as the primary source of connection do not “feed the soul.” There is no substitute for good eye contact and close physical proximity. The irony is social media was created to decrease feeling lonely and alone but actually amplifies it. In family sessions, many, if not all, talk about how they feel lonely and hoped that social media would fill this void but were unsuccessful.

Adolescents typically think they are invisible or always on stage. These polar positions can occur on the same day for any adolescent. They think they are invisible when they are spending more time on their phones not getting enough likes and/or views, whatever that means to them.

This causes them to work harder on their online stories and identities, decreasing the proximity with their non-virtual friends. Many adolescents begin to look for the “genuine” or “real” friends, determining they are only present in social media and not in their own hometown or within the family walls. In the family, these themes are very common when there is already a pattern of disengagement (invisible) or enmeshment (always on stage).

The adolescent also thinks their peers are waiting for them to make a mistake so it can be posted online. This position makes them feel as though they are always walking into the cafeteria for the first time as a freshman in high school. Adolescents are supposed to make mistakes, struggle, learn about relationships with typical external distractions (friends, family, media, work, and politics). But does social media fill the lonely times when the adolescent and young adult are reflective and recoup?

Being invisible or always on stage prevents the adolescent from developing close connections with peers, teachers, coaches, or other family members. This results in adolescents seeking temporary relief from asking a “person” and instead getting information from social media.

Information on the app is monitored by the algorithm and is not as embarrassing or stressful as asking a family member, friend, or teacher. This is where social media begins to enter the family, impacting the adolescent development and challenging their family’s belief system.

The algorithm also motivates the adolescent to seek select information that aligns with their narrow/closed view about politics, friendship, religion, sexual identity, sexuality, gun laws, suicide, mental health, or any other hot topic.

The Atlantic, 60 Minutes, Pew Research, the New York Times, and the Wall Street Journal have done a great job discussing all the different ways social media has triangulated members of our families. The New York Times article on suicide, “Where the Despairing Log On and Learn Ways to Die,” by Megan Twohey, or The Wall Street Journal essay, “TikTok Diagnosis Videos Leave Some Teens Thinking They Have Rare Mental Disorders,” by July Jargon are exemplars.

Social media focuses on the “person” and navigating them to topics they are interested in and picking what tribe to belong to. The information is flowing into one part of the family system and not to the whole family which triangulates family members against virtual friends or influencers. This occurs if the family is already in a state of constant conflict or conflict avoidance. A recent 60 Minute piece discussed how China does not allow TikTok to bring up divisive topics to their children or adolescents.

For the adolescent to decrease feelings of anxiety and depression, they must work for the “likes” and “views.” They will be trying to affirm their sense of self, but many times they will be accused of bragging and will feel they are not good enough when comparing or competing with others.

Body image and feeling unattractive are especially amplified by social media’s filtering app. Many plastic surgeons are reporting an increase in adolescents wanting to get surgery to look like their filtered self. Current data shows that 55% of surgeons report seeing patients who request surgery to improve their appearances in selfies, up from 42% in 2015. They want fuller lips, bigger eyes, and smaller noses. “This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the lines of reality and fantasy.” (1)

When I’ve met with families and these themes come up, I have encouraged them to discuss these themes which have allowed me to see the systematic position of each family member, system of care and the influencer/algorithm.

Every family has its struggles and at times feels out of control when it goes through a stage of what Monica McGoldrick calls its family life cycle. I have seen this especially when a family enters my office as it is attempting to (re)adjust to the needs of their childhood, adolescent, or young adult. Now add the influence of social media to one or all members of the family, the spiraling becomes more intense.

Crisis of Voluntary Play for Children

The importance of free and voluntary play with children to teach them how to give and take has been well documented. There is no substitute for non-virtual relationships in the early stages of childhood. Antithetical to this, algorithms require constant attention, taking the time away from connecting with others face-to-face.

Whether it is the child who requests to go on the smartphone or the parent who gives the child a cell phone in social situations (i.e., play dates, restaurants, long car rides, it decreases the opportunity to negotiate, argue, entertain themselves, compromise, and resolve conflict. This “tech choice” leads to delaying the development of the family and prevents them from moving to the next stage of a family with an adolescent.

Children Entering Adolescence Have Not Learned to Play

There comes a point in families when adolescents are told they are no longer a child, yet neither are adults. For some adolescents, not knowing the initial stages of voluntary and free play puts them into limbo looking for answers. The adolescent and family know on some level they are missing the tools for non-virtual relationships.

First, this is where the social media’s algorithm and influencers potentially intensify the family’s struggle. When the adolescent looks to social media for the answers, this intensifies conflict. Naturally, the adolescent wants to grow away from the family. They want to connect more with peers.

The adolescent in families with intense enmeshment/disengagement and different forms of coalitions struggle the most. This is where social media’s algorithms direct the adolescent to find a group. The algorithm pulls the adolescent in to spend more time on their app, resulting in the app making money and the adolescent searching for connections separate from the family.

However, virtual connections encourage the same patterns of enmeshment/disengagement and the different forms of virtual coalitions. These intense virtual connections are sometimes in opposition to the non-virtual relationships of the family and/or community.

Secondly, this social media generation has grown up learning to communicate more virtually and less in person, especially during COVID. Many adolescents have decided that they would rather communicate virtually. It is hard for some adolescents to look into someone’s eyes, read body language, and feel the energy of being in proximity because it makes them anxious. Look at any lunchroom at any local high school. If the school allows students to be on their phones during lunch, adolescents prefer to spend time on their phones working to maintain a social virtual hierarchy.

Social media offers a prime context for navigating these tasks in new, increasingly complex ways: peers are constantly available, personal information is displayed publicly and permanently, and quantifiable peers’ feedback is instantaneously provided in forms of ”likes” and ”views.” (2). Many of us who grew up before social media can only imagine if our mistakes were on a permanent record and followed us around for the rest of our lives, never allowing us to move forward.

Thirdly, the family does not have a chance to limit the adolescent’s time on the apps because the social media’s algorithm encourages constant attention, reinforces isolation from family and non-virtual friends.

Many parents have approached me saying, “The phone is their lifeline to manage their anxiety,” or, “The phone is the only way they connect with their friends.” During these moments, I have found it useful to explore how the whole family has come to the belief that the social app has become a way to maintain the homeostasis of the family.

A Non-Virtual Family Map

I often ask families about their virtual and nonvirtual family maps. I think it is important that we ask the family about their social media involvement to understand the virtual map of the family. Do families understand the impact of the social media algorithm? Do families know how to get out of the social media web? Do we ask each member of the family who they talk to virtually or non-virtually when they are struggling?

In initial evaluations, I often explore if the family is aware of how many hours they are spending on the social media apps. It is important to assess if the family is aware of how much social media raising/influencing is involved in the marriage, parenting, and sibling subsystem. Some providers want to focus on social media addiction, but the algorithm is not like any other “addiction.”

The algorithm allows many of the family members to covertly — and sometimes overtly — bring influencers into conflict with different members in the family. These virtual relationships amplify the family’s symptoms, and unfortunately today’s therapists use the medical model to diagnose the adolescent symptoms, further pathologizing and pushing the relationships in the wrong direction. This narrow view further sets the enactments, reinforcing the enmeshment, disengagement, and coalition patterns.

Non-Virtual Family Map

It is hard to shift our medical model training from a focus on the individual’s (child, parents, siblings) deficits to one that acknowledges strengths and competencies within individuals and the family system. When individual therapy does not make significant change, families often turn to family therapy as a last resort.

After experiencing this different approach, they often express frustration that they were never given the opportunity to move forward together, instead deferring to the experts for the correct intervention and diagnosis.

Structural Family Therapy was so different in the 1970s and 1980s; it was transcendent. While many new theories of family intervention have reached the mainstream, so too have many reverted to focusing on the individual. When starting individual therapy with the adolescent, I have found it important to ask the adolescent to overcome the algorithm on their own without their parents’ involvement. As family practitioners, we need systemic thinking more now than ever to approach the intense cultural impact of algorithms and influencers.

Below is a “traditional” family map that does not consider social media. It represents a compilation of families I’ve seen in therapy, rather than any one family. The symptoms include those typically seen in family practice — poor school performance, school avoidance, vaping, drinking, and using drugs.

From a system’s orientation, the symptoms are a result of the functional and dysfunctional interactions within the family system.

It’s hard for me to understand how therapists begin assessment and treatment without considering or involving the whole family. Some clinicians might say the conflict is too high, and it would only impact the adolescent negatively. Others might assume from the start that one or both parents are not willing to work or are too busy. Some might even be unaware of the importance of beginning from the position that families do not have the strength to make change.

Sometimes therapists and school staff buy into and reinforce the belief that the child or teen is the problem. In the case of this particular map, Mom “reportedly” goes to her private therapist while the son sees his own therapist. Mom and son separately complain about dad to their respective therapists and to the school staff. When mom and son voice frustration about dad and each other in the individual therapy session, disengagement with dad is reinforced. Mom and son are trying to get the type of connections from the system of care that they cannot get with Dad.

While this disengagement takes place, the son turns to his peers, attempting to pull away from mom’s enmeshment, activating her to pursue more. At home, Dad complains that his wife and son always bring up their therapist who agrees that he is unavailable and/or flawed. When this occurs, Dad becomes more distant and angrier, feeling like he is the odd person out.

When Mom gets angry at dad, she turns to her son and vents to him which activates him to challenge his father about money, drinking, and the way he treats her. At other times, the son may jump into the conversation when the parents interact about money, drinking, or the way he treats Mom.

When I attended graduate school, the common exercise was to map the triangles in the family system. Based on the above map, there are at least 24 triangles that are activated in the family-school-mental health system. The 24 triangles are:

  • The mom, son, and dad
  • The mom, son, and school social worker
  • The mom, son, and principal
  • The mom, dad, and school social worker
  • The mom, dad, and principal
  • The mom, dad, and school social worker
  • The mom, dad, and school principal
  • The mom, son, and mom’s friends
  • The mom, dad, and mom’s friends
  • The mother, dad, and dad’s friends
  • The mom, son, and son’s friends
  • The mom, son, and son’s therapist
  • The mom, son, and son’s psychiatrist
  • The mom, dad, and son’s psychiatrist
  • The mom, son’s therapist, and psychiatrist
  • The mom, dad, and son’s therapist
  • The mom, school social worker, and mom’s therapist
  • The dad, son, and son’s therapist
  • The dad, son, and son’s friends
  • The mom, son, and mom’s therapist
  • The mom, dad, and mom’s therapist
  • The son, son’s therapist, and school social worker
  • The son, son’s therapist, and psychiatrist
  • The son, school social worker, and principal

These 24 triangles are at the same time difficult for adults in the family to appreciate, even harder for an adolescent, and deeply challenging for the clinician to manage. In those triangles within the family where cross generational coalitions are activated, the symptoms in the family increase. I have often been challenged whether to discuss the impact of all these cross generational interactions with the family and whether it is important to differentiate the healthy, less healthy, and unhealthy ones from each other

On top of the above complexity, other questions arise like “where did the boundaries go?” The therapist must keep in mind how the boundary between the family and the outside world becomes invisible and the symptoms become more intense, to the point more professionals are recruited to “fix the dysfunction.”

I have also had to maintain awareness of how managed care’s enforcement and reinforcement of the medical model has influenced me and other members of the community of care, including other therapists, psychiatrists, physicians, and schools. This reinforcement has an impact on the family’s interaction with the son focusing only on his diagnosis and the correct medication, while failing to address the family relationships.

As mom turns to the school and the system of care for answers, things are not changing. She reports that her son is getting worse. Mom blames dad’s aloofness and dad blames mom’s overindulgence. Mom increases calls to the psychiatrist. The psychiatrist adjusts the medications frequently. The frequency of crises increases and the boundaries between the family and the outside world are dissolving due to the interaction between the family and the system of care.

The number of alliances increases between different family members and different professionals as more professionals/agencies are pulled into the drama. Professionals unintentionally begin to write/rewrite the individual’s and/or family’s stories, especially when utilizing the medical model.

With more stories, there are more opposing interests for each family member. This phenomenon between families and agencies is a result of a collision when both parties collaborate to uphold sociocultural trends. The goal is not only to interrupt multiple unhealthy alliances with existing professionals/agencies, but to also prevent new transactions from developing. (3)

This phenomenon was usually seen when the system of care worked with economically challenged families. We now see this also occurring with families of significant means because they can afford an individual therapist for each family member and psychiatrist(s) if needed.

As we look back at the map, it is now easier to understand that because the family has already identified what they think is the problem, it really needs to address the triangle between mom, dad, and son. It doesn’t really matter where to begin. A clinician can enter through mother-son enmeshment and coalition, father-son disengagement, or parental/marital disengagement.

It might also be useful to address the system of care coalitions between the therapist and school with the mom and son. Having the family identify how to change the interaction between the whole system allows them to move forward. It may be a challenge because getting directives from an expert, rather than looking within their own system, is what they have come to expect.

Using a Virtual Family Map to Identify Issues in Families

Before talking about the influence of social media on the family, it is important to acknowledge some of the “players” in social media. The system of social media has many parts. Social media success is dependent on an algorithm, which encourages frequent interactions by virtual and non-virtual friends.

The frequent interactions result in the shareholders receiving monetary return on their investment, the employees maintaining their jobs and bonuses, and the advertisers increasing the visibility of their product resulting in increased sales. The influencers are dependent on social media to reach as many people as possible to receive income from the app. There is a lot of pressure to have an effective algorithm to support social media.

As you next look at a map depicting the interactive nature of the family and social media, it is important to keep in mind that the 24 triangles from the non-virtual map are still present, and the family boundary is already disintegrating with the school workers, friends, and therapists to seek help with the identified patient.

Now in addition to these non-virtual professionals and friends, the family is inviting social media’s virtual friends and influencers to seek help with the identified patient. Clients (and non-clients) often turn to virtual friends and influencers to provide the same connection as non-virtual friends, but these connections are void of physical closeness. Children and adolescents believe a virtual relationship can replace a non-virtual relationship. But all virtual relationships are void of physical closeness in which touch, eye contact, and a warm smile can feed the soul.

The family can turn on a social media app at any time of the day or night and the outside world is invited into the family, increasing the number of triangles exponentially. From the clinical perspective, it is critical to examine what actions (social competition, social comparison, loneliness, etc.) in the family trigger a member(s) to invite social media into the family. The therapist must also discuss how social media algorithms are activating/triggering the member(s) of the family to turn to an app to surf or post an event. This increases the time spent on the smartphone to maintain these virtual friends, non-virtual friends, and influencer relationships.

At times, social media decreases connection with non-virtual relationships and increases the connection with virtual friends and influencers. In the therapy session with this particular family, some members discuss how they rely on virtual friends and influencers more because “they understand me more than the friends in my own town/school.”

The adolescent believes these virtual figures want to listen to them more than family and non-virtual friends. It is important to ask the family what influencers and virtual friends provide that their own family members or non-virtual friends cannot. This allows the clinician to address the patterns and interactions in the family.

In the map below, I do not draw the number of different social media apps, influencers and virtual friends who are involved with the family. However, I do recommend when meeting with families, to draw each app, virtual friend, and influencer to show the number of triangles the family is managing or attempting to manage. For simplicity’s sake, I use one (black) box to represent all the social media apps and one box for all influencers and separated mom and son’s virtual friends.

 

Husband, Wife, and Social Media Triangle

What is the impact of social media on marriage? The wife turns to social media and influencers to figure out how to “fix” her marriage. The wife tries to talk to her husband about what she has learned about marriage on social media. The husband discounts the wife’s attempts to “educate him about marriage.” She eventually gives up on the marriage and “wants to focus more” on her son. She also tries to connect with previous friends and boyfriends from past life because she feels lonely and alone “looking for a connection.”

What you will see in this triangle, and all the triangles which involve social media, is a substitution of a virtual relationship for a non-virtual relationship whose connections are full of conflict or conflict avoidance. The virtual relationships convey an illusion of meaningful connection, but the person(s) feels alone and lonely because it lacks the important ingredients for a fulfilling relationship.

Mother, Father, and Social Media Triangle

Now the wife stops working on the marriage and focuses on parenting. The husband is not aware of this decision, focusing on “making money to provide food, clothing and shelter.” The father continues to feel alienated, disconnected, and disempowered, becoming angry towards the mother and son. The mother turns to school staff, therapists, non-virtual friends, virtual friends, and influencers for ways to “fix her son.”

This fosters more of an enmeshment with son, and disengagement with Dad. The son turns to school staff, his therapist, non-virtual friends, virtual friends, and influencers. Each family member describes a feeling of disconnectedness trying to overcome the feelings of being lonely/alone. Dad voices his frustration, complaining that he is “old school,” and they are “hypnotized by that damn phone.”

Mother, School, and, Social Media Triangle

In this triangle, mom calls the teachers and guidance department for support. She has frequent phone calls with the guidance counselor because the guidance counselor “is an expert with adolescents.” As you can see, dad is left out of the interactions with the school.

After a few months, her son’s behavior is not changing, and mom is frustrated with how the school is not helping her son. Mom begins to turn to social media looking for answers. Mom spends hours on the app talking to non-virtual friends, virtual friends and reading/commenting on influencer’s posts. Mom displaces healthier activities with time spent on social media. Mom begins to complain that the school is not meeting the goals set out by the Individualized Education Plan (IEP). Mom cites information from influencers from social media and the internet. The tension rises between the school and mom.

Schools today are under tremendous pressure to perform. Schools are understaffed, and do not have the mental health training or support to bring in a countercultural systemic approach into the schools despite the money being put into schools after COVID-19.

Parents, Son, and Social Media Triangle

Mom is spending hours on social media looking for answers to why her son is struggling. She also spends time looking for connections. The son also spends hours on the app interacting with non-virtual friends, virtual friends and reading influencers’ posts.

Mom pursues the son, but he only is aligned with her to challenge dad’s limit setting. When the parents attempt to be aligned, the son acts out more. We see the son increase his conflict with parents, who struggle due to their enactment/conflict avoidance with each other on how to help their son. This results in the father leaving and the mother turning to social media to find answers or overcome feelings of loneliness.

When the family interactions are in intense conflict or conflict avoidance, many children, adolescents, and young adults get most of their answers from non-virtual friends, virtual friends and influencer’s posts. The son is seeking temporary relief by getting information and trying to affirm a sense of self.

The non virtual, virtual relationships, and influencers introduce beliefs that are the opposite of the family’s beliefs and further impact the self-esteem of the adolescent. The son discusses what he learns from social media of what “real parents are like.” The decrease in face-to-face communication with family increases his anxiety, depression, irritability, and intrusive thoughts. This also confuses the family of how their family member can “think so differently.”

Son, Non-Virtual Friends, and Social Media Triangle

The son in the session discusses constant social competition/comparison, working for social currency, and thinking he at times is invisible to his non-virtual friends. The son gradually believes his non-virtual friends “don’t understand.” He believes he cannot turn to his parents because “What do they know?!”

The son begins to engage in the same interactions with his peers as his parents and avoids turning to his peers for support. The son begins to spend more time on social media with virtual friends and influencers to seek select information that matches a narrow/closed view, hoping to avoid conflict/interaction. The son then turns more to virtual friends and influencers for answers. Again, this increases his time on his smartphone and increases the family’s sense of not being good enough for each other.

Remember, the son believes there is “less stress” getting information from a stranger, pop culture icon, or a virtual friend than an enmeshed mom, disengaged father, or face-to-face with a peer(s). However, the decrease in face-to-face communication with family and non-virtual friends increases his anxiety, depression, irritability, and intrusive thoughts.

Despite the time spent on social media, the son feels alone/lonely, looking for emotional, face-to-face and physical connection, but does not have the words to express these thoughts to each other.

Mom, Therapist(s), and Social Media Triangle

Dad continues to be absent from the triangle that involves the therapist. The mother attends her own therapy and attends her son’s sessions to discuss what new information she has seen on social media.

She reviews with both therapists what she has learned on social media about new treatment, new medication, and new diagnoses. She advocates with all providers that her son is incorrectly diagnosed, hoping that would help him with his symptoms. The quality of training of the therapist determines their response to entertaining or challenging mom’s research. This may result in mom seeing a new therapist.

The individual therapists and psychiatrists are not looking at how the parents avoid “getting on the same page.” They are reacting to reports by mom about the son’s behavior. Mom and dad are unable to interact differently because they have not figured out how to work together to decrease their son’s phone usage to increase his time with non-virtual friends. The professionals are avoiding addressing the parent’s avoidance!

Mom, Psychiatrist, and Social Media Triangle

Dad is absent from the triangle that involves the psychiatrist. Mom becomes disgruntled with the psychiatrist. She begins to challenge the psychiatrist’s diagnosis and medication recommendation. The psychiatrist recommends if mom is not satisfied with his assessment, she seek a second opinion. Mom begins to look for a psychiatrist who agrees with what she has read on social media.

Son, System of Care, and Social Media

The son is seeing his individual therapist 1-2 times a week and his psychiatrist once a month. He is also spending 2-8 hours on his social app each day. The therapist has not assessed the hours the son is spending on his phone. The app is only showing views/opinions/likes/images that interest him.

The son begins to complain that the therapist does not understand him and challenges his therapist saying, “This doesn’t help.” When the therapist explores the son’s statement, he begins to discuss information from “reliable sources” from social media and influencers. He too begins to diagnose himself and discusses medication that can help. When the system of care discusses reliable sources such as universities and professional journals, the son becomes irritated saying “I don’t want to read them.”

Son, School Staff, and Social Media

Not only does the system of care increase their sessions, but the school staff increase their time with the students. The number of triangles with the son in the school increases between the child study team, teachers, and administration.

The teachers are pursuing him to get his work done — offering to meet him before school, lunchtime, and after school to complete his work. He never shows. The son is seen in class on his phone. Some teachers ignore him, and others nag him. When a teacher challenges the time he is on his phone, he tells the teacher other instructors let him do it.

The social worker is calling him down to discuss his avoidance of work and disruptive behavior in the classroom. Only when the son becomes overwhelmed, he discusses with the school social worker his home life and that medication is not working. The vice principal is meeting with him to give him detentions. The son feels frustrated with the school stating, “They are only doing this because it is their job.”

Son, Non-virtual Friend #1, Non-virtual Friend#2 with Social Media

The son leaves school to go home to continue to work on his non-virtual relationships on social media. It becomes evident that in social media apps, the same social stressors occur online like in school. It is exhausting to navigate being included and avoid being excluded at school and online. The son and non-virtual friends are jockeying for social currency and social position, never getting time off to charge their own social battery.

The son and non-virtual friends stress about the images they post. They are anxious about what the image means to them and others. The son is trying to understand the unspoken rules for posting and the reaction by his peers regarding the image. The son worries if the image appears “authentic” and will help him maintain his position inside the social media group or if a new group be formed without them.

Son, Non-virtual Friend(s), and Virtual Friends

The son struggles connecting with his non-virtual peers. He is not getting feedback from his non-virtual friends about his art and his physical appearance and finds out they have different chat rooms that do not include him. (Remember, he does not want feedback from an overly involved mom or detached father.)

He begins to look for feedback about his art and physical appearance from virtual friends. When looking for connection outside the non-virtual friend group, he states he is looking for virtual friends who are nonjudgmental.

But as time went on, it began to mirror the non-virtual group. Some of his virtual friends on social media become competitive and attempt to increase their social currency on this platform. They do this by making fun of his physical features and his art. This mirrors some of his non-virtual friends’ behavior. The son frantically searches for another virtual peer group that he believes will not activate anxiety by not challenging his views, providing a stress-free venue.

As the son increases his time searching for virtual peers and influencers over non-virtual friends — reinforcing a closed system, increasing isolation at school, and decreasing time to sleep at home. His virtual relationships are now more important — increasing time spent on the app and continuing to strive for more likes and views.

Lack of face-to-face contact with family and non-virtual friends fosters more of a virtual enmeshment with virtual friends. He describes them as “nonjudgmental” and “more accepting.” This further increases his self-doubt and increases his feelings of loneliness and creates a virtually closed system (Virtual Enmeshment).

Son, Virtual Friends, and Influencers

The virtual group is important to maintain when avoiding contact with his parents and non-virtual friends. The son describes his virtual friends as more “authentic” and describes his non-virtual friends as “fake” and “not genuine.” However, some of his virtual friends on social media become competitive and attempt to increase their social currency.

The son frantically looks for another group that is an anxiety and stress-free venue. This further increases his self-doubt and increases his feelings of loneliness. This increases the symptoms of anxiety and depression when waiting for approval from virtual friends saying, “They are the only ones who understand me.”

As the son looks for new virtual friends, he and his virtual (and non-virtual) friends look to influencers for answers on how to portray themselves. Influencers work hard to establish and maintain their position in their virtual community. The influencers are working hard to make money and increase their viewership. The influencers often ask adolescents to agree with their beliefs and recommend products they are selling. The influencers work hard to appear on the “right side” of an issue.

As the son tries to replicate the beliefs of his preferred influencers, he looks for fellow virtual friends that have done the same “research.” They notice the more they make comments in opposition to a belief, it increases their views and likes.

As the symptoms in the family increase in intensity, the members increasingly must decide who to align themselves with in the virtual and non-virtual triangle. The therapist highlights this and encourages the family to discuss and identify the boundaries of virtual and non-virtual triangles that maintain these alliances/symptoms. This allows a family to discuss non-virtual triangles that are underutilized, which reinforce healthy boundaries that benefit the family.

Using Exploring Questions to Make Circular Statements

Much has been written about joining, unbalancing, and mapping in SFT. One of the beautiful ways Structural Family Therapy (SFT) uses language is by employing circular statements to connect the family member’s behavior in the system. When SFT enters the family, the systems therapist uses the family’s own observations to connect their interactions.

It is important today to make a circular statement to widen the lens in which the family sees how all virtual and non-virtual relationships impact the relationship in the family. Below are some examples of circular statements using the words used by each family member.

I agree with you, Mom, that as long as you do not have a voice with Dad and work together, your son will not stop posting explicit images on Snapchat

Dad, as long as you sound like a drill sergeant, Mom will not find her voice as a woman and work with you as a wife and mother of your son who will continue to believe he must mirror images on Instagram

Mom, I agree that the harder you work, the less Dad helps you with parenting your daughter— your daughter will have to turn to influencers about how a woman should look and act

Peter (son), as long as your mom is worried about the frontstage appearance, she will fight with your father who is more concerned about your backstage struggles with you and your mother

What do your virtual friends give you that you cannot get from Mom, Dad, or your non-virtual friends?

Conclusion

Many are worried about the continued increase in suicide, suicide attempts, and mental health issues in the family and how Congress is powerless to challenge these companies. Many providers are not looking at what has changed in our lives in the past 25 years.

Relationships are becoming more complicated than ever. Many families and therapists are unaware of the impact of the system of care and less aware of the impact of the ubiquitous “algorithm.” It is hard to understand how the algorithm works because it is important for these companies to keep the algorithm secret for fear of losing profit.

We must also remember that each influencer, virtual friend, and nonvirtual friend has their own family map. Just as many professionals do, influencers understand how their stories, views, and images echo in the family.

Are families aware of the alliances that occur with virtual and non-virtual friends and influencers? Are we aware that when more virtual influencers and friends enter the family, more alliances increase establishing social hierarchy, increasing social competition and social currency? Are we, the clinicians, aware that influencers and virtual friends unintentionally/intentionally begin to write/rewrite stories in the family and permanently on the internet?

We must begin to understand that with more stories, there are more opposing interests for each family member. This phenomenon between families, virtual friends, nonvirtual friends, and influencers (social media) is a result of collusion when all parties collaborate to uphold their preferred sociocultural trend.

The goal is not only to highlight and interrupt the multi-alliances with existing social media but to highlight the transactional pattern in the home that maintains this pattern. Remember, a virtually closed system impacts all family members, whether one or all are using these platforms excessively.

References

(1) Susruthi, R., Myara, Maymone, B. C. & Vashi, N. Selfies-Living in the era of filtered photographs. JAMA Facial Plastic Surgery. 2018 20:6, 443-444.

(2) Nesi, J. (2022) The impact of social media on youth mental health: Challenges and opportunities. North Carolina Medical Journal, 81(2), 116-121.

(3) Colapinto, J. (1995) Dilution of family process in social services: Implications for treatment of neglectful families. Family Process. 34:59-74.

Questions for Reflections and Discussion

How has social media influenced your personal and family life?

How does the author’s premise resonate with you and the way you practice family therapy?

How have you integrated social media and app use into family therapy?

In what ways do you agree or disagree with the role of social media in family systems?

© Psychotherapy.net 2023

Building on Family Strengths to Solve the Puzzle of Child Protection Work

Posted on by Psychotherapy.net Team

Information is a difference that makes a difference.
                                               — Gregory Bateson

In nature, it is said that whenever there is a poisonous plant, there can be another nearby which contains its antidote. When it comes to helping families, the same is true that for every problem identified, the resources for resolution can be present somewhere in the family’s ecology.]

Unfortunately, especially for underserved families, competition among divergent treatment philosophies, practices, and limited resources create an unintended conspiracy within the mental health and social service delivery systems — perhaps a benevolent one, but one which nonetheless curtails the identification of systemic homeopaths. The unfortunate consequence of this inability to use potential “antitoxins” naturally present within the client’s ecosystem is inefficiency for the service delivery system, stressed-out workers, high turnover, burnout, and a spiral of reduced possibility in which hope’s grasp is tentative at best, and non-existent at worst.

Mental health and social service clinicians working within the childcare system must search for strengths and solutions that are present, though perhaps hidden, in clients’ ecosystems. The approach is based on systems thinking and the idea gleaned from the practice of Structural Family Therapy (SFT) that change in any system, whether it be a family system or a social services agency, is best affected by the lived experience of doing.

Crossword puzzles as a paradigm stresses thinking and doing as an “out of the box” means to a problem-solving end. This practice mines the strength-based belief of creating a “virtuous circle” — one which recognizes clinicians’ and supervisors’ capacities and creativity, like those of the families they serve.

In resource-poor environments, when the goal of training is the enhanced ability to search for strength, this is not simply a training “add-on.” Rather, it is a foundational principle that requires the same persistence and consistency that Minuchin and other family therapists demonstrated was present in the natural environment in which clients and their families are embedded. The naturally occurring strengths in clients’ ecosystems can be uncovered by robust “doing,” which is an optimistic and energetic search for resources and resilience within both the family and the larger ecosystem of change.

Collaborative Case Planning

Like the proverbial butterfly catcher with net in hand, human service organizations have long been involved in a quest to capture the elusive chrysalis of change. What distinguishes efforts at reform and the ability to succeed is an ecological, “whole systems” approach. Children, families, problems, and possibilities are viewed in toto — economics, social, political, educational, gender, vocational, racial, location, class, and psychological elements are all in play. It acknowledges the margins and builds accountability.

The human and fiscal expense of doing otherwise speaks to the futility of programs that do not account for the organic and sometimes chaotic environment that families attempt to survive and thrive in.
As the 19th century Prussian Field Marshal Helmuth Carl Bernard Von Moltke reminded us, “No plan survives contact with the enemy.” In this instance, the enemy of high-quality service delivery is the tendency to replicate the existing system rather than undergo the reformation needed to absorb the family’s own healing powers.

Another systemically inspired practice that infuses underserved families with greater choice, and ultimately health, is collaborative case planning. This time-honored intervention gets all the major players to the table — including the family — and in the process, becomes a kind of exercise in agency topography that borrows from the tradition of Hartman and her colleagues, who pioneered ecomapping of family systems for adoptive placements.

By using the wide-angle lens of mapping families in all their contexts, resources and potential pressure points can emerge for their potential effect on the child and family. From the agency perspective, efficiency and collaboration are increased with an ecomap; everyone can see who is doing what and when and how it is being done. As a form of “observational therapy,” an ecomap can have the same heliotropic potential. However, as business has learned, outcomes can be improved, but not always for the reasons one might think.

Unfortunately, the promise of systemic work and its healing potential as envisioned by therapists who worked in the family trenches is not always realized in the battles to transform larger systems. For clinicians in the human services, or for those who train them, the pitch of a systemic perspective too often mirrors the president throwing out the first ball of baseball season — well intended, lots of hoopla, but doesn’t reach the plate. Without a clear picture of where they fit in the larger service-delivery system or a sense that they can make a difference, workers can feel overwhelmed, disempowered, and disheartened.

The financial cost to the system in turnover and lost productivity can be measured. The loss of wisdom, the discontinuity of care, and the loss of hope, however, are beyond calculation. In that regard, the experiences of child welfare clinicians mirror the isolation that can permeate the system within which they work and the families that they treat.

It is for this reason that systems of care were re-designed to “wrap” services around families and to minimize the dilution of family processes that occur as a by-product of traditional service delivery. In a sense, “wrapping” can enrich underserved families with a wider net of resources in the way families of higher classes can choose their providers and supports more selectively.

Capitalizing on Strengths

In tracing the strands of effective, systemically inspired service delivery, there is one constant thread: strengths. Thank goodness! But just as it was found that a rising economic tide does not raise all boats, so too can the tidal waters of strength not elevate the all-too-often porous vessels of bureaucracy.

What is amazing is how far a little strength can go, even in conditions that are wanting. There are, after all, some quite beautiful plants that flourish in the shade. Sadly, however, in the wrong bureaucratic hands, even strengths-based practice can invite the agency equivalent of Frankenstein picking flowers with the little girl — it’s a nice idea, but eventually the monster kills it.

How, then, to help clinicians to see that “It’s the difference that makes a difference”? Is there a way to aerate the sometimes root-bound tangle of the childcare bureaucracy so that its ability to heal can be given the room to breathe and prosper? How to give clinicians — especially those just out of school — the understanding and confidence to “trust the process” of searching for strengths, both within disrupted families and the systems designed to serve them? Moreover, are there ways to create a culture of caring and learning transfer so that clinicians see themselves as “action agents” within the larger bureaucratic tangle?

Part of the answer lies in family therapy’s history and co-development with cybernetics — the study of how systems developed the concepts of circularity, non-linearity, recursion, the process of self-correction, and the ways family and organizational systems maintain stability/homeostasis while balancing that with change and transformation. Gregory Bateson and his colleagues at the Mental Research Institute (MRI) in California, along with other early adapters, were the pioneers in this new way of thinking that set the stage for family therapy as we know it today.

Using a notion central to Structural Family Therapy (SFT) about strength and extending it to conceptualizing strength as a verb can be unintentionally overlooked when children and families in dire need get lost within the morass of bureaucracy. The SFT concept of healing is more about thinking of strength as a verb. It’s not so much a matter of finding strengths within the family’s ecosystem as it is strengthening the resources that are hiding in the weeds, so to speak. In that regard, it is more of a leap of faith — that whatever challenges a case presents, health can prevail.

Businesses and non-profits share a challenge: getting their message through environmental “clutter,” or the glut of choices that compete for our attention. How, then, can human service organizations solve the multiple staff training dilemmas they face?

The skills and belief set needed are interwoven and important: ensure the safety of the child and family, reduce decision clutter, increase the active search for strengths, attend to and nurture family connections, expand the problem-solving lens to include extended family, community and idiosyncratic, home-grown resources, and get paperwork in on time. One path on the way toward answering this organizational koan is this: increase experiential capital by linking the worker and their day-to-day decisions with the larger mission of the organization.

Thinking Outside the Therapeutic Box

Bridging the gap between what we know and what we do, however, is no small feat. In Why Didn’t You Say that in the First Place: How to Be Understood at Work, Richard Heyman unravels this knotty problem with a question and a refreshing answer: “Why is it that ‘a picture is worth a thousand words?’ The picture is not talking about something — it is the thing the talk is about.”

From this perspective, to truly “get” the uber-goal of searching for strength and translating that into action, workers must experience the “felt sense” of search and discovery —finding something where apparently nothing exists. This experience is analogous to an “enactment” in SFT, in which the family is guided by the therapist in an interactive experience between members that is designed to offer them new opportunities to use underutilized strengths.

Many consider enactments to be the heart of Structural Family Therapy. The value of enactments is two-fold. First, as a “real-time” assessment tool, and second, for their change-producing potential, both of which scaffold nicely for training in human services.

Enactments between family members during therapy can principally occur in two ways, either spontaneously or through the therapist’s direction, and they are used in two ways, to assess family patterns and to promote change. Spontaneous enactments are readily available ways of interacting that might be thought of as familial “tells” (like the poker player whose nervous smile foretells the bluff), showing habits of relating in which relational organization is embedded. While some might consider these patterns to be so deep as to be unconscious, another way to think of them is as learned ways to relate and survive in the world.

The persistence of patterns can transcend the pull of context. Habituated behaviors tend to reveal themselves in multiple settings— a therapist’s office, a restaurant, school, work, or home. The persistence of these patterns can be linked to the tendency to reduce anxiety through prediction and habit. As the pioneer family therapist, Virginia Satir notably said, “Most people would prefer the misery of certainty over the misery of uncertainty.”

Like an artist who steps back from the picture they are painting, clinicians have the capacity to use themselves differentially, moving in and out of the family system to gain perspective. Minuchin described this as “use of self,” in which the therapist positions themself with the family from “proximate, median or distant” perspectives.

Harry Aponte has written about how therapists can make use of their own personalities, family of origin, and life experiences to guide clients during enactments in the “then and there” of limiting patterns so that they experience themselves and one another with increased possibility and hope.

Like a music student first learning scales as a prelude to improvisation, experiential training can evolve into a more responsive, “whole systems, both-and” approach in which requirements and innovation can co-occur. For example, when supervisors at one county office of a state child welfare agency were asked about their staff’s training needs, their response was, “To be able to think on their own/to think outside of the box.”

Their request comes from the experience of guiding their workers through the complicated bureaucratic and interpersonal seas of child protection. As Mumma wrote in his insightful piece about his agency training in systems work, “Taking these concepts (ways of thinking) and making them work in a particular agency setting is the real work of training.” The analogy of crossword puzzles can make that work a bit easier.

Finding Best Clinical Practices

Just thinking about all the aspects of a case — its who’s, what’s, and how’s — can be a bit overwhelming. Cases in the investigative and early treatment stages, particularly for newer clinicians and social workers, may seem all forest and trees, abounding with unanswered questions.
Over the years, agencies have found genograms, ecomaps, and structural maps to create a set of “blueprints” that graphically represent families and agencies in a way that quickly sorts out relationships and priorities. These tools have been essential in widening the practice/thinking lens to include others who may have clues to potential resources.

The rise in “manualized” treatment and the emphasis on evidence-based treatments has helped to sort through these difficult choices and prescribe “best practices.” While this is a necessary step in the right direction — much like learning scales is in music — it can be insufficient to encompass the unpredictable nature of cases. There needs to be a “both-and” approach that brackets safety, consistency, and growth with improvisation. Thinking in terms of crosswords can do just that.

In its own way, a blank crossword puzzle graphically resembles a complex clinical and, in this case, social services-related case — lots of questions, some inter-related, some not, and just to make it interesting, a few black boxes. As President Clinton said in the crosswords-based movie, Wordplay:

Sometimes you have to go at a problem the way I go at a complicated crossword puzzle. You start where you know the answer and you build on it and eventually you unravel the whole puzzle. And so, I rarely work a puzzle with any difficulty, one across and one down all the way to the end in a totally logical fashion. A lot of difficult, complex problems are like that. You must find some aspect of it you understand and build on it until you can unravel the mystery you are trying to understand and then you build on it and eventually you unravel the whole puzzle.

When one acts as if the answers are there, though perhaps hidden, the puzzle’s resolution moves from the shakier, contingent ground of “if” it will be resolved, to the more possibilistic ground of “how.”

Crossword Puzzles as Metaphor in Child Protection Work

Do you think I know what I am doing?

That for one breath or half-breath I belong to myself?

As much as a pen knows what it is writing,

Or the ball can guess where it’s going next.

Rumi

When a case opens in child protection, the most compelling, sometimes unanswerable question is “Who will keep this child safe?”
If an injury has occurred in the home, the prima facie answer may seem obvious: “no one.” In this instance, unless resources are surfaced, the child will need to be placed outside of the home, “in the system.”

Starting the exploration of strengths from a crossword paradigm assumes that like the printed puzzle, all the answers may not be initially apparent, but once safety is established, one can begin to answer the eternal risk-safety dilemma: Can the person(s) who caused or permitted harm now be responsible for safety? If one only looks at the alleged abuser, then the likelihood is that the answer to the question will be “no.” If more contextual factors are also considered, so, too, are possibilities.

The work becomes both retrospective and prospective, invoking Einstein’s dictum, “You can never solve a problem on the level at which it was created.” The “who” and “when” questions are now also answered by “how.”

The “how” to find and fill those potential strength-based empty boxes begins with questions like “Who else watches the kids when you go out?” or, “When you are having a rough day, who do you talk to?” or, “Who are some of the people you count on?” These ground-level questions are more than a set of techniques, they are the personal implementation of a larger policy that has the capacity to both be safe and value the child’s primary connection.

Enacting Possibility to Help Families in Crisis

Like the Zoysia grass, the grass/weed whose initial plugs merge over time into a uniform carpet, training from a Crosswords perspective can grow the seeds of organizational interpersonal attachment. One way to underscore the marriage of mission and method is to give training participants a felt sense of difference.

The enactment of possibility begins when participants fill out a blank crossword on their own. After five minutes of working alone in silence, the trainer helps the participants process their “silent” experience at multiple levels: What did you notice? Did you fill in the boxes you knew first, or did you have a system? What did it feel like? Did any of you get stuck? How did you get out of that — what did you do? Typically, people report a range of answering strategies — some very methodical, “I do every ‘across' first, then I start with the ‘downs,’” others more radiant, “I just see which ones I know and then go from there.”

Next, the trainer asks the participants what it felt like to do the puzzle. What did they notice about their mental/emotional and physical states? “It was quiet.” “I kind of got into it.” “It was frustrating.” “I felt tense.” “I was worried other people would see how much I didn’t know.” “I kind of enjoyed it.” “It’s like Solitaire or Wordle, I just got lost in it.” All their answers provide abundant raw material to talk about their work, their stresses, successes, and the strategies they use to problem solve. And it sets the stage for helping them think “out of the box” by using the other boxes.

To widen the lens, the trainer may provide another enactment. This time, they can ask participants to form small groups of six or fewer, telling them that they have another five minutes to work on their puzzles, but this time, together. People begin to talk, share their answers, laugh, and fill in the blanks as they see how quickly they can solve the new crossword together as a team.

When the time is up, the group is asked to process their experience and compare it with doing the puzzle alone. Inevitably, they notice the energy level, productivity, speed of producing answers, and their own internal experience of connecting while connecting the dots. In future puzzling cases, this brainstorming model can supply added, shared resource clues to support and, most importantly, help the clinician in their search for resources within the family and larger system.

Materials Needed: Copies of a Crossword Puzzle

Total Amount of time: 10–20 minutes

Lessons Learned: Start with strengths within and around the family, fill in the answers you know to discover the answers you don’t.

One does not need to know all the answers to get all the answers.

A “wrong” answer is eventually corrected by the context of right answers.

Just like a case, one does not know all the answers when starting — answers emerge over time often from unexpected sources.

Persistence pays off — but so does taking a break and getting help.

A Family Crossword Comes Together

The first time I (LPM) met Kyla and her mother, Teresa, was across a cold table in an institutional room. Kyla had been in the residential treatment facility for almost ten months following a series of escalating behavioral incidents in her previous foster home. I thought back to my meeting with the family’s caseworker, who told me that Teresa and her partner Linda’s relationship was volatile and created an unsafe environment in the home. Kyla’s father, according to the caseworker, was out of the picture.

During my first several months working with the family, I felt as if very little progress had been made. Each week, I’d pick Teresa up and drive her to the residential facility for family sessions. Dutifully, I went to family court, holding space for an equally enraged and devastated Teresa on the way home each time reunification was pushed back. I consistently showed up for the family, and despite good rapport with both mother and daughter, Kyla’s behavior remained a challenge and our family sessions felt focused on the crisis of the week, as opposed to addressing underlying family dynamics and struggles.

One day, Teresa unannouncedly brought her partner Linda to session. From that point, treatment changed almost immediately, as both Kyla and Teresa seemed more engaged and open during family therapy, and we began to focus less on minor incidents and more on boundaries and communication within the family system.

Still, somehow, it felt like a piece of the family puzzle was missing. I could sense that Teresa and Linda were holding something back, particularly when we discussed their co-parenting practices. This final piece fell into place one day when I went to pick up Teresa and Linda and Robert, Kyla’s father, eagerly and unexpectedly hopped into the van. It quickly became clear that Robert had been actively involved with the family all along.

I finally could see the full picture of the family structure and their dynamic. Teresa, Linda, and Robert were in a polyamorous relationship. Robert had been understandably hesitant to engage with the child welfare system out of concern that the polyamorous relationship would be condemned, and reunification denied.

The case that had “simply” been presented to me as an unreliable mother with a violent partner unable to meet the emotional needs of her unstable daughter was actually one where a child had three caring adults who wanted to support her. With all the pieces in place and the entire family finally engaged in treatment, meaningful therapeutic work ensued, Kyla’s behavior improved, and she came home.

Conclusion

“The solution to pollution is dilution.”

Using crossword puzzles as a conceptual framework and training method opens workers and the organization to both the learned and the lived experience of complexity, strength, possibility, and the importance of connective relationships when working in child protection. We know that systems can mirror the systems that they treat. For instance, In Child Welfare, the insidious nature of poverty is such that it can quietly, but inexorably, leach into the soil of good intentions in such a way that the attachments between worker and family, workers and other agencies, worker and supervisor, and workers themselves, can suffer the pollution of despair.

This is not to say that using crossword puzzles will wall off the effects of these potential systemic toxins. It is to say, however, that healthy, connected relationships can be grown and nurtured and, over time, create “the difference that makes a difference.”

***

The author would like to thank my friends and colleagues who helped me fill in the blanks, both across as well as up and down. A special thanks go to Lauren McCarthy (LM) for providing the case of Kyla.

Addressing the Relational Impact of Mental Illness

Posted on by Psychotherapy.net Team

While it can be isolating, mental illness is not an isolated experience. It affects more than just the individual: it impacts friends, family, spouses, significant others, and co-workers. I recall working with a married man who developed Major Depressive Disorder around the time his wife had their second child. He became emotionally distant, socially isolated, lethargic, couldn’t focus, took time off work to the point of being fired, and lost interest in sex. His wife struggled bitterly. She felt completely overwhelmed with the care of two young children. Her husband, on whom she once depended, was no longer contributing. She felt like she had to care for him as well and try to keep the family financially afloat since she was the only one working. Despite the challenging circumstances, she tried to keep their intimacy intact, but he had no interest in sex, going out, connecting with their friends, and he struggled to track during conversations. As you can imagine, this put a strain on their relationship, which they eventually ended. Neither one of them wanted the divorce, but the wife hit her breaking point, and her husband couldn’t find the energy to fight for the relationship. This is a sad story that is reflective of how mental illness impacts a marriage, a career, parenting, and personal finances.

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When working with clients, I try to keep in mind the relational impact of mental illness in all its facets. Mental illnesses, like depression, affect the individual in every sphere of their life, including the social/relational. The above example illustrates how lonely the man felt, and how inexpressible his psychological and physical experience was to his wife. There were no words that existed in his mind or in their relationship for him to utilize. He and she were left in a wretched state of ambiguity. And despite her best efforts, she could not intimately access the depths of his depression. She, too, had no words. She couldn’t prevent feeling shut-out, as if she had been barred from his heart. Her dream was to feel unimaginable connection and joy at the birth of their child, but what she got was facing single-parenting while married.

Needless to say, there is a ripple effect of depression. The man’s relationship with his child will forever be changed. Certainly, it is within his grasp to foster a loving and connected relationship with his child, but he will have to do so with additional barriers due to the divorce, physical distance, child support, navigating co-parenting, and potential co-step parenting.

From my perspective as a clinician, problems are compounded when family and friends don’t understand the nature of mental illness, however, this is not always obvious to my clients and their loved ones. When trying their best to understand their loved one’s struggle, some may conclude that they aren’t trying hard enough, that they don’t care, or that they are seeking attention. Without information, without a sufficient explanation, bad interpretations fill the void, which only lead to judgment and alienation. As a clinician, I step into that void with accurate and compassion-filled information. My aim is to coach clients who are struggling with mental illness as well as their family members and explain that they may be tempted to personalize or create a negative attribution for their loved one’s behavior. It is tempting, natural, and understandable why they would do this, and yet, it is often a mistake in judgment. I try to explain that if their loved one had cancer, they wouldn’t take it personally or judge. Certainly they might have big feelings of sadness or anger at God or the universe, but there would be no assignment of blame to the diagnosed individual. They wouldn’t think, “Why did she choose to have cancer? They must want attention.” That would be absurd, and the vast majority of people would never think this.

So why would a wife, husband, partner, child, friend, or family member personalize a loved one’s depression, anxiety disorder, or phobia? I encourage my clients and their social network to make a genuine effort at understanding mental health disorders. It is natural to want to know as much as possible about a disease when a loved one may be diagnosed with a medical disease. As a clinician, I encourage clients to take that same impulse and learn as much as possible about their loved one’s mental health diagnoses. Ignorance only creates barriers to relationships, and my hope is to remove any barriers to social connection in my client’s way, as well as within their social network. A client is only as healthy as their community. Therefore, I want to empower clients to empower their communities, to mobilize those around them to seek out information and more deeply understand the psychological realities they are dealing with. And to find that middle ground of embracing the mental illness of your loved one but resisting the urge to define them by it.

***

Thinking back to my client mentioned earlier, I wonder how things would have been different if both the husband and wife had more awareness about depression. I wonder how the two of them may have pulled together, rather than apart, if they had known earlier on that the husband was being affected by a mental health disorder. If they had only had the words and concepts to understand not only the husband’s experience of depression, but also the relational impact that depression brought to their marriage and family. The wife was just as much a sufferer of depression as was the husband. This new understanding could have been a catalyst for collaboration, support, mutual understanding, and shared problem-solving.

Family Therapy in the Age of Zoom: What a Long Strange Trip It Has Been

Posted on by Psychotherapy.net Team

If there is no plan, nothing can go wrong
Kim Ki -Taek — Parasite

It’s not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.
Charles Darwin

It’s recycling day, can’t we just put the kids outside on the curb?
Parent — Pandemic, week five

Dude!…You’re Glitching!
Fourteen year old girl on Zoom session

Long Strange Trip

The pandemic has changed the larger world forever and will forever change the world of therapy. Our therapeutic ecology — how we practice our craft, where and with whom — will never be the same. It’s as if we’ve clicked into a science fiction show and can’t change the channel because we’re in it — clients and therapists have become talking heads, connecting as best we can and collectively feeling the fatigue attrition that accompanies the absence of being in person. The Grateful Dead were right: it’s been a long strange trip, especially for the empaths.

Michael is a single man in his thirties. He’s suffered a lifetime of painful shyness and being overweight. His job requires computer skills, so he spends most of his time in his cubicle, with little socialization on the phone or with co-workers. He’s described breaks and lunch as “torture.” Prior to lunch, he would get revved up with good intentions and then, he said, “I’m like Wile E. Coyote chasing the Roadrunner — I hit the wall.” One time, he got the gumption to attend a meet-up group for shy people, and no one showed. Yet, despite these challenges, he’s determined to be more social. Then, something happened. At our last Zoom therapy meeting, he was more confident and relaxed, like he’d just put on old slippers — smiling and even cracking jokes. For me, it was a kind of optimistic disorientation. At first, I thought that it was the combination of medication, his Wile E. Coyote resolve and hopefully some of the therapy that, like the British Baking Show, had produced a slice of Magic Pie. It wasn’t — it was the pandemic.

Because of “social distancing,” Michael paradoxically experienced being together with people while he was apart. Everyone now shared his life — now he could enter conversations with the knowledge that others also shared the taut, jangled wiring of his interior. It was as if he became an Italian apartment-dweller sheltering in place with his neighbors and singing together with them off their shared community of balconies, everyone listening with hearts joined in the absence of judgement and the voices of hope. Better still, because of the imposed distancing, Michael could now be safely social.

The Zoom Era

And what about therapists — what is this doing to us? Many are working from home. Those of us with children, pets or partners and who don’t have a home office have to find a “quiet space.” Ha! Good luck with that basement, people! Or, if we’re lucky and the landlord isn’t banning entry, we can go into our off-site office space — but that, too, has its own set of Zoomy consequences, not the least of which is “Zoom Fatigue.” By day’s end, sessions can feel like you’re in the front row at a lecture on sofa cushions where the speaker can see you. Just as you start to blissfully nod off, your head suddenly jerks back, and you snort loudly and say something weakly therapeutic like, “really..?” and then wipe the drool onto your sleeve — très embarrassing.

Zooming our client’s home space is not without merit. Back in the day when I was a probation officer in Cabin Creek, West Virginia, and then a social worker doing school evals, and then a research therapist on a project with heroin addicts and their families, I was blessed with being both witness and participant in the amazing diversity of the human condition. You learned to go with the flow and, you swam in the deep end of the family pool — dogs, cats, kids, babies, ferrets, frogs, multiple TV’s, radios blaring, grandparents, people who just showed up whom you didn’t know, dinner on the stove, or a silence that also spoke to you — all this before the age of the Internet. It was so powerful that when I first started my private practice, I would ask families to invite me to dinner and a family session at their home. “Now, we have Zoom — welcome to the shallow end. But we can all still learn to swim.”

You can observe a lot by watching.
Yogi Berra
Peter Lopez, a family therapist on the board of The Minuchin Center for the Family, is a home-based family therapist. On one of his Zoom visits, he wanted to speak to both parents and have an enactment with them that would increase the parent’s executive capacity and demonstrate to themselves and their kids that Mom and Dad were on the same page. In a moment of inspiration spurred by there not being enough headphones for everyone, he asked the parents to “move closer together so you can share…”

Another family therapist, a young woman who works with a diverse population of low-income families and mandated, substance-abusing high-risk teenagers, finds that being “in & not in” someone’s house can diminish her connection and, in some cases, embolden teens to challenge her — like the fifteen year old teenager who greeted her on FaceTime lying in his bed with his shirt off. “Would you do that in my office?!,” she asked, incredulous. “Uh, no, but I’m not in your office….” “Well, when we meet on Facetime, you are in my office!” And then, softer — “So when you put your shirt on we can start, and you can tell me how you’re doing.”

She still delineates the boundaries — for the kids she sees, her office is their safe space. To compensate for the in-person absence, she’s upped the amount of between-session “homework” that she and her clients then share at the next session. Trauma and disconnect are prevalent. A young girl being raised by her grandmother whose mother is absent provided a path in between sessions. Together they came up with an assignment to come to sessions with a weekly playlist of songs that emotionally spoke to the client. The girl picked “How Could You Leave Us?” by NF, which should come with a warning label and tissues — it’s remarkable.
We have to be inter-connected with everyone and everything.
Thich Nhat Hanh

You cannot solve a problem from the same level of consciousness that created it.
Albert Einstein

An informal survey asking therapists to describe their experience of practicing Zoom therapy in the pandemic seems to break into two distinct groups: one, maintaining a kind of Buddhist perspective of acceptance –— that life is suffering and impermanence in which every day is an opportunity to practice mindfully — to another, a bit less accepting — “I fucking hate it!”

A Third Way?

Which begs the question — is there a third way? The short answer is “Yes.” And it’s not without precedent. Einstein’s quote is like learning a brilliant escape trick from a gifted magician. The magic is not what is seen or said but in what he doesn’t say. What he omits is the specificity of consciousness — it does not have to be higher or lower, just different. And we therapists are all about being different. To be effective, we access different aspects of ourselves that then activate different and more adaptive aspects of our clients. It’s what Minuchin described as the “differential use of self.” If we want others to be different, then we have to be different. For systems thinking and for family therapy, in particular, those differences in thinking were already in the works well before the pandemic.

Lynn Hoffman pointed out in Foundations of Family Therapy (1981) that “the advent of the one-way screen, which clinicians and researchers have used since the 1950s to observe live family interviews, was analogous to the discovery of the telescope. Seeing differently made it possible to think differently.” And by circular extension, thinking differently also comes from acting differently.

Up until now, we’ve relied on our in-session felt experience, one-way mirrors and videotaping to guide ourselves as instruments of change. One recursive emotional and visual distinction between the now and the then of the one-way mirror’s transformative introduction, is that families could not see the people behind the glass, nor could the people behind the glass see themselves being seen. Videotaping sessions, however, offered a “third” answer, giving therapists the capacity of “seeing” themselves and the family’s patterns in context. It shined a light on how to experiment with adapting interventions systemically and collaboratively. While inventing Structural Family Therapy, for example, Minuchin, Jay Haley and Braulio Montalvo invited family members behind the mirror. They recognized cultural and class differences between themselves and the “natural healers” from the minority community that they were training to be therapists. Minuchin realized that “in order to join, we needed to change.”

“With Zoom however, there is a binding irony that holds therapists and clients in its’ grasp. It is as if we share front row seats watching a mystery play”. The opening scene’s roiling dense fog and dim lights mask the fullness of detail, so we squint, holding our breath hoping to see what’s really there. We’re doing our parasympathetic best to figure out the plot. It’s the work of it that fatigues us and leaves us wondering if this is as good as it gets.

Therapy is therapy as therapy does, but how we use ourselves in this new environment re-boots an age-old clinical question; what exactly is both necessary and sufficient to produce change? Montalvo called the position from which we work “The possibilistic premise.” Meaning that regardless of the location of the family’s pain, we are still faced with respectfully challenging the system’s homeostatic “stuckness.” We know that we can effect those changes in person. When Zooming, however, it can sometimes feel as if we’re “Major Tom,” floating in space, attempting to weld the hull as we circle the earth.

So, as Bowlby, Susan Johnson, the Gottmans and our own families have shown us, the quality and kind of our earthly and relational attachments are important. While we may feel even more like Russian Dolls, breathlessly stacked within each other’s context and the context of the world writ large, it’s not a question of “if” we adapt and attach in different ways, it’s more a matter of “How?” Perhaps as Theodore Reik suggested, we should listen with greater clarity, not just with a “Third Ear,” but now with ear buds. We are finding ways to compensate for what’s lost with diminished sight and the absence of physical presence. Our adaptive make-up is yielding results. However because we are inherently empaths, we feel the absence of presence. But we shouldn’t feel bad entirely. Rumi’s poem, “Love Dogs,” reminds that “the howling necessity” implores us to “cry out in your weakness,” such that “the grief you cry out from, draws you toward union.”
It’s the end of the world as we know it, and I feel fine.
R.E.M.

Postscript from the Bunker

After not seeing our granddaughters at our house for eleven weeks, my wife and I share a grandparental Folie à Deux — an ache like an old injury that we’d come to accept, now reawakened with every primitively crayoned coloring book that hung on our walls like an in-home Children’s Louvre. As grandparents of a certain age, now when my wife and I see all their stuffed animals in a pile, we silently share the Buddhist themes of impermanence and suffering. It feels like a Christmas Story staging of Toy Story — our precious time together is ghosted in front of us as a reminder to our mortal selves that “this is it.” This perfect time of their lives, full of wonder and imagination, is just another pandemic curtain closing on the “Duck Duck Goose” show. Now our own mortality is awaiting, as quiet mourners do when “joining” family and friends on a Zoom funeral.
Alone together.
Dave Mason

Then there’s this — amidst all the noise, people find themselves and others. I see a recovering alcoholic/substance abuser in his thirties. He’s been in recovery for seven years. He has a great sponsor and a solid home group. As the pandemic continued, he began to miss the in-person connection with his group and his sponsor. So last week, with the intent of doing “Step work,” he and his sponsor sat safely apart on his sponsor’s back porch. As night began to fall, he said that without any cues, they both simultaneously became silent and quietly surveyed the backyard as darkness fell. He said it was one of the best conversations that he’d ever had.

Like the scene from Little Miss Sunshine, when on their way to the “Little Miss Sunshine” contest, Dwayne flips out after finding out that his color blindness has just destroyed his dream of joining the Air Force, getting away from the “fucking losers” that constitute his family and having a life of his own. He’s profanely inconsolable. His mother says, “I don’t know what to do!” Then his stepfather says to Olive, “Olive, do you want to try talking to him?” Without a word or hesitation, Olive gingerly makes her way down the embankment, ignoring the dust scuffing up her red cowboy boots, and squats down next to her big brother. She puts her arm around Dwayne, leaning her head onto his shoulder. She doesn’t say a word. They both sit together as one in the silence. Quietly, as if whispering a confession, Dwayne says, “O.K., I’ll go.” He then helps Olive up the hill and says to his family, “I apologize for the things that I said, I didn’t mean them.” They load in the van and continue on.

“Off in the distance is a billboard, the message faded but visible, “United We Stand.” We can hope”.

The Performing Art of Therapy: Acting Insights and Techniques for Clinicians

Posted on by Psychotherapy.net Team

“Where does the actor acquire the understanding that for the doctor takes years of study?"
-Theater Director, Peter Brook

Act I: Therapists as Performers

Therapist, you are a performing artist, whether you realize it or not!

The moment a client enters your office, you are on stage, face-to-face with an audience, a scene partner, and a variety of characters you do not yet know how to play (after all, our clients both become and cast us in all of these roles faster than we can say, “How can I help you?”). And every move you make—or don’t make—influences the treatment, the play, the story you tell together.

“Like actors, as therapists our appearance, aura, voice, and relational responsiveness often leave stronger impressions on clients than the words we say or the techniques we use”. This is not to say that our clinical training is of no use; of course it is. But effective technique is less about what we do—less about reading a script by rote—and more about how we do it, how we use ourselves, how we perform our interventions.

When you watch actors performing in movies or plays, do you think about their techniques?—whether they used Strasberg, Adler, or Meisner? Probably not. You are more likely moved by the performers themselves—their ineffable presence, their use of self. Likewise, our clients are more affected by us than by our schools of thought—whether we studied psychoanalysis, CBT, or family systems.

No matter what kind of therapist you are, if you approach your work like an actor—or better yet, like a performing artist in your own right—I promise you will become more awake, alive, and engaged with your clients, while also having a greater capacity to care for yourself. I offer this promise as a psychotherapist who has used my experience as a trained, professional actor every day.

The skeptical reader may think that the words “perform” and “act” don’t belong in the therapy office. When I tell people that I use my training and experience as an actor more than any other resource as a therapist, they often take me to mean either that I’m “fake” with my clients, or that I deploy literal dramatic exercises in session. I’m not (or at least I try not to be) fake with my clients, and I rarely, if ever, use theatrical interventions in session, unless I believe they might be useful for a specific client in a specific moment. However, when I simply think about my clients the way actors think about their characters and scene partners, I enhance my capacity to dive into the deep end of their stories, beyond the words they speak—their “scripts”—even when I do nothing more than listen to them compassionately.

I may not end up doing anything radically different in session from what any other clinician might do instinctively. But by thinking of myself as a performing artist, as opposed to just a clinician, I find creative ways to join my clients in their emotional subjectivity, relate to them like a character who can help them grow, and allow myself to expand personally in the process.

Again, to be clear: “Acting” does not mean being fake, it means finding truth within a given set of circumstances. So, in that sense, “as therapists we are all actors: we use our selves (our primary instrument) to help bring other people’s authentic selves to life”.

Below is a pair of vignettes, each including a significant learning moment for me as an actor, and a corresponding revelation as a therapist. These dramatic/therapeutic narratives, illustrate how my use of self helped me to pursue the three main objectives that apply to the creative process of both artforms:

  1. To create a treatment frame in which our scene partners feel safe, oriented to the nature and purpose of our work, and free to participate in it.
  2. To join our clients in their emotional subjectivity, like actors embody their characters.
  3. To relate to our scene partners as a character who can help them to heal and to grow.

Act II: Using My Self as an Actor

I was 20 when I was cast as the gun-obsessed Quigley in Hyperactive, an edgy play about teen angst by Olga Humphrey. Quigley was described as a “masculine, hard-edged” adolescent, whose favorite magazine was Soldier of Fortune. I was an effeminate, soft-natured man, whose favorite magazine was Entertainment Weekly—in other words, nothing like Quigley. But I was also an actor, and as an actor’s my job is to find diverse characters within myself, even if they seem very different from me on the surface.

Other than having a teenager’s build, the only quality I seemed to share with Quigley was the determination to prove my worth. In my case, proving myself not only meant getting hired, which I did, but also finding some genuine version of this unlikely role within me. My greatest challenge was to make an empathic connection with Quigley’s bullish personality, his gratuitous language, and (most difficult of all) his obsessive, violent fantasies. All these qualities—or symptoms, if you will—made me extremely uncomfortable and seemed to alienate me from him, rather than to invite me into his emotional world.

My first task was to create a framework for my rehearsal process, within which I would have room to discover and explore who this person was, through trial and error—ideally without judging him. Rather than begin with preconceived acting choices for Quigley—much like therapists are often tempted to impose treatment interventions onto new clients—I needed to find a way to let him speak to me on his own terms. And since my head could not make sense of this boy, I had to find a way to access him viscerally—using my body, voice, and imagination.

As I began reading his crude and aggressive lines aloud at our first rehearsal, I imagined I was one of the bullies from my own high school past. I widened my legs, puffed out my chest, and spoke with an affected tough-guy bellow, straining to produce the intimidating, nasty persona adopted by so many males from my youth.

The result was what the kids call a “fail!” “My performance was cartoonish and over the top”; I’d created a caricature, not a human being. “Um, that’s a bit much,” my director said, with a penetrating squint of disdain in her eyes. Humiliation flooded my body and shut down my spirit. My effortful impersonation seemed to expose my limitations as both an actor and a man. I wouldn’t need to try so hard if I was actually talented or masculine enough, I thought to myself, further shamed by my inner critic.

But in the same moment, a window opened for me into Quigley’s inner, subjective life. I had unwittingly, but effectively, joined him in his debilitating self-consciousness, vulnerability, fear, loneliness—and self-hatred. His core intention wasn’t to intimidate and destroy other people, I realized. Those behaviors were secondary to his primary objective: to protect himself, validate himself, survive.

With those visceral motivations living in my body and mind, I could commit to Quigley’s macho expressions while maintaining an underlying sense of vulnerable truth. And as I played with this duality—grounded in my own fear of failure, and my instinct to overcompensate for it—I increasingly understood how he/I was motivated by a desperate need to be validated by other people. I could now bring a genuine version of him (and me) into the rehearsal studio with my scene partners, supported by the technical breathing and vocal exercises, as well as mind/body practices I had developed in drama school. (Again: the creative use of oneself is not a replacement for technique, but rather it informs the performer of what specific moves we need to make at any given moment in our scene work.)

By the time the production was on its feet, I was able to embody Quigley without extraneous effort: from his brusque introduction to his cathartic end, in which his mother and best friend hold him in their arms and thwart him from carrying out a violent attack on his classmates. Actors often try to force emotion and tears in high-stakes moments like this—not unlike therapists when we impose heavy-handed clinical interventions onto challenging clients we want to “fix.” As my actor friends say, we often try to “play the end of the scene” too hastily, rather than allow ourselves to be present in every step of the journey.

But I didn’t have to strain myself to find Quigley’s deep-rooted pain for this scene. All I had to do was surrender my feelings to my scene partners, with whom I’d cultivated a great deal of safety and trust throughout our creative collaboration. As we performed the climax of the play, Quigley’s taut energy thawed from my jaw, neck, and shoulders—where it had been deployed as a shield—and it dispersed throughout my body, accessing a range of other emotions. In fact, at one point I awakened to the insight that all along Quigley had been defending against, and overcompensating for, the absence of his father. It’s an abstract clinical exercise to analyze a data point like this about a person’s life, either in a script or a psychological evaluation. “But when we make efforts to join that person in all their subjective bodily, emotional, and intrapsychic complexity, we expand our capacities for empathy”, mutual recognition and creative transformative action, both on and offstage, in and out of therapy. Best of all, we learn to relate to that other person (character or client), no longer through the trailing edge of their transference, as the recipient of their resentment, frustration and fear, but through the leading edge of their transference—as the embodiment of their generative desire, longing, and hope.

Act III: Using My Self as a Therapist

Harry burst into my office each week like he was in a race against time; he wanted answers, and he wanted them fast. A straight, white, corporate millennial, he was used to instant gratification, and he expected no less from his therapy. He emphasized that he already understood himself “extremely well,” and that all he needed from me were “professional tips” to reduce stress in his highly successful life.

I was flattered; I’d been cast in the role of commercial guru, the kind who might dominate the American market with bestselling, confidence-inspiring catchphrases. Except I felt too slow, discursive, and insecure to play this part for Harry, more the man behind the curtain than the great and powerful Wizard of Oz. Each week, I expected him to look at me incredulously—much as I’d feared audiences would respond to me portraying a butch, gun-wielding teen—and see that my training and degrees were all a sham. I anticipated the day he’d tear back the curtain and expose me as the talentless hack I felt myself to be in his presence.

On the plus side, Harry showed up for our weekly “rehearsals” consistently, which spoke to the frame I had provided, which apparently made him feel safe enough to “play” with me. But each scene between us had a palpable yet indiscernible tension. First, he’d summarize his week, speedily and with the energetic poise of a cocky movie star—shoulders back, chest protruding forward, eyes sparkly with intense self-assurance. Then he’d present a dilemma—“I need to make more time for relaxation and balance,” for example. At this point, he’d look to me as if to indicate it was my turn to perform, and to prove I was a worthy scene partner.

I would then try to seize the spotlight, so to speak, masking my self-conscious insecurity with a commanding delivery of a line like, “I recommend yoga, three times a week. Put it in your calendar.” I was desperately trying to personify the omnipotent coach I imagined he wanted me to be. And though my “acting choice” arguably answered Harry by his own method, it felt as though I was trying way too hard to impress him—much as I had overcompensated in my bullish portrayal of Quigley, as I stumbled through my first few rehearsals of Hyperactive.

Eventually, I’d look back on these moments and realize how all these unnerving sensations could help tune me in to Harry’s complex internal world, and to join him there. But in the meantime, I felt blocked, like a superficial actor who failed to connect with his character on a deep personal level.

Over time, it became abundantly clear that Harry couldn’t be bothered with my attempted interventions. He’d wince disapprovingly at my suggestions and say things like, “Yoga never works for me. I just end up obsessing about the more productive things I could be doing with my time.” At the end of our sessions, “he’d stride out of my office with a proud posture, leaving me behind to reel in a slouch of inadequacy”. I couldn’t seem to reach him, no matter how hard I tried. I felt like the FBI agent Tom Hanks played in the movie Catch Me If You Can, endlessly chasing Leonardo DiCaprio’s slick and wily character, a master of escape.

This frustrating dynamic manifested in a number of ways between us, including our weekly schedule. Harry would frequently ask to alter our meeting times due to his ever-changing obligations, and I’d accommodate him more than I wanted. I did this because I was afraid to disappoint him. Not only did I sense he’d fire me if I didn’t manage to keep up with his demands, but more significantly, I had an inexplicable sense of dread that he’d erase me from his mind entirely if I let him down. Unwittingly, I was tuning in to Harry’s inner life. I could feel his deep ambivalence about trusting and depending on people vibrating within my own body. And as it turned out, my fears were not unfounded.

One day, after two years of working together, Harry raised the emotional stakes of our scene work. I was running behind (by about a minute), between notes and phone calls, and he had no intention of waiting; it was his time, and he’d enter my office if he wanted to. I was completely shaken off-center as he blasted through my door. Within the flicker of a second, my face flushed with a combination of shock and shame, but also disapproval and a smidge of anger.

As we made eye contact, Harry stopped in his tracks—and his reaction to me was startlingly evocative. While his body asserted its typical conviction, his eyes betrayed a doubt, fear, and deference that I’d never consciously sensed from him before. Since I was too caught off-guard to address this novel improvisation between us in the moment, Harry made a beeline for the couch and shared his latest dilemma as if nothing had happened.

The latest dilemma, it turned out, was that his long-term girlfriend, of whom he’d always spoken glowingly, had proposed to him. “It came out of nowhere!” he exclaimed wide-eyed. “I was totally thrown off my game. Shaken.” Hmm, like what just happened to me now? I thought to myself. “We’ve talked about getting engaged for a while,” he continued, “but I just thought when it happened, it’d be…different.”

“You mean you thought you would be the one who proposed?” I asked.

“Well, yeah,” he replied. “I mean, not because of gender roles and tradition and all that. It’s just…I would’ve made sure it was perfect.”

“What would you have done differently?” I asked.

His eyes squinted as he struggled for an answer. “I guess I just wish she…” he paused for a while, “seemed surer of herself?” As we talked, he realized that this proposal had surfaced an implicit contract in their relationship: that he was in charge of their major decisions as a couple. His girlfriend had gone out on a limb and broken that contract—and now Harry was struggling to understand why he didn’t feel safe following her lead.

Uncharacteristically, his body sank back into the couch as he stared blankly in silence for a while. Finally, he spoke again: “Maybe she’s not the right partner for me.” There it was, the confirmation of my underlying fear; if his long-term girlfriend was expendable, so was I.

“It’s normal to feel a range of emotions at a pivotal time like this,” I said in an effort to validate him. “I appreciate your confusion and doubt, and since your girlfriend seems willing to give you some time to reflect, I suggest we continue talking before you make any big decisions.” He seemed momentarily held by this, but as I watched him take a minute to shield himself with his typical smug poise before leaving the office, I understood deep inside that this sense of security was tenuous, for both of us.

“Harry colonized my mind for the rest of that day, much like a challenging character might consume me as an actor”. At home, I looked in the mirror and tried to emulate his self-possessed posture. As my shoulders dropped back and down, my chest expanded, and my eyes and mouth affected Harry’s cool-guy charm, I began to recall the unpleasant sensations I’d get when trying to play the part of his expert guru. The external posturing I would affect at those times didn’t feel grounded in confidence, but instead seemed to serve as a shield to my internal self-doubt and fear of rejection.

Suddenly, I understood that the same was true for him. The look on his face when he’d barged into my office earlier that day, and the months and months of tension between us, began to make more sense. And as I joined his mind/body experience of self, I realized that what he really wanted was not for me to catch up to him or project the same overcompensating confidence that he did, but to get ahead of him. He longed for me to become someone who could set boundaries with him, disagree with him, and ultimately, care for him—without getting caught up in the same debilitating self-criticism that plagued him. But how could I successfully embody these qualities in the therapy room, and become the character with whom Harry longed to relate?

I thought about the end of Catch Me If You Can, when Tom Hanks learns to approach Leonardo DiCaprio no longer as an elusive fugitive, but as a boy abandoned by his father. I thought also of Harry’s father, who’d died suddenly of a heart attack when Harry was a child. Gazing in the mirror and focusing on the sensations within, I rediscovered what I had first learned with Quigley: biographical details about clients and characters alike resonate within us much more richly when we embody them, rather than simply study or analyze them. I then shifted roles and explored ways that I could present myself to Harry that might make him feel safely held.

I drew inspiration from men, in my life and onscreen, who were both palpably strong and nurturing, including Tom Hanks, Robin Williams, and Barack Obama. I considered their physical groundedness, the clarity of their thoughts, as evidenced by the easy poise of their heads, but also, most significantly, their emotional openness, illustrated by the lack of tension and flow of energy in their chest region.

As I played with where I felt these qualities in my own body, I didn’t try to impersonate the men superficially, but to connect with the experiences in my life—like caring for my younger brothers when I was growing up and being a camp counsellor—that brought out the warmth and confidence Harry needed from me now.

“When Harry next raced into my office, I was prepared to get ahead of him, and relate to him with focus, calm, and an embodied sense of security”. As we revisited the previous session, I validated his anxieties about depending on his girlfriend (or any intimate “scene partner” in his life) and invited him to talk about the pressure he puts on himself to “be ahead” of other people, including me.

Throughout this session, there was more ease, vulnerability, and play between us than ever before. But it wasn’t what I said, so much as how I’d learned to be in the room with him, that made the difference. I was even able to recommend self-care activities like yoga, which he’d rejected in the past, in a way that he now responded to with complete openness—in theater terms, same script, better performance.

As Harry exited that day, he turned around in the doorway, took a moment, and then said through the shimmer of a tear, “Thank you.” I simply smiled in return, maintaining the combination of groundedness, strength, warmth, and vulnerability that we’d discovered together in our session.

Finale

While I waited for my next client, alone in my office, I reflected on the connection Harry and I had found, and I recalled an interview with Meryl Streep, in which she explained that in her view, her success as a performer was only as good as it was “the last time.” Thinking of our sessions ahead, I knew we could expect more tension, insecurity, fear, and doubt to manifest between us. But at the same time, I knew my acting training could help me perform on this different kind of stage, where we’d continue to explore various versions of ourselves together.

I initially felt I needed to be someone else in order to access both Quigley and Harry. Like so many actors and therapists, I am driven by the desire to please my collaborators, to be the “expert,” and to “get it right” on the first line reading. But at the same time, in order to connect with our clients, characters, and scene partners as performing artists, we must practice our craft with humility, patience, and the belief that we are enough. We must trust that if we show up to each “rehearsal” with the willingness to be fully present—along with our vulnerabilities, naivete, and deep self-reflection—we will give our creative partners what they need to be present with us as well. Especially if we engage each other in a process of imaginative, empathic play.

Through our respective play sessions, Quigley and Harry both showed me that their apparent toughness, butchness, and self-containment were part of me as well—keys existing somewhere within my instrument, even if I don’t embody them every day. But an even greater revelation for me in both cases, was that the idiosyncratic “soft” qualities that makeup my everyday self—and that I originally believed were obstacles to bringing both young men into the spotlight—turned out to be exactly what they needed to find hidden keys within their own instruments. By playing these untapped versions of ourselves—even, and perhaps especially, when we felt inadequate—each of us found a way to breathe, to integrate, and to become more fully alive.

Note: This article has been adapted from Mark O’Connell’s new book, The Performing Art of Therapy: Acting Insights and Techniques for Clinicians, and his article “Character Work: What Therapists Can Learn from Actors,” in the Psychotherapy Networker, March/April 2019 issue. 

Louis Cozolino on the Integration of Neuroscience into Psychotherapy—and its Limitations

Posted on by rezendevknowfully.com

Neuroscience or Neuro-psychobabble?

Sudhanva Rajagopal: Lou Cozolino, you are a psychologist and professor of psychology at Pepperdine University, where you were a teacher of mine. You’re a prolific writer and researcher on topics ranging from schizophrenia, child abuse, the long-term effects of stress, and, more recently, neuroscience in psychotherapy and the brain as a social organ.As a clinician in training, it seems like there is a lot of neuroscience talk out there in our field, and it gets used to legitimize anything from specific interventions to whole theoretical orientations. My first question to you is, for the clinician in training, how do you recommend that we see through the noise of all that to what is actually helpful in the room with a client? How does knowledge of neuroscience play out in the room and what is actually important for the clinician to know?

Louis Cozolino: There are two main realms where neuroscience can aid clinicians. One is case conceptualization and the other is for clients who aren’t really open to a psychotherapeutic framework or an emotional framework. For them a neuroscientific explanation or conceptualization of their problem is often something they can grasp while they can’t or won’t grasp other things.

People who learn a half a dozen words about neuroscience think they’re neuroscience literate.

But there’s so much psychobabble and neuro-psychobabble out there, and the thing is if you say something is the amygdala as opposed to saying it’s anxiety or fear-based, you haven’t really upgraded the quality of the discourse. You just substituted one word for another. So the risk is that people who learn a half a dozen words about neuroscience think they’re neuroscience literate.

Learning neuroscience takes dedication. It takes work to get beyond the cocktail level of conversation and clichés. It took me ten years to feel like I had any sense of what was going on and I studied it pretty intensively. So I think we all have to be careful, but even more importantly, just because you know some neuroscience doesn’t mean you know anything more than the therapist who doesn’t. It’s really about how you use that information to upgrade the quality of the work you’re doing.

SR: In your book, Why Therapy Works: Using Your Mind to Change Your Brain, you say that science in many ways is just another metaphor. Do you think there are dangers to people using neuroscience to legitimize their work?
LC: Well, sure. There’s a fellow, Daniel Amen, who does these SPECT scans of people and he’s been selling them for thousands of dollars for probably 20 years now. It’s hard to know whether any of his data has any meaning. All we know is he’s made a hell of a lot of money doing them. The danger is in selling things before you know that they have any legitimacy, so you have to watch out for snake oil salesmen just like you do when you’re buying carpets and used cars.
SR: So how do you recommend that someone like me goes about finding and learning about neuroscience in a way that’s helpful? How do I avoid the snake oil salesmen?
LC: It’s important to realize that knowing neuroscience doesn’t make you a good clinician—in fact it doesn’t make you any kind of clinician at all. So I would say for beginning therapists, it’s probably best not to pay too much attention to neuroscience.Learn a few things about it but focus on getting the best supervision you can in a recognized form of psychotherapy—psychodynamic, cognitive, behavioral, family systems, etc. And avoid the passing fancy of all of the new therapies; every day there’s a new therapy with a new set of letters in front of it.

SR: Yeah there are so many different kinds of therapies these days.
LC: Try to learn something that isn’t just a fad, because the fads—I’ve watched hundreds of them come and go over my years. But if you cleave to psychodynamic training and cleave to cognitive behavioral, Gestalt, family systems training—those are the things that you can hang your hat on. Then you can learn the fads to add to your tool box. The fads are very sexy and they create the illusion of understanding because they’ve got fancy terms and nice workbooks and such, but really you’re not a thinker when you’re doing those things, you’re more of a mechanic.Now neuroscience is sort of like a sidecar to conceptualization, but you’ve got to remember the motorcycle is the real tried and true way of thinking about clients. You know, what is a particular problem? What is mental distress or mental illness? Where does it come from developmentally and what are the tried and true ways of approaching it and treating it?

Every Therapy is Embedded in Culture

SR: Speaking of tried and true ways of thinking, you say in your book, “Psychotherapy is not a modern invention, but a relationship-based learning environment grounded in the history of our social brains. Thus the roots of psychotherapy go back to mother-child bonding, attachment to family and friends, and the guidance of wise elders.” My question is, where do you think psychotherapy fits in to the context of healing traditions that have been around for millennia?
LC: Well, I think one thing that seems to be different over the last hundred years in psychotherapy is a kind of structured recognition of the fact that the therapist is imperfect and contributes in a lot of different ways to the problems. The tradition of wise elders was one of an authoritarian stance: This is the truth and I’ll take you on this journey with me to change you into my likeness. To whatever degree psychotherapy has evolved past that has to do with the self-analysis of the therapist and the recognition that whatever pathology exists in the relationship between client and therapist, some—hopefully not the majority, but some—pathology in the relationship comes from the therapist.That type of recognition is a step forward. There are probably some steps backward too. Often psychotherapy is ahistorical and acultural—or at least tries to be—but every therapy is embedded in culture. There is a kind of pretense about an objective scientific stance that is just a fantasy. So in some ways, wise elders in a tribal context with a long history are probably advantageous for some people as compared to psychotherapy.

SR: I was flipping through the index of your book and noticed the word “culture” appears exactly once, though you do talk about the wisdom of the ancients, about Buddhism and Confucianism and some of the Indian traditions. Seems to me that once we start relying on these kind of generalized, evolutionary, and biological forces as explanations for things, there’s a risk of painting people’s lived experience with a pretty broad brush. What’s your take on the importance of culture as it relates to neuroscience and psychotherapy?
LC: From an evolutionary perspective, a basic principle is biodiversity, and culture is too blunt an instrument to understand people because there are so many differences within culture. I think in terms of every individual being an experiment of nature. Every family is a culture in and of itself, and the more different someone’s cultural background is from mine, the more there is for me to learn. I think that culture needs to be interwoven into every sentence of every book, not just included in some special chapter of a book.
SR: From my point of view, many of these older cultural practices have been repackaged and rebranded as psychotherapy theories and techniques. The “mindfulness revolution” and transcendental meditation are based on ancient cultural traditions, but they are marketed as if they are especially effective because they are “new” and “evidence-based.” What is your stance on that?
LC: Having studied religion and philosophy and Sanskrit starting back when I was in college in the 70s, the self-awareness of meditation has been part my worldview since long before it became a cottage industry. But even back then there was the Maharishi Mahesh Yogi and the Beatles, and it was coming into the cultural context. Now people have figured out how to package it as a way to sell more therapy, which isn’t all bad, but runs the risk of becoming “the answer.”

I think we’re in a race between global destruction and global consciousness, so we’ll see who gets to the finish line first.

What I’ve been hoping for since I first discovered Buddhism in the 1960s, is that as the world gets smaller and as people from different cultures communicate more, the wisdom of the ancient Eastern philosophies will be interwoven with Western technology and we’ll come to some higher level synthesis of understanding and consciousness. I think we’re in a race between global destruction and global consciousness, so we’ll see who gets to the finish line first.

SR: Can you say more about that?
LC: Well, it’s a slow evolutionary process for the types of awareness that people four or five thousand years ago discovered in India and Tibet, in China, in Japan, to penetrate Western culture. The Western world view is so different—for so many people it’s almost impossible to conceptualize an internal world; everything is external. Everything is about creation, growth, and, in a more destructive sense, conquering and genocide.So there are forces of destruction—of each other and of the planet—on the one hand and then there are the forces of consciousness and wholeness and a sense of oneness of the species on the other. So will we understand that we’re all brothers and sisters on a spaceship before we destroy the spaceship?

“There only needs to be a piece of you that’s a psychologist”

SR: How can psychotherapy play a positive role in this race you’re talking about? Or psychotherapy as we know it in the Western world?
LC: Well, one of the problems with psychotherapy as I see it is that psychotherapists tend to be sort of passive—they retreat from the world of leadership and create very insulated relationships in their consulting rooms. But for the field of psychotherapy to have any impact, it has to be expressed politically and socially. The types of ideas and theories that we’ve researched and studied, like the importance of early child rearing, self-awareness, authoritarian personalities, positive psychology and so much else, need to become part of political discourse both to elevate it and also have an impact on how resources are distributed.

One of the problems with psychotherapy as I see it is that psychotherapists tend to be sort of passive—they retreat from the world of leadership and create very insulated relationships in their consulting rooms.

Evolution is a slow, meandering process. All you have to do is watch the Republican debates to see that. It reminds me of junior high school in the Bronx in New York where we used to engage in chop fights, which was all about humiliating the manhood of other guys just to get a one-up. It doesn’t make me optimistic about the evolution of consciousness, but we’ll see what happens.

SR: I want to move onto something you said in your preface that I liked a lot: “Like monks and soldiers, therapists of all denominations assume that God is on their side.” What do you think are the limitations of psychotherapy and where does it come up short against the human condition, cultural walls or seemingly immovable, systemic injustice? In other words, when do we have to admit that psychotherapy is just not helpful or effective?

LC: The risk with psychology and psychotherapy is that it can lean too much in the direction of helping people tolerate rather than fight against oppression. Self-awareness and self-compassion are crucial experiences and skills that we foster as psychotherapists, but there needs to be a balance there. You can’t become too much of a psychologist. There only needs to be a piece of you that’s a psychologist and there’s another piece of you that has to be willing to go out and fight for systemic change.

As I said before, psychologists tend to watch from the sidelines, and that’s why as a field it has relatively little impact. In fact, the profession gets a lot of bad press because there are plenty of famous psychologists who do staggeringly immoral and unethical things. They are the basis of the cartoon version of the therapist nodding their head and going, “uh huh.”

SR: You talk about psychology as being an essentially solitary profession. Are there people you can think of who aren’t standing on the sidelines?
LC: Psychologists you mean?
SR: Yeah, psychologists.
LC: No. Can you?
SR: Not off the top of my head.
LC: Psychologists are really good at telling other people they should do something. It’s sort of like life by proxy.
SR: Indeed.
LC: Another problem in psychotherapy is a lack of appreciation or respect for anger; anger is always something you’re supposed to manage. Or you’re supposed to learn how to behave appropriately in society, but that’s not always an appropriate response, especially if you’re a member of an oppressed group. It’s really important sometimes to go on picket lines and carry bricks and defend yourself and make a lot of noise.I very much respect the Black Lives Matter movement and I watch them in these Trump rallies, and they’re getting pushed around. It breaks my heart because it reminds me of a lot of bad memories from childhood during the Civil Rights Movement. And I’m sure you’ve seen pictures too of what happened in India with the British, of people being hosed and slaughtered. There’s a tendency in human behavior to objectify differences and we really need to fight against and not tolerate that. I’m hoping that, given that Trump is consolidating and activating the anger of people in this culture against immigrants and foreigners and God knows what else, that it also energizes the liberal base and brings out a new progressive movement as well.

SR: Absolutely, but this idea of psychologists carrying bricks and taking up arms seems really at odds to me with this image we have of psychologists as dispassionate observers, people who are sitting in their therapy chairs saying, “uh huh.”My interests lie in political action as well and I do remember, at least from my dad’s generation and my grandfather’s generation, thinking about British rule and the independence movement in India and the idea of people really taking a stand. But that doesn’t seem like something psychologists really do. Even in the room with a client, we’re not taught to take a stance on things, you know?

LC: In fact it’s the opposite. Everything that we believe is interpreted as countertransference and non-neutral. It creates a real rift in people. It’s hard to imagine that a lot of younger psychologists with any sort of a political drive would be attracted to psychology. It will continue to attract people who want to stay on the sidelines in the world or avoid the conflict.
SR: How is that going to change?
LC: In truth I don’t know. In the 60s we had something called community psychology, which was very radical at the time and which still exists, but it’s not prominent at all anymore. One of the main focuses of community psychology was to identify those people in the community or in the tribe that other people went to for assistance—people like hairdressers and bartenders and cab drivers. These are the people that folks in trouble tended to talk to, so community psychology emphasized educating people in the community that were sort of hubs of interaction. The field has gotten so much more insular since then.

Transitioning From a Beta to an Alpha

SR: I want to go back to something you said about anger that intrigued me. I’m just thinking back to discussions and supervision I’ve had in training, and whenever anger comes up, you’re told there’s something “behind” the anger. You know, there’s shame behind the anger, or sadness behind the anger. How do you feel about anger as just a primary kind of emotion? And do you think it has value both for the therapist and for the client?
LC: If you’re going to become empowered, if you’re going to transition from a beta to an alpha in your life, you really need to be able to get back in touch with your anger because it can be very propulsive, very helpful in life. It evolved along with caretaking and nurturing because it’s not just necessary to feed and nurture babies, but to protect them.Anger is the only left-hemisphere emotion that we consider negative, but anger is a social emotion, unlike rage. It can be engaging, relational, constructive. In order to combat the social programming that leads to shame, we have to get at least somewhat angry—at both the voices in our head and out in the world that shame us, disempower us, keep us from speaking up.

When I think of somebody like Gandhi or Martin Luther King, Jr., I think of the courage it took to walk into angry crowds. It’s so moving to me and such a powerful act. We can’t just be passive about these voices in our head and in society. We have to get angry because our anger and our assertiveness and our power are all interconnected. If you give up your anger, you give up your power.

SR: Agreed. Tell me a little bit about your idea of the social synapse.
LC: The more I studied different physiologies, social psychologies, organisms, the more I realized that there is a very complex highway of information that connects us via pupil dilation and facial expression and body posture and tone of voice, and probably a hundred things that we haven’t even discovered yet.What we’re doing in psychotherapy, and in any relationship where we’re trying to be soothing and supportive and nurturant, is connecting across the synapse between you and someone else. You’re trying to create a synergy between the two of you and have an effect on their internal biochemistry that enhances their physical health, their brain development, their learning. If you’ve ever been with a really good teacher, you know that in part because you feel a lot smarter because you’re connecting with someone who’s stimulating your brain to work better. If you’re with a bad teacher, you feel dumber, and you get pissed off and angry. And there are not a lot of good teachers out there so you’ve got to cleave to the good ones.

But also there’s a different chemistry between different people. Someone who’s a good teacher for one person may not be a good one for another. Same thing with therapists. Every therapeutic relationship creates a new organism—a dyadic field— and sometimes it works and sometimes it doesn’t. The chemistry part we often don’t have any control over.

SR: Going back to the brain and neuroscience, where do you think we are in right now in the field and where are we headed?
LC: Well, we’re all over the place in brain science, but there is a great deal of focus right now on genetics. In other words, looking at the relationship between experience and interactions and how the molecular level of the brain gets constructed and changes over time in relation to the others and the environment. I think that the translation of parenting and relationships in psychotherapy into actual protein synthesis and brain building is an incredibly complicated but very important paradigm shift that is going to be playing out probably over the next century at least as we uncover those things.Another shift in neuroscience is getting past the phrenology of looking at individual brain regions related to specific tasks and starting to look at these new technologies that measure brain connectivity. In other words, how do different areas connect to regulate each other and synergize? The next step will be figuring out how two or more brains interact and stimulate each other.

I don’t know where the technology to research that is going to come from but I think it’s on the horizon. We’ve got to get beyond thinking about brains as individual organs and think about how they weave into relational matrices so we can understand human connection and have a scientific view for the types of things that Buddhists and Hindu meditators and Tibetan scholars have been thinking about for the last several thousand years or so.

Why Does Neuroscience Matter?

SR: How would you explain to an existential psychotherapist why these advances in technology and in brain science are at all important to what they do?
LC: I don’t know if they are important to what they do. I don’t think neuroscience is more important than Buddhism—it’s basically just another narrative.
SR: Interesting.
LC: It’s just another way of looking at things. Think about when you’re at a museum looking at an exhibit and you’re walking around it trying to experience it and appreciate it from a number of different angles.That’s pretty much what reality is. We walk around it and we have these different ways of thinking about it and explaining it that are partially satisfying and partially unsatisfying. Buddhism is incredibly satisfying a lot of the time and very unsatisfying some of the time. So when you get bored with one way of looking, you want to look at something in a different way. For me it’s interesting to combine and integrate different perspectives but I don’t think that you have to subjugate one to the other.

In the 1950s Carl Rogers was talking about how to create a healing relationship. Fast forward 65 years and now neuroscience is discovering pretty much what Rogers was talking about. Am I better off talking about it from that perspective than listening to Carl Rogers? I don’t know. But it makes me appreciate what Rogers says even more and in a deeper way when I can see it from this scientific perspective.

SR: That makes sense.
LC: If Buddha were alive, he’d say, “Of course,” right? “There’s 5,000 research studies you did, but all you needed to do was read the Sutra and you would have figured it out.”But I think it’s interesting to just keep learning about life from as many points of view as possible. When have your read enough novels?

Each novel you read is a new way of capturing the universe, and they’re entertaining and stimulating and make you feel human. I feel the same way about the sciences, which is why I love reading E.O. Wilson’s work on ants, because I learn a lot about humans by reading about ants. So many things we do are very ant-like. Plus, ants are interesting.

Nobody Has the Answer

SR: Ants are very interesting. That’s a great way to look at it and I completely agree. Moving away from neuroscience for a moment, I’m curious about how your clinical work has changed over the years.
LC: It’s changed constantly. When I started as a student of pastoral counseling at the Harvard Divinity School, Carl Rogers was one of my teachers, so my first real training was Rogerian. The reason I got interested in counseling in the first place was reading Fritz Perls’ Gestalt Therapy. Then when I ended up at UCLA I realized you have to learn cognitive behavioral therapy whether you like it or not. So I was trained in that. I did a couple of years at a family therapy institute in Westwood in L.A. My supervisors were psychodynamic and my therapist at the time was a Jungian, and then I had a couple of other therapists who were psychodynamic and Gestalt.I was working with people who had been severely traumatized as kids, so I got interested in neuroscience through a study of memory, trying to figure out what the heck was going with the memories of people who’d suffered severe trauma.

Since then, my heart is more in the object relations world, I think mostly because it matches my personality and the type of relationships I like to create with people. But I’ve woven in neuroscience, attachment theory, a bit of EMDR, some meditation and self-awareness exercises. It’s a hodgepodge of all the different things that I’ve learned, but I don’t really feel like I’ve got a hammer and everybody who comes in is a nail. It’s more like I’ve got a toolbox of 30 or 40 years of things that I’ve been collecting and I try to figure out how to match as best I can to the needs and the interests of the client.

SR: Is there a certain population or certain pathologies that you’ve been working with more lately or that you’re more interested in?
LC: Not really. My practice is pretty general and I like to keep it that way. I don’t really like to see the same problem over and over again. I always think of psychotherapy as kind of like a collaborative research project. People come in and we work together to figure out what’s going on—how did it arise? Is there any hope of making it better? I really like having problems I haven’t dealt with before.
SR: What do you wish you’d known as a beginning clinician?
LC: When I started, I was looking for an answer and I wanted to know who had the answer. So

I tried to become a disciple of one person or another person. It took me quite a while to realize nobody has the answer. Everybody has a little piece of it.

And what I’ve got to do is just learn the best I can and then sacrifice and move on. This is a very ancient Rig Veda philosophy—every day you wake up, you sacrifice the day before, you move on, you create a new reality.

Had I understood this, I would have spent a lot less time worrying about finding the truth and being acceptable to whatever godhead I happened to run into at the moment. I think idolatry is the problem. Idolatry and objectification.

SR: It’s hard to avoid being exposed to that as a student. At least in my experience, in every new class you’re exposed to something people think is the answer, the best way to look at things.
LC: In my experience, the degree to which someone is enthusiastic and adamant about having “the answer” usually reflects the degree of insecurity they have and their lack of ability to tolerate their own ignorance. If we’ve learned anything, especially when it comes to diversity, it’s that we have to embrace our ignorance and be curious as opposed to leading with certainty.Jacob Bronowski was a physicist who died about 20 years ago, but he did this wonderful documentary about visiting Auschwitz, where his whole family was slaughtered. He waded into the mud behind the crematory and grabbed a handful of mud, realizing that his ancestors were part of this soil, and said, “This is what happens when we’re certain.”

Certainty leads to ideological beliefs that supersede humanity. At a less dramatic level, we get so enamored with our philosophies and our therapeutic beliefs that we miss our clients because we’re so convinced that we’ve got to convince them we’re right about the things we believe should be true.

SR: So last question here; where do you think the field as a whole is going?
LC: Well, I don’t think mental distress is going anywhere. I think that more and more people are going to be having psychological problems as society and civilization become increasingly crazy. No matter how many therapists the schools pump out, the world is creating plenty of suffering, so there will always be a need for therapy.And though there will always be therapists trying to create revolutionary new therapies with great acronyms, I think that the tried and true methods will remain strong and stay strong because they’re tapping into fundamental constructs in human experience—the need to connect with other people, to be able to leverage our thinking to modify our brains, to ask questions about ultimate meaning and existence.

Where the field is going to have to upgrade its sophistication and quality is in the areas of like pharmacology, epigenetics, psychoneuroimmunology, diet. All of the actual mechanisms that create and sustain our brains will have to become part of the dialogue about how we help people sustain and maintain health. This might just be my Eastern philosophy bias, but we’ll probably be moving in the direction of more holistic, integrated thinking and treatment—not just combining East and West, but integrating scientific discoveries into our case conceptualizations and treatments.

Finally, I hope that psychology becomes more integrated with education. I have a book series that I’m editing for W.W. Norton which is on the social neuroscience of education, and we’re pushing to have psychologists, neurologists, neuroscientists and educators communicate more so that the things we’re learning can be integrated into each field.

SR: Well that seems like a great place to end. Thank you so much for taking the time to share a bit about your work and your life with the readers of psychotherapy.net.
LC: It was a pleasure, thank you.

Lynn Ponton on the Challenges and Joys of Working with Teens

Posted on by rezendevknowfully.com

A Delicate Balance

Rachel Zoffness: Lynn Ponton, you are a practicing psychiatrist and psychoanalyst who has been working with teens for over thirty years, and are author of the books, The Romance of Risk: Why Teenagers Do the Things They Do and The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls. Let’s start with some of the salient issues that come up when you’re working with children and teenagers. I find that confidentiality when working with kids and teens is often a tricky subject because teenagers have rights as clients and they want to maintain their privacy, which is critical to the alliance. But at the same time parents want to know what’s going on with their children. How do you maintain this delicate balance?
Lynn Ponton: I think it begins with the first session, and even before, when you talk with the parents on the phone—you have to alert them about how you run your therapy practice and your work with kids. I almost always say that I try to encourage privacy with the teens so that they feel open to talk with me, and I will tell their child during the first session that I’m going to try to keep things confidential, but that there will be some exceptions, and I let parents know that right away on the phone. In general, I meet the teen with the parents before I even start and I alert everybody to the parameters and the boundaries around confidentiality.
RZ: So that both the teenager and the parent are on the same page and know exactly where you stand.
LP: Exactly. The kinds of things I would need to share with parents, which I’m clear about right from that first session, would be drug use that was risky or risky behavior that would result in serious self-harm. And sometimes other things—abuse when it’s disclosed has to be shared with the parents for a variety of reasons, and because I’m a mandated reporter.

It’s often hard for a teenager to tell their parents these things directly, so I’ll offer to meet with them and their parents and we’ll work together to help them disclose this material. Collaboration with the young person assures them that even if they do tell me something, it’s not going to be reported over the telephone to their parents. They’re not going to find out about it by surprise. Instead, we’re going to collaborate together as a team to make sure that parents know this.

Of course there are times when this doesn’t always work perfectly. Having worked with kids for more than 35 years, there have been exceptions where I’ve found out quickly that a teenager is suicidal and I have to let the parents know. Maybe we have to work toward a hospitalization period or something like that, but I try as much as I can to have the teenager be part of this process and be involved with it.

Cutting

RZ: You mentioned a very hot button and interesting topic, cutting, which to me seems to have become almost a contagious and trendy behavior among teenagers. What’s your thought about that?
LP: Well, self-mutilation in all of its forms is something that therapists have to learn to feel comfortable with working with teenagers. It’s a big part of our work to connect with them, to know about it, to seem comfortable with it and not put off by it when we hear about it in a session. I first saw it about 30 years ago and wrote a paper on it in the ‘80s, which talked about self-mutilation as a communication. As you point out, it’s a contagious risk-taking behavior. In a group of teenagers, one will do it and the others will copy. They’ll think, “I’ll try it and see what I can learn from it.” That’s how that process really starts. In the ‘80s there were big concerns about self-mutilation because of sharing of implements and a lack of understanding around HIV risk, so we had to be very careful about that until we better understood it.

I think it’s often scariest for parents. So how do you work with teens around the cutting for parents? How do you help a teenager who is cutting really find other ways to cope with some of their feelings and to develop identity in a healthier way? In general I try to educate teens about cutting. I often employ them to get involved in it, to look online, look up articles about cutting. We’ll have conversations about it so that it’s really an educational process with them.

Some teens don’t want to engage in that process.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it. This is something private that they’re going to do to help themselves feel better, so I’ll respect that, but I’ll still engage in conversations with them about it. I want to make sure that if they are cutting that it is safe in other ways. There’s significant risk of scarring, of infection—there’s a whole lot of risks that are associated with it.

Many teens cut because they say they feel better afterwards. A number of papers point to the beta endorphin release with cutting—the focus then becomes the physical cut and not the emotional pain that they’re feeling. So it accomplishes a lot for teenagers, but it is an unhealthy coping strategy and risk-taking behavior that you have to work with teens to limit. There are many different ways to do that.
RZ: The way you talk about cutting, it sounds like it might serve an important function for the teenagers who are doing it. What would you say to people who say that it’s just an attention-seeking strategy?
LP: Your question is well placed because I think a lot of times therapists who work with teenagers are faced either by teachers or parents or even other therapists who say, “I don’t want to work with those teens. They’re engaged in a lot of attention-seeking behaviors. How do you handle that?”

I think many behaviors in life are attention-seeking, and often we’re seeking greater attention from ourselves, that we pay attention to our own pain. Teens usually cut because they’re in pain and they don’t necessarily understand their own emotional pain but when they cut, it allows them to at least understand that it’s a painful thing that they’re dealing with. So, yes, it is attention-seeking, and adults will often be drawn in to it. Teachers at school are shocked when they find out about it and they’re worried other kids will cut.

But I think there are a lot of other factors that play in to cutting besides seeking attention. I’m also interested in questions about molestation with cutting. Were they ever hurt? Did they ever suffer abuse? Are they using that in the context of cutting? Has it become very ingrained, so it’s a behavior that they use as a coping strategy that they may have done thousands of times and they find themselves unable to stop? How does it fit in with their family?

Does their family know much about it?
There are many, many reasons why young people cut, and attention-seeking is only one of them.
One of the cases that I worked on for a long time, a girl cut because her father was a surgeon. He talked about cutting all the time, a different kind of cutting, but she imitated him in a kind of identification with her father. It took a long time to unravel, as it wasn’t obvious at the beginning of her treatment. There are many, many reasons why young people cut, and attention-seeking is only one of them. And it’s not often the major one. You have to address the complexity of the behavior and also the feelings that go with them.

Five Perspectives

RZ: I think some professionals are concerned that giving too much time and attention to cutting might be positively reinforcing. So it seems to me that as a clinician addressing it you want to find a balance between over-reacting and under-reacting.
LP: I think that’s more of a strict cognitive behavioral model way of looking at it, and it gets to the question of models and how they affect our work. Cutting is a behavior, but it’s attached to many other perspectives that we look at when we’re engaged in therapy. I try to look at things from at least five perspectives.

One is the more dynamic-relational, where you engage and are looking at aspects of the relationship—how it affects you, the parents, the cutting behavior, all of that. How disclosure plays a role in that. Attachment. Therapeutic alliance. Then there’s the behavioral model. A lot of therapists don’t use that model, but I think it helps to focus on the behavior. I often have kids keep a timesheet or a workbook on their cutting behavior and have them draw their feelings at the time that they’re cutting in addition to recording the number of times they cut. It’s a kind of cutting journal that we look at from a behavioral perspective. We also look at their thoughts that are occurring at the time that they’re cutting, so we can target really negative thoughts.

Then there is the family system. Cutting is usually very much connected with parents in some way or another—they’re worried about the parent’s reactions; they’re worried about feelings they have that they feel the parents can’t help them with. A lot of our kids have trouble with self-soothing, so they’ll cut to self-soothe. The parents might like to learn how to help soothe their teen, or help their teen gain self-soothing mechanisms, but they don’t even know the cutting is going on so they can’t focus on that area with them. Or they, themselves, may be unable to self-soothe and not know that it’s an important skill that you need for raising teenagers.

Carl Whitaker always said, "You lose the parents, you lose the family, you lose the case."
And then there’s the aspect of meaning for the teenager. What does cutting mean to them? Do they think about suicide? Some cutting is related to suicide. Self-harm that is related to suicide is very important to pay attention to, not just for our board tests but in our office with our kids.

Lastly there’s the biological perspective. With some kids that I work with, they carry biological conditions which may lead to increased cutting behavior. Prader-Willi Syndrome is one of those that has some increased cutting and self-harm. You want to be thinking about underlying conditions that might contribute to this behavior.

All of those things are going through my mind, so I’m not thinking, “if I pay attention to this behavior I will reinforce it.” Instead I’m working on all of these levels if I can. I didn’t start with this in the first year or two of being a therapist working with kids, but the longer I’ve worked with kids, the more I’ve been able to see the complexity of so-called simple behaviors.
RZ: I really appreciate that more systemic approach to working with families because when you work with children and teenagers you’re never just working with a child. You’re always working with the family and the larger system.
LP: One of my greatest teachers was Carl Whittaker, a well-known family therapist I worked with as a young medical student therapist in Wisconsin. He always said, “you lose the parents, you lose the family, you lose the case, Lynn.” I kept that in mind and it’s really helped me with all of these cases.

Manualized Treatments

RZ: Apropos of what you just said, I was trained in manualized treatments and I do see a use for them. But a lot of therapists think they’re mumbo jumbo and that they don’t address and can’t respond to the spontaneity of what happens in treatment face to face with clients. How would you make a case for manualized treatments, if at all, or what would you say to people who don’t believe in them?
LP: Well, there are now manualized treatments in dynamic relational work. There are over 400 manualized treatments that I know of in working with children and adolescents from a behavioral modality. Family therapy, too, has manualized treatments. I don’t think there are any in the more existential perspective, because it kind of runs counter to manualization. In biological therapies they have always had manualized treatments for how you evaluate symptoms and work with things.

When I work with young therapists—and I supervise a lot of residents, fellows, psychologists, psychiatrists who are at all stages of training—I really encourage them to pick one or two manualized treatments and really learn them—go away for a day or a weekend, learn the strategy, practice it, and try to become familiar with it. Even if you’re going to be a strict psychoanalyst or family therapist, I think they’re valuable because they teach you how to focus on specific things, how to evaluate. Often manualized treatments have an evaluative component built in, so you have to look at your actions and evaluate how they’re working at the end. That’s a very important part of all therapy.
RZ: Measuring one’s progress?
LP: Exactly. That’s the key, I think, in mastering some of our work. Now, which ones would I recommend? I think one of the best ones to know about is the basic cognitive behavioral therapy approach as developed by Aaron Beck at Pennsylvania. He was my supervisor when I trained there as a resident, and it’s a very successful modality to use. It helps us understand the impact of negative thinking. Another supervisor of mine was Joe Weiss, who worked on Control Mastery theory—which is about negative thoughts and ideas and the power of unconscious beliefs. I admire Marsha Linehan a great deal and the Dialectical Behavioral Therapy model. I’ve had some wonderful conversations with her about her work with adolescents and I think she really grasps what it’s like to work with high-risk adolescents. I would encourage almost anyone to look at her book on working with high-risk adolescents. It’s a wonderful model and it adds much to the work we do with young people. A third area that I think people should look into is trauma. We work so much with trauma as child and adolescent therapists. There is a trauma focused interview that we can do with kids that I use all the time. It’s very useful in diagnosis and at looking at symptom category.

I think learning a little bit about any one of these models helps any child and adolescent therapist function in a more complete way.
RZ: So it sounds like what you would advocate for is an understanding and knowledge of these manualized treatments because it gives you, as a clinician, more tools in your tool belt to pull out for individual clients as they come to you with their individual differences.
LP: It’s one of the reasons the tool belt concept is helpful. But it also makes you feel more comfortable as a therapist, knowing that you have some grasp of these different ideas. Knowing that you’re not following one dogma, but are open to new ideas, because I think ultimately as therapists we end up constructing our own way of working. The theories that we use to support our work, the collection of tasks and techniques that we define and use—these form the basis of our work . It’s very valuable to look at other people’s constructions, integrate them into our own work and say, “hey, this is useful for me. It works with these patients. I can really take this and run with it.” I mentioned five perspectives that I’ve accrued over maybe 35, 40 years of work, but I anticipate over the next 40 years there are going to be others that will greatly benefit our work as child and adolescent therapists.
RZ: There are therapists and other mental health practitioners who would say that defining yourself as eclectic dilutes your work. Do you believe that that’s true? How do you define your theoretical orientation when asked?
LP: I remember that same question from 35 years ago in residency. I think having multiple perspectives strengthens our work, and there are multiple perspectives within each of these theories, so it’s not like people who belong to one model are necessarily doing some ossified therapy that was created by some individual or group of individuals. In my work, I want to stay open and patients open me up.

One reason I like adolescent work, even though I feel like I’m getting older, is that it keeps me young. It keeps me open to new ideas. My patients actually taught me how to text on my cell phone; my patients are coded in by their first name so that they can call me and have a relationship with me.
My patients actually taught me how to text on my cell phone.
I remember one of my other supervisors, Hilda Brook, who worked a lot with eating disorders, was working with teens into her 70s and early 80s in a wheelchair, and she had greater facility with them than even I have today in my 60s. We can continue to grow in our work with teens if we stay young in other ways.

Texting

RZ: You bring up a very important and hot button issue when working with teenagers, which is texting. And I think doing therapy with teenagers and kids today is a whole new world because teenagers and kids are used to communicating through their technology. What are the upsides and downsides of deciding to be a clinician who texts with your clients as you are?
LP: I think it’s important to be aware of some of the legal parameters around texting. Many of us work with large organizations, and it’s important to be aware of HIPAA regulations and such. HIPAA doesn’t regulate all therapists, only certain therapists who are involved with electronic billing, which you might be if you work in a large institution and you bill electronically. In that case you are HIPAA regulated and with regard to texting, HIPAA states that you cannot be sending clinical decisions through a texting modality or an unsupervised modality. You have to have some regulations around it.

When I worked at UCSF for 35 years, I was in a large system that was HIPAA regulated. My texts, which I did with teenagers for 10 years during that period, dealt with scheduling, and if they texted me about an issue that I was clinically concerned about, I’d have them come in so that we could then talk about it and then work on it in person.

But the texting connection I think is very, very important with teens and therapists. Not all therapists can do it for a variety of reasons. Not everyone feels comfortable with it and not all teens have phones. I’ve done a lot of work with homeless teens, who usually don’t have phones, so you have to figure out other ways to communicate with them.

But the bulk of teens out there today do have access to texting and they will communicate that way, often just to check in with you. They may just want to know you’re there and I think that sets up a relationship with them. I don’t always respond to those texts, but they know that I’m receiving and reading them.

But let’s say you’re not HIPAA regulated, so you can put anything on text. I would still say if you’ve got a big clinical concern with a teen—let’s say they text you, “I’m cutting, I think it’s out of control, I’m feeling really anxious”—I’m going to call them immediately rather than text, and most likely try to get them in to see me if I can. So it’s not that I’m sending long texts back and forth about that type of behavior. I’m really using it as a way to communicate to stay in touch.

Other ways that teens will keep me informed, they’ll often text me, “Saw an article you should be reading, doc,” or “thought you’d like this.” Those things are important because it is a reciprocal relationship. I’m largely involved in educating young people, but they help me a lot, too, and I get a lot from them.
RZ: For therapists in private or group practice who don’t work for large organizations, is there a downside to texting? For example, what if you lose your phone?
LP: I think that gets back to just have their first name, maybe an initial afterwards, but no way that they could really be identified. And if they’re very sensitive texts you can also erase them, although we all know that things are out in the cloud forever. So be aware that that information is out there.

This is also one of the things that you should discuss in the first session. I often discuss with my patients my availability, how they can get a hold of me, so they know that I will have their first name on the cell phone, and their phone number, and that I’m fairly easily accessible. I believe one of the reasons I’ve been so successful with teenagers and their parents is because I have very good accessibility. I take my cell phone all over the world when I travel. I do have somebody on call to cover, but I’m available in that way. But let’s say that cell phone is lost, and I’ve never lost my cell phone, though I fear it all the time, Rachel. I’m looking around for it and I worry about memory loss and loss of cell phone. But if it’s lost I think you have to alert the patients, especially those that you’re texting with, that there is a risk and the cell phone was lost. Most of them are not that concerned about it because their whole name is not out there. There’s not a lot of information out there. But I think it’s important to do that. But I also know from forensic cases that you can actually remove data from a distance off of a cell phone, which might actually be required if you work for a university or large organization.

Sexting

RZ: Technology and internet use seems to be a primary source of conflict between parents and kids. Do you see this a lot in your practice? And how do you go about addressing it both with the parents and with the children?
LP: Very young kids, 9, 10, 11, 12 are using the internet or videogames or other media for large periods of time, and parents are often seeing symptoms—kids are struggling with school, their concentration is impaired, and they’re not engaged in other activities or relationships.
Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
I think that that’s a very important area to be aware of. Parents need education around the signs to be looking out for when kids are struggling. We need to think about their media profiles, how much time are they on TV, how much time they are playing videogames, how much time are they on internet, and what different modalities they’re involved with.

When families come in, I’ll have both the kid and the parents keep a journal and write their feelings down about what’s happening when there’s a confrontation at home regarding this behavior. And all of that comes back into the session. I often will use the family modality to meet at that point and we’ll talk about what’s going on in that type of interaction.

The other area that comes up frequently with teenagers is sexting—texting sexual material. During the past five years I would estimate I’ve had 50 teenagers referred to me who have been involved in sexting activities.

In general, the girls are involved in sexting pictures, nude photos of themselves that have caused some great difficulty. These are often selfies where the girls will hold the camera out in front of themselves, often in their bedroom or bathroom, sometimes partially clothed, sometimes not, and then they’ll text the photo to a friend or friends, and then it gets texted everywhere. That type of interaction is very important to pay attention to and I’ll generally work with the teenage girl alone and talk with her about what happened. The feelings around sexual development are very private and tender, and it’s deeply shocking that this is suddenly exposed to a large group of people. I work with the family around this behavior, too, and sometimes will meet with parents alone to help them understand why this behavior might have taken place.

I would say a smaller number of the sexting cases, roughly 20%, are boys texting nude photos of themselves, but they’re mostly texting nude photos of girls. There are also laws involved with this and I’ve been involved with the FBI and other law enforcement officials around how to handle these cases. There’s awareness in high schools now that they have to report these cases when they discover that boys are texting sexual photos of girls. Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
RZ: How do you handle those cases when they come in?
LP: First be aware of the legal ramifications. Second, encourage them to get legal advice, because we as therapists can’t provide all of that. Third, I often will meet with the boy individually and try to get a sense of what happened and work with them around that. Many boys are shocked that this has happened. They may have thought they were doing what the other guys at school were doing, that it was cool, they were getting more status. But I’ve also seen boys who’ve had long-standing problems and the texting of the sexual photos is connected to other sexual difficulties that they’ve been struggling with. They may have been molested. They may have molested another person. So to be aware of that, to be open to hearing about that is very important.

Parents of boys are often very angry about this process. They feel that the boy is at a disadvantage because though he sexted the photos, it was the girl who originally sent the photos out so it should be her responsibility. Helping the parents see that we have to take a deeper look at what’s going on with their son under these circumstances is really, really important and not easy to do. You have to stay open to their feelings about their boys being scapegoated, but at the same time point out this is something we have to pay attention to.

The intersection of online work and sexuality is really a key area to focus on, to get as much help as you can as a therapist. Sometimes if I have a question, even today I’ll go to another therapist that I think has more expertise in this area and get supervision.
RZ: Are there particular resources for therapists who want to learn more about how they can be better clinicians when addressing something like sexting?
LP: Yes. I’m not going to toot my own horn about this, but I’ve written an article that’s online about sexting and working with clinicians that I think is very helpful. It has a literature review of a couple of cases and ten guidelines for parents and therapists around this area. There are not recent and current books because it’s a fairly new topic, but I think it’s something we’re going to see more of in textbooks and articles. A lot of young psychologists’ dissertations have been done on sexting, and those are valuable if you can get a copy and read them.

Learn to Like Kids

RZ: What advice do you have for beginning clinicians treating kids and teens?
LP: The most important thing about doing this work is that you have to be knowledgeable about your own childhood and adolescence. You have to have thought about it, its impact on your own development, the issues that you might bring to the work, questions and preconceptions about it, etc. I encourage almost all therapists to have their own experience in therapy and to explore some of these issues.

Second, what helps the most in this work is really loving children and adolescents. Having a strong love for that age group or working toward it. Let’s say you don’t love it, you’re kind of afraid of it, maybe you’re going to work toward a passion in that area. You’re going to learn why you’re afraid of that age group and you’re going to try it out and get supervision with somebody who is really very good at it. It is a group that is fun to work with, is very challenging, and can really be a growth opportunity for you as a therapist. But I’d say try to develop a passion for it. Learn to like kids. Learn a lot about child and adolescent development. I think either being a parent or playing a role with your nieces and your nephews and other kids is really important.

Third, you’ve got to be able to work with parents. When I was younger and starting out one of my mistakes was that I thought I knew what it was like to be a parent long before I was a parent, and I was often angry with how parents treated kids. By now I’ve gone through decades, I’ve had my own kids and I see it differently. I see myself as a valuable resource to parents and I have great empathy for them.

Sometimes I have to do very difficult things with parents.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby. The police were there and there was obviously a lot involved with this, but we had to save the baby and rip the baby out of the mother’s arms. So there are things that you often have to do in this work that are not very easy with parents and I think I’ve learned how to do those with concern and empathy as I’ve grown older and become an older therapist. But at the beginning I would say stay open to the work with parents. Keep your eyes open. Realize you don’t know everything.

Fourth, Don’t just accept a dogma. Try to integrate and construct your own idea of how to do the work. I talked earlier about the five perspectives I use but think about those that work best for you, yourself, as a therapist, and with the patients you’re working with.

Lastly I’d focus on the first session and developing a good alliance with kids relatively quickly. That first session is really important—how you connect to your passion, staying open, not being judgmental. Watching tapes of other therapists do first sessions can be really helpful, or being in a study group where you share information about your sessions with kids. Or even observing preschool teachers, who are often very good with kids, welcome kids into the classroom, integrate them, and get them playing and involved in activities. All of that adds to our abilities in that area.
RZ: What do you think has helped you become a better clinician?
LP: Years of experience have helped a lot. Reading widely has helped a lot. Having my own children has helped a lot. I have four—two step sons and two daughters—and I’ve learned from all of them. It’s not been easy.

Supervising younger therapists has also been really helpful, because I’ve listened to their problems and I really try to figure out what they’re going through, which keeps me more in touch with what it’s like to start this work. This is not easy work. There’s a lot to learn. We make a lot of mistakes in it, but we do a lot of good.

Maybe the last thing I’d say about it is I’ve been so impressed over all the years of working with adolescents how many return. They bring their own kids back for treatment. That keeps me in it more than anything—having the kids come back with their own children, and seeing that they’ve shared things I said to them. This is not everybody, of course, because I’ve had over the course of my career two adolescents who killed themselves. I’ve gone through a lot of difficult experiences, as have my patients, but I am impressed with this type of work and how much we can help kids if we stick with it.

It’s wonderful work that makes you feel very good about your life’s work at the end of it. I don’t see myself at the end of it, but I have talked with others, like James Anthony, a role model of mine who was a wonderful child therapist who worked with Anna Freud. When I was a very young student I had the opportunity of working with him in London. He loved the work and he still continues to teach me things—and he’s in his late ‘90s. He talks about having patients come back and treating the grandchildren of the children he saw. That is an amazing thing. It’s a chance to be very connected with others in life really.

Suicide

RZ: It sounds incredibly powerful to have had such a positive impact on someone as a teenager that they want to bring their own teenagers to you once they have had children. It also sounds incredibly powerful to have lost an adolescent client to suicide and I’m wondering if you feel comfortable talking about that a little bit.
LP: It’s a reason that a lot of therapists seek out supervision.
RZ: It’s admittedly my worst fear.
LP: I think it is for all of us. It’s not just the legal aspects of it. We all carry liability insurance and we’re worried about that part of it—but it’s also just the connection. I will say that I really remember these patients and their treatment very, very well because of going through this and thinking about it a lot. The first was a young man who killed himself when I was the director of the adolescent unit at UCSF.
RZ: How old was he?
LP: He was 19 and he had very severe bipolar disorder. He stopped his medicines when I went on vacation and then went into the woods and shot himself. I had arranged for somebody to cover me during this period of time. It was a short vacation, but still enough for this to happen. I’ve thought about it a great deal, of course. It’s changed the way I take vacations. I still take them, but I’m very alert, thinking about coverage and concern about these teenagers and children when I leave.

I spent several months working with his family. They had anticipated it more than I had and that surprised me. I went to the service and worked with them in a collaborative mode, which I did not charge them for, and they were very grateful. I’ve stayed in touch with them in some ways, though that happened I’d say roughly about 30 years ago now.

The other suicide was about 20 years ago and was a patient I’d worked with for years. She had a chronic psychotic condition. She was a very bright young woman and I had spent a lot of time with her. She had promised me that she would not harm herself until she was 30 years old, and then she killed herself not long after her 30th birthday. So she stayed alive working with me for years I think to try to get better, and we tried everything. Family therapy, medications—and it was clear that she was going to be living with a chronic psychotic illness that was incredibly painful for her.

I still think about her all the time. I think she helped me in many ways to understand that sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
Sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
We can discuss that with them, we can work to help them, many different things can be done, but there are limits to the work that we do. She left me a number of drawings she drew and painted. I think a lot about her family. I worked in much the same way that I described with the earlier boy. I met with her family and had contact with them for a long period of time. I still think about her all the time.
RZ: I bet. I think this is particularly important to talk about for young therapists who are, as you mentioned before, maybe put off entirely by cutting because they’re so scared of it, or don’t want to work with suicidal clients because they’re so afraid of losing a patient. It’s really valuable for me as a young therapist to hear you talk about having gone through this worst fear with a couple of your clients and not only did you get through it, but it made you a stronger clinician ultimately.
LP: I think ultimately it did. Of course, a big part of this was questioning what I had done with them and if I had made the right decisions.
RZ: Of course.
LP: Had I done something wrong?
RZ: That’s natural.
LP: I think any therapist who has had a patient suicide question their work. Families question their interactions with their children after suicide. We all think about it. I work with many teenagers, especially here in the Bay Area, who have had friends suicide, and the young teens question what they could have done to help their friend. It’s not only us as a group of therapists who question ourselves, but it’s really the world that comes forward to question itself around suicides.
RZ: It seems like that’s the first question people ask friends, family, and therapists alike: What could I have done? Could I have done something different or better? And I think that is a real challenge.
LP: It’s natural and appropriate to ask those questions and explore them, but it’s also important to really understand that there are limits in life to what we can do. It’s important in this line of work to talk about this aspect of it.
RZ: That’s a very realistic and compassionate perspective. Thank you for your time and for your wisdom.
LP: And thank you for your good questions, Rachel.

Infertility on Both Sides of the Couch

Posted on by rezendevknowfully.com

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

“I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished.” Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? “Should we start putting money into a college fund? Or should we begin grieving about not having a child?”

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. “How could she brutalize her body from treatments and spend so much money to conceive and carry?” I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. “The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments.” We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. “She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.” She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.