Spilling Over Modernity’s Borders and Boundaries: A Decolonial Story About Alzheimer’s, Family, and Migration

“¿De dónde eres?” My friend’s 9-year-old niece asked me shortly after we were introduced to each other during Christmas. This was in Bogotá last year at my high school friend’s place. She sat next to me, leaning slightly toward me. Her question seemed fueled by a kind of curiosity that two strangers at times share when wanting to rush through the unfamiliar and quickly find a common place from where to discuss matters of much greater importance, like her Christmas presents. It must have been around 15 years since my high school friend and I last knew about each other’s lives. Various life circumstances might have contributed to vanishing from each other’s lives—including living in two different countries—until whenever the day was going to come for us to meet again and pick up our friendship right from where we left off to catch up on whatever many years in between.

My eyes shot open and met her curiosity, sensing all over my body the shock of her question. Did she unwittingly render me foreign to and within my homeland? I wondered.

“Pues de aquí. De Bogotá. Rola 100%!” I said to her, stating what for me was the obvious.

“Es que hablas diferente.” She further explained.

“¿Y tu?” Le pregunté,” pretending to ignore the state of my body, and attempting to reciprocate an interest in our origins.

“De acá.” Me respondió, while organizing her Christmas presents for their exhibit.

My friend overheard our conversation. On the way to the kitchen, she provided some context to resolve her niece’s confusion and to create mine.

“Ella es de aca pero hace mucho que no vive aquí por eso habla así.” my friend explained with the tone of certainty of an irrefutable conclusion.

“Así cómo ???” I yelled in horror; but she had now gotten lost far back in the kitchen as the Christmas host.

Like many, I became well acquainted with the origin question as an immigrant, hence actual foreigner to the sociopolitical and material history of my host country, the United States (U.S.); as well as with the experiences of those who although were born in the United States are inadvertently or intentionally rendered foreign in their homeland by others. This is, when informed by discriminatory singular and monolingual principles about nationals and foreigners from a land. Having left Colombia as an adult, in the U.S. the socio, geo, and body-political history of Latin America/Abya Yala I carry, materializes not only in my accent but in my interactional manners, phenotype, epidermis, and knowledges, which intertwined with local racializing practices, continuously mark the well or ill intended curiosities of the inquirers, nationals or immigrants alike, about their assumptions about my foreign origins. Regardless of their intent, in foreign soil, I share my origins with my chest filled with air, trying out a new sense of pride in the diaspora evoked by its nostalgia, not quite reaching patriotism but maybe darn close to it, if I were to speculate on what incarnated patriotism would be like:

“From Colombia.” I usually respond to that question and sometimes I point at my wrist when I wear its colors.

Re-entering: From Here and From There Migration Experience

During the last couple of years, I have been spending more and more time in Bogotá than I ever have since the early 2000’s when I left. My mother’s health and increasing loss of memory called for it. Although no doctor would diagnose her with Alzheimer’s in her late 80s, that was the family’s narrative about that part of my mom’s life and our relationship with her still to this day. Her four daughters were no longer living in Colombia. My three sisters and I migrated to the U.S. at different times during our adult lives, for different reasons that required no explanation. Mom and dad raised us during the Colombian armed conflict, intensified by the international drug war and the U.S. intervention.

In a country living and enduring the ongoing wounds of war, poverty, and state neglect, as it is the case for many countries living through long-standing conflicts around the world, as I recalled, for many Colombians across various socio-political circumstances, since birth, the idea of leaving Colombia becomes part of what it means to live in Colombia, aspiring for refuge elsewhere. Violence humiliates the homeland and elevates the non-realizable promises of foreign land. Those of us who realized the idea of leaving Colombia represent the 6% of the population who currently live outside of the country—primarily in the U.S., Spain, and Venezuela. According to the Migration Policy Institute, Colombians are the largest group of South American immigrants in the U.S., representing 2% of U.S. immigrants. Colombian migration to the U.S. has increased three times as fast, from 144,000 Colombians in 1980 to 855,000 in 2022.

During our lives in the U.S., mom would come to visit for various periods of time, visiting with each one of us across states. My dad traveled once, which was more than enough contact with U.S. soil for him, given his politics. We would stay in contact through daily emails or texts, otherwise. Also, from time to time, I would travel to Bogotá for a long weekend or so for a visit. Before migrating, and all throughout the Covid pandemic, my oldest sister lived with and cared for mom in Bogotá until the impending heart-wrenching decision finally came knocking at the door to meet the four of us face to face.

The emotional intensity, and dedicated care my sister and her children had been providing mom with for the last few years had proven to be no longer sustainable for either of them. Con cabeza fría, we had to make the overdue decision, even against mom’s wishes that she no longer remembered. Mom needed to be relocated to a specialized nursing home for her proper care. She had outlived friends and close relatives. My father died back in 2008, and we heard that mom’s last living sibling, the oldest, Alberto, was still alive but bedridden in deteriorating health conditions. He died not too long after mom moved to the nursing facility.

My relatively advantageous immigrant conditions afforded me alternatives that only so many immigrants in the U.S. have in similar circumstances, with aging parents still living back in our home-countries. I began traveling to Bogotá regularly during the last year before mom died, spending months at a time with her while working remotely. My sisters would visit when able. Daily, morning and afternoon, raining or not, I would walk back and forth to visit mom at the nursing place in the north area of Bogotá from the small place nearby I rented during my stays. I would pick up on my way some kind of dessert for my mom’s sweet tooth that memory loss had forgotten to forget. I became very well acquainted with mom’s co-living folks and their visiting families; and also the nurses, aids, physical therapists, and cooking and cleaning staff, majority women, to the extent that exceptions for their visiting hours became the new visiting hours. It was through their lives—the only people I had close contact with at that point in Bogotá—that I re-entered a sense of living a life in Bogotá, although still having more than one foot in my immigrant life in the U.S., to which I remained virtually connected through a laptop.

Through life at the nursing home, I reintegrated myself to the familiar tensions of the Colombia Nation-State’ s sociopolitical heartbeat, revealing along the signs of the 24 years that have passed and have transformed both the country and my politics in the diaspora. The tensions were palpable. On the one hand, the advantageous circumstances of the families who could afford their relatives to live there were visible. And, on the other, so were the injurious sociopolitical conditions and longstanding neglect by the Nation-State toward the lives of the people working there. Although responsible for the care of the facility’s residents, they had to do so while undergoing living conditions that seemed to cry out in state neglect. This was one of the other jobs they needed for their survival and the survival of their family.

Some of their children were being educated under precarious conditions in public schools. Evictions from their home were more tangible month after month. The impeccable makeup of some of the women working in the kitchen kept hidden the marks of patriarchy’s hands from the night before, some of which was documented in futile police reports as well as in her self-defense fingernails imprinted on his skin. Their clothes served as curtains behind which their bruised bodies were concealed, while their bones would heal from their forceful impact against the wall, or the push down the stairs. Their children were their witnesses. According to the Colombian newspaper, El Pais, between May of 2023 and 2024, 149.017 family violence incidents and 630 femicides were reported in the country. Limping, the women would arrive on time at the nursing home after a 3-hours-long commute from the south of Bogotá to care for my mom with the best of dispositions possible. Story after story, the nostalgic Nation-State Colombia of the diaspora that I was so proudly holding tight to, wearing it on my wrist, and expanding my chest, started to melt throughout my body, transpiring through my skin, forming a polluted stream of outrage that took off running through la Avenida 19, running all the red lights, turning toward la Autopista Norte, eventually merging with Bogotá River, considered one of the most contaminated rivers in the world, according to WSP.

My relationship with mom that year was not exempt from a sort of re-entering experience. It was similar to how my re-entering to a life in Bogotá was. On occasion, mom would seem as if she could see in my face sort of a familial resemblance but not quite family. I was beginning to feel that way about everyday life in Bogotá although not linked to a matter of memory but migration. I recognized aspects of what I remembered was my homeland out of the unrecognizable features of the obvious changes since I left. I was able to discern some things but not others with my renewed borderland eyes as a Colombiana inmigrante en the U.S.

My life from when I lived in Colombia during the late 1900s met with my life as an immigrant living in the U.S. since the beginning of the 2000s only to discover they had already met over two decades ago and have become inseparable since. My memories from Colombia were never left behind. On the contrary, they carried me through the making of a new life in a new land. After all, we can’t separate ourselves from the history that makes us. I have been living both lives simultaneously, through a multiplicity unfolding either in Colombia or the U.S.

A sense of foreignness within the familiar, and a sense of familiarity within the foreign helped me discern the experience of dwelling in the borderlands, which my friend and her niece also brought out in the open during Christmas, when I reconnected with them months after mom died on March 29, 2023. The borderlands became a point for reflection on what it was bringing forth—difference—to ultimately transcend modernity’s definition of difference as fracturing borders or boundaries since the conquest of the Americas—the colonial difference. Walter Mignolo has written extensively on this topic.

The colonial difference refers to a hierarchy of separation (for control purposes) through the development of borders or boundaries that create races, cultures, Nation-States, identities, languages, genders, etc. Modernity’s colonial difference fractures the bones of the communal into hierarchical separate pieces whereby those lower in the hierarchy can be thrown down the stairs or against the walls of separation that it created. Thus, my friend nieces’ question about my origins, became a recognition of difference stemming from my 24 years in the diaspora crawling up my Colombian accent to renew it within a sense of plurality. My renewed accent marks a difference that does not have to be of borders, exclusion, fracture, or separation, but of relationality and connection out of what it means to live relationally, or in more than one world simultaneously.

I have heard many stories, mostly from Mexican, Chicanxs, Mexican-American, or Texanes, about their experiences when returning to their homelands in the Nation-State of México. They shared being made to feel that they do not belong on either side of the border: “not from here, not from there,” “ni de aquí, ni de allá [neither from here nor there].” I understand this to be a symptom of modernity’s logic of criminalization by difference and punishment when crossing the border. Anything that does not represent nationalism on either side of the border, thus promotes monolinguality, monoculturality, or singularity, is destitute and criminalized. On the contrary, from the borderlands of my experience, I am thinking about immigration interrogating the borders while being interrogated; thus, opening at the same time possibilities to rethink the fracturing premise of separation modernity promotes into being “from here AND from there, simultaneously, thus relationally.” This revised premise eases my body when facing the origin question by Colombians in Colombia.

Rendering the Familiar Unfamiliar: Radical Listening

More often than not, mom did not know exactly who I was, or when and where we may have met at some point in our lives. Only a couple of times, she recognized me as her youngest daughter, “marce,” as she used to call me. Although she never forgot her name, Gloria, she did not know where she was nor recognized her own image in the mirror. Sometimes I was her youngest sister, and other times, she would address me as her nurse or aid. When I would rub her hands, the touch would call her to reposition her hands and to start giving me instructions on how she wanted her nails done that day. When I would pass my fingers through her hair, sometimes she would address me as her hairdresser, or quite firmly in a tone I did not recognize, she would push my hand away demanding that I do not touch and mess her hair.

As much as mom did not remember that I was her daughter, I did not always fully recognize mom in the body and interactions of the 89-year-old woman living in the nursing home—except during her brief inconfundibles momentos [unmistakable moments] of humor here and there. This was not surprising to me, having learned about similar yet different stories from folks from various backgrounds with parents living with Alzheimer’s or dementia, not only in my therapy work. My family was now living through those stories but creating our own. Our story is also likely to be my story about possibly inheriting from mom a life with Alzheimer’s yet to manifest, at least as far as my memory can tell thus far.

Although not surprising, witnessing mom’s increasing experiences of discomfort, suffering, and loss of conversational abilities was at times hard. Yet, unexpectedly, under such unfortunate circumstances, not being remembered by mom at times opened alternative relational possibilities. But it required radical listening to recognize these as possibilities and through the rather overwhelming presence of Alzheimer’s. I have learned radical listening from various perspectives that I carried with me every day to the nursing home during my visits. These include perspectives on borders, memory, history, and aesthetics shaped by my lived experiences as a bilingual immigrant, my understanding of Narrative Therapy in English as a family therapist, and mostly by my engagement with the decolonial project from Abya Yala y el Caribe in Spanish and Spanglish as a member of the civil political society. These are perspectives that have shaped not only my family therapy work but my life as I write here.

Cognitively speaking, Alzheimer’s configured mom and I as strangers, no longer family. We became foreigners to one another. Most interestingly, however, it rendered us foreigners to modernity’s concept of the family. As an immigrant, working and living in community with immigrants in the U.S., questioning, revising, expanding, or delinking from the westernized idea of family has not been uncommon. Migration is a context for the necessary renegotiation of our ties and kinships within the context of voluntary or involuntary separation, and deportation. For example, during the current administration in the Nation-State of the U.S., during the last four years, nearly 4.4 million people have been deported to more than 170 countries according to the Migration Policy Institute.

Mom and I became foreigners to the western idea of the family settled and promoted in Colombia, and many other parts of the world, through Catholicism, heteronormativity, patriarchy, capitalism, and their institutionalization of relationships. As one of mom’s four non-adopted or non-in vitro children, our half a century-long enfleshed relationship was governed in great part by humanized fracturing assumptions of reproduction, motherhood, productivity, and gendered relationships founded on who gave birth and who was birthed to constitute a family. Thus, oddly, Alzheimer’s liberated us, not from accountability for all the headaches I caused mom over the years, rather, from thinking ourselves, and listening to each other, through the institutionalization of boundary-based relationships, its imposed social expectations, and Nation-State’s laws whereby the western family has been instituted as some sort of a social mandate. If I were to take a guess, these sort of institutionalized human laws and western concept of the family might be the sort of conundrums that would make la Pachamama, Madre Tierra, shake the earth. Mom’s forgotten aspirations for my life and my sisters’, which included growing up to become Colombian mothers, with good husbands, and decent, healthy, economically independent (from men), and hard-working women, were no longer shaping our relationship.

Deinstitutionalized by the unfortunate circumstances of Alzheimer’s, thus no longer being a Colombian mother and a Colombian daughter in the modern sense, we learned each other and cared for each other otherwise, sometimes minute by minute. The fracturing logic of the family boundaries planted by modernity was removed. Thus, I understood care to be instead about honoring the relationship with the person I owed my existence to in so many ways in addition to giving birth to me. As a family therapist, I am attentive to what the global and western concept of family imposes on relationships in an exploration of what sort of relationships are possible otherwise or in addition to.

My relationship with mom was unpredictable and in constant movement. It was to be discovered by dwelling in the moment of its expression. We had to discover who we were, a cada momento (every moment), according to the memories invoked and received as they came, no matter what. Was I the hairdresser, the woman who does her nails, her sister, one of my sisters, her nurse, or any other character out of my mom’s history? I could not arrive at the nursing home with certainty of who I was, but with clarity of where my existence—and my sisters’— came from. I became someone only through the act of being with mom and our memories, some of which we invoked together.

We connected through the ever-changing moment of the circumstances that brought to life some of the memories of what we were made of. The circumstances I am referring to were for the most part sensorial. The senses evoked sparkles of memories, interconnected with other memories, both hers and mine. The taste of the daily desserts, my touch, the temperature of my hand over hers, the boleros we listened to, the noise from the novelas on the TV we stared at, pictures of her younger life, the colors and textures of my clothes, my gray hairs, the co-living folks’ speech or appearance, the birds’ colors and their singing having Bogotá’s traffic as their symphony far in the background, as well as the colors of the flowers around us when we sat outside in the garden evoked memories intertwined. Those memories that have shaped, among other things, our half a century relationship, not only formed our lives but who we were to become moment by moment. I realized I was mom’s sister, por ejemplo, only in the brief moment that she saw me as her sister. Undoubtedly, we were radical historical and relational beings.

I can’t help to think about how social relationships, including relationships within the context of westernized therapy look like when we are to arrive at the encounter with someone else not with certainty (or doubt of) of who we are as therapists but with clarity about where we come from—as historical beings. This shifts away from the mainstream conceptualization of the therapist as an empty (no history) interventionist, solely performing according to the regulations of the institution and professional Eurocentric theories to be good or effective therapists. As historical therapists, instead, we become available to engage and receive the encounter with another, attending carefully to our histories, intentionalities and how we are shaped by the experience of the encounter. Thus, similar to who I became when visiting mom, who is the therapist is not independent from the encounter with who consults. The therapist becomes a therapist in the encounter with the person who is consulting. This shift requires an initiative to des-institutionalize the therapist, and to foreignize westernized therapy perspectives that situate an ahistorical therapist.

The Sensorial Grammar and Temporality of Memories

As mom’s cognitive abilities continued to deteriorate, it seemed as if for those of us around her, her presence in this world began to disintegrate into oblivion. She was talked about, no longer engaged with, her body moved from one place to the other, and words were put in her mouth, at times necessarily. Her existence was for the most part reduced only to her possibilities, or lack thereof in her present, in the here and now. Although her body was present, the growing absence of thought, reason, and the ability to access frameworks of intelligibility to express ideas in the present moment seemed to cast doubt on her very existence. Hence, if we were to recognize mom’s existence and vivid presence in this world, it required us—decolonially speaking —to overcome modernity’s spatial (here), temporal (now), universal assumptions. It also meant to cast doubt on the overemphasis on cognitive function, (capitalist) productivity, modern storytelling (or framework of intelligibility), and conversational skills as the only ways of being or existing. Then, it became more possible for me to continue to relate to mom, to learn from her, and to be transformed with her.

I came to understand that the sensorial had become the grammar of our communication, through memories. Mom’s life was unfolding through her bits of memories that situated us in their respective temporalities. Although evoked in the present, mom’s slivers of memories were transgressing modernity’s contemporary framework, its universalized linearity—past, present, and its spatial metaphysics that places the present as the monopoly for the principles of what is real and represented as real. She brought me into her life to take part in events that were happening before I was even born. When some of the aides or co-living folks would overhear our conversations at the nursing home, however, it was not uncommon that they would mistakenly “correct” mom’s temporality when instructing her about their (modern) sense of time—the time most of us operate under. They would persist in telling mom what year, place, and person she was, alluding to the calendar present even though it did not match the temporality of her memories. I could see in mom’s face deep concern and confusion by their efforts. She was in complete disbelief and shocked by how wrong and confused they were.

“What are they saying?” She would ask me.

Thus, even as an unborn person, unquestionably I was mom’s companion through the pieces of her history from a time that for folks in the nursing home and in the majority of the Eurocentrically educated world, was not chronologically feasible. Both of us experienced those brief moments often to resolve whatever concerns she may have had, at times involving her parents and siblings—my grandparents, aunts and uncles, all biologically dead—and her childhood home in La Candelaria, in Bogotá’s historic downtown. She worried if we had locked the house after we left, or if we had brought the keys with us, if we had enough time to eat dessert and get home in time before her younger sister, Estella, would get there, or Alberto, her oldest sibling, would pick us up. It seemed as though the sensorial grammar of our communication implicated mom’s entanglement with what decolonial theorist Rolando Vázquez calls a relational idea of time and space that doesn’t have either a geometrical, chronological, linear, or circular understanding of time like modernity marks reality.

I got a sense of the temporality of mom’s memories not by asking mom her age, since she no longer had reference to that kind of time-thinking. Modernity’s temporality—defined by calendar date, clock time, age, or generations—were not determinants for tracking her stories or a reference to time. Instead, it was the people who featured in that memory and its setting that gave me a reference to the time of the events, making them feasible. Her experience in the present was happening through her history—that is, through her memories from a time when her parents were alive, she was living in la casa de La Candelaria with her siblings, and I had not been born. Hence, there were no westernized life span or human developmental theories that would serve as frameworks to interpret her experiences.

Instead, the vegan cheesecake de maracuyá of La Despensa, the bakery around the corner of my rental, would bring to the surface memories that contained mom’s lived experiences with their own temporalities in no specific order. Events would unfold through particular relationships and their settings. Her memories jumped from one moment to the other according to what the cheesecake called for, and I jumped along. Following her memories was more helpful than listening to them from assumed theories of time, stories, and development. I would say, decolonially speaking, that relational time re-dignified mom’s existence that modernity’s capabilities of erasure through its overinflation of cognition, the contemporary idea of time, and the metaphysics of presence had rendered it suspicious. For modernity, Alzheimer’s had placed mom in an evacuated present time—with no history. She was seen as living in an empty time like Walter Benjamin’s because all that counted as a measurable reality was no longer mom’s reality. Thus, on the contrary, from de-modernity, I would say that by radical listening to the plurality of mom’s lived experiences in their own terms that modernity destitutes through erasure, the senses restituted.

Sensorial Invocation

One of the settings or temporal references that would come up quite a bit in mom’s memories was the colonial casa de La Candelaria of my grandparents. It was the house where mom and her siblings were born and raised until she married dad. This was also the house that kept many explanations of the scars still visible in my body—head, knees, and face by roller skating throughout the house from one patio to the other, running up and down, and playing with my sisters on the swing set by the large fig tree in the back patio still standing. Every weekend mom would take us to visit our grandparents. The house was finally sold to an Italian man much later after my grandparents died. He renovated it into a hotel, maintaining its colonial architecture.

Late afternoon on Sundays when Bogotá’s traffic would be more bearable, I would drive mom from the nursing home to la casa de La Candelaria. The first time we got there I was dying of anticipation for the memories and experiences we were about to live together and for what I was going to learn about mom’s history once she would see the house and the colonial neighborhood. I was hoping that seeing the material presence of the house we have visited several times, through her memories, imaginatively, from the nursing home, would call upon a flood of pieces of memories here and there, unleashed from Alzheimer’s and running loose through La Candelaria’s narrow streets, passing through la Catedral Primada were she married dad, right across from the presidential residence, el Palacio de Nariño.

Overjoyed, I would yell out calling and pointing out various landmarks of our shared history through the neighborhood. I had not been there in years! It was extraordinary to be back. To my surprise and quite a bit of disappointment, my persistence in calling upon mom’s memories was futile. The house we had been at through the memories evoked and configured from the sensorial grammar of our relationship was not the material house of la casa de la Calle 11 con 2nda in the year 2023, nor its representation. It existed in a different temporality.

Over a year after mom died, cousins on my dad’s side, my sisters, and I were finally able to arrange a time to meet in Bogotá and drive to my dad’s family farm in Sasaima, one hour away with no traffic, to bury mom’s ashes. She is buried next to my dad’s, my paternal aunt’s, and paternal cousin’s ashes. They are overlooking the mesmerizing landscape of the Andes mountains, surrounded by the farm’s variety of lush vegetation that my dad had a deep connection to. The scars on my body that la Casa de la Candelaria could not explain, the farm in Sasaima could from rolling down the hills, swimming, and barbecuing with my sisters and cousins during the various trips with dad’s family growing up. Unlike the scars of the women working at the nursing home, these were privileged scars of a life from the minority in Colombia also living in the midst of Colombia’s armed conflict. Privileged and all, even so, neither la casa de La Candelaria nor the farm in Sasaima were exempt from becoming sites for violence where kidnappings took place of an aunt and cousins on both sides of the family while I was still living in Colombia.

During our day or weekend trips to the farm growing up, at lunchtime the family would get together and sit around the large dining table to eat what the land offered–herbs, vegetables, and fruits among other foods. We were always served delicious vegetable soup with cilantro. In the diaspora, I have experienced being at that table and sipping soup with cilantro millions of times. Cilantro calls on that memory. In a split of a second, cilantro opens the door for me to enter into that moment although I am on U.S. soil. It brings me to the sensing of the taste of food, the light coming from the wood windows, the touch on my skin of Sasaima’s humidity in the mid 70’s, and the crackling sound of the straw woven mats. I can’t recreate that experience otherwise. I’ve tried. I can see static images but can’t experience the sensation of being there that cilantro brings to life.

Returning to the farm in 2024, I was amazed by being at the same table, eating the food of the land, and soup with cilantro. I couldn’t believe it. It did not take me too long to realize though that it was a different “coming back,” it did not feel the same as the experience of the memory from the diaspora. It was as if the memory linked to cilantro existed in a life with a different temporality, in a parallel reality, yet intimately connected to the material farm. Just like mom’s experience of driving by la casa de La Candelaria in 2023, the vividly sensed farm within my connection to cilantro also belongs to a reality that was embedded in a different temporality, and therefore a different relationality. It is a place I can no longer drive to on my own—no matter the traffic or the day —but I can taste my way to it.

In connection to a decolonial premise, I would say that la casa and the farm exist in memories that do not subscribe to an understanding of modernity’s contemporary, its linear temporality, and notion of reality as presence. Although I would say that our memories surfaced in the present as expressions from a relational time, relationally, not always on our own volition, but under certain circumstances, such as sensorial. According to Vázquez, these memories, like all our memories, live in a plurality that is always moving. Hence, memories are not chained to a particular date or someone’s age in a dead or static past, for example. In that sense, these memories are not representations of the material in the present—mom lived certain moments of her day at La Casa de la Candelaria while being at the nursing home, but could not recognize the material house on Sundays when we drove by.

Our lived experiences live in our memories and grow their own heartbeats, giving us life. We are made of memories, collective memories, with their own lives, sensings, and times. Our existence comes from those memories. Thus, it might be more suitable to say that memories are beside us. They are not deep in history but wide in history, next to us or in front of us, accompanying us, guiding us, and constituting our lives, even though they do not always show up in the present, unless relationally and sensorially called upon.

Like my memories, mom’s seemed to be interacting with other memories, perhaps being that the reason why it was possible for me to join her in a moment in her life when although I had not been born, memories of my aunt, uncles, grandparents and the house better helped me to be there for her and with her. Therefore, although mom’s ability to recall events that took place in the nursing home that morning, an hour ago, or last week kept dwindling, her memories interconnected to mine and our senses kept alive aspects of what she had lived, shaping how she lived, and continue to live through us, her four daughters’ memories and the memories of all she had contact with, perhaps even before she was born.

Her existence spilled over modernity’s placed boundaries of her skin to re-exist via her relational memories in a relational time that has kept her alive after her biological death. Mom got to re-exist, inadvertently putting doubt to and rendering suspicious for me modernity’s persuasive cognitive driven and over inflated perspectives that previously rendered mom’s life doubtful and suspicious, when her life was reduced to be only cognitively spoken about.

Re-existence: Restitution by De-institutionalization

After getting over my disappointment from my mom’s unexpected response to La Candelaria, I chuckled a bit and rolled my eyes while driving back to the nursing home before it got dark. “Really?” I thought. Although I had been experiencing and learning from the ongoing and uncertain movement of my relationship with mom, and attentive to what the unpredictability that each bit of memory would offer to us, my over-a-decade of experiences as a therapist, academic, and researcher—Eurocentrically trained—couldn’t help it but to show up.

I realized that I had begun to identify a pattern of response from mom to “study it” and identify its conditions or context. I tried to generalize it by manufacturing similar conditions for the sustainability of the pattern of response. I wanted to replicate it. In doing so, I was attempting to manipulate mom’s response at my will by driving her to la casa. Ugh! I was guided by my own assumption and best intentions to create a “happy” moment for mom. I am fairly confident in saying that this is somewhat similar to modernity’s logic of knowledge production in therapy.

Based on the therapeutic model’s theory of change—or what the therapist believes (based on research) makes people “happy” (well, stable, healthy, or problem free etc.), interventions are identified with expected outcomes (via research or clinical case examples) to be replicated (mostly to a homogenous population). Such interventions are technified or manualized for easier distribution, consumption, and implementation for others to use with the persuasive generalized promise of delivering an outcome of change to help a-historical people. I am afraid that by doing so, I was imposing a boundary between the subject (investigator) and object (mom) to arrogantly identify sensorial tools for change, to technify and manualize our relationship based on modernity’s arrogance to self-define what is good for others.

Very gladly so, unintentionally perhaps, mom sort of delivered a candid middle finger—not the first nor the second in her life—at my attempts at technifying our relationship. I received her delivery happily. I had re-institutionalized our relationship, losing sight of the possibilities that come from the borderlands, memories and their sensorial grammar, relational time, and defamiliarization from modernity’s logic of erasure.

Mom’s implicit middle finger reconnected me to our lived experiences to sense more clearly what institutional practices do and fracture, like the institutionalization of the land, bodies, relationships, healing, and histories. Thus better discerning deep connections—being from here AND from there—to my home-land, in various relational times, my languages, and relationships with the people I owe my existence to, the food the land offers, the Andes where my parents ashes are spread, la casa and the farm along with their explaining histories, the Bogotá altitude, the strangers in the street, the acquaintances of the bakery around the corner, and the long-time friends and the people they owe their existence to. These are the sort of experiences that contribute to de-institutionalizing my work as a therapist and training therapists, to begin conceptualizing our work first and foremost from the histories that make us.

Author’s Note: I want to thank Jill Freedman & Gene Combs at the Evanston Family Therapy Center and their 2024 training cohort for listening to my reading of an earlier version of this story, which helped me revise it. 

Successful Use of Haleys Strategic Model of Family Therapy

As a marriage and family therapist, I often find myself drawn to the road less traveled. In a field dominated by well-known approaches like Cognitive Behavioral Therapy and psychodynamic therapy, I’ve discovered the beauty and power of a model that, while rarely discussed in contemporary literature, possesses a distinctiveness that sets it apart: Haley’s Strategic Model.

Challenging the Traditional Model of Therapy

At first glance, this approach might seem unconventional, even daring. Its directive nature challenges the traditional therapeutic stance of non-directiveness, opting instead for a proactive, solution-focused approach. This alone makes it a rarity in today’s therapy landscape. But it’s precisely this departure from the norm that makes it so intriguing and, in my experience, incredibly effective. This therapeutic method stands out for its bold departure from traditional therapeutic approaches as it challenges the status quo of non-directiveness and passive exploration. Numerous clients shared with me the allure of a solution-focused approach, which they did not think was possible given the passive exploration they had come to expect from psychotherapy. What truly sets this model apart is its emphasis on strategic interventions. Rather than probing into the depths of past traumas or exploring abstract concepts, this model is all about pinpointing the problem, devising a plan of action, and executing it with precision. It’s like a finely crafted puzzle, where each intervention is strategically placed to unlock the path to change. But make no mistake — this approach isn’t for everyone. It takes a certain type of therapist, one who isn’t afraid to roll up their sleeves and dive headfirst into the complexities of family dynamics. It requires a keen eye for patterns, an intuitive understanding of systems, and a willingness to challenge conventional wisdom. More importantly, it takes a deep sense of empathy and compassion. Despite its directive nature, Haley’s model is rooted in collaboration and understanding. It’s about meeting clients where they are, acknowledging their struggles, and empowering them to take control of their own narratives. Using this therapeutic method isn’t just about following a set of techniques; it’s about embodying a mindset — a mindset that sees problems not as obstacles, but as opportunities for growth and transformation. It’s about embracing the uncommon, the unconventional, and the uncharted territory. In this model, two key techniques stand out: strategic interventions and paradoxical techniques, each serving as powerful tools in the therapist’s toolkit. So, what does it take to steer the ship in Haley’s Strategic Model? Effective implementation hinges on a blend of qualities and skills that go beyond the traditional therapist toolkit. Patience, creativity, and adaptability are essential, as is a keen understanding of family dynamics and systems theory. Being able to think on your feet and pivot strategies as needed is crucial, especially when faced with complex and ever-changing family dynamics. Balancing the directive nature of Haley’s approach with collaboration and empathy requires finesse. While strategic interventions are at the core of the model, it’s equally important to create a safe and supportive environment where clients feel heard and understood. I’ve found that taking the time to build rapport and establish trust lays the foundation for successful therapy. It’s about finding the delicate balance between guiding clients toward change and empowering them to take ownership of their journey.

Clinical Application of Haley’s Model

Strategic interventions are precisely targeted actions designed to disrupt dysfunctional patterns and facilitate change within the family system. I recall a client, let’s call her Sarah, who sought therapy for her strained relationship with her teenage daughter. Sarah felt overwhelmed by her daughter’s rebellious behavior and constant defiance. During our sessions, I introduced a strategic intervention by prescribing a specific communication exercise for Sarah and her daughter to complete together. This task aimed to improve their communication skills and foster a sense of understanding and connection. As they engaged in the exercise, Sarah and her daughter began to open up to each other in ways they hadn’t before, leading to a breakthrough in their relationship dynamics. Paradoxical techniques, on the other hand, are seemingly counterintuitive strategies used to evoke change by embracing resistance or amplifying symptoms. In another case, a couple, let’s call them Mark and Lisa, sought therapy for their constant arguing and power struggles. Despite their initial reluctance, I introduced a paradoxical technique by prescribing a “fight schedule” where they were only allowed to argue at certain times of the day. This approach initially seemed absurd to Mark and Lisa, but as they adhered to the schedule, they began to realize the futility of their constant arguing and started to communicate more effectively outside of their designated “fight times.” Of course, navigating the directive approach isn’t without its challenges. Resistance from clients can arise, whether it’s skepticism about the effectiveness of strategic interventions or discomfort with the idea of change. In these moments, patience and perseverance are key. I’ve learned to approach resistance with curiosity rather than confrontation, exploring the underlying fears or concerns that may be driving it. One striking example of overcoming resistance involved a young boy, let’s call him Max, who was brought to therapy due to behavioral issues and defiance at school. Max had a history of pushing back against authority figures and was initially resistant to the idea of therapy. He viewed it as just another attempt by adults to control him. Instead of adopting a traditional authoritarian approach, I decided to honor Max’s self-determination and autonomy. I engaged him in collaborative discussions, allowing him to voice his opinions and preferences. Together, we set goals for therapy that aligned with Max’s interests and values, empowering him to take an active role in his own treatment. As therapy progressed, I introduced strategic interventions tailored to Max’s unique needs and preferences. For example, instead of prescribing specific behaviors for Max to follow, I invited him to brainstorm alternative solutions and encouraged him to take ownership of his choices. Over time, I witnessed a remarkable shift in Max’s attitude towards therapy. His resistance softened, and he became more open to exploring new perspectives and strategies for managing his behavior. By honoring Max’s self-determination and empowering him to be an active participant in his therapy, we were able to achieve meaningful progress and foster a sense of agency and empowerment within him.

***

From its directive nature and emphasis on brief interventions to its strategic focus on systemic change, Haley’s model has provided me with a refreshing alternative to traditional therapy approaches. By harnessing the power of strategic interventions and paradoxical techniques, I have been able to navigate complex family dynamics with precision and creativity, fostering meaningful change and empowering my clients to lead more fulfilling lives. While a bit intimidating earlier on in my career, I have enjoyed, and my clients have benefitted from embracing the innovative and the unconventional and daring to explore new horizons in my practice. With this therapeutic method as my guide, and of course, my clients’ willingness to trust me and enter into new territory with me, new opportunities for growth and transformation have revealed themselves. Questions for Reflection and Discussion In what ways have you traveled unfamiliar roads as a therapist? What model of family therapy works best for you and why? What do you find most rewarding and challenging in doing family therapy?

Julie Bindeman on Reproductive Mental Health Care, Dobbs, and Beyond

Lawrence Rubin: Hi, Julie. Thanks so much for joining me today. You describe yourself as a reproductive psychologist whose specialty centers around reproductive challenges related to fertility, pregnancy, and abortion. Did I get that right, and can you elaborate a bit on what this professional identity means?
Julie Bindeman: Reproductive Psychology is not the kind of specialty you’ll find in graduate school departments. In fact, I’m working with some colleagues to look at what is the curriculum around reproductive health in graduate programs these days. Thus far, it’s not as encouraging as I would hope it would be.
The reproductive time period actually can be anywhere from the time somebody begins to menstruate or begins the ability to produce sperm, all the way to—for men and cisgender men—more so end of life, and for cisgender women into the early 40s-ish (from perimenopause through menopause). So, it’s several decades of a person’s life.
For so many of those decades, cisgender women in particular, spend time trying to avoid pregnancy. It becomes very interesting when everything that we’ve been taught about preventing pregnancy gets turned on its head when we want to become pregnant. We have a lot of conversation in our schools about sex ed, but we don’t have any about fertility and what that means and what that looks like.
So it’s the whole gamut between the attempts at getting pregnant, even deciding, “Do I want to have a family,” and considering that; “Do I want to have a family now with this person, do we feel like we’re compatible;” all the way to, “We’re struggling to get pregnant and we need to seek out a reproductive endocrinologist for infertility,” which is a very specialized doctor.
So, I think, because there’s a specialty in the medical world, and because psychology is a little bit slower to catch up, historically speaking, the idea of a moniker of a reproductive psychologist provides some clarity about what I do, which is different than other psychologists, but also is a very particular niche that involves a lot of study.   
LR: This reminds me of a cartoon I once saw of two girls sitting on a park bench, reflecting on their lives ahead. One of them says, “Well, I think after my second divorce, I will…” It makes me think, Julie, that although the reproductive age physically starts around puberty, people’s ideas of reproduction and parenting and maybe even fertility—probably begin before they were born. Perhaps, a reproductive legacy.
JB: There’s a concept called the “reproductive narrative.” It encapsulates the idea that we all start having a reproductive story early in life, and that story changes, and it’s just as valid of a story if someone is not interested in parenting as it is if someone is very interested in parenting. And when we meet potential partners, we have to see how our reproductive stories mesh, and sometimes they mesh really well, and sometimes there needs to be some negotiation.

Reproductive Mental Healthcare in the Era of Dobbs

LR: If part of the reproductive narrative entails a chapter on the act of becoming pregnant either willingly or unwillingly, then I would think that part of that narrative, from the perspective of a reproductive psychologist, would include discussions around abortion.
JB: Here, let me assist you with it. One of the big concerns for some clients who come to me about deciding whether they should get pregnant or not, is, “Is it safe for me to carry a pregnancy in the state in which I live, and if it’s not, do we need to move?” They explore concerns like, “Do we need to move just for our pregnancy?” In certain states, people are really putting their lives on the line just to have a family.
LR: I’m not going to hide the fact that part of my intent for this interview was my interest, as I hope it will be the interest of many of our readers, in how the Dobbs ruling has impacted mental health clinicians working in the area of reproductive health. In that context, and first, how has Dobbs impacted Julie, the person of the therapist? We’ll get to Julie the therapist later.
JB: I wasn’t surprised. When the leak came in terms of what the ruling was going to be, there was already so much talk about. People were saying, “this can’t be it,” and “they’ll never do that,” and “we’re talking about established precedent for 50 years.” Unfortunately, I was sitting there saying, no, this is it, this is what the intention is. It’s only going to get worse from here.
I remember even having a conversation with my dad, who said, “No, that’s just like hysterical thinking.” Looking back to when the Dobbs decision was finally released, I wish I could say I was surprised. I was not! I had been seeing this coming since Trump was elected, quite honestly. That was the reason that I marched the day after the inauguration. I could see it coming. It was very clear to me that they were going to use whatever mechanisms of power that were available to restrict reproductive rights. So that was one part.
As a mom of someone who was born a cisgender female, I was and am also worried because my child has their whole life in front of them, and you know, I’m not sure if they’ll have a family or not. They might. They might not. That’s yet to be seen. So, I’m concerned for what their choices might look like and what is available.
I have two kids that were born cisgender male, and I worry about them and their potential partners. I knew this was going to impact IVF too. So, when the ruling in Alabama came down, people were like, “Oh my God,” and I was like, “Yeah, no, of course it’s going to IVF next, because the logical conclusion is personhood and personhood being conferred to an embryo.   
LR: The second part of my original question is, “How has Dobbs impacted the way that you are in the room with clients who are thinking about it or going through the abortion process, and what advice springs from that for other clinicians doing it or thinking of doing it?
JB: I happen to live in a state (Maryland) that is very protective of reproductive rights and, in fact, has a shield law. I submitted a letter to the committee that was reviewing it when it was a bill to say that in addition to physicians, let’s protect mental health professionals, because I think that’s an important inclusion that we have, in terms of what we might know.
When I think about worst-case scenarios, I think about people connecting the idea of personhood or person status to a fetus, and then connecting it to laws that already exist. So, if you don’t realize you’re pregnant and you have some wine, is that now endangering the welfare of a child or child abuse? Or if you have an abortion, is that considered child abuse, feticide? I think they will go after women. Even though right now they’re going after physicians, I think they will go after women eventually. It just makes logical sense to me. So that’s sort of my catastrophizing, but again, I don’t think it’s that far off.
As a therapist, I think there have been several weeks of my career that have been indelibly difficult, and nothing I learned in graduate school has been helpful. I was a grad student during September 11th in Washington, DC. That was tough because how do you process an experience with someone when you’re living it too?   
And I would say that for my clientele, the next time I had that experience was the 2016 election. I had clients, who, like me, were grieving, because we saw what the implications could look like.
And then I would say that the third time it happened in my career was the Dobbs decision. I had people calling who were panicked about it. “Are my embryos safe?” was a question I got asked a lot by clients, and I would be like, yeah, for now they are—you know, again, depending upon where you live.
Many of my clients were feeling helpless and angry, and of course, I shared that sense of anger and righteous indignation. I think it’s really challenging to be a clinician when you’re experiencing in real-time exactly what your clients are experiencing too, when you don’t necessarily have the perspective that often we are able to bring to our clients, when we’re not living what they’re living. When we do live what our clients are living, it’s so hard to have that sense of perspective, because our fear centers get activated, or at least mine does.
For clinicians who are either practicing or considering practicing in this domain, it’s important to know your state laws and how they apply to you. If you’re a clinician in Texas, for example, where they have that SB8—which is the bounty hunter laws that it’s so lovingly referred to as—clinicians are in danger under what that law is, and it is a civil penalty. So, anyone can rat you out for any reason, especially if they’re motivated by money. It’s a $10,000 fine. That’s not nothing! Most of us might not have that lying around to pay. So that becomes a very real risk.   
There are other states that are starting to look at that. There are other states that are looking at assisting minors in having abortion care. So as clinicians, I think for the time being, HIPAA protects us, but it’s really important that we are careful about what we say in our notes because notes can be subpoenaed. And so, if I’m talking to a client about an abortion they are planning or an abortion they had, I’m not going to come out and write, “… spoke about abortion.”
I might say something like, “spoke about family planning” and have it be really vague. I think those of us that are practicing in PSYPACT states also need to be aware of what are the other laws in the states where our clients might be sitting in that we don’t necessarily know because they’re not necessarily connected to the statutes that relate to psychology.   
LR: Would you say there is a dividing line/light switch moment between the way you walked into the room pre- and now post-Dobbs? On the morning after, pun fully intended, did you walk in more nervous, more fearful, and aware of having to be far more conservative or careful with your words?
JB: As a clinician who is very up to date on the laws of my state, which I know most others may not be, I’ve been an advocate for many years. I’ve helped to lobby to get some of those laws passed. And so, I wasn’t concerned, because I knew my state legislature—and in a lot of ways, I know many of them personally—that they were going to protect reproductive rights, and that is what they have done the last couple of years too. So, they did not disappoint.
Our state has done some really great things. As I said, they passed a shield law, they’ve expanded who can perform abortions. So instead of it having to be only a physician, it’s been expanded to physician assistants, nurse practitioners, and midwives, which is awesome. More care, we like it! Our Governor has gotten our own sort of storage of mifepristone and misoprostol— ‘mife’ and ‘miso,’ as it is.
So, I didn’t feel that light switch. One of my best friends who lives in Texas did feel that light switch. She had also been living under SB8 two years prior, so she was not surprised. She had had some time too, to be like, okay, now we’re really going to do this because we don’t have the Supreme Court protections. What’s happening in Texas is legal versus legally dubious.   
LR: It sounds like one doesn’t even have to identify as a reproductive psychologist or work in concert with physicians to experience these issues, because anyone who practices couples therapy or family therapy might find themselves thrown into this reproductive ring. As such, it’s just smart to know your state laws, to connect with advocacy resources, and to be very, very careful of what you’re saying and how you say it. And based on your writing, you don’t bring up abortion explicitly but talk in hypotheticals.
JB: One of the things I do as a reproductive psychologist is to conduct third-party evaluations for prospective gestational carriers. And as part of that conversation, we talk about abortion and because they are not pregnant, there’s no concern. I can talk about abortion till I’m blue in the face. They are not pregnant. Everything is a hypothetical.
But I may talk hypothetically, if they live in Texas and there is a problem with the pregnancy. I may say something like, “You are now eight weeks pregnant. You cannot get care in Texas. Let’s talk about where you can go to get care? You know that your doctor is not going to be able to save your life should your life be on the line unless it’s really dire and, you would have to ask yourself if this is something I want to risk?” It’s about looking at each client’s risk profile, which has changed since Dobbs.   

Abortion Counseling as Mental Health Care

LR: But, outside of these specific evaluations, you also do what you might call generic psychotherapy, where the issues may, but most likely will not come up. We are traditionally taught not to bring up religion or politics unless the client does, so is it the same when it comes to reproductive health and abortion if a client doesn’t broach the subject?
JB: Of course I bring it up. I bring it up because everyone thinks that once you get pregnant, it ends with a baby, and that’s just not the case. Not that I’m trying to freak my clients out that are newly pregnant and excited and whatnot, but we talk about, “Hey, have you had a conversation with your partner, should this pregnancy go in a way that you don’t expect? What might that look like? And, you know, it’s a hypothetical because it’s a very rare occurrence. And, I’d rather you have this conversation before it happens than have to have that conversation for the first time as it is happening because it’s just too much to unpack in that moment as you have to make a critical decision about the pregnancy.”
LR: You describe abortion as healthcare. Would you say that the kind of counseling that you do considers abortion as mental health care?
JB: Absolutely. I come at this from the side of the law of my state, which is specific in saying that mental health is a reason for someone to obtain abortion care past 24 weeks. I also come to it from a religious perspective, which may sound kind of odd, but in the religion that I grew up in and that I practice, which is Judaism, one of the tenets is that you save the existing person at all costs. My religion doesn’t see a developing fetus as an existing person. It sees it as a potential person. So, unless that fetus is basically sticking out of someone’s vagina—sorry to be so graphic—and has taken a breath, it is not a person.
LR: I just want to draw reader’s attention to a chapter in your new book that has a comprehensive table called, “Religious Points of View about Abortion.”
JB: When people think about this, and they’re like, “oh, but I don’t see people who are having babies because I work in geriatrics, or I work in pediatrics. This isn’t important to me. I don’t need to know this stuff.” And to that, I say, “actually you do, because how are you talking to your parents of the kids you work with about, what was the reproductive story that that child was born into? Were there losses before that child was born? After that child was born? Was it a long journey? Was it an uncomplicated journey? Was it fraught, and you weren’t sure this baby would ever get there? This is in addition to, was the baby in the NICU or anything like that, that you’re going to want to know about your patient.”
I also think it’s important because if we’re seeing young kids, their parents are often trying to expand the family, and sometimes it doesn’t work as easily as the first time. And so, how do you support a young child who knows there’s something happening with their parents but doesn’t know what it is and doesn’t have that understanding of what infertility might be or pregnancy losses might be? How do you help the parents talk to their child about it? How do you help, as a therapist, talk to the child about it, give them a place to have their own thoughts and expressions?   
For those that work with an older population, and I’ve had older clients who have been still traumatized by the Dobbs decision, because of the abortion they had in the 70s, either pre-Roe or post-Roe. Or even talking about how this is going to impact so many people and having that empathy for it. And that sadness of what I thought I knew, what I thought I could trust, that 50 years of precedent went down the drain.
So, it’s come out in lots of different age groups, and I think it’s really important. I’ve had male clients talk about it too, their concern about abortion and it not being an option—and not in that kind of cavalier, like, I don’t want to deal with that kind of way, which I think we often ascribe to men when we’re talking about abortion. That doesn’t seem to be the case, but somebody I care about might be very impacted by this.   
LR: What are some of the myths around abortion that clinicians—whether reproductive clinicians or not—need to consider when abortion enters the clinical frame?
JB: So let me first dispel a couple of myths that have existed about abortion. Abortion does not cause future infertility. Although I can’t tell you how many of my clients who had abortions when they were younger, and then as they wanted and were ready to have a family, struggled with infertility, how they made that causal. But I’m like, nope, there is nothing causal to that.
Abortions don’t cause cancer, so that’s really important to know. Also, there is no such thing as post-abortive syndrome. That is not a thing. I appreciate the American Psychological Association for a deep dive that they did in 2008. And one of their conclusions was, nope, there is no need to add something to the DSM about post-abortive syndrome. It is not a thing.
What I think is important for clinicians to think about is what research tells us, which is that most people with access to abortion feel relief. Now, there are some circumstances like terminating for medical reasons—I’m not lumping that into that. That’s a very different, specialized circumstance. But the majority of people who are seeking out mostly first-trimester abortions experience relief—95% of them!
In that 5% who might not, they might experience regret. And where this gets confabulated is the idea that regret becomes mental illness versus regret is a feeling just like lots of other feeling experiences a human can have. And it is a feeling that will come and go. And so, we don’t need to pathologize regret!   

A Reproductive Psychologist’s Personal Journey

LR: For those among our readers who have read some of your other work, can you give us—and I don’t mean to diminish it in any way—a little bit of the experience you had as Julie, the mom, along your own challenging reproductive journey?
JB: When people ask me how I found this work, I tell them I came to it honestly. My early grad school experiences centered on teens and kids. That’s what I was really interested in, and so I worked at a high school, where one of my seniors was pregnant. The way the school managed it was incredible. They threw her a baby shower, and when the baby was born, different people watched the baby so she could still go to class so she could graduate on time. What an incredible community to circle around her and help her. It was amazing.
As I continued, I worked at another school that was Catholic, and one of my seniors got pregnant. That was a very different experience. It was interesting in that conversation where we had to sit with the mom and tell her what was going on, and the mom was like, okay, cool, we’ll get an abortion. And the kid was like, nope, I don’t want that.
At the time, I didn’t make much of those experiences. I later had my own kid. When he was about 18 months old, my husband and I reflected on how great he was and decided we needed another one because the world needs another one just like him—since all children, of course, are carbon copies of one another, right?!
We did not have an issue conceiving the second time, although I had in my mind it would be a little harder because I anticipated it would take six months. In retrospect, I guess I was ambivalent, thinking I would have more time than one month. I wasn’t quite ready to have another kid, but there it was.
That pregnancy was over just as soon as it started, when at eight weeks, the ultrasound showed that I had had a miscarriage. It’s called a “missed miscarriage” because it was shown on ultrasound and I had no knowledge of it. I had a D&C. Interestingly, I had begun specializing in postpartum health after my son was born, so after the miscarriage, I wanted to learn the difficulties of the postpartum experience.
We don’t talk about postpartum and how hard it is. We really don’t talk about pregnancy losses which seem to be shrouded in secrecy. So, it wasn’t until my own miscarriage that I realized how insensitive I had been when my friends had had miscarriages. I didn’t know what to say, and so I went to the platitudes, that I think most people go to because we want to be helpful. Rarely are platitudes helpful!
My doctor was optimistic and encouraged us to try again, which we did. I became pregnant very quickly, and while everything seemed to be progressing in those early weeks, I was bleeding. Our anatomy scan at 20-weeks suggested that we have a second opinion. We were referred to a maternal fetal medicine specialist (MFM), where we learned that our baby had hydrocephalus, and ventriculomegaly, in which the brain ventricles were measuring much larger than they should have.
We were told that the best-case scenario was that our baby could live into his 40s with the developmental quality of life of a 2-month-old. That was not a best-case scenario for me! That was not the life I would want to bring into this world, and it was not what I would want to do to my son, not what I wanted to do to my marriage.
We called our clergy and talked about options, one of which was labor and delivery, and the other was that we could drive to New Jersey for a surgical abortion. I was confused because I knew abortion was legal in my state, so why did we have to go somewhere else for surgery? I later pieced together that six months before, a physician named George Tiller, who had performed an abortion in Kansas, was shot to death. His death created so much of a chilling effect that the doctors in my area stopped performing abortions. I ended up having to labor and deliver a little boy who died. It was awful, and both very different, and compounded by my miscarriage. We were later told that this was a lightning-strikes-once situation, a one in a million, and that we should try again when we were ready.
It took me about four months before my cycle came back and my story gets redundant in this way. We tried for one month and got pregnant. I was very nervous during that pregnancy, which we learned was with a girl. I was getting scanned all the time and found out at 18 weeks that the also had ventriculomegaly, hydrocephalus, and partial agenesis of the corpus callosum. Because I was 18 weeks, I was able to access a surgical abortion with one of the kindest doctors to whom I was, and am, very grateful.
We tried again quickly because I didn’t know if I would have the courage to keep trying. And we got pregnant immediately, and this was a pregnancy where I didn’t feel any symptoms, and I was disconnected from it.
At 18 weeks, the MRI showed that we were having a girl and that she was healthy. I was excited and terrified. I asked them to show us the pictures of the last baby we lost and the baby I was carrying, and the differences were so clear. The brain of the baby I was carrying had all sorts of contrasting grays and whites, compared to the blackness in the image of the baby we had lost, which represented fluid. It was a beautiful picture. I went through the rest of that pregnancy fairly terrified, and I think my MFM probably had some vicarious trauma because she had been with me from the beginning.
We went back for my checkup at 36 weeks, and she asked me, “how do you feel about having a baby this week?” I had four more weeks so I said, “I’m good.” She half-joked, “it wasn’t really a question. You’re going to have a baby this week. When would you like to have your baby?” She just didn’t want anything to happen to this child. So, my daughter was born weighing 5 lbs. even. She was fierce. We had a “normal” stay in the hospital, and then they let us go.
When she was about 14 months old, I said to my husband, “hey, so, you know we always talked about three.” He looked at me like, “are you effing crazy?” I said something like, “I must be, but I really want to try for three. If it works, great. If it doesn’t, that’s fine.” And, again, we got pregnant the first time we tried. When we got an MRI at 18 weeks—and this pregnancy just felt so different to me because I was in a place where whatever happened, happened— and my husband was really excited because it meant we could get a minivan. I remember saying something like, “I will not get a minivan unless we have the number of children we might need for a minivan.” He was like, “okay!”Our son was born healthy, and now I have an 11, 13, and an almost 17-year-old. We are very, very done.

LR: I certainly appreciate the depth of your sharing, Julie. when you first started talking about it, I thought, “She’s probably told this many, many times, and it’s going to be very matter of fact.” But you told the story as if it was so fresh, and it just suggests to me that this part of your narrative will always be alive for you, as it problably is an will be for others who have had challenging reproductive journeys.
JB: Can I read you something as you say this?
LR: Sure.
JB: In the acknowledgement section in my book, I write about my story and actually dedicate the book, to the two babies we lost. “…I am grateful for these two babies I said goodbye to before I could say hello to, as they awoke me to the passion for reproductive mental health, and, primarily, the intersection of abortion and mental health.”

Ethics, Competency, and Advocacy in Reproductive Mental Healthcare

LR: This begs the question, “Are there limits to self-disclosure in reproductive psychology, reproductive psychotherapy?”
JB: It’s a really interesting question that I look at from two different vantage points. So, one vantage point is if you’re a therapist with just sort of a normal population, whomever that normal population might be, and you become pregnant, the pregnancy itself is a disclosure, isn’t it? Like there’s a point in pregnancy where you just can’t hide it, and so it’s a disclosure, and I think it’s useful for patients to know so that they can plan, and they’re not surprised.
And then, you know, there can be a lot that might come out in the transference around maternity and nurturance, and things like that. So, I think it can actually lend itself to a lot of really useful therapeutic material. I think if you’re working with the population that I’m working with, I didn’t have a choice but to disclose because I wanted to give my clients an opportunity to change therapists if they needed to. I wanted to acknowledge, “Hey, seeing me pregnant could be really triggering, and I don’t want you to feel like you have to stay with me. Because I get it, and it can be really, really hard.”
It also came out in other ways, like with a client for whom it took months to disclose that, as a child, she had experienced terrible sexual trauma committed by a relative. She was with me through my losses, and she was with me through the birth of my daughter. After my daughter was born, she was able to say she felt like her “badness” and “evilness” contributed to my losses. She felt responsible for them.

LR: That’s very sad.

JB: Yeah! We did some good work around that. Without the disclosure, that work couldn’t have happened. I didn’t show up at my office Friday afternoon after that first ultrasound. So, you know, I had to have someone tell my clients something. And again, lots of interesting things came out from it.

LR: a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional GroupDo the APA, ACA, and NASW have resources for clinicians who are finding themselves in this therapeutic arena, or who are considering or looking for guidance through live contact?

JB: Not so much within the larger professional bodies. Perhaps NASW. I couldn’t tell you specifically. Where I get a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional Group. Thats where a lot of the research and work is being done. APA has had more since the Dobbs decision. Sorry to be pitching my book, that wasn’t my intent, but the reason I decided to edit this book was because there wasn’t anything for the mental health professional that had a client that was now experiencing or considering abortion.

You can’t refer someone out when we’re talking about days or weeks to decide to have an abortion. You have that ethical obligation not to abandon our clients, and we have an ethical obligation to not practice outside of our competency. And so, this book is to fill that gap in between competency and not abandoning clients.

LR: Could you recommend a couple of potential paths for advocacy for clinicians who want to get into it and make a difference that way?

JB: I think it depends on how much you want to do. There are lots of advocacy opportunities such as volunteering for a state delegate campaign in your district and talking directly to them, I found that useful and interesting. Or, talking about it at a City Council meeting where you can go on the record. You can talk about healthcare in that kind of way. These are sort of smaller things that people can do.

There’s organizations like the National Abortion Foundation. They not only have abortion funds through them, but also provide a warm line to people. I don’t think it’s a hotline. They train people so that they can help talk to people that are struggling. So that’s a great organization.

There are lots of local abortion funds. That’s a great way to get involved again, you know, depending upon how involved you want to be. So, for a birthday fundraiser one year, I’m going to pick out an abortion fund. This is where I want my contributions to go, like, contribute to this in my honor.

I have lobbied at the state level, even not in my state. I’m happy to talk to anybody. And my husband had the opportunity to go to the City Council meeting, which is where our delegates were going to talk about what happened in session. He said, “I was going to share our story, but do you want to do it? I can give the time to you.” And I said, “Oh honey, they have heard it from me. They need to hear it from you.” I was really, really proud of him.

LR: It sounds like part of what got you through your pregnancies was you and your husband moving together as a unit. I probably should have asked this question earlier on, but “Have you had the experience of working with any women or families who have been denied abortion?” I know this was addressed in the “Turnaway Study” and is very state-specific.

JB: In my state, that is not an issue for people because it’s so protected here. That being said, I’m part of PsyPact, and was working with someone in a restricted state who had gotten a poor prenatal diagnosis and who was trying to decide what to do. Part of our worked centered around getting more information. A lot of her wait-and-see was about getting further along to get more information about the pregnancy. And every piece of information she got was like adding crap to the pile. There was never good news that she was given. It was just bad, bad, bad, bad, bad.

They got to the point where they felt, “our baby is not going to survive, and this is awful, and I think we’re both ready to terminate the pregnancy.” But she lived in a state where accessing that kind of healthcare was really challenging. She had resources, she was smart, and she had people that she could connect to that could help her connect to other people.

So, initially, her abortion was denied by the hospital. They’re like, nope, we’re not going to do it. And then it was denied by insurance, they’re like, nope, we’re not going to cover it. And the hospital is like, well, if your insurance says we can’t do it, we can’t do it. So, it was sort of this merry-go-round.

She was finally able to get connected to the vice president of her insurance company and shared with him what she had gone through, and what was happening, and what she needed in terms of healthcare. He pulled the strings he needed to pull so that she could have an abortion. But otherwise, she would have had to travel.

And we do see that a lot. We’re seeing more and more people that have to carry to term because they don’t have the luxury of traveling. And while abortion funds are great, they can’t fund the entire expense of traveling and procedures, particularly later in pregnancy.

LR: On that note, I want to alert readers to the importance of the Guttmacher Map, which lists the levels of abortion restrictions by state. Julie, are there any questions I should have asked, or that you would have liked me to have asked?

JB: I don’t know if it’s a question per se, but just something to leave people with. My abortions defined what I do and defined how I work and gave me purpose in terms of the scope of practice. However, they don’t define who I am. They are just a part of who I am, but they are not the defining measure.

And I think when some people experience trauma related to their abortion or traumatic abortions, it doesn’t mean that all abortions were traumatic, are traumatic. But when people experience that kind of trauma, it’s so easy to have it define them, that they become defined by their trauma. We see them all the time in our patients, regardless of what kind of trauma it was. Or they’re trying to run from it so much that they—so they’re not defined by it. Through a lot of work that I’ve done, I feel like it’s a part of me. It’s one aspect of me. It is not the whole description of me, but there was a time where it was—like it was all I was doing.

LR: This ties into your earlier mention of the reproductive narrative and how we are born into reproductive narratives that sometimes define the entirety of our reproductive journey. I’m reminded of clients who bring with them the legacies and trauma of their ancestors, such as slavery, the holocaust, and other atrocities.

JB: Well, if you’re thinking about Norma, who was the original plaintiff in Roe versus Wade, she was the third generation of people who had unintended pregnancies but had no recourse, and she wanted a recourse. What ended up happening in that pregnancy—she had already had two other babies who had gone into foster care and then eventually were adopted—and so this third one, she adopted out because the courts were (are) are really slow.

There is a fantastic book called The Family Roe. The way it is written, and how it weaves it all, is just incredible. I think you asked earlier, too, about what resources are available for clinicians. There is an email that you can subscribe to. It’s a Substack you can subscribe to, and the journalist’s name is Jessica Valenti, and her Substack is called Abortion Every Day. She is really keeping tabs on what is happening on a granular state level, not just federal, but she’s been keeping tabs about like, what is the status of getting abortion on the ballot in different states, and what are the shenanigans that some representatives are trying to do to prevent it.

LR: Clearly, we’ve only scratched the surface, so I’ll simply end by saying thank you so much, Julie.

JB: Thank you, Larry.

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Effects of Social Media on Child Development: Healthy Strategies

Positive Effects of Social Media on Child Development

As a marriage and family therapist, I have found it essential to recognize the positive — and negative — effects of social media on child development in my therapeutic work with families. Social media platforms offer opportunities for young clients to connect with peers, access educational resources, and explore diverse perspectives. Through online interactions, they can develop social skills, empathy, and cultural understandings, enriching their social development.

Additionally, social media provides a platform for creative expression and self-discovery, allowing them to explore their interests and talents. By engaging with educational content and participating in online communities, children and teens can enhance their knowledge and skills in various areas, fostering intellectual growth and curiosity.

Furthermore, social media can facilitate communication and connection within families, especially in today’s fast-paced world. Platforms such as Facebook and WhatsApp enable families to stay connected, share experiences, and support one another across distances. For families undergoing transitions or facing other challenges that put distance, both physical and emotional, between members social media can serve as a valuable tool for maintaining bonds and strengthening relationships.

By acknowledging these positive aspects of social media, I have successfully incorporated them into my therapeutic work with families, leveraging digital resources to promote healthy development and resilience. Through psychoeducation, communication skills training, and family interventions, I have helped to empower families to harness the benefits of social media while mitigating potential risks.

Here are a few practical strategies I have found to be highly useful:

  • Digital storytelling- encouraging families to use social media platforms as a tool for sharing their stories and experiences. By creating digital narratives, families can express their thoughts, emotions, and challenges in a creative and engaging format. This process can foster self-expression, promote empathy, and strengthen family bonds.
  • Psychoeducational resources- sharing informative articles, videos, and infographics on social media platforms to educate families about child development can provide parenting strategies, and useful mental health guidance and information. Providing accessible and relevant information can empower families to make informed decisions and adopt healthy practices in their daily lives.
  • Online support groups- facilitating virtual support groups or forums on social media platforms can help parents to support their children’s connection with peers, the sharing of experiences, and receipt of support. These online communities provide a safe space for families to discuss challenges, seek advice, and build solidarity in navigating the complexities of parenthood and family life.
  • Collaborative goal-setting- using social media platforms to engage families in collaborative goal-setting exercises and activities can encourage them to set specific, measurable, achievable, relevant, and time-bound (SMART) goals related to their parenting practices, family dynamics, and child development goals. By sharing their progress and achievements on social media, families can celebrate their successes and inspire others to pursue their goals.
  • Digital mindfulness practices- integrating digital mindfulness practices into therapy sessions can help families cultivate awareness and intentionality in their social media usage. Encouraging families to practice digital detoxes is a powerful process that includes setting screen time limits and engaging in activities that promote offline connection and presence. By fostering a mindful approach to social media usage, families can develop healthier relationships with technology and prioritize meaningful interactions with each other.

By incorporating these practical strategies into therapeutic practice, I have helped families to harness the positive potential of social media to support them in productively impacting their child’s or children’s development. Through collaboration, education, and mindful engagement, I have empowered families to navigate the digital landscape with intentionality, resilience, and well-being.

Negative Effects of Social Media on Child Development

While social media offers various benefits, it also presents significant challenges and risks to child development, necessitating careful consideration and intervention in my therapeutic work with families. Research has consistently shown that excessive use of social media is associated with increased rates of anxiety, depression, and low self-esteem among children. The pressure to maintain a curated online persona and the constant comparison with peers can contribute to feelings of inadequacy and insecurity.

Moreover, social media platforms can serve as breeding grounds for cyberbullying and online harassment, posing serious threats to children’s emotional and psychological health. Children may experience harassment, ridicule, or exclusion from their peers, leading to significant distress and trauma. Additionally, exposure to harmful content such as violent imagery, explicit material, and misinformation can negatively influence children’s attitudes, beliefs, and behaviors.

Furthermore, social media can contribute to the erosion of face-to-face interactions and family dynamics within households. Excessive screen time and digital distractions can disrupt communication and bonding among family members, leading to feelings of disconnection and isolation. In some cases, parents may struggle to set boundaries around screen time and monitor their children’s online activities, further exacerbating these issues.

To effectively address these negative effects of social media on their child’s or children’s development, I have implemented targeted strategies and interventions with them. These strategies include:

  • Psychoeducation- providing families with information about the potential risks of social media and how it can impact child development.
  • Communication skills training- helping families develop effective communication strategies for discussing social media use and setting boundaries around screen time.
  • Family interventions- facilitating family sessions to address issues related to social media usage, cyberbullying, and online safety.
  • Collaborative goal-setting- working with families to establish clear goals and guidelines for healthy social media usage within the household.
  • Referral to specialized services- connecting families with additional support resources, such as mental health professionals or digital wellness programs, when necessary.

Strategies for Supporting Healthy Social Media Usage

I have also found it essential to equip myself with practical strategies for supporting healthy social media usage among my clients. These have included:

  • Promoting digital mindfulness practices- integrating digital mindfulness practices into therapy sessions to help families cultivate awareness and intentionality in their social media usage. Teaching mindfulness techniques such as breath awareness, body scans, and mindful scrolling has helped my clients develop a balanced and mindful approach to technology use. By practicing digital mindfulness, they have enhanced their ability to regulate their emotions, manage stress, and maintain healthy boundaries with technology.
  • Encouraging offline activities and face-to-face interactions- emphasizing the importance of offline activities and face-to-face interactions in promoting family bonding and well-being. I typically encourage families to prioritize offline activities such as outdoor play, family meals, and creative projects that foster connection and presence. By balancing screen time with offline experiences, relationships have been strengthened and resilience has been cultivated in the face of digital distractions.
  • Modeling healthy social media usage- leading by example by modeling healthy social media usage in my own professional and personal life. I demonstrate responsible online behavior, such as respectful communication, thoughtful content sharing, and mindful engagement with social media platforms. By modeling healthy habits, I have hoped to inspire families to adopt similar practices and create a positive digital environment within their own households.
  • Providing ongoing support and guidance- offering ongoing support and guidance to families as they navigate the challenges of social media usage. I am available to address concerns, answer questions, and provide resources to help families navigate difficult situations online. By offering personalized support and guidance, I have empowered families to overcome obstacles and thrive in the digital age.

Case Application

Recently, I had the privilege of working with a family who were grappling with the challenges of social media use in their household. James and Keisha, the parents, expressed concerns about their teenage daughter, Jasmine, spending excessive time on TikTok and the toll it was taking on her mental well-being. Jasmine, like many teenagers, was drawn to TikTok for entertainment and connection, but often found herself feeling anxious and inadequate after scrolling through her feed.

During our therapy sessions, we delved into the ways TikTok was shaping Jasmine’s thoughts, emotions, and behaviors. We discussed the importance of digital literacy and critical thinking in evaluating online content, especially on platforms like TikTok where trends and challenges can quickly go viral. Together, we established clear guidelines for healthy TikTok use within the household, including designated screen-free times and open discussions about online experiences.

As part of our therapeutic work, we integrated digital mindfulness practices into our sessions to help Jasmine and her family develop a more mindful approach to TikTok usage. We practiced techniques such as mindful scrolling, deep breathing, and engaging in offline activities to promote presence and connection within the family.

In addition to their digital mindfulness practices, the family began implementing a weekly family game night as a routine offline activity. They set aside one evening each week to gather and play board games, card games, or engage in other fun activities that didn’t involve screens. This allowed them to bond as a family, laugh together, and create cherished memories outside of the digital world.

Over time, I witnessed significant progress within the family as they implemented the strategies and interventions we discussed in therapy. Jasmine became more mindful of her TikTok usage, learning to recognize when she needed to take breaks and engage in offline activities. James and Keisha became more involved in their daughter’s online experiences, providing guidance and support as she navigated the complexities of social media.

During one of our therapy sessions, Jasmine shared a digital story she had created about her journey to finding balance with TikTok. Through a series of videos, photos, and captions, Jasmine expressed her thoughts, emotions, and reflections on her relationship with TikTok and the impact it had on her life. It was a powerful moment of self-expression and growth for Jasmine and her family, as they realized the importance of open communication, empathy, and mindfulness in navigating the challenges of the digital age.

As we concluded our therapy work together, I felt grateful to have had the opportunity to support the Thompson family in their journey towards healthier TikTok usage. Through collaboration, education, and support, we were able to empower them to navigate the digital landscape with confidence, compassion, and resilience. It was a testament to the transformative power of therapy and the positive impact it can have on families in today’s digital world.

***

As a marriage and family therapist, I have found it crucial to advocate for positive digital citizenship and support healthy child development. I have also remained vigilant in educating families about the risks and benefits of social media, while providing them with the tools and resources needed to navigate this complex terrain.

Questions for Thought and Discussion

In what ways do you (or don’t you) resonate with the author’s experiences?

How do you address this issue in your clinical work with teens and families?

Can you think of one particular clinical experience around social media that challenged you?

Sasha McAllum Pilkington on Grace and Storytelling at the End of Life

Lawrence Rubin: (LR): Sasha, thanks so much for joining me today. I was drawn to the narrative stories you’ve shared through your hospice work in New Zealand and the incredible way you help the dying and their families. But before we begin, I know you had something you wanted to say about your work with these clients. 
Sasha McAllum Pilkington: (SP): Kia ora, Lawrence. Thank you very much for having me. Tēna koutou katoa. Hello, everybody. My name is Sasha, and I work as a counselor for Harbour Hospice. We provide specialist palliative care for people in the community and have an inpatient unit. I work mainly as a counselor in the community. I just wanted to say that sometimes when I’m talking about practice, I use stories to illustrate what I mean, and I wanted people reading this to know that I do that with the consent of the people that I’m speaking about and with respect to their confidentiality. So, thank you. 

Meaning Making in the Shadow of Death

LR: I'm glad that you started right there, Sasha, because my very first question is, what does your way of co-creating stories with dying clients say about what you believe works in therapy or consultation?
SM: I think being alongside people who are dying, and their loved ones, is very important. When I speak of being “alongside,” I am referring to supporting a person to reflect on their experience and what matters to them in ways where they experience themselves as worthy of respect and holding knowledge about their own life. I think recognizing our shared humanity is significant in working with people who are seriously ill and approaching death. We are all mortal beings with bodies that can become unwell, and we can all suffer. I am no different in this regard from the people whom I meet in my work and keeping that idea forefront in my mind allows me to see the person beyond the illness and whatever changes that imposes. Change is a shared endeavor and, in my view, takes place in the relational space. So, the stories I have co-created with the people I have met show, I hope, a spirit of collaboration and the importance of the therapeutic relationship in generating change. It can be very hard living with a life-ending illness so I hope the writing acknowledges that while showing what might be possible for both the person who is unwell and the therapist.

You might notice that I use some unusual language constructions as we talk. My use of language reflects some particular understandings that I think are important therapeutically. For example, I speak of “the person who is dying” rather than “the dying person” to acknowledge that people are more than the illness they live with. They are more than the problems they live with. As a narrative therapist, I think identity descriptions are important as they influence how we think of ourselves, what we think might be possible for us, and then how we might respond. The identity of “dying person” can limit how the person sees themselves and then influence how they might respond and act.   

LR:
I speak of “the person who is dying” rather than “the dying person” to acknowledge that people are more than the illness they live with
Some might say that hospice work, at the very end of someone's life, either by natural causes or an illness, is the end of a story. But I'm hearing you say something that suggests that the storytelling that you co-create is not simply about an end.
SM: Relationships endure beyond death, don't they? One of the opportunities I get is to talk to people about the kinds of stories that they might like to endure and to meet with families and ask them what kinds of stories they might tell about that person after they have died. This puts me in mind of a family meeting I was part of that took place on a rural property with a farming family. The men were sitting around in their gumboots — big blokes who probably had never spoken to a counselor in their life, let alone been anywhere near one. I was asking the person who was dying how they would like to be remembered, and then the family what stories they'd be telling about their loved one.

At first, the family were shy and hesitant to talk. But as they warmed up, they started to tell some really funny farming stories, which were brilliant. One was about how the man fell out of the tractor and just lay there because he couldn't stand up but had insisted that he go on working. And these men started to laugh as they were sharing these stories from their lives, and then one of them said to me, “Oh, I thought you counselors were meant to make us cry, not laugh.” It was quite delightful. Talking about such stories not only can nurture the relationship with someone after they have died, but they can also make it grow. The written stories we co-create therefore often reflect not just how a person has died but what might endure from the relationship family members have had with them. For example, the published story called “A Small Hope,” which illustrated how a therapeutic conversation brought forward some beautiful memories two young children had of their father, and then how they were developed into legacy stories they could carry with them throughout their lives.   

LR: And perhaps that flies in the face of what the uninitiated believe counseling in hospice to be, which is about sadness, crying, and lamenting. But it sounds like the storytelling that goes on in these last days, or weeks, or months of your clients' lives are not just about sadness and grieving and saying goodbye, but almost like living eulogies.
SM: I think the work really reflects the richness of life and what people have to lose. There are stories of both great sadness and also the savouring of life, and what has been most precious. There is a lot of crying, but there is also a lot of laughter. People walking past my room sometimes wonder what on earth’s going on when they hear all the laughing coming out, and it can change from moment to moment. So, yes, the conversation can reflect what and who has mattered most to a person, the real richness in their life, and ways of living, as well as losses they may be experiencing. 
LR:
I'm always listening for the beauty in people's lives, the stories, the nested stories within whatever we're talking about
Has this particular way of working with the dying and their families over the years changed the way that you ask questions?
SM: Yes, writing collaboratively has changed my questioning. I've been writing therapeutic letters and collaborative notes for decades now and writing stories that illustrate practice over the last 10 years. It has changed both my way of questioning and what I’m listening for, as well.

If I'm looking back on conversations, say, in a transcript, it gives me the chance to really look closely at my questions and to think, “How could I have asked them better? What work is that question doing? Has it been helpful?” That constant examination and thinking about questions has really allowed me to be a lot more intentional and be more skillful in my questioning. At the same time, I think my listening has changed. I'm always listening for the beauty in people's lives, the stories, the nested stories within whatever we're talking about. Just the other night, someone was talking to me about accompanying a family member who was dying and said, “You know, the job of the family is to deeply love,” and it just really struck me. I heard that clearly and in a way, perhaps, that I wouldn't have prior to doing all this writing.  

LR: So, the stories, the notes, that flow from these interviews are, in a sense, love stories, stories of love, and how that's permeated the lives of the dying and their families?
SM: Yes, sometimes. I’m very much listening for expressions of Aristotelian goodness such as love and kindness, compassion, courage, determination, and because I'm listening for it and inquiring into those spaces, it very much comes forth. I was just thinking of your use of love. I mean, it is a form of love, doing this work, I think, isn't it?
LR:
there is an idea that the work is all sad, and what I would say is that it can be both sad and uplifting and enormously meaningful
Well, it certainly is, in my mind, the ultimate act of giving. And if love is defined in part or in whole by giving, then when you are sitting with a dying client and their family, it is, I think, the deepest form of giving. So, yeah, I think it is about love the way you describe it. What have you learned from working with the dying and their families that may encourage others, perhaps those who are sheepish, to venture into this particular domain? 
SM: I really hope that the stories I’ve published will encourage those who are interested in this work, and support them in gaining some confidence and feeling prepared for what they might encounter. I think, as we were saying previously, there is an idea that the work is all sad, and what I would say is that it can be both sad and uplifting and enormously meaningful. This work does require me to be present for suffering and to be able to enter some of the taboo areas of life. But having said that, when people are approaching death, there are also stories of what's been important and what's been good about living, and they can be incredibly rich. For me, I think there's something also about working with problems that can't be solved, that can't be fixed, and being alongside a person and making sense of what's happening… Conversations that generate helpful meaning making, that are transformative perhaps, or reveal the extraordinary in the taken-for-granted. For me, anyway, that's enormously rewarding. 
LR: So, because their futures are so foreshortened and their death is so inevitable, it's not like looking forward to alleviating depression or looking forward to lessening anxiety. It's looking forward to an absolute end and helping them to prepare for that end with the greatest sense of meaning they can.
SM: Yes, indeed. Meaning making is a significant part of the conversation I have with people. Making sense with people about what is currently happening to them as they live with the illness and also reflecting back on their lives. Having a sense of living meaningfully is very important to most people at the end of their lives. Every person's life is different and people bring different things to their dying. However, while our conversations talk about dying and perhaps what they might be afraid of, or what dying means to them, we also talk about living. We may spend time speaking about how they might like to spend the last phase of their life and what is precious to them, for example. 

Narrative Therapy: Discourses Around Death and Dying

LR: Your clinical work is grounded in the Narrative Therapy tradition of Michael White and David Epston, so I’m wondering what are some of the dominant discourses around death and dying that may actually be unhelpful to clinicians working with the dying and their families?
SM: When I first started working in palliative care, I noticed that there were many cultural messages about a “right” way to die and a “right” way to live with an illness that were highly influential in shaping people’s experience of the end of their lives. I learnt that dominant cultural discourses could be helpful for some people whereas for others they positioned them as not getting it right in some way.

One cultural idea that springs to mind is the idea that death is a bad thing to be fought. If you have a curable illness or apply this idea to your experience in particular ways it can be very useful. However, for many people living with an incurable illness, the idea of a fight can start to become unhelpful. It might lead to them fighting the illness at any cost, for example, forgoing quality of life in pursuit of more and more treatments to avoid dying. Or it may position them as either winning or losing a battle, which can be a very unhelpful and limited description for someone who is dying.

Part of my role is to create a space for people to reflect on how they are going about living with the illness and approaching death so they can examine whether they are doing it in ways that fit with their values and what matters to them.

I've illustrated therapeutic conversation with people who have taken up a fighting stance against an illness with different consequences in some of my papers. For example, in the first story that I ever wrote, I met with a man who refused to acknowledge he was dying and was fighting by continuing to work rather than spending time with his family, and that didn't fit with his values. For him, the meaning of fighting his incurable cancer was not abandoning his wife, and he decided to have some enormous experimental surgeries. It was a really important thing for him to do. A fighting stance can work for someone. I can think of another person who had a really traumatic childhood, as did his wife. They had found each other at a young age, and it had been a very happy relationship. And for him, the meaning of fighting his incurable cancer by having some enormous experimental surgery was not abandoning her. It was a really important thing for him to do. The cultural idea of fighting can be both unhelpful and helpful. Dominant ideas aren’t usually good or bad in themselves. However, if they are guiding a person’s life, are unexamined, and don’t fit with their values, they can be problematic. It's more important how particular cultural ideas are applied, the way that they affect people’s relationships with themselves and their experiences, and the meaning they hold as a way of approaching death.   

Another dominant Western idea that can have unintended consequences is the message that we should be positive. In fact, Carla Willig describes the pressure to be positive as a cultural imperative in Western societies. At the end of life, the idea that we must be positive can shut down talk of our mortality and of suffering leaving people alone in their experience. Part of what I do is to listen and be present for stories that are often silenced. They may be experiences of suffering or fears about dying for example. There are few relationships where people can speak of such things. The idea we “must be positive” affects health professionals, family, and friends as well. It may have family members and visitors trying to cheer people up rather than acknowledging what a person is going through. So, at times, it can be a very persuasive and unhelpful idea.  

There are many cultural discourses that can cause people distress when they are approaching death. The idea that relationships end with death, and we have to “move on” rather than that relationships continue beyond death. And then there are some of the individualistic discourses; Western discourses such as “the reason that I've got cancer is because I didn't eat right, exercise enough,” and so on, right? People are often made to feel they are to blame and individually responsible for the bad things that have happened in their lives even when they are societal issues. Those are just a few examples. I find Narrative Therapy helpful in untangling ideas so that the people I meet with can examine them more closely.  

LR:
another dominant Western idea that can have unintended consequences is the message that we should be positive
What is it about Narrative Therapy that helps you to untangle some of those dominant but unhelpful discourses with the dying and their families?
SM: Narrative Therapy has encouraged me to be curious about another person’s world and to use questioning practices to inquire about ideas that a person raises in conversation. This allows the ideas to be brought forward so the person can examine them and reflect on their influence on their life. The dominance of certain discourses or ideas can mean they are taken for granted as “truth” and unexamined. Narrative Therapy has trained me to pull apart the threads of an idea in collaboration with the people I meet with and to look for how that idea impacts on different groups of people with the workings of power in mind.

Hope is an experience that I commonly examine with the people I meet with. Hope can mean many things to many different people, and I can't assume that I know the meaning of it in a particular person’s life. I might ask, “What does hope mean for you?” There’s an example of such a conversation about hope and the questioning I might use in the story “A Small Hope.”

I think Narrative Therapy really lends itself to assisting people at the end of life to reflect on the cultural ideas that are shaping their experience and then choose and think about how they want to go about the end of their lives.   

LR:
Narrative Therapy has encouraged me to be curious about another person’s world and to use questioning practices to inquire about ideas that a person raises in conversation
And that sort of brings us back full circle to our opening when we talked about storytelling, co-creating stories, co-creating notes. You've said in your writing that in working with the dying, you try to bring forward identities other than illness. What did you mean by that?
SM: We're more than the problems that we live with, aren't we? We're more than an illness that we have, but when we're unwell with a serious illness that's perhaps kept us from doing what we normally do over a period of time, the idea of being a sick person, the sick identity, if you will, can really take over. And identities matter. They don't just speak to our past and to who we think of ourselves being, they really influence our decision-making and what we think is possible for us. So, the idea of being a sick person, if it takes over, can be quite limiting in what a person thinks is possible for them, and it can lead to ideas such as a person thinking that they're a burden or that they've got no way of responding to what's going on with them.

I, for instance, can think of a person I saw who didn't feel that his life was worth living because he thought he was a burden to others. When I met him, one of the things I noticed was that despite this man being unused to living with other people and describing himself as a bit of a hermit, the carers kept coming into the room. I asked him about this and the relationships with the carers and discovered he actually learned all about their families and the countries that they'd come from.

I discovered that he was someone who was deeply respectful of others and who was able to get on and make the people around him feel really good about themselves. And through exploring this, we were able to expand his possibilities by bringing forth identities of him as a person whom others liked, as someone who cared about other people and so on. I guess we were able to bring forth a sense of living meaningfully for him. The identity we brought forward of him as someone who could give to others and make them feel valued was really helpful in starting to push the idea that he was a burden out the back door.   

LR: And you wouldn't have known that had you not been at his bedside to actually see the community in action.
SM: Exactly, it was very helpful. In fact, people would be knocking on the door when I'd be seeing him. It was really quite something, and he was very surprised. He hadn't actually noticed how many people liked and cared about him until I began to ask him about all the visitors and what might lead them to want to spend time with him. 
LR: And that's one of the essences of Narrative Therapy, which is looking to take what they call the thin story and add depth and richness. So, I can see how someone approaching the end of life can become overly focused on that singular event, which you, through your storytelling, expand and enrich.
SM: Yes. The idea of a person being just sick or dying is a thin story of who a person is. Bringing forth the depth and richness of who they are can be enormously therapeutic. As I get to know people, I am listening for who and what matters and has mattered to them in their life and how they have gone about their life. As they share these details, I particularly listen for Aristotelian virtues that are expressed in how they have lived. The themes of virtues give rise to the possibility of rich identity descriptions for the person — them being a compassionate or kind person for example. Such identity descriptions are very helpful for someone who is unwell, as it is possible to enact them with a sick body. If someone’s been a great sportsman, that’s not going to be such a useful identity going forward even if it is something pleasurable to remember. Let me share an example of how these rich descriptions of a person can give rise to sometimes transformative responses.

I was once asked to see a man who was living with a number of very serious conditions. He was refusing to speak about his dying even though he was in the last few weeks of his life, and was insisting on having resuscitation even though it would be hopeless and at the same time very traumatic for his family. He was self-medicating to the point where there was real concern that he might accidentally kill himself and wouldn’t discuss his future care needs. It had come to a critical point, especially for his family. When any of our staff tried to speak with them about any of these matters, he became angry. After an incident where he shouted at one of our doctors, I was asked to go out and see him.

I went out and met him and his wife, and as is common practice for me, I began by asking him about himself and his life aside from the illness. As we discussed who and what was important to him, I was listening for Aristotelian virtues that he had expressed in the way he went about his life. I learned that he dearly loved his family. They were incredibly important to him, and he was very concerned about their well-being. I learned that he was a really considerate employer who knew all about the families of his employees. He personally bought them Christmas presents. He was a very kind man. And I also learned, in his early life, that he was a courageous person. He was an adventurer. He had been involved as a bystander in a very violent and frightening incident and had behaved with incredible compassion and courage. So, these are identities that I sought to bring forward through inquiry as I hoped that they might be helpful to him.

After nearly an hour, he said to me suddenly, “Sasha, you've got it.” And I said, “Oh, may I ask what is it that you think I've got?” And he said, “You get why I want to live. You get why I don't want to die. You will be my death philosopher, and I will talk about dying with you.” We were then able to talk about his dying and how resuscitation would be hopeless and traumatic for his family to witness. Remember, family really mattered to him, and that value was very present in the conversation. We were able to talk about his hopes in taking the medication, that it was harmful, and also about what he might want for the end of his life. I don't think it was just that he felt seen and heard, which was so important, but also that he was able to access parts of himself that he needed to have those conversations. The conversation and the two we had following this one allowed us to plan for him to have a dignified peaceful death with his family nurtured as well.  

Building Meaning at the Threshold of Death

LR: Well, it sounds like you're giving these folks an opportunity to contribute to the narrative rather than being a passive recipient of the traditional story of the dying person and giving them a sense of agency, and utility, and value. This makes me wonder, based on something you said in one of your wonderful writings that working with the dying is sacred. What did you mean?
SM: I meant that I think it needs to be revered, that we need to give every respect to the people we're talking to, that I need to give every respect to the person I'm talking to. I'm entering the most tender areas of a person's life. They may not have been able to share their fears, their experience, with anyone prior to that moment, sometimes because they want to protect those they love most, sometimes because it is taboo to go into these territories, and no one has been able to ask or even wonder.

I might be talking with a person about what their fears are about dying. What part of dying are they most frightened of? Just recently, I was talking with someone about her deep shame at the thought of other people seeing her naked body. Another was frightened about incontinence, and how would she maintain her dignity? These people are worthy of my every respect, and when they're able to share some of those fears or losses, it's the gift, and it's a gift to be honored, I think.  

LR:
these people are worthy of my every respect, and when they're able to share some of those fears or losses, it's the gift, and it's a gift to be honored
So, you don't use the word “sacred” necessarily in a spiritual or religious context.
SM: No, I'm using it just in the sense of to be revered but perhaps a bit more than that. The hospice has a Māori name called karohirohi, which means where the light hits the water, the liminal space, the space between living and death, and perhaps there is something about that space that's sacred, something that’s out of the ordinary. It's something to take great care of.
LR: By virtue of it being a liminal space, it is out of the realm of day-to-day experience. It really pushes one to be somewhere they've never been before. And to have the courage to do that, whether we call it heroic or sacred, special, unique — there may simply not be a word — but I do love the word “sacred.” Sasha, can you give an example of having worked with a client who, in spite of your best efforts, was not able to embrace meaning, was not able or even willing to take you up on your invitation to write a story that their survivors could have?
SM: I think you raise an important point. I adjust what I do according to the person or family I am meeting with and what it is that they want and works for them. I don't write stories with everybody as it’s not right for everyone for lots of reasons. I think that there is almost always the possibility for assistance, and supporting people to have a sense of living meaningfully if they are willing to have a conversation. Some people have more to grapple with than others and I may not be the best person for them to talk to. Someone else might be a better fit. I think it is for me to adjust and try and discover what works for each family. People have different ways of approaching death and living with illness. Talking may not be their preferred option or what is best for them. I respect their knowledge of themselves and what they want.  
LR:
I think that there is almost always the possibility for assistance, and supporting people to have a sense of living meaningfully if they are willing to have a conversation
They're very lucky then. What lessons about death and dying have you learned from working with the Māori?
SM: Many. I read Michael White's paper, “Saying Hello,” and learned about the idea of relationships continuing beyond death, but Māori, who are the indigenous people of Aotearoa New Zealand, have held that idea for 1,000 years or more. Māori incorporate their tipuna, their ancestors, into daily rituals. The idea that those who have died are part of our lives is a taken-for-granted idea within their culture and is a powerful example for me.

When I was learning all of this in the ‘80s, family therapy, thinking systemically, wasn't necessarily the usual way of thinking. Whereas, again, for Māori, thinking systemically, meeting as a group and working things out, was, again, a practice that they had done for 1,000 years. And I think the other thing is that the way that they mourn is, in my mind, very enlightened. For example, a tangi or tangihanga, which is a funeral, takes place over days rather than in an hour, giving meaningful time for connecting and expressions of grief. Such a practice has influenced the time my family and many others give to mourning. And I believe that New Zealanders touch their dead more than any other culture in the world, and perhaps this is part of the legacy and influence of Māori. I feel I’ve benefited from the influence of Māori processes.   

A Week with Virginia Satir: The Gift

I don’t know about you, but what really tightens my jaw is all this necessity of “proving yourself” with an evidence-based approach. What ever happened to “genuine,” or “being yourself,” as practiced by Carl Rogers or my role model, Virginia Satir?

As a lowly undergrad with an associate degree in human services, my best friend, a psychiatric nurse, and I had the opportunity to attend a weeklong training conference with Virginia Satir and Jane Loevinger as presenters. What a thrill to see them in action!

A Retreat for Connecting and Growing

The setting was September at Starved Rock State Park near Oglesby, Illinois — a magnificent Indian summer. The trees were brilliant shades of orange, reds, and yellows. The sun was hot with temperatures in the 80s every day. The park followed the river, and waterfalls and hiking trails were explored when we were not in session. Home was The Lodge.

There were exactly 102 participants divided into 34 triads (Satir said everything happened in triads), 17 families during the day for breakout practice sessions, and a large group (33) for the evening session, which we kept for the entire week. During the day, we would break into our triads or families to practice what was taught in the lecture. In the evening, the three large groups were left to come up with their own agenda. Virginia and Jane disappeared, emotionally exhausted, I presumed.

I remember that first evening sitting in this large circle of fellow attendees with either their arms or legs crossed. I knew enough about nonverbal body language to understand defensiveness and vulnerability. We waited for someone to assume the role of leader and take control. Someone suggested we go around the circle introducing ourselves. Out came the titles; psychiatrists, psychologists, social workers. I am sure they were not particularly impressed when I identified myself by name since I had only an associate degree in human relations. I certainly was intimidated! I wondered why I was there!

There were many things to like about Virginia Satir. One was her simplicity. You can read and appreciate her books, Making Contact, People Making, and Conjoint Family Therapy, Satir: Step by Step without a college education. You can share and teach it to common, ordinary everyday people.

Other qualities I valued in Satir were her compassion, genuineness, and effective use of self. She did not shy away from physical contact. She used touch. Participants at all her seminars would approach her during break to shake her hand or receive a hug, trying to capture some of her healing energy.

We knew she was an only child and her parents met over a pickle barrel, that she shied away from the color lavender, and had a down to earth sense of humor. My friend and I took up a collection from the group and bought her a lavender shirt. I will never forget the IIIFFI club. (If It Isn’t Fun, F— It club!)

Our lecture on this day was on being an effective therapist. Her basic message was that to be an effective therapist you must see, hear, and feel at the client’s level. When I returned from break, I discovered “my practice family” had volunteered or been chosen to be the demonstration family for a role play. We stayed in our designated area and the rest of the group gathered around us. Virginia asked for a volunteer to work with this family.

Something happened to me within the context of my family. Emotionally, I was overpowered by the pain I felt. It became more than a role play. I let whatever I thought or felt fly. The Family made short order of several different therapists, who could not penetrate the wall of anger and pain. At first, I felt the anger of the observers because I would not cooperate or allow the therapist to work nicely with my family. I then felt them drawing in closer and closer, hanging on to my words and emotions. I could feel them all and I didn’t care.

When we took a break at lunch time and the others left, I looked at Virginia and with tears running down my face, I said, “I don’t think I can take much more of this.”

She looked at me with a little smile at the corner of her mouth and a twinkle in her eye and said, “Feeling something, are you?” I went to my room, emotionally drained and physically exhausted. When we gathered again after lunch, we were outdoors in the warm sunshine. I had stabilized emotionally. The family was seated in a circle once again. Virginia asked the group what they would like to do with this family, and they said, “We would like to see you work with this family.” And so, she did. One by one she went around the circle. She took their hand and spoke to them in a soft and gentle manner, touching them with her words.

I was going to be the last one she would speak to. I had been really disruptive. I wondered what she would have to say to me. When she got to me, she paused, and taking my hand said, “In order to be an effective therapist, you must see, hear, and feel at the client’s level. When I meet someone as beautiful as you, I just want to give them a hug. May I?”

This great lady who everyone wanted to hug, was asking to hug me. I stood up not to take but to receive a priceless gift! She touched me. I never planned to enter, let alone complete my career as a child and family therapist, but I did!

I understand why I have such an intense dislike for the phrase “evidence based.” I do not fit in that box. I do not enter a therapy session with a brain-based approach in mind. I enter with my heart. Satir’s gifts, her use of self, of touch, and her message of simplicity, are part of me. I can hold a client’s anger. She validated me, a lowly undergrad in a sea of professionals. To this day, the words, “see, hear, and feel at the client’s level,” ring in my heart!

Effective Family Therapy Using Football Metaphors

Joshua, age 8, was referred for treatment for anger management and aggressive behavior occurring in the home. After the development of a therapeutic rapport between Joshua’s mother and myself, she began to discuss problems she was experiencing with all three of her boys. She described it as “boys will be boys” behavior which consisted of hitting, pushing, kicking, disrespecting each other with name calling, ignoring personal space, taking personal property, and progressive physical contact (rough-housing) until someone was hurt or crying.

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This was an otherwise solid, stable, two-parent family with no apparent deep-seated issues. Basic needs were met comfortably. The family had a shared interest — they were united in their love for football! All three boys played in leagues. Dad was a football coach, and mom was a football mother. During football season, league play and NFL on TV dominated their lives.     

Shifting Therapy to a Focus on the Family

When working therapeutically with children, I have always considered it important to know their interests, because it can be both a bridge to the therapeutic relationship and serve as a tool to help the child buy into the treatment process. After meeting with Joshua’s mother individually, we shifted the focus from an individual treatment focus to a family focus.

With both parents onboard, Joshua’s mother and I designed “Life is Like a Football Game,” a behavior modification program for decreasing unnecessary and inappropriate verbal and physical contact.

Amid laughter, Joshua’s mother and I translated the boys’ inappropriate behavior into metaphor using football terminology, and then built the behavior modification program and incentives. We then scheduled a family meeting to discuss implementing the Game. Family members were asked to wear caps and jerseys supporting their favorite football team.

In the family meeting, the “warm-up” conversation focused on the teams they represented and the teams they liked to watch. Staying in the metaphor of football, we discussed rules, breaking rules, and consequences for breaking rules. We talked about players who broke the rules and did not demonstrate respect for the game, the coaches, the referees, and the consequences of those behaviors leading to sitting the bench or losing the game.

The conversation was shifted into behaviors occurring in the home and Joshua’s presenting issue was reframed as a family one. It was the team that was struggling, rather than Joshua, and Joshua needed the support of his team, and they needed his. The boys were told we would use football language to work on the game. The parents were introduced as coaches and referees (complete with whistles). The boys each received a handout of the rules, penalties, points sheet, and award levels. We read the rules and penalties, and discussed “The Plan.” The following Saturday was set as “Game Day.” The family enthusiastically left the session and looked forward to Game Day.   

Family Therapy as a Game of Football

The Rules of the Game
  • Game Day will begin on Saturday at 8:00 AM each week.
  • Each player will start the day with 35 Player Points.
  • Each penalty will cost the player 7 points from his individual score.
  • If a player loses all his points for the day, he will be placed in the locker room (mentally) for the remainder of the day and out of that day’s game.
  • The coaches will total each player’s points on Friday evening at 9:00 PM. Awards will be determined at that time.
  • Awards may be accumulated. Points will begin again on Saturday morning.
Football Terms

Timeout: The intentional use of separation between players to regain control and respect for the rules of the game. A referee, coach, or player may call timeout. If the referee calls timeout, he/she may designate where the players receive the timeout. If player calls timeout, he may designate where he wants to take the timeout and the other players must find neutral zones not in the same room. Time outs will be 5 to 10 minutes in length and determined by who calls the timeout.

Instant Replay: Infractions may be available by cell phone. Players beware; you are being watched!
Penalty: A consequence for demonstrating a lack of respect towards a player, coach, referee, or the rules of the game. The following are penalties you will be called for:

  • Illegal Motion: The use of facial expressions, hands, finger, arms, legs, feet, or any body part to accidentally/purposely annoy or irritate another player, which communicates a lack of personal respect.
  • Illegal Blocking: The intentional use of any part of your body to stop the forward progress of another family member who is making movement to a determined destination such as the refrigerator, the XBox, their bedroom or any other room in the house, or the community environment.
  • Pass Interference: The intentional physical or verbal interference of a player in the discussion between a referee/coach and another player.
  • Holding: The intentional physical use of restraint by one player of another when there is no play activity involved.
  • Unsportsmanlike Conduct: A verbal and/or physical demonstration of behavior by a player in the home, school, or community that demonstrates a lack of respect for the property, personal, and physical boundaries of another player, referee, or coach, or carries a threat for potential harm or safety to the player, another player, referee, or coach.
  • Roughing the Passer/Roughing the Kicker: The deliberate physical striking, hitting, or wrestling of one player towards another player after the play has been completed or whistled dead by the referee.
  • Intentional Grounding: The deliberate throwing or hurling of any object not meant to be thrown (toys, XBox controllers, shoes, balls outside of a game context) by a player to another player as an expression of anger, frustration, or retaliation.
  • Ineligible Receiver/Illegal Possession: The taking or receiving of the property of another player without the permission of the player.
  • Delay of Game: Plays called by the referee or coach will be completed within 90 seconds “It’s time to go…Put the XBox away, etc.…” or the player involved will receive a penalty.   
Tiers of Privileges Awards 
  • Lombardi Trophy AFC 85-105 Points: monetary $6, batting cages, movie theater movie with parent or a friend, Cocoa Keys outing/Magic Waters, Rockford Aviators Game, Volcano Falls, anything in the Hallas or Heisman Trophy
  • Hallas Trophy NFC 64-84 Points: $4 award recognition, 30 minutes uninterrupted XBox time, may choose a fast-food restaurant (individual meal with parent), have a friend overnight, have a pizza delivered at home, game time with a family member, fishing time with Dad, 2 hours YMCA time, anything in Heisman Trophy
  • Heisman Individual Trophy 49-63 Points: $2 weekly award recognition, movie or game rental, pick a favorite meal, food, or dessert for a family home meal, trip to the $1 store, shopping with mom, tennis time (60 minutes per award), quality time with a parent of choice  

Family Response to Therapeutic Intervention

There were multiple factors that contributed to the success of the intervention. A critical factor was two stable parents in a stable marriage providing a stable home environment and consistent use of “The Plan.” The intervention occurred in the home where the problem was occurring which made it more naturalistic — home team advantage, so to speak. The family knew and loved football, so it was not difficult for the coaches/referees or players to understand, competitive spirit, the rules, the penalties, and the consequences. The behavior modification plan was built on a positive platform to encourage competition and success. Even the child doing the poorest was still a winner. Hidden in the incentive rewards system was a lot of parent quality time!

I would occasionally touch base with the mother, who indicated she and her husband were all initially very busy calling the infractions to drive home the seriousness of the issue. Eventually, the parents were able to put down their whistles and use verbal reinforcement. Over the course of time and with consistent repetition, the boys began to call infractions on each other — self refereeing. Problematic behaviors did decrease. The parents and the boys were able to apply this coded language when they were out in the community to literally “head things off at the pass!”

My total involvement with this family was less than 3 months! This family was able to take the sport they loved and apply it to their relationships with each other in the football game of Life.  

Questions for Thought and Discussion

What were your impressions of this therapist’s intervention?

In what ways have you integrated creative interventions in your practice with children and families?

What did you see as the benefits and possible limitations of this particular approach? 

Mary Jo Barrett on the Collaborative Treatment of Incest and Complex Developmental Trauma

Lawrence Rubin: Hi, Mary Jo, thanks for joining me today and sharing your clinical expertise in the systemic treatment of incest and complex developmental trauma. Just before we went live, you were sharing an experience you had while giving a webinar this last weekend, and something caught my ear that I wanted to ask you about. You suggested that there is something different between what is currently being practiced in the field of incest and complex developmental trauma, and what, in your experience, is correct, or what should be practiced.
Mary Jo Barrett: That’s a good place to begin. When I first started, which was 45 years ago, I was a worker for the state, basically doing in-home counseling. I discovered that in all these child abuse and neglect cases, there was a significant number of cases involving incest and sexual abuse — whether immediate family members or close family members or clergy or whatever. I would go to my supervisors for guidance, but no one really knew how to treat it.
For example, Minuchin told me that I didn’t need to focus on the incest. I just needed to look at restructuring and building a hierarchy, and that the incest would then be alleviated. Carl Whitaker, who I was madly in love with, basically said, “You know what? I don’t know what to tell you.” At least that was honest. He said, “I do schizophrenia. You better figure out how to do incest.” He was my teacher, so I decided I needed to figure it out.
And so, over the years, I started asking my clients more formally about incest and sexual abuse. I also had my supervisees ask their clients. And whether I was conducting training in Europe or here, I began to ask the clients what the most effective thing about their therapeutic experiences was, and what about the therapy they had received made it “good therapy.”
Basically, nobody said “techniques.” They said what we know they would say and did actually say. It was the relationship between the therapist and client. But they even said more specific things. And of the specific things they said, I narrowed the list down to what I call the five essential ingredients of trauma treatment. But what they said applies to all models of treatment. And as we know, none of these models are better than the other I developed what I call a meta-model that applies to any trauma protocol that exists based on these five essential ingredients. And so, whether you do IFS or CBT or SC or any of the alphabet soup of techniques or protocols that are out there, they will be successful if they have the five essential ingredients.   

The Key to Effective Trauma Treatment is Collaboration

LR: What exactly are these five ingredients for effective trauma treatment?
MB: People, especially those who have been abused, need to feel that they have value, power, control, and connection. So, these “ingredients” include the client:

  • feeling valued
  • learning specific skills in finding resources
  • understanding contextual variables needed for an engaged mind state
  • developing workable realities
  • building a hopeful vision for the future

When a therapist, case manager, or foster care worker gets stuck with a client who has been abused or neglected, I suggest that they don’t go back to the protocol, but instead to the relationship.

LR: Going back to the question that I opened with, how do you see what’s in the zeitgeist now, what’s popular now, as being lacking in comparison to this collaborative model that you developed?
MB: The basic essence is that I go to the client to tell me what to do, versus going to a model or technique to tell me what to do.
LR: Can you think of a recent clinical instance in which the relationship seemed that much more important in the moment than any technique or model?
MB: Larry, every day! That is my model. Every session. In every session when you’re talking about trauma, there will be an impasse. I call it differently. In any moment, there’s going to be what I call a traumatic stress, which means the client, because of their trauma, is going to experience therapy as dangerous.
As we always say, survivors often see danger where danger doesn’t exist. I mean, that’s a standard thing. But that happens in therapy all the time. That’s because the therapeutic relationship is based on hierarchy and attachment. There is a hierarchy, right? I mean the therapist has more power. And the therapist is often controlling the sessions or the direction or what’s going on. And there’s a necessary attachment. There’s going to be an attachment between therapist and client.
Abuse and neglect are embedded in hierarchical attachment relationships. Now, the thing is, every time I say abuse and neglect, people might go, “But we’re talking about trauma.” And I’m saying, again, almost all the trauma cases we talk about revolve around interrelationship violations.
LR: So, if we practice anything other than a collaborative model, then we may in some way be replicating the hierarchical violation in the family that contributed to that abuse.
MB: I’d say that a majority of these clients anticipate and experience, from time to time, that violation in the therapeutic relationship.
LR: So, if the therapist moves too quickly or dives right into the trauma narrative or says, “Tell me about this,” or, “I’d like you to do this,” they are abusing their power? Even using directive words or a tone of voice or body posture can trigger a client so that they feel unsafe. And that’s when you would be cognizant of that, hypersensitive to that, and readjust any of those facets of your approach?
MB: Correct. And the collaborative change model is exactly that cycle. What you just described. And what’s interesting to me is that the collaborative change model is a natural model. And when I describe it, folks at the clinic say, “Oh, my god, yeah!” And the good clinician says, “That’s what I do in my sessions anyway.” And all I’m saying is, make it conscious. It’s a natural cycle of change.
The first phase is creating a context — which is creating refuge, making assessment, figuring out what’s going on — then making a direction, deciding what kind of intervention to use. And then when we start doing our interventions, which is natural, we’re challenging, right? And the relationship becomes embedded in this hierarchy because I’m sort of pushing and challenging by asking them to do something different. And in that moment, the client might experience a moment of fight-flight-freeze-submit. Or fix! And I have to, as a clinician, recognize that.
And in that moment, instead of pushing harder to make an assumption of, “Oh, they can’t tell,” or whatever it is, I need to stop and recreate a context of change. So, at that moment, I stop and say, “What do you need now? What’s going on? How do you feel? Should I slow down? What’s happening?”
I’ll give you an example. I had a client who often during the sessions would say, repetitively, “You don’t get it. You don’t get it. You don’t get it.” And I’d often get defensive. I’d sometimes want to say, “Well, help me understand,” or, “Explain it.” And then one day after the session, I was thinking, “I think that’s a trauma response. So, I said, “I’m wondering if when I’m doing something that triggers you, you experience me as threatening and go into ‘You don’t get it’ as a repetitive response.” And she really thought about it and looked at it and she said, “You know, I’ve often felt there’s things you do that remind me of my mother.”
This client’s mother was like Joan Crawford’s character in Mommie Dearest, and we’re not just talking severely abusive. I asked her what reminded me in those moments of her mother. In response, she said that I talked loudly, and it was the way I dressed in skirts. She experienced me as dressing in a way that was, for her, reminiscent of her mother, which she experienced as provocative. I don’t know that it was, but she experienced it as such, so for her, it was.
So, when we then had that conversation, and from then on, I did consciously change how I dressed on the days I saw her. And I consciously changed my voice. And after that conversation, she never said, “You don’t get it,” again.
LR: So, when she emphatically repeated, “You don’t get it, you don’t get it,” it was metaphoric for something like, “You’re not hearing me, that hurts, stop it, you’re not hearing me, you’re dressing in a way that confuses me. You’re not hearing me. Daddy did this, or Mommy did this, or my brother did this.” It’s like this broad statement of, “I am feeling abused right now.” She may not have been able to put a finger on exactly what element of your relational moment was triggering her, but “You don’t get it,” meant, “I am feeling powerless and unsafe.”
MB: Violated. She was feeling violated.
LR: She was feeling violated. Because you’re much more cognizant about the relationship and the attachment, and breaches in the attachment, you were able to look inward and ask yourself, “What could I be doing? How could how I be talking? What would I be wearing? What might we be talking about? What is it about the way I’m asking questions that could be replicating at some level what happened in her family?”
MB: Yes.
LR: Did I get it right?
MB: You did get it. I should bring up my PowerPoint. You’re doing a very good job. I have three slides that I use in trainings, which I introduce by saying, “These are the three watchwords or phrases of my faith.” The first one is by Mandela that says, “A good head and good heart are always a formidable combination.” The second one was by R.D. Laing who talked about the importance of awareness by saying something like, “If you aren’t aware that you’re not aware, there’s nothing you could do to make change.” And the third one is by Jay Woodman which says that “Life is a series of cycles of getting lost and finding yourself.” And that each time you’re lost, if you look at it as a possibility, then you will find yourself in a new place. And so, my thing is, therapy is a cycle of getting lost and finding yourself again. And once you’re aware of that, you integrate your mind and your brain, your heart, and you’re golden.   

The Healing Power of the Therapeutic Relationship

LR: Is there something about trauma, and incest in particular, that drives clinicians to cleave to techniques and theoretical models; bypassing what they truly know to be effective, with is the relationship?
MB: It’s an integration of the two. When we spoke with these clients, it was clear that they did need new skills. It was the third most important thing, not the first. But the first thing they said was connection. The second thing they said was they had to feel valued, and they had to value the clinician. Then they said they had to feel empowered. And then they said skills.
Everybody that’s developed a protocol model is going to argue with me and say the relationship is the basis of all those protocol models. I would say I got you; I believe you. But if you ask the people who are trained in those models, they will say the emphasis is on the protocol and the interventions.
And they would also say that the difference is that when they’re stuck or a client gets activated, that it’s “go back to the protocol,” versus going to the client to collaborate.
LR: I wonder if there’s something about trauma, and particularly incest, that compels clinicians, especially those who aren’t experienced, to have to “do something.”
MB: A hundred percent! This is actually the new thing that I’ve added to the “fight-flight-freeze” paradigm, which is “fix.” So, I think what happens when a clinician becomes overwhelmed — I call it a place of traumatic stress — fix becomes part of a trauma reaction. The traumatic stress reactions.
When a therapist falls into a “fix-it” state, that should be an indication that they are in the trauma field and are feeling dysregulated. They then have to get re-regulated in order to move to a different place. And it’s the same with the client, who at that moment needs skills to re-regulate themself. I don’t believe when a client or a therapist is dysregulating, that’s the time to automatically use a technique.
LR: So, by jumping in with “a fix,” the therapist might be trying to regulate themselves at the cost of their client’s regulation.
MB: I want to say one other thing which is not going to be popular. I believe that when therapists jump in with a technique, they’re hoping it’s a solution for the consumer of their services.
LR: Giving them something.
MB: Giving them something, which is capitalism. Everything is an agreement in the contract with my clients.

The Importance of Working Systemically with Incest

LR: Someone reading this interview might say, “Well, it sounds like she’s working with the individual,” but I know you’re deeply systemic. So, I’m assuming that this collaborative model infuses your family work around complex developmental trauma?
MB: Yes. Most of the clinical work I do is with couples and families. And this goes back to the research we did with these clients who said that rarely, if ever, did other clinicians include their family. So, what would happen is that after those sessions with the “other” therapists, these clients would go home and have abusive fights or get hit. Or a parent would continue the abuse or violate.
Here, I go back to what I said earlier. Abuse, neglect, and childhood developmental trauma are embedded in a relationship of hierarchy and attachment. So, I believe healing should happen in a relationship.
I want the therapy to recreate some of the crisis right in the room with me. So, if there’s a fight, and dissociation, we all can witness it together and address it in the moment — together. If there’s eyeball-rolling that then triggers the other person, I want it to happen in the room, because those are the cycles that cause the traumatic stress at home.
Everything I’m saying to you here and now is what I say in the first session. When I start a session, I want the safety in our relationship to spill over into their relationship. I want their relationship to be a source of regulation. Not me. I don’t want to be the primary person in their lives.
LR: I can see how this would apply working with intimate partner violence. But are you saying that in cases where there is past or present childhood incest, that you would work systemically with either the current or past family members?
MB: Let me delineate two things. One; when the incest is currently happening and its children, yes, I include everybody. But I have all sorts of rules and boundaries. If it’s currently happening, and in most states, if incest is currently happening, then usually the perpetrator, whether it’s a sibling or a parent or not, is kept away from the child, right?
So, I don’t bring the alleged offender, or the offender, into the room with the victim until they’ve acknowledged facts. So, if they’re denying facts and saying, “She made me do it,” or, “He made me do it,” or, “It never happened,” I don’t do family with them. But I would do family with other family members. But I don’t bring the alleged offender into the room until after they’re no longer denying facts. 
LR: Is that enough? Just getting past the point of denial? Would they have had to have done some significant reparative work of their own before you brought them into the room with the victim?
MB: They are in therapy. Yeah. I mean if it’s currently happening, then the offender is in individual and group therapy, according to how I think good incest therapy should happen. And the rest of the family are either in individual, group, or family treatment for whatever their issues are. And the kids could be in individual concurrently with the family therapy.And then when the violator has met certain criteria, then they can start coming into the sessions.

LR: So, who’s your client? In a case of incest, where it happens currently, or even in the past, who do you identify as the primary client?
MB: The family. But/and my collaboration is with all. It’s a team. I mean it takes a village. Absolutely. When we’re talking incest, it can’t be done effectively by one therapist.
LR: Do you or can you even work effectively with adult survivors of childhood incest?
MB: I’ve developed what I call the “family dialogue program,” which is for adult survivors with their families. And so, I do bring them together but it’s different. I often do it in these intense weekend workshops because if people live all over the country, it depends on if we’re doing therapy about wanting to talk about the abuse and neglect or are we doing what I call the third reality, which is, let’s just focus on the future. Let’s not focus on, did it happen, didn’t it happen, what’s going on? Let’s just focus on, am I going to come to your funeral? Am I going to come to Passover? How can we be in the room together? Am I going to go to my niece’s wedding? Are you going to ever meet your grandchildren? That kind of thing.
LR: That presumes that the perpetrator must take responsibility. They must be willing to listen, at least. Be present and listen. In other words, if you want to ever see your grandkids, you’re going to listen to me. You’re going to hear me. And that perpetrator may leave not feeling very healed, but at least he or she will have given the opportunity to the victim to be heard.
MB: And that’s why I call it the third reality. Because we’re just focusing on, “it’s not about your reality,” it’s about if you want to see your grandchildren. If I want to come to your house, are you going to be able to tolerate me…you know, me believing this and being in the same room as you.
LR: In a sense, it’s a way for the victim to recapture some power.
MB: Oh, absolutely. And that’s what most survivors will say to me. I mean a lot of people have said, “I was in therapy for 10 years, and that weekend with my father was the most important thing in my healing.”

The Gratification of Working with Trauma and Incest

LR: Okay, okay. My guess is that many in private practice would run when they receive a referral for incest. But you seem to run toward it.
MB: I don’t think people in private practice run from the adult survivors, but they run from when it’s currently happening.
LR: Why is that?
MB: Because I think it is one of the greatest taboos. And they never learned how to deal with it. And I think they never learned how to manage. And they often don’t understand how anybody can even want to see their father or their brother or their mother based on what they’ve done to me. Or done to them. Done to the victim. And so, I think a lot of them experience transference and/or feel inadequate.

I don’t know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”
And in terms of me, Larry, I supposed we could get me on a couch to figure out why. I do remember very distinctly one time bolting out of bed, like sitting up straight. I don’t know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”
But I would rather work with incest any day of the week over depression because people I work with change. And I see that change. I have seen plenty of sex offenders change. And I’ve had the fortunate experience of being able to follow up on some of my very first cases. I’ve seen one of my first cases 40 years after they stopped. It was an unbelievable experience.
Well, partly it was fun because I got to ask them all sorts of questions. I’ve always been a very creative therapist, where I just make shit up as I go along, that seems to fit. I remember one of my cases — it was incest and domestic violence. The father was in supervision and was told he couldn’t be within 365 yards of his family when he first got out of jail. He actually parked a mobile home 365 yards from the family home. And he was something else.
About a year into it, maybe less, I went back to court to get permission to have him come to family sessions. And he did. And one time, I was doing a good old family therapy looking for strengths, and I said to them, “You’re not always abusing each other. There are times when you’re not. Let’s talk about those times.” And the kids were younger, like 16, 11, and 10. I handed out these little recipe cards where I asked each family member to write down the recipe for nonviolence. Like a cup of this, and 3 tablespoons of that.
I gathered them all and laminated them, and then had them talk about it. The mother said, “It’s half a cup of going to church, and another quarter of a cup is no alcohol.” I mean that kind of stuff. And so literally 30 years later, I interviewed the same family. And the woman, the daughter who was the incest survivor was 40-something. I asked her a couple questions, one of which was whether she had gone to any trauma therapy. She said, “Why would I? I already had it.” So, I asked, “When you were getting married, or dating, what was that like? Were you always anxious? Were you afraid?” She opened her purse and pulled out the laminated card, and said, “I only dated people that had the ingredients.”
LR: Talk about having an impact. Wow, that must have felt great.
MB: I burst into tears. I didn’t do the initial interview, one of my graduate students did. But I was behind a one-way mirror, because who wouldn’t want to see one of their first clients? I went in and I asked them questions. So, in fact, there’s an example of the use of a particular skill. I don’t know that- would it have been the same if it hadn’t really come from them? I don’t know.
LR: Had you not had a relationship, they wouldn’t have taken the cards to begin with.
MB: Right, right.
LR: Do you see yourself in charge of the treatment village when working with the perpetrator?
MB: I have a case right now of sibling incest, and one of the kids is a young adult, but not even, I mean probably a teenager still, 18, 19, who is in individual therapy. I’m trying to do a family session because the parents have two children. So, the parents are involved, and the son who offended his sister. And I’m trying to coordinate. And the sister’s therapist didn’t call me.
LR: What recourse do you have?
MB: Well, the recourse I have is the parents. He is still a teenager. So, the parents can call this person up and say, “Our daughter signed a release, we signed a release. You need to call.” I’m not saying it in a nasty way. But I try to avoid doing that because I don’t need to start an adversarial relationship. But that’s the recourse I have. If the person was an adult, I mean I’d still have the parents to talk to their child and say, “Look, we want to heal this.” As it turned out, the son’s individual therapist calls me and cooperates. We have a great working relationship.

The Complex Arena of Incest Work

LR: Earlier on in one of our conversations, you said, “Incest is virtually neglected in our field.” Clearly, incest hasn’t stopped.
MB: Incest hasn’t decreased at all since I started in the field in ’78.
LR: What do you mean it’s neglected? By clinicians? By researchers?
MB: : I think everybody’s neglecting it. I think that the problem is that we’ve lumped trauma into one thing — complex developmental trauma.

I think that there is something very important to calling violence or violations what they are. Incest is unique. It’s not just a sexual assault. It’s unique because this is often a relationship where the people also have a very positive connection. “This is my parent,” they might say. I had a client way back, I mean again, 30 or so years, who wrote a poem. The one line that sticks out into my head was — and I don’t think she was writing it just to me, it was in general — she said, “I asked you to put an end to the abuse, and you put an end to my family.”

LR: Oh! Did she write the poem to you?
MB: I don’t think it was to me because I asked her. It was to the system. She’s another one that I still have contact with because periodically she’ll write me and say things like, “I just had a baby, just won a marathon.” I mean that kind of stuff. I think professionals feel anxious. I think they feel traumatized. I think it feels like you said. It’s such a moral violation that, as clinicians, we don’t know how to manage. How do I manage that I care about somebody? How do I manage that this woman stayed married to somebody who sexually abused her child?

I just think the taboo is so deeply entrenched that it causes such distress to those who work in this area. I just was working with a family where one of the children was sexually abused. And the other two weren’t. And when I talked to all of them, I said, “All of you were abused. But what happened to Susie is more of a moral violation.” And so that’s why people can’t tolerate it. I think there’s something about not being able to tolerate it. Like I said, I can find something positive. It makes sense to me that someone can be abused by a family member and still care.

LR: The popularity of complex developmental trauma overshadows the clinical attention on sexual assault.
MB: All I know is that so many clients tell me that people either never asked them or understood it. So, it just gets lumped into a category of trauma. And all traumas are not created equal. I’m not saying incest is worse than being physically abused. I’m not saying it’s worse, I’m just saying it has its own unique connected relationship with somebody they cared about who I also had many positives. And it leaves me even in some ways more confused because it isn’t linear or simple. Even if the person was abused by somebody that came and left like a babysitter or Boy Scout leader, with whom they also had an intimate relationship, it’s very confusing. 
LR: The deepest form of betrayal.
MB: Yes. I think sometimes clinicians can’t manage that level of complexity. Which goes back to your question; “Give me some techniques, it makes things less complex. I can feel better about myself if I know how to do this. Do that.” Larry, every single day, I go, “Wait, I don’t know what I’m doing exactly. What do I do now? I just had this explosion.”

I was sitting in the room last week with somebody that got up, grabbed something off my table, threw it on the ground, and smashed it. “I got to go,” they said So, I said, “Wait a minute, okay, let me figure out.” What was I going to say in that moment? “Follow my finger?”

LR: What did you do? How did you handle the moment?
MB: What I did in that moment was said, “I need a drink of water. You need to sit down. I am feeling afraid. And I want to talk about this. But right now, I need to calm down. And you need to. We both need to.” I had been seeing this guy for a while. It made sense to say, “We need to regulate.”

Well, the wife was there, and they have a child. But the child wasn’t there. I had a separate session with the child. And I had a separate session with the wife. I did break them all up. And then I had a session with him, and we just talked about it. And I talked to him. And of course, like every other, he said, “This is what happens when she does blah, blah, blah.” “This is what happens when my child…” And I explained to him that acts of violence are linear. I don’t think I said “linear,” but… “I get it. It is all these other things that activate you. However, you have to make a decision about how you’re going to react to these things.”

LR: I would see where a younger therapist, or a frightened or threatened therapist might have ended the session immediately, out of fear for themselves, out of loss of control of the session. But you saw it as part of the way the system functions, and your role in that moment was to regulate. To me, the external regulator, the governor of sorts. Is apology critical?
MB: Acknowledgment is important, not apology. Because people say they’re sorry very easily.
LR: So, how do you know when an acknowledgment is sincere and productive, moving forward?
MB: So, when somebody is going to make a formal acknowledgment, it’s a planned session where they write a narrative. They write it down, they talk about… Basically, I have them talk about facts, impact, responsibility. So, they’re giving it to me beforehand. And that’s part of the therapy process. They’re writing their acknowledgement as a therapeutic technique. So, they’re writing this, and that’s how I know it’s sincere.
LR: What are some of the common presenting problems that people come to therapy with that raise your incest red flags?
MB: Well, on that level, they probably don’t look any different than any other form of abuse, neglect, or violation. They really don’t. Eating disorders, self-mutilating, suicide. Any of those things. Most of these are symptoms, I think are survival skills. I think they’re skills that people have used over time to survive their abuse and neglect. And now it’s become problematic. The skills themselves are problematic. The skills work. If I drank too much, if I cut, if I was sexually promiscuous, if I was suicidal, if I was dissociating. It might have worked to avoid memory and pain. That’s how I tell my clients; that most of their symptoms are utilized to avoid memory and pain until they don’t.

And now the symptoms themselves are causing the pain. To me, incest doesn’t look any different. What happens is, as I start my sessions by asking people how they heard about me.

If they didn’t know my name, they might have typed in “trauma, abuse, childhood something.” And it’s not just “therapy.” Usually, they got to me, somehow, they typed something else in. Or they got to me through a therapist. And so, when they say trauma, which is usually what it is, I then say, “Look, if we’re going to talk about it, we’re not going to talk about it now. But I need you to know I feel really comfortable talking about incest. I feel really comfortable talking about sibling abuse. I feel comfortable talking if you beat each other up.” So, I’m just saying, down the road, if any of those things come up, I feel comfortable.

LR: Has there ever been an instance where all roads pointed to incest and the person allowed you down that road, right up to the door, and then just closed it in your face?
MB: No. When I take a family history, when I do a genogram, and everything points to incest, I might just say, “You know what? I just need you to know from what you’re telling me; I’m not saying it was incest. But there might be, it could have been. It feels to me like emotional incest at least. Like you are hierarchically your father’s peer. Or it feels like you and your brother turned to each other in ways to get affection that you didn’t get from anyone else or your parent(s).”

So, it doesn’t have to be. And this isn’t your question. But it’s a question people often ask me. Do you need to know all the story to help? And the answer is no. 
LR: And I think clinicians sometimes may forget that incest is a violation of hierarchy. It’s a violation of trust. And not all incestuous relationships are sexual. Are there any questions I could have asked or should have asked?
MB: Well, I mean we have maybe a couple of million. But I think what I would say is, you know, we should talk again.
LR: I would like that. Thanks Mary Jo.

Makungu Akinyela on Testimony and the Mattering of Black Therapy

Lawrence Rubin: Hello, Makungu. I first became aware of your work through conversations with Drs. David Epston and Travis Heath, both of whom have worked clinically and written within the Narrative Therapy sphere. However, they've also made me aware of different approaches to narrative storytelling, including the oral tradition of West Africa, and your work. And that led me to an interest in Testimony Therapy. With that said, what is testimony therapy and what is testifying? 

Testifying and Testimony Therapy

Makungu Akinyela: Testimony Therapy is a discursive therapy, related to Solution-Focused Narrative Therapy, and any of those therapies that we think about that focus on privileging people's stories about their lives. I tell people that testimony is a narrative therapy with a small “n” because testimony and testifying come from my tradition — the Black cultural tradition, to testify. The way Black folk use it is to tell your story but also to tell the story that you want told about you, to give your testimony. It has some roots in the Black church experience. Folks who are from the South or have been to the South and maybe to a Black church, might have witnessed a testimony service or folks testifying in church where they get up and tell a story. There are parts to testifying it. Usually, a testimony starts out with what I call a doom-and-gloom story. For folks who are into Narrative Therapy, Michael White and David Epston used to call it a thin telling of the story.
testimony therapy is a discursive therapy, related to Solution-Focused Narrative Therapy, and any of those therapies that we think about that focus on privileging people's stories about their lives
So, it starts off with this real doom-and-gloom narrative that goes something like, “Well, I woke up, and the doctors told me that I had cancer and I was going to die. And I've been sick ever since and in bed and I couldn’t get up. And that’s what my life is about.” That's the doom-and-gloom telling. But then usually a testimony begins to sound like, “But if it had not been for my friend or my neighbor, who came to give me support and help…” The important thing about that testifying process — the dialogue — is in Black orality, which is that orality that we are grounded in, the oral telling of stories.
And that call and response becomes a community telling of the story. It's not just the storyteller telling the story
There's also call-and-response. As the “testifier” begins to tell that doom-and-gloom story, there is a response to the call. The “witnesses” let them know that they're listening. “Wow! Really? Well, okay. Amen. I get you.” And that call and response becomes a community telling of the story. It's not just the storyteller telling the story. The witness to the story, by engaging with the story, also helps to shape where the story goes. The testifying usually goes from doom-and-gloom to the call-and-response, and then all in the “community” begin to identify what I call the “victorious moments” in the story.

Narrative Therapy might say those victorious moments contradict the thin telling of the story. And as you get to those victorious moments — if it were in a church ceremony, as people begin to give that feedback, that response to the call — they begin to say things like, “Yeah, it wasn't so bad. It was good.” And then people might start seeing the blessings in their lives in the middle of the doom-and-gloom.

The story begins to become a little stronger and a little more positive. By the time the story finishes and all have experienced victorious moments, transformation has happened, and the testimony becomes, “This is the story that I want people to have of me. This is the story that I want.” It uses narrative ideas, and for folks who are familiar with Narrative Therapy, the preferred outcomes have replaced the doom-and-gloom, thin story.

the critique that testimony gives to narrative therapy is that all storytelling and all ways of telling stories are not grounded in the metaphor of literacy
The important thing about testimony therapy is that it is a discursive therapy. I consider it a narrative therapy in the sense that it's a storytelling therapy. I agree with the narrative therapist, that people use stories to constitute their lives, to describe and explain the meaning of their lives. The critique that testimony gives to narrative therapy is that all storytelling and all ways of telling stories are not grounded in the metaphor of literacy. Narrative therapy, the therapy that was developed by Michael White, David Epston, and that is contributed to so strongly by all those other great people — you know, Steve Madigan, Jill Combs, and Gene Freedman – all those ways of doing narrative therapy are particularly grounded in the metaphor of literacy.   
LR: Storytelling in a linear kind of way. 

Oral Culture: A Different Kind of Listening

MA: Exactly, in very linear ways, even the metaphors that are used such as “Turning over a new page, re-authoring our lives.” So, the metaphors reflect the culture that it comes out of, which is primarily a culture whose consciousness is developed through literacy. What testimony therapy says is, “What about those people who come from cultures that are predominantly oral cultures, grounded in orality?” Like the culture of Africans from West Africa, where my folk come from, the culture of so-called African Americans who, basically, trace our lineage and heritage back to West Africa?

Our cultures are primarily oral. So, the thing that shapes our thinking, the way we talk about and think about relationships is grounded in that orality. Storytelling will look different, and the meaning that's given to the story is different. And so, within testimony therapy, rather than being grounded in the metaphor of literacy, I ground it in the metaphor of orality and musicality. Does that make sense? 

LR: As a narrative therapist but also as a client-centered therapist, I would be validating. I would be using nonverbal gestures. I'd be highlighting unique outcomes. I would be listening to elements of the client’s story, which are doom-and-gloom-centered, and asking for counter-stories. What would I be doing differently if you were my therapist in this interaction and coming from that oral tradition? Now, what would we be adding as therapists in this moment? 
MA:
I'm paying attention to the rhythm and the beat of a conversation
I'm paying attention to the rhythm and the beat of a conversation. So, it's not just the words of a conversation that are important, right? It's not just listening to the words that are coming out of your mouth. It's how the words are coming out of your mouth. I'm paying particular attention to things like the relationship between bodily space and the words, the rhythm that's created through bodily space. I'm paying attention to things like the expression on your face because those are all things that also begin to define orality.

In other words, people from oral cultures don't just use the words out of their mouth. It's the tone of the word. You know, where there might be three or four ways that I can use the same word, depending on the tone, it means something different. Also, it might be even the way I might use my body. You know, sometimes people make jokes about Black women. You know, if a Black woman is talking to you and she starts snaking her neck…what's the meaning of that? So, no matter what the words are that she's using, that body motion, the way she takes up space, begins to define the rhythm of the conversation –   

LR: So, what feedback would you be giving me in the moment?  
MA: I would be getting in rhythm with you, right?  
LR: You would be mirroring? 
MA: I might be mirroring, or I might be thinking, “Wow, he's really agitated here. And I might even slow down my rhythm, and I might begin to speak more slowly. And I might even become a little more reserved, again, because I'm believing that the rhythm and the beat of our conversation is just as important as what you're saying. I might be taking note of and become curious about what the emotional content of your speech might be at that moment, and I’d bring that out.

I'm a testimony therapist whoever I'm working with, just like narrative therapists
I was talking to a couple just the other day. Now, this couple happened to be White, but I'm a testimony therapist whoever I'm working with, just like narrative therapists. A narrative therapist, whoever they work with, they're simply using their cultural understanding to engage the work. And that's what I talk about with this. I don't believe that “techniques” in themselves fix things or do things.

But with that couple, there was a conversation going on. In this case, it's a heterosexual couple. The husband listened to the wife say something, and it felt as if she was saying he was the problem. But he was his usual calm demeanor, almost a flat effect. But he began to describe how he was resentful that she was making him into the problem. Sometimes, not always but sometimes therapists are really afraid to engage emotion, particularly “negative” emotion, right?   

LR: I'm on the edge of my seat. So, how did you manage yourself with that White couple?
MA:
one of the things I point out is that oftentimes, particularly for Black people, we're encouraged to suppress our emotions
First of all, I validated what he had to say. And then I said, “You know — ” Let's call him George. Not his name. “George, I get the feeling that you are real pissed off about right now. And I'm really appreciating that. I'm really glad that you got pissed off enough to say that.” In other words, rather than running away from the emotion, to name the emotion — because I also believe that all our emotions are important. You may have read one of my articles, and one of the things I point out is that oftentimes, particularly for Black people, we're encouraged to suppress our emotions.
LR: Especially anger. Especially anger. 
MA: Right, especially anger! You're not supposed to do that. I believe that my work as a therapist is creating a space where all emotions are safe, and all emotions can be validated and understood and experienced. Because one of the things that I'm trying to do when I'm working with my clients is — and again, these are my philosophical understanding of this work — that, under conditions of oppression or suppression, people are alienated from their emotions.

A lot of the ideas that I work with come from the psychiatrist, Frantz Fanon. And Fanon talks about alienation, which comes with colonization. And when people are alienated from their emotions, they don't feel their emotions. They don't experience their emotions. So, the emotions control them rather than them being in control of their lives. And so, a lot of the work that I do is about helping people to feel their feelings, to experience their feelings, and to dis-alienate themselves from that.   

LR: So, going back to George and his wife, you highlighted what you surmised to be George's emotional reaction, his alienation from his emotions. And you helped encourage a conversation around that. How is that different from what a good Rogerian therapist or a linear narrative therapist might do? 
MA:
one of the big complaints that I often get if I am referred a Black client, who maybe has previously had a White therapist, is the cultural uncomfortability that they felt in those relationships
That's a good question. And one of the emphases that I make is that this is not about trying to find something that on the front looks like a radically different practice. It's about worldview and understanding. One of the big complaints that I often get if I am referred a Black client, who maybe has previously had a White therapist, is the cultural uncomfortability that they felt in those relationships. It's like that person just didn't seem to get them. They say, “Well, they just sat there and listened. They didn't say anything.” You know, they didn't say anything.” Sometimes they'll even say, “They didn't tell me what to do.” And I'll say, “Well, you know, I'm not going to tell you what to do either.”

But again, it's just that interaction, that responding in those conversations in oral ways as opposed to this kind of a linear conversation. I ask you a question, and then I quietly wait for a response. And then I assess that response. “Okay.” And then I ask another question. And then I wait for a response. That's that linear conversation. Even when I'm doing supervision, I don't want therapists to try to be like me. In this field, that's what a lot of people do, particularly from our generation. You know, we used to go to those demonstrations, and we would be mesmerized by the experts.

LR: Nobody could be Albert Ellis, regardless of how hard they tried.  
MA: Yeah. But, again, when I talk about Testimony Therapy, I'm talking about a conceptualization of the work that we're doing, which is grounded in a philosophy. In a very similar way, when Michael and David began to develop Narrative Therapy, for the most part, they were grounding their therapeutic work in the philosophies of Michel Foucault, in other words, a conceptualization of the meaning of the word. Does that make sense, what I'm saying?

So, you know, human interaction is human interaction whatever the culture, but there are conceptualizations that define the meaning of the interaction. There's a difference between people who come from oral cultures and, again, how stories get told and the meaning of those stories, and people who come from literary cultures.   

LR: What about when you're working with a Black client, a Black couple, a Black family who don't identify with their ancestral roots, who have no connection to the oral tradition of West Africa? Does that make a difference? 
MA:
I believe that when Black people say, “Hey, I know I'm Black. I'm Black,” that's not about having some deep sense of West African culture, because culture doesn't work like that. You see, the culture of African American people is African, I believe
I think you're asking a philosophical question. Just off the top, I say, okay, probably that couple that you're describing in that way wouldn't even be coming to see me, right? But also, I think this is about a perception of what culture is and what culture means. I believe that when Black people say, “Hey, I know I'm Black. I'm Black,” that's not about having some deep sense of West African culture, because culture doesn't work like that. You see, the culture of African American people is African, I believe.

It's African in the context of 300 years of colonization, but it's still African. And that doesn't mean that people go around every day thinking, “I'm African. I'm African.” They just are. They're being what they're being. Using Frantz Fanon once again, he once said, “A tiger doesn't have to proclaim its tiger-tude. It just is what it is.”

I described the whole idea of a Black church testimony service, right? That's African. Those are African ways of engaging. People don't name it that, but that's what it is. You know, the way that we talk, right? When we talk about Black ways of speech that we call Ebonics. I guess the more professional way is AAVE, African American Vernacular English. I'm speaking to you right now in pretty standard English. But if it wasn't you and it was somewhere else, I would be talking in Ebonics. But the thing about the way that I speak — I call it my grandmother's language — is that it’s grounded in a mixture of African and English vocabulary, but primarily West African syntax and grammar. It comes from there. 

And this gets far beyond therapy, but we've got tons of research that shows the continuities, the continuations, the relationships between the cultures of African people in the western hemisphere, who are here because of enslavement and other things, and Africans on the west coast of Africa. So, when I'm talking about culture, I'm not talking about something that's this kind of mechanical thing that is easily identifiable. I'm talking about what we understand about the nature of culture, which is constantly moving, changing, and growing. Does that make sense?  

Double Consciousness

LR: It does. Is there an implicit assumption or a presumption that an African American client, a Black client, has experienced or has internalized colonization and is living a story that really is one of adapting to those colonializing practices, whether or not they acknowledge it or feel it or resent White people?
MA:
every Black person has two souls in one dark body, an American soul, meaning White, and a Negro soul. And they're constantly fighting and struggling against each other
Absolutely. And, again, I ground my ideas in, like I said, Frantz Fanon and W. E. B. Du Bois, who was probably one of the greatest minds of the 20th Century — from the whole 20th Century because he wrote his first book in 1903, and he died in 1964. But he wrote a book called The Souls of Black Folk. In there, he defines this idea that's called double consciousness. Basically, he calls us Negros, but he says every Black person has two souls in one dark body, an American soul, meaning White, and a Negro soul. And they're constantly fighting and struggling against each other.

That's something that I could never explain probably to you because you've never been through that. But to be a Black person who is constantly doubting their Blackness but also affirming their Blackness at the same time, right? If I told you, as a little boy — we're about the same age — one of my favorite shows used to be Dennis the Menace. Remember Dennis the Menace?   

LR: I remember Dennis the Menace.  
MA: And wanting to be Dennis the Menace but also saying, “Wow. I wish I had hair like Dennis,” or, you know, “Wow. How come my mom doesn't stay home and bake cookies all the time? My mom is up working,” right? You know, “My dad doesn't wear a tie except on Sundays,” right? But it's also giving meaning to that. Or growing up — again, we're in the same age group – remember Tarzan on Sunday afternoon, the Tarzan movies?
LR: I do. Johnny Weissmuller, yep. 
MA: – and identifying with Tarzan more than the so-called natives? And, as a matter of fact, not wanting to be the native. That's the double consciousness that Du Bois talks about. Fanon calls it the zone of nonbeing.
LR: The zone of nonbeing? 
MA: And Fanon, going from Hegel's master-slave hypothesis. I don't know if you're familiar with that.
LR: Familiar only by name. 
MA: Fanon says that's about the idea of recognition and consciousness, that we become conscious of ourselves by being recognized by others. Now, that's fine, but Fanon says, in a colonial situation, the colonizer never recognizes the colonized as human, right?
LR: And the colonized don't recognize necessarily that they have been colonized. 
MA:
In the colonized relationship, the third person is always in the middle of the relationship
Sometimes. Exactly. But also, what he says, in the zone of nonbeing, the colonized is never able to have a “normal” relationship.” Because a normal relationship is this, Larry: I and thou. I see you. You see me. We recognize each other. We are conscious of each other. In the colonized relationship, the third person is always in the middle of the relationship. 

So, in describing another person, and this is using me hypothetically, I might say, “You know that guy over there? He's dark-skinned, but he's handsome.” So, in other words, there's another measuring stick to that person to help me describe that person. “You know that guy? He is really dumb for light-skinned dude.” So, there's always these relationships that are in the middle of our relationships. These are the things that affect relationships.

I'm a family therapist, right? These are the things that begin to affect relationships even when they're unspoken. And if you're not aware of the nature of those things, that's what testimony therapy brings to the forefront, that these are also things that are important to think about in these situations. When I've got a husband and wife come in, it's not just the problems they have. It's the problems they have that have been exasperated (sic) in the everyday lived experience of just being a Black person growing up in America.   

LR: Is there a presumption that all Blacks, all African Americans have this double consciousness whether they're aware of it or not? 
MA: Absolutely. Can you be Black in America and not always have this small voice in the back of your head? For Black women, the decisions about how they fix their hair is a political decision and not just a daily decision. The choice. How they do that. Decisions about how we speak and how we are heard, right? If we speak and our speech sounds too Black, or if we speak and our speech sounds too White, right?
LR: Or not white enough. 
MA: The clothes that we might choose to wear. All of those are decisions which are grounded in, “How will I be perceived?” And it's not just how I will be perceived. Also, I'm concerned about how other Black people are perceived because I'm afraid that how they're perceived also may have some effect on how I'm perceived.
LR: So, the Black person is always being evaluated. And if they're not receiving overt criticism, there is this other consciousness in which they're either comparing themselves unfavorably to other Blacks or unfavorably to Whites. So, your clients, to the one, your Black clients experience oppression whether they are conscious of it? 
MA: Even if it is not named that. There's always this question of… For instance, I was at a conference last week. And my wife and I were about to open our hotel door. I was kind of casually dressed, had a nice little jacket on. You know, my wife is super colorful and flamboyant. So, she had some colorful clothes on. There was a White family about three doors down, and I think they were locked out of their space. And we went to our door, and we opened it up, and one of the women said, “Oh, it's down here." She's telling us, “It's down here.” And we kind of looked confused. And she says, “Oh, never mind.” [laughs]
LR: They thought you were the help opening – 
MA: They thought we were the help. [laughs] You know, I wasn't dressed in any kind of uniform or anything like that. And so, now, the part of that is, you know, my wife kind of got a little… She's like, "Argh.” I said, “Look.” As I thought about it, I was like, “Wow. Why?” What was that about? Why would they assume that I was the help? What is there about me that looked like the help? I wasn't dressed like the help or anything else. But there was that quick assumption. That's what the young people call everyday microaggressions. It's like those things that make you wonder. Now, you're not quite sure, but it's, again, to always have those thoughts. It is not an unusual thing for me to have conversations with my clients, and in some way experiences like that come up in the conversation. Or ideas like that come up. And, again, this is not about people being hyper-politicized or understanding. This is the everydayness of life.
LR: Black life. 
MA: What testimony therapy is about is about having a framework to understand that and to understand the meanings of that and a framework that allows us to engage those conversations in ways that feel safe and also are not committed to having you just basically fit in. You know, our traditional training as therapists is to help people fit in. Do we really want people to fit in to that experience of life, or do we want to give them ways of challenging that and seeing themselves in more powerful ways? 

Therapy Embraces Culture

LR: Is psychotherapy with Blacks/African Americans diminished if the therapist does not take a testimony-oriented approach or that does not focus on that double consciousness?
MA:
I don't get into the wars about what approach to therapy is best
No. The reason I'm not going to say that is because I don't think just taking a testimony approach, even though I think that the things that I talk about are valid and should be dealt with, is critical because I don't get into the wars about what approach to therapy is best. But I do think that the dominant Eurocentric approaches to therapy are oppressive in that they try to force people to fit into a cultural context that is not their home. That is the subject of the book that I'm working on which is about decolonizing therapy, and that idea of decolonizing and dis-alienating the work that we do away from that kind of therapy which basically assumes Western ideas and cultural values. Eurocentric ideas are the norm and, in that context, the best way to help people's mental health is to help them better be able to fit into those norms. And so, we use those Eurocentric approaches to fit people in.
LR: I appreciate this and am very excited by this conversation, and I see how animated you’ve become — your gestures, your tone, your body movements. And I guess, if I was doing a testimony-type therapy, we would be talking about this experience between the two of us. 
MA: This is what I do in my therapy room.
LR: So, if you believe that all Black America has double consciousness, is therapy with Black folks less than good enough therapy if we don't touch on the issues of double consciousness and colonialization? Is it incomplete therapy by definition? 
MA: If we are not aware of that reality, yes! I believe that the reality of double consciousness, the zone of nonbeing, as Fanon calls it. But there has to be a consciousness of the lived experience of Blackness in the West.
LR: Living in a Black body. 
MA: – and how, as a family therapist and systemic therapist, that impacts relationships. That's always the undercurrent of relationships. Even when it's not spoken, even when it's not something that people are consciously aware of in sophisticated ways, it's impacting the way they think. 

There's always this comparison. When we talk about Black male and female gender relationships, there's always that under thing. You know, it's always racialized. When you have Black men who don't like Black women, they say specifically, “Black women ain't shit.” Black women may be thinking, “You know what? I can't stand Black men. I'm thinking about dating out of my race because these men…”

It's all of them, right? And the thing that defines them is their Blackness. That's what makes them Black. So, it defines those relationships. When people are afraid of how their kids look. “I don't want you braiding your hair like that. People are going to think you're a gangbanger or something.” 

LR: Or have “the talk” with them. 
MA: So, this lived experience shapes relationships. And, again, so th

The Realm of Our Industry

From The Grieving Therapist by Justine Mastin & Larisa Garski, published by North Atlantic Books, copyright © 2023 by Justine Mastin & Larisa Garski. Reprinted by permission of North Atlantic Books.

“In the beginning, we were all psychotherapists. And it was good.”

—Bruce Minor, Minnesota Member of the MFT Community

THE TIME HAS COME to face our industry and sit with the ways the therapy system in which we work helps us, hurts us, and holds us to a standard impossible to meet. Throughout this book we have touched on many issues facing our work; now we are looking specifically at the system in which we work. No longer a collection of individual practitioners who see each other as fellow members of a therapeutic federation, our industry (therapy) has become compartmentalized, industrialized, and controlled by third-party payers.

As you begin this leg of the journey, we invite you to pause and reflect on the mentors and experiences who supported you on your quest to become a therapist. We welcome you to reflect on mentors of both the past and the present, as well as those with whom you had a challenging or even fraught relationship. Even those mentors and supervisors who we experience as awful can teach us valuable lessons (though that does not exonerate them).

When it comes to mentors and supervisors, we, the authors, have had the best and the worst. For this chapter, we reflect on some of the greats from our local MFT community: Anne Ramage, PsyD, LMFT, our graduate school professor who taught us so much more than we ever realized there was to know about Carl Whitaker; and the collective of marriage and family therapists who have sustained the Minnesota field for decades, some of whom also became our supervisors and mentors: Ginny D’Angelo, LICSW, LMFT, Bruce Minor, LMFT, Briar Miller, LMFT, and Michelle Libi, LMFT.

You blink and end your repose to find that you’re alone. It feels as if you have awoken from a dream. You rise from your resting spot and begin to walk down the winding path toward the sound of a river. As you walk, you notice the crunch of twigs underfoot and hear distant birds. Is one of them the red-winged blackbird? Neither your bird friend nor the forest yeti are anywhere in sight. Perhaps you dreamed them.

You look up at the branches of a nearby tree and notice a small silver shape clinging to a twig. Pausing, you raise up onto your tiptoes and realize that this is a cocoon, perhaps belonging to a butterfly or a moth. You gaze at the cocoon for a moment longer, noticing it shake as the small creature inside struggles with its transformation. Change is such hard work, you muse, and resume the hike. As you walk you notice that you have many aches in your body. How long were you sitting in meditation? You stretch your neck from side to side as you continue to make your way down the mountainside.

As you breathe in, the air is fragrant with the scent of dried leaves and warm earth. You wonder at the way the seasons seem to have shifted around you on your travels. As you look around the forest bordering either side of the path, you notice hints of yellow and orange in many of the leaves. The wind shifts, blowing the undersides of the leaves up, causing them to shift and sway. It reminds you of a distant memory, but as you grasp for it, the memory skitters out of reach.

The path winds down the slope, and you lean slightly backward against the tug of inertia and gravity. The sun’s rays are just the right amount of warmth, offering a radiating blanket of heat against the cooler air temperature. You look down and slightly to your left, and you see a ribbon of blue snaking through the undergrowth far below: a river. It looks like a nice place to pause and rest. You estimate that you have at least another mile to walk down the mountain before you reach the riverbank. You walk down toward it.

Therapy’s Big Brother

Once upon a time, as Bruce Minor reminds us, we were all just psychotherapists. In the very, very beginning of our industry, there were just small- to medium-sized collectives of human beings throughout the American and European continents — composed mostly of wealthy men and a few audacious women — gathering together in an attempt to suss out the nature of the human mind and heart. From these meetings, the field of psychoanalysis was born.

While these early theorists and practitioners engaged in practices that we would gasp at today — Freud psychoanalyzing his daughter, Jung sleeping with several of his patients who then became therapists-in-training — their mistakes became the foundations upon which rules like “no dual relationships” were based.

These early therapists did not have insurance agencies or managed care with which to deal. But they also tended to focus on treating the bourgeoisie — the European upper middle class who could afford to pay for things like this newfangled “talking cure,” thanks to their monopoly on industry. Neither Jung, Adler, nor Freud himself (founding psychoanalysts all) had to consider whether high-quality psychotherapy happens in increments of forty-five, sixty, or ninety minutes. We bring you this abbreviated history lesson to remind us all that our present constructs have not always existed. Not only have they not always existed, but they might not actually be the most effective structure for treatment.

When family therapy was new, co-therapy and one-way mirrors with reflection teams were the standard of the day. When Justine tells graduate students about these once-standard training practices, they are in awe. “But how did that get paid for?!” they exclaim. The short answer is that decades ago, universities, particularly public universities, had more money in the humanities and social science departments.

Insurance once reimbursed for far more therapeutic services than they do now. Then Justine will often go on to tell her students about sitting in her own graduate school classroom at Hazelden Graduate School of Addiction Studies (now Hazelden Betty Ford) and hearing her professors talk about the changing landscape of drug and alcohol treatment.

Structured limitations are necessary for high-quality therapy (recall the example of sandtray therapy and the need for a literal box within which to put the sand, from chapter 2). Certainly, the case could be made that American psychoanalysis and drug treatment of the 1970s and 1980s was in need of a bit more clinical oversight. But the evolution that followed brings us to a dystopian present where third-party payers like insurance companies are dictating the terms and conditions of treatment. They’re also dictating the amount of money that the clinician receives for the work they do based solely on their licensure, rather than on the type of work they’re doing. These payouts are often inadequate at best and paltry at worst. Because of variable reimbursement rates, the amount of time and effort needed to handle billing issues, and the hoops clinicians need to navigate to get even the small amount of money they’re paid, private-practice clinicians are increasingly opting out of the insurance model. This causes frustration for would-be clients, and for other clinicians.

Licensure Drama

Have you ever had an issue with another clinician and thought, “Well, that’s just because they’re a Ph.D.; doctorate school sucks all of the fun out of you”? Or perhaps you’ve thought, “They don’t teach master’s-level clinicians anything about diagnostics.” Third-party payers and clinicians determine their reimbursement or compensation rates based on a number of factors, including education. Hierarchical thinking dictates that the more education and experience a person has, the more they should be valued.

The main way that we express or show value is through monetary compensation. However, this very quickly leads to confusion and resentment when master’s-level clinicians and doctoral-level clinicians are working at the same practice or agency, and are performing, at least on paper, the same job functions. Disparate training and licensure requirements can lead to differences in case conceptualizations, standards of care, and clinical interventions.

Certainly, these varied perspectives can be helpful if discussed and processed through open and honest clinical dialogue. But who has time for that? We don’t say this to minimize or undermine the value of care coordination. The reality, though, is that third-party payers don’t reimburse for care coordination. Contemporary clinicians are lucky if they can connect for five or ten minutes via phone either just before the beginning (seven a.m.) or just after the end (seven p.m.) of their clinical day. Thus, it’s no surprise that confusion and even infighting across licenses and education levels abound.

Justine recalls a question from a student about this infighting: “But who is actually above the others? There has to be a hierarchy, right?” Justine responded that while it may feel as though there is a hierarchy, the reality is that we’re a community with a variety of skills. We don’t need to fight among ourselves. She said that just because someone with a doctorate has more education than someone with a master’s degree, that doesn’t make them better than or above the master’s-level clinician. This is a social construct that we get to question and challenge, because it no longer serves us.

The tangible difference between master’s-level and doctoral-level clinicians lies in the area of assessment. Folks who complete doctoral programs are schooled in the practice of psychological assessment and usually graduate with the third party-payer reimbursable skill of psychological assessment.

With gravity on your side, you make it to the bottom of the mountain faster than anticipated. The sound of the river rings in your ears as you push through the bracken toward the riverbank. The grass along the shore is a deep green and only slightly prickly as you kneel down and bend over the water, cupping your hands to take a long, cool drink. Once you have quenched your thirst, you sit back on your heels and stare out across the blue water, leaning into the rays of the sun at your back. You notice a butterfly flapping its wings and landing on a nearby flower.

App Therapy Is the New In-Home Therapy

Newly-minted therapy graduates find themselves staring down the gauntlet of the licensure process, which usually entails several examinations, hours of supervision, and even more hours of direct client care. Depending upon the state where you live and the license you’re pursuing, you may find it very difficult to get a job that pays you money while you acquire hours you can count toward licensure.

Over the past few decades, the entry-level job for graduates in this predicament was in-home family therapy. Often considered the grunt work of the therapy industry, in-home family therapy requires practitioners to work long hours and drive long distances for very minimal pay. In 2014, when Larisa was working as an in-home clinician, she didn’t even make minimum wage, so she worked another job part time as an after-hours crisis counselor.

Today’s graduates have a new, additional option: they can become app therapists. Similar to other gig jobs like Uber Eats and Lyft, clinicians who work for therapy apps such as BetterHelp, TalkSpace, and Larkr are either populated by associate-licensed or fully licensed clinicians, and they work entirely through their company’s telehealth app interface. They tend to have very large caseloads (pitched to them as a “great opportunity to get your licensure hours”), minimal time with an assigned clinical supervisor, and demanding clinical expectations. Most therapy app jobs market their services to prospective clients with the promise of a readily available therapist, translating to the expectation that the therapist is available to the client at least via chat through most hours of the day and night.

Larisa vividly recalls many of her lectures with Dr. Anne Ramage for a number of reasons, not the least of which is that Dr. Ramage is an excellent professor and an enigmatic speaker. Among all of Larisa’s memories of Dr. Ramage’s Carl Whitaker quotes and experiential roleplays, she recalls the professor advising time and again that “in-home jobs will be waiting for you as soon as you graduate. They’re tough. You need to be ready. But they’ll give you excellent experience in working with families.” Then Dr. Ramage discussed the MFT techniques from that particular lecture that might apply to in-home work, and she explained the basic safety strategies of which in-home clinicians needed to be aware.

When Larisa graduated, she did indeed take a job as an in-home family therapist. The night before her first day, she reviewed the strategies she had learned from Dr. Ramage:

1. Arrive five minutes early and look up the homes you’ll be visiting in advance so you can plan your parking strategy. Never schedule sessions late in the evening or after dark.

2. Be ready to set clear and consistent boundaries, and for those boundaries to be tested.

3. Pack a change of clothes and hand sanitizer.

4. Review your agency’s privacy policies.

5. When you enter someone’s home, assess for safety and your own exit strategy. Although it is rare that clients will ever mean you harm, things can and do get out of hand when you are in the family’s own space. You get to protect yourself first.

This survival guide doesn’t apply to folks who are working for therapy apps, but the need for both support and coping strategies is no less acute. If you’re working for a therapy app, we, the authors, offer you deep compassion and the following tips:

1. Plan an exit strategy. What does this mean? It means a human being can’t sustain years of work at the rate demanded by therapy apps. So, it’s essential for you to decide how long you can sustain working for a therapy app before you go the way of a younger Larisa and start losing your hair and developing insomnia.

2. Find a supervisor outside the therapy app. Yes, you will probably have to pay for this supervision, and that will likely cause financial stress. However, it is crucial for you to have a guide whose sole investment is in you and who exists outside the system in which you work, to help you regain perspective and hold boundaries around things like time management and availability.

3. Remember that any symptoms of burnout (i.e., signs of physical or emotional distress) you’re experiencing are likely the cause of moral injury — harm caused by the system in which you work — rather than any fault of your own (we’ll discuss these concepts in more detail in the next section of this chapter).

4. Manage your expectations for yourself. However, you envisioned your therapy experience, it likely did not involve a smartphone application called “Better-something.” You can’t do depth psychotherapy in this kind of context; what you can do is help your clients with basic coping strategies and compassionate presence — sometimes, but not all the time. You’re not required to have 24/7 availability, no matter what your company tells you. Not even standard laptops can run constantly forever; they need to rest and update.

5. Reach out to your community. When you work in an online environment, it can be difficult to get your emotional needs met. Please remember to engage with other living beings outside your work environment who understand some of what you’re going through and who can show up for you.

Burnout and Moral Injury

The Realm of Our Work has changed in ways that we never imagined over the course of the collective traumas of the 2020s. Suddenly the norm is to work in a virtual therapy room, and some clients expect to have regular access to their therapist via text messages and video chat services. This isn’t what we thought the field would look like.

When Justine imagined her future as a therapist, she saw herself engulfed in a scarf, with a teacup in hand, sitting across from her client in an overstuffed chair near a small fire in a fireplace, surrounded by books. She envisioned herself helping people and feeling filled up by the work, then returning home to a pleasant evening all to herself — overall a very calm and steady way of life.

This is not reality. For a time, she did have the tea and the overstuffed chair, but the rest of the fantasy was just that — a fantasy. Justine now works behind a computer and sits in a rolling chair; her view is full of microphones, a ring light, and multiple monitors. For her, the change in our industry has been the death of a dream. The death of any dream is an ambiguous loss that even therapists are not always good at recognizing and finding compassion and ritual to help them move through it.

Of course, parts of what Justine imagined the life of a therapist to be all those many years ago, before she ever entered the field, were simply inaccurate. Even before teletherapy and therapy apps took over the field, the life of a therapist was rarely calm and steady. It had moments and longer periods of such calm, but the nature of therapy is to work with volatile emotions. The emotional intensity inherent to the profession impacts even the most experienced and boundaried of therapists.

Larisa’s experience differed in that she had a logical view of what life in the field would be like. She felt like she had prepared herself emotionally for the trials of holding space for people and their emotions day in and day out. She believed that this preparation would act as a shield against any future catastrophe. The sadness came when she realized that no matter how prepared she had been, the situation was worse, and far more unpredictable, than she could have imagined. She was ready for the stresses of people’s everyday lives and even for their great despair and trauma, but she was unprepared for the collective trauma of our age stepping into the therapy room and into her own life. She was totally unprepared for how political leadership would fail her and everyone else in her country during this time of great collective need.

In her younger and more impressionable years, she believed that even though power is corrosive and toxic to politicians, when they were faced with clear and present disaster, they would channel their highest selves and work to help people. Now Larisa realizes that America’s representative government has devolved into rule by the wealthy elite who use their resources to buffer themselves from the pain and the needs of their constituents. Sometimes the despair she feels is crushing. Perhaps you can relate.

As we sit with the tragedies that have befallen our profession, it is no wonder that so many therapists struggle with burnout. Burnout can be defined from many perspectives. For the sake of brevity and clarity, we offer definitions of both individualized burnout and systemic burnout. Individualized burnout occurs when a person is so emotionally exhausted that they chronically struggle with depersonalization, which is emotional, physical, and cognitive numbness that makes the person unable to feel present in their own body or life.

Systemic burnout is also known as moral injury, which is when a person experiences symptoms through no fault of their own; rather, the symptoms result from harm caused by the system in which they work. Moral injury was first defined by psychiatrist Jonathan Shay as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.” Wendy Dean, Simon Talbot, and Austin Dean expanded upon this definition when they argued for clinician burnout to be redefined as moral injury:

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin [sic] of our working lives and our guiding principle when searching for the right course of action.

But as clinicians, we are increasingly forced to consider the demands of other stakeholders — the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security —before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.

The article quoted above speaks solely to the experience of medical doctors, but its implications are clear for the chronic systemic burnout faced by so many in helping professions, including (but not limited to) therapists, medical technicians, nurses, and case managers. Helping professionals are increasingly placed in a double bind; that is, they’re being placed in situations from which there is no escape, and they’re being asked to perform at least two mutually exclusive actions simultaneously. They’re being asked to care for clients but also to please many other stakeholders, all without the amount or quality of support that they need. Just like all double binds, this is an untenable situation that causes distress within the clinician.

We, the authors, appreciate the distinction between burnout and moral injury. The concept of moral injury takes the onus off the individual, because there’s not enough self-care in the world to account for a system that’s set up as a no-win situation. When larger systems talk about “burnout,” that terminology allows them to let themselves off the hook for the clinician’s pain. The system can then pass the problem back to the clinician as a personal failing, rather than a systemic one. The therapy field is currently crying out for systemic change. We cannot do everything and be everything to everyone. It is impossible, and it is destroying us.

The butterfly’s orange and black wings flutter back and forth as it buries its face in a Black-eyed Susan. You contemplate the effort that it took for this butterfly to metamorphose from a caterpillar. It went through a violent transformation in the cocoon to become this creature. It’s not a pretty process. The butterfly must flap and flap and flap its wings inside the cocoon to strengthen them. It can be a difficult struggle to watch, and an onlooker often wants to help the butterfly be free from its enclosure.

But if it’s released from the cocoon early, the butterfly won’t have the strength to fly and survive. It must struggle to become strong. As you stare at the butterfly, considering its beautiful wings, you start to breathe into your own bodily awareness. You notice the many places where you’re holding tension and feeling stiff and sore. Perhaps you have also been flapping your metaphorical wings, becoming something new.

Grieving Tools — The Pain Paradox

As you might remember from chapter 2, pain can be a pivotal part of the meaning-making process. When paired with reflection time, pain can help us learn about our core values and live a life in accordance with them.

Yet because we work in a field that values sacrifice and the pain that entails, therapists are also far more susceptible to what Freud would call the martyr complex, and what we refer to as hero/savior/sacrifice syndrome. The pain paradox explores the tension between pain as both catalyst for change and a state of prolonged suffering. Particularly in helping professions, suffering for our work is often framed as positive, meaningful, or altruistic. This harmful social construct can lead clinicians to stay in harmful jobs “for the sake of the clients” and sacrifice their own health in the process.

The pain paradox invites clinicians to question their social constructs around both pain and meaning-making. In the therapy room, the pain paradox is a tool that clinicians can use to help clients who are themselves engaging in harmful behaviors for the sake of “meaningful pain.” Let us explore how you can use the tool of the pain paradox as you navigate your personal struggles outside of session, and how to use this tool with clients inside the therapy space.

Client

Pain is not the enemy, nor is it to be avoided at all costs. Sometimes what brings clients to therapy is the erroneous idea that we, their therapist, can help them learn how to disengage with their feelings entirely because these feelings are causing them pain. Of course, the reality is that we can teach them distress tolerance skills to be present with their pain and their feelings so they can learn to listen to the important messages carried by their feelings.

However, clients can sometimes mistake pain for purpose. We see this frequently with our creative clients. So often the idea of the “crazy artist” takes hold of clients. Several of Justine’s clients were terrified of feeling better. They believed that their sickness and the distress it caused fueled their art. But the reality was that after going through treatment, these clients were all able to continue making amazing art, and in fact they did so with more frequency and focus. Another part of the process of working with these folks is helping them see that they’re full human beings who are more than just the art they craft.

Many fear that if they lose the art then they lose themselves and they no longer matter. However, in our experience, part of their healing journey entails exploring areas of their life outside of art. Eventually, they come to see their art as but an aspect or a planet within the vast cosmos of their lives.

Therapist

For many of us, the desire to make meaning from our own pain drew us to the field of psychotherapy. Most therapists have experienced some type of mental distress, whether it’s childhood trauma, an eating disorder, bullying, discrimination, or an abusive relationship with chemicals. For many of us, surviving this kind of pain was only the first phase of the healing process, with the second phase being meaning-making.

The pain paradox is a gentle invitation for therapists to carefully consider ways to cultivate meaning and joy outside the therapy field. Although our work as therapists is absolutely meaningful, it is also back-breakingly painful at times. If you don’t have other avenues or ways to make meaning and find purpose, you’ll find it even more challenging to take breaks from the field, regardless of how long such a break lasts, because you struggle to see the “you” outside the office. You need not try something life altering or huge. When Larisa was recovering from a severe case of moral injury, she began making playlists, an activity she had not engaged in since her college days. This small daily activity helped her to begin to reconnect with playful and creative energies outside her clinical and professional work.

The difficult message that Justine received was that her time as a direct-care therapist was coming to a close. After over a decade of work, and so many clients helped, she began to feel that her meaning-making was now to be found in the classroom, on the stage, and on the page. She experienced a great deal of pain as a therapist during the pandemic and the social justice uprising, but the pain invited her to consider where new meaning could form. The answer was that it was time to guide the next generation of clinicians and to hold the hands of those who are still in the trenches. As of this writing, Justine is currently working on the slow transition out of direct client care.

Due North: Self of the Therapist

One of the struggles inherent in walking the dialectic between the system and the individual is despair. In the case of moral injury, which is caused by a series of broken systems subjecting clinicians to harmful double binds, it can feel like there’s little or nothing for a therapist to do beyond retiring from the field. While this certainly is an option, we offer you another one: harm reduction and intentional activism.

As you may already know, the harm-reduction model of addiction recovery focuses on making small, actionable changes that mitigate abusing behaviors, rather than prescribing total sobriety. Our intention is to invite you as a clinician to assess the harm you’re currently facing in your career and how it’s affecting you. You can’t immediately change the systems in which you practice therapy, but you can make a concerted effort to mitigate the negative impact that these systems have upon you.

Some ways that you might limit the harm you experience include limiting the number of hours you work or the types of clients or clinical presentations with which you work. Perhaps you currently work in a place with an unreliable schedule, and that causes you distress; is it possible to have a more structured schedule? If you’re not being given time for breaks or lunch, is this a conversation you can have and a boundary you can set with your site supervisor? These can be small or large changes, but any change can go a long way to help mitigate the harm you’re experiencing.