Category: Family Therapy

Dead Basement: Opening a Family Therapy Time Capsule

Posted on by Psychotherapy.net Team

It all started sometime last year when I began a quest to clean out my basement — I’d not seen the Swedish “Death Cleaning” shows yet, so I was on my own. I mistakenly thought I could just start tossing the mounds of journals, articles, books, and conference nametags so our kids could be spared the work after I died — but then…there it was…

Family Therapy History Makers

A December 1974 — Volume 13 Number 4 issue of Family Process. A Multidisciplinary Journal of Family Study Research and Treatment, with a faded stamp from the Library of the Philadelphia Child Guidance Clinic. An article by Mara Selvini Palazzoli, Luigi Boscolo, Gian Franco Cecchin & Giuliana Prata entitled: The Treatment of Children Through Brief Therapy of Their Parents. An asterisk: “Translated by Paul Watzlawick.” I smiled remembering a dinner with them, drinking, laughing, and telling jokes. Hmm, when was that…?

As I opened the journal to page 429, something happened. It was as if I were just teleported back 49 years, now the eager graduate school student who just got out of the Army. The moment even had a soundtrack — Amy Correia’s song, “The Bike,” in which she told the story reflecting on the life of her uncle Pat, from whom she’d inherited the bike. She sang that in his youth “… life was laid before him like a platter before a king/he was young, and he was handsome/and the world was alive with meaning…”

So, I re-read the article — a treat from my younger self. It reminded me of when I was in the service and smoked heavily doing mental health reports in the stockade. Cigarettes were 26 cents a pack on post. I remembered watching the puff of the clouds as I exhaled, which evoked another song — a commentary on aging — David Bowie singing, “Time may change me, but I can’t trace time…” So, I kept the journal, for now…. only a hundred or so other journals in the “Dead Basement” — waiting for the right music.

I felt like ditching these old journals would be the academic equivalent of tossing my Beatles albums because they’re “too old,” which is to say that my “toss-to-keep” ratio is terrible. I feel like I’m one of those seniors in an Atlantic City Casino — smoking, hunched over “my” slot machine, air tank and hose to my nose, my ciggy aglow, and hoping for the Triple Cherries that may never arrive. (BTW, the RTP — “Return to Player,” averages $90.00 on $100.00 of betting if you play long enough…)

I wonder if people in other professions hoard in the same fashion. Does a doctor flip through their stack of appendix pictures and say, “Yep, this one’s a keeper…?” And how does all this play out with our respective “bucket lists?” Are therapists really cool “bucketeers,” driving through national forests in their RV’s stuffed with journals, texts, piles of Family Therapy Networkers from the ‘80s (like the one with the EST guy, Werner Earhart on the cover) and plastered with bumper stickers that have the AAMFT logo, a Forest Gump, “Shit Happens” classic, and some retired social work humor, “Social Workers Work…But Not Any More ?” And then, the Fireside Chats — hopefully fascinating and diverse, or like listening to Dwight, from The Office talking about how much he misses his Beet Farm…

Today was rough — Trash Day. I managed to get four journals out. If Gregory Bateson were here, he’d say that I’m only reaching half of the what’s necessary and what’s sufficient equation. While it’s necessary to chuck the old journals, I’m not tossing enough to make a dent in the piles. It happened again this morning. The culprit: a journal with yet another Philadelphia Child Guidance cover, this time with the library stamp for library shoplifters: “Please Do Not Remove from Library.” At that moment, past became present and I could feel it — my personal time machine: “Volume 4 Number 1 January, 1978: A Structural Approach to a Family with an Encopretic Child,” by Maurizio Andolfi and then, “Struggling with the Impotence Impasse: Absurdity and Acting-In” by David Keith and Carl Whitaker.

I hadn’t thought about Carl in years. I was very lucky. I’d worked with him after Minuchin left for New York and started the Minuchin Center for the Family. Carl and his wife, Muriel, came to PCGC “in residence twice for months at a time.” During one of those residencies, he and I were seeing a family together and one of the kids was noisily zooming around the room. I whispered, “Dr. Whitaker, shouldn’t we do something to help quiet things down?” But I said it so quietly that he didn’t hear me, so I said it again, louder — all he said was, “Not my kid.”

The father heard him, got up, and caught his son on one of his noisy rotations and then gently put him in his lap and the session went on successfully. Whitaker had worked his magic in just three words. Today, staring at the journal, I heard him again, and again, he taught me to trust our unconscious, like when ET was leaving Earth to go home, touching Elliot’s forehead and saying, “I’ll be right there,” so too will our memories — even if we don’t have the prompts.

Love is Not All You Need: A Revolutionary Approach to Parental Abuse

Posted on by Psychotherapy.net Team

The Referral Letter

The referral from Dr. Adams, the psychiatrist, read:

13-year-old young woman took an overdose of paracetamol 3 weeks ago. Called mother who took her to Accident & Emergency. Seen and followed up over last 2 weeks. No suicide ideation. Discharged to GP. Family issues. Please can you meet with this family this week?

Session One, Part One: Overdose and Desperation

A few days later as I (Kay) walked into the waiting room at the family medical practice where I worked, I saw Becca hunched over her cell phone, radiating animosity. Her mother Jane sat on one side of her, eyes on the latest New Zealand Woman’s Weekly story, but without the eye movement of a reader. Her father, Al, resigned, stared out the window at the dripping rain. Susie, Becca’s 15-year-old sister, picked absent-mindedly at her nail polish.

My step faltered as I sensed that the meeting ahead of me might be testing but I strode in, hand outstretched: “Hi! You must be Becca. I’m Kay.”

Temporarily startled, a reluctant smile escaped her as she awoke from cyber-land. “Hi, you must be Jane. Hi, Al. Hi, you must be Susie. Would you like to come up?” I gestured toward the stairs that led to my office stairs. As I reached the first landing, I noticed Becca glancing at herself with uncertainty in the floor-to-ceiling mirror that filled the stairwell. The family awkwardly found their way to their seats. I began my usual introductory patter but didn’t get far before Al expostulated, “Look, we need to sort this out! We can’t handle it any longer.” His eyes shot towards the brooding Becca. “She hit her mother in the face the night before last and then she locked herself in the bathroom for hours. We tried to get her to come out and talk but she just shouted abuse at us.”

Jane glanced towards me as she found some words.

“Becca went very quiet, and I got really scared. We thought we had taken all the medicines out of the cabinet after the overdoses, but we couldn’t help worrying after what happened the other week. We took turns sitting outside the bathroom door just listening in. Eventually, she came out and went up to her room. It all started when Al tried to tell her she couldn’t carry on talking to me like she was.”

“Becca,” I ventured, “did you realize that your parents are feeling so scared and don’t know what to do?” My question was met by a “no” that ricocheted around the room like a bullet. “Becca, would you be willing to help me understand what has been going on in your family?”

Becca’s reply began with a fake whine which escalated to foul-mouthed accusations. “She’s always saying, ‘Honey, what’s wrong?’ What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong is that she’s annoying me. My mum is a stupid bitch with no life. That’s what’s wrong.”

I said, “Becca, is this way of talking the kind of talking that is causing trouble in your family?”

Becca said, “This is so fucking dumb.” Susie let out a protracted sigh.

“Becca, stop talking like that. It’s not fair. Mum and Dad have had enough and what have they done to you?”

The door slammed loudly as Becca made her exit. Jane leapt out of her seat, but Al caught her by the arm.

“Let her go. You always go after her. It’s no good. You can’t keep running after her like this.”

Concerned to sidestep the impasse between them, I spoke up.

“Okay, how about I go downstairs and find out what’s happening, and we can take it from there?” Al and Jane nodded, defeated. Susie was pale.

It turned out that Becca had found the back door to the building. I caught a glimpse of her crouched down with her back against her parent’s car, head between her knees. She looked up, saw me and went to sit on the other side of the car, out of view. I asked Emma, the receptionist, to keep a discreet eye on her. When I went back to the room, Jane and Al agreed to sit it out.

Al began, “It’s good you have seen her like this. We are falling apart. We can’t do this on our own.” There was a moment’s silence. Al looked to Jane. Jane’s shoulders began to rock as if she were holding back sobs. Al continued, “Becca doesn’t treat her mother like a parent. I mean she says things to me that I would never, ever have thought of saying to my parents. You just want to slap her face, but you can’t you know?”

Jane, her body stiff, said with a look of desperation, “The other night, Becca was screaming at me that the dinner was ‘crap’ and ‘shit.’ Adam, our 4-year-old, hid under the table. It broke my heart to see him so scared of her because he loves Becca. I feel like we are losing Susie too because she can’t stand it. She is staying ‘round at her friend’s house all the time.”

Al looked towards Susie, raising his eyebrows.

“You’re no angel either, Susie, but at the moment you come a long second to Becca.”

The story unfolded. It appeared that this was a long-standing pattern which had recently escalated from initial bad-tempered-ness to dramatic, life-threatening actions. I discovered that Al and Jane considered that they were being held hostage by Becca’s threats to harm herself, both subtle and explicit. Such threats followed any insistence that she carry out some duty that she didn’t wish to fulfill such as tidying her bedroom or if Jane said “no” to her persistent demands for money or to stay out late.

Jane had begun to fear returning home from work, anticipating that she would be met with yet more demands from Becca, and find herself caught once again between holding out against them or risking further threats of self-harm. Al was also finding home life unbearable. He longed to be able to “fix things” for his family but, in the face of Becca’s threats, had no idea what to do and couldn’t find words for the mixture of frustration, fear, and anger that preyed upon him. Al had started going around to his friend Mike’s house each night for a drink until what had started as occasional visits had become habitual. He felt guilty that he was not at Jane’s side but told himself and Jane, “I no longer have a place in this family. I am sick of being abused in my own home.”

Jane and Al had no idea what to do. Becca had been “seen” by Mental Health Service several times and, after the usual assessments (in which “mental illness,” abuse, and other possible sources of distress were excluded as a cause of Becca’s behaviour), the service had come to the conclusion that the overdose and threats of self-harm could best be explained by what was referred to as “family dynamics” and suggested that Jane and Al seek family therapy. That is how they arrived at my door.

How many parents, confounded by a family life that has become dominated by teenage tantrums, threats, violence, and the dread that their daughter might respond to any challenge to their demands with an overdose or violence, would be willing to talk about how they fear living in their own homes? How many would tell family and friends? Wouldn’t it be more usual for parents in this predicament to remain silent in their humiliation that their own child is abusing them? Of those family members and friends who had some knowledge of the situation, how many of them would be too respectful to speak up about this family’s predicament without being invited to do so?

Could these tantrum overdoses and the tyrannical threat of them instigate a servicing of young people’s every want? What might these young people be led to think about themselves if their each and every whim was serviced? Where would this lead? How might this have them lead their lives? How might this affect their family life? All these questions went through my mind as we reflected on this family and their tribulations; all these questions guided us in our considerations. This is the story of a family worn down by tantrums and abuse. This is also the story of a mother who decides to revolt.

Session One, Part Two: When Loving and Giving is a One-Way Street

“You know, Kay, we’ve always said, ‘love is all you need.’ It’s been our motto. I’m beginning to think we’ve made some big mistakes because I can’t understand why Becca is behaving like this. We have given them all so much love. We have always bent over backward to make sure that they are okay. It’s just so unfair. I try to listen and understand but she doesn’t want to talk to me anymore, and then she starts with her threats. I know I shouldn’t give in to them, so I try and hold my ground, but I feel like I have overreacted. Then I feel bad and give in. I know I shouldn’t. I just feel like I am stuffed!”

Jane’s voice faded into despair. As tears began to form in her eyes, she wiped them away hurriedly with the sleeve of her hoodie. Al chipped in, his voice weary with resignation.

“I just don’t know where we’ve gone wrong.”

I addressed the despairing Jane and displaced Al.

“Do you think it’s possible that all your loving and giving has become a one-way street, and that somewhere along the way your children’s wants have become confused with their needs?”

Jane swallowed hard.

“We’ve always tried to give them what they wanted. I always thought that if we respected them, they would respect us, but they don’t seem to. I just find it so hard to know what to do.”

I asked, “What do you think Al?”

Al shifted uneasily in his seat.

“What’s going to happen to them in the hard world out there?” he said wearily. I wondered if servicing their children’s needs had, contrary to their good intentions, been depriving their children of invaluable life lessons.

“Al,” I asked, “are you concerned in any way that unfairness has crept into the care of your children in that, by giving so much, your children may not have had enough opportunities to learn what they need to learn to live in the hard world out there?” Al had no trouble replying:

“Yep. I don’t think they have any respect for other people, and they don’t know how to be responsible.”

“Susie, what do you think of the idea that your parents have been unfair to you by not helping you to be ready for the hard world out there? Do you think that maybe, out of their love for you all, they need to find ways of mothering and fathering that might seem unfair to you now but may prove to be fairer to you in the long run?”

Susie stared at me, her eyes fixed in surprise, then she recovered herself. “I don’t think they’ve been unfair, but I suppose we have had it pretty easy. I don’t know, it’s getting me down too.”

“Susie, have you been worried about Becca?” Susie’s lip began to tremble. “Susie, how would it be if I carried on speaking with your mum and dad to see if we can find a way to help things be better for Becca and for you all? Would it be alright if I spoke with them without you present? I think your mum and dad need to find the way forwards on their own as your parents.”

Susie’s face softened with relief. Jane and Al agreed that the next time we met we would continue to explore how this habit of unfairness had taken root in the mothering and fathering of their children. I warned them that the road ahead might well be a rocky one and that other parents facing similar challenges are often met with intensified threats from their daughters or sons when they re-establish their parental authority. Jane and Al left our meeting, sobered by the realisation that they could go no further along the road that they had been travelling but relieved to be no longer standing paralysed at this crossroads.

Session Two: The Dif?culty of Knowing What’s Fair and What’s Unfair, What’s Unreasonable and What’s Reasonable?

Jane announced that there had been something of a turning of the tables. The day after our session she had decided that it was time the girls learned to do something for themselves. Instead of doing their clothes washing for them as she had always done, she had left their washing lying on their bedroom floors where they left it and stayed in bed herself for an extra hour. When later that day Susie asked where her clean washing was, Jane simply said, “Oh, I’ve given up doing your washing now.” Much to her surprise, Susie asked her to show her how to use the washing machine. Not surprisingly, Becca had left her dirty washing in a heap in her room.

Al, who was running late, joined us. I put him in the picture.

“We were talking about wants and needs and I was asking Jane about whether or not your parenting in the past has been about 'loving and giving?’”

“Well Susie has been getting too much until now,” Al responded. “My sister set her up with an interview as a summer lifeguard and she didn’t even bother to go. Lynette was really annoyed about it and had a real go at me. She said, ‘You two have to toughen up with those girls.’ I’ve realised she’s right.”

“What do you think you have been serving? Have you been serving her wants or her needs?”

“Her wants!”

“What do you think her needs are?”

“Her needs are to take some responsibility for herself. She hasn’t lifted a finger all holidays. She’s just sat at home emptying our fridge.”

“At what point do you think mothers and fathers should let their children know that if they as parents continue to take responsibility for them, they will be depriving them of taking responsibility for themselves?”

“Well, we do but we don’t stick to it,” Jane said.

“Yes. We lay down the law and then we give in,” Al replied.

“Looking ahead to when Susie is 40 years old, do you have any idea what she might wish you had done or said to her right now, aged 15?” I asked.

“She’d say ‘take responsibility for yourself’ wouldn’t she?” Al suggested.

“I suppose so, but we would have to make her do it and I would find that very difficult,” Jane responded.

“You said last time we met that you have a motto of ‘love is all your need.’”

“Yes, you know I have always thought that if we just loved our kids, it would all work out,” Jane said. “Last Sunday morning was a real low point. Becca started swearing at me when I got home from a late shift and was on my bed with all her friends drinking and eating. I found myself thinking ‘whatever happened to my lovely daughter?’”

“Do you think it’s possible that in the past, even though your intentions have been so very loving, love has been confused with giving in to what your children want?” I enquired.

“I guess so. I just thought they would love us if we loved them and that if we respected them, they would respect us,” she said.

“Are you coming to question how children learn love and respect for their parents and others?” I asked her.

“Yeah, I guess I haven’t made a point of them respecting me so maybe they haven’t learned it. I lose their respect for myself every time they say ‘no’ to me and I let it go,” she said.

“Al, what do you think about this? How do you think children learn to be loving and to practise respect?” I asked Al.

“Well, it’s been harder for Jane,” he said, adding, “I’ve always worked long hours and before we had Becca, we agreed that she would stay home and be a full-time Mum. We were really hanging in for Becca.”

“Yes,” Jane agreed. “You see Susie isn’t Al’s. I had Susie when I was 17 and I was a single parent until I met Al when Susie was 2. We had some problems and had IVF. Then she was preemie and we thought we were going to lose her. It was a terrible time.”

“Given you had to go through so much heartache to have her, did you ever think that Becca deserved special treatment in any way?” I suggested.

“We were just so thankful that she had survived,” Jane admitted. “Looking back now, I tried to give her the best of everything, and we doted on her.”

“Yeah, it was our one time away from her and she was all we could talk about,” Al said.

“Do you think that loving Becca so much has led you to be especially sensitive to her moods, wishes, and feelings?” I asked them.

“When I look back now, I think so,” Jane said.

“To be honest, she was very spoilt,” Al added after.

The Letter

The next day I wrote Jane and Al the following letter.

Dear Jane & Al,

It was good to meet you yesterday. As I mentioned, I often write to families after our sessions to ensure that I have adequately understood their situation and in addition to ask questions I wish I had asked during the session itself.

Sure, enough some questions came to mind whilst I was reflecting on your situation. I would be most interested to hear your answers or any thoughts you might have about these questions next time we meet. If you think that I have not described what we talked about fully or have misunderstood your situation in any way, could you also bring it to my attention next time?

Jane, before Al arrived you talked about some changes you had made. You said that a couple of days before we met, you had decided to have a ‘lie in’ and had resolved that you were no longer going to do the girls’ clothes washing. You also informed me that you felt you hadn’t had enough expectations of the children in the past and that you wished that you had started years ago. But you said that your lie-in was not as peaceful as you had hoped because you found yourself troubled, wondering whether or not your expectations of the girls were unreasonable or unfair.

Jane, do you suspect that your expectations may be having a late growth spurt but that perhaps, and very understandably, you are feeling a few growing pains? After all, have you ever noticed how overnight changes often feel as uncomfortable as a new pair of shoes to begin with?

Jane, do you have any ideas about why it was difficult for you to work out what expectations might be reasonable and fair? Do you think it may have been in part because your expectations of Becca at least, have been so shaped by the weight of your gratitude for her very existence?

Now that you have decided that your children can learn to serve themselves rather than being served, what kind of response do you think you might anticipate from them as time goes by? Do you think that they will take kindly to your new expectations which express your love for them in a way that serves their needs rather than their wants? Or do you think they might protest the changes in some way or other?

Jane and Al, towards the end of the session we talked about how separating your children’s wants from their needs had been especially hard with Becca.

Isn’t it understandable that if you have waited so long for a child and then when she is born and you are in fear for her life, you might want to treat her with especial care? Is it any wonder that your love and concern might leave you blinkered to some of her needs and sensitive to her wants?

Jane, do you think your ‘special care’ of Becca might have had a bearing on ‘giving in or setting boundaries and sticking to them?’ Thinking about it now, do you suspect that weak boundaries might be even more painful for you than for her in the long run?

You both told me that you don’t want to make your children unhappy, but then you talked about some realities that life holds. You said there was a difference between real unhappiness and tantrumming. If you always say ‘yes.’ if you’re always ‘manipulated.’ Where do your children hear ‘no’ from? What kind of lives will they lead if they never hear ‘no?’

Al and Jane, at what point do you think a mother or father should say to a young person: ‘I will not allow you to have such power over our family anymore; we are in charge, not you?’ Truth be told, what do you guess Becca would most like her parents to do right now?

I cannot believe that departing from the ways in which you have mothered and fathered your children in the past is going to be easy. In fact, would you consider that it might be one of the most difficult things you might ever take up in the course of your lives?

I look forward to meeting with you again on the 4th of March. Best wishes,

Kay Ingamells

Session Three: ‘Self Sensitivity’ 90%, Sensitivity to Others 10%

Jane came on her own to the next session. Although Al told her he was busy at work, she suspected that he had been overcome by his feelings of powerlessness and resignation. We began the session with my reading the letter aloud to Jane. Jane reported that the letter made her “realise I thought being a loving mother meant taking care of them in every way 100% of the time and this has made it difficult for them to respect me as well as for me to respect them.”

Once again, she reported some novel developments. Jane had “put her foot down” when Becca had decided at the last moment that she didn’t want to attend her surf rescue training.

“I said, ‘we are going in the car now,” Jane said. “And when we got there, she said, ‘Don’t make me go. You’re so mean, I hate you.’ I found it really difficult, but I insisted she stay. I went away feeling really upset but when I came to pick her up, she said she had enjoyed it.”

“Did you take a stand for what you knew in your mother’s heart was right only afterwards to be undermined by guilt for not responding to her wants?” I replied.

“Ummm I did.”

“How come you put your foot down even though the guilt was putting such pressure upon you to give in?”

“Well, I thought it was the best thing for her.”

“Does putting what was ‘best for her’ first rather than giving in to her wants say something about your wisdom as a mother?”

“Yes! That I know what’s right for her and it’s okay to say it and insist that she does what she says she will do.”

“Do you think guilt would have got in the way of your motherly wisdom in the past?”

“I think it would have. I wouldn’t have wanted the children to plead and cry. I wouldn’t have wanted them to be unhappy. I would have brought her home again.”

“What has enabled you to act on your motherly wisdom and use your motherly voice lately rather than be sidetracked by their pleading and crying?”

“I don’t know.”

“You’ve given me one example after another of how you have used that motherly voice very powerfully and afterwards.”

“And yet I don’t feel in control. I don’t feel in control at all.”

“Do you also think it is possible that using your motherly voice is uncomfortable because you are not that used to speaking with it yet?”

“I said to Susie when she butted in, I said, ‘I’m the mother. I’ll decide what Becca will do and what she won’t do. I don’t need input from you.’”

“Do you think that it’s possible that your children have developed over-sensitivity to themselves and to their own feelings and insensitivity to you and to your feelings?”

“Yes!”

“If you were to put that in percentages, what percentage of the time do you think they are sensitive to their feelings and what percentage of the time do you think they are sensitive to your feelings and the feelings of others?”

“They consider their own feelings 90% of the time. Al is really kind and generous and caring, but certainly he would put what he wants to do above anything or anyone else, especially me.”

“What happens to your feelings and to your needs?”

“They get forgotten.”

We talked about the effects this imbalance of sensitivity, e.g., self-sensitivity, versus other sensitivity was having in her relationships with her children and their relationships with her. Some of the questions I posed were:

“Would you be interested in restoring the balance between Becca’s over-developed sensitivity to herself and her under-developed sensitivity to others and in particular to you as her mother?”

“What kind of struggle would you expect if you were to pit your mother’s wisdom against the widespread mother guilt?”

“Overdoses as tantrums” and a big night out.

A month later, I had a call from a worker from the after hours Mental Health Crisis Team to report that Becca had taken another overdose. The overdose had followed an argument with her mother about tidying up her room in which Becca struck her mother in the face breaking her glasses. Jane had to go immediately to her optometrist as she was due to start work an hour later and could not work without them. Becca tried to stop her mother leaving the house, but Jane had no choice but to do so. Becca took the overdose as soon as Jane left. This overdose posed a greater risk than the earlier ones and it looked like she was, in a manner of speaking, “upping the ante.” Jane became concerned that Becca would take her own life and so arranged a safe haven for her at Becca’s aunt’s home for a few weeks.

Becca was seen for an urgent psychiatric review. The psychiatrist concurred that Becca’s overdoses appeared to be an extreme reaction to her parents attempting to set appropriate boundaries. A safety plan was put in place with the parents, and I met Jane and Al a couple of days later. To my surprise Al and Jane were not as shaken by the overdose as I had expected. Instead, they concluded that Becca’s extreme behaviour was her way of “testing us.”

We discussed how they had dealt with tantrums when their children were toddlers. On seeing the similarities between toddler tantrumming and Becca’s extreme form of teenage tantrumming, Jane and Al became inspired with a renewed courage and confidence. It now appeared that perhaps this was a problem that they recognised and not only had some experience in handling but could rightfully assume they might overcome. The next morning, I had a phone call from Jane. She had discovered from the mother of one of Becca’s friends that Becca was planning a big night out to a nightclub in the city with a group of teenage friends. The nightclub called Krave was in the heart of the city, an hour by bus from the suburb that Becca lived in. Jane and Al told Becca that she couldn’t go as she was underage. Becca was outraged and insisted that she would go regardless. Jane later discovered that $100 was missing out of her purse and challenged Becca who, as usual, denied taking it.

Jane and Al enlisted the help of Becca’s aunt, uncle, and elder brothers to come around that evening. Despite this, Becca made her escape out of her bedroom window.

The team hot-footed after her, combed the local mall and found her waiting at a bus stop with two friends. Al took hold of her arm and asked her to get in the car. Becca began to scream “blue murder,” shouting “you are not my parents. I don’t know you. Help someone! Help! Help!" The passers-by that had assembled called the police who arrived very quickly at the scene. The police believed Jane and Al’s version of events rather than Becca’s street theatre. Becca’s protest resulted in her being handcuffed, read her legal rights and taken down to the cells.

I asked Jane how she felt about the evening’s events.

“It’s good to be in charge at last. I have never seen Becca so demure. The police wouldn’t release her until she had promised not to harm herself.” Guilt had not had its way with Jane this time.

Session Four: Instigating the Revolution

While Jane and Al had begun to turn the tables on the habits of parenting which had flourished on their sensitivity to their children’s feelings and servicing of their wants versus their needs, I was concerned about the extreme nature of Becca’s actions and that Al and Jane’s newfound determination could be compromised in the face of them. Consulting with David in supervision, we decided that a community approach was needed to match the gravity of the situation and to provide sufficient reinforcement for Jane and Al’s fledgling initiatives. While no approach was without its risks, any alternative

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

Posted on by Psychotherapy.net Team

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

— Leonardo Da Vinci

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Impact of Social Media on Family Relationships

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Crisis of Voluntary Play for Children

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

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

Children Entering Adolescence Have Not Learned to Play

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

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

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

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

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

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

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

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

A Non-Virtual Family Map

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

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

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

Non-Virtual Family Map

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Using a Virtual Family Map to Identify Issues in Families

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

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

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

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

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

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

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

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

 

Husband, Wife, and Social Media Triangle

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

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

Mother, Father, and Social Media Triangle

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

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

Mother, School, and, Social Media Triangle

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

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

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

Parents, Son, and Social Media Triangle

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

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

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

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

Son, Non-Virtual Friends, and Social Media Triangle

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

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

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

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

Mom, Therapist(s), and Social Media Triangle

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

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

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

Mom, Psychiatrist, and Social Media Triangle

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

Son, System of Care, and Social Media

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

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

Son, School Staff, and Social Media

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

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

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

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

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

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

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

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

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

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

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

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

Son, Virtual Friends, and Influencers

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

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

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

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

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

Using Exploring Questions to Make Circular Statements

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

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

References

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

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

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

Questions for Reflections and Discussion

How has social media influenced your personal and family life?

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

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

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

© Psychotherapy.net 2023

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

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

Collaborative Case Planning

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

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

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

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

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

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

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

Capitalizing on Strengths

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

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

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

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

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

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

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

Thinking Outside the Therapeutic Box

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

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

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

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

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

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

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

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

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

Finding Best Clinical Practices

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

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

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

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

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

Crossword Puzzles as Metaphor in Child Protection Work

Do you think I know what I am doing?

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

As much as a pen knows what it is writing,

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

Rumi

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

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

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

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

Enacting Possibility to Help Families in Crisis

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

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

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

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

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

Materials Needed: Copies of a Crossword Puzzle

Total Amount of time: 10–20 minutes

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

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

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

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

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

A Family Crossword Comes Together

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

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

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

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

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

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

Conclusion

“The solution to pollution is dilution.”

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

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

***

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

A Path Towards Self-Compassion and Healing

Posted on by Psychotherapy.net Team

Foundations of Relationship

To be in an intimate and interdependent relationship with another person is one of the most challenging endeavors in life, which is why conflict in relationships is one of the major reasons many come to me for therapy.

Clients often reach out to me because they are in pain and struggling with a significant relationship break-up. It is particularly difficult for my clients to be in a close relationship with others if they do not have a conscious relationship to their own self. Thus, an important task in therapy is to identify what it means for them to first be in an intimate relationship with themselves. This may include learning how to sit with their feelings of emptiness, being present with their bodily sensations and emotions, and examining their past. Therapy can be challenging, but it also offers clients the opportunity to heal wounds and to reclaim the forgotten and disconnected parts of themselves that may be unconsciously re-enacted in current relationships.

Many women come into my office suffering with low self-esteem, depression, and anxiety. They feel isolated, alone, and long for a sense of purpose in their lives. They long for connection and believe that closeness with another will help them feel complete, that being in love will alleviate their emotional pain. Close contact with others in reciprocal and enduring relationships is both a biological and psychological need, which increases their urgency to be in close partnerships with others.

Many of the relationship problems I work with are fueled by the belief that another person can fill their emptiness and replace the pain with feelings of love and passion. However, as my very wise mother once said, “we fall in love to the same degree that we are lonely,” fall being the operative word. In this context, if a client falls in love out of distress, to fill a void or erase the emptiness, there is a good chance it will lead to more distress. Family therapist John Fogarty asserts that our emptiness and pain are related to our relationship to our most distant parent. If that is accurate, then healing comes when we can help clients reclaim the hurt child of the past and repair their wounds there. If not, they are at risk of getting trapped in the past and replaying their early stories in adult relationships. To help ensure that dysfunctional patterns of the past do not get re-enacted, unlocking and facing the past becomes an important goal in therapy.

The Case of Alana

Alana was referred to me by a clinician from an inpatient substance abuse program who had diagnosed her with Post-Traumatic Stress Disorder (PTSD) and a severe Cannabis Use Disorder. Her clinician explained to me that since Alana entered the program and stopped using marijuana, she had become flooded with horrific memories of child abuse. The referring therapist was concerned that Alana would be at risk of relapse if her PTSD symptoms, which included flashbacks, were not addressed. I have found that it is not uncommon for people to turn to the use of substances to manage their PTSD symptoms of flashbacks and hypervigilance.

When Alana walked into my office for our very first session, her fragility was immediately apparent. She was small in stature, five-feet tall and thin. Her head was down, her shoulders drooped, and she did not make eye contact. She talked softly, almost inaudibly, and had long pauses between sentences. She was easily startled, and when she heard the door in the waiting room close, she jumped, and her body tightened. This was certainly a shaky start for this fragile and uncertain woman.

A year into treatment, Alana entered one particular session smiling and happy. She had had a lunch date with someone she had met through a friend. During lunch they discovered they had a number of commonalities: they both loved animals and had dogs, they loved to hike and travel, they were both teachers and enjoyed working with young children. At the end of lunch, they exchanged numbers and he “promised” he would be in touch. Alana was happy, and I was happy for her. She had worked hard in therapy and was gaining a stable foundation in her life without the use of substances. I interpreted her desire to reach out and make a connection with another person as a sign that she was moving forward in her recovery. Four days after this particular session, I received a call from Alana who asked for an “emergency session” because, in her words, “I am not doing well.” During the session, Alana was shaking and could not stop crying. She said she felt she was going down a dark abyss and was fearful she would never return. She had reached out to me because she was desperately trying not to “spiral out of control.” She was afraid she was going crazy. Contacting me for that emergency session was her attempt to anchor and ground herself. Alana explained the trigger that brought her into the emergency session was that Michael, the man with whom she had been on a lunch date, had “promised” he would be in touch with her but she had not heard from him. In the four days since they had lunch, Alana texted him and tried calling him a number of times, but he was not responding. She drove to his house to check if his car was there and if he was home. The lack of contact with Michael was bewildering, and Alana began to doubt if the positive feelings she experienced during lunch were “one way” and “all in my head.”

Alana’s levels of fear and anxiety were high. In general, I have found that when a client’s feelings are exaggerated and seemingly out of proportion to the current situation, it is a signal that their emotional response has roots in unresolved experiences from the past. When these clients are in a highly emotional, reactive, and anxious state, a rational response actually raises their level of apprehension and serves to exacerbate the client’s sense of disconnection from the therapist. With this in mind, I asked Alana if she was willing to slow down, breathe more deeply, and focus her awareness inward on her body. We had done similar exercises in the past, and Alana was not new to this type of therapeutic inquiry. However, familiarity does not always make this journey any less challenging. It takes courage to sit with and explore the bodily sensations and feelings that are experienced as overwhelming.

I was aware of Alana’s abuse history and her terror associated with feeling abandoned and alone. As a result, I used phrases like “You are not alone—we can take a look at this together.” I could see she found these words soothing and the words helped her to self-regulate. Her face relaxed, her breathing became easier, and her words and the quality of her voice softened. The following is a segment from the session (C represents client and T represents therapist):

T: Is it okay to take a few moments to breathe and go into your body?
C: Yes.
T: What part of your body wants to talk now?
C: My stomach and throat.
T: How do you know your stomach and your throat want to talk?
C: My stomach and throat feel tight.
T: Anything else?
C: My stomach feels tight, like it wants to throw up, and my throat feels like it is hot and on fire.
T: Your stomach feels tight like it wants to throw up, and your throat feels tight like it is hot on fire—anything else?
C: No.
T: Which do you want to take a look at first—your stomach or your throat?
C: Stomach.
T: Is it okay to stay with the sensations in your stomach?
C: Yes.
T: Your stomach is tight and wants to throw up. If you could give it a feeling, what would the feeling be?
C: I don’t know.
T: Breathe… What would tight and wanting to throw up be—mad, sad, glad, or scared? Breathe into the tightness in your stomach, just for a moment. Can you give the tightness in your stomach permission to relax? Then it can tighten up again.
C: It feels scary.
T: Can you stay with scary?
C: Yes—I am alone, and it’s dark.
T: Is it okay to give room for scared and alone in the dark?
C: [With eyes closed she nods yes]
T: Breathe… I am right here with you. What might happen if you let yourself feel scared and alone in the dark?
C: I would disappear and never come back.
T: What would happen if you disappeared and never came back? Breathe and stay with the tightness in the stomach.
C: I would never be able to find my way out of the darkness.
T: What would happen if you could not find your way out of the darkness?
C: I would disappear and be lost forever—I would not know how to find my way back.
T: Can we go into the nausea?
C: [Nods. After a few moments] The tightness and nausea help keep me in my body.
T: So the tightness and the nausea in your stomach protects you and keeps you connected to your body so you do not get lost in the darkness?
C: Yes.
T: Is it okay if we go to the sensations in your throat?
C: Yes—It is tight and hot like it’s on fire.
T: If tight and hot like it's on fire could talk, what would it say?
C: There are no words—just a sound.
T: What sound would it make?
C: A long, wailing cry.
T: Can we stay there?
C: Yes—the wailing cry is the sound of all the fear and pain in my stomach.

Alana started to sob. She was finally able to put words to her visceral experience which, until this moment, was out of her awareness. As the session continued, Alana was able to explore the childhood event that was fueling her current experience with Michael.

C: For as long as I can remember, my father would beat me and pushed away my attempts to get close to him.
T: When was the first time you can remember being pushed away from your father when trying to get close to him?
C: I can remember when I was three or four years old and my father was sitting in the living room chair watching television, sipping on what I know now was a glass of scotch. I was staring at him from across the room. I knew I needed to be quiet and almost invisible so as not to get him upset. While sitting on the floor, I slowly and quietly moved closer and closer in proximity to where he was sitting. I just wanted to be near him and hear him breathing. I wanted some kind of connection. When I finally got close to him, he stood up from the chair, and without a word he kicked me and I curled up in pain. I could hear the door slam behind him as he left our apartment.

Alana was able to stay with the bodily sensations that eventually led her to this memory. As the session continued, Alana made the link between her past and the pain and fear she felt when Michael did not contact her. Over time, Alana came to understand that her relentless and arduous pursuit to contact Michael served as a protective function—to avoid the pain associated with the memory of her father’s abuse. Michael’s lack of contact triggered the despair that she struggled with in dealing with her most distant parent—her detached, angry, cold, and physically abusive father. Alana had spoken about this emptiness and pain in previous sessions. She was keenly aware that her substance use that began at the age of 11 was a way to soothe the pain of rejection and abuse from her father. At these crossroads, when the present felt like the past, Alana was at risk of relapsing and resorting to past mechanisms to self-soothe. For Alana, this included drinking alcohol and using substances.

In later sessions, Alana named this trigger as “wanting connection and being kicked by my father.” Naming the trigger allowed Alana to achieve awareness and take control of her emotions and behaviors when she perceived a disengagement from others. The awareness allowed her the space and time she needed to self-regulate, re-evaluate, and think of more appropriate and rational responses to perceived rejection.

When Alana finally heard from Michael, he explained that he had not been in contact because his father had a heart attack and Michael was called home to be with family. Michael also explained to Alana that he did not think this was a good time for him to begin a relationship, because his free time would be spent with his parents during his father’s recovery. I also assumed that Michael was overwhelmed by Alana’s frantic attempts to get in touch with him. Alana’s desperation had its origins in her early life experiences. Michael became an object of Alana’s distress, which was manifested in the barrage of compulsive texts and phone messages. This objectification contributed to the rupture in their relationship—a rupture that occurred soon after meeting one another, when the lack of a strong relational history did not promote efforts towards a possible repair.

As with most of my clients who experience trauma-related distress, Alana expressed a desire for a secure, comforting, and safe relationship. Despite this desire, Alana’s connections with others could be depicted as highly dysregulated, frantic, and fraught with friction and misunderstanding. Many of the women I have worked with who have histories of trauma are more likely to undergo autonomic nervous system (ANS) responses of fight/flight and/or shutdown/collapse. These physiological states are mechanisms that assisted them in surviving overwhelming physical and/or emotional experiences. However, over a long period of time, after the threat passed, these states no longer served a protective function. Instead, fight created more animosity, flight kept them running in fear, and collapse didn’t allow them energy to live life fully. Eventually, these protective states interfered with their ability to think clearly and make thoughtful decisions. In Alana’s situation, the lack of response from Michael put her in a hyper-aroused state, causing her to be vigilant and unable to maintain calm, think about consequences, and come up with alternative solutions. From this hyper-aroused position, Alana misinterpreted Michael’s distance as rejection and responded with a high degree of emotional intensity and pursuit behaviors. Her attempts to restore the connection was her misguided approach of trying to soothe the feelings of terror associated with being kicked and rejected by her father. Alana believed (just as her three-year old self had) that her only relief from the pain and emptiness was through reconnecting with Michael.

My goal with Alana and clients with similar challenges is to bring the unconscious to conscious awareness by remembering and examining the early experiences and emotions that fuel their current reenactments. One method I have used in many cases is exploration of core beliefs, which creates a psychic prism from which all experiences and relationships are perceived. In therapy, I explore core beliefs with my clients, the feelings attached to each belief, the origins of the belief, and how the belief and feelings are exhibited in present-day behaviors and one’s worldview. Beliefs often include, but are not limited, to such thoughts as “I am defective,” “unlovable,” “a misfit,” “alone,” or “a failure.” The associated feelings are just as varied and include feelings of grief, sadness, loneliness, shame, anger, and fear. If an individual’s core beliefs and the source of those beliefs remain out of awareness, then the person is at risk of reenacting the past in the present, always with the hope of a different and more affirming outcome. The chronic, painful, and recurring patterns of our lives can be reframed as our younger and fragmented parts of self that are calling out for attention.

The child in all of us hopes to be seen and heard, yearning to be found and reclaimed. This can be framed as a call to bring us back to ourselves. It is in reclaiming our earlier selves that our emancipation and release from the past begins, and that we can start our journey toward rebuilding lives that resonate with our authentic intentions, desires, and values.

Clients with complex and relational traumas share stories of unthinkable acts of abuse that they experienced as children. For many clients, the therapeutic process challenges what they have learned in order to defend, protect, and keep themselves safe and, for some, to stay alive. The therapeutic journey requires the client to expose their vulnerability, fragility, and imperfections. For survivors of trauma, to be vulnerable is equivalent to being weak and at risk for being hurt. Thus, to allow themselves to be vulnerable takes great courage. Courage is the place where they confront fear, anger, sadness and/or shame. However, clients also bring hope—hope that somewhere, in all the confusion, desperation, and negative internal dialogue, life can be different, and that on the other side awaits a better way of being and living in the world. When the client doesn’t have hope, the therapist can hold it for them.

***

The women I interviewed for my book on survivor moms emphatically stated that their relationships to their therapists served as the model they used to develop healthy relationships. The therapist and the therapeutic process taught them how to effectively communicate. In therapy, they learned how to listen, ask questions, talk about feelings, solve problems, tolerate strong emotions, and stay composed when engaging in difficult conversations. Their therapists offered the means to increase feelings of self-worth, enhance self-care, and create a compassionate connection to themselves. This fostered inner confidence and the capacity to develop healthy and intimate relationships with others. Their therapists’ abiding presence offered them an opportunity to sit with, feel, and explore their deepest wounds in a safe and contained relationship. The therapeutic process also afforded the opportunity to become more deeply attuned to themselves and others and enabled an understanding of both the vulnerability and resilience of being human. The knowledge, tools, and wisdom that comes from one’s own healing could then be transferred to the ways they interacted and responded in their relationships with intimate partners, family, friends, and, as importantly, with children—the next generation.

Us Versus It: Racism, Family Treatment, and Eco-Systemic Considerations

Posted on by Psychotherapy.net Team

As an Eco-Systemic Structural Family Therapist (ESFT), I help families establish and learn new patterns of interactions both within and outside of their homes by creating a contextual frame in the form of “Us versus It.” Using this frame, which refers to the family (Us) versus the impacts of racism (It), I attempt to help each member of the family to view their problems and possible solutions in the context of broader issues related to race and racism. Hence, here I will reflect on my work in the therapy room from the perspective of my child client, their caregivers, the therapists, and the ESFT model.

The Child

“It should not be like this; it should not be like, this Miss Paula.” I sat quietly as I listened to my 14-year-old Hispanic client Valentina express her agony over the recent killing of George Floyd, the racially charged incidents surrounding police brutality, and the global protests in support of the Black Lives Matter movement. As I sat quietly, listening to Valentina’s innocence being diminished at this sensitive stage of development where her sense of self, identity, and beliefs about herself and the world are being shaped by the horrific reality of what she described as “not normal,” I began reflecting on my role as a therapist of color. Identifying the truth of Valentina’s distress did not bring me comfort as I realized uncomfortable conversations about race and racism needed to be had.

Not knowing what response I was expecting from this 8th grader who wants to live in a world where she does not have to be “the adult” in her father’s household and where her mother does not have to devote all her time to working multiple jobs in order to take care of her and her younger brother, I asked Valentina, “What do you understand about what is going on in the world today?”

As we discussed the differential treatment of people of color, Valentina began to identify that she herself belongs to a marginalized group. Drawn to tears, I felt empathetic as I heard Valentina describe her hurt over possibly being racially profiled or being told to “go back to her country” because she speaks fluent Spanish. With the decades of individual and systemic racial injustice and inequality that people of color, specifically black people, have experienced in the United States, a significant negative impact on the mental health and wellbeing of the members of this racial outgroup has occurred as well.

From differences in socioeconomic status, to impoverished conditions of living, to discrimination within organizations where there are limited opportunities and resources for African Americans to grow professionally, racism is very much still prevalent today, as affected families are still disproportionately disadvantaged in their access to opportunities for wealth, education, employment, and housing.

As a black female myself, as I reflected on this not-so-surprising inequality and injustice black people are subjected to, I thought about the families who come each week to my therapy office looking to change systems and patterns within their family and establish better attachments with their children. A significant portion of these families are African American, and in one form or another are a representation of the experience of all black people in America. Early in his life, my 10-year-old African American male client learned social cues signaling to him that he was different from his classmates from other racial groups simply because he looked different from them. My 6-year-old female client refers to her mixed-raced skin color as “ugly” and her white mother’s skin and hair as “pretty.”

The Caregiver

The more I have felt challenged to create the space to conceptualize my clients from a broader sociocultural perspective, the more I have acknowledged the “hard truths” that my African American family clients bring into the therapy room every week. Some of these hard truths include my 12-year-old African American male client Andre’s grandmother/legal guardian, who has been raising him since he was a toddler, sharing her fears about raising two African American men from different decades. She experienced the same fears for Andre’s father when she was raising him that she now experiences while raising Andre.

I recall feeling cold as I listened to Andre’s grandmother narrate her feelings as she recalled watching and re-watching the video recording of the killing of George Floyd. I personally could not bring myself to watch the complete video, as I was overwhelmed with sadness and hurt from the injustice and perpetration of violence against black people—especially black men—by the police and criminal justice system. However, I sat in the session hearing my client as she narrated the events that occurred in this video as if it were Andre’s father or Andre. As I heard her, I saw her “hard truth” that she saw Andre’s father and Andre in George Floyd.

Discussing her feelings about raising a young African American male in a world where racism is not only prevalent but inescapable because it is being recorded, she expressed how much effort she has put into raising a “kind, caring, intelligent” young black boy, but also how that is not enough to guarantee his safety or access to the best opportunities. It appears that Andre’s grandmother may have some regret around how she raised Andre’s father, as she recalled “sheltering” him out of fear, which contributed to his not being responsible or self-sufficient.

To understand why Andre’s grandmother felt that it was safer to “shelter” his father when raising him helped me to better understand the connection between impoverishment and segregation, and the high levels of crime, substance abuse, mental illness, and violence that she had attempted to protect Andre’s father from and was now trying so desperately to protect Andre from.

When I think about impoverished neighborhoods, I also think about my 13-year-old African American female client Tracy’s biological mother, who lost her son in a “suspicious” car accident a few years back about which my client reports, “There is more to the story we will never know.” Tracy’s mother, who since losing her son became very active in seeking justice for him and other young black males like him, has also acknowledged that her son often got into trouble and that their “unsafe” neighborhood had a significant impact on how he lived his life.

Although well aware of the effect one’s environment and upbringing can have on them, I still found it difficult hearing Tracy’s mother express the disadvantaged conditions of living she and her family have experienced, and how they cost her the life of her son. Tracy’s mother’s grief sits with her every day, as this was not only her child, but a child whose life she continues to prove to anyone who will listen…mattered!

The Therapist

As the recent racially charged incidents in the country made me reflect, perhaps anew, on what role I am currently playing as a therapist of color in and outside of the therapy room, I went back to the ACA Ethics Code, which says, “The primary responsibility of counselors is to respect the dignity and promote the welfare of clients.” It also directs counselors to actively understand the diverse cultural backgrounds of the clients they serve, and to explore their own cultural identities and how these affect their values and beliefs about the counseling process. These words are the core of competent and compassionate multicultural practice.

In the context of these ethics, “it is even more important for me to see my clients not how I want to see them, but rather how they want to be seen”. If I have a African American single mother of two who is managing two jobs and unable to remember session times, my first conceptualization of that client should not be of her as “lazy” or “forgetful,” because it may just be she is a mother trying to provide for her family and may need a little extra support from me, such as a twice-weekly rather than weekly session reminder.

Former NFL player, motivational speaker, and pastor Miles McPherson believes that every consultation should be a race consultation. The problem comes when you have assumptions based on a social narrative stemming from your own beliefs and upbringing. Putting them aside and having a race consultation allows us to let our clients tell us who they are. I view McPherson’s ideology as a positive and useful one in that it allows me to enter the therapy room viewing it as a “race consultation” with the goal of setting aside my preconceived race-related notions about my clients. This orientation also frees me of the fear of acknowledging my “blind spots” because it gives me room to learn as well as see where I may be falling short. Not acknowledging the racial elephant in the room is like being comfortable doing the wrong thing.

I have come to realize the importance for therapists who belong to non-black racial groups, specifically white racial groups, to be more knowledgeable around the historic and systemic disadvantage African Americans have experienced for decades and how that plays a role on their mental and physical health. Culturally competent therapists who are knowledgeable around the impact of systemic and intergenerational racism may be in a better position to “buy-in” with their clients, that is, to recognize their own privilege and take the extra step, like making an extra phone call to a client when needed, advocating for a client who needs extra resources from the community, or exploring their own cultural identities beliefs as they help their client identify their own.

The Model

The Eco-Systemic Structural Family Therapy (ESFT) framework identifies certain overlapping and interacting individual, systemic, and societal patterns that contribute to the interactions, hardships, and coping strategies of the African American families with whom I frequently work. This framework posits that the symptomatic child is reflective of the breakdown of family life as an adaptive response to hardship. Using this collaborative, strength-based, and trauma-informed model, my work with families applies the four pillars of ESFT—attachment, co-caregiver alliance, executive functioning, and self -regulation—to help develop caregiver-to-child attachment, strengthen the level of functioning and skills caregivers have in order to perform day-to-day tasks for managing their lives and the lives of their child, identify social support systems that help the family build caring and stable environments, and observe how the family makes meaning of and copes with emotional and affective experiences.

Take, for example, my 9-year-old African American male client Tyree, whose “Core Negative Interactional Pattern” (CNIP) includes Tyree’s getting “easily frustrated” and instigating fights with his sister, which leads to Mom yelling, Tyree being punished, and then Tyree’s “shutting down” or engaging in emotional outbursts such as yelling, crying, or screaming.

When I think about what hardship, tragedy, and trauma that may contribute to these presenting problems Tyree exhibits, I think about his witnessing domestic violence between his father and mother on several occasions. Additionally, his father is currently incarcerated, and his mother now occupies the single-parent role and is busy ensuring that she is able to financially provide for Tyree and his siblings. Given these changes in Tyree’s family system, it is useful for me to recognize his interactional pattern within the family as a reaction to the loss of having his father in the home and the burdens on the entire family unit against the racial/cultural backdrop of their lives.

In such cases where caregivers may suddenly take up the role of single parent or have been upholding the role for a very long time, ESFT promotes executive functioning and caregiver-to-child attachment with concepts like “Ennoblement,” where caregivers are able to view themselves as competent, caring, and able to keep their child safe. For instance, my work with my 11-year-old African American male client George’s mother included a consistent level of “Ennoblement,” as she needed a reminder and affirmation that she was competent, caring and able to keep George safe even though she did not currently have the support from his father. Because of the hardships experienced by George and his mother, many sessions with this family included George’s mother expressing the difficulties of being a single mother and lacking a support system.

I have learned that it is essential for African American mothers and their families in particular to be empowered, as research indicates that most African American homes are female-headed homes helmed by mothers, grandmothers, and aunts. According to the United States Census Bureau, the percentage of White children under 18 who live with both parents almost doubles that of Black children. This data is very reflective in my therapy room, as a large proportion of the African American families I see are single-parent families which are female-headed.

***

In thinking about the various children and family members with whom I have and will work and reflecting on my role as a therapist of color using the ESFT model, I aspire to bring deeper and more meaningful racially-informed conversations into the therapy room. I hope to do so by creating a safe space for more racially-sensitive and race-oriented conversations between caregivers and their children. In doing so, I also hope to join more authentically and empathetically with African American families while together we construct more adaptive narratives.

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

Posted on by Psychotherapy.net Team

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

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

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

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

Long Strange Trip

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

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

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

The Zoom Era

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

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

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

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

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

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

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

A Third Way?

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

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

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

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

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

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

Postscript from the Bunker

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

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

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

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

Daryl Chow on Reigniting Clinical Supervision

Posted on by rezendevknowfully.com

Supervision at the Crossroads

Lawrence Rubin: Good morning Daryl. Thanks for sharing your time with our readers. Your research and writing suggest that supervision as it has traditionally been practiced is in crisis. What is the crisis in the field of supervision that you are responding to in your work?
Daryl Chow: I think there are weaknesses in the status quo practice of supervision, and that is something that we should pay attention to and do something about. I think change needs to start to grow from what we know from the research, as well as from clinical practice in supervision. We need to do something that's closer towards two domains: helping therapists improve their performance and, while they're doing that, also emphasize what they are learning. So,
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time.
LR: What does it mean to help supervisees or therapists grow and develop, as opposed to just performing in supervision?
DC: In my online course, Reigniting Clinical Supervision, we make an important distinction from the get-go between coaching for performance and coaching for development and learning. Coaching for performance is one way of doing clinical supervision where we help each therapist improve in the stuck cases they are presenting in supervision. This is indeed important in helping them work through the clinical issues that may be blocking progress or preventing them from making inroads in their work with clients.

But I also think what supervisors need to support is an undulating process of helping clinicians with their stuck cases, while also trying to glean general principles with which they can help clinicians then create or identify patterns that are showing up through these stuck cases. It is a matter of looking closely at the cases in which the clinician is not making progress in order to help them in their own personal and professional development. This transcends a case-by-case supervisory discussion in order to focus on the therapist’s growth edge; those skills and characteristics that are generalizable, or what Wendell Berry talks about in terms of agriculture, which is solving for patterns. So, these two worlds of coaching, or supervising for performance and development, need to come together in the supervisory relationship.

If you look at the literature right now from Edward Watkins and others who have done great work in the study of clinical supervision, we have not made any progress. If the outcome of effective supervision is reflected or measured in client improvement, we have not actually moved the needle.

Tony Rousmaniere and his colleagues wrote a paper in which they concluded that
the variance in client outcome accounted for by clinical supervision is less than 1%
the variance in client outcome accounted for by clinical supervision is less than 1%, which means not much, right? That's concerning, because we put so much time, effort, and money into supervision. So, while I don't think I would use such a strong word as crisis to describe the field of clinical supervision, there is definitely a need for change. I really think that we are seeing things slowly changing on the ground level and there are people who are trying to change what we have come to accept as standard practice in supervision. 

Supervising for Development

LR: Okay, so what is the supervisor actually working on when she is focused on the supervisee's development?
DC: Well, the short answer is specific stuff such as the supervisee’s learning objectives. And their learning objectives are based on their performance. I will give you an example. If a clinician was to seek help from a clinical supervisor, that clinician (the supervisee) would first need to have a baseline of their performance, not just at the client-by-client level, but based on a composite of cases that they're seeing that provides them with enough reliable client outcome data.

And then, from those results, they would try to figure out where they're at before deciding where they need to go and what issues they need to address in supervision. I think that's a critical first step, because better results in in clinical supervision as measured by client outcome are obtained sequentially, not simultaneously. By that I mean we need to figure out where the supervisee is at. If their clinical outcomes are average, that really doesn’t say much about what they need to do in order to improve their performance. It is a matter of taking the second step, which is zooming in or focusing on those areas of clinical practice and therapeutic relationship where that clinician needs to improve. Simply focusing on the fact that the clinician is “average regarding their clinical outcomes,” doesn’t tell the supervisor where she needs to focus her lens regarding the supervisee’s skills and development.

So, as an example, if a clinician’s performance was average compared to international benchmarks, the supervisor would then focus in on those cases in which the clinician was stuck. They might listen to some recordings of the clinician’s work to discover that the clinician and the client did not develop therapeutic goal consensus. And it is often the case that
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions. You and I both know that the goalpost changes as we go, right?

Sometimes the goal is to figure out the goal, to figure out what is or should be the focus of the session. Then the therapist and supervisor work on that one specific area. And then—and this is the critical piece—if the clinician and client are indeed working on goal consensus, it's important for both the therapist and the client, as well as the therapist and the supervisor, to follow through with the work towards that goal and then determine if doing so actually had an impact on therapeutic outcome.  
LR: And just to define the outcomes variables you're talking about—are you talking about outcomes in the client progress, or in the supervisee’s behavior?
DC: I think you hit on an important note, because the feeling of benefit for the therapist does not mean actual benefit for the client that they work with. Remember, we're dealing with two steps removed from the office, so we need to make sure that the work we are doing with the supervisee translates into positive outcome for the client. It's almost like a paradox if you see two overlapping circles. Yes, it's about the supervisee’s performance, but if you focus purely on their performance, you're not going to go anywhere with the client. You're going to be riddled with anxiety. "Am I doing well? Am I doing badly?" And there's so much judgment involved.

We need to see the impact on our clients and see if our learning leads to impacting the people that we're working with. If the learning was focused on goal consensus, we want to see that it actually translates to an actual impact on the clients that you're working with on that level, on one client at a time. But we also want to see if that helps you to move up your effectiveness above your baseline. 
LR: It seems you're saying that, if a supervisor is good at his or her job and guiding the supervisee effectively in the deliberate practice of therapy, then the client will by definition improve.
DC: Wouldn't you expect that?
LR: I would, but isn't it possible that—and I'm not trying to be provocative—but that a supervisor may be very effective in guiding the supervisee or the clinician in deliberately practicing their craft, but the client doesn't improve? Does that mean that the supervision failed? Or might it just be that something was missed? In other words, can you have good supervision and still poor therapeutic outcomes? Or do poor outcomes in therapy mean that the supervision was not effective?
DC: That's a really good point that world-champion poker player, Annie Duke, talks about in her book, Thinking in Bets. She makes a very important distinction which I think we need to think about slowly and carefully. And the point that she was making is:
we tend to conflate outcomes with process
we tend to conflate outcomes with process.

She says that when we get a poor outcome, let's say in the game of poker, we think that our process is responsible for that outcome. She says we tend to conflate the two. If you take some time to think carefully about how you're making decisions, how you're building the process and making a good plan, then if the outcome is bad, don't make that conflation too quickly.

Because in the game of poker, just like in the game of life, there's a lot of random noise, a lot of things that are beyond your and my control. But if you understand with the help of a supervisor that you are working on something critical—in our case, goal consensus because we know the effect size for goal consensus is huge, then it becomes a matter of focusing more directly on building that particular skill in supervision, not other skills unrelated to goal consensus.

And if goal consensus is indeed important—even if one client doesn't work out well, you don't want to go and throw the baby out with the bathwater. You want to just go back and refine goal consensus building skills again. Close the loop. And this is one thing supervisors and therapists can do, is to make sure that, after a discussion, they close the loop.

It sounds so plain and simple, but I think it's really something that's lacking in supervision as well as clinical practice, that people don't really close the loop by figuring out ways to refine the important skills in supervision that actually impact client outcome. If you continue doing this with other clients, will this have an impact as well? 

Deliberate Practice

LR: Along these lines, you have an upcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, with Scott Miller and Mark Hubble. How can supervisors use deliberate practice to improve not only their supervisee's performance but their own performance as supervisors?
DC:
When we are working in supervision… we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client.
It's a brilliant question, and I know, Lawrence, we've talked about this. My belief at this point is I think that it is critical. We are really in the early days of this type of investigation, but I think it's an important area to work on, and here's why.

My belief is that knowledge is multilevel. When we are working in supervision, we are doing just that because we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client. And let me just use an analogy from the world of music. I'm always impressed by not just what the musician does in a music studio or how they work. I'm always interested in who else is in the room. And one of the things that comes up very often for me is the role of the producer. Sometimes it's the group of artists itself, and sometimes it's someone else.

And a couple of people that stick out to me are Brian Eno, who has worked with Talking Heads, Madonna, U2, and Rick Rubin who has worked with death-metal bands like Slayer. He's worked with many Hip Hop artists. He's also worked with the late Johnny Cash. There’s something about being in the presence of these types of producers that brings out the best in the musicians.

My question is twofold. One, what the hell are these producers doing that brings out the best in the musician? But I also am interested in how I can help others and myself be able to become more like a coach or mentor the likes of college basketball’s John Wooden. And the one thing that I think is becoming a little bit clearer as I go is that we really need a system of practice, a way to systematically organize ourselves around how we think about supervision. So, when I say system, it just means as simple as: how do we track outcomes?

My mentor and collaborator, Scott Miller, talks a lot about feedback-informed treatment. To me, measuring what we value is key, because measurement precedes professional development, so it is critical to help people, supervisees in this case, to systematically track their outcomes and to have a system of coaching already in place by the time they come into supervision.

And then we develop a taxonomy of deliberate practice activities so we know where they're at in the baseline, how to help them figure out a way to deconstruct the therapy hour and then pick up little things that they can work on. So, I guess my short answer, or rather my long answer is really, to figure out a system that can function as a platform from which we can begin to work on the more nuanced stuff in the role of supervisor. Am I making sense about this? 

A Portfolio of Mentors

LR: You are indeed, Daryl, and related to this notion of the producer and artist working in collaboration, you recommended that clinicians build a portfolio of mentors. Does that mean that, even though supervision is, as you call it, a signature pedagogy, that clinicians should build a production studio of sorts with other professionals? 
DC: As much as supervision is a signature pedagogy for our field, what's interesting for me of late is how people reaching out for consults or coaching often follows having given up on working with a supervisor for various reasons, unless they are in an agency setting where that is provided. But, yes, I think the idea of a portfolio of mentors is to say that
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you.

And what you want to do is to create a community of people that you can turn to, that you can talk with, and then maybe a certain person you turn to more routinely. For instance, I've known a supervisor for more than a decade, and I always return to her. But if there was something else that was missing, or I wanted to stretch out and pick another mind to think of it from a different perspective, I would reach out to other people, even people who are so-called experts, and send them an email. I would ask them, "What's the fee? Can I come talk with you?" And most people are friendly. 
LR: In a way, isn’t that what you are trying to provide through your online supervision training, Reigniting Clinical Supervision?
DC: My focus for Reigniting Clinical Supervision is to help clinical supervisors design better learning environments that sustain real development for therapists, so as to achieve better client outcomes. The choice of an online learning platform is not a mere substitute for live teaching. Instead, gleaning from the best of what we know of optimizing learning, adopting a “one idea at a time” drip-based method of delivery of content and maintaining learner engagement, helps the busy practitioner weave what they learn into practice, and return to renew and reconsolidate new knowledge as a result of being in the course with me and other clinicians/supervisors.

Here’s how I think about the difference between a live training and how Reigniting Clinical Supervision is designed: A real-time training/workshop is like a river. It is a constantly flowing torrent of ideas. If the learner steps out of the river for a few minutes, or needs some time to think, he is now behind. The learner may be able to ask questions but needs to constantly try and catch up and not fall behind. A chance for a revisit of the content after some time of reflection is not possible, with only the notes or slides that you've captured.
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time, and pace herself as she moves along; the water remains the same. This stillness allows for pausing, revisiting the material, reflecting, and connecting with past knowledge. Online learning at its best allows for the learner to ask questions, revisit the materials, and for the person to master a difficult segment before moving on.
LR: Within this community of mentors model, there are different factors that predict therapeutic outcome. They include goal consensus, alliance and repairing therapeutic ruptures. Can the same principles be applied to improve supervisor performance and development?
DC: Hopefully, that's paralleled or modeled within the supervisory work. I would encourage supervisors to also elicit feedback within the supervision. And most of us do that, but it is also important to do it in a way that's a little bit more about a ritual. This would mean using some quick check-ins that give the supervisee some space to think about it, and then to explore the nuances of the supervisor/supervisee relationship. It's much harder when you really know somebody well, like the supervisor knowing the supervisee, to give feedback.
LR: Have you experienced working with expert clinicians who are lousy supervisors?
DC: I'm thinking of the converse. So, let me look back in my mind. I don't mean this in any disrespectful way because I really respect this person's work. Jay Haley of the strategic school of family therapy talked about this and said that he was really good as a supervisor, but not as good as a therapist [laughs].
LR: I think of myself as being a better supervisor and teacher than therapist. In your language, perhaps that’s because I have not deliberately practiced therapy.
DC: Yes, right.
LR: I've performed therapy, but in the words of Scott Miller, I've not deliberately practiced it. So, it's interesting that just because someone may be a very competent clinician, it doesn't mean that they have the patience or skill to guide a fellow clinician as a supervisee, and vice versa.
DC: This harkens back to your question about the role of training supervisors in how they do deliberate practice, because, to me, there are overlaps, of course, but there are also distinct skills required in their roles as supervisors and therapists.
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction.

Cardinal Supervision Mistakes

LR: Talking about getting lost in the weeds, you wrote an article for us about seven mistakes in clinical supervision. If you were to pick the top two cardinal mistakes from that list of seven that supervisors make, which ones flash red to you, and what can supervisors to do about them? 
DC: This is tough because the language around mistakes is all negative. I think, for me, the one that I've seen in my own experience and through my own mistakes is that of too much theory talk.
I think we talk too much. On the ladder of abstraction, talk is quite high up there
I think we talk too much. On the ladder of abstraction, talk is quite high up there. Bear in mind, when we're in supervision and in the absence of the actual client, we spend all our time talking in abstractions, at the level of theories about the client rather than about the therapeutic relationship.

When we're doing that, we've got to bear that in mind, that we don't have that person there, and we're talking at the level of theoretical abstraction, so many steps removed from what is occurring between the supervisee and the client. It's very easy to speak of it from whatever orientation or whatever philosophy you hold, without joining the dots of what's going to ripple down into the actual therapeutic relationship where the real work is happening.

Another big mistake in supervision is that when the clinical work is stuck and the supervisee and client are not making progress, the supervisor may say something in an attempt at being supportive to the supervisee like, "Well, at least they keep coming back, right?" In this instance, the supervisor is doing little more than what I call, patting them on the back–encouraging the supervisee without giving her any clear direction out of the stuck situation.

I'm really conflicted about that statement that I hear very often. Is that good enough for you, that they still come back? Or what else? What else can we be thinking of? How do we escape this domain of just talking on their level and to be able to make some real impact?  
LR:
Another big mistake in supervision is…encouraging the supervisee without giving her any clear direction out of the stuck situation
I know that being able to effectively conceptualize a clinical case, to think about it from different theoretical perspectives, is important. But you're saying, Daryl, that sometimes we err on the side of overthinking the theory at the expense of guiding the supervisee in building the relationship with their client, and then we congratulate the therapist for minimal progress? Seems like damning by faint praise.
DC: Yes and no. I think all prudent supervisors know that therapeutic relationship really matters. And by therapeutic relationship, let's be clear, it's not just about the emotional bond, even though that is one critical part. But the other part is the focus, which is about the goals, the directionality, where it's going. The next is also about whether there is a cogent method for both the therapist and the client. Are we in agreement? Is there a fit in where we're going? All those things relate to the therapeutic alliance.

I think most people are focused about that. But as you will see in the upcoming blog that I am writing for Psychotherapy.net, I will be talking about the three types of supervisory knowledge. One type of knowledge is about the content knowledge, about the clinical case, about the psychopathology. Those things are necessary but not sufficient. The second type of knowledge is the process knowledge about how you engage with somebody who's, say, depressed? How do you engage with somebody who's anxious? That's a process or type of relating kind of knowledge. How do you have that kind of conversation? As David Whyte, the poet and philosopher, would say, "the conversational nature of reality." How do you engage in that? How do you come into being with another person into that field? But the third one is conditional knowledge, which is; if you're working with somebody who's depressed due to bereavement, it's going to be very different than when you're working with somebody who is depressed as well but due to, say, domestic violence. The context is very different, and you need to figure out a way of relating with them given the different situation. So, by considering all three of these in supervision; playing into the content knowledge, process knowledge and conditional knowledge, I think the supervisor can synergize them for the benefit of both the therapeutic work and the development of the supervisee. The supervisor and supervisee having this multi-level conversation will benefit both the client and the supervisee. 

The Humble Teacher

LR: What do you see as some of the important personal qualities of an effective supervisor or a clinician who might become an effective supervisor?
DC: For me, of course,
a good teacher is somebody who is willing to be a good student
a good teacher is somebody who is willing to be a good student. If I'm picking a supervisor for myself, I'm always looking for somebody who implicitly—and it's not something that people would say explicitly, is willing to be wrong, willing to seek the counterfactuals, and then to have by default a stance of humility not just because they're trying to act humbly or bragging about their humility.

This humble teacher will say, “Hmm. Oh, hang on a second. I've really never thought of that.” And they're rethinking. That, to me, is interesting. And it's not because they don't have a wealth of knowledge. It's because this is dis-confirming what they know. And that's so exciting. That's like fresh air, you know, when you're working with somebody that way.

Additionally, somebody who has mental models or mental representations and concepts in their head about different ways to think about clinical situations and suggestions for the supervisee. They know that when they're facing this kind of situation, they have what Gerd Gigerenzer calls fast and frugal heuristics. They have little maps of how they will approach stuff. You know, they've thought it through before. They have ideas in their memory bank that they will pull into their working memory.

And you know that because when they're just giving off-the-fly statements, you know that it's off the fly. But if you know that they've thought about it, you realize their mental networks are vast. They know that it's an “if-then” situation, and they're thinking about it and all kinds of communications. That excites me because that shows to you this person has done some thinking before meeting with you. 
LR: Is this what you refer to when you say that true experts think like novices, or beginning therapists, while true novices think they're experts? Is it related?
DC: I think so. [chuckles] I think so.
LR: I like that idea that the expert supervisor, who may or may not be an expert clinician, has these—what did you call them—fast and frugal heuristics? Was that the term that you used?
DC: That's right, and I mean that's the term from Gerd Gigerenzer, who studies cognitive science. He talks of the importance of having these sorts of heuristics. You know, the way we've been terming it is mental representation. Things that happen might not just be easily explained using therapeutic models but by different ways of thinking. Like, what do you do if you meet somebody who is angry or depressed in the session? These heuristics or maps are not like stock answers but are based on clear principles that flow from these mental representations. What do you do with somebody who doesn't have a goal? How do you work with them? They have a rough and ready guide.

At the Cutting Edge

LR: So, the supervisor should aspire to flexible thinking, drawing on different belief systems, different ways of looking at the human condition, different interpretations of the same clinical presentation? It sounds like the advanced supervisor is out at this cutting edge of creativity, untethered to any one way of thinking.
DC: Yes.

This domain of creativity is something I'm really interested in. I think one thing we need to remember about creativity is that it's about something novel and something useful coming together? Wouldn't it be great if supervisors were not restricted to thinking solely in terms of the field of psychotherapy in the course of doing their supervision, and could bring in greater creativity?

Just thinking about architecture, music, art—thinking about other aesthetic forms and how all of these can inform ways of thinking. Coming back again to the example about goal consensus, why do we need to only think about this within the domain of psychotherapy? Why don't we learn about how other fields and business organizations think about creating focus? 
LR: So, we should consider using a flexible system of metaphors that transcend psychology and psychotherapy. When we first contacted each other, I mentioned that there seemed to be almost a spiritual undertone to the way that you described your personal philosophy of living and helping. Am I seeing it correctly, that there's a certain spirituality or spiritual dimension to your work as a clinician and a supervisor, and perhaps we should embrace that as well?
DC: Well, I'm grateful that you picked that up. To me, the answer is yes. And I think that's personally a deep embedment in my life. I was raised a freethinker from my Singaporean days. You know, this means I'm free to think or whatever that means. But I converted to become a Catholic when I was 21. When everybody else was running out of the Church, I was going back in. So, to me, that was my start.

But I think, fundamentally beyond religion, what's really driving me on a first principle level is human dignity. And the way I think about this is that
if a person comes to seek help and opens up to another person, that's a sacred moment
if a person comes to seek help and opens up to another person, that's a sacred moment. We need to honor that. We need to figure out a way that we can help each other come alive, because it's not just about creating purpose and meaning, but it's really to help each other come alive. And the therapist needs to come alive. The therapist needs to be alive and kicking and playful and to be able to ignite that. And the therapist also needs help and guidance from a supervisor. And for the supervisor to do that, the supervisor also needs to come alive. 
LR: I remember Bill Moyer’s interview with Joseph Campbell at George Lucas’ Skywalker Ranch. He said to Joseph Campbell, “So, you're saying that people are searching for the meaning of life?” And Campbell said, “No. People are searching for the experience of being alive.” How does that find its way into the world of supervision, that tripartite relationship between supervisor, supervisee, and client? Where does that element of being alive get infused in that three-level process? And whose responsibility is it?
DC: Sounds like a family.
LR: Yeah, doesn't it?
DC: Yeah. I think everybody is going to come into play. I think it is the interaction. It's this ecology of a systemic perspective that's going to be important. How does it come alive? You know, I think we need some kind of platform for this to work, which we have talked about. But I think it critical is to keep this conversation going. Once we see that therapists are working hard to improve in what they are doing—once they figure out the baseline, once they figure out what to work on based on the baseline, then they develop a system to help them do their practice on an ongoing basis. And that they see the payoff of what they're doing.

It's like your child who's worked hard for the math test and starts seeing see the result. There's the real payoff. I mean the whole temperature of the room changes. Their focus becomes more intrinsic. And at that point, the role of the guidance is going to evolve as well. There's always going to be state of change. You’re right when you pointed out that quote from Joseph Campbell as well. That's something I'm very familiar with, and I think it's important that we continue to keep the conversation alive within clinical supervision as well as at the level of the therapist and client. 

Fanning the Flames

LR: So, just as we encourage clinicians to take care of themselves and to grow and to rest and to seek meaning and a reason for being alive, so too must supervisors continually replenish and rest and grow and seek internal expansion, because if they wither, then the supervisee withers and the client withers. Who are the roots, and who are the leaves in this tree? It's a quite interconnected system.
DC: [chuckles] It is. It's just like our world now, isn't it? I mean I'm suddenly reminded about this teenager from Sweden that's really been striking me about what she's doing. I don't know if you follow the news about Greta Thunberg and how she's doing this protest about climate change and rallying a million teens around the world to protest about how the adults in this world had better take this seriously. And she's been going on global forums just speaking about this.

And I heard one of her speeches which she starts by saying, “Our house is on fire. What would you do if your house was on fire?” And she expands on that. And I think that's so important, that somebody her age is speaking about this. 
LR: So, supervisees must find ways to, in your words, reignite supervision. I have one last question. You were born in Singapore, you live and practice in Australia, and you've traveled the world doing training in therapy and supervision. What have you noticed about teaching and supervising cross-culturally?
DC:
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people, trainings and our roles as therapists and supervisors. But, of course, each culture has its own subcultures that you're dealing with. But to me, really what's striking is how much similarity there is. We're all in the same boat.
LR: What do you mean, the same boat, Daryl?
DC: We're all struggling to get better. We all want to. I mean all therapists and all supervisors want to do a better job. And that propels us. That makes us stay hopeful. It makes us invest time, money and effort to go and do CPE [continuing professional development] activities. You know, we're all trying to get better. But what's implicitly underneath that wish to get better is worry. We do worry about, “Am I getting any better? Is what I'm doing really helping to translate?”

And people are asking this question as they are looking deep, long, and hard. And I think the onus is on us as a collective, as a field, to start to come together, to start to build this brick-by-brick, to help out from the therapist's level and the supervisor's level, and to help us build this house, build it up again, and to help us to get just that 1-2% better each step of the way. Because the payoff and the morale that comes with that is going to move us even further. 
LR: So, if everyone in that multilevel relationship strives to be a little bit better, then the whole system becomes better.
DC: That's right.
LR: If client outcome improves, then that goodwill is shared beyond the therapeutic space. If the supervisor is dedicated to practicing their craft, then they are in a better position to teach clinicians. And if clinicians practice deliberately, they are in a better position to help their client. And that is consistent across cultures.
DC: That's right. And, you know, I'm not the only one who is doing this, but I think I've started doing this whole thing about clinical supervision because I think we are a critical piece to the puzzle. And I think this one little story might help to illuminate this. You know, this gentleman, he knocks on his son's door, and he says, “Jamie, wake up, please. Wake up. You've got to get to school.”

Jamie then says, “I'm not going.” And the father says, “Why not?” He says, “Well, Dad, there are three reasons. First, school is so dull. And second, the kids tease me. And third, I hate school anyway.” And the father says, “Well, I'm going to give you three reasons why you must go to school. First, because it's your duty. And second, because you're 41 years old. And third, because you are the headmaster.”
LR: [laughs]
DC: I think we play that critical role. We do need to show up. And when we show up, we then need to think about what's our status quo and what's the one thing we need to start in order to refine our work to bring us alive again.
LR: To play that instrument a little better, to hit that tennis ball a little straighter, to run a little bit more efficiently. The supervisor must have a commitment to continued growth and development if the supervisee and the client are to improve.
DC: Yes, and I will say one last thing, if I may, Lawrence.
LR: Of course.
DC: If we use the musician analogy, I don't think it's to play the instrument a bit better.
LR: No?
DC: I think it's to play the instrument well enough but to be able to become better songwriters. I think that's a tougher job, because you can get technically better as a musician, but to write the next Hard Day's Night or Yesterday or Bohemian Rhapsody, I think that's a different skill. And I think we need to find a way to become better songwriters in our field.
LR: So, we can make better music together and because the audience is indeed listening.
DC: That's it.
LR: I think on that note, Daryl, I'm going to say goodbye, and on behalf of our readers, thank you so very much.
DC: Thank you.

Jay Lappin on Family Therapy—The Long View

Posted on by rezendevknowfully.com

A Social Justice Lens

Lawrence Rubin: Good morning Jay and thanks for sharing your time with me. You’ve been practicing and teaching family therapy for several decades, in which time certain issues affecting families continue to remain relevant while other hotspot issues have gained prominence. May we start off by addressing some of these hotspot issues that family therapists need to address?
Jay Lappin: Sure. I think that one of the constants has been around social justice and poverty. We see the effects of the political decisions being made by different administrations and their changing priorities, including most recently around immigration. One of the things that I remember from my interview with Sal Minuchin a few years ago was him saying that, back in the day when we first started doing family therapy, we thought that they could change the world one family at a time. There was this thoughtful pause, and then he said, “We were wrong.” And that’s what got him into doing larger systems work, and myself as well.There are wonderful efforts by non-profits like The Annie E. Casey Foundation who are really taking this on, and it also still continues with family therapists who are doing home visits in impoverished communities which built on the early years of social work, and then on the work of Sal and others like Braulio Montalvo back in the ’60s. But we haven’t changed the world just yet.

LR: For the average family therapist who is not on the Southern border or who’s not in one of those areas where he or she is likely to see these families impacted by immigration policies or poverty, what guidance can you give them around working with families suffering social injustices?
JL: I think just being aware that social injustice exists, that there are commonalities among all families and their circumstances, but also as unique differences between families. That systemic perspective helps a lot. I just had a case involving a young man, a minority kid in a school system where there was a big incident. Because of my good fortune of working at the local clinic and being aware of the systemic issues, the line of questioning I used for the parent took a different turn. It was more of a talk about what the community was like and what it was like to be a minority family within a majority-culture town. And it really felt like things changed in the sense that there was space for that conversation. And I think that we can all make that space about those differences and be aware of them.
LR: There’s so much of a necessary push these days for therapists to become sensitive to and aware of diversity issues affecting individuals and, of course, families. So, is it our ethical obligation when working with, as you say, a minority family in a majority system, to bring in these social-justice issues, even if the family doesn’t address them? Is it our obligation?
JL: I think so, especially for those of us that are majority-culture folks. I know enough that I know that I don’t know enough about a minority family’s location in society. And I think to pretend that it’s not there is doing a disservice to the family and to the process of therapy. And, you know, the thing in systems work and all therapy is that you read the feedback. So, what happens when we open up the space for that conversation and what does it lead to and how does it change what we’re doing in the therapy? At the end of the day, they still want things to be better for their children, and that’s cross-cultural. I think we can do better when we create space to have those conversations.
LR: Do we expand a social-justice lens beyond culture and race when working with families these days? Are there other hot-button social-justice issues—you mentioned poverty—that we need to open the door to and invite into the family therapy space?
JL: Well, income differences. The vast majority of clients in my private practice, are majority-culture folks—middle-income and well-situated. The issues of social position, money and resources are still there, although on the other end of the spectrum. It’s all a part of the soup that we live in. I don’t see there’s any downside to working with these clients necessarily, but it’s very easy to get kind of a narrow lens just because that’s who’s in front of you.I remember a story Sal told me years ago during an interview. When he was young he had a psychology teacher who was a fan of Rousseau who made the case that delinquents were part of a larger system and the social institutions in which they lived. During the time that Sal was in high school, his family went from very good circumstances to losing pretty much everything as a result of the Depression. They lived in poverty. Sal’s story was about reminding ourselves how lucky we are, but also the obligation we have to all members of society. As family therapists, we must be open to conversations with families around the issues that are important to them, ones around which we may have little direct experience.

The Temptation of Sameness

LR: Clearly then, family therapists must be humble, aware and sensitive to the needs of minority-culture families. What about other hot-button issues like the breakdown or denuclearizing of families, and the newer ways that families are coming together—gay and single-parent, step, adoptive and foster families?
JL: I think one of the great things about being a family therapist is that you get to bear witness, to be a part of that change that you’re talking about. In family practice I see more and more of those denuclearized families that come in with different combinations. The classic ’50s Ozzie-and-Harriet family is changing and in a big way. But at the end of the day, they are all still families. They still love their children, and that crosses those old boundaries. We still have to do our jobs, but the context is shifting, and I think it gives us more possibilities, too, to think outside of the box.
LR: So, these new ways that families are coming together present challenges and opportunities for family therapists to expand their core skills? Are there specific ways that family therapists can expand to open up to these changing ways that families come together?
JL: Yes, I think that one of the ways that we get to do it is by working with different populations, because there is always the temptation of sameness. We do what we know. But, you know, there’s that old saying, “if you want to know about water, don’t ask a fish.” We can put ourselves in situations in which we feel different and that we experience other families. Home visits, I think, are a great way to do that. You can tell a lot about families, about how they live together, and it also stretches us a bit. I think both young and old therapists need to have an opportunity to do that. I think it helps our work and stretches us.
LR: Are you saying that the changes affecting families and the way that families are adapting to those changes is a clarion call to family therapists to dig deep, push hard, keep climbing learning curves and look for new ways to connect with new families, because each family that walks through your door is different?
JL: I think it’s all about difference. A picture is worth a thousand words because the picture is what the talk and the words are about. So, for example, Sue Johnson‘s work with attachment understands that talk therapy is necessary, but it’s not sufficient—it’s really about the enactment. It’s the felt experience of those different situations and pushing ourselves that challenges limiting patterns. You have your bag of tricks and you get reliant upon them, and, why? Because they work, after a fashion. So, it’s about taking a risk.And, that’s fair because it’s a risk for a family to come for treatment. Sal had this great saying that families are wrong about two things when they come to see us. First, they’re wrong about the location of the problem. It’s not the kid. He or she is an identified patient, so it’s the family system that’s the patient. And second, families are mistaken about is who is going to fix it. They look to us, but our position is that the inherent strengths are there in a family, that they have all these over-determined patterns, which is what brings them to us. So, I think, in this respect, we’re not asking any more of the families than we are of our ourselves, and I think that’s more fair.

LR: If Sal said that families come in with two errors in thinking, one is who the patient is, and the other is who will fix it; what might be some of the fundamental thinking errors that family therapists bring into their work?
JL: Oddly enough, the same two things. It’s a challenge. Family therapy can be tough, because you have all these people in a room. One of my early fatal mistakes with a family was when I thought I was being this wise, young guy that could figure stuff out quickly. It was a family I’d seen only 10 or 12 minutes in which the father was a plumber. So, I start spouting off—“blah, blah, blah, you should do this, you should do that” and the man turned to me and said, “How can you tell? You only met with us for a few minutes.” And because I was young and even more stupid than now, I said, “Oh, well, you’re a plumber.” And he said, “Yeah.” And I said, “How long does it take you to figure out that there’s a leak in the basement?” And the guy just looked at me with a lot of anger. I never saw the family again. So, either it was a one-session cure, or it was an abysmal failure. But I remember that I really hadn’t respected them. I hadn’t taken the time to join, and I was trying to be show-off. “Look how much I know.”So, I think it’s always the read-the-feedback thing, and we learn from the families as much as they learn from us.

An Alphabet of Skills

LR: Sal Minuchin taught you (and others) the importance of enactment, joining and challenging. How do you teach these fundamental skills to new family therapists who may be intimidated or challenged by a family?
JL: We came from an academic tradition where you teach theory, you teach theory, you teach theory, and then you practice. And Jay Haley had this great idea that you have people do things first and then retrospectively go back and say, okay, what happened? What happened when you turned to the mother and asked her to talk with the son? What was going on with you?So, it’s more that style of teaching where you’re consistent with the model of having people do things. When I teach, it’s lots of role plays, making up families. And then I have just some basic rules that I’ve come up with over the years, like thinking of joining as a traffic light—you have a red light, a yellow light, and a green light—and when you’re working with a family, you should always be in the yellow.

For instance, in New Jersey, you go through the yellow lights, and in South Philly, people don’t stop at stop signs. You kind of roll through the intersection. And I say if it’s green, that means it’s a bit too easy—Lyman Wynne had this expression of the rubber fence where you’re working with a family and you think, God, I’m really joined well, like it’s really the strength of homeostasis. So, green, not so good. Yellow, perfect.

But I’ll tell them if it’s a red light, you have to rejoin. So, if you’re trying to frame something or get an interaction going and you’re just getting that red light, then you say, okay, I need to reconnect, find another way to make this happen. It’s that constant reading of the feedback, and when you do role plays or approximations of families, then you can say, “What was that like when the family wasn’t with you on that? What happened? What did you come up with?”

And then you’ll go deeper with the students, and they can say, “Well, you know, it reminded me of this, where I felt this way.” So, okay, how are you going to shift that, because you’re going to be working with families. You’re going to have that capacity to be flexible. It’s like muscle memory almost, that you have to do it over and over again.

LR: You had said that Minuchin also taught you about the strategic use of self in the room. How important is this in the teaching and learning of family therapy?
JL: You probably don’t have it down in Florida, but here in New Jersey and Philadelphia, we have row homes which all look very similar from the outside. They’re each the same size and distance apart from each other, have the same foundations and the same layout. It’s like a rectangle. But when I used to do a lot of home visits, going from one person’s home to the next could be completely different. The next person’s home could even be on the very same block. So, that for me was a metaphor because my foundation is in systems work and structural theory, but the larger framework, what’s in the house and how they live, is up to the families.I think you have to just do it or it would be like reading about how to play guitar. That’s great if you already know that “A” has three sharps, but unless you’re playing it and having somebody saying to you, “What was that? Where were you going with that? What did you want to do? Let’s see if you can come up with another way,” you’re not going to improve your skill set. I lament the loss of one-way mirrors and taping. It doesn’t happen as frequently as it did back in the day.

LR: My experience has been that there are a lot of people out there doing family therapy, charging for family therapy, writing about family therapy, lecturing about family therapy, and they don’t seem to understand or really appreciate systems theory. They’re not students of the foundational theory that drives all models of family therapy. And I lament that. Do you see that as a problem?
JL: I remember talking to Sal and Braulio about this. They had this idea that you could have what is called an alphabet of skills. The idea was if you taught these skills, you could be a competent family therapist. And, indeed, many people did and are.But Sal said, that having an alphabet of skills is like teaching somebody the alphabet and then expecting that they can write sonnets. Like the idea of putting a room full of monkeys at typewriters who would type a Shakespeare play, by chance, after thousands of years. Having an alphabet of skills is necessary but not sufficient to practice competent family therapy. So, people need a bigger container. I think that what you’re talking about is having the systems foundation. It’s a deeper, bigger container to hold those ideas and to have the freedom to experiment. You’ve got to know where this stuff comes from, and I think it helps to have that foundation.

And I Got Dinner

LR: What are some of the personal and professional obstacles that family-therapy trainees need to overcome in order to eventually practice effectively as family therapists?
JL: I think first is finding an agency that values home-based family therapy. Back in the early days of clinic work, especially in the cities, you’d have people come for outpatient therapy, crowd the waiting rooms, and then you there’d be a large population of people that you could see.The shift to home-based family therapy, which, as you know, followed in the social-work tradition of doing work in people’s homes, changed things, so that people, especially poor families, didn’t necessarily have to get to a clinic. By going to people’s homes, you very quickly get a sense of what is happening. When I first went into private practice, I only had a handful of clients, so when I saw families, one of my requests was that they invite me for dinner. It was great, because, literally, within minutes, moments, you would have a whole set of new ideas. The theories I had about families when I went to the house was…

LR: Out the window.
JL: Right exactly. It was very humbling at times. And I’d have the kids show their rooms and their stuffed animals and their toys. And it was just such a rich environment, and then we’d have a family session after dinner. I got dinner.
LR: And they got therapy. And you did a hell of an intake by wandering through their rooms and sitting at their dinner table.
JL: Yeah, it was great. I think that the home-based work is really remarkable, and it’s a challenge. I remember being a research therapist on one of Duke Stanton’s projects with heroin addicts and their families. In those days, you’d have these massive cameras and tripods and all that stuff that you’d be lugging into people’s houses.So, in the middle of these intense moments, you’d think, oh, boy, this is really it, we’re going to tip the scales here. And then the dog would run through the scene or somebody’s diaper was wet, or the phone would ring. So, you would have all these multiple things happening at the same time, and you would have to figure workarounds. And you would really get a lived sense, an experienced sense. As opposed to talking about it, you were experiencing it.

LR: Clinicians and trainees attend workshops where clinicians show these wonderful, rarified clips from magnificent and timed interventions; but the reality is that families are messy. Families are complex. Families are chaotic. And maybe that’s one of the reasons why some people run from family therapy like the plague while others run to it. I wonder if there’s a difference in would-be family therapists regarding their tolerance for complexity, chaos, and ambiguity.
JL: Yeah, you’re right. It could be very chaotic at times, noisy…I just think it’s such a privilege to see the family in total, because when you see the kids individually—and, certainly, there’s a place for that in the context of family work—it’s not the same. You get so much more if you can see the whole family. For me family work is the best, and one would hope, even from those rarified clips, that people get excited about it and want to do it.
LR: I’m a child therapist, a play therapist, and I always say to my trainees that when you see a kid, they’re going to bring their family along with them. You have to be open to inviting the family in. So, is child therapy, by necessity, family therapy.
JL: There was a recent piece in The Inquirer about a Yale study on children that were anxious. The bottom line of the study was that they figured out that one of the principal causes of the kid’s anxiety was the parents. And I thought, are you kidding me?

Appy Hour

LR: What a surprise!
JL: So, their treatment model was having the parents figure out ways to help the children tolerate anxiety so that they were no longer hovering or helicoptering. And, really, when you think about it, it’s more of a systemic version, but it’s under the heading of teaching the kids.Years ago at the clinic where I worked there was research on pain. This fellow Sam Scott, who was one of my supervisors, a brilliant guy, had studied some with Erickson. Sam and Ken Covelman and Bruce Buchanan, who was my partner in teaching at the clinic, were working with families to develop ways to have kids who were experiencing extreme pain through psychosomatic and physical illnesses, get calmer.

Sam and the crew had developed this wonderful script that accounted for systemic interactions between the parents and the kids. The parent would say, “What we’re going to be working on today is helping you to feel more relaxed.” And then, in parentheses, the parent would have something that they would read to themselves that would say something to the effect of, “And while helping my child to relax, I want to breathe more slowly and thoughtfully.”

Just inserting that spacing or that timing helped the kids and the parents simultaneously to relax, which is different from the kind of individualized mindfulness training where you’re just teaching a kid how to relax. The back and forth accounted for the relational context.

I was teaching a family therapy course a few years ago at Penn and Drexel, and I realized that there were no students in the class that were as old as our youngest child, and I thought, “Oh, God, I am so ancient.” So,I created this thing called Appy Hour. At the beginning of class, the students would present apps that were helpful in teaching relaxation skills. It’s corny, but it was great, because they were all about finding these very cool apps. And if I see a kid individually, I’ll have the kid teach the parent how to relax and show what they learned on an app. As you were saying earlier, having that systems foundation just helps you think differently in a situation.

LR: So, whether you’re working with an adult, a husband, a wife, a lover or a child, you can work with any individual within a family, and as long as you are thinking and acting systemically, you’re helping everybody. You’re not targeting one person, even though one person may be the person that you’re working with.
JL: Yeah, there was a really good, two-part CD that Alan Cooklin and folks from England put together, and I had the privilege of interviewing Braulio Montalvo for it. I asked, “What are some of the seminal ideas about Minuchin?” This tape is called “Inviting the Family Dance.” Braulio said, really, the most important thing for him was Sal’s idea about part to whole. When you’re working with part of the system, you always keep the whole system in view, no matter who is in the room. If you have the kid, a parent or both parents, you’re always thinking of the whole system as kind of a backdrop. So, it’s reflected in having a kid learn an app and then teaching it to his parents or teaching it to her brother, moving from that idea of part to whole.

Tango with Me

LR: You’re engaging and empowering the whole family. In the linear world of individual psychotherapy, the push is toward evidence-based practice and manualized treatments. Has this push been part of the story of family therapy?
JL: I think, historically, one of the reasons that family therapy is around today is because, in its early years, family therapists took on the challenging populations—eating disorders, schizophrenia, delinquency, minorities—ones that for a lot of reasons resided at the margins of the prevalent psychodynamic and psychoanalytic models of the day. It was as if family therapy was being told, “Fine, do what you will—see if you can do better! And boy, did they. For Structural Family Therapy (SFT), the challenge to the status quo began in the Sixties at the Wiltwyck School for Boys in New York. Minuchin, Montalvo and others frustrated by the poor outcome with individual treatment decided, “This isn’t working—we have to do something different…”With support from an NIMH grant, Structural Family Therapy researched the development of a family/systems-based model with poor, minority delinquents and their families. Their research and the early bones of SFT were published in the 1967, Families of the Slums. Absent the internet, there was tremendous synergy and cross pollination—Minuchin making his way out to MRI and meeting Bateson, Haley, Don Jackson; Murray Bowen doing his work with schizophrenics; Whitaker’s developing his Experiential model; Satir’s Conjoint Family Therapy published in 1964. It was as if a whole new language and culture were sprouting up, rules were broken, the one way mirror and the capacity to videotape changed everything. And, like Gil Scott-Heron said, “the revolution will be televised,” and it never stopped.

LR: Along related lines, is manualized intervention antithetical to family therapy?
JL: I think there is a place for manualized care. Ultimately, I think that every therapist has to make their treatment their own. Sal would talk about the family dance, a “Tango.” Sue Johnson also has embraced tango dancing as a metaphor. And there’s some of us who are old enough to remember Arthur Murray’s Dance Studios where they would have the feet painted on the floor.

The Long View

LR: Steps! Actual, certain, steps that are important to take, but also instilling the importance of the therapist bringing their own person and adapting to constant changes. You know, “Dancing with Arthur Murray,” that would be a good family therapy article.Jay, you’ve mentioned in our phone conversation and in this in this interview about your relationship with aging. How has this relationship with aging played into your work as a family therapist?

JL: I think it’s made me more appreciative and humble, and grateful for the work. It’s the best job ever, really, when you think about how lucky we are to be part of people’s lives. And I think being a parent and being married for 48 years has given me perspective that I didn’t have when I was younger and new to family therapy.I think the aging process, being married a long time, having kids and grandchildren, the good fortune of amazing supervisors, mentors, students and clients, alongside experiencing painful losses of family, friends and clients, all of it gives you a certain perspective. Also, reading the Persian poet Rumi and Thich Nhat Hahn’s wisdom has slowly but surely shaped my appreciation of time and impermanence. I really value those present moments with families and with couples and individuals. I just continue to pinch myself about how lucky I am to be able to have that, and that people invite me into their lives to help them, and I do the best I can.

LR: How has this appreciation found its way into your clinical work with families?
JL: Someone I see experienced a profound loss of a child. All of my own family-of-origin issues played out alongside the experiences of this particular family. My youngest brother was 5 when he died of leukemia, and it had a profound impact on my family. Our oldest son, after he graduated college, came down with non-Hodgkin’s Lymphoma and he’s fine, and I’ve had malignant melanoma.Years and years ago, Sal and Pat Minuchin used to host these summer events at the end of the externship. People would come to the clinic for training from all over the world and Sal would host barbecues and there’d be teaching and learning. I was sitting in a group of students, and he was going around asking them about their families and their kids and so forth. He skipped me and went to somebody else. Afterwards, I said, “Sal, I know that you asked everybody about their families, but you skipped me. How come?” He said, “Because you don’t have any children yet.” And then he said, “It makes a difference.” When you live that experience, your perspective, for better or for worse, changes. Of course, he was right.

Once you have children, once you’ve experienced those kinds of losses, how can it not affect your worldview?

I think I’ve been more appreciative of that, and I think that shows in the way that I still challenge overdetermined patterns in the family, and challenge the ideas people have about themselves and always assume a strength-based model. It’s the therapist’s responsibility to come up with a context for those different slices, or, as Dick Schwartz would say, those parts of themselves that can be more manifest in a room, and then to recognize them when they happen.

Forrest Gump Meets Jay Haley

LR: You’ve jokingly referred to yourself as the Forrest Gump of family therapy. It’s a great metaphor, since you’ve had these incidental but powerful moments with the likes of Sal Minuchin, Carl Whitaker, Paul Riley, Braulio Montalvo, Marianne Walters and Barbara Bryant-Forbes. But you also have to be a Forrest Gump in your clients’ lives in order to be fully engaged with them at their own pivotal points.
JL: Larry, did I tell you the story of how I became a family therapist? My Jay Haley story? It’s to your point of being Forrest Gump and just being aware. In 1972, my wife and I got married on September 2nd, and I was drafted into the Army on September the 20th. I was very lucky that one of the nice things that Nixon did, if we can say that, is that he said only people that volunteer to go to Vietnam would go to Vietnam. So, I thought, okay, I’ll take my shingle, you know, shovel shit for the next few years, at least I’m not going to ‘Nam.So, I got out of being sent, and through a series of, again, Forrest Gump-like events, I wound up in Fort Gordon, Georgia and was assigned to work in the Mental Hygiene in the stockade and in the maximum-security block. I was seeing prisoners and thinking, “I have no idea what the heck I’m doing with these guys.” I was sitting in cells smoking, 26 cents a pack, how could you not smoke, and thinking, “Shit, I’m really lost here.”

So, I went to our psychiatrist, who was a man by the name of Art Warwick, who looked like—even then, Alan Dershowitz, who smoked a pipe. He had kind of fuzzy hair and wire-rimmed glasses, a brilliant guy. And I said, “Art, I’m lost with this stuff about how to see these guys.” I said, “Is there anything I can read to help me be a therapist, because I have to counsel these guys?” So, he’s smoking a pipe in a very cliché psychiatrist way and he puffed a few and said, “Get Strategies of Psychotherapy by Jay Haley.”

So, I sent away for it and the thing finally arrived and I started reading about Haley and Erickson and I just thought it was incredible. I wanted to do this kind of therapy.

The years went by and lo and behold, I wound up working in Philadelphia Child Guidance Clinic. I meet Jay Haley, and my head was like a dirigible because I couldn’t believe I was getting to work at that clinic. So, Art and I stayed in touch. I went to see him and we were sitting drinking beers, and talking about Army days, and I said, “Art, by the way, when you recommended Strategies of Psychotherapy to me, is that because you saw me as a good, strategic, structural family therapist?”

So, Art had this shit-faced grin on. He was smoking a pipe again. He kind of looked at me and said, “No.” I said, “No? how come,” and he said, “Well, your name is Jay and Jay Haley’s name is Jay and I thought it was kind of funny.”

Parting Words

LR: That’s your illustrious, effing origin story! You are Forrest Gump, Jay.Would you offer some parting words for the people who are going to read this interview, whether they are brand-new family therapists, graduate students, seasoned therapists, or old horses like yourself? If you had to condense your wisdom into some Salvador Minuchin-esque type of statement that people will be quoting 50 years from now? No pressure though, no pressure.

JL: Yes. Sal was a poet, as was Braulio. I think I would say, do family therapy—it’s the best job you’ll ever have. And whatever job you have after that, it will help you. It will help you with the people that you serve. It’ll help your family. It’ll help your children. There’s no aspect of your life that it won’t touch, and in a good way. And it’s a gift, and you’ll say your thanks for it.
LR: You had me at hello, Jay. I really want to thank you for sharing your stories, your wisdom, your decades of experience, and I anticipate many more wonderful stories.
JL: Thank you, Larry.

Lynn Ponton on the Challenges and Joys of Working with Teens

Posted on by rezendevknowfully.com

A Delicate Balance

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

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

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

Cutting

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

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

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

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

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

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

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

Five Perspectives

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

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

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

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

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

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

Manualized Treatments

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

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

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

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

Texting

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

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

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

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

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

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

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

Sexting

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

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

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

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

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

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

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

Learn to Like Kids

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

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

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

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

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

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

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

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

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

Suicide

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

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

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

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