Category: Group Therapy

Teaching Prisoners to Lead Grief Support Groups

Posted on by Psychotherapy.net Team

A Novel Prison Hospice Program

Most people are unaware that many prisons in the United States have hospice programs. What makes them unique is that they utilize select inmate volunteers to serve as caretakers for the dying. The prisoners go through extensive vetting with the hospice staff, current volunteers, and the prison wardens. Once chosen, they become a part of the care team along with the doctors, nurses, and clergy. Most recently, four psychiatry residents from Tulane Medical School were part of a new program that trained 31 caregiver-inmates at four different prisons in Louisiana to facilitate in-house grief groups.

Prior to the grief support project, I had not worked directly with the incarcerated population. Thus, my knowledge of this kind of working was abstract and superficial. It was mostly two extremes, the horrible gruesome details of the crimes that had been committed, or the stories of those who had been wrongfully committed and their civil rights stripped from them for years. I (HC) was intrigued when my therapy supervisor, Dr. Marilyn Mendoza, spoke with me about her experience with Angola’s hospice project and her visits to other facilities. I wasn’t sure what to expect when she connected me with Mr. Jamey Boudreaux, the director of Louisiana Mississippi Hospice and Palliative Care Organization, to talk about the project.

The goal of our grief support project was to teach a select group of incarcerated individuals to lead grief support groups for their peers. In the state of Louisiana, whenever an incarcerated individual meets with a mental health professional, a document is generated which goes into his or her file. These documents are available for the Department of Justice to review. As you can imagine, there is significant stigma that mental health notes will negatively impact the decisions of the Pardon and Parole Board. Thus, by having trained incarcerated individuals provide bereavement support to their community, the dreaded mental health documentation can be bypassed. In addition, having peers with shared experiences lead groups allows participants to feel more comfortable in sharing their stories.

The project involved six participants selected by the corrections facility as individuals that had qualities that made for a good peer support facilitator. Depending on the number of participants, there could be up to 15 weekly meetings. The first three weeks were focused on introductions, outline of the project, and didactics of grief and groups. Weeks four to nine was a six-week adult grief support group led by a facilitator (in our case, psychiatry residents). The weeks contained different topics of introducing their deceased loved ones, sharing a photograph, sharing an item, writing a letter, planning for a special day, and reflecting on the experience. Weeks 10 to 15 repeat the same format but with the participants assigned a week to facilitate.

A Clinician Embraces a New Challenge

Although the outline and the project seemed straightforward, I was worried. I had no prior experience in working with therapeutic groups. Was the setting going to be conducive to groups? Would I be able to establish rapport with the participants? Would I be able to relate to the participants? Would I feel safe where the groups were being conducted? Would the participants be comfortable sharing sensitive information with me?

As I prepared the didactic material, the day for the first visit came. I was grateful that Mr. Boudreaux, who was familiar with the corrections facilities, accompanied me to Elayn Hunt Correctional Center located in St. Gabriel, LA. On the drive, he shared the history and changes that have occurred in Louisiana’s corrections facility. The security process included confirming our identity, searching our vehicle, confirming our identity again, and a complete body scan.

As we walked down a long walkway between chain-link fences, I pondered on all the different possible crimes that people may have committed to bring them to this facility. I had the list of names of the participants that would be joining me. Through public records, I could easily look up the details of their charges, convictions, and sentences. I decided not to as it was unnecessary to know for our work together. In hindsight, I like to think it would not have changed my perspective of the men I worked with, though I will never know for certain. Mr. Boudreaux also mentioned on our drive that it was a faux pas to ask incarcerated individuals why they are behind bars and for how long.

As I prepared, I wondered if I would have difficulty in getting the men to discuss their feelings. I felt that perhaps being in a cold, rigid setting would have made it difficult for them to be vulnerable in sharing their emotions. Would I have any credibility as a “free person” who had no idea what life was like in prison? Being a soft-spoken Asian woman, would I be able to redirect the group if discussion derails into a heated conversation?

As we continued towards the Skilled Nursing building, a few casually dressed men greeted us and I was unsure if they were incarcerated individuals or staff members. The Skilled Nursing building provided the highest level of medical care for the sickest residents. I instantly felt at home as the inside looked, sounded, and even smelled like the regular hospital units I was accustomed to. The eight participants were waiting in a room surrounded by windows facing directly at the nursing station. The men politely shook our hands and introduced themselves.

Mr. Boudreaux had been working with them on improving the education and resources available for the men providing end of life care. As I listened to them reflect on their work, I was struck by how passionately they spoke of their work and their patient advocacy. When I gave them the general outline, multiple participants asked thoughtful questions and seemed very eager to learn. They shared that the experience providing hospice care has been very difficult yet rewarding. I learned that these men are given the option of learning a trade or receiving more education. Hospice was neither and it was completely voluntary. Despite being a thankless job, this core group of volunteers devoted their time to helping others as it gave them a sense of purpose.

The first three meetings were lectures based with PowerPoint slides printed on physical paper. Each person came prepared with writing utensils and jotted down notes as I talked. They were engaged and asked insightful questions. They were interested in topics from the neuroscience behind grief to the spiritual aspects of grief and loss. They even made a point of asking if I could bring the articles or books I listed on the reference page at the end of the packet. There was a genuine curiosity to learn as much as they could.

A Surprising Place for Compassion

Week four was our first official session using the peer-support model. Having never led groups prior to that time, I was a bit anxious. We started the session by discussing ground rules of respectful listening and confidentiality. They shared how important confidentiality was in a setting where at times what you say can be used against you. Each person shared how he slept at night (“like a baby” can mean two totally different things), how he felt, and introduced the person whom they were grieving. They were all immediate family members, some that had passed years ago and some only months ago. As the sessions progressed, I became more comfortable.

Something the men have told me multiple times was that the course gave them the opportunity to learn skills that were not only helpful in facilitating grief groups, but also supporting their own family in the free world. I was inspired by their motivation and passion for helping others and often found myself lost in thought on the long drive home. I reflected on what it was that made this experience something I looked forward to weekly. Working in outpatient psychiatry, I sometimes feel drained by patients coming to me for a quick solution. It was refreshing that these men were looking within themselves for the answer. I was grateful that they felt comfortable in being vulnerable. There were lots of laughs and some tears shed.

When the second half of the lessons started, where the participants were each assigned to facilitate group, it did not feel repetitive as the men created new topics to focus on. Though each participant had their own style in facilitating, they all possessed great leadership skills. Many of them were trusted mentors and already possessed counseling skills. They created a therapeutic environment for sharing. I felt that in comparison to the sessions that I led, which might have been separated by a sense of power differential, they were building onto the conversation.

They chose interesting topics such as reflecting on their favorite memories, sharing where they keep photos and why, and what items from their loved ones they would like to have. There were times when the men disagreed with each other and respectfully brought up their own perspectives. They also provided comfort for each other. We frequently discussed how their loved ones continue to live through them and how spirituality and their culture affects the way they grieve. At the end of every session, they expressed gratitude for having a space to share.

Although our primary focus was on grief, it was only natural that we also discussed other sensitive topics. There was a lot of discussion about trauma and “the hand you were delt.” They described past life decisions as choosing between a series of what consisted of only bad options. Psychosocial factors made it very easy to choose a life of crime and drug use. It also made it difficult to trust others. It was after incarceration that some were compelled to take the arduous, personal journey of searching for purpose. Religion and spirituality were often sources of comfort and guidance.

During our discussions about grief, I reflected on how although it was such a personal journey for everyone, the universal stages of grief were ever-present. Some men spoke of their loss in superficially lighthearted manner as to not disrupt the complex, darker emotions lying underneath the surface. Some shared their experiences of shifting between the various stages of grief. Some shared how they grew from the experience. In some ways, being isolated from the outside world made it easier to stay in denial for longer. It was difficult to have a sense of closure, there was limited opportunity in attending funerals or, especially during the pandemic, to share the grief in-person with another family member.

As hospice volunteers, they have all experienced grief from losing patients. They each took shifts keeping vigil at the bedside of their fellow dying inmate, ensuring that their last moments would not be alone. After a patient died, they felt that it was only appropriate to push the emotions to the side to attend to the many other duties. They described a sense of relief in then having a gathering dedicated to sharing complex emotions. We felt less alone. I say we because the men included me into their groups. This was a foreign experience to me as I have mostly limited self-disclosure in my practice. Each person was a successful facilitator, I felt heard and supported.

Our last session was bittersweet. I felt proud of all the work the participants did and was confident that they would be able to lead grief groups successfully. Echoing my initial concerns, some of the men wondered if others would be able to share their feelings and personal details of their lives. Throughout the weeks, I gave them supplemental material regarding compassion, reflective listening, exploring feelings, and managing strong emotions. I could see that they studied the additional resources, sometimes quoting them or utilizing specific skills. The last session, I gave them a handout on termination. They quickly read the title and declared that they didn’t like that word termination because it sounded too definite. I like to think that the things we have learned from each other will continue to positively impact our lives.

***

The award ceremony was a bustling event with some unfamiliar faces of important people at the facility. I brought some snacks that were required to be repackaged in clear containers. One of the men made two different homemade cakes that tasted professionally done. Compared to our usual intimate group, it felt a bit foreign as I called each participant by his legal name to obtain his certificate. I have come to know them each by their nicknames, their unique personalities, and the stories they have shared with me. The car ride home felt a lot like being let out for summer break after graduation from college. There’s a sense of uncertainty about whether I will be able to reconnect with these wonderful, caring people I have met or if this was truly the last time I will see them.

This has been one of the most meaningful experiences that I have had in my career. During times I feel exhausted and drained from clinic, I think of my time at Elayn Hunt. The men reminded me of the fulfillment and joy that comes with being able to help others. Their passion for learning is truly infectious.  

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

Posted on by Psychotherapy.net Team

Gay Sons and Their Mothers

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

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

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

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

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

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

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

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

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

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

LR: Incensed about? 

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

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

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

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

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

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

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

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

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

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

Intersecting Identities

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LR: Gay Jewish geography.

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

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

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

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

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

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

LR: It’s not affirming.

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

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

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

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

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

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

LR: They’re going to catch up.

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

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

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

The Key to Effective Trauma Treatment is Collaboration

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

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

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

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

The Healing Power of the Therapeutic Relationship

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

The Importance of Working Systemically with Incest

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

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

The Gratification of Working with Trauma and Incest

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

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

The Complex Arena of Incest Work

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

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

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

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

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

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

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

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

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

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

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

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

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

How to Use Play Therapy in Prisons to Create Hope

Posted on by Psychotherapy.net Team

Imagine this scene with me: 15 men sitting across from each other at a long table, deeply engrossed in building with LEGOs. Joking and laughter punctuate moments of serious concentration as pieces of LEGOs are found and various minifigures find their place within the emerging structures. In another group, there is the eruption of victorious joy and the groan of agonizing defeat as the men play a variety of board and skill-based games in small groups and pairs. Two of the men simply throw a rubber ball to each other, a timeless game of catch.

Common Therapeutic Themes in Inmates

Grown men playing and telling stories from their play?! Yes, the scenes described above take place in a prison, a place where themes of “play” and “play therapy” are not usually enacted.

This work was born from my realization that if play could heal wounds in my adolescent and adult private-practice clients, it could be a powerful agent in reconnecting a former inmate with his child. After witnessing that reconnection firsthand, I could not get the thought out of my head of how many fathers there must be sitting behind bars, isolated from their children.

I discovered that there are many. There is also a great deal of recidivism, as incarcerated men face not only the daunting task of assimilating back into life outside of prison walls and the demanding requirements of parole, but also of rejoining families, rebuilding careers, and adjusting to a new chapter post-incarceration.

For many, it is overwhelming and confusing. Low self-worth, lack of self-awareness, deficient resources for self-repair, and difficulties in self-regulation contribute mightily to probation violations, inability to establish steady jobs, and difficulty reassimilating into their families and communities.

I soon discovered that prior to their time in the penal system, many of these men had spent time in foster care. I heard stories of abandonment, abuse, and self-rejection, often resulting in alcohol and drug abuse. It became painfully clear that many of the men were in desperate need of self-repair, and that these unresolved wounds played a large part in not being able to rebuild their life after leaving prison.

I experienced firsthand through my visits that prison is terrifying and chaotic. I have never witnessed a more stressful and unpredictable environment. For each visit, I passed through four checkpoints with buzzers, and the ominous and jarring sound of iron and steel slamming behind me. I would then walk a quarter mile surrounded by razor wire that gleamed in the sun like wolf teeth. I was constantly reminded of the utterly unforgiving conditions and lack of beauty that embodies this place.

I was, and still am, continually alert for the unpredictable, while at the same time, buoyed by my playful interactions with the men. Deep within this place there is a room where something miraculous happens. It is where play transcends the bonds of despair, transporting men — if only for brief moments — to a place of inner freedom and exploration.

How to Use Play Therapy in Prison

The Play in Prison Project that I developed is multi-faceted. It is scaffolded within the framework of “self-development” built upon the psychic Lego pieces of self-regulation, self-understanding, self-acceptance/forgiveness, and self-repair. Group members are taught self-regulation skills, how to identify negative schemas and change them, and how to build tools to identify and express feelings in an adaptive, prosocial way.

Play is woven throughout each of the group activities which incorporate the use of building toys, toy figures, games, and expressive art material (drawing and painting) designed to create a sense of safety, while also stimulating a curious mindset as new narratives of self are created. Overall, play is the glue and the foundation, making it possible for these men to be anchored in the here and now, looking at the self through the lens of this very moment while staying regulated and processing emotions and thoughts in real-time with the other men in the group.

Within the structure of this group, my role is that of a play therapist: tracking, reflecting, affirming, and even joining in play if invited. Through the group processing, I facilitate discussion using summaries, reflections of content and meaning, and affirming the observations and insight of the group members.

As a play therapist, I have spent years observing and joining others in play. I play regularly as an open-water swimmer, basking in the feeling of being lost in something huge while adapting my body to whatever the ocean offers me that day. Play lessens defenses. After just a few minutes, the men are laughing and conversing; even those that are silent often emit a smile.

Play allows for self-expression and ownership with no apologies, as evidenced by a victory whoop, and the feeling of mastery as a creation finds its way to completion. Play creates pathways for language. The men share stories through their creations, identifying emotions, and expressing themselves without shame or pretense. Play breeds a spirit of authenticity and presence. During our play, many of the men have new realizations of their worth and value as they can be present and comfortable.

Play is healing. The men can return to something awful that occurred in their pre-prison life, playing it out sometimes non-verbally, and changing the outcome based on what they know about themselves in the present moment. Play allows for connection and relationship building.

An all-too-common theme within prison walls is the lurking paranoia of being unsafe and the urge not to trust anyone. The men practice bonding through play, and elements of rough and tumble play within competitive gaming allow for the testing of these bonds.

Finally, play allows for self-repair. Through storytelling, the men engage in working through conflict with others, opening pockets of shame and self-rejection, and finding forgiveness that comes through creative and intentional play.

Clinical Case Study: Hope Shatters the Darkness

Jimmy has three years left to serve on a 15-year sentence. He is a father of two adult children and has grandchildren.

Jimmy was raised by his grandmother after his own mother lost her parental rights due to drug use and incarceration. Jimmy never knew his father. His grandmother passed away when Jimmy was nine, and he went to live with extended family members.

Eventually, Jimmy ended up in foster care where he remained until he turned 18. This period of his life was turbulent and involved many foster placements, poor school performance, and return stays in various juvenile detention centers. As Jimmy entered adulthood, he became involved in street life, leading to arrests and eventually long-term incarceration.

Jimmy was drawn to the Play in Prison Project because of his desire to rebuild his relationship with his adult children. He admitted that he carried shame and suffered daily from remorse and self-loathing. Life had hardened him, and he wore that hardness as a shield.

The toy he chose to represent himself in the first session was a big truck with blacked-out windows. “I’m big, people see me coming, but I keep everything hidden from everyone. When things get hard, I drive away.” During LEGO play, Jimmy created a tall building and used LEGO minifigures to represent guards. “I’ve tried my whole life to protect myself because nobody was there to protect me.” During a play session using expressive arts, he drew a dark cave with a solitary figure. “My brain tells me I’m living the life I deserve. My choices have put me here and there’s no light in sight.”

Halfway through The Project, Jimmy told the group that he wrote a letter to his children and had received one back in return. He wept as he read part of it aloud — it contained words of anger and hurt. The group helped Jimmy see that even though the letter was painful, it was at least an opportunity to communicate.

Play in the form of competitive games helped Jimmy to see and slowly accept himself in the moment. Playing a game in which he and a partner were paired together, he realized that it was not realistic to judge himself based on his past. Using LEGO bricks and minifigures, he built a large house with windows and an open door. The minifigures represented his children, grandchild, friends, and other family members.

He told the group he felt empowered to respond to the letter he received because of slowly learning to evaluate himself more fairly and positively in the present, as opposed to the horrible and painful events of his past. “The old me would have just stayed away. I don’t want to do that anymore.”

At the final session of the group, Jimmy drew a shattered cave with light streaming out of it, emanating from the solitary figure. At the end of the rays of light were people that represented his family and community. At the top of the picture, he wrote the words, “Free in My Light.”

Final Reflections on the Healing Power of Play Therapy

The Play in Prison Project has provided me with a rare opportunity to witness the power of play in a dark place with forgotten people. At this stage in The Project, I am volunteering because I saw a need in my community.

I am gathering data with the hope of submitting a grant to expand this work with other practitioners of play into other facilities. I have learned to be particularly mindful of being respectful of the institution, its employees, and its residents.

There are far too many examples of good programs that were started in prison settings for the purpose of research but ended abruptly when the researchers moved on. Because play and play therapy are novel and nourishing experiences, they were quickly, and perhaps not unsurprisingly, embraced during participation in The Project. Group members enjoyed the opportunity for safety and self-expression in an otherwise hostile environment where self-defense, hopelessness, and a constant state of vigilance were necessary for survival, both emotional and physical.

Some of the incidental comments in the surveys I collected and positive behavioral outcomes of The Project were a testament to the power of play in creating self-understanding and self-regulation. “For the first time in my life, I have learned to stay relaxed and not react.”

Comments about play creating a pathway for self-forgiveness and self-repair often surfaced: “I finally understand that I’m not the person who did the things that got me here; it’s part of my story, but I am who I choose to be in this moment.”

Play for some of these men led them closer to authenticity, intentionality, and connection in their everyday lives, helping to step closer to erasing shame, isolation, anger, and despair. Not uncommonly, I heard comments like, “I reached out to my children/grandchildren; I rebuilt the relationship with my wife/family members; now I know how to play with my kids, and I look forward to seeing them at visitation because I’m not ashamed of who I am anymore.”

Brooke Sheehan on Psychotherapy Behind Bars

Posted on by rezendevknowfully.com

On the Inside

Lawrence Rubin: Brooke, you are the director of the intensive mental health unit in a correctional facility in the Northeast with acute, subacute, and chronic clients. What are some of the greater challenges that you’ve experienced working therapeutically in this facility?
Brooke Sheehand: I think, for social workers or any clinical staff that decides to get into correctional work, grit, toughness, and the ability to roll with quick-moving and unpredictable changes are important. I’ll give you an example. You might have a schedule of clinical and therapeutic activities like individual and/or group therapy, when all of a sudden, there might be an ICS (Incident Command System) alert, which calls for an immediate response to some type of problematic event.

to get into correctional work, grit, toughness, and the ability to roll with quick-moving and unpredictable changes are important

A resident on the correctional side of the facility, what outsiders typically refer to as a prisoner, could be having chest pains, which obviously calls for immediate attention, or a piece of equipment goes missing, and you have to do a search for that equipment. These kinds of things, not to mention conflicts between residents, derail what you might have otherwise planned therapeutically for the day. I’m pretty lucky because I work on the mental health unit, as opposed to the correctional side of the facility, where the primary focus is on mental health events, and where we generally get to keep going. This shared focus really helps to maintain the stability of the therapeutic community, or milieu.

Another challenge is working with the residents on my unit for whom simply being locked in causes its own stress because they lack control over their immediate environment, their only world, at least for the present.

LR: I used to work in a forensic unit of a state psychiatric hospital, which had a very particular feel for me, and it wasn’t pleasant—far from it. What’s the “feel” of a mental health unit within a prison?
BS:

Unlike the correctional side of the facility, the mental health unit feels very familial

Unlike the correctional side of the facility, the mental health unit feels very familial, which is interesting because that’s not a term you’re usually going to hear from residents in a correctional environment. And I think the staff would say the same thing. Despite the wide range of residents from the acute to the chronically mentally ill, we seem able to create a balanced environment. For example, our longer and long-term residents are able and willing to check in with new or acute folks, which allows them to introduce them to the way that we do business on the unit. And oftentimes, that includes letting these new or acute folks know that we don’t get caught up in typical prison politics, like if someone brings you coffee, they’re not looking to have a favor in return. We really stress the importance of residents on the unit doing things for each other because they care about other people. You might not see this nearly as much on the correctional side of the facility.

LR: So the residents live in the mental health unit as opposed to visiting a clinic for an hour or so for individual or group therapy?
BS: Exactly. Folks end up doing treatment at different intervals that work for them and their clinician. We also have activity therapists, and they really help. If the clinician establishes a treatment plan, those activity therapists help with non-clinical activities, like social skills or physical activities that might be outside of the resident’s comfort zones. An example I usually give is that we have beachball bowling, which provides for social connection, teamwork, and goal-directed activity. And in addition, it’s fun for residents.
LR: Is the mental health unit comprised of both male and female residents, as well as mixed pathologies, from acute all the way to chronic?
BS:

most commonly, we see people with psychotic disorders, either acute or related to chronic conditions like schizophrenia, bipolar disorder, or schizoaffective disorder

Yes. I would also say that most commonly, we see people with psychotic disorders, either acute or related to chronic conditions like schizophrenia, bipolar disorder, or schizoaffective disorder. Those are all really common. And I would say most people who come into the facility are dually diagnosed, which is a very common and more recent trend; as well as both males and females.

LR: So, it’s not a substance abuse unit per se. But you might have people with substance abuse problems mixed in with other folks who do not abuse substances and who may be experiencing depression or bipolar disorder.
BS: Absolutely. We definitely have people who experience major depression, and those who experience anxiety—although I would say that’s a little less. More commonly, we have people who are actively delusional or for other reasons are unable to navigate the regular prison environment.
LR: What are some of the clinical or therapeutic challenges that the residents on your unit experience?
BS: Our unit is really a need-to-know unit, which is so unique in the correctional realm. So, for example, the correctional officers on my unit do have more mental health training, which is a cool difference from other facilities that don’t have a mental health unit. But, like all the staff on the unit, whether they are mental health-trained or not, everyone is involved in all aspects of treatment planning and implementation. You just don’t see that in a lot of other correctional facilities.
LR: So this is a true therapeutic milieu, where everyone is technically a part of the treatment team.
BS: Absolutely. Everyone, from the behavioral health techs to intensive case managers, to the clinicians, to the correctional staff.

A One-Stop Shop

LR: You have a DSW (Doctor of Social Work). What is your primary function?
BS: I do an array of things. In addition to individual and group therapy, I still have my hand in the less exciting parts of day-to-day management in terms of staff supervision and training, as well as helping with intake and discharge planning.
LR: Parenthetically, is this mental health venue common in the prison system in your state or, as far as you know, across the country? Because it sounds rather unique.
BS:

Our unit is also quite unique because oftentimes facilities attempt to expedite stabilization by quickly treating residents from the correctional side with medications

As far as I know, there is not another facility or unit that has something like this. We’ve had different people from different agencies even within our own umbrella trying to develop something similar. It’s really difficult if you don’t have a lot of stakeholders on board. Our unit is also quite unique because oftentimes facilities attempt to expedite stabilization by quickly treating residents from the correctional side with medications, getting them back to some baseline, and quickly sending them back. So their stay can also be very short. Our unit can take a little bit longer. These particular folks actually get a shot at trying to navigate their way out of the criminal justice system.

LR: So, some are referred directly from court into the intensive mental health unit, after which they go back into society? Or do they go back into the general population on the correctional side of the prison? Sorry to use television terms like “gen pop.”
BS: It can vary. I think that’s one of the other interesting aspects of our model, since we have those three levels of care (acute, sub-acute, and chronic) that for all intents and purposes, should not exist together in a single place.
LR: Where do folks go after completing treatment on your unit, if that is the correct term?
BS: To different gen pop settings, which could be a different correctional facility—whether that’s back to the county jail or to another state facility. We also have folks who will go to a state hospital. And then we also have folks who will be released.
LR: These gen pop residents are the ones who are not living in the intensive mental health unit, but rather what you refer to as the correctional side.
BS: I’m also thinking of that criminal justice realm, where they’re perpetually in this cycle which leads them out but inevitably back to prison for reasons that might be more related to mental health issues. We try to get them into outside settings that are really focused on mental health.
LR: Do you have a psychiatrist who works on the unit or just visits the unit and prescribes meds?
BS: We are fortunate enough to have a psychiatrist who is embedded in our team, which is wonderful. And they really are an essential part of the team. Because what is very different, I think, about an intensive mental health unit in a correctional setting, is that if and when the residents are acutely psychotic, they’re going to need a med adjustment, you know, at the drop of a dime. And we’re really able to do that because that prescriber is embedded with us.
LR: A one-stop shop.
BS: Yes. Exactly.

Working Within the System

LR: What are some of the nontherapeutic aspects of your work, when you’re not sitting in a session with a resident, doing traditional therapy?
BS: Entering into the world of the correctional environment as a clinical person can be quite distressing. You see people engaged in a broad array of challenging behaviors, including self-injury or hunger strikes. When people are confined, they can resort to some really desperate measures. And so I think that’s definitely one of the more challenging aspects of the job.
LR: So, there are issues that some of the residents bring with them into the facility, but some psychiatric behavioral issues that evolve as a result of being in the facility. What other kinds of behavioral and emotional problems develop as a result of being in the facility?
BS:

I’ve got a lot of folks I work with who are lifers or simply won’t outlive their sentences

I think one of the biggest components and barriers for these folks is the lack of control over their own life. I mean, I’ve got a lot of folks I work with who are lifers or simply won’t outlive their sentences. When they have people on the outside whom they’re still trying to be connected to, there’s so much that they miss or are not able to participate in, or celebrate, or grieve. This leaves many of these residents feeling absolutely cut off and without meaningful or rewarding outlets.

LR: What are some of the unique therapeutic challenges of working with a so-called “lifer”?
BS: That’s one of those predicaments where you have to be really comfortable being uncomfortable and able to walk together through this barrier of acknowledging that this person is in this very limited environment forever. And oftentimes, I’ve found that by just calling that what it is and not trying to tiptoe around it, you become better able to provide the necessary supportive interventions. These particular residents really just want to talk about that and acknowledge that this is a different walk and a different journey for them than for someone who might be getting out in nine months.
LR: How has your training in social work, as opposed to that of a clinical psychology background, prepared you to work in this particular environment?
BS: The fundamental difference that I often see is that our training as social workers is really based on a systems orientation as opposed to an individualistic one. I see systemic barriers and challenges more quickly on the unit and am prepared to think and act more quickly to address those.
LR: Can you explain that?
BS: The unique part of this type of job is that I’m working right there in the middle of the intersection, so to speak. We do a lot of work with families, especially in the world of mental health, because many of our residents still typically have connections, both on the inside and outside, and in many cases that includes family members who care. And for these family members, it can really be difficult to navigate the system of care that their loved one is embedded in. That can often leave family members on the outside feeling both hopeless and helpless. And the flip side is that working in the milieu requires constant attention to the politics on the unit, as well as the ebb and flow of policies that flow from the Governor’s office.
LR: In this context of the systemic orientation, what kind of family work are you able to do as a therapist in the facility?
BS:

even before the pandemic, we were able to do a lot of family work through Zoom and Skype

I worked with one of the residents and his mother who was actually able to come into the facility for visits. We were able to do some family work right there, which was pretty unique. And even before the pandemic, we were able to do a lot of family work through Zoom and Skype. And we are also able to provide extra assistance to those families who struggle due to enmeshment, which can be exacerbated by the confinement of one of the family members.

LR: Would you do family work with someone who is a lifer?
BS: Oh, yes. In fact, we do. And that’s been very therapeutic. One of our lifetime residents has family members who live out of state. It’s been a gift to be able to work with the resident and his family on a fluid, continual basis, through which they actually get to mend and work on enhancing their relationship even though they will never live under the same roof or close to one another again.
LR: Can you think of another family with whom you’ve worked that was particularly poignant for you as a clinician?
BS: One that comes to mind is a gentleman who was able to do some inner younger-child work that he really hadn’t been able to do when he was actually young. It was the safety of distance, both from his own childhood and his family members, that allowed him to work through these complex issues. And so, they have, let’s say, like a 30-minute video conference that they’re able to do. Doing it this way gave both sides the time and space between these remote sessions to sort through things.
LR: How did the isolation that COVID forced upon us impact the family work with some of these residents who depended on family members’ coming to the facility?
BS: It absolutely did have an impact. I think you’re right in saying that there are some folks who really are pretty fortunate. In my experience with folks in this system, particularly those with mental health needs, many have burned a lot of bridges, and they don’t have people who come anymore. But for the others, and a couple come to mind, not having those connections has been a challenge. But video conferencing has really lifted people’s spirits and allowed them to stay connected.
LR: In this context of connection, what are some of the benefits that you’ve found by doing group therapy with the residents?
BS: Before we even get in the room for group treatment, they’re all there. Everyone is there, which is so cool. I’ve worked in a lot of places and with other populations, and folks just don’t show up at the same rate for group therapy. They all really push each other to get outside of their comfort zones and be there for the group.
LR: Are your groups process groups, or are they psychoeducational groups, and are they unique to being inside of a prison?
BS: Working with this very interesting and mixed cohort means that we have to get creative a lot. We do a lot of processing, a lot of meeting people where they’re at during the day. And I’m telling you, that’s where the magic is. People really seem to connect with that and feel like they’re able to be heard. We’ll have people who—even if they’re chronic—still struggle with a lot of delusional thoughts. It’s amazing to watch group members patiently help these particular folks get back on topic. The group knows how to re-center itself and continue on.
LR: It sounds like an incredibly cohesive group of residents, despite the diversity of their psychiatric needs. Have you found any particular method or theory of therapy more useful with these incarcerated residents?
BS:

staff are always available and willing to respond to the residents’ needs, and quite honestly, the residents are very protective of the staff

When it comes to the work in this type of environment, I’ve never felt more successful or seen therapists be more successful then when they’re able to forge a relationship. And that takes that kind of grit that I was talking about earlier, because people can be afraid, coming into an environment like this. I have done a lot of work in homes and have even delivered meds to people, so I’ve seen the importance of connection. In here, staff are always available and willing to respond to the residents’ needs, and quite honestly, the residents are very protective of the staff.

LR: So, we’re not talking about CBT being preferred over DBT or being more appropriate than ACT—we’re talking about core relationship-building skills that you might find in client-centered therapy?
BS: Absolutely. But I do want to mention that we use all those other modalities as well. Because each has something to contribute, depending of course on where people are. But definitely, the relational aspect goes far and beyond.

Gendered Issues

LR: You’ve written a few blogs for us on some of the challenges of working with women around pregnancy, parenting, and even your own pregnancy while working here.
BS: Many of the women in here are on a new journey of their own. It has really tugged at my heart working with the women, because there were so many folks who are in the throes of losing their children or have lost children. And I have had both of my pregnancies while working here. I worked with a pregnant resident who understood that she was going to have to give up her child, which was very hard to witness. But being able to navigate those waters in a truthful way, particularly as I happened to be pregnant at the same time, I was grateful to be able to help her get to a place where she was like, “Looking at you is so difficult for me.” A lot of growth and healing came from that relationship.Being with the men can result in a range of unexpected and awkward questions. That has to do with the elephant in the room of human sexuality, which can also be very uncomfortable. I’ve gotten some really bizarre questions.

LR: Oh, that you got pregnant as a result of sexual activity and they’re not allowed to have sexual activity! I get it now. Does sexuality—sexual behavior, sexual behavior problems—come to the fore in your clinical work?
BS:

a lot of the men I work with have had really either horrific or very challenging relationships with women

I think that is a huge component in this type of work, especially from the vantage point of being someone who identifies as female and working with folks who identify predominantly as male, and who are constantly trying to figure out their own equilibrium. Oftentimes, a lot of the men I work with have had really either horrific or very challenging relationships with women. Or didn’t get any education around human sexuality. So they’re trying to guess how to piece this all together. Most younger males have gotten a lot of their sexual and even relational references and experiences through pornography. So that’s their lens, and they don’t have the context for how to have healthy interactions with women.

LR: Can we circle back to some of the issues that pregnant inmates experience?
BS: Postpartum depression and anxiety are huge. The depression piece, I think, is so important. I think, oftentimes once you have a child, the mom kind of gets left behind. And you can see that, too, in an environment like this where people are kind of like, “Okay. You’re separated. Now, let’s just move on.” But there’s so much there happening, you know, hormonally and mentally, that requires a lot of attention. Because, if you don’t, someone could end up suicidal.
LR: What about those residents who have lost access to their children, who lose their parental rights after they give birth, or who have—as a result of their criminal or mental health histories—lost connection to their own children? What are some of the challenges in working with them?
BS: This is one of the points I’m always eager to talk about. One thing that really jumps out is that most women who are incarcerated are here because of substances or some type of interpersonal relationship. It takes about 15 months from arrest to sentencing, which is the amount of time that it takes to be away from a child before an agency like a Department of Human Services would take away or petition to take away a child. So the system kind of sets these women up for failure and undermines their ability to build a relationship with their child.
LR: And the children lose precious and necessary early attachment to their mother.
BS: And so many of these folks are impoverished, which means that the bail system makes it that much harder for these women to reconnect with their children during that very sensitive bonding/attachment period.
LR: It sounds like there’s an inevitable cycle of attachment disruption, depression, alienation from the children, and attachment disturbance.
BS: BS: Absolutely.

Developmental Impairment

LR: You mentioned in one of your blogs that you work with incarcerated residents who are on the autism spectrum or have intellectual disabilities. What are some of the challenges that you face in working with these residents?
BS:

A correctional system is just not built for folks on the autism spectrum or with intellectual disabilities

A correctional system is just not built for folks on the autism spectrum or with intellectual disabilities, despite the fact that we’re seeing more people with these types of disabilities entering the system. I think this environment is really confusing for folks with such an obtuse vulnerability, because it’s really easy for other folks to take advantage of them by using them for their own gain. There’s a lot of data to support the idea that folks with these types of disabilities do better in smaller, contained units. And it can be really dangerous, because they are more easily victimized physically and emotionally, which contributes to their already fragile coping skills.

LR: I would think, then, that for these folks you would have to focus on life skills, survival skills?
BS: Absolutely.
LR: Why do you think that the residents on the autism spectrum or those with intellectual disabilities end up in prison as opposed to residential treatment centers on the outside? Have they committed crimes? It seems so complex.
BS: My experience has been that we have these gaps in our community services network, not only in my state but across the country. What I’ve seen happen is that someone with these particular difficulties who lives in a residential setting typically acts up in response to a stressor that is beyond their ability to cope with. They end up in emergency rooms or in police custody. And then, very quickly, charges are filed against them. And once they’re in the system, it’s really challenging to get them to where they need to be. Another thing we’re seeing is related to their difficulty navigating the sexual realm, where they may end up committing a sexual offense, albeit unknowingly.
LR: They don’t really understand what they’ve done. Are they amenable to corrective therapeutic work in your facility?
BS: You really have to find ways to teach the concrete skills—it’s almost like going back to middle school for them—and really helping them get that formative education on just, first, how to have a social relationship. And then bridging that with behaviors that are socially appropriate and what behaviors they need to have hard boundaries around.

Preparing for Re-Entry

LR: How do you prepare soon-to-be-released residents, and what are some of their psychological needs that need to be addressed in therapy before they go?
BS:

We definitely do a lot of normalizing around this huge gap that exists between the world inside and the world outside

We definitely do a lot of normalizing around this huge gap that exists between the world inside and the world outside. One of the things that I think has been most pronounced is technological advances. Sure, we use tablets in here, as I mentioned before, but there’s still a huge plethora of technological skills that they just don’t have, like chip cards, which seem so second-nature to us on the outside. Even cell phones have changed so rapidly and can be so very confusing. So we try to do a lot of practical things in these areas to prepare our residents who will need to catch up to the technology on the outside.

LR: With no experience in this domain, I think of the movie Shawshank Redemption and wonder about the psychological challenges of freedom from incarceration.
BS:

getting them ready to reconnect on the outside, we kind of try to wrap them back together and cinch them up

Absolutely. I think one of the biggest ones—and you kind of hit on it in your remark—is the anxiety that is inevitable upon their release and the temptation to push everyone away as they try to wrap their head around this very big transition. We really try to work with them to stay aligned with the values that make them individuals and some of the important insights and messages they got while they were inside. Many of these folks are kind and loving people who enjoy humor and relationships. So in getting them ready to reconnect on the outside, we kind of try to wrap them back together and cinch them up and allow them that space to move through this big impending change.

I think COVID has added a whole other layer to this, especially for those residents who will need to quickly connect with resources for substance abuse support on the outside, many of which are virtual. And these folks have been so accustomed to face-to-face groups on the inside. They desperately need continuity in their sense of community.

LR: What suggestions would you offer to fellow clinicians on the outside who might be working with these released residents?
BS: I love that question. I think one of the biggest things clinicians on the outside can do is to look at their own intrinsic biases about this population of clients. While a lot of momentum has been generated towards working with people who are incarcerated, I worry that many struggle with the idea that these folks are bad seeds. A lot of people, in their lifetime, have driven drunk or violated some rule. But there’s a fine line that is easy to overlook, especially in the United States where we incarcerate more people than anywhere else. Many of us are connected to someone in our family or close circle of friends who has crossed the line, so we really need to look at that and try to wrap our arms around these people.
LR: Have you come across any misconceptions or particular biases that clinicians on the outside have when they see the clients that you discharge?
BS: My residents are particularly challenging because they’re coming from an intensive mental health setting. I worry that clinicians assume that they’re automatically going to be violent, that they’re not going to be someone who follows the rules, and that they’re not going to be able to handle the treatment. You know, if you build that bridge, people are going to be able to meet you there. But it takes immense vulnerability to walk out of a correctional facility and try to get back into the world. So, if we could kind of build that bridge together, that would be huge.

Summing Up

LR: Brooke, how has working in a prison impacted you as a person, as a mother?
BS:

I think through this journey I’ve definitely been able to see people as fellow walkers in this life

That is an awesome question. I think through this journey I’ve definitely been able to see people as fellow walkers in this life. We’re all human beings. And I really, truly believe that no one should be judged on their worst day. And I’ve definitely worked with a lot of people who have committed a lot of different crimes and come with a lot of different baggage who will adamantly say that—we are really just fellow human beings. So it’s definitely changed my mindset to viewing the world as this place where we’re all just doing our best.

LR: You will have wonderful insights to offer your own kids when they’re old enough to appreciate them. Last question. What obstacles have you encountered as a woman coming into corrections in a clinical facility with a doctorate?
BS:

The challenge of being a female clinician is that people sometimes think I’m like a hug-a-thug or something like that

I think a correctional environment, just by sheer nature, was not designed to house women. When they first decided that they were going to have prisons in the world, they were really designed around men. So there’s that. Then, you have a hypermasculine environment, which is not a criticism. It’s a paramilitary society—so it’s very based on order. It can be very strict at times. The challenge of being a female clinician is that people sometimes think I’m like a hug-a-thug or something like that, where, oh, gosh, you’re just going to have no regard for the rules, and you’re definitely going to be someone who doesn’t have boundaries because you’re a woman. And that’s really not true. I think having a doctorate has also been a very interesting experience. Because I will be with a male colleague who also has this doctorate, and they will call him “Doctor” and me by my first name.

LR: Sounds like you’ve had your challenges, Brooke. But you’ve also found your stride.

How an Anti-Tech Group Therapist Became a True Believer

Posted on by Psychotherapy.net Team

Therapists’ offices have always intrigued me. Much like the artwork on the jackets of old vinyl records, they secure my memories with pleasing visual touchpoints. Pre-and post-session rituals marked my weekly appointments: stopping off at the same deli for a coffee, sitting on a park bench, browsing the poetry section in the corner bookstore; such places served as footholds for the different phases of my psychological awakening.

First Wave

After twenty-three years in my own cozy therapy office, it was time to say goodbye. The downtown institute that housed my practice went bust, and the landlord heaved dozens of veteran therapists out onto the cold winter streets of Manhattan.

As I packed up my books, rolled up my oriental rug and wall tapestry, and wrapped my Buddhist knick-knacks in newspaper, everything in my office took on meaning; the spider-cracks in the plaster ceiling that I had planned to paint, the well-worn grooves in the carpet from my trusty Aeron chair, the slight sag in the center of the couch that held so many stories.

I considered my attachment to my cozy therapy office as I closed the door behind me for the last time. Walking home that night, I realized that all my personal therapists and their offices were gone too. Soon after, the pandemic hit.

Second Wave

When New York City shut down, I thought that I had no choice but to shut down, too. As a group therapist, I couldn’t see how my groups could survive. Individual patients would have phone sessions—but therapy groups? Over the years, I had amassed ten weekly, ninety-minute groups, consisting of over 100 individuals. What would happen to them?

So I phoned a fellow group therapist and asked if she planned to shut down. She guffawed:

“Why on earth would I do that?”

“But how will your groups meet?”

“I moved them to Zoom.”

I paused and asked in all earnestness: “What’s a ‘Zoom?’”

When Worlds Collide

Could therapy exist without walls? Would I be able to sense unspoken feelings from patients from a flat two-dimensional image? Could a screen transmit subjective and objective countertransference, induced feelings, subtle body movements, and the endless emotional tics and hiccups that appear in face-to-face sessions? I bristled at the thought of moving my practice online. But the pandemic forced me to face a stark reality: evolve or face extinction.

When I told my group members that we were moving online, their reaction was mixed. The older patients responded with cranky disapproval.

“How could you degrade the group in this way?” one asked me.

“I share your concerns, Alan. Let’s give it a try and see how it goes.”

I left out that I had two college tuitions to pay, a home mortgage, elderly in-laws to support, insurance premiums, and countless other monthly expenses that the pandemic wasn’t shutting down. To my great relief, the younger people accepted the proposal enthusiastically. “What’s your URL?” they asked.

“I’ll get it to you soon,” I replied. I immediately searched “URL” on the internet and discovered that it meant “uniform resource locator.” What the hell was that?

Boomer to Zoomer

With the help of my teen daughters and a nine-year-old MacBook crammed full of family vacation photos, I learned the basics of Zoom and patched together a weekly schedule.

Next, I had to consider the background for my sessions. Visually, my home presented a minefield of challenges. Every wall and bookcase overflows with family pictures, children’s artwork, and cardboard boxes containing my old office and my daughters’ dorm rooms. So, I dragged an old film projector screen out of storage, erected it behind me, and turned on my computer video camera.

It was my first visit to my cyberspace office—me floating in a wall-less white space.

The big day finally arrived. I sat in front of my computer, took a deep breath, and logged on to Zoom. My anxiety kicked in, and I found myself forgetting nearly everything my daughters taught me. Messages like “Samantha is in the waiting room” popped up, and I clicked. One by one, group patients began to appear in their square “Brady Bunch” boxes.

“It’s so good to see everyone.”

“I missed group!”

“I’m glad we can still meet.”

I immediately pleaded for patience with my computer skills; the group members delighted in my vulnerability. “Don’t worry, we’ll get you through this.” Soon everyone was chatting and catching up like old friends.

To my surprise, the group was flowing—disjointedly, yes, but flowing. I discovered that many members were scattered throughout the country, unable to travel back to the city. One woman was participating from the Czech Republic, which wasn’t allowing flights in and out of the country. I marveled that online sessions make it possible for members to attend from nearly anywhere.

“Hey, where’s Steven?” a younger group member asked. “He never misses group.”

Steven, a grey-bearded father figure with a sunny disposition, was the oldest and longest-running group member. Anxieties about his health were being expressed when a message popped up: “Steven is in the waiting room.” I clicked on it quickly. I was getting good at that.

When Steven’s gaunt face appeared, group members gasped; his eyes were sunken, and his usually bright outlook was dimmed beyond recognition. He had COVID.

“I’m so…happy…to see you all,” Steven wheezed. As he related his journey from a mild cough to high fevers and the ER, the group hung on his every word. “I’m so scared, Stephen said, “I don’t want to die. Not now.”

Soon tears were flowing, and cyber hugs were being dished out. By the end of the session, Steven managed to smile again. “You guys…are a…miracle, ” he said as he gulped air, “This is the first time I felt hope since…this nightmare…began. Thank you. Thank…you all.”

As we signed off, another miracle occurred: I had become a true believer.

New Standards

After a few weeks, I could feel the online groups start to lose vitality. Immediacy, the beating heart of group, was waning. Instead of an exhilarating experience that challenged ingrained characterological traits and inspired emotional intimacy, the online groups devolved into lackluster support sessions. Members stopped relating to one another and were monologuing about themselves. Energy dwindled, attendance ebbed, and newer members dropped out.

My office was gone, and my groups would be, too, if I didn’t take action. To succeed in cyberspace, I had to reinvigorate my leadership skills and set new standards. I needed more energy, focus, and clarity.

I launched an entirely new set of pre-group rituals. Thirty minutes before every session, I set aside time to review each group members’ development. I reviewed their histories, revisited their goals, and considered new ways of challenging them. I even incorporated group members into my daily Buddhist practice. Every morning, I reviewed my groups, targeted each group’s member’s emotional growth in my daily meditation, and considered new ways to engage them.

I became determined, from the moment I signed onto Zoom, to hit the deck running. I pushed members to take more risks and focus. I scanned their faces constantly for any emotional shifts and evidence of unexpressed feelings. I confronted any signs of repression.

“Samantha, what was that thought?”

“Steven, you seem distracted.”

“Alan, can you put that frustrated look into words?”

No sooner had my groups slowly jump started to life than I realized that they were suffering from another problem: a loss of boundaries. Group members became voyeurs. During sessions, members gave tours of their homes and showed off their living spaces, partners, pets, or children. Such distractions ran wild and fueled resistance to relating. During the first few weeks, members also signed into the group while snuggling in bed, eating meals, feeding their dogs, smoking cigarettes, baking bread, or casually sipping a tumbler of whiskey.

One young woman greeted her group from her bathroom, fresh from a shower. As she towel-dried her hair, her bathrobe fell open, revealing her bare shoulders and the tops of her breasts. “Oops! Sorry!” she crooned as group members ogled her.

It was time to reassert boundaries. I firmly reminded everyone that the group rules applied online: no eating, no walking around, no texting. Anything that distracted from relating to one another was banned. I also instructed members to pick a spot in their homes and sit for the entire group, no more multitasking.

And finally, I requested that every member prepare for group by revisiting their intentions and considering the following three questions.

  • Why did I join the group?
  • What are my feelings toward my therapist and fellow group members?
  • What emotions am I holding back?

To my surprise, group members expressed relief. The reassertion of boundaries lowered everyone’s anxiety and quickly brought the relationships in the group back into play.

A Cure Through Love

As of this writing, it has been ten months since my groups began meeting online, and I’m delighted to report that they are bustling with new members. Yes, my cyberspace therapy office isn’t cozy, but I have learned that therapy isn’t about places—it’s about relationships. As long as relationships remain the central focus, therapy can thrive nearly anywhere.

Freud suggested that in essence, psychoanalysis is a cure through love. The pandemic continues to test my mettle as a psychotherapist but doesn’t quell my love of the work, a love that I’ve learned can transmit through a computer screen. Not only is love limitless—it’s officeless, too.
 

How Self-Disclosure of Learning Differences Guides My Clinical Relationships

Posted on by Psychotherapy.net Team

Origins of Empathy

As a child, I remember the frustration of not being able to tie my shoes, ride a bike or grip a pencil. The fact that I needed extended time on tests and note takers throughout high school and college was no less discouraging. However, one of my greatest challenges was adapting to adult employment and social demands; a process during which few people seemed to care about my specific struggles. I still remember fearing the supervisor who would criticize my handwriting and the sting of rejection after a first date. Although my therapists were empathetic, I was often curious about whether they had similar personal experiences, and whether disclosing them would have strengthened the alliance between us. Now, as a therapist who specializes in working with young adults with learning differences, I have made self-disclosure not only a basic component of treatment, but also part of how I present myself to the outside world, as my personal story is published on my website as well. This dynamic has led to a transference and countertransference between my clients and myself that starts from our first session and strengthens our relationship in many ways, while also providing an opportunity for us to reflect on our differences.

Part of my initial interest in becoming a psychotherapist and coach stems from my personal experiences struggling with learning differences. I am interested in using some aspects of my life to help other young adults with similar diagnoses navigate their challenges. It is reported that 75 to 85 percent of young adults on the spectrum are unemployed, and although the exact statistics on unemployment among adults with other learning differences are not known, it is widely thought that they also face a variety of barriers.1 The clients that come to my practice often say that they are struggling to manage their workload, navigate interpersonal situations with colleagues and bosses, and establish friendships and romantic relationships. “Preserving the uniqueness of their challenges while drawing on my own experiences is a tricky balance as a psychotherapist”, but I have developed a few strategies for doing so.

Fellow Travelers

My clients frequently find me through my writings for the NVLD (Nonverbal Learning Disorder) project, a non-profit that disseminates research and builds awareness regarding this unique visual-spatial disorder. One of the first things I tell them is that everyone’s experience is unique, and that my job is to help them to navigate their lives while also drawing on some of my own personal experiences related to common issues such as self-disclosure in the workplace, creating organizational systems and finding mentorship. The key is to listen fully to their stories and experiences, helping them to brainstorm and find their own solutions, while also offering, when appropriate, some personal anecdotes that might be helpful for their specific situations. An example could be a client who states that he or she is not sure how to best self-disclose their learning difference to their employer. We may explore ideas about different times and places to self-disclose, and I can talk about what I have learned from my own experience. I have found that many clients often appreciate this approach, stating that when I speak from a personal viewpoint it helps them to trust me more and feel as if I can relate better to their experiences.  

If transference in psychotherapy normally consists of unresolved feelings and expectations that are placed onto the therapist–oftentimes in an unconscious attempt to recreate or approximate a past relationship, and countertransference is the therapist’s resulting conscious and/or unconscious feelings that are projected onto the client, “the therapeutic relationship between two young people with learning differences is ripe for the enactment of these feelings/experiences”. I often find that the clients I work with report a feeling of safety and security, perhaps seeing me as an older sibling or parental figure, especially when they describe feeling understood or supported by my being in a unique position to empathize with their learning differences.

Transference & Countertransference

One client, whom we will call Joyce, frequently contacted me after our therapy had ended in order to ask questions that usually began with “since you have and know about NVLD…” Because our work together had ended, I redirected her to another therapist who practiced in my office, but she did state that she had felt a sense of security and safety with me that she may have felt earlier with her mother, whom she used to call to help guide her with difficult situations. In some ways, she may have unconsciously seen me as a parental figure helping her to navigate difficult questions related to her job and personal life. 

While working with male clients, I have often found that the transference/countertransference relationship may take on a different form. This is due to the fact that there is an element of both bonding and competition; many of the young men I have worked with may have a complicated history with women, especially regarding rejection and feelings of emasculation, a topic about which they may look to me for understanding. While I do not usually disclose my romantic status or experiences, by validating the unique challenges of dating with a learning difference and providing some practical steps for managing these feelings, I establish a bond with these clients, who describe previous male friendships in which they discussed these issues. A dynamic of male companionship can often form between my clients and me. However, some of my male clients have also seen me as a source of competition, and have reacted strongly, stating “you don’t know anything” or “how can you understand me?” Admittedly, it may be uncomfortable for some of my clients who see me as a “success story,” especially when they are struggling to find work or build interpersonal relationships. This is also a dynamic that I try to work through with them, making space for it to be discussed in the therapy room.

I attempt to use my countertransference as an indicator of not only how I should respond to the client in the room, but also of when, if and how I should self-disclose. A dynamic of male connection may lead me to respond to a client’s disclosure regarding rejection in the dating world with a few suggestions for improving one’s strategies, perhaps with the caveat that I have learned from my personal experiences. Depending on my relationship with the client, I may also use my countertransference as an indicator of my familiarity with certain aspects of the client’s professional experiences. For example, I remember identifying with a client I will call Michael, when he described challenges figuring out certain aspects of his job, as I have had similar experiences. However, if a client expresses competition or hostility towards me, I may also notice a feeling of defensiveness that arises in me, which will cause me to be more cautious regarding self-disclosure. Again, “countertransference can be an indicator of when and how to self-disclose”.

In my clinical work, transference and countertransference are often sparked by the patient’s vulnerability in the therapeutic relationship, something that individuals with learning differences will sometimes go to great lengths to conceal. Sometimes, they will hide behind a veneer of competence, lest anyone discover their sometimes painfully embarrassing challenges. The transference and countertransference dynamics in a therapeutic relationship often emanate from these struggles becoming visible, causing relief, vulnerability and perhaps shame at the same time. An articulate and thoughtful client, whom we will call Jenny, recounted how she had transferred to a reputable private school to receive more academic support and was subsequently abandoned by her previous friends, who stated, “So you think that you are better than us?” Despite distancing herself from her new school’s perceived “preppy” culture, she was reticent to explain that she had enrolled there because the workload and lack of individual attention at her local public school had become too onerous to handle. Quite the opposite of feeling “better,” her true reasons for transferring were a source of embarrassment. Hence, she described feeling “invisible” to her former friends, as they had falsely assumed she must have chosen the school for its supposed prestige. Jenny’s story prompted me to reflect on how many of my peers had also judgmentally questioned my parents’ decision to send me to small private schools, with statements such as, “Wait! How many people go to your school!? That’s weird.” Not to mention, “Are your parents rich or something?” I stated to her, “It is so frustrating and somewhat ironic when people assume you attend a private school because your rich parents want to help you escape the chaotic real world of public education, instead of the reality that you would do anything to be able to thrive while attending a school with over thirty students per class, loud and confusing hallways, and overwhelmed teachers.” Jenny thanked me, and although I never disclosed my experience, the fact that I had made hers visible created a positive transference between us. In that moment, I may have seen her in a way she would have wanted to be seen by an empathetic friend.

“Group therapy sessions necessitate a different kind of self-disclosure” and create a different stage for the expression and integration of transference and countertransference into the therapeutic work. I led a small group on developing dating skills for young men on the spectrum. The participants asked me, “Do you have a girlfriend,” and “What dating experience do you have?” I did not answer the first question but did confirm that I had faced some the challenges in this area. I added that I had developed some strategies and techniques of my own for finding success. My self-disclosure sparked an ongoing discussion of the struggles of dating between the group members, a discussion in which I was a participant in but not the expert leader. In other words, my self-disclosure leveled the playing field, so to speak, which facilitated a deeper and more meaningful conversation in the gruop. Because the participants acknowledged that they did not feel comfortable speaking about these issues with anyone else, the transference that may have developed was that of a relationship between intimate friends. Regarding my countertransference, I also felt a sense of kinship with the other participants.

Self-disclosure regarding around my learning differences and a careful monitoring of the related transference and countertransference relationships with certain clients has enriched my clinical work. My clients have had both positive and negative reactions to my self-disclosure, which has provided an important opportunity for deepening the clinical relationship. While not all my clients react positively to knowing that I also have a learning difference, the majority have developed a trust and willingness to explore how my self-disclosure may help them in treatment. Although I will continue to make sure that sessions focus on clients and not on myself, I believe that, overall, my decision to self-disclose has been a positive experience for clients.

Resources

Carley, J. M. (2017, April 13). The Employment Shift: Rethinking Autism Employment Initiatives. Fallbrook, California , USA.

Working with Teens: The Good, the Bad and the Ugly

Posted on by Psychotherapy.net Team

“I never set out to work with teens.” For many years after I started my private practice, people would ask, “what is your specialty?” and I would demure. I thought it was pretentious to say I’m a “specialist.” I didn’t feel like a “specialist.” I also thought it would be boring if I specialized. I wanted to mix it up (a little ADHD?). But I soon found myself gravitating to adolescents and young adults, and them to me. Given my years of training in family therapy, it started to feel natural that I would work with this population, those not-quite-children but not-quite-adult people who most therapists feared. And then I had two teen girls of my own; one now 20. What better breeding ground for insight could there be, I thought. Boy, or should I say girl, was I wrong!

Girls Will Be Girls

A therapist can no more easily treat herself and her family than a doctor can heal herself. As far as I can tell, my own family problems stem back generations. Mark Wolynn’s recent book called, It Didn’t Start with You: How Inherited Family Trauma Shapes Who We Are and How to End the Cycle lends some credence to this assertion. Jewish-check, anxiety-check, narcissism-check, mental illness-check. And the list goes on!

“I sought to correct all that with my girls. Clearly, I overreached.” Not only did it not help to hold myself to exacting, unrealistic and perfectionistic standards; it was in fact, impossible. Fast forward to last weekend, my girls now 20 and 17, fistfighting (I kid you not) over a sweatshirt.

My sense of failure runs deep but I am thankful that I was blessed with pure luck with these two. My insights are largely useless. My husband, however, excels at mediation (he’s a lawyer after all), and he has filled in the missing pieces on numerous occasions. We make a good team. Nevertheless, my girls have taught me a number of key things:

1. Each kid is different.
2. They teach you.
3. The “0-60” phenomenon of the teen brain is alive and well.
4. Use humor.
5. Be strong. If you are emotionally weak, they will have no one to push against, leading to a failure to launch.
6. No matter the age and stage, be patient. As soon as you master it, it changes.

Mary and her Parents

There are some cases that make me feel like a complete idiot. Take the case of Mary. She never wanted to be there. My first tenet of teen therapy is that they have to own it. It’s their life. If I am doing all the work, something is wrong. It took me a long time to realize this one. It’s great to get them when they’re young enough to change but old enough to understand, which I’d put at 17– a beautiful age! Raring to go to college yet clinging at will to parents, kids this age are a pleasure to help. Change comes fast and furiously and if you’re lucky you’ll get hugs in there too! They go off bolstered by the therapy, and they don’t come back. On the other hand, if they are there against their will it’s a different story. We know this. No therapy is going to work by force.

Mary had a history of acting out and strict, somewhat eccentric parents who did not understand her difficulties (see “Far from the Tree” by Andrew Solomon). With this mismatch, things got off to a miserable start. She was returning from a multi-thousand-dollar wilderness program of questionable long-term repute. “Please fix her from here,” her parents dumped on me. And so I did, sort of. She continued awful acting out, rages, mood-swings, and long before I knew it there was a team of professionals all over the case. No problem. We continued to integrate her back to home. But the back-to-family part never happened. You see, the parents were the problem. This is hardly uncommon. Now they were avoiding me. They were done. I tried to explain to no avail that their participation would be key. More avoidance. So, we continued weekly until the girl simply said “this entire enterprise is futile. I give up.” What a sad case indeed when parents induce helplessness in their teens. Where will all her energy go, I wondered sadly. The case had fizzled out before my eyes. After questioning my abilities, I concluded that this was case was doomed from the start. Her only channel was anger and that wasn’t a channel I was on. Thankfully there was group therapy to warm the soul and I gladly referred her to the care of another clinician.

Group Therapy with Teens

Witness however, Cecilia. Her case was the best! Coming from a childhood of unspeakable trauma, she was rescued by a relative and set on another course. When she came to group therapy, she was literally an outcast from school, home and family. The group embraced her. She lit up each week. In my group there are no restrictions except on gossiping and phone use. I actually pretend that I am the most casual and chill person on earth so that they talk as freely as possible. It’s like when you’re driving your kids to the mall and they’re in the back seat, with no eye contact, finally telling you the most important thing they ever shared. That is my posture in the group. The more I lay back, the more they seem to talk. These kids have no other avenue to ask questions about sex, drugs, birth control, family, siblings, mental illness, physical issues, sexism, racism and relationships. They even accept academic support from me. I become like a big sister in the group, and it works. Cecilia grew to become her class president. She vented for a solid two years about her childhood. She was made to feel normal. She heard from other kids of all backgrounds. They all became “normal” together- normalized by the group process. Who doesn’t have a crazy mother/father/sibling/uncle/friend/teacher? My god, they were normal! Just the celebration of that became the group creed. We welcomed newcomers with near joy. Parents waiting outside would never have believed it. Their angst-filled, moody, belligerent offspring had finally shed their shells. I almost never told anyone my secret. Do you want to know the secret to teen group therapy? Pretend you’re not there, do not wince at disgusting revelations about sex, and by all means allow cursing of all stripes and colors.

As the “core group” began to solidify I worried if I was being effective and compulsively tried to “deepen” the conversation. As I began to relax, they were able to tell me that they liked the group just the way it was. Just talking, venting, sharing and taking turns. It soon became clear that my need to control and get it right and my own insecurities still plaguing me after all these years of experience were beside the point. The group had sustained itself. Nevertheless, the interventions I made aimed to reinforce the shared group values and purpose, the universal nature of the teenager experience and the shepherding of the inner self to the surface despite fear. I also increasingly pushed the more reticent members to link up their past with their present, thus gaining insight for the first time. Finally, I was “motherly” in that I could see from where I sat that life would ultimately deal them their share of traumas, yet I knew they could withstand it by holding that space for them, quieting down my own thoughts. By testing their judgment or lack thereof with their peers, they gained the self-knowledge to withstand pain rather than avoid it.

Teens and Divorce

Parents have often asked me what the best/worst age for a child to be at the time of divorce. There are many answers to this. First off, it depends not only on the age at divorce but rather on how the parents handle the divorce that really matters. Second, all ages suck, period, end of story. But divorce in the teen years royally sucks. Social/emotional development is significantly impacted. What the research says is not pretty: not only does the effect of divorce on teens have a huge impact for years, but also, it lasts forever and ever. The researcher Judith Wallerstein has asserted that unlike a parent’s death which has a beginning, middle and end, divorce just goes on and on. Once again, the teen brain, volatile as it is, is not prepared and will surely rebound with rage, defiance, profound risk behavior, testing limits and all the things you tried as a teen but on steroids (social media strikes again). So, buckle your seatbelts on this one and seek help early and often.

“One of my teen clients of divorce casually sent a nude photo to a boy in 10th grade”. The next day, it traveled around the school with the speed of rumor and she found herself in the hospital dealing with a new diagnosis- humiliation. With one parent working round the clock and the other nowhere to be found, she did what anyone in that situation would do, she went underground. The numbing, cutting and sheer embarrassment got worse. She started cutting school too. Each setback snowballed mercilessly. We had to get her back to herself. The therapy consisted of gradually starting her activities again, putting it behind her and structured-only phone use. To this day, she calls me every year on my birthday and says, “if it wasn’t for you, I’d be dead.” She is now a successful hairdresser hoping to open her very own shop. Her parents’ divorce was the hardest step from teen to adult, but she got by because she persisted, used her strengths and had a passion.

Older teens feel lost, insecure and socially stigmatized after divorce. The post-divorce financial uncertainty adds to the overall stress. College plans can change. One divorce created a situation with the parents telling their twins in my office, “surprise, we can no longer pay…” Plus, shuttling between two homes can be disorienting, to say the least (or in the case of my own parents’ divorce, jetting between two coasts). Parents often dwell on how and when to tell their children that they are getting divorced, rather than the aftermath. Just like birth plans, divorce plans go awry. Better to sort it out for the long-haul than have it scripted in the short.

I try to help the teens in therapy by “joining” with their rage. Damn straight your parents suck. They are the ones who should be here! Once I do that, and establish trust, rapport and confidentiality, it is easy to win their hearts and minds. I provide gentle support and strategies for coping and self-care while reminding parents that part of the confusion is normal teen angst. If parents make the common error of ascribing all behavior to the divorce, then guilt steps in and over-compensates in many forms including the of throwing money at the child, which rarely helps.

More times than not, my job is to mitigate confusion. You cannot believe what’s in these kids’ heads. For younger kids, they go right to the most concrete –will my room be pink at Mom’s house still? Can I have two stuffed animals-one for each house? If my parents separate, will I ever see dad again? Are my grandparents still going to be my grandparents? For teenagers and young adults, it can be far more morose, as it was for me with my own parents’ divorce. “Why why why?” is one refrain. The other is a lurking sense of doom some might call dysthymia. As soon as I labeled that for myself as an adult, I started to get help, including antidepressants. The clinicians’ definition of the word would be a “low-grade depression.” I call it, the lowering of expectations, always second-guessing myself. Demystifying the wild ideas kids and teens formulate goes a long way toward alleviating crippling anxiety and dread. It’s hard enough to grow up without constant stress in this world, let alone have your parents fighting all the time. One family was fighting so badly about the kids’ shoes at each house that I offered to go to Payless and buy them a second set of sneakers.

I now run a successful teen support group for kids between the ages of 13-19. I remember how my losses haunted me at that stage, but I never had the words to feel and let go–I was constantly grasping for meaning or truth that didn’t exist. I tortured myself to figure something out about my family. But all that I got in return were meaningless intellectual insights that couldn’t sustain me. Nevertheless, I did rebound. I got many degrees and certificates, had scores of talented friends and married the love of my life. Economic times have since hit us hard, but our fortitude is paramount. “I model this resilience to my patients through gentle wit, disclosing when necessary that I “get it.”” Then reminding them there is no one path; there is no perfect; there is only you, open to the ups and downs, or as my yoga teacher would say, “meeting each moment as a friend.”

It All Adds Up

A perfect case to illustrate when all cylinders are firing in teen therapy is Megan. This teen came in with what I call the “break up story.” Megan, like many other girls with whom I have worked, was a ruminator. So, the task is how to utilize all the teen’s strengths just to make it to another day. Why? The phone (you didn’t think I would forget the social media part, did you?). Because I was an “early adopter” of the internet age and even worked in the field of online production and community building in its heyday, I have always taken a favorable view of technology. That said, if my daughter doesn’t unwrap her phone from her head soon I’m going to throw it into the Hudson River. It is her permanent appendage. There is no doubt in my mind that she would benefit from a screen break. But instead of being that mom who limited screen time, I was actually the mom who was the first on the block to get the kids a phone. That did not make me popular among the neighborhood parents. I prefer to know where they are. On the other hand, I have friends who have their adult kids on “find my friends” which would literally put me in a full-time state of panic. There must be balance.

Megan started cutting in 9th grade because she already had a family history of poor emotional regulation combined with an awkward style and no real avenues for getting her feelings straight. Her father was absent and alcoholic. Her mother was a determined and high functioning administrator who was always on the brink of a breakdown, and who could blame her? Therefore, Megan was accustomed to caretaking not care-receiving, which she desperately needed. In therapy, she was able to use her intellect and motivation for good. I encouraged her to think of things in a less catastrophic/dramatic, black and white and exaggerated way. “My boyfriend friended his ex on Twitter” she would say. “So what!” I would chime. “I’m stalking him. I see he’s online at 3am. I saw him with her. She liked his status.” It goes on. Yes, this goes to his character of questionable trustworthiness. But does it REALLY matter? Growing up in the 70’s and 80’s has made me a bit cynical to what real love is (memories of Kramer versus Kramer dance through my brain). I try to get them from point A- everything matters, to point B- nothing matters. “The therapeutic technique most attuned to this might be called Freud-light”. What is getting in your way of allowing this process to work? What is coming up as a trigger/resistance? What can we work through/process/vent/feel/release/analyze or simply let go of to move forward? Nevertheless, the point is the phone doesn’t matter! What matters is can he be at the right place at the right time, can he talk and communicate, can you be friends first and foremost, do you even know him, can he get off his phone…? Megan started putting herself first. She got into the college of her choice. A big girl with body-image issues, she bought herself the shiniest red prom dress I have ever seen and danced right through to morning!

What’s my Theory?

Lest you think that I’m just flying by the seat of my pants, there is plenty of theory to support my approaches. I rely on several methods and philosophies, yet I’m not married to one. I lean toward mind/body (Van Der Kolk, Levine), existential, person-centered (Rogers) and family systems (Haley, Minuchin, Bowen), and group (Yalom.) Much of my work is based on the idea that anyone can relieve anxiety by allowing it to flow through you. Just like going to the gym, anxiety is a habit of mind that if practiced will be reinforced. It’s the faulty circuit of fight or flight. It’s the mammalian brain. The goal (CBT and DBT) is to allow yourself to practice a better way of coping. A way with ease and equanimity; a way with kindness and support. A middle way, a way that allows you to press the pause button while you cool off. Getting flooded by one’s emotions is useless, so learning CBT (“I’m a mess and everything is a mess” to “I made a mistake; humans make mistakes and learn from them” makes good sense.” With DBT, “let me calm down for a second–getting worked up is totally unproductive. I’m just going to breathe and let it pass,” you will most likely get results. What I have not done more of until recent years is appreciate the role of trauma in that it can completely derail or retard the above process to the point of paralysis.

Lessons Learned

Therapists may turn away from working with teens because of their volatility and the resultant risks involved in their care. They flake out of appointments, come late, walk out, don’t return calls, and show up high and hungover. Their parents are often difficult, defensive and in denial. Sessions have to be coordinated with who can drive when, a logistical nightmare from volleyball to work to therapy and back all after a parent has put in a full day’s work. In short, it’s a pain in the butt. Nevertheless, teens are fast learners, quick to laugh out loud, they can cry their hearts out one week and the next week show up like nothing happened. They leave you with all the debris while they move on. My kids started doing this in daycare. Sobbing when I left, then an hour later, having the time of their lives. You simply can’t take it all personally. This takes a concentrated effort on the part of you, the therapist and mom, to feel as deeply and sensitively as they do, and then drop the whole damn thing. Only time can teach you that.

What it has taken me my whole adult life to learn is that there is no absolute answer. There is no one truth. There is no lasting stability. There is only you, open to the shattering of reality, embracing the change; knowing that change is the only constant. My history of loss/resilience/loss makes my therapy genuine. My genuine interest in teens, my blessed gifts from my parents, and my profound belief in being curious is what helps the therapy. It’s the turbulence, the roller-coaster, the deep pain and sorrow, and even the helpless confusion that instructs me how to remain flexible, less anxious, more prepared and physically more resilient (Yoga!). I still crave stability, but I have learned to create it for myself both inside and outside of the therapy office.

The God of Psychoanalysis

Posted on by Psychotherapy.net Team

In The Beginning…

Twenty-five years ago, I was part of a psychoanalytic group that met once a week. A dozen or so mostly Jewish and mostly well-to-do urbanites and their psychoanalyst would sit together in a large room on the ground floor of a pre-war apartment building on the Upper West Side and talk to each other for 90 minutes.

Here, in the span of an hour and a half, marriages were made and broken, grand and passionate affairs were embarked upon only to be rescinded before they started, even plots to murder were hatched and committed—in fantasy only of course. Religions too were swapped and dumped with abandon and new ones were taken on with fervor.

In the beginning I paid them no mind mostly, but was amused by the goings-on, almost as if it were street theater. What business did these things have with me? I was the son of a rabbi who had his troubles with his father, his god and women. Someone had suggested being part of this “theater troupe” would benefit me and so I went coughing into my fist.

The Forbidden Apple

Once, an astoundingly beautiful woman entered the group. She was the kind of woman that made men purple with passion and women green with envy. Blonde and lithe with legs that stretched to the Adirondacks, she was the classic femme fatale. And smart like a whip too.

She came to the group because she wanted to get married—and now, she said.

“Get her married,” the analyst gently commanded the group. 

There was a small hubbub. 

“Who do you want to marry?” asked one middle-aged matron.

“I can’t believe a girl like you would ever have a problem,” some Joe quipped.

“Is this a love problem?” another woman asked.

The beautiful young woman turned to the analyst: “This is what I mean! I attract attention, but I don’t get what I want.”

“I’ll marry you,” one good-looking but roguish man blurted out. 

What if one does actually fall in love in the group, I wondered? Is it like falling in love with your analyst—permitted to feel and talk about, but forbidden to act? It was as if psychoanalysis had taken a page from Genesis and said: Of all the fruit trees in the garden you may eat, but of this one….

I quickly learned that one had to take certain things on faith that certain restraints were for the best. If you were running away from religion to look for anarchy, psychoanalysis was not the place. 

“Why don’t you tell her how you feel?” the analyst suggested. “That would be far more helpful to her.”

“I love the way you look,” the man said abashedly. The comely young woman first rolled her eyes and then squirmed in her chair. “I don’t want to have this conversation. I feel totally uncomfortable.”

““You know,” the analyst said firmly, “it is your job to be uncomfortable—and to keep talking anyway.”” 

“But I don’t want to,” she protested.

But others encouraged her. “You could drop the subject if you want to, but this is an opportunity to say anything you want,” another woman in the group told her. “Tell him and us exactly what you think and feel,” she urged.

The woman looked at the analyst and then at the group. “Okay,” she said hesitantly. “I don’t like him! And what’s more is that he’s going to give me all this syrupy talk and I am going to feel I have to give him something that I don’t want to. I am going to feel obligated to him. He reminds me of so many of the men I know. It’s like he just want to put his tongue down my throat…”

“Why live in the future?” the analyst interrupted. “Why not hear his words and then tell him how much you don’t like him? In fact, tell him how much you hate him.”

“Okay,” she said, now intrigued.

The man continued. “Is it my fault I like her?” he said, turning to the group as a whole. “She’s beautiful!”

“What’s beautiful about her?” the analyst asked. 

“Her face, her hair…” and then he trailed off. 

But the analyst would not let it go at that. He pushed further.

“What about her face, what about her hair? Is there anything else beautiful? Tell her for crying out loud. Tell the group, tell the entire New York City for that matter!”

“Yes,” said the man gathering strength from the group. “She has the most beautiful legs I have ever seen!”

“I agree with you there,” the analyst said. “Michelangelo could not have done a better job.” 

The woman no longer squirmed. She seemed to accept the group member’s words and even complimented him in return. The group breathed the breath of satisfaction. 

Nothing Human is Alien

There was a feeling in the group that nothing human is alien and having been raised in a culture of “holiness” and mild separateness, this was a balm to my soul. There was one area, though, where I did feel separate: I had no money and nearly everyone else in the group did. (I had a social work degree, but floundered in various low-paying and ill-suited jobs before I eventually studied psychoanalysis and started my own practice.) But being young, I laughed this off. It was unimportant, I thought, and I would scrape by. What was happening in the group was far more important than mere money concerns. Or so I reasoned.

Each week I attended the group it became more absorbing and relevant. In fact, no sooner did we finish with one person’s difficulties, than the group would move on to somebody else: here a person was dissatisfied with her work-life; there a man pined for the unavailable lost love; still another longed for an erotic connection. This cycle of needs, longings and wants reminded me of an infant. A moment of satisfaction follows a feeding, followed by sleep and then frustration. Were we tired, hungry, wet, in need of a shower or something?

Such was life. It was neither bad nor good, but simply what was. Irritations were voiced, gripes, complaints, yearnings, desires were expressed. Each was dealt with. Everyone tried their best with each other. We talked and listened and abided by all of the commandments most of the time. 

In the meantime, I made enormous progress with women. I became a different man. “That which my mother and father could not teach me about my worth as a man and my place in the world, my desirability—these precious things, the group taught me.” Save for one thing: my progress around money was stymied; the flow of financial nourishment was painfully uneven at best.

It’s not as if money wasn’t talked about in the group. In fact, one of the big psychoanalytic commandments was about payment: Thou shalt pay the analyst. Thou shalt pay him well and promptly. Always you must remember to pay. 

Most of us went along with it just fine, but one person in the group resisted once. “I’m sorry I missed our session, but I don’t feel I should have to pay for that. It was an emergency. I thought I was having a heart attack…Should I have to pay for that?”

“I should charge you double,” the analyst retorted. “Once for missing the appointment, second for despising yourself and the group so much that you didn’t even think to call us to let us know that you were having a heart attack.”

To me he often said sternly: “You make money intermittently because that is how you were nourished. You had an intermittently functioning mother and the world functions intermittently for you. You will need to say more about that in group in order for your life to get better.”

Yes, the analyst was brilliant; and daring. He wore $1500 sports jackets, $300 slacks and $500 shoes. In a field unfairly characterized by menschy but nebbishy stereotypes, (think Judd Hirsch) he was a massive force. In fact, he wasn’t afraid to enact each of the cardinal sins (especially greed). They were mostly in the service of life. He modeled for us that it’s not so bad to be bad, maybe it’s even good to be bad. And if he was greedy, what of it? A little bit of greed can be good. 

In many ways he was an excellent model for me. But besides that, the truth is that I loved this man terribly, though I didn’t know exactly why. He was not an easy man, nor was he easy to love. Most often he was neutral to sympathetic, but beneath that he could be cold, brutal and unyielding, withholding words and warmth. “I am an analyst,” he would say, “not a social worker.” I sensed that though he justified his coldness and objective stance in the name of “analysis,” this also served as a cover. I was sure that he suffered and he could not metabolize his own pain. What’s more he suffered existentially, I imagined, just like me. I suspected that he too had come from the Jewish barrio. Perhaps beneath his glitz and glamour, the smells of chulent and potato kugel were not alien to his nostrils. Perhaps he too had once struggled over the Talmud and whether or not to run to the synagogue or away from it. When I asked him about this, he would slyly evade the question in the famous manner of nearly all analysts, but he did it in such a way that I knew and he knew that I knew too. 

"Have You Tried Being a Shoeshine Boy?"

People enter psychotherapy when they are in great pain and within a few sessions their symptoms start to abate, but not in psychoanalysis. Here, each of us seemed to be in it for the long haul—not for symptom relief, but for character maturation. For example, I remember one man had lost his job and he was attacking himself for not having yet found another. Bald, short and fat, he worked for one municipality or another in some kind of administrative role and he would recite his bleak story for the benefit of the group. He would come in with heavy sighs, sniff and complain: “I’ve been laid off. I’ve sent hundreds of resumes. I’m 58. No one wants me.”

Finally after several weeks of this, the analyst shouted out: “Have you tried being a shoeshine boy?” (He really did look like a shoeshine boy) “Really, I hear the city needs one. Why don’t you buy one of those kits and you could go on the subway…”

“You’re making fun of me…”

““I am making light of you. I am not making fun. I don’t take you nearly as seriously as you do,” my analyst would say.”

Within a few weeks he had found a good job. You would have thought he would have left the group, but far from it. He stayed, as many others did month after analytic month, year after analytic year, forking over good money. What was going on here in the church of psychoanalysis? What kept people coming?

I too kept coming even as it began to dawn on me that my karma of obtuse struggle and deprivation might continue regardless of how much I knew about mother and father or even how angry I got. Years went by and I had not even the slightest thought of leaving. I wondered if that made me a believer in psychoanalysis. Or perhaps, I thought, the opposite was true: Attending weekly sessions was a way of not having to believe–the same way that some might attend synagogue in order to not have to deal with G-d. Or maybe I stayed because of the love of the people in the group or perhaps the love of the analyst? These questions ran to the core of my being. What was I all about?

Even as I paid attention to these questions other thoughts came to me. “Everything that seemed both right and wrong with religion seemed both right and wrong about psychoanalysis.” For one thing, it was circular. When the analysis was working, and you made progress in life and you felt happy, that was great; when it wasn’t working, well, that meant more analysis and even more commitment. Your prayers have not been answered; well the answer is to pray more and harder.

“You haven’t helped me,” one woman would say. “I am still in the same stupid job and marriage for all these years.”

“Who you are you angry at?”

“All of you…”

“Who most of all?”

She turned and like the wicked witch of the East, pointed a finger at the analyst. 

“I pay you. My life is supposed to get better.” 

“What is better?”

“You know!”

The analyst turned to the group: “Does anyone here know what she means?” 

One woman piped up. “How are we supposed to know what you want? You don’t say anything from week-to-week. You sit in silence, stewing.”

“Why don’t you get rid of that bozo anyway?” another man shouted out.

“Because I love him…?”

“You love him? But you carp about him all the time.”

“He’s the misery I know.”

“Well, are we also the misery you know. You stay with us here in your misery and you don’t let us know minute-to-minute how you feel. You don’t connect with people, you pickle with them. We’re all pickling together with you…in a barrel of misery.”

She stammered and turned pale. “But I both love and hate everyone….”

“Why can’t you tell us?”

“I have terrible thoughts. Sex and violence….” 

“A person must put all of his thoughts and feelings into words…”

And so it went.

The Fall

After many years of faithful group attendance it would seem that I had gained immeasurably. I had found my way in love and work; I had my own thriving practice and had become “wise” to myself and my foibles. I was secure in the Edenic paradise of psychoanalysis and group. Many an energetic afternoon was spent in the womb-like feeling of a pre-war climate-controlled Upper West Side fortress. We listened to each other, yelled at each other, and got better, smarter and wiser.

But my family and expenses grew at a far greater pace than my income. I had never been sufficiently realistic about money and was mortgaged and borrowed to the hilt, all the while thinking magically that I would be saved by psychoanalysis.

While membership in the church of psychoanalysis had always been expensive (and worthwhile) it had become unmanageable. It was 2007 and just ahead of the spectacular mortgage crisis the bank had shut the spigot on my home equity line. I had nothing. The doctrine of “say everything” as a cure to all of life’s ills began to sound tinny. There were realities now to consider—forces like falling real estate prices, recession, that were impervious to even the formidable powers of psychoanalysis in general and to this psychoanalyst in particular who told me, “you should be here twice or three times a week in order to accomplish what you need!”

There was something else too. Something I had to consider. In long relationships one has—in marriages, families, with groups, synagogues, communities, tribes and religions—there is often anger, even hatred, beneath the surface. While one devotedly participates, attends, pays dues, an equal and opposite negative feeling can form—something like what Jung described as the dark or shadow side.

In a flash, this side can get jarred loose from behind the veil—a fire that badly burns and can gut a 20 or even 50-year relationship in an instant. So that’s what you’ve been thinking and feeling about me all along!

Such a thing happened here too. They and the analyst saw my departure from the group as a “resistance”—something without real merit, perhaps even something that I was doing to them. I in turn felt they were in a small way responsible for my financial disaster. After all, had they not sweet-talked me (at least by my recollection) all these years with blandishments on the one hand and psychic fire and brimstone on the other? You need us or you will be forever damned! They, not surprisingly, would have none of it. We had words, terrible words. And these words devolved into name-calling. To the man I had admired and loved for more than a decade I spoke harsh truths. ““You’re a greedy man. You are running a psychoanalytic synagogue—a money-grubbing mill for your own benefit. You’re a disgrace to the profession,” I added for good measure.”

The man whom I had loved and thought loved me became hostile and erupted like a volcano. “You’re a chazir,” he shouted at me, his slip of Yiddish a sign of his rage. “A pig, a pig!” he screamed at the top of his lungs. “You are a disgrace to nineteen years of psychoanalysis.” I gave as good as I got, but I was stunned, traumatized. I paid him one last time and walked out, vowing never to return.

It might be hard for someone who has not experienced the intimacy of psychoanalytic treatment to understand the depth of my feelings of sadness, hurt and betrayal. It is like having biblical-sized curses hurled at you at gale force by your own father. Even as I relived that horrible moment in my mind a million times—of him screaming at me and calling me names—I would never pick up the phone again to call him. I would spit on his grave.

In the meantime, just as Adam became a lot more interesting and productive after having been cast out of the Garden of Eden, I too got to work in high fashion. I built a small empire of psychoanalytic groups in the height of economic Armageddon. Even as I grieved for my analyst, I clearly was able to prosper without him. I was ready to chalk up the relationship to another chimera—a false god.

But a few weeks ago I got a message. “You have proved your point. It’s been five and a half years. It’s time.”

I had thought that the relationship had been murdered, forever relegated to harsh dreams and a raw place in my mind. Words cannot always be retracted. Some things cannot be taken back.

Could it have been for five-and-a-half years we had no contact, but we actually were in communion with each other? How much does this resemble a life where God Himself seems absent and yet every once in a while we feel he has been with us in some form all along? Devout believer or atheist, these may be the very comforting and troubling facts of our existence. Psychoanalysis, like religion, calls us back with its rhythms and vibrations, its gentle waves of thought. How could I not answer its plaintive song?
 

Epilogue: My Return

The day of my return was as beautiful a fall day as there ever was–a day that made a case for life itself. Broadway of Manhattan’s Upper West Side was teeming with people and commercial purpose. I was early and took a walk. New York was like a big friendly courtyard. I stopped by one of the Korean flower market/delis for a handful of lavender orchids.

I walked past the corner of 79th where men sell 20-year-old copies of Playboy along with scarves and old paperbacks, a place where the smell of the subway in summer wafts up through the gratings. That particular corner is a strange nexus of half-hearted commerce that bleats along in a netherworld between handouts, thrift and light industry. 

At 3:25 I knocked on his door and walked past the threshold that I once swore I would never again cross. But here I was. I waited in the waiting room and at the concerted hour and minute we were, once again, analyst and patient, face-to-face.

He was taken aback by the sight of me, I could tell. I had gotten gray. In your late 40s it comes upon you suddenly, like an overnight frost. He was grayer too. Such is life. He was gentle and warm. “How are you? How have you been, you look well, more distinguished,” he put his hand on his chin, miming the growth of gray whiskers.

“Yes, well one becomes gray,” I said. “This can’t be helped. And of course, it’s been 5 and a half years.”

“Too long…”

I sat down.

“Something happened here that hurt you,” was how he began.

“Yes,” I said, and I began to tell him exactly how, but I interrupted myself. I had brought with me a letter—a letter that he had written me after our first meeting exactly 24 years ago. It was in his own handwriting on his letterhead.

“Here, I want you to see something.” I handed him the envelope.

Ever the analyst on guard for booby-traps—real, psychological, symbolic or imagined—he said, “what is it?” He hesitated to take hold of it.

“It’s a letter, from you, dated October 24, 1988. I’ve saved it for 24 years.”

It was a response to a letter that I had written him following our first meeting, which lasted not more than 16 minutes. A quarter of a century ago his office was cross-town, and I remember it was bathed in late afternoon sunlight. He wore a seer-sucker suit with pinstripes the color of the sky.

“What is the first memory of your mother?” he had presciently asked.

“I was two or three years old and standing at the edge of the railing of my crib and she was looking in on me.”

“If you are looking to get married or even to get along better with women, then this is the group for you,” he said. “The most beautiful and wonderful women in New York City are in my group.”

One could scarcely understand what it meant to me at that time to get help from a strong man with women. I needed to connect with women. That I knew, but I scarcely knew how. And I knew he would help me. Nevertheless, I was not quite ready to join the group for various reasons; I was, as he grasped instantly, and I later came to understand, ambivalent.

“Shall I encourage you, discourage you, or let you feel the freedom to be ambivalent for as long as you need to be?”

With that simple line I was hooked on psychoanalysis for a quarter of a century. Here I had come from a background of non-stop commandments, one had to, one must, one should—and now I could be deliciously ambivalent.

“What is the charge for today’s consultation?” I asked him then.

“No charge,” he said.

I took him up on his invitation to be ambivalent, but when I came home I wrote him a letter telling him of the freedom he deftly helped me to experience in his office. I would join him in a few months.

The letter he wrote me in response was now in his hands and carefully, he opened it.

“I too enjoyed our meeting,” he wrote. “It is good for you to take as much time as you need. I look forward to working with you in the right time. I have the idea I can help.”

He held his own letter with evident satisfaction.

“From the day I met you,” I continued, “I knew that you were one of the most significant people I would ever meet in my life.”

He smiled with even greater satisfaction.

We then talked about my understanding of what happened 5 years ago and how he hurt me. At first he seemed to resist, passing my reaction off to transference, but as I quoted his words back to him, he seemed to concede that he erred.

“You were vicious and brutal,” I said. “Was I after all these years, your father, one of your siblings (all of whom I knew)?”

“You were somebody from past, it’s true. Someone I did so much for who took every opportunity to throw it all back in my face.”

“19 years of treatment and I was him?

“I am afraid so.”

“Well, that explains a lot then. My words, my true heart-felt words, things that I told you about yourself then were internalized by you as an attack. But of course, they were said to you out of love—the very first time that I could love and say the truth. What you called a disgrace to psychoanalysis was actually my highest achievement. I was trying to find a way to work with you!”

“At last he nodded. “I hurt you and I apologize.””

“I accept,” I told him.

We spent more time catching up. He remembered every detail of my life and my family. It was a good meeting. Our minds were facing each other not just our bodies. I would be in touch soon to resume our work.

“That would be welcome,” he said.

It seemed deceptively easy. Is that all it took? Were a few minutes of talking and clarification to heal my wounds sufficient to restore our severed relationship?

Yes, it took one session and five-and-a-half years of pain, for both of us. (It was clear to me he had been in pain about it.)

“What will be the charge today?” I asked, with my check already pre-signed. (Modern analysts tend to raise their fees regularly so I anticipated a hefty hike.)

“There is no charge for today’s session,” he said. “It is an acknowledgment of our relationship.”

“It is touching that you acknowledge our relationship that way,” I told him.

We bade farewell. It was two days exactly before the Jewish New Year. “Shana tova,” he said. “A gut yahr,” I replied.

I had gone back to the analyst who hurt me. It wasn’t the first time that I had taken a risk for love, but it was one of those times love was well rewarded.

Psychoanalysis, like religion, calls us and calls us back with its promise to hold our hurts, our wounds, and our grievances. And some of us keep coming back almost as if we can’t help it. Perhaps this is as it should be. One doubts, one hates, one loves, but one forgives too and often one returns. During High Holidays, one is even permitted to return without having to know why and in psychoanalysis, my analyst, once said, it's Yom Kippur every day.
 

The Tao of Anger Management: A Yield Theory Approach

Posted on by rezendevknowfully.com

“The gentlest thing in the world overcomes the hardest thing in the world.” —Lao Tzu

Brian had been incarcerated for taking a baseball bat to his girlfriend’s truck with her inside of it; he then pulled her out and beat her unconscious. He was out of prison and in my anger management group for two weeks when he reported, “What I did may have been too much, but she deserved it because she stole my money.” He claimed that he shouldn’t have gotten in that much trouble because it was “my truck anyway,” and besides, she “slipped and hit her head on the ice.” Brian was still in the precontemplation stage of change: he didn’t think he had a problem.

Things got worse before they got better. The following week Brian was furious when he came to group, complaining that he had been called in by his probation officer two days in a row to be drug-tested. The only reason for this, he claimed, was that his ex was “sleeping with a cop.” In a state of rage, his face flushed, his fists and feet pounding wildly, he shouted about police corruption and denounced his ex-girlfriend, the “whore” who was just out to get him. 

Instead of asking him to calm down, take a breath, or do anything other than be where he was in the moment, I simply validated him. I imagined what the world would look like from Brian’s perspective as I said, “Man, that’s just plain messed up.” I knew that Brian didn’t know anything other than what he knew in that moment, and he needed someone to see what he saw, so I went with him further: “You know, it sucks that you work so hard to be sober, and then people go and pull this shit, and test you even more.” I paused briefly, made a projection about what he might be thinking and added, “I mean, they tested you literally, but they’re also testing your limits too. It’s like they’re trying to set you back.”

He responded emphatically, “Exactly! They’re pushing me!”

“You know what?” I said, “this was kind of messed up, so I’m not even going to ask you to calm down right now.” I paused, shook my head, and waited for a moment before continuing. “In fact, even if this is supposed to be anger management, it would be stupid for someone to think you need to learn from this right now, because you have a right to be pissed off.”

He nodded his head in agreement, and he was visibly calmer, so I went on.

“I’m not going to tell you to learn anything from this right now, but let’s say this was tomorrow at this time, what do you think you might say about this experience?”

“I don’t know.” He paused. I waited. “I guess I would say that I probably overreacted.”

I then said, “I’m not going to say that you overreacted because it was really messed up, but, I don’t know—I wonder if this was like a week later… I wonder what you’d say about this experience then?”

 “I don’t know,” he said. “I guess I’d say that probation has a right to test me two days in a row in case I’m using or something.” He was calming down more, and moving more and more into his frontal lobes.

So I said finally, “Look, I know you’re pissed off, and I see you’re hurting about this, and we don’t need to talk about this tonight—but if this were a month from now, I wonder what you might say about this whole night?”

Almost completely calm now, Brian replied, “I guess if this were a month from now, I would probably look back on this night and see that I was still doing the same thing I always did: blaming her for me not wanting to be drug tested.” 

The shift occurred. The door was open to future work. 

Behind the Mask

"Treat the people as trustworthy, and they will be trustworthy." —Lao Tzu


When Brian came in furious and outraged, it could have elicited fear in me—he was, after all, an imposing figure—but I knew that Brian wasn’t angry at the world or at me; he was angry at having to take responsibility for something unpleasant. When that happens, people are usually blinded with rage, but not likely to hurt someone they don’t know. Brian was scared to face the world without what he had come to depend on: drugs to alter his state of mind. He was not ready in that moment to genuinely be accountable for what he did—so that was not the time to get on a soapbox and criticize his actions. 

More importantly, Brian didn’t scare me because I am armed with the knowledge that anger masks fear. Just as you wouldn’t walk into a costume party and believe that goblins and monsters are suddenly alive and dancing with each other because you would know it was people dressed in costumes, so too do I see that when people are angry, they are wearing a mask to hide what is really going on inside them. It was important for me to trust the deepest part of Brian’s essence: the part that is, in my view, inherently good. 

As a therapist, my goal is to facilitate people’s journey through the depths of their undiscovered psyches in a way that helps them move beyond the battle of the ego/true-self dynamic so that they can find, hold, and live in expanded consciousness. My working assumption is that the essence of people is much deeper than what we can see on the surface. This assumption helps me view people as vastly greater than their actions, and infinitely more than any pain and suffering they have caused or experienced. 

I specialize in working with people who have been convicted of violent crimes: murder, rape, and the abuse of others. The work is not easy, but it is some of the most rewarding work that I have ever done, due in part to the amazing transformations that I’ve witnessed throughout the years. I’ve watched gang members gain awareness and perspective enough to walk away from their gangs; I’ve seen people who train as fighters walk away from street fights; I’ve seen people who have spent their lives believing that life is about getting “respect,” make incredible changes and learn to more deeply respect themselves and the world around them. 

“No one sets out to be defined by his or her worst moment in life, yet almost every violent offender is judged, convicted, and defined by his or her worst moment.” Just imagine if everyone in your life defined you by your worst moment, that this moment accompanied you like a badge of shame throughout your life, limiting all future possibilities, including your hopes and dreams. It would seem terribly unjust; and yet this is what we do with violent offenders. They carry the burden of our shadow projections and are left believing that they are terrible people because they have done terrible things. And because they lose hope about the possibility of breaking free from these deeply internalized expectations, they live up to their self-fulfilling prophecies by continuing to do terrible things. 

The startling recidivism rates in our country (close to 70% of violent offenders return to a life of crime after imprisonment) should be all the evidence we need to understand that our system of rehabilitation-by-incarceration alone simply doesn’t work, but it’s not. The “more shame, more guilt, and more punishment” approach—though it has a long history among treatment of violent offenders—has led to 7 out of 10 people returning to lock-up. It’s clear that it is time for a new approach to this problem, and it requires a change in consciousness, not only among violent offenders, but also among the population at large. 

Yield Theory

“Knowing how to yield is strength.” —Lao Tzu


My approach to working with clients who have committed the most heinous of crimes is grounded in what I call “Yield Theory,” a powerful and compassionate approach to communication that essentially boils down to radical empathy delivered with intentionality. Taoism is a spiritual tradition—the core of which is seeing beyond the black and white world of either/or, good/bad, and recognizing balance through the single essence of everything. Founded by the legendary Lao Tzu more than 2,500 years ago, “Tao” means the way. For me, the journey that clients take to personal growth is the same as what we all undertake along the way in life.

Yield Theory differs from radical empathy in that in addition to attempting to think and feel entirely from clients’ perspectives, therapists also go with or literally yield to what clients are saying in the moment, with the intention of guiding them to new insight on situations. This approach involves more than simply understanding that multiple factors contribute to violent interactions—you must cultivate the ability to not resist even the angriest outbursts. Yielding entails both joining with the essence of who clients are, and “going with” clients to circumambulate their fight-or-flight responses so they will be more open to the possibility of healthier options.

The underlying assumption of Yield Theory is this: If we lived every day as another human being—not just walked a metaphorical mile in that person’s shoes, but actually had the exact same cognitive functioning, affective range, and life experiences—then we would make every single decision that that person has ever made. Every single decision. This goes beyond simple empathy: it is the capacity to truly recognize the essence of others, and non-judgmentally accept who people are, regardless of their choices and actions—including violence. 

By yielding with others and genuinely trying to understand why they have done what they’ve done rather than judging them, I have found that people are more than just willing to open up and talk—they are also much more open to the possibility of change. I have found that by accepting the essence of people, I have an easier time approaching violence with compassion. The Yield Theory framework has allowed me to rid myself of judgment and do the job I was intended to do: assess people accurately and help them change and lead lives directed by their true selves (their essence), rather than by their egos (introjected identities). 

My anger management program is predicated on respecting all human beings who enter treatment, regardless of their actions, and strives to meet every person where he or she actually is. I call it, “conscious education rooted in compassion.” Even the most resistant clients who ardently deny any accountability for significantly harming others are accepted as readily as those who are actively seeking change. Everyone has a story, and people’s cognitive functioning, ability to process emotions, and life experiences shape and continually influence them.

“Though many therapists and counselors may claim to “accept all people,” in practice, most struggle in their work with people who have violent tendencies.” It could be that the natural fight-or-flight response triggers their survival fears and causes them to write off violent offenders as incapable of change, dangerous, and hence deserving of judgment; but it could also be because human beings tend to value their own standards of living, beliefs, and ideas over those of others and in subtle and often unconscious ways judge people who are different—particularly when those differences appear threatening. 

It is hard for most people to grasp that fully accepting a person who commits a violent crime has absolutely nothing to do with condoning that person’s actions. Truly understanding this, however, makes all the difference in our work with those who are pushed the margins of society. 

Components of Yield Theory

Vulnerability takes courage—especially amongst people who define themselves by how “tough” they are—and yet I have found in my anger management groups (which are open, so there always new people coming in) that people share with the same level of vulnerability and honesty as any therapy group I’ve ever witnessed. I believe this is due to the key components of Yield Theory that I apply in my groups: acceptance, the elimination of shame, mindfulness, creativity, conscious education, non-attachment and authenticity.

Acceptance
The potential for everything great and everything terrible resides inside all human beings. If a human being has performed an act, then it is accurate to say that it is “human nature.” If we can accept the nature of human beings (that we will at times be loving and kind, at other times hurtful and cruel, and everything in between and beyond), then we can evaluate others, as well as ourselves, in terms of trying to simply understand human behavior. Furthermore, if we accept the premise that we cannot do one single thing to change the past, and we merely have the ability to impact the present to shape the future, then we can see that pejorative, judgmental approaches do little to impact the present or future in positive ways; whereas acceptance of what is, along with acceptance of the essence of people, can set the stage for conscious learning and change.

With Brian, it was important to accept him for the essence of who he is, and from there to accept where he was cognitively and emotionally in that moment. From his perspective, after all, things were unjust and unfair, so acknowledging that was an important first step.
 
Shame
Years of studying people who commit violent crimes has led me to the conclusion that people who live in shame act out of shame.Eliminating shame, therefore, has become central to my work. At first glance, it may seem difficult to swallow the idea of not shaming someone who has committed a violent act; however, as David Hawkins (2002) suggested in his “map of consciousness,” shame is the lowest form of consciousness that human beings experience. What I have learned is that it is difficult for human beings to make highly conscious choices from low levels of consciousness, so helping people have expanded consciousness becomes paramount to changing their actions.

It would have shamed Brian to try to get him to see what he did wrong while he was in a state of fear and anger. It was not the time to have him acknowledge responsibility or even awareness of anything he did that was hurtful. Instead, it was important to work with what was available for him cognitively and emotionally in the present moment.

Mindfulness
Mindfulness was first described in the Dhammapada as a way that the Buddha taught others to observe and keep constant watch over their thoughts. Engaging in “right mindfulness” entails expanding the awareness that we have not only for ourselves, but also for the world around us. The more mindful we can be in every moment, the more likely we are to consider alternative ways of interacting with others. Mindfulness begins with self-awareness, but it also extends to an awareness of the environment and what is going on inside other people as well. As a group leader, I both practice and teach mindfulness. Though it is fairly easy for therapists to learn how to teach or simply read a basic mindfulness exercise in a group setting, it is the role modeling of mindfulness (i.e., the therapist’s constant awareness of present moment intra and interpersonal experiences) that seems to make the biggest impact on clients. As many people who teach mindfulness would explain: mindfulness must be lived to be understood. 

It was important for me to be mindful and aware of my own thoughts when Brian began railing against his parole officer and his ex, and to be careful not to get caught up by them. I tried to be as aware as possible about what might be going on inside of him, based on what I was seeing in him and my own internal reactions, but ultimately the best we can do as therapists is project what we imagine others are thinking, and then check those projections. In this instance, my projection appeared to be accurate. But mindfulness goes much deeper than just awareness of my thoughts and his; it is also an awareness of the environment in the moment, and a willingness to stay present with whatever unfolds without reverting into a reactive or defensive posture.

Creativity
In my experience, having the ability to genuinely meet a diverse group of clients where they are separates average therapists from very good ones. If we are charged with meeting people where they are, then we must consider that people have varied learning styles, and forcing clients to only get information in the way that we think works is, in my view, irresponsible. To implement creativity in therapy is to constantly evaluate one’s own communication style, and to be open to adjusting it accordingly to what people need. I believe the onus of communicating effectively rests with the therapist, so when clients are not getting what we are communicating, I believe it is our responsibility to find creative ways to meet them where they are. Creativity can come in the form of analogies, metaphors, techniques, or even just in the openness to develop new ways to say things in ways clients can fully hear. 

In the heated moment with Brian, I chose to use a future-self technique with him. I have found that in working with a largely angry population, being able to think quickly and creatively is not only a bonus, but a necessity. 

Conscious Education

“What is a good man, but a bad man’s teacher? What is a bad man, but a good man’s job?” —Lao Tzu

In my view, it is the responsibility of therapists to offer something more than just listening to their clients. Teaching skills is essential to helping people who are struggling with anger. We cannot expect people to respond differently to the world until we teach them different options. For counselors to implement conscious education, they must be willing to teach concepts patiently and compassionately until clients understand the ideas. This is quite different than simply relating concepts and assuming that clients understand them. In conscious education, therapists do not assume their clients should already have specific information; instead, they make the effort to teach in compassionate ways that meet diverse learners where they are.

As a former tenured professor, I know all too well how lengthy the discussions can be over the semantics of what does and does not constitute teaching. Outside of the world of academia, however, I would argue that we are always teaching others—even if the lesson is about how we are likely to respond in a given situation. I know from further interactions with Brian that he learned that day how to implement the future-self technique. He subsequently reported using it several times and even taught it to another group member during an anger management session.

Non-attachment
The idea of non-attachment is at the foundation of healthy learning. Whereas it is fairly easy for most Westerners to understand the idea of attachment to material goods through identification (“I’m a homeowner” or “This is my car” or “I am a good person because I have a high-paying job”), the notion that we are equally attached to our ideas seems far less widespread. “As long as our ideas are a part of who we are, we become defensive when people disagree with us.” When we can separate ourselves from our things, as well as from our very ideas, we are engaged in the process of non-attachment. As therapists model this concept, they create a safe path for clients to learn to express themselves openly, knowing they will not offend their therapist in any way. 

As a caution to those becoming too attached to the idea of non-attachment, Zen practitioners offer the concept of the “soap of the teachings.” Consider that to clean a shirt, it is necessary to use soap; but if the suds are not rinsed out, the garment will not truly be clean. In this same way, non-attachment to the idea of non-attachment becomes central to practicing the concept. 

In the case of Brian, I was not attached to his response, and would have been content with being off base had he told me that was the case. I was also not attached to the technique I was using with him; had it not helped, I was ready to readjust my technique to something more useful. 

Authenticity
People can spot disingenuousness easily. Mirror neurons are not only the root of vicarious learning, but are also the key part of our neurology that helps us identify when people are being authentic with us or not. It is well known in our field that clients will use the inauthenticity of their therapists as a reason they cannot or should not have to change. On the other hand, when people experience authenticity and know that we sincerely have their best interest at heart, they are much more open to learning about themselves.

The most pragmatic way therapists can convey authenticity is to regularly practice the ideas that they are teaching in their personal lives. It is paramount to practice what we preach. We do not have all the answers, nor should we purport to. We make mistakes as equally as our clients: not better or worse mistakes, just different mistakes, and we are all in this process of experiencing what it is like to be fully human. 

Conclusion

“Can you love the people and lead them without imposing your will?” —Lao Tzu

To understand people’s stories is, in a sense, to journey with them to the depths of their psyches. As a modern journeyman, I like to use vehicles as an analogy for journeying. Here’s my analogy for using Yield Theory to work with clients: Imagine that you are riding in a car and you come to a merge point (a yield sign). You merge with another car until you are side-by-side. Suspend what you know about reality, and imagine that as you travel beside the car long enough, the other driver sees that you are going in the same direction, so he invites you into his car. 

As a passenger now in this person’s metaphorical car, you have a better opportunity to see the road as he sees it, through his windshield. As the trip goes on, perhaps the driver gets tired and is ready to rest for a bit. You are now trusted enough to take the wheel. When you do, you can help steer the car down a more effective path. 

Lao Tzu said, “What is painted on these scrolls today will appear in different forms in many generations to come.” Similarly, the words of all therapies emerge at different times and come in different forms, but they are always essentially the same. For Yield Theorists, accepting the core of who people are, finding creative ways to communicate so that we are actually heard, teaching in some form, modeling openness, facilitating awareness and being authentic are therapeutic concepts that are simultaneously a way of life. 

The first practice of the Tao is something called undiscriminating virtue. It means taking care of those who are deserving and also—and equally—taking care of those who are not. When therapists practice Yield Theory, they are practicing undiscriminating virtue by immersing themselves into the psyches of others—regardless of anything they have done up to that point. Violence as a human construct probably cannot be eliminated; however, people—even those with the most violent backgrounds and intense struggles with anger—can learn a different way. 

We can continue to stand on our soapboxes and preach against violence and against the people who perpetrate it, but violence will always exist and shaming people simply doesn’t work. If we truly want to help people overcome their violent tendencies, we must work from a place of consciousness, choose to merge with others—see the world as they see it, attempt to understand what they understand, and help support them in their journey to new levels of awareness and peace. 

“To the highly evolved being, there is no such thing as tolerance, because there is no such thing as other.” —Lao Tzu