Category: Approach

Therapeutic Fanfiction: Rewriting Society

Posted on by Psychotherapy.net Team

In our work as geek narrative therapists, we’re often asked if we actually use fanfiction in session, and the answer is yes, we really do! For those who are unfamiliar with the term, “fanfiction” refers to creating one’s own stories based on beloved characters from existing pop culture narratives. Using fanfiction in therapy enables clients and therapists to rewrite the hero’s journey using narrative techniques. Since fanfiction is most often character-driven—getting inside the head of a character and asking “what if”—we can do the same with our clients, asking them to explore “what if” scenarios for themselves. For many clients, seeing themselves as the hero feels unfamiliar, and this is where fandom attachment or parasocial relationships can be uniquely helpful. Clients can use their emotional connection with fandom characters to create therapeutic fandom avatars and craft a fanfiction story that mirrors their own lives. With therapeutic support, they can begin to see their own heroism from the perspective of these beloved characters.

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Such was certainly the case for Cas (an amalgamation of several actual clients), a 25-year-old gender non-binary individual (biological gender female) of Ashkenazi Jewish descent, struggling with anger management issues and the fear that they would always be other. During our first session with Cas, they verbally noted our Adventure Time BMO, short for ‘BeMore’ tea mug, commenting that they had never seen a tea mug that was “quite so square.” We took this as an invitation to begin using therapeutic fanfiction early in our work. We shared that BMO, the gender nonbinary robot and video game console, was one of our favorite characters in Adventure Time, and asked Cas if they, too, enjoyed this cartoon. Cas eagerly explained that they loved this cartoon and that BMO resonated with them because BMO is on a journey to be “both a little living boy and girl who drinks tea.”

In the next few sessions, we fully employed the narrative tool of externalizing a problem via everyone’s favorite green superhero, The Incredible Hulk. This conversation was again initiated by Cas who remarked on the Hulk painting displayed on our wall: “Ha! That’s really true: mad does make sad.” We engaged Cas in a narrative therapy discussion around Bruce Banner, a.k.a. The Incredible Hulk, explaining to Cas that just as Bruce was not Hulk, they, i.e. Cas, were not their anger. We explained that understanding themselves as both connected to, but distinctly different from, their anger, might help them start to understand anger’s presence and reason for being in their lives. We then used the language of the Hulk comics to process their recent angry outbursts.

In subsequent sessions, we used the increased insight that Cas was gaining around both anger and the events that trigger anger to help them create a fanfiction action plan using Bruce Banner/Hulk as a stand-in for Cas. As part of this work, Cas was to pay mindful attention to their mood state, and when they noticed that they were beginning to feel angry, to place themselves into an Avengers fanfiction story in the role of Bruce Banner. They were to imagine that the team was working on a case and to ask themselves who was needed most—Bruce Banner or Hulk—playing out both scenarios to determine who would be best equipped to resolve the situation at hand. If the answer was Hulk, then they were to give themselves permission to feel anger without shame. If the answer was Bruce, then Cas was to engage in deep breathing and call upon their inner Black Widow to say soothing words to calm the inner Hulk. This was effective not only because this type of verbal play added a feeling of fun and whimsy to therapy, it also helped Cas maintain enough distance from anger so that shame was not triggered. Over the next three months of weekly sessions, Cas was able to continue the use of therapeutic fanfiction to both develop and implement strategies to de-escalate feelings of anger and to increase their frustration tolerance. They felt more in control of their inner Hulk.

At first blush, fanfiction and the hero’s journey may feel like disparate concepts for clinical work, but we have found that these concepts are not only congruous but incredibly healing in a therapeutic setting. Because there are fewer pop culture narratives made specifically for queer audiences, and because of queer marginalization in general, these conversations are all the more important and powerful. Therapeutic fanfiction allows queer clients to pick up the red editor’s pen and begin to adapt the story of their lives, creating a narrative in which they are the hero.   

What Do I Say Now? Coping with Uncertainty in Unstructured Psychotherapy

Posted on by Psychotherapy.net Team

Come On, Be Helpful!

“I’ve been thinking about what we discussed last time,” the client began. “I think it would be best if I came here for long term therapy and I have to leave in half an hour.”

For a moment I was mind boggled by this dramatic expression of ambivalence. But I shouldn’t have been entirely surprised. The client, a 23-year-old woman named Sandra, had been disconcertingly difficult to pin down in the previous session, our first. She had come to therapy at the suggestion of other people, had described vague symptoms, and, when questioned about issues that sounded significant, had consistently denied that they troubled her much.

My work with Sandra occurred while I was in graduate school, and relatively new to doing therapy. At that time, I was still struggling with a problem that many of us experience early in our careers, especially when doing unstructured and/or non-behavioral psychotherapy: anxiety about how to respond to a client who gives you no clear focus and leaves you feeling increasingly lost.

I had encountered several such clients. Unlike the “easy” clients I’d always imagined and sometimes actually gotten—that is, clients who responded readily to questions and who moved quickly into important issues—many other clients were not so easy, and some especially not. For example, they might have trouble articulating their concerns, or, after articulating them, might find it hard to talk. Or, they might become superficial or tangential, or might seem unable to voice any clear focus or sense of what I could do to help them. “I knew it was my job to find the right questions to clarify their issues”. I was committed to exploring their concerns from a humanistic and psychodynamic perspective because I knew from my own experience how valuable such exploration could be. But this approach to psychotherapy rarely gives definite answers; rather, it emphasizes the importance of gradual self-discovery. And my training in these orientations now seemed hopelessly abstract and irrelevant in the face of these more difficult clients, and of their confusion—and my own—about what exactly we needed to do. My confusion was often accompanied by a nagging feeling of anxiety that sometimes bordered on a panicky sense of paralysis: Come on, Michael, do something helpful! But what?!

At the time, I did not know how common this anxiety is among inexperienced therapists—especially those of us who are inclined toward hyper-responsibility. In his excellent book Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy, Jon Allen recalls how lost and anxious he felt when he treated his first patient with systematic desensitization only to find that the patient was not satisfied with structured treatment and just wanted to talk about his problems. Allen went on to describe how he spent much of his early career hoping to find a clear-cut structured procedure for working with such patients, only to realize, eventually, the “utter folly” of his quest.

Exhausting Learning Curves

Much later in my own career, I saw the same struggle in many of my students when I taught an undergraduate course in elementary counseling techniques. The students were eager learners, and many had been in therapy themselves. When I cautioned them early in the semester that good counseling cannot be achieved simply by applying rules and techniques, they expressed understanding and agreement. But when they embarked on regular practice sessions in which each of them had to counsel another student about a real issue, these students had to face, for the first time, something that every counselor and therapist has to confront at one time or another: the anxiety of sitting face-to-face with another human being who is struggling with a real issue, and realizing that you haven’t the faintest idea what to say or do next. A few of the students had impressive natural skills and took to unstructured work like ducks to water; but most of the others experienced varying degrees of anxiety, sometimes expressing intense frustration that they were not learning enough.

I tried to explain to them that there is a learning curve and that as you increase your knowledge and experience in counseling, your anxiety is gradually replaced by a disciplined sensitivity and intuition that begins to guide your exploration. But the problem with this kind of reassurance is that the learning curve to which it refers is maddeningly difficult to describe. I will attempt to do so below, but it may be helpful to start by telling a story that clarifies the kind of learning curve I am talking about.

A few years ago, a young woman approached me in a coffee shop and identified herself as a student who had taken my counseling class ten years previously. She told me that she had gone on to attain a masters degree in a mental health profession, and she said that she wanted to thank me because my undergraduate counseling class had taught her more about doing psychotherapy than any of the courses she had taken in her graduate program. Naturally, I was delighted to learn that she had gotten so much from my class. But what really surprised me was that I remembered this student quite well, and that her course evaluation, which I still have, had expressed great anger about how little she had learned in my class!

So, what is this mysterious learning curve to which I refer? Well, it involves a number of things: learning how to create a supportive atmosphere; learning how to draw the client out with the right kind of questions; learning how to listen—really listen—to what the client is saying; and learning how to follow the many hints and leads in what the client is saying that may not be entirely obvious to the client himself or herself. Of course, these “hints and leads” are different for every client, which is why they cannot be specified in advance. But it is possible to show examples of this discovery process by looking at specific cases; and this brings me back to the client I described at the beginning of this article, Sandra.

An Introspective Swamp

As I have already mentioned, Sandra had presented in her first session in a way that was elusive and confusing. She had voiced vague complaints of anxiety and a general sense that she did not know if she could open up to a therapist. She was equally vague about the history of her anxiety, stating that both her mother and a friend named Matt had encouraged her to seek therapy after she had experienced abusive treatment by a man she had dated briefly. When I asked her about this and other experiences in her life, she had touched on several apparently important topics, including a sense that her relationships with men never seemed to work out; yet she denied that any of these issues had troubled her much. She expressed a feeling that it would be nice to talk to a therapist about these things, but she also questioned whether therapy might just lead into unnecessary rumination and depression. Given her ambivalence, I had suggested that we meet for three to five sessions to evaluate her concerns and then decide about possible further therapy.

As noted at the start of this article, she had begun her second session with the disorienting announcement that she had decided on long-term therapy and that she had to leave early. The remainder of this session did little to clarify where she was coming from. I began by asking her what had made her decide she needed long term therapy. She replied that she had had a long and intense conversation with her friend Matt in which they had discussed her personality. Matt had told her that she was “neurotic,” that she had “the worst self-image of anyone that he had ever met,” and that she needed therapy. After this, “Sandra had fallen into an “introspective swamp” and had been depressed for most of the week”, eventually concluding that she must be “messed up” and in need of long-term therapy.

Remembering that she had wondered in her first session about therapy leading to unnecessary rumination and depression, I reflected that she seemed to have mixed feelings about therapy. On the one hand, she felt she needed long term therapy, but on the other hand, she worried that too much introspection might lead into a “swamp” of depression, as had apparently happened with Matt. She quickly dismissed this possibility, however, and said that therapy once a week would not be too much introspection. Her dismissal seemed a little too easy.

Since I wanted to determine if her wish for therapy was coming primarily from her—as opposed to Matt—I asked if she could tell me which areas of her life might be problematic.

“Define problematic,” she said.

“I’d rather leave that to you to define.”

“Well, do you mean my childhood, or what?”

“I wasn’t necessarily thinking of your childhood. I was wondering about problem areas in your present life.”

“I’m not sure. I can’t think of any.”

“Well, last time you mentioned that your present life is not too happy in certain areas”

“True, but they’re not that bad. They only seemed that way when I thought back on them.”

“My confusion was increasing rather than decreasing”. She wanted therapy but seemed to be saying that she had nothing to work on. I tried again.

“How was it that Matt convinced you that you were neurotic?”

“Why do you ask?”

“Well, I understand that Matt thinks you’re neurotic, but I don’t know how you see yourself, what you think your problems are.”

“I don’t know what my problems are. That’s why I’m here!”

My head was starting to spin. I tried a different tack.

“What do you want in life?”

“Well, I’d like to graduate, to get good grades, to get a good job that pays well, and to have happy relationships.”

“Are you getting what you want?”

“Academically, yes. I have friends, and I’m getting along with my parents all right.”

“What about happy relationships?”

“Well, my love life is not perfect. But I believe it will get better.”

“What do you suppose is interfering in your love life right now?”

“I really don’t know,” she said. “Maybe it’s just a coincidence that nothing has worked out so far.” As I was pondering this, she added, “Is this normal?”

I observed that she seemed to be concerned about the process of the evaluation. She replied “Yes, you’re right. I shouldn’t do that.” I replied that there was nothing wrong with being concerned about it but that it might be helpful if we talked about it more in our next session. She said “No, that’s okay. I promise not to ask so many questions next time.” As our time was up, the session ended on this note.

Managing Uncertainty

Over the next week, I thought a lot about this case. I was baffled by Sandra, and frankly had no idea where to go from here. It wasn’t even clear to me that she needed therapy or, if so, why, since she was unable to identify a focus and seemed to have come to the clinic under significant pressure from her friend Matt.

I was starting to experience some of the anxious confusion described above—the kind of distress that early-career therapists experience, particularly in sessions where the client’s concerns seem persistently vague and elusive. Like Jon Allen, I could feel myself longing for reassuring structure. I considered referring Sandra for psychological testing, but as I thought about it I realized that this was more to still my own anxiety than to aid in evaluating her. I thought about doing a more traditional evaluation, asking her about various areas of her life (work, family, friends), but we had already done some of this and it appeared to be leading nowhere. I thought about focusing further on her feelings about being evaluated, but there was a very real possibility that we might end up spending the rest of the evaluation talking about the process of us talking about the evaluation!

As previously mentioned, this case occurred while I was still in graduate school, and I can add now that it was at just the point when the learning curve was beginning to bend for me. I had experienced confusing clients before and knew that the anxiety they evoked in me could signal important dynamics, both within our interactions and within the client. I knew that if I could read these signals correctly and use them to guide further therapeutic actions, they could become an aid rather than a hindrance in the treatment. I had absorbed a significant amount of clinical theory that had helped to guide this process. And one theoretical insight that had struck me as particularly relevant to coping with my own anxiety in doing unstructured psychotherapy was a central tenet of existential psychotherapy—the idea that every act in life, and in psychotherapy, is, in some sense, a “leap of faith,” a “jump from being into nonbeing.” There is no way of knowing where it will lead; what really matters is how we handle the uncertainty.

I thought about this now and realized that the most important thing that I could give this client was the willingness to continue the unstructured work, to step once again “from being into nonbeing” with her, and to see where it led.

Sandra arrived early for our third session. When we met, I began by asking if she had had any thoughts about our previous meeting. She said that she had. She had decided that Matt’s “thing” was therapy and that he had influenced her too much. She had also thought about the questions I had asked about her life and her relationships and had decided that most of her questions were “Dear Abby type questions,” like how to act on a date and when to kiss someone. She said that she would like to have a longer-term relationship, but she added that her relationships were not too brief and that brief relationships could be fun too. When I asked about the anxiety she had mentioned before, she said that she did feel “sort of” anxious at times, but “not too often,” and she speculated that maybe she just got too wrapped up in thinking about it.

At this point she suddenly asked, “What do you think of me?” I replied that she seemed concerned about being analyzed and noted that she had wondered about normality in our last session. She agreed that she had wondered about this—especially when she was in high school, a time when she had been shyer and more introverted—but that this was not much of a problem anymore. I said that I had the impression, however, that there was something attractive to her about the idea of therapy. She admitted there was, and asked what other people talked about. I replied that they talked about a wide variety of things and that I wondered if she was concerned, again, about whether she was normal.

“Yes, I probably am,” she replied. “I’m only here because of Matt. He called me just before I came today and said, ‘Don’t back out.’ I told him “Now listen, I’m going to go by whatever the counselor says. It’s up to him.”

“Why didn’t you tell him it was up to you?”

“Matt would never accept my judgment.”

“Suppose he didn’t. What would happen then?”

“He would say ‘You’re making a big mistake, you’ll be sorry!’ Then I’d have to defend myself to him, especially if things went badly and I became upset later.”

“Wow!” I said. “That sounds pretty uncomfortable. You’d have to defend yourself, maybe at a time when you were already feeling upset about something else. I can understand why you wouldn’t want to be in that position.”

“Yes, it would be uncomfortable! “I don’t know why I’d have to defend myself to Matt. It’s not up to him. We’re not doubles”.”

“What do you mean?”

“He seems to regard us as emotional doubles. When I first told him about the abuse I experienced, he described how he had been in a similar situation once. But we’re not that much alike. He doesn’t necessarily know what’s best for me. No one knows everything.” She sounded a little surprised by this insight.

At that point, I reminded her that when she had first come to the clinic she had said that her mother had also recommended that she come in for counseling. She said that that was true, that her mother had also felt that Sandra had been traumatized by her recent experience of abuse. When I asked why, Sandra explained that her parents had known she was upset and that her mother had attributed many little reactions of Sandra’s to the abuse. She added that her parents were surprised that the abuse had not “blown her away” or “freaked her out.” She had always been “sort of high-strung” and they had expected her to react a lot more negatively than she had. I commented that sometimes people in families fall into certain roles; the family expects them to be a certain way and then they begin to see themselves that way. I wondered if this had happened in her family and if it had had anything to do with her concern about how normal she was. She seemed quite interested in this idea and said that it might. She said that her whole family was somewhat volatile and that she was just a little more open about her feelings than the others.

By this time, we were nearing the end of the session and she said to me, once again, “What do you think of me?” It seemed appropriate to give her more feedback at this point. I told her that I thought she was very influenced by other people’s evaluation of her. I added that I suspected this had something to do with her experiences in her family and that it had operated regarding Matt. She said “Well, Matt is kind of a unique case” and then stopped mid-sentence and corrected herself, saying that a boyfriend she had had in the past had done the same thing. I suggested that we discuss this further in our next session. She said thoughtfully, “Yeah, they don’t have divine inspiration.”

Lessons Learned

Sandra and I met two more times. During the first of these sessions, Sandra reported that she was in a good mood and felt good about our previous session. But, she had realized that her parents had imposed labels on her many times, such as “hyper” and “emotional.” We explored her relationships with men and how she might better, or at least differently, handle feelings of insecurity. We also discussed whether further therapy would be helpful. I emphasized that her own judgment about this was most important.

In our final session, Sandra said she had been feeling good and that she had been taking things more in stride since our sessions. She had tentatively decided not to pursue longer term therapy, but she asked if she would be able to see me if she decided to come back later. I said she could, and we decidedly left the door open; however, she expressed satisfaction with things at present and a sense that she could deal with things on her own. She did not return.

I have described this case in some detail because it embodies a moment when I became particularly aware of how one can manage one’s anxiety about doing unstructured treatment while feeling lost at sea in a complicated therapeutic dynamic. Sandra’s presentation, particularly during her first two sessions, had evoked significant anxiety in me due to its elusive and confusing character. Before our third session, I had given much thought to this and realized that “I had to accept my anxiety, recommit to the unstructured approach, and follow it through to increasing clarity about Sandra and her concerns”. Reflecting on the case now from a more experienced vantage point, I see three factors that made this possible.

First, I had already accumulated a degree of confidence from my previous experience working as a volunteer counselor and a graduate intern. Of course, confidence is a double-edged sword. It does not always match good performance and can even reinforce poor work, a fact which therapists—especially new therapists—cannot afford to ignore. But in my previous work, I had gained real experience and had supportive supervision that had taught me a great deal. Looking back on my work with Sandra, I now see that even amidst the confusion of our first two sessions, I had laid more groundwork with her than I had initially realized—if nothing else than by taking her concerns seriously and working hard to understand them. And Sandra’s movement toward greater openness, her willingness to revisit material I had not understood, her remaining in the session she had planned to leave early, her arriving ahead of time for her next session and her increasing interest in therapy all suggested that she was feeling a greater sense of trust in our work. I believe, therefore, that some confidence was justified. But perhaps more importantly, if this had not been the case—if things had been moving in the opposite direction toward greater confusion and discomfort in the sessions—I believe I had also acquired some justified confidence in my ability to recognize when these kinds of problems develop, to point them out, and to carefully engage her in an exploration of why.

Second, by this time in my career I had studied a variety of theoretical perspectives on psychotherapy and I was able to draw on several of them during my work with Sandra. Having these perspectives available gave me the tools to ask questions that seemed to move the process forward; and furthermore, they had sensitized me to important clues in what Sandra had already said—the “hints and leads” to which I alluded above. In the third session, particularly, I can now see that—while I was not conscious of it at the time—I drew on several different theoretical perspectives in the following interventions to better understand and work with Sandra: (1) Rogerian reflection (to deepen our understanding of her concerns about normality, rumination, depression and social influence); (2) existential confrontation (to point out that the decision about further therapy was hers, not Matt’s or mine); (3) Rogerian empathy (to validate her concerns about Matt’s criticism); (4) psychodynamic exploration (of the childhood sources of her self-doubts), and (5) systems theory (to consider the role she might have fallen into within her family).

Though I drew on diverse perspectives, “I believe I escaped the dangers of shallow eclecticism” and/or using various techniques mechanically (as I was later to warn my students against) because I was also developing my own overarching theoretical perspective, which was primarily psychodynamic. From this perspective, I was forming a rudimentary sense of Sandra which could point the way forward in using these interventions productively and which was roughly as follows: She was a young woman whose family circumstances and social experiences had left her with some issues of hurt, shame and over-reliance on the opinions of others; but her inherent strengths and intelligence were also enabling her to develop an increasingly strong sense of autonomy. Her ambivalent presentation in therapy reflected feeling caught between, on the one hand, wanting to explore in detail the sources of her insecurity; and on the other hand, wanting to assert her autonomy and move on with her life. Between the second and third sessions, I came to realize that the most helpful thing I could do for Sandra was to sideline my own anxiety, to stay with her exactly in the middle of her ambivalence, and to use what I knew about psychotherapy to help her discover precisely what she wanted to do.

The third and most important factor that made this possible was the inherent strength of the client herself. Even though she was, at times, exasperatingly vague and ambivalent, she also showed a consistent commitment to hang in with the therapy and continue exploring her concerns. In fact, Sandra’s investment in the treatment and her ability to use it successfully highlight a crucial truth for me about psychotherapy, one that should be both sobering and reassuring to any relatively new therapist: in the final analysis, the most important factor in successful treatment is not the work of the therapist but rather the work of the client.

This point can hardly be overemphasized. Anxiety in new therapists is almost always accompanied by an overestimation of the importance of their own interventions. Of course, interventions are important, but not as important as the client’s ability to use them. This fact may be a blow to our therapeutic egos, but it should also be deeply reassuring. My students sometimes feared that they would make a mistake that would damage the client. I assured them that all therapists make mistakes and that these mistakes, in themselves, are rarely damaging. What is truly damaging is when we fail to realize that we have made a mistake and go on to make it again and again—usually as a result of inadequate training, impaired self-reflection, narcissistic overconfidence, or some combination of the three.

Barring serious mistakes by the therapist, most clients will get better if they are motivated to do so. Even without psychotherapy, most people who suffer from psychological problems will tend to show improvement over time. But competent psychotherapeutic help from any number of theoretical orientations can significantly strengthen and reinforce this process, especially when the relationship and fit between the client and the therapist is good. And in unstructured psychotherapy, the commitment of the therapist to step with the client “from being into non-being” can play an important and helpful role.  

Responding to an Immediate Negative Transference

Posted on by Psychotherapy.net Team

A Cold Opening

When my friend and colleague, Jessica, called to make the referral, she said, “She’s an analyst, really smart and a great person. You’re going to love her.”

Sally arrived in my office about ten minutes before her appointment began. When I opened the door to the waiting room to invite her in, I saw a tall, thin, woman with gray hair. She was dressed simply in a gray wool skirt and black turtleneck sweater, but there was something elegant, almost aristocratic in the way she carried herself when she got up from glancing at a magazine and entered my office. I felt instantly inferior to her.

I greeted her: “Hello Sally, why don’t you come in.” I invited her to sit wherever she was comfortable. Then I sat in my chair and faced her silently. I thought about the fact that she was a more experienced analyst than I was. If she had never been in treatment before, I might have waited a minute and if she was silent said, “So tell me what brought you to see me.” But since she was an analyst herself, I just waited for her to tell me why she came.

“You’re pretty cold, aren’t you–silent and cold. But maybe that’s not bad. Maybe that will be more analytic and help the transference come out faster than if you were warm and fuzzy.”

I was taken aback because I don’t imagine myself as silent and cold. I thought I was warm but giving her the space to present herself. Indeed, this was the first thing I learned in my first class in analytic training. So I was speechless when Sally accused me of not knowing how to begin a session properly; but before I had a chance to respond, she continued.

“Let me tell you about my history.” Her face was expressionless as she pulled aside her long gray hair that was partially covering her right temple and continued. “When I was five years old, I was in front of my house waiting for the school bus with my younger brother. A car ran me over and I almost lost my right eye. I was in the hospital for months. They saved the eye, but I have this scar.” She pointed to a slightly indented grayish patch of skin that started at the edge of her eye socket and extended to her hairline. I made an inaudible noise and grimaced to express my understanding that this was a traumatic experience. But she continued before I could utter a sentence. “Then when I was 15, my mother, brother, sister and I were going to California to see my maternal grandmother who was dying. My father dropped us off at the airport in Chicago and then before we got on the plane, a policeman came and told my mother that my father and his driver were in a car accident and my father was dead.” Again I gasped, this time in disbelief that so much tragedy had befallen her at such a young age. But she continued telling the story without affect as if she were giving me a chronology of what she did over the weekend. I wanted to say something empathic to her, but I would have had to interrupt her to do it. So I just decided to listen until she gave me an opportunity to speak.

When Sally finished telling me the history she thought was relevant for me to know, she turned to telling me about her present life. She told me she had a husband, son and daughter. Then she got around to why she came.

Are You Orthodox?

“I’ve come because I’m depressed. I was terribly depressed a few years ago and went into couples’ therapy with my husband John. It helped, but I’m depressed again and I’m also worried about my son. He doesn’t have a job and I’m afraid he’s not doing the right things to get one. Also, I’m going to be 60 and I feel terrible about it…”

I was about to ask her what was so terrible about being 60 when she continued;

“The thing is that I think there’s something wrong with my brain.” She started to get teary for the first time. “I used to remember everything. But now I take notes on every single session because I’m afraid to forget; I walk into a room and forget why I came. I go to get the car and realize I forgot the keys. I know something is wrong with me.”

I thought to myself, I constantly forget what I’m looking for and where I put my keys.

My impulse was to reassure her. I wanted to blurt out: Oh, that’s nothing. I do that all the time. If she were a friend, rather than a patient, that’s what I would have done.

Sally continued in a voice that sounded frightened. “I think I may be getting Alzheimer’s. I always remembered everything and now I have to make lists to remember things.”

I have to make lists to remember things too. I resisted the impulse because reassuring her might seem to her that I wasn’t really hearing her. I didn’t want to trivialize her anxiety. And, after all, “there could be something wrong with her brain”.

“I went to a neurologist and he said there was nothing wrong. But I heard about this cognitive test regimen you can take and I’m going to do it.”

I wanted to say: That sounds like a good idea. But she continued without skipping a beat.

“I don’t want anyone who knows me to know about this. Some analysts talk about their patients with each other. But I think that’s terrible. I came to you because you’re not involved in my circle. I won’t tell any of my friends except Jessica and I’m terrified of them finding out.” I felt stung by her pointing out that I wasn’t “in her circle.” But I knew I had to let that go. I knew what I should say was: “What’s the terror?” But I didn’t want to cut in. I looked at the clock and the session was over, but I would have had to interrupt her to tell her. But then, as if she knew the session was over, she said,

“You haven’t said anything all session. You just sat there like a silent analyst. I guess you’re quite orthodox or maybe you’re just inexperienced.”

I felt “put down” and misunderstood. I needed to say something, but the session was over and I was feeling furious at her. I was afraid I would blurt out something angry. I dug my nails into the palms of my hands to try and get control over myself. “Well, we’re going to have to stop in a minute. But I think it’s a good thing that you’ve come because it sounds like you’ve experienced a great deal of trauma and loss. Turning 60 seems to be a catalyst for re-experiencing those feelings again.”

I sat in my chair for a few minutes after she left and thought about what I was feeling about her and what my friend Jessica had said about her. “You’re going to love her.” But I didn’t love her; I was struck by how controlling and critical she was during the session. I wondered about the disparity in our perceptions of Sally. What’s was going on here?

A Transference Blooms

When Sally returned the following week, she seemed calmer and less frightened. My back relaxed. But then she began the session by noticing that my chair seat was higher than the other chairs in the office.

“No therapist has a chair higher than her patient. It’s such a basic thing.”

I felt like my mother had slapped me across the face. I could feel the sting in my cheeks. I wondered if my cheeks were red and if she could tell. It had never dawned on me to consider the height of my chair in comparison to the other chairs in the office. Sally’s criticism made me feel like a fool. Once again I dug my nails into my palms to try and get control of myself. I spoke very quietly:

“What does it mean if my seat is higher than the others in the room?”

“You must be insecure and need to be higher than your patient. I have never been in a therapist’s office with seats of different heights.”

I bit my lower lip, trying to control my rage. “You seem to equate the height of the chairs with differences in status.”

“Yes, I feel like you’re trying to be superior to your patients.”

After what felt like a long pause during which I was trying to tamp down my anger, I said: “To my patients, or to you?”
“Yes, of course, to me.”

Trying to keep my composure, I spoke slowly and quietly: “Are we competing?”

“Yes, I guess we’re competing. I don’t want to feel lower.”

There was silence for a moment. She seemed to immediately understand that her feelings about the chair were more about her than me. Then she went back to the story about her father’s death that she had told me about the prior week which indicated to me that we had come to some transferential understanding of the importance of the height of the chairs in my office. I could feel the muscles in my back relax.

“My father had a driver. They drove Mom and me to the airport because we were visiting Grandma in California. The driver hit a truck and my father wasn’t wearing a seat belt so he was thrown from the car. He was probably decapitated.”
I felt stunned and I’m not sure if I gasped. Part of what staggered me, aside from the inherent horror of what she was saying, was that Sally said it without affect as if she were saying: “My father was probably wearing his blue suit.” That amplified my shock because I was completely unprepared for it. “I had an image of her father’s bloodied head flying onto the highway” while his disheveled body was thrown to the side of the road. I was speechless and Sally went on to another topic.

“I’m really angry at John because he keeps saying my anxiety about losing my cognitive capacity is silly.” She's worried about losing her head, I thought.

“That must feel like he doesn’t understand how frightening it is for you…" I said. "Unfortunately, we are going to have to stop for now.”

The next session I was afraid to open the door to my office and invite Sally in. I could feel myself tightening up in expectation of her criticism. She was consistent.

“You know it’s really odd that your magazines are old and you cut off the address label on the magazines in the waiting room.”

I felt exposed. What did this mean about me?

“I’ve never seen such a thing.” She continued, “You must order the magazines for your house and then bring them here!” She was outraged at the idea.

It was true; she was right. I didn’t really understand what was wrong with doing that.

“What is it about taking the mailing labels off the magazines," I asked, "that is upsetting to you?”

“It means that you don’t subscribe for the office, you subscribe for your house.”

“What is it about that, that’s upsetting?”

She took a breath; she was trying to figure it out. “My parents had a very romantic relationship. Every night they had a cocktail in the living room together when my father came home from work and we weren’t able to talk to them or even go in the room during cocktail hour. I think it feels the same to me. Your patients are secondary to your real life. We get the magazines with the label torn off.”

I felt that something important was happening. Each week she came in criticizing me and I felt exposed and inadequate. Each time we were able to understand what these criticisms meant to her, but we had not talked about what it meant that she was always criticizing me. I felt a dread that reminded me of how I felt when my mother came home from work. There was always something I had done wrong. I wondered what it meant that I was dreading Sally’s next criticism of me. Was this my countertransference or was this what she felt about her mother? Or both!

Fits and Starts

The next session Sally came in saying she felt very depressed. She realized that she forgot to put on make-up or comb her hair before she came to my office. She analyzed it herself:

“That’s very interesting. I’ve never done that before. I seem to want you to see me without any decoration.”

I thought that was a great breakthrough; she wanted me to see how she really feels underneath her façade. I decided to take a risk and make an interpretation.

“You’re critical of me, but I think you’re hyper-critical of yourself.”

“You mean you think I’m projecting my own feelings of inadequacy on you?”

“Yes exactly. I think you’re treating me the way your mother treated you.”

“I feel so relieved. Yes, that’s right.”

I felt that was an important moment in our work together. I finally addressed how critical she was of me. I was much happier to see her when I opened the door to my office the next week.

Sally handed me the check to pay the bill for the prior month. I took the check and crossed off her name in my book to indicate she paid.

“What are you doing that for?” She said in an outraged tone.

“Doing what?”

“Writing down that I paid you. I’ve never heard of anyone doing that.”

“I don’t know what you mean.”

“You mark it down after the patient leaves, not while I’m here.”

I was feeling speechless once again. I never noticed what Anna did after I gave her a check because I always turned around and walked over to the couch to lie down. I was barely able to utter: “What does it mean that I’m marking down that you paid while you’re here?”

“It’s unprofessional that’s all. Anyway, I’ve been thinking about whether I want to see you or not. It’s a big trip from where I live to get here.”

“Do you think there might be something more to it?”

“Well, I liked what you said last time. It made me feel much better to think that you’re not inadequate; I’m just projecting. But “I think I liked you better when you didn’t talk”. I want to know what you think, but when you tell me what you think it’s what I’d say if I were you.”

“Is that good or bad?”

“I don’t know. When you were silent it gave me room for my own associations.”

I felt damned if I did and damned if I didn’t. It felt just like my situation with my mother—whatever I did it would not be right.

“Do you think not wanting to see me might be related to my saying something that was helpful to you?”

“Yes, I think I’m competitive with you. I want you to help me, but I don’t want to feel you can help me. Especially because you’re so much younger than I am.”

Well, I thought, she’s certainly not like my mother. Sally’s able to consider my questions and look at her own behavior.

The next time I saw Sally she told me she was feeling much better about herself and about me. She realized that her family was very focused on status differences. Her parents were contemptuous of blacks and Jews.

“Do you think that’s related to your feelings about me?”

“Well, you’re probably Jewish and I seem to be competitive with you.”

In the next few sessions Sally told me she felt I was “too nice” and “not analytic enough.” Once again I felt like she was poking a finger at me. It took energy to find something to say to her that wasn’t defensive and angry. Finally, I was able to remove myself and see what this was about. I suggested that “analytic” was her term for cold and uncaring. I was the first female therapist she had and she was ambivalent about whether she wanted a mother who was cold and critical like her mother or warm and “too nice.” Of course, Sally continued to criticize me, but we had developed a working alliance and now the work could continue.  

Online Therapy: An Unexpected Space of Freedom

Posted on by Psychotherapy.net Team

Taking Risks

The dramatic story of the Saudi teenager Rahaf al-Qunun¹, who fled her family and country in order to request asylum elsewhere, resonated with many people in different ways. The oppressive background in which women like her evolve is generally far from our eyes, but I have, through my online therapy work, experienced several very touching stories from women in the Middle East.

Engaging in therapy is something that even Westerners do not enter into lightly. It requires taking a risk in opening themselves to a stranger to exercise the power of vulnerability. For women from countries such as Saudi Arabia, this entails a completely different level of personal risk and exposure. The fear of being misunderstood, judged, medicated, or reported to their family and consequently punished harshly, makes it nearly impossible for them to reach out for face-to-face psychotherapy.

As I grew up in Soviet and then post-Soviet Russia, I have firsthand experience of feeling trapped in a place where state-imposed values and rules did not align with my own. The exercise of one’s intellectual freedom turns into a road to salvation when other freedoms are unattainable.

For women in hardline Middle-Eastern countries, online therapy offers a safe space in which to exercise intellectual and spiritual freedom—they can explore their religious doubts, talk openly about their sexuality, voice their frustrations and anger, and eventually find meaning in their experience.

In an interview in The Guardian, Rahaf al-Qunun points out that in her country, no matter their age and life experience, women are treated like children. In a society governed and controlled by men, they are stripped of all power and infantilized.

These women continually strike me with their courage and resilience. One such brave woman was Laila (an amalgam of Middle Eastern women with whom I have worked in online therapy).

Laila’s Story

Laila was 36 and unmarried. She had a stable and reasonably well-paying job at a bank. When she received a promotion, she was allowed to move out of the family home to a nearby town in order to take the position. She was allowed to do this because her youngest brother lived in the same town and worked at the same bank. He was also unmarried and they lived in the same block of flats. He drove her to work every morning, as she was not allowed to drive herself.

Her brother was much younger but had more rights. Laila “needed” him for assistance with the most routine tasks—for example driving her to work or for travelling out of the country for a professional conference. This is how things work: women are made to need men.

Laila was different. At a deeper level, she did not believe or feel that she needed men. She did enjoy the company of some of her male colleagues and rare friends, but she did not desire them. Leila realized this about herself as a teenager, when back at school she felt compelled to kiss the beautiful face of her female best friend.

One of the duties Laila was not able to escape was mandatory attendance at family gatherings. She would sit there, her face uncovered, surrounded by women talking about their children and their little sons running around—already enjoying their privileged status in front of their sisters—and painfully feeling how little she belonged there.

All this fuss around men felt ludicrous to her. It was an ironic situation after all—she had to uncover her face with women to whom she felt attracted and was expected to be separated from men who represented no risk to her emotional balance.

Laila knew that she would never be able to live the life that she dreamt of. She loved her brothers, despite often feeling angry with them. She also loved her father, even if he would not listen to her or take her achievements seriously. She knew that, for her family, she was “damaged goods” and she would remain so, as she would never marry and give them children.

Laila eagerly waited to get old enough to stop receiving proposals from men that she did not know, who, as she grew older, wanted her as a second or third wife. In the meantime, she had occasional moments of joy with her few female friends and secretly experienced excitement and lightness in the body-less company of her virtual friends from the online community of women just like her.

Autocratic states use mental health stigma to control their citizens.Laila was very scared of being accused of being mentally ill. This is exactly what happened to Rahaf al-Qunun who, in the statement released by her family after her escape, was labelled “mentally unstable.”

An Online Refuge

As a therapist who works online with clients, my personal background helps me to understand and relate to what these women experience. Mental illness was stigmatized in the USSR, easily exploited by the authorities to punish and isolate any individual not complying with the strict rules of collective functioning. Therapy was almost nonexistent and was considered a medical treatment for alienated sick people. Online therapy was not an option as it is now, offering an opportunity to reach out to someone from a different culture, which can be useful when someone is trapped in an unfriendly world.

The effects of living in an autocratic country on individuals’ mental health are many. My female clients from hard-line Middle Eastern countries suffer from depression, anxiety, insomnia, dissociation, and difficulty trusting others.

Their individual boundaries are constantly transgressed and violated. The psychological effects of being raised in such an environment are like those experienced by a child growing up in a narcissistic family: the needs of the parents’ system (the society) take precedence over the needs of the child (the individual).

The only way to avoid being mistreated by a narcissist is to limit their power over you or to stay as far away as possible. Oppressed women like Rahaf al-Qunun have every right to rebel and protest as do children of narcissistic parents—they entirely depend on their caretakers and cannot freely leave their country or their family.

Individuals raised in cultures where they must abide by a very strict set of rules that do not take into account their needs, learn how to hide, to keep secrets, to lie. This is a natural way of adjusting to a system that does not accept parts of you; it becomes a question of survival. Such secrecy leads to an impression of living a double life. The cost of such fragmentation is often a lack of intimacy with parents and disconnection from those who are not aware of the “other” life that quietly happens inside or in the online space.

In a way, as their therapist, I must play a part in this secret parallel world, as my clients also hide from their families the fact that they are in treatment. Therapy, especially with a Western therapist, is seen as a transgression. My clients must come up with a plausible pretext for isolating themselves with their computer in a private room within the family home without being disturbed. I am often presented as a colleague, or an online English teacher. Here, the fact that their older family members do not speak fluent English comes in handy. The second language creates the much-needed safe and private space, in which they finally can explore their inner worlds, and the conflicts with the outer world in which they live.

Behind the Veil

I do not share a mother tongue with many of my clients so we must speak in English. Such use of the third, neutral language plays an important role in how the therapy evolves. It facilitates sharing thoughts and dreams that are defined as unacceptable in the clients’ original culture. Speaking English also provides us with an opportunity to play on even ground—as fluent as we are in our second tongue, we are still both foreigners, negotiating our accents, sometimes looking together for the right word. This experiment in equality has an additional reparative value, as being fully recognized as equal is not an easily obtained right in these women’s world.

As a Western woman with a limited knowledge and experience of Middle Eastern cultures, I let my clients guide me through their personal stories shaped by the culture, family, and place into which they were born. With them, I become an avid learner as we move towards a shared goal—a better understanding of who they are and who they want to be within the limits of their world. As we advance, pushing these limits becomes an existential necessity. For any transcultural therapist, this is a rather familiar role, but online therapy expands this in an extraordinary manner.

I have also had the opportunity to work with some Saudi women living outside of their country in Europe or elsewhere. Those with liberal, well-to-do and open-minded parents can study abroad. The sudden freedom comes with another set of psychological challenges—these young women must adapt to the transition and find a place in this new world, negotiating an acceptable balance between their original cultural values and the norms and expectations of the new place and culture.

During this stressful time, therapy offers them a space for dealing with conflicts and dilemmas that arise along the way—to wear or not to wear a headscarf; how to explain to their foreign peers the values and rules they choose to abide by; how to deal with anxious parents’ visits and a stressful life in an unfamiliar environment. Interestingly, they still retreat back to the familiar online space—which feels safer—to find friends or develop romantic relationships.

“Why does it matter that we, freer men and veil-less women, understand the struggle of women in these regions of the world” where many types of freedom are restricted? Will our understanding of their condition and our empathy change anything for them? My intuitive answer is ‘yes’; otherwise I could not do my work as a therapist. But how so?

Humans are social creatures, and the way we are looked at by others very often matters. We all have secret stories about how bad or how exposed we felt when people around us looked at us, judging our looks, words, or differences. In these circumstances, we feel shame. People with a handicap, sexuality difference or cultural/ethnic difference, all those who differ in some ways from the majority know far too well the emotional toll of such unwanted exposure.

How can a woman wearing the full veil feel when walking in the street in a tourist area of a big Western city? She is entirely covered in a black veil, her face hidden. On both sides of the veil we feel uncomfortable. The veil is a barrier, and, when we do not see the face behind it, we struggle to empathize with the individual. Behind the veil, there is sometimes deep discomfort and a feeling of shame. They may feel trapped, and our misunderstanding of their condition and our judging them for choices they do not have, may add to their suffering.

To connect with others and to be understood, without their body being seen, can be a challenge for these women. It is another reason why the online communities of Saudi women are thriving. Probably this is also what makes online therapy a hopeful space in which they can develop a connection with a Western therapist who represents this “other.”

As with any therapist, I am here for those who have psychological difficulties and struggle with some form of conflict. Surely, many women living in the strict Middle Eastern countries are happy enough with their circumstances, and not all of them would relate to my clients’ stories. But even if women I meet in my practice are a minority, it is important for them to be seen and acknowledged in their struggle, and to be offered a safe space like online therapy in which they can feel recognized and strive toward a better life.

Resources
1 Rahaf al-Qunun: “I hope My Story Encourages Other Women to be Brave and Free”

Therapy with a Condom On

Posted on by Psychotherapy.net Team

Editor's note: The following is an excerpt taken from Maybe You Should Talk to Someone: A Therapist, Her Therapist and Our Lives Revealed, by Lori Gottlieb, published by Houghton Mifflin Harcourt © 2019 and reprinted with permission of the publisher.

Shall We Skype?

“Hi, it’s me,” I hear as I listen to my voicemails between sessions. My stomach lurches; it’s Boyfriend. Though it’s been three months since we’ve spoken, his voice instantly transports me back in time, like hearing a song from the past. But as the message continues, I realize it’s not Boyfriend because (a) Boyfriend wouldn’t call my office number and (b) Boyfriend doesn’t work on a TV show.

This “me” is John (eerily, Boyfriend and John have similar voices, deep and low) and it’s the first time a patient has called my office without leaving a name. He does this as if he’s the only patient I have, not to mention the only “me” in my life. Even suicidal patients will leave their names. I’ve never gotten Hi, it’s me. You told me to call if I was feeling like killing myself.

John says in his message that he can’t make our session today because he’s stuck at the studio, so he’ll be Skyping in instead. He gives me his Skype handle, then says, “Talk to you at three.”

I note that he doesn’t ask if we can Skype or inquire whether I do Skype sessions in the first place. He just assumes it will happen because that’s how the world works for him. And while I’ll Skype with patients under certain circumstances, I think it’s a bad idea with John. So much of what I’m doing to help him relies on our in-the-room interaction. Say what you will about the wonders of technology, but “screen-to-screen is, as a colleague once said, “like doing therapy with a condom on.””

It’s not just the words people say or even the visual cues that therapists notice in person–the foot that shakes, the subtle facial twitch, the quivering lower lip, the eyes narrowing in anger. Beyond hearing and seeing, there’s something less tangible but equally important— the energy in the room, the being together. You lose that ineffable dimension when you aren’t sharing the same physical space.

There’s also the issue of glitches. I was once on a Skype session with a patient who was in Asia temporarily, and just as she began crying hysterically, the volume went out. All I saw was her mouth moving, but she didn’t know that I couldn’t hear what she was saying. Before I could get that across, the connection dropped entirely. It took ten minutes to restore the Skype, and by then not only was the moment lost but our time had run out.

I send John a quick email offering to reschedule, but he types back a message that reads like a modern-day telegram: Can’t w8. Urgent. Please. I’m surprised by the please and even more by his acknowledgment of needing urgent help–of needing me, rather than treating me as dispensable. So, I say okay, we’ll Skype at three.

Something, I figure, must be up.

At three, I open Skype and click “call,” expecting to find John sitting in an office at a desk. Instead, the call connects and I’m looking into a familiar house. It’s familiar to me because it’s one of the main sets of a TV show that Boyfriend and I used to binge-watch on my sofa, arms and legs entwined. Here, camera and lighting people are moving about, and I’m staring at the interior of a bedroom I’ve seen a million times. John’s face comes into view. “Hang on a second” is how he greets me, and then his face disappears and I’m looking at his feet. Today he’s wearing trendy checkered sneakers, and he seems to be walking somewhere while carrying me with him. Presumably he’s looking for privacy. Along with his shoes, I see thick electrical wires on the floor and hear a commotion in the background. Then John’s face reappears.

“Okay,” he says. “I’m ready.”

There’s a wall behind him now, and he starts rapid-fire whispering.

“It’s Margo and her idiot therapist. I don’t know how this person has a license but he’s making things worse, not better. She was supposed to be getting help for her depression but instead she’s getting more upset with me: I’m not available, I’m not listening, I’m distant, I avoid her, I forgot something on the calendar. Did I tell you that she created a shared Google calendar to make sure I won’t forget things that are ‘important’”—with his free hand, John does an air quote as he says the word important—“so now I’m even more stressed because my calendar is filled with Margo’s things and I’ve already got a packed schedule!”

John has gone over this with me before so I’m not sure what the urgency is about today. Initially he had lobbied Margo to see a therapist (“So she can complain to him”) but once she started going, “John often told me that this “idiot therapist” was “brainwashing” his wife and “putting crazy ideas in her head.”” My sense has been that the therapist is helping Margo gain more clarity about what she will and will not put up with and that this exploration has been long overdue. I mean, it can’t be easy being married to John.

At the same time, I empathize with John because his reaction is common. Whenever one person in a family system starts to make changes, even if the changes are healthy and positive, it’s not unusual for other members in the system to do everything they can to maintain the status quo and bring things back to homeostasis. If an addict stops drinking, for instance, family members often unconsciously sabotage that person’s recovery, because in order to regain homeostasis in the system, somebody has to fill the role of the troubled person. And who wants that role? Sometimes people even resist positive changes in their friends: Why are you going to the gym so much? Why can’t you stay out late—you don’t need more sleep! Why are you working so hard for that promotion? You’re no fun anymore!

If John’s wife becomes less depressed, how can John keep his role as the sane one in the couple? If she tries to get close in healthier ways, how can he preserve the comfortable distance he has so masterfully managed all of these years? I’m not surprised that John is having a negative reaction to Margo’s therapy. Her therapist seems to be doing a good job.

“So,” John continues, “last night, Margo asks me to come to bed, and I tell her I’ll be there in a minute, I have to answer a few emails. Normally after about two minutes she’ll be all over me—Why aren’t you coming to bed? Why are you always working? But last night, she doesn’t do any of that. And I’m amazed! I think, Jesus Christ, something’s finally working in her therapy, because she’s realizing that nagging me about coming to bed isn’t going to get me in bed any faster. So, I finish my emails, but when I get in bed, Margo’s asleep. Anyway, this morning, when we wake up, Margo says, ‘I’m glad you got your work done, but I miss you. I miss you a lot. I just want you to know that I miss you.’”

John turns to his left and now I hear what he hears—a nearby conversation about lighting—and without his saying a word, I’m staring at John’s sneakers again as they move across the floor. When I see his face appear this time, the wall behind him is gone, and now the star of the TV series is in the distant background in the upper-right corner of my screen, laughing with his on-camera nemesis along with the love interest he verbally abuses on the show. (I’m sure John is the one who writes this character).

I love these actors, so now I’m squinting at the three of them through my screen like I’m one of those people behind the ropes at the Emmys trying to get a glimpse of a celebrity—except this isn’t the red carpet and I’m watching them take sips from water bottles while they chat between scenes. The paparazzi would kill for this view, I think, and it takes massive will-power to focus solely on John.

“Anyway,” he whispers, “I knew it was too good to be true. I thought she was being understanding last night, but of course the complaining starts up again first thing this morning. So I say, ‘You miss me? What kind of guilt trip is that?’ I mean, I’m right here. I’m here every night. I’m one hundred percent loyal. Never cheated, never will. I provide a nice living. I’m an involved father. I even take care of the dog because Margo says she hates walking around with plastic bags of poop. And when I’m not there, I’m working. It’s not like I’m off in Cabo all day. So, I tell her I can quit my job and she can miss me less because I’ll be twiddling my thumbs at home, or I can keep my job and we’ll have a roof over our heads.” He yells “I’ll just be a minute!” to someone I can’t see and then continues. “And you know what she does when I say this? She says, all Oprah-like”—here he does a dead-on impression of Oprah—“‘I know you do a lot, and I appreciate that, but I also miss you even when you’re here.’”

I try to speak but John plows on. I haven’t seen him this stirred up before.

“So, for a second I’m relieved, because normally she’d yell at this point, but then I realize what’s going on. This sounds nothing like Margo. She’s up to something! And sure enough, she says, ‘I really need you to hear this.’ And I say, ‘I hear it, okay? I’m not deaf. I’ll try to come to bed earlier but I have to get my work done first.’ But then she gets this sad look on her face, like she’s about to cry, and it kills me when she gets that look, because I don’t want to make her sad. The last thing I want to do is disappoint her. But before I can say anything, she says, ‘I need you to hear how much I miss you because if you don’t hear it, I don’t know how much longer I can keep telling you.’ So I say, ‘We’re threatening each other now?’ and she says, ‘It’s not a threat, it’s the truth.’” John’s eyes become saucers and his free hand juts into the air, palm up, as if to say, can you believe this shit?

“I don’t think she’d actually do it,” he goes on, “but it shocked me because neither of us has ever threatened to leave before. When we got married we always said that no matter how angry we got, we would never threaten to leave, and in twelve years, we haven’t.” He looks to his right. “Okay, Tommy, let me take a look—.”

John stops talking and suddenly I’m staring at his sneakers again. When he finishes with Tommy, he starts walking somewhere. A minute later his face pops up; he’s in front of another wall.

My Idiot Therapist?

“John,” I say. “Let’s take a step back. First, I know you’re upset by what Margo said —.”

“What Margo said? It’s not even her! It’s her idiot therapist acting as her ventriloquist! She loves this guy. She quotes him all the time, like he’s her fucking guru. He probably serves Kool-Aid in the waiting room, and women all over the city are divorcing their husbands because they’re drinking this guy’s bullshit! I looked him up just to see what his credentials are and, sure enough, some moron therapy board gave him a license. Wendell Bronson, P-h-fucking-D.”

Wait.
Wendell Bronson?
!
!!
!!!!
!!!!!!!

Margo is seeing my Wendell? The “idiot therapist” is Wendell? My mind explodes. I wonder where on the couch Margo chose to sit on her first day. I wonder if Wendell tosses her tissue boxes or if she sits close enough to reach them herself. I wonder if we’ve ever passed each other on the way in or out (the pretty crying woman from the waiting room?). I wonder if she’s ever mentioned my name in her own therapy— “John has this awful therapist, Lori Gottlieb, who said . . .” But then I remember that John is keeping his therapy a secret from Margo—I’m the “hooker” he pays in cash—and right now, I’m tremendously grateful for this circumstance. I don’t know what to do with this information, so I do what therapists are taught to do when we’re having a complicated reaction to something and need more time to understand it. I do nothing—for the moment. I’ll get consultation on this later.

“Let’s stay with Margo for a second,” I say, as much to myself as to John. “I think what she said was sweet. She must really love you.”

“Huh? She’s threatening to leave!”

“Well, let’s look at it another way,” I say. “We’ve talked before about how there’s a difference between a criticism and a complaint, how the former contains judgment while the latter contains a request. But a complaint can also be an unvoiced compliment. I know that what Margo says often feels like a series of complaints. And they are—but they’re sweet complaints because inside each complaint, she’s giving you a compliment. The presentation isn’t optimal, but she’s saying that she loves you. She wants more of you. She misses you. She’s asking you to come closer. And now she’s saying that the experience of wanting to be with you and not having that reciprocated is so painful that she might not be able to tolerate it because she loves you so much.” I wait to let him absorb that last part. “That’s quite a compliment.”

I’m always working with John on identifying his in-the-moment feelings, because feelings lead to behaviors. Once we know what we’re feeling, we can make choices about where we want to go with them. But if we push them away the second they appear, often we end up veering off in the wrong direction, getting lost yet again in the land of chaos.

Men tend to be at a disadvantage here because they aren’t typically raised to have a working knowledge of their internal worlds; it’s less socially acceptable for men to talk about their feelings. While women feel cultural pressure to keep up their physical appearance, men feel that pressure to keep up their emotional appearance. Women tend to confide in friends or family members, but when men tell me how they feel in therapy, I’m almost always the first person they’ve said it to. Like my female patients, men struggle with marriage, self-esteem, identity, success, their parents, their childhoods, being loved and understood—and yet these topics can be tricky to bring up in any meaningful way with their male friends. It’s no wonder that the rates of substance abuse and suicide in middle-aged men continue to increase. Many men don’t feel they have any other place to turn.

So, I let John take his time to sort out his feelings about Margo’s “threat” and the softer message that might be behind it. I haven’t seen him sit with his feelings this long before, and I’m impressed that he’s able to do so now. John’s eyes have darted down and to the side, which is what usually happens with someone when what I’m saying touches someplace vulnerable, and I’m glad. It’s impossible to grow without first becoming vulnerable. It looks like he’s still really taking this in, that for the first time, his impact on Margo is resonating.

Finally, John looks back up at me. “Hi, sorry, I had to mute you back there. They were taping. I missed that. What were you saying?” Un-fucking-believable. I’ve been, quite literally, talking to myself. No wonder Margo wants to leave! I should have listened to my gut and had John reschedule an in-person session, but I got sucked in by his urgent plea.

“John,” I say, “I really want to help you with this, but I think this is too important to talk about on Skype. Let’s schedule a time for you to come in so there aren’t so many distract —”

“Oh, no, no, no, no, no,” he interrupts. “This can’t wait. I just had to give you the background first so you can talk to him.”

“To . . .”

“The idiot therapist! Clearly he’s only hearing one side of the story, and not a very accurate side at that. But you know me. You can vouch for me. You can give this guy some perspective before Margo really goes nuts.”

I Won’t Do It!

I noodle this scenario around in my head: John wants me to call my own therapist to discuss why my patient isn’t happy with the therapy my therapist is doing with my patient’s wife.

Um, no.

Even if Wendell weren’t my therapist, I wouldn’t make this call. Sometimes, I’ll call another therapist to discuss a patient if, say, I’m seeing a couple and a colleague is seeing one member of the couple, and there’s a compelling reason to exchange information (somebody is suicidal or potentially violent, or we’re working on something in one setting that it would be helpful to have reinforced in another, or we want to get a broader perspective). But on these rare occasions, the parties will have signed releases to this effect. Wendell or no Wendell, I can’t call up the therapist of my patient’s wife for no clinically relevant reason and without both patients signing consent forms.

“Let me ask you something,” I say to John. “What?”

“Do you miss Margo?”

“Do I miss her?”

“Yes.”

“You’re not going to call Margo’s therapist, are you?”

“I’m not, and you’re not going to tell me how you really feel about Margo, are you?” I have a feeling that there’s a lot of buried love between John and Margo because I know this; love can often look like so many things that don’t seem like love.

John smiles as I see somebody who I assume is Tommy again enter the frame holding a script. I’m flipped toward the ground with such speed that I get dizzy, as if I’m on a roller coaster that just took a quick dive. Staring at John’s shoes, I hear some back-and-forth about whether the character—my favorite!—is supposed to be a complete asshole in this scene or maybe have some awareness that he’s being an asshole (interestingly, John picks awareness) and then Tommy thanks John and leaves. To my amusement, John seems perfectly pleasant, apologizing to Tommy for his absence and explaining to him that he’s busy “putting out a fire with the network.” (I’m “the network”). Maybe he’s polite to his coworkers after all.

Or maybe not. He waits for Tommy to leave, then lifts me up to face level again and mouths, Idiot, rolling his eyes in Tommy’s direction.

“I just don’t understand how her therapist, who’s a guy, can’t see both sides of this,” he continues. “Even you can see both sides of this!”

Even me? I smile. “Was that a compliment you just gave me?”

“No offense. I just meant…you know.”

I do know, but I want him to say it. “In his own way, he’s becoming attached to me”, and I want him to stay in his emotional world a bit longer. But John goes back to his tirade about Margo pulling the wool over her therapist’s eyes and how Wendell is a quack because his sessions are only forty-five minutes, not the typical fifty. (This bugs me too, by the way). It occurs to me that John is talking about Wendell the way a husband might talk about a man his wife has a crush on. I think he’s jealous and feels left out of whatever goes on between Margo and Wendell in that room. (I’m jealous too! Does Wendell laugh at Margo’s jokes? Does he like her better?) I want to bring John back to that moment when he almost connected with me.

“I’m glad that you feel understood by me,” I say. John gets a deer-in-the-headlights look on his face for a second, then moves on.

“All I want to know is how to deal with Margo.”

“She already told you,” I say. “She misses you. I can see from our experience together how skilled you are at pushing away people who care about you. I’m not leaving, but Margo’s saying she might. So maybe you’ll try something different with her. Maybe you’ll let her know that you miss her too.” I pause. “Because I might be wrong, but I think you do miss her.”

He shrugs, and this time when he looks down, I’m not on mute. “I miss the way we were,” he says.

His expression is sad instead of angry now. Anger is the go-to feeling for most people because it’s outward-directed—angrily blaming others can feel deliciously sanctimonious. But often it’s only the tip of the iceberg, and if you look beneath the surface, you’ll glimpse submerged feelings you either weren’t aware of or didn’t want to show—fear, helplessness, envy, loneliness, insecurity. And if you can tolerate these deeper feelings long enough to understand them and listen to what they’re telling you, you’ll not only manage your anger in more productive ways, you also won’t be so angry all the time.

Of course, anger serves another function—it pushes people away and keeps them from getting close enough to see you. I wonder if John needs people to be angry at him so that they won’t see his sadness.

I start to speak, but somebody yells John’s name, startling him. The phone slips out of his hand and careens toward the floor, but just as I feel like my face might hit the ground, John catches it, bringing himself back into view. “Crap–gotta go!” he says. Then, under his breath: “Fucking morons.” And the screen goes blank.

Apparently, our session is over.

Ethics Over Coffee

With time to spare before my next session, I head into the kitchen for a snack. Two of my colleagues are there. Hillary is making tea. Mike’s eating a sandwich.

“Hypothetically,” I say, “what would you do if your patient’s wife was seeing your therapist, and your patient thought your therapist was an idiot?”

They look up at me, eyebrows raised. Hypotheticals in this kitchen are never hypothetical.

“I’d switch therapists,” Hillary says.

“I’d keep my therapist and switch patients,” Mike says. They both laugh.

“No, really,” I say. “What would you do? It gets worse: He wants me to talk to my therapist about his wife. His wife doesn’t know he’s in therapy yet, so it’s a non-issue now, but what if at some point he tells her and then wants me to consult with my therapist about his wife, and his wife consents? Do I have to disclose that he’s my therapist?”

“Absolutely,” Hillary says.

“Not necessarily,” Mike says at the same time.

“Exactly,” I say. “It’s not clear. And you know why it’s not clear? Because this kind of thing NEVER HAPPENS! When has something like this ever happened?”

Hillary pours me some tea.

“I once had two people come to me individually for therapy right after they’d separated,” Mike says. “They had different last names and listed different addresses because of the separation, so I didn’t know they were married until the second session with each of them, when I realized I was hearing the same stories from different sides. Their mutual friend, who was a former patient, gave both of them my name. I had to refer them out.”

“Yeah,” I say, “but this isn’t two patients with a conflict of interest. My therapist is mixed up in this. What are the odds of that?”

I notice Hillary looking away. “What?” I say.

“Nothing.”

Mike looks at her. She blushes. “Spill it,” he says.

Hillary sighs. “Okay. About twenty years ago, when I was first starting out, I was seeing a young guy for depression. I felt like we were making progress, but then the therapy seemed to stall. I thought he wasn’t ready to move forward, but really I just didn’t have enough experience and was too green to know the difference. Anyway, he left, and about a year later, I ran into him at my therapist’s.”

Mike grins. “Your patient left you for your own therapist?”

Hillary nods. “The funny thing is, in therapy, I talked about how stuck I was with this patient and how helpless I felt when he left. I’m sure the patient later told my therapist about his inept former therapist and used my name at some point. My therapist had to have put two and two together.” I think about this in relation to the Wendell situation. “But your therapist never said anything?”

“Never,” Hillary says. “So, one day I brought it up. But of course, she can’t say that she sees this guy, so we kept the conversation focused on how I deal with the insecurities of being a new therapist. Pfft. My feelings? Whatever. I was just dying to know how their therapy was going and what she did differently with him that worked better.”

“You’ll never know,” I say.

Hillary shakes her head. “I’ll never know.”

“We’re like vaults,” Mike says. “You can’t break us.”

Hillary turns to me. “So, are you going to tell your therapist?” “Should I?”

They both shrug. Mike glances at the clock, tosses his trash into the can. Hillary and I take our last sips of tea. It’s time for our next sessions. One by one, the green lights on the kitchen’s master panel go on, and we file out to retrieve our patients from the waiting room. 

Joseph Burgo on Shame, Narcissism and the Art of Empathy

Posted on by rezendevknowfully.com

A Personal Journey

Lawrence Rubin: You’ve been a practicing psychotherapist for over 30 years and have authored several best-selling clinical books. You seem fascinated by the clinical concept of shame. What’s its appeal to you personally and professionally?
Joseph Burgo: I guess it begins personally because for the last 15 years I’ve been coming to terms with my own shame, learning to recognize the role it has played in my life that I didn’t quite understand even at the end of my analysis. During that time I’ve been applying my new understanding to my clients in my clinical practice, and writing a book about it that would be helpful to people who aren’t necessarily in therapy. So, I suppose it’s the case that when you’ve been researching, and writing and thinking about something for a while, it takes a central role in your life.
Right now, it seems to me like shame explains almost everything
Right now, it seems to me like shame explains almost everything.
LR: It seems to be a really elastic concept that can be applied to all forms of pathology and client presentation. What kind of therapist do you think you were before you worked through your own shame issues?
JB: I was a blank-screen, classical sort of psychoanalyst trained in the object-relations school—Melanie Klein, Donald Winnicott, those people. I focused on issues of need and dependency because, from the object relations framework, everything is viewed in the context of maternal-infant relationships—what it’s like for a baby to depend upon her mother and the emotional impact when dependency doesn’t go very well. This is when the infant must protect itself from unbearable feelings of pain and disappointment.

That was the old paradigm. I wouldn’t say that I don’t think that way anymore, but I focus more now on shame and self-esteem. I don’t like the word self-esteem but it’s the word we’re stuck with. I focus more on shame and defenses against shame, the way we protect ourselves against feelings of defect and unworthiness, rather than defending against feelings of neediness and helplessness. 
LR: If your personal work on shame has allowed you to be freer of its pull, would you say that, irrespective of the type of therapy you practice, you’ve become a better or different therapist as a result of your own resolved shame issues?
JB: I like to think so. I’ve become a more empathic therapist for sure. I’ve always been empathic and had the ability to empathize with what my clients were going through, but for too many years I regarded that as information I needed to use in order to formulate interpretations. I still do that, but often now it means that I need to say something a little more personal or more directly empathic like speaking to the agony of their shame and letting them know that I have felt that way too. I understand what they’re going through in a way that isn’t distant, isn’t intellectual, but is immediate and authentic.
I’m much more likely to communicate my affection for my clients because I think that feeling joy and interest from another person is a very healing experience
I’m much more likely to communicate my affection for my clients because I think that feeling joy and interest from another person is a very healing experience. It isn’t enough just to make interpretations.
LR: That’s interesting because somewhere in my readings about or by you, you said that clients must wait for their therapists to grow enough to be able to help them. Is that what we’re talking about here?
JB: It is, and when I wrote that I was thinking in particular about two of my very long-term clients who went through a fallow period in their therapy until I addressed my own shame, and then understood shame better and could help them address theirs. That took a while. And it’s interesting that one of them will sometimes refer back to that period when I hadn’t quite figured it out as a fallow period, when we were kind of spinning our wheels.
LR: That fallow portion of the therapy was in part influenced by the growth that you had not yet made!
JB: I think eventually I was able to communicate that to them. However, in the beginning of that fallow period, I defended myself. I had been giving the correct interpretations, but they weren’t making use of them. I didn’t say that, but I think that was my attitude, and it was a somewhat blaming attitude.
LR: It must have been very empowering for you and those particular clients to reach out of that fallowness and find your ways to growth.
JB: It was. It was very productive. It was very moving and relieving that we found a way through that impasse.
LR: You also mentioned that you’ve been most successful in helping those clients whom you have found endearing. Has your own growth around shame allowed you to find clients more endearing and maybe, by association, have you felt more endearing?
JB: I don’t think so. I think this has been a feature of my work from the very beginning. The longest-term client I’ve dealt with, who I’ve mentioned in some of my writing, is very difficult, very volatile, probably in the realm of borderline personality disorder. And yet, endearing to me from day one for some reason. I don't know why, and that was many, many years ago.
LR: Do you find that you’ve become more endearing as a person and a therapist as a result of the work you’ve done on your own shame?
JB: It’s something I hadn’t thought about before. I know I’ve become warmer, more accessible, less intimidating for sure. I don't know if I’ve become more endearing. I think to my closest friends, yeah, probably. They will remark on how I’ve changed.
LR: What are some of the signs that a therapist is being overly influenced by their own shame to the point that it’s adversely affecting their work?
JB: I would say that one of the most common ways is for the therapist to hide behind their professional role and to allow clients to view them in an idealized light–as if they’ve got it all together. This sustains a therapist’s own defenses against their shame. I think this is common, and you hear about therapists who are amazing to their clients, adored by them, and their personal life is a disaster.

The Value of Shame

LR: What do therapists need to understand about working with clients whose pathology is shame-based? Clients don’t come in wearing t-shirts saying, “I’m shame-based.”
JB: I think there are several things. First, I think we need to expand our idea of what shame is.
We’re stuck in this paradigm in which shame is viewed as this uniformly bad thing
We’re stuck in this paradigm in which shame is viewed as this uniformly bad thing, and it usually has to do with some intolerant social perspective, some way that people are influenced by perfectionism and intolerance in the broader culture, and the work of John Bradshaw and toxic shaming. That’s the way we view it. That’s one of the things I try to challenge in my new book, to help people, both clients and therapists, look at shame as something else. The other thing I’m trying to do in that book is to look at the ways that everybody defends against shame. There are a consistent set of defenses that people use when shame is unbearable in their lives. I talk about as avoiding shame, which is in the realm of social anxiety; denying shame, which focuses on narcissistic issues; and controlling shame, which is more in the realm of masochism and self-deprecation.

I think you have to learn to recognize a defense against shame, understand what it is, and then help the person to gradually, over time, defend less against it, understand what it is that they’re running from and learn from it. Sometimes, when we’re behaving in ways that we don’t respect, we have a lesson to learn about our behavior, and shame is a message to us that we need to take a look at ourselves. Sometimes shame is telling us we need to try harder and that we’re not holding ourselves accountable. Sometimes shame is telling us that we have some room to grow. That’s a way I really try to reframe shame as an opportunity for growth rather than this uniformly bad thing.
LR: If we look at shame as part of being a human, we can then consider whether it is serving us and how we can develop a new relationship with it so that there’s more room for growth.
JB: I think so. I think that’s a good description.
LR: You wrote about a client named Caleb, the one we highlighted in the excerpt on this site in a chapter called “Superiority and Contempt.” Upon reading, I didn’t like him and know that you struggled to feel connected with and empathetic toward him. What impact did he and clients like him have on you?
JB: It’s a challenge working with a client like that because your own feelings of worth are impacted. Intentionally and inevitably, when a client like Caleb is in flight from their own shame and defending against it, they will often project it onto other people and then hold them in contempt as inferior and defective. Even though I’ve evolved a lot, I still see the transference and the working relationship between therapist and client as a microcosm of the client’s issues, and often the best way to address them.

Caleb was always trying to make me feel inferior, that he was better than me, that I wasn’t very smart and that I wasn’t very insightful
Caleb was always trying to make me feel inferior, that he was better than me, that I wasn’t very smart and that I wasn’t very insightful. If you’re not aware it’s very easy to become defensive and to make the sort of interpretation that might be shaming to the client, or to sort of shore yourself up, and end up in a tit-for-tat relationship. It’s a conversation that’s being had beneath the conversation in therapy.
LR: Exactly. This very morning, I had to decide to delete a contact from my phone contact list, a guy that I’ve known for 50 years. We are in a constant tit-for-tat, but it seemed that at the core was his need to shame me. He finally stopped communicating with me, and then I texted him on his birthday and got no response. I texted him again yesterday with no response, and this morning I was thinking, and this was my own shame talking, “What can I say that will shame him the most deeply?” And I came up with a perfectly crafted text that would have probably put him through the roof, but instead I decided that that’s sort of a poison you take waiting for someone else to die, so I just said “the heck with it,” and deleted his contact.
JB: The difficult thing about that experience is when someone doesn’t communicate with you and ignores your texts, what they’re saying to you is that you are unworthy of their attention, which is shaming. It’s painful when you express interest in somebody else and they don’t return it. That’s a kind of shame, and it’s natural for people to want to retaliate in kind and to say, “No, you’re the one who ought to feel ashamed.” But you did really do the right thing, which was to recognize that you wanted to shame him, and then decide not to do it.

The Flip Side

LR: We seem to be in a golden age of narcissism. A few years ago, you wrote, The Narcissist You Know. Why are we all so fascinated by narcissism? 
JB: Well, I will start off by saying that nobody wanted a book on shame. I originally tried to sell a book on shame about 10 years ago. It was called Learning from Shame: The Less Traveled Road to Self-Esteem, and nobody wanted it. I was told by agents and editors that the book was a downer and that nobody wanted to read about shame. So, I said, well okay, I will then write a book about narcissism, which I see as the flip side of shame, because everybody’s interested in narcissism right now.

I think that
as a culture we’re fascinated by narcissism in the wrong way. I think we’re not horrified enough by it
as a culture we’re fascinated by narcissism in the wrong way. I think we’re not horrified enough by it. We’re not repelled enough by it. We’re fascinated by it because we really enjoy these images of people–particularly celebrities–who seem to have it all, who are beautiful, rich and successful, and we like to believe that somebody actually does get to have that ideal life. Then we spend our time on Facebook, Instagram, and Twitter convincing everybody else that we’re leading this incredible life, that we have these amazing vacations, and we go to these fantastic parties, and here’s this amazing meal I’m having at this incredible restaurant. It all feels really unhealthy to me. 
LR: So, narcissism is a destination for people in hopes that once they are on display and revered, they will be able to escape shame? So, as you say, narcissism the flip side of shame?
JB: Yes it is. It’s the primary defense against shame, to disprove to everybody else and yourself that you’re damaged in any way.
LR: What’s interesting to me is that both are equally illusory and not tangible, though both can have tangible impacts on the body and mind. They seem so illusory but so powerful in their ability to just take over a person and deprive them of a true sense of self.
JB: Well, I agree. I think the problem is that for the narcissist, shame feels like an actual condition, an actual state of being in which they’re damaged, defective, ugly. It’s felt on an almost physical level to be a real sort of damage, a deformity, and that’s unbearable. So, they try to create this opposite steady state, this idealized self, that’s perfect and complete, which completely denies the existence of that other steady state: shame and the sense of being damaged.

That’s the problem I see.
The quandary for the narcissist is that either you’re perfect and you’ve got it all together—you’re fabulous; or you’re so damaged and defective that you’re beyond hope and there’s nothing to be done
The quandary for the narcissist is that either you’re perfect and you’ve got it all together—you’re fabulous; or you’re so damaged and defective that you’re beyond hope and there’s nothing to be done. 
LR: And it makes sense that the dichotomy of shame and narcissism are part of borderline functioning, this either-or, black or white, idealized or brutalized images of others.
JB: Absolutely.
LR: Is that why in your writing and thinking you’re drawn to borderline pathology–because it is the epitome of this dual narcissism-shame quandary?
JB: I also see the same issue in bipolar disorder. You see people vacillating between thinking that everything about themselves is so damaged, so screwed up that it’s hopeless, and then going on a manic flight into some magical state in which none of that’s true; they’re super powerful, super capable, they can do anything. I see the polarity not only in borderline symptoms but also in bipolar symptoms.
LR: We seem to be so caught up in seeing bipolar disorder as a so-called emotional disorder of dysregulation, so we medicate people for it. But the medication is not going to modify the core dynamic that drives the bipolar behavior, which is the vacillation between shame and narcissism.
JB: Exactly.

The Challenge of Treatment

LR: What are the clinical challenges of working with narcissistic clients, especially those whose narcissism is considered toxic? It must be very trying and demanding for a therapist.
JB: Well, yes. But the truth is that the people who have extreme narcissistic symptomatology usually don’t come for therapy. They think they’re fine or they’ve got some other mechanism for dealing with it that doesn’t involve acknowledging their own difficulties and asking for help. But when they do come, it is a challenge, whether or not you’re dealing with someone like Caleb, the therapist client we were talking about who projected shame into me, or some of the clients who struggle with borderline symptom.s People who have struggled with borderline symptoms are challenging because they go back and forth between idealizing you and hating your guts. As the transference gets underway, it’s a very volatile and emotionally immediate relationship in which what’s going on between you and how you’re viewed is at the core of the work. It’s very painful to have clients say, “Fuck you. I hate your guts. You’re a leech feeding off my neediness,” and on and on and on. I’ve had clients say the most vicious things to me over my career, and the hard part is that the clients I’m describing often are very insightful in certain ways, like they’re able to identify something true about you but use it against you in a really hurtful way. So, your own issues get stirred up. Are you going to defend against that because it’s so painful? Or are you going to hear it and maybe learn something from it yourself? I don't know. I would say
I’ve grown the most with my clients who were the most difficult
I’ve grown the most with my clients who were the most difficult.
LR: I can imagine that a therapist who’s not done their personal work around shame and whose self-esteem vacillates would have the most difficulty and be caught up in the most damaging counter-transference relationships with clients like this.
JB: I think so, and I think those clients probably don’t stay very long with that type of therapist.
LR: I briefly had a client who I really messed up with because he was like Caleb, but younger and much more energetic, and I constantly found myself trying to prove myself. And there are some clients I’ve had that I wish I could call now and say, “I’ve grown. Can you come back and give me another try. I think I could help.”
JB: Oh, do I know that feeling. And the shame of failure. I feel that.
LR: Some people reify therapists, perhaps out of their own shame and inadequacy. We are the mental health celebrities, the equivalent of the celebrity athletes who they idolize. Then when we fail in their eyes we also fail in our own.
JB: Yes, absolutely. It’s kind of nice to be idealized in the beginning. It can easily feel great that somebody thinks you’re a really together person, and you’re full of insight and empathy, and they look up to you and want your attention. That’s flattering, right?
LR: Until it’s not.
JB: Until it’s not. Until they flip to the other side.
LR: You got that little thing there, doctor, in your teeth and now I’m going to just tear you to shreds.
JB: Exactly.
LR: It seems that working with these complex, characterologically involved clients is not about going to an evidence-based manual and pulling out a couple of techniques drawn from a meta-analysis. It’s not that kind of approach. Can you say a few words about the orientation, beyond technique, that’s necessary to work with narcissistically damaged or shame-influenced clients?
JB: It’s a very personal experience for the therapist because inevitably you’re going to be triggered and your own narcissistic issues are going to be stirred up. So, working with that kind of client means that you have to be paying a lot of attention to yourself. You have to be learning and growing from your shame experiences and acknowledging when you’re off base, when you make a mistake, when your interpretations aren’t helpful, and modeling a kind of ability to tolerate shame experiences and to learn from them for your client. So, it’s really personal, I think.
LR: I’m just sort of wandering back to this morning and how I spent 15 minutes crafting the most toxic, shaming message I could to someone who seemed hell-bent on diminishing me over the years, five decades, and how liberating it was, although painful, to delete his contact. Not that I couldn’t find him if I needed to, but the symbolic gesture of saying to myself, “I won’t allow myself to be shamed in this way anymore because I don’t need to pursue shame.” It came with the package.
JB: But they key element there, I think, is that you said it was painful.
Too often I think we want to take flight into some sort of superior position where we don’t feel any pain
Too often I think we want to take flight into some sort of superior position where we don’t feel any pain. We want to think “In fact, they weren’t worth wanting anyway. They were a terrible friend and I don’t really care about them.” That’s an understandable position to take. I always think that allegory of the fox and the grapes explains so many things. That’s one position we can take but what you said is, “Look, this isn’t good for me because this hurts me.”
LR: The allegory of the fox and the grapes?
JB: It’s the “sour grapes” story. There are some grapes hanging over the wall and the fox keeps jumping up to try and get them because they look so yummy. And then when he can’t he finally decides, well, they were probably sour anyway, I didn’t want them.

Rebuilding Esteem

LR: You have been interviewed by countless folks like me. You’ve offered your words in a public venue. You’ve written, so your words are out there. Does this feed your narcissism in a good way or bad way?
JB: I’d say both. In my new book I talk about how the real antidote to deep feelings of shame is to behave in ways and achieve things that build self-respect and pride to sort of off-set this sense of defect and damage. That has been absolutely true for me. I was at a low point in my life following the economic downturn in 2008 and 2009, following the end of my first marriage. I was just feeling bad about myself. The temptation was to sort of give up and to sink into despair. But I worked hard instead to build my website, rebuild my practice, write my first, second and third books, and to become an authority in some sense on a number of subjects that matter to me. I would call that healthy narcissism, building pride and self-respect, and I feel so much better about myself now than I did 10 years ago.

At the same time there’s a part of me that wonders: Why aren’t I Brene Brown? Why don’t I have my TED Talk?
At the same time there’s a part of me that wonders: Why aren’t I Brene Brown? Why don’t I have my TED Talk? And why aren’t I a public authority who’s making lots and lots of money off very similar ideas? So, I think there’s an unhealthy sort of narcissism that wants me to be bigger and better than I am. 
LR: I understand in ways that sort of transcend this interview. My work with Psychotherapy.net came at a really good time for me. I was a low point professionally, just tired and drained. Teaching but not giving, more withholding than anything else, and wondering how much I really knew and protecting what little was left of my energy and empathy. I feel good about what I do know and what I’ve learned. I feel better about myself, so I think there are those of us who, like you said, embrace opportunities to escape shame and others see shame as sort of a deceptive friend that we can’t quite let go.
JB: That illustrates exactly what I’m trying to say in the book. There was a choice point in your life. You could have continued in that kind of ungiving way. You could have abandoned your profession and looked for something else, or you could find this opportunity that allowed you to apply everything you knew in this new framework where you felt good about yourself. You built self-esteem by doing something you feel good about.

Exploring Defenses

LR: We’ve been talking about shame and narcissism, your training, and your own professional evolution. It seems that at the core of your understanding and your work is the notion of defense mechanisms. You wrote a book called, “Why Do I Do That?: Psychological Defense Mechanisms and the Hidden Way They Shape Our Lives.” Is it always necessary to attend to a client’s defense mechanisms? And if we don’t, is the therapy doomed to a lesser level of effectiveness?
JB: No, I don’t think so. We all have defenses. We couldn’t get through life without our defenses, and some defenses are healthy and helpful. I don’t think those need to be pointed out or challenged. But, when defense mechanisms are deeply entrenched and pervasive, they get in the way of everything. And that’s why we have to draw our clients’ attention to them and help them understand what they’re defending against, so that they can deal with the pain in a more constructive way. For example, narcissism is a defense against shame, and we need to help our clients see how their defenses—their narcissistic behaviors that are meant to defend against shame—are causing all sorts of trouble in their lives, and that the solution is worse than the problem.
LR: So, if a therapist is not psychodynamically trained, and does not understand how to work with defenses and is themselves shame-based or defended against shame through narcissism, is the therapy doomed to a lesser level of positive outcome if for whatever reason defenses don’t get acknowledged or worked through? Is it just going to be patchwork?
JB: I think that a lot of growth and development can occur even if somebody doesn’t think the way I do. Even if they don’t view people in terms of their defensive structures or they don’t see shame in narcissism the way I do, lots of growth can occur. There are a lot of great cognitive behavioral therapists who are helping people, but certain issues aren’t going to get addressed, that’s all. I think that the deeper, more profound issues aren’t going to be addressed. That doesn’t mean it’s not helpful.
LR: The book itself is a self-help manual. I agree, as you said, that a lot of good work has been done by CBT therapists. There are apps for CBT. There are self-help manuals for CBT. Is a self-help manual for dealing with defense mechanisms really going to be helpful without the supplemental work with a real live therapist?
JB: I have clients who have asked me the same question and challenged me on having written self-help books. I don’t know. I do know that I hear from people all the time who have read my book saying how helpful it was to them and how it opened their eyes to themselves and they saw things they hadn’t seen before. You know, I just feel that most people can’t afford therapy. That’s the bottom line. Are we just supposed to say, “Well, you can’t afford therapy, so you’re doomed?” Or do we try to find some way to bring these ideas that inform our practices into a book that people can read, and offer them exercises that they can work on? I feel kind of obligation to do that.

Digital Empathy

LR: As we wind down, I want to draw attention to your involvement with distance therapy for these last five years. What are some of the advantages and disadvantages that you see in this delivery method?
JB: Mostly I see advantages because it gives people the opportunity to have contact with a professional when there isn’t anybody they can see face-to-face. I’ve worked with ex-pats in other countries where there isn’t anybody available. I’m thinking of a client I work with who is married to a Japanese woman and lived and taught in Japan. He couldn’t find anybody there that really would be able to understand him and his culture. So, there’s that great advantage, or there are places where there just isn’t anybody.

It’s usually very convenient for everybody involved, but sometimes there are obstacles. The client might live with somebody else so privacy can be a challenge. When I was in analysis it was really time consuming because I had to leave enough time for traveling and parking. When you do it digitally, you can log on and have your session and then you’re done with it.

Other therapists are often very skeptical about the fact that you’re not in the same room and feel that that might mean there’s a lack of immediacy and lack of a real personal empathic connection. I understand that, and I understand that’s got to be true to some extent but, especially after researching how empathy works in my last book, it’s not magic, and it doesn’t necessarily have to do with physical proximity. When we empathize with other people, we are reading their emotional experience on their faces, and we are unconsciously bringing our own facial expressions into alignment with theirs, which stimulates an echo of their experience inside of us. You can do that on a video screen, and I do.
I do feel a deep empathic connection with my clients when we’re face-to-face over a computer
I do feel a deep empathic connection with my clients when we’re face-to-face over a computer. I have worked by telephone. I won’t do it anymore because it’s so inferior if you can’t see somebody’s face.

The other thing is there’s often an extra bit of information that comes with seeing a client in her own milieu that you don’t get when they come to your office. That’s your terrain, right? I wrote an article for The New York Times about some of my clients who have pets and who connect from their homes, and how I get to watch them interact with their animals and I learn things about them that way. You learn things about people by what they choose to include in the video frame for their sessions. You sometimes have intrusions from people who forget that your client is in session then and they’ll come into the room or there’ll be sound from another room in the home. There’s all these extra bits of information that make it a very rich experience.

I do understand the reluctance of some therapists to work this way, and the sort of mystical view of empathy as this kind of ESP that happens when people are physically in the same space, but my experience tells me otherwise.

One of the personal bonuses of working in distance therapy is just this exposure to all these people I never would have had the chance to meet and work with on the west side of Los Angeles. It affords me the freedom to transcend the only thing I have never liked about my job, which is that I’m stuck in one place. I spent two months in Europe this summer and I worked the whole time. It’s always been my dream to not be a tourist but to just go somewhere and have my daily life there. I would do what I would normally do but at the end of the day rather than being home in Los Angeles or Palm Springs, I’d be in London or Paris, which is what I did, and it was fabulous.
LR: So, doing distance therapy can be liberating in that you’re in many places by virtue of the clients with whom you’re working, but you can also be in many places and sort of get filled up in that way.
JB: That’s a good way of putting it.
Distance therapy feeds me, and it makes me a happier therapist to be able to do that
Distance therapy feeds me, and it makes me a happier therapist to be able to do that.
LR: A happier therapist is a better therapist.
JB: Yes.
LR: Has it expanded your world view as a therapist in addition to making you a happier therapist?
JB: I like to think so. It’s kind of a humbling experience. I remember I was working with a man who came from a wealthy family in India. He had grown up in India, then been educated at boarding school in England, and was presently working in a family business in Dubai. There were so many aspects of his experience that I had to keep reminding myself that my set of cultural assumptions really weren’t going to hold true for this guy. I just had to listen and learn a lot about his experience and not try and impose my own fully Westernized values on him. It was challenging.
LR: I would imagine that the ability to rise to that challenge is based on one’s humility, but as you said, it is about empathy–the willingness to open yourself to others no matter who they are, where they are, and how they struggle.
JB: People might have different sets of cultural values and assumptions but their faces all express emotion in the same way. That’s biological.
LR: I guess that is as good a place to stop as any. Thanks so much for your time today and the wonderful conversation.
JB: I really enjoyed this interview, it was different from many that I’ve had before. Thank you for reading my books and for giving me the opportunity just to go on at length about subjects that mean a lot to me. This was very enjoyable.

Changing Places

Posted on by Psychotherapy.net Team

The Nesting Instinct

Thirty years is a long time. When I started my psychotherapy practice as a newly-minted licensed psychologist in 1986, I didn’t expect to spend my entire career in one office. But the brownstone building and the location were great, and the space felt comfortable. The office was part of a suite with five offices, a shared waiting room and a bathroom. It was a large room with windows overlooking a tree-lined street. I never felt the desire to relocate my practice. Recently, however, the noise from new tenants in the apartment above my office became intolerable. The landlord was unwilling to intervene and clients were starting to look up at the ceiling due to the sound of a toddler jumping out of bed overhead. Additionally, the condition of the waiting room and bathroom had deteriorated. My frustration finally compelled me to start looking for new office space.

Although psychotherapy is about helping people realize change in their lives, personally I am often resistant to change. I love to travel and explore new things, but ever since my parents’ divorce when I was a young child, I developed a strong nesting instinct. Creating familiar and warm surroundings is core to my well-being. I will venture out into the unknown, but I like my surroundings to stay the same. “Moving is not something I do lightly”. During those same 30 years, I had moved homes twice, each time to accommodate a growing family. I was always grateful that my office stayed the same. It was the constant in my life, a proverbial “room of my own.”

There had been days when the comfort of my office extended to me as much as it did to my clients. Each time I was pregnant, I would nap on the couch whenever I had a free hour. The office was never cluttered with the accouterments of young children or the inevitable accumulation of “stuff.” Every night as I closed the door behind me, I knew I would find the office in the same condition the next day. The familiarity of the space was reassuring to me.

Time for Change

Therapists often admonish clients against “a geographical cure,” but sometimes relocation is the right decision. As I began looking for a new office, I knew I wanted to stay in the same neighborhood. Keeping my phone number and location was important to the stability of my practice. I was fortunate to find, just three city blocks away, an office with large windows and my own waiting room. The ceilings were higher and the building was non-residential. I signed a five-year lease, guaranteeing myself some permanence. I reassured myself that there were important lessons for me, as well as my clients, in this decision.

In the weeks leading up to the move, I was aware of feeling uncharacteristically unsure of myself. Finding a new parking space was challenging and I regularly forgot the code for the bathroom in the building as I checked the progress of the renovations in the new office. When I had the opportunity to meet the psychologist who was leaving the office, he reassured me that “The office has good karma.” He was retiring after 30 years and welcomed the opportunity to bequeath this important space in his life to another psychologist. He shared helpful insights about how the building worked and volunteered to introduce me to fellow therapists on the floor. His clear desire for me to be happy in the office eased some of my doubt about having made the right decision. The fact that he had had a successful practice in that space for thirty years seemed like a good omen.

It was critical for me to manage my own anxiety about unforeseen consequences of moving so that it would not be detrimental to my clients. Like all therapists, over the years I had weathered personal difficulties while continuing to work. During those times, I relied on a few trusted colleagues to support me. This time, through word of mouth, I sought out other therapists who had moved offices to learn from their experiences. It was enlightening to learn just how complicated most therapists find this decision. We all agreed that our attachment to our office was a by-product of our work. Opinions varied about how far in advance to tell clients about the move and whether or not it was important to bring anything from the old office to the new one. One colleague who had moved due to a fire in her old building, rather than by choice, spoke about how this trauma had been more than some of her clients could bear and consequently they did not follow her to her new office. Another colleague shared that after his move a few of his clients told him how uncomfortable they had found the previous office, something he had not been attuned to. In retrospect, he realized that his own comfort in the space had kept him from recognizing how dilapidated the surrounding neighborhood had become. These conversations, along with my own self-reflection, led me to wonder what was in store for me as I made my own move.

My Clients React

A therapist’s office reveals the personality of the therapist in subtle ways. Although family photos or other highly personal artifacts are typically absent, the color of the walls, the seating, and the artwork are chosen with care to convey safety and comfort. Indirectly, these choices do reveal something of our personalities to our clients. I had redecorated my old office a number of times over the years. Now, as I looked at the new space I was about to occupy, I wondered what to bring with me and what to replace. A complete makeover felt too unsettling. In the end, I decided I would paint the walls the same green I have loved for the past eight years and keep most of my furniture. I added an oak, two-drawer, lateral file cabinet and changed the artwork from Gauguin to Sargent. Having my own waiting room for the first time, I thought about how I wanted to present myself to potential new clients as well as my current caseload. It was exciting to have more control over my space. I doubt I would have felt comfortable in a professional office building at the start of my career, but now I was ready to leave the homey brownstone I was used to.

A month before my moving date, I informed my clients of the coming change. Relieved to learn I was not retiring, they had varied responses to the news of the relocation of my office. It was revealing to learn how deeply some of them were connected to the physical space, while for others the transition seemed seamless. One client enthusiastically said, “Where are we going?” Some were thrilled the new office would be closer to public transportation. Others talked about how much they loved the tree outside my window, and a few worried whether the new space would feel as comfortable as the one they knew. A couple of clients asked me directly what had led to my making this decision and when I shared my reasons about the noise from above and the general deterioration of the common space each one commented on how my decision to act made them feel cared for.

One long-time client, a woman who had a history of sexual abuse as a child, was very attached to my physical space. She revealed that, during many painful and uncomfortable hours of therapy, she had memorized the order of the books in my bookcase and counted the seashells on my windowsill when eye contact was too penetrating for her to bear. She took time to say goodbye to the office and to reflect on the hard work she had done over the years to voice her deepest fears. Her one request was that I put the books back on the bookshelf in exactly the same order.

One of the hardest truths for therapists is that we rarely get to hear the end of the story. On moving day I found myself overcome with an array of emotions, as I sat on the floor of my old office boxing up my files. Like long-forgotten photo albums dusted off only during a move, each file brought back the connection I had made with the person whose name it bore. There were some people I had seen for a single visit, but whose stories I had never forgotten. I’d known others for over twenty years. I grieved again the loss of someone’s son and the tragedy of a terminal illness. I calculated the current age of past clients and let myself wonder about them. Had he found love? Did she have children? There were clients for whom I was not a good match, a few who had left in anger. Reflecting on the depth of connections with clients past and present reminded me anew of why I love being a therapist.

Looking Back, Moving On

As I walked from my old office to the new one with boxes of files in my arms, I was aware that these were possessions too precious to leave to the movers. Of course, it is my duty to protect the privacy of my clients, but physically moving these files, my life’s work, over three trips, on my own, to their new home gave me confidence that this was a positive change. In a very real sense I was moving alone, but all the people I had known over the years were coming with me. I was no longer a brand-new therapist, but a seasoned professional eager to continue my work. Suddenly, the journey from my old office to my new one felt less like starting over and more like an affirmation that I was on the right path.

All of my clients chose to follow me which was a relief. I knew the move presented an opportunity for each of them to reflect on their commitment to therapy, and to me, at this point in time. For those where the connection between us felt more tentative, I was not sure if the disruption of the move would tip them toward terminating therapy. Other clients touched me by their vocal appreciation for my presence in their lives. A few even brought me “office warming” gifts and I was reminded that my ability to receive as well as give in my role as a therapist is helpful. I can model change, not just prescribe it. In fact, since the move, two of my clients who were unhappy with their living situations have made moves of their own. Perhaps this is mere coincidence, but I suspect not.

Change isn’t always for the better, but when it is, it is a great reminder that holding on for too long can be detrimental to growth. Initially, when faced with the need to move, I saw only the potential for loss. In fact, the opposite occurred. I am no longer distracted by unwelcome noise and the new space is beautiful. By listening to my feelings, but still taking action, I enhanced my own capacity to change. Undertaking this move at this stage of my career has reawakened in me the joy I felt starting my own psychotherapy practice so many years ago. The relocation of my office has affirmed for me the value of taking care of oneself. Unconsciously, I was overly attached to my old office and I failed to recognize that change could actually help me thrive. The insights I have gained from this experience will undoubtedly help me both professionally and personally.

Everyone loves the new office, particularly me. But the most important lesson I learned from changing places was summarized best by one my clients, “The office doesn’t make the therapist—the therapist makes the office.” After thirty years of practice, I have more confidence in what I offer my clients and I am looking forward to a vibrant next chapter in my career.
 

Introducing Multi-Lens Therapy

Posted on by Psychotherapy.net Team

What’s Going On?

What exactly is causing the emotional difficulties that your client or your patient is experiencing? You would think that this would be the central question a practitioner is hoping to answer, since it is certainly reasonable to suppose that treatment should connect to causation. Yet a taste for investigating what is really going on has been lost over the decades. As helpers, we’ve moved toward too-easy labeling, and accepting the idea that it is reasonable to help our clients without understanding what is going on “with” or “in” them.

This taste for investigation has been lost for many reasons, among them:
1) The DSM is loudly silent on causation; 2) The idea of “symptoms” and “symptom pictures” has firmly taken hold; 3) Training programs which are psychologically-minded focus on one theoretical framework or another, reducing the complexities of causation to “what fits our model”; and 4) It is so darned hard to actually know what is going on “inside” and “with” a given person.

How can we restore something as essential to the healing and helping process as knowing what is going on? There is no perfect answer but a step in the right direction is the following:
providing helpers with multiple lenses through which to view their clients’ troubles. This multi-lens approach reminds practitioners that they shouldn’t be looking for some single cause, like faulty plumbing or a traumatic childhood, nor should they be operating from one orientation, say a biomedical or a psychodynamic one. Rather, a lot is almost certainly going on, each aspect of which may be contributing to your client’s difficulties.

This updated way of proceeding is called multi-lens therapy. It takes as it starting point that, as a helper, you do what you do because of what’s going on, not irrespective of what’s going on. The DSM seems not to care about “what is going on.” As therapists, we most certainly ought to. If your client has an actual biological problem, they need one sort of help. If they hate their job, another sort of help is required. If born with certain sensitivities, they need another sort of help. It is absurd (and not okay) that a helper would look only at putative “symptoms” rather than what’s going on. It is likewise absurd (and not okay) that a helper would throw up their hands and say, “I don’t do causes.” Therapists may have gotten into that habit but that is a habit to break.

It may indeed turn out to be impossible to identify the cause or causes of a given client’s distress. But that is no reason not to try and no reason to pretend amnesia about the whole matter of causation. So, how should a therapist or other helper think about causation as that word pertains to human beings? The first principle is to think expansively rather than reductively. Multi-lens therapy provides twenty-five lenses through which to view and think about a client’s distress. That may sound like a lot but that is as it should be. Causation in human affairs is neither transparent nor simple.

You can be of help to a client even if you can’t discern what’s going on. You can be of help by being warm and supportive. You can be of help by virtue of your listening skills and your ability to carefully reflect back what a client is saying. You can be of help because you understand human nature and can usefully wonder aloud about your client’s behaviors. But that you can be of help without knowing what’s causing your client’s distress doesn’t mean that you should dismiss causation as “not something I do.” To engage in that dismissal would be to shortchange your clients and, worse, to set the stage for big mistakes.

Multi-lens Therapy

In multi-lens therapy, you take the position that there is no single way to look at human affairs. That a client is presenting a problem that he or she is calling “depression” doesn’t mean that you suddenly know what is going on. You don’t know if your client is in existential despair about having no life purpose, in a dark mood because of chemicals they are taking that have darkened their mood, in anguish about an unravelling marital relationship, or announcing something that has always been true for them, a matter of temperament. You do not know and the very least you can do is announce to yourself, “I do not know, let me check.”

How you check on possible causation depends on your therapeutic style. But informing that style should be an understanding of what might be going on. “Multi-lens therapy provides you with twenty-five ways of thinking about what might be going on”. These twenty-five lenses include the lens of original personality, which helps you think about a client’s basic temperament, the lens of formed personality, which reminds you about how “stiff” and intractable personality becomes over time, and the lens of available personality, which is a useful way to conceptualize your client’s current “amount” of free will and ability to change. Also included are the lenses of biology, psychology, development, family, social connection, circumstance, trauma, stress, and more. (You’ll find the complete list at the end of this article.)

Acquiring a working sense of these twenty-five lenses and learning ways of using them in session make for more powerful and helpful work. By proceeding in this way, as a multi-lens therapist, you don’t reduce what’s going on to “treating the symptoms of mental disorders” and you don’t operate from any reductionist theoretical orientation. Rather, you accept the largeness of human reality, a largeness that includes the complex nature of causation as that word applies to human affairs. Multi-lens therapy returns the idea of causation to therapy and helps therapists work more deeply, more powerfully—and more truthfully—with their clients.

A key to practicing multi-lens therapy is listening for causal hints. Clients regularly hint in passing at what’s causing their distress. The hints we get from a client help us determine which of these many causes are more probable than the others or maybe even which is the central cause. Nor is it hard to hear these hints if we train ourselves to listen for them. For instance, say that a client is presenting a relentless “down-ness” which you’re both likely to call “chronic depression.” Imagine that your client says the following in passing:

“I was raised Catholic but eventually became a Buddhist.”

You might nod and allow this information to pass by. Or, as a multi-lens therapist, you might take this as a causal hint, suggesting at the possibility that your client has had problems making sense of meaning and life purpose, problems which were not answered by her birth Catholicism and which perhaps are not being answered by her adoptive Buddhism.

You would then investigate. A hint is a door waiting to be opened. In this case, one sort of investigatory question might be: “Has Buddhism done a good job of serving your meaning and life purpose needs?” Another might be, “That’s interesting. What did Catholicism lack that Buddhism provides?” A third might be, “What attracted you to Buddhism?” Each of these questions honors the possibility that your client’s despair may be connected to her inability to keep meaning afloat and her difficulties identifying and “owning” life purposes.

You don’t know for sure that this is the case and you’re treating her announcement as a hint and not a revelation. But you may be on to something, even something crucial. You can only know by stopping your client’s narrative and asking. Many therapists prefer to rarely interrupt or even to never interrupt, but a multi-lens therapist sees careful interrupting as a key principle of helping. “I find that if I interrupt in a spirit of genuine inquiry, clients are neither disturbed nor offended by the inquiry. Indeed, they relish it.”

Suppose that your client mentions in passing, “As far back as I can remember, I was sensitive.” You could simply nod. Or you might consider this a causal hint that perhaps some feature or features of her original personality are implicated in her despair or are even, maybe directly or maybe obliquely, the cause of her despair.

Taking her remark as a causal hint worth pursuing, you might ask “That’s interesting and maybe important. If your basic sensitivity somehow connects to you feeling down, what does that suggest, I wonder?” You might ask, “I wonder, wouldn’t a sensitive person be down more often than the next person just by virtue of her sensitivity?” Or you might ask, “If, as you say, you were born sensitive, that’s going to amount to a lifelong challenge, isn’t it?” Each of these questions opens the door to a fruitful and likely pertinent chat about original personality: about what it means, what it signifies, and how it matters.

Consider another sort of situation. Your client says, “I’m having a terrible time at work. I see things that aren’t making sense there and when I point them out I get yelled at. I tried to tell my parents about it when I visited them and they just put me down as “not a team player” and “not a realist.” All I could think about was what a failure I am. I can’t figure out why my life is such a mess!” This is a lot to unpack but a multi-lens therapeutic approach provides you with a straightforward way to proceed.

You might say, “You know, there are lots of different possible causes of your distress. What you just said brings to mind at least three or four possible causes. One is that stress may be a major culprit. You sound under a lot of stress. A second is that, since you were born with an incisive mind, you don’t take easily to humbug; and that may make it much harder to deal with dishonesty at work. A third is that your family is still tormenting you. A fourth is that you can’t get past the idea that you’re bound to fail. Do these all seem to be in play?”

By saying this, which may sound like a mouthful but which is quite easy to say with practice, you’ve looked at the situation through four different lenses (the lenses of stress, cognition, family dynamics, and original personality), helped your client better understand the multiple reasons for her distress, and provided a roadmap for your work together. You can work on whichever of these your client identifies as the most pressing. At the same time, you can keep the others “at the ready” to work on as time permits, when they reappear, or when it seems smart to return to them.

Your client is likely to reply, “All of that is true!” Then you can take any one of the following approaches (or others, of course). You could say, “Which of these four seem most important?” You could say, “Let’s pick one of these to focus on – which one do you think it should be?” You could say, “That’s a lot, isn’t it? That’s probably why you’re feeling down, because so many things are combining to get you down. What do you think you might like to try, given these several different challenges?”

Your client is likely to appreciate this approach, as it matches her experience of life and honors that many challenges are confronting her all at once. “Your client will therefore become more invested in the therapy, dig deeper for her own solutions”, and feel herself to be in a genuine collaboration. A solid direction for the work to take is likely to emerge; the groundwork will be laid for future work.

As to that future work, proceeding with it might sound like the following. Say that you’ve been working on stress reduction for some weeks. At some point you might say, “Remember that we agreed that there were multiple things going on causing your distress. We’ve been working on stress reduction, which is great. But I wonder if we should take a look again at those other challenges? Maybe those toxic family dynamics, those thoughts that aren’t serving you or how your talent for seeing through humbug is affecting you at work?” In this way, you can refocus the work through any of the twenty-five lenses when and as needed.

Building Talking Points

In addition to listening for and responding to causal hints, you might want to create talking points that you begin to use regularly to communicate important ideas to clients. You might want to create a talking point around the idea of multiple lenses, freeing your client from the belief that “exactly one thing” is causing her distress; a talking point around the relationship among original personality, formed personality, and available personality, which will help your client think about her basic temperament, her stuck places, and her remaining free will; and many other useful talking points. Here is how using one of these talking points in session might sound.

Imagine that you are in session with a client who has announced that she wants to make some changes in her life.

Therapist: “Okay, so you know that you want to make some changes.”

Client: “Yes.”

Therapist: “Because currently you’re pretty unhappy and pretty stuck?”

Client: “Exactly.”

Therapist: “Let’s say that we do come up with some changes that you might want to make. How free are you to change?”

Client: “What do you mean?”

Therapist: “Here’s what I mean. Let me present you with a model. Imagine that personality is made up of three parts, original personality, formed personality, and available personality. Original personality is who we are at birth: our temperament, our smarts, our native abilities, all of that. Formed personality is who we become—the hardened person we become over time. And available personality is our remaining freedom, the part of us that is still able to make changes, see through our own games, etc. I see available personality as a sort of amount that can and does fluctuate—sometimes we are less free, say when we’re caught up in an addiction, and sometimes we’re freer, say when we enter recovery. Does that make sense?”

Client: “It does.”

The preceding was a characteristic talking point of multi-lens therapy. Once you create these talking points, they are very easy to use in therapy. In this case, you’ve presented your client with three huge ideas in a simple paragraph. You’ve announced that temperament matters—that who she was at birth matters. Second, you’ve announced that her formed personality is likely to be hard to alter, given that it has “solidified” over time. Third, you’ve provided her with a picture of what “freedom” looks like, opening the door to important existential conversations.

If you can say the above, or something like it, you will have presented your client with some big ideas and a frame that she can use for the rest of her life to help her think about her own personality, about where she is stuck and where she is free, and about how she might want to “make use of her current available personality” while also “increasing the amount available to her.” That is a lot to provide a client!

Therapist: “So, thinking about this model, how much availability personality do you think you have?”

Client (thinking): “Not very much.”

Therapist: “Okay. That’s where most people are. That’s one of the things we have to contend with, that lack of freedom. So, what might help increase that freedom?”

Client (thinking): “I don’t know.”

Therapist: “Fair enough. Let’s think about it together. Imagine that you were just a little bit freer. What would that look like?”

Client: “I would tell Bill what I think. I would have more of a voice.”

Therapist: “And if you spoke up, you would feel freer?”

Client: “Yes.”

Therapist: “But?”

Client: “But that feels much too dangerous.”

Therapist: “Feels dangerous or is dangerous?”

Client (thinking): “Both.”

Therapist: “Okay. Let’s tease that apart. What’s the actual danger?”

Client: “We’d be in conflict. And I hate conflict. And it might put us on the path to divorce.”

Therapist: “Okay. What’s the feeling part?”

Client: “That’s all tied up with me having authoritarian parents and having my voice silenced again and again as a child. That still frightens me, the vision of my angry mother and my angry father. Those feelings are very large and very terrible.”

Therapist: “Okay. So, we have two truths. Speaking up is dangerous and feels dangerous. Let’s see if there’s anything to do for the one and anything to do for the other. Okay?”

Client: “Okay.”

Here’s another situation where responding to causal hints with a spirit of inquiry and careful talking points deepens the work. Your client says, “Visiting my in-laws, who are very old-fashioned and the opposite of progressive, makes me really anxious. I get so anxious that I get sick beforehand and sometimes get too sick to travel. This makes my husband really angry, because he’s sure that I’m getting sick on purpose just to get out of visiting. He scolds me and shuns me and my way of coping is to spend hours talking to my sisters, who are the only people I can trust.”

The issue here isn’t anxiety per se. The issue is the whole picture. To provide an anxiety “diagnosis” (that is, an anxiety label) and to opt for anxiety as the sole focus is the current reductionist practice. “A multi-lens therapist unpacks this narrative, looks at it through the lenses of culture and society, trauma, social connection, instinct, and perhaps other lenses as well”. She replies, “There’s a lot going on here. It sounds like you’re in conflict with your husband’s family’s values or they’re in conflict with yours. That’s one part of it. Then there’s the ongoing trauma of your husband’s scolding and shunning. There’s the wonderful, positive social connection piece with your sisters. And it sounds like your body is having an instinctive, self-protective reaction to the situation, warning you that things are not okay. Does that capture what you just expressed?”

It would be lovely if you are exactly right but it doesn’t matter if you are exactly right. You are simply inquiring; and your client will appreciate it that you are trying to get a real handle on her situation. A talking point that you might add in the course of this collaborative inquiry is the following: “When there’s a lot going on we have to be patient and tease apart the various threads. It won’t pay to just slap on a label and call you anxious. We want to figure out what’s going on that’s making you anxious and, more than that, we want to improve your whole life. Agreed?”

Focusing the Lenses

Your current way of doing therapy may not include much teaching, explaining, or using talking points like the ones above. But if you’re engaged in explorations and investigations with your clients, as I believe you should be, that requires that you help your clients understand what you have in mind. You want to be able to say, “That’s one possible way to look at what’s going on. But there are also other ways. Can we check those out?”

If your client agrees, then you will need your talking points so that you can introduce those “other ways of looking at what’s going on” in simple and clear ways. With those talking points at the ready, you’re much more likely to learn what’s really going on, which then allows you to aim your helping in the appropriate direction. By paying real attention to what may be causing your client’s distress, you greatly increase your therapeutic options.

Of course, that you have done some excellent work discerning causes doesn’t mean that you or your client will then know what to do. But that information must prove valuable, at the very least insofar as it prevents you and your client from misunderstanding what is going on. And it is bound to suggest possible avenues to try. Whether those avenues will prove fruitful must remain to be seen. But you are traveling down them for good reasons, because you have inquired and listened.

Psychotherapy as an idea and as a practice has not completely escaped critical scrutiny. But, on balance, the critical psychology movement and other critics of contemporary mental health practices have more often taken aim at deconstructing the mental disorder paradigm, as reified in the DSM, than deconstructing the psychotherapy paradigm. “Psychotherapy has managed to fly a bit below the radar of critique”.

But it has needed critiquing, in large measure because it has taken too cavalier an attitude toward causation. What a doctor does is generally well justified by virtue of the fact that he is treating the causes of things as well as their symptoms. He cares if it is a virus and he cares which virus it is. What a psychotherapist does is on much shakier ground, since psychotherapy has taken a cavalier attitude toward causation and not made “investigating causes” a central activity of the practice. Therapists, provided by psychiatry with a checklist way of labeling clients, have been rather left off the hook when it comes to tackling the matter of causation.

A multi-lens therapist is on much more solid footing, since he or she can say, “I check carefully for causes by investigating the causal hints I hear and the causal clues I get. I then connect my helping strategies to what I learn. If I can’t discern what is causing my client’s distress, I can still be of help, because talk helps and support helps. But I don’t act like causes don’t matter and I do my human best to figure out what’s really going on. This is no easy task, as causation in human affairs is typically complex and obscure. But I try.”

The following is a list of 25 lenses gathered over the course of my clinical career through which to investigate causation. It is not meant to be comprehensive, but it does a good job of not being reductionist and allows for a lot of rich thinking and investigating.

1. The Lens of Original Personality
2. The Lens of Formed Personality
3. The Lens of Available Personality
4. The Lens of Circumstance
5. The Lens of Time Passing
6. The Lens of Mind Space
7. The Lens of Instinct
8. The Lens of Individual Psychology
9. The Lens of Social Psychology
10. The Lens of Development
11. The Lens of Biology
12. The Lens of Family
13. The Lens of Cognition
14. The Lens of Behavior
15. The Lens of Social Connection
16. The Lens of Experience
17. The Lens of Endowment
18. The Lens of Stress
19. The Lens of Trauma
20. The Lens of Emotion
21. The Lens of Culture and Society
22. The Lens of Environmental Factors
23. The Lens of Psychiatric Medication and Chemicals
24. The Lens of Creativity
25. The Lens of Life Purpose and Meaning

Multi-lens therapy asserts that if you are leaving out temperament, social and cultural realities, life purpose and meaning issues, and the other lenses through which a multi-lens therapist looks at her clients, you are leaving out too much. You are operating from too limited a place and making it harder on yourself to be effective by virtue of not meeting your client where she is “really at.” If you do meet her there, she will trust you more, warm to you more, engage responsively, and do more work out of session. Multi-lens therapy paints a truer-to-life picture of human reality and also makes the work of psychotherapy much easier. There’s a lot to value there.
 

From Cultural Competence to Cultural Humility & Equity

Posted on by Psychotherapy.net Team

What if traditional notions of “cultural differences” in clients have been misleading? The over-representation of children of color in the welfare system is more about policies and institutions that fuel disenfranchisement, and less about cultural attributes.

Despite being a cherished ideal in psychotherapy for decades, the term “cultural competence” has become increasingly flawed. It has poorly accounted for the power dynamics present not only in psychotherapy, but also in broader institutional and healthcare settings. It has also overlooked social injustice and contextual and structural influences essential to someone’s “culture.”

“Cultural competence” was coined by anthropologist James Green in 1982, and then disseminated to the fields of social work, psychology, psychotherapy and counseling. It is based on classifying culture by race and ethnicity. It has emphasized prior assumptions of cultural difference among ethnic groups. These classifications easily stereotype people, dismiss key intragroup differences and areas where they don’t apply, and consider culture as a monolith. This overlooks the reality that there are often more within-group than between-group differences among many categorized in certain groups. For example, the classification of “Asian” can overlook differences between Cambodian, Korean, and Japanese.

Becoming “competent” in someone else’s culture is not only insufficient, but largely untenable, especially if we have never been immersed in it. “Culture” is too nuanced for psychotherapists to “master.” Essentializing culture has become a disparaging form “otherizing,” and risks colluding with the power of the dominant group. The “other” focus also implies that default is White, and “others” as non-white, non-cisgender, non-English-speaking, non-Christian, non-heterosexual, etc.
Notions of competence are most flawed because they overlook the dominant status of the White group, the status quo of power over marginalized groups, and depend on overly formulaic prescriptions about how to do therapy with “them.”

“Cultural humility” is a promising replacement. It acknowledges the fluidity of culture and pushes individuals, communities, and institutions to scrutinize social inequities. Humility acknowledges differences in power and challenges injustice and related barriers at the broader levels outside of the client’s immediate social web. The shift from competence to humility is from an expert stance of understanding “others,” to emphasizing accountability in addressing institutional barriers that impact marginalized clients. For instance, the oil fracking in Colorado in neighborhoods with low-income Latinx communities is associated with negative health outcomes. Low-income communities also tend to be more dangerous, less sanitary, and less resourced. This is not a reflection of cultural characteristics.

“Cultural equity,” like humility, examines institutions and systems of subordination across and within cultures. Equity specifically examines the relations between power, privilege, oppression, family, and communal life. While competence aims merely to learn a group’s history, values, and attributes; humility and equity strive to reduce oppression and injustice. While competence stresses sheer self-awareness, encouraging practitioners to be more comfortable with differences, humility and equity add thorough assessment to the inherent power disparities in therapist-client relationships. Competence has also focused primarily on race or ethnicity, deemphasizing other germane disparities, such as SES, disability, sexual orientation, and gender identity.

Ana, age 18, an excelling student, has a mother from Guanajuato, Mexico, and stepfather from San Diego who is currently in jail for drug-related charges. Her mother brought her here at 9-years-old to escape Ana’s violent father, a policeman who muscled his power to block her and Ana from protection. Ana and her mother have no nearby relatives. She applied for DACA status in 2013. She came to therapy feeling depressed, barely able to get out of bed or attend school for 2 weeks. Despite acceptance into UCSD, her dream university, she was unable to access financial aid due to her legal status.

We explored her situation as being privileged growing up speaking English with a native-born step-father yet subjugated as an undocumented immigrant with temporary DACA protection. We attended to her persistent fear about her status. I humbly acknowledged that it’s impossible for me to have a complete understanding of how culture and systems of injustice impact her although I have lived in Mexico and had a Mexican partner. I recognized how my privilege as a graduate-level educated and White male US citizen may blind me from certain crucial aspects of her experience. We collaboratively strived to decrease the inherent power differential between us by encouraging her feedback throughout therapy.

In response to mentioning that the term “Latinx” is gaining popularity because it emphasizes inclusion, she self-identified as Chicana to convey pride in her dual heritage. We then discussed the unjust disparity in financial access despite her academic merit. From researching in-session, we learned an empowering loophole: a co-signer may help her access aid, something her high school’s career center did not know, and reached out to nearby clergy who presented her predicament to the community to secure a co-signer.

***

Cultural competence is not merely a set of skills and techniques acquired through hard work. While competence emphasizes knowledge acquisition, humility and equity stress responsibility at individual and institutional levels. While competence would imply that problems come from lack of knowledge or awareness, humility and equity recognize power differentials, and call for action and changes in attitudes about diverse clients and the broader forces that subjugate them. Clients from disenfranchised communities have less access to quality services, a lack of linguistically and culturally appropriate services, financial barriers, scarce time, and limited knowledge of resources available to them.

If you want to lead and effect change for clients, a technical and knowledge-based competence focus will not suffice. Training in humility building and equity appreciation are the keys to building improved relationships between therapists and clients. We begin to make a key difference when we attend to the equitable distribution of resources and confront unjust politics, practices, and policies, and examine how they influence one’s “culture.”

Resources

Almeida, R., Hernandez-Wolfe, P., & Tubbs, C. (2011). Cultural equity: Bridging the complexity of social identities with therapeutic practices. International Journal of Narrative Therapy & Community Work, (3), 43.

Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2015). From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education, 34(2), 165-181.

Let’s Meet in the Middle

Posted on by Psychotherapy.net Team

We all want our feelings to be understood. But even if we have a significant other with whom we feel understood, we may find that we become misaligned as career and family life evolve and change. Nowhere is this more true than with professional couples and dual-career families as they take on new role-based challenges.

Recent research¹ indicates that the dynamics affecting the quality of a couple’s relationship stem from differences in motivation (approach/avoidance orientations) and patterns of interpersonal behavior. I look at both factors in the case of Meg and Paul, two highly educated professionals, each with histories of neglect in childhood. What I also consider is a style of engagement that seems well-matched to the experience and expectations of professional couples.

Couples Issues

By the time strain and conflict have become chronic, partners have often done a good deal of blaming and fault-finding with one another. It doesn’t help, but it’s almost unavoidable, as people lose their capacity to see things as they really are. Only later, after bumping up against the reality that they are stuck and that it's probably not entirely their or their partner’s fault, might they conclude that outside help, objectivity and perspective are needed.

I believe we can learn a great deal from working through our issues—their causes, course, and resolution—as couples. Doing so not only makes us happier in our couples, it makes us smarter managers, leaders and collaborators in the workplace. But of course, these truths can seem rather remote when we are in the throes of relational conflict and cannot yet see a pathway forward.

Even with awareness of our need for help, we retain the need to protect ourselves against being found lacking. We may privately hope that a therapist will take our side and that we’ll be vindicated. Couples are often ambivalent, wanting perspective but simultaneously maintaining defenses. Disarming them is about eliminating threats to emotional safety and ensuring that each person has the chance to be heard. To satisfy these conditions, we must be an empathic and assertive mediating presence.

Being heard, in this context, is more than an auditory task, and it involves more than an exchange between therapist and patient. When therapists listen actively, they provide a hearing for all three persons in the room. As the therapist and couple together reflect upon this active listening process, the couple notices how different it is than what normally happens in their exchanges at home. Thus, safety and learning depend upon how the therapist facilitates, moderates and contains the listening process.

Individual or Couples Therapy

There are times when individual therapy prior to or in addition to conjoint therapy may be indicated. When either or both members of the couple suffer from an acute mood disorder or chronic mental health problems, their capacity to participate in couples therapy may be limited. And sometimes they just can’t believe that something different and good can come from discussing their issues with their partner, not yet. But I’ve found that they’re likely to underestimate their readiness to participate in couples therapy.

In my practice, I work mostly with professional couples, the same demographic I’ve served for over 25 years in my executive coaching practice. When it comes to helping relationships, they seem to welcome an active, norm-setting agent who is willing to reign in behaviors that threaten conditions of safety and openness, or that derail productive engagement. Their basic ego strength is usually adequate. They tend to default to a practical sense of urgency to “fix” things. While their impatience and an action bias can impede progress, initially I find it helpful to leverage these attitudes to generate motivation.

They may be more skeptical and scared than they’re willing to admit, but they know they need help. They haven’t found a way to do it themselves. So, the therapist must find ways to intervene early, to validate their decision to seek therapy, and to change the way they communicate and interact. When we can model a tolerance for conflict and an ability to notice and discuss how their polarized attitudes and behaviors operate reciprocally to sustain conflict, we earn credibility. And that’s critical. Professional couples more than others will be looking for evidence that we’re competent.

Meg and Paul

When I met Paul, he was presenting with anxiety stemming from work and marriage. He was on an SSRI for anxiety and on Ritalin for ADHD. He reported a childhood replete with dysfunction and less than good-enough parenting. Raised in a small town in Alabama, he adapted by retreating to a rich imagination and creative talents, later attending a top art school in the Northeast and then settling in Brooklyn. I didn’t have to tell him his family of origin was dysfunctional. He knew it and ran as fast as he could to escape it.

Soon, it became clear that adapting at work (from artist to manager) was not nearly as challenging as making things work at home with Meg. Like Paul, Meg had a history of insecure attachment, growing up in a pastor’s home in rural Connecticut. After a failed marriage that produced two boys, she met and married Paul, who hadn’t had much success in dating or sexual intimacy. She, too, was bright and won a scholarship to an Ivy League college, but she had responded differently to childhood issues.

Meg was a fighter with an excitable temperament and a penchant for order and control. Both had suffered neglect, but Paul had taken a route of pathological accommodation and escape, while Meg had gone the way of rebellion and escape. Neither had healed the wounds of neglect. As their lives became more complicated by a third child, increased financial demands, chronic patterns of conflict and naïve hopes gave way to long-standing vulnerabilities, and each sought individual therapy.

The Circumplex Emerges

When Meg and Paul came in for their intake interview, the tension was almost immediately manifest. Sitting at either end of my six-foot sofa, they made no attempt to conceal the distance that had grown between them. I asked them to tell me what caused them to seek therapy at this time and suggested that Paul, the meeker of the two, talk first. He spoke carefully, haltingly at times, always rounding if not blunting the point of the issues he raised. I conjured an image of one navigating a minefield.

Meg sat stern-faced with arms crossed as he spoke, casting dismissive glances his way as he struggled to express himself. There was eye-rolling too, which caused me to wonder how far he got in speaking his mind at home. It was all she could do to limit her dissent to nonverbal communications as Paul spoke. Then, when it was her turn, Meg’s voice rose in angry criticism. Her first aim was to correct Paul. As she flushed with anger, Paul went pale with fear.

Her fault-finding with Paul was peppered with global accusations prefaced by “you never” and “you always.” She painted a picture of his inconsiderateness, broken promises and selfishness. Neglected as a child, she suffered it again in her marriage to Paul. Her voice rose well above the norms for my office–yes, I have such norms. So, I intervened. With a hand gesture signaling a timeout, I said, “Meg, do you have any idea how overwhelming your energy is right now?” She halted and I continued, “You’ll have to turn it down a bit if we are to communicate.”

She was taken aback and flushed from red to rose as a sudden pause prevailed. Paul sat quietly, still pale, anxiously awaiting the next steps. I can imagine the reader might wonder about the force of my presence and the effects of my behavior. Most of my clients (consulting practice) and patients (clinical practice) describe me as down-to-earth, caring, sincere and constructive. Even in my most direct moments I believe they recognize a positive intent in my face, words, and actions.

I expressed a grounded confidence. I assured them that they need not accept nor reject anything I said too quickly. I encouraged them to simply consider how it might be relevant for them. My tone with Meg and Paul was neither harsh nor timid. It was not aggressive; it was assertive. It was not out of control; it was tempered and composed. My first intervention was to invoke norms of propriety in the consulting room. This atmosphere of civility became the defining quality of dyadic communication in the therapy.

After the “flareup” was extinguished, discussion resumed. I asked how representative this episode was of the problems they’d been experiencing. They admitted that it was all too common. The difference was that at home Paul would usually not get the initial words out. Rather, Meg would define the violation Paul had committed (being late or forgetting an errand), and he would go quiet, retreat for a while, and then later try to explain himself and perhaps become defensive.

Meg would later remark on how being with Paul was like having another child. Paul didn’t agree with this characterization, but fighting it only meant extending the quarrel. So, he usually quit at this point, believing it was not worth the pain and wouldn’t change the outcome anyway. The more she played the role of his parent, the more he was cast in the role of a child.

We used the interpersonal circumplex² to consider this chronic pattern. I have found this model quite useful with couples. It plots interpersonal behavior in two-dimensional space using two axes, Dominant/Submissive and Friendly/Hostile. Using the model, we’re able to see how our expressed behavior is likely to “pull” a style of behavior from others. On the one hand, a dominant expression tends to pull a submissive response, and a submissive expressive style pulls a dominant response. On the other hand, friendly and hostile expressions seem to invite others to respond in suit. So, how did this apply to Meg and Paul?

They had been interacting in the hostile side of the circumplex, Paul from the submissive area (passive style) and Meg from the dominant area (aggressive style). We also observed that my intervention came from the friendly dominant area (assertive style). Finally, we noticed that the pause arose from the “neutral” space in the middle of the circumplex as a pause for reflection on communication style. Thus, the title of this article and my suggestion to couples that when they notice tension building, and before it becomes entrenched conflict, they tell themselves that it may be time to “meet in the middle.”

Communication Styles Chart

 Figure 2 Communication Styles (Penberthy, 2016)
 


About Motivation

Of the many ways to characterize motivation, a fundamental way of conceptualizing it is through the approach/avoidance paradigm. It’s been around since Neo-Freudian thinkers like Karen Horney, Erik Erikson and Harry Stack Sullivan, and builds upon the interpersonal point of view. It gained even more support from the observational studies of mother-infant attachment. Its central thesis is that we are essentially social beings with needs for connection and intimacy. As adults, these needs manifest in our intimate relationships with others, and also in our interdependency in the workplace.

“What we learn early in life from caregiver relationships shapes our beliefs and expectations about what is possible and probable”. When our caregivers are attentive and available, and as we and they learn how to jointly navigate nonverbally and pre-cognitively in ways that satisfy our needs, we develop a sense of trust: “I can rely on others to care, to read my behaviors, and when they fail, they don’t abandon me. No, they persist until my needs or insecurities are resolved.”

Such successes in adaptive learning and development promote an approach orientation. This includes beliefs that most problems can be solved with help, and that those with whom we share our lives at home and at work are usually willing and able to be helpful. We act from a benevolent hypothesis about others’ motivations and with optimistic beliefs about what we can do with their help. But absent this positive early-life experience, we may approach relationships with less trust and positivity, with more suspicion or doubt, and often with fears of abandonment.

Patterns of Avoidance

In the case of Meg and Paul, we observed histories of maltreatment that would understandably lead to lower expectations of what might be possible in relationships. They might look for (project) evidence of the betrayal and mistrust they experienced early in life in the contemporary behaviors of those they hoped would be there for them.

For Meg, it was an ostensibly kind and service-oriented father (pastor) who seemed to have little time and interest for her needs. He turned his attentions elsewhere, perhaps in ways that won him esteem in the eyes of those he helped. And her hopes of finding enduring love with her first husband failed. Like her father, he was “selfish.” And now, as life’s demands on Paul increased, she saw him too as neglecting her out self-interest. It was reinforced daily when he arrived home late or forgot to stop at the market.

Meg had been on alert for signs of neglect since she was a little girl, all to guard against more rejection, and she found them in her adult relationships with men. We could describe this motivational orientation as avoidance. She might ask Paul to do things, but her expectations of his delivering on these requests were very low. She was fully armed to express her anger and mistrust of him every time he fell short. In her eyes, he was breaking a promise, and she wasn’t taking it anymore. She increasingly threatened divorce in her moments of peak anger and frustration.

Paul’s mode of avoidance was more obvious. It was based on his fear of conflict learned as a child. Meg’s stern look and voice tone signaled a threat to which he reacted with an impulse to retreat. Neither he nor Meg could readily identify in the moment the fears and vulnerabilities they were replaying from childhood. They were both caught up in self-protective (defensive) routines intended to distance them from harm. That is, until in session we would enter the neutral zone represented on the circumplex model.

Noticing and suspending the visceral grip of legacy, avoidance-based emotions and motivations, adaptive approach-oriented motivations, goals, and behaviors became available. This pause simply hastened access to the approach-based responses that had been activated in Paul after Meg finally collapsed in emotional exhaustion and despair from her angry outbursts. Meg’s approach behavior was activated as she finally welcomed Paul’s concern, support, and sympathy when her aggressive energies had quieted. They both took roundabout routes to dialogue.

These, then, were the dispositional tendencies of motivation that energized their chronic patterns of conflict. The avoidance-based mindset had governed behavior with increasing frequency. I noticed that the approach-based resolution strategies were not working as often or as well. They were both feeling exhausted and discouraged. Both, especially Meg, were losing hope that things could change. Their differences in personality and behavior seemed unchanging, perhaps unchangeable.

It took concrete behavioral analysis of specific situations to shift their focus to variables that they could realistically influence or control. We had to do a great deal of situation analysis in our therapy sessions to acquire a basis of trust and positive expectations for change. We had to recognize the way they were both setting unrealistic and unattainable goals, and how they were neglecting adequate attention to the positive thoughts and behaviors that could interrupt their old routines.

Finally, we had to notice how different the results of our in-session problem solving were from their out-of-session efforts, and to ask ourselves why they were different. They recognized that there was little they were not able to do behaviorally if they approached it deliberately and thoughtfully. They had to own the responsibility for doing this work, and they had to recognize the payoff in doing the work, individually and as a couple.

Getting to the Point

The advantage of couples therapy for Meg and Paul was that it made them more responsible and accountable sooner. Their contributions to the problems were noticed and called out in real time. Faster-acting avenues of change became available. My observations were grounded in specific situations. It’s an approach that safeguarded them both and returned our focus to salient themes of reciprocal interaction that underlies their conflicts. Concrete "do’s and don’ts” emerged as takeaways.

They internalized a capacity for assertive problem solving that extended beyond the consulting room and their relationship, and into the workplace. Meg reported less ruminating, guilt and resentment. Paul described a growing sense of confidence and ease in his interactions with Meg. They regressed on occasion and learned how to grow from the experience. They deepened their insight and skills in the process of repairing one or two significant ruptures along the way.

“Disposition does not mean “chipped in stone.”” Their differences in temperament (Paul more laid back and Meg more intense) remained. However, both discovered a greater sense of freedom from the automatic expression of their avoidant motivations. They learned that their reactive tendencies from early life were important to notice (somatically, emotionally, cognitively, relationally). These tendencies were not to be dismissed, denied, or taken as fact; rather, they became valued as warning signs.

I accommodated their sense of practical urgency by anchoring change efforts in concrete behaviors and specific situations. In this way, they were able to more readily see the behaviors that help and hinder realization of their change goals. They learned to appraise and re-appraise their expectations for change against standards of what was realistic and achievable. In the process, they noticed how slowing down for a reflective pause could speed things up. They found reason for hope in these skilled practices.

Concluding Reflections

Each couple is unique, and the helping strategies of their therapists will vary in approach, length of treatment, and frequency and duration of sessions. Having said that, I usually tell couples that it will take us 4-6 weeks to determine if couples therapy is working for them. By then, we’ll have a good idea of what the core issues are and what is required to address them. And we’ll do that by actively engaging the couple in the process, which means they’ll be more able to make informed decisions.

Through early steps of progress in session and practical guidance for change between sessions, they acquire skills and build trust and confidence in the therapist and in each other. Guidance may be more directive in the early phase of therapy, but it becomes more non-directive as positive norms of attitude and behavior take effect. As an easier, less defensive quality of exchange becomes possible, the role of the therapist becomes more that of consultant and coach.

Couples’ gains are sometimes achieved in waves over longer periods of time (6 months or more). For others, significant change, for example restructuring relational dynamics and communications, might occur in 6-8 weeks. And when does it stop? That too varies, but insofar as our work is goal-focused, we are better able to jointly assess how they are doing, what they’ve learned, and when termination or transition to a maintenance schedule might be advisable.

My approach to helping others as a coach and therapist has always been assessment-based and goal-oriented. Goals in this sense represent purposive aims that give meaning to our actions and accomplishments. These are considerations that weigh heavily in the hearts and minds of most professionals. When these “stakes” are called out in terms of the people they want to be and what’s required to realize these aims, I’ve usually gotten their attention. And after a good deal of experimentation with new skills at home and at work, their attention is firmly planted in interpersonal space, knowing more than ever that success at home and at work is about relationships.

I have found that goals and commitments are most robust when they’re grounded in the personal truth we can only obtain from rigorous assessment. That’s why our assessment must be a joint process. Couples must play an active role in interpreting the data that I help them collect, including the patterns of behavior that I help them surface in our sessions. Couples must personally discover the power of meeting in the middle, in that neutral zone of reflection. It is there that defenses melt away and the consequential costs and benefits of change can be seen. In that way, we soon acquire a call to action—“Let’s meet in the middle”—which can give us reason to halt the cycle of escalating conflict and see things as they really are.

References

1. See for example Kuster, M., Bernecker, K., Bradbury, T. N., Nussbeck, F.W., Martin, M., Sutter-Stikel, D., & Bodenmann, G. (2015). Avoidance orientation and the escalation of negative communications in intimate relationships. Journal of Personality and Social Psychology, 109, 262-275

2. Thanks to Kim Penberthy for permission to use her version of the circumplex model: Penberthy, J. Kim (2016). Effective Treatment for Persistent Depression in Patients with Trauma Histories: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Paper presented at the meeting of Anxiety and Depression Association of America (ADAA) Conference, Philadelphia, PA.

For further information on the circumplex model, it’s history and use, see Horowitz, L., Wilson, K.R., Turan, B., Zolotsev, P., Constantino, M., & Nenderson, L. (2006). How interpersonal motives clarify the meaning of interpersonal behavior: A revised circumplex model. Personality and Social Psychology Review, 10, 67-86.