As a practicing psychotherapist, I hear a lot of stories. These stories are, without fail, complex, nuanced, and multidimensional. But, often, clients come to therapy with a singular focus on only one element of their larger story. In narrative therapy, the term is “problem-saturated” story. Part of my work as a therapist is to guide clients to widen their lens beyond this problem story and recognize that many of their stories are actually a story within a story (within a story). The act of locating these missing story parts and creating an alternate narrative is a way to alter the problem-saturated story and to clear the way for a new, more accurate, and helpful story to emerge. I enjoy little more than when a therapeutic opportunity presents itself — it feels like a gift. So, when John, a 76-year-old gay man, shared his story with me, it came with a giant bow on it: here was a perfect opportunity for a narrative therapy approach. John’s story began like this. It felt as if he had spent his entire life being “sneaky,” and feeling remorseful for what he described as his “untrustworthy ways.” As he began to share his life story, however, a very different story presented itself.
Category: Approach
Sidestepping the Dependency Dance in Psychotherapy
“Not I, nor anyone else can travel that road for you. You must travel it by yourself. It is not far. It is within reach.” – Walt Whitman
We’ve all had someone text us a single question mark after not responding to them within the timeframe they expect. You know the one. It looks like this:
“Can I come over — 12:00pm?”
“?”
I mean, did your question mark wander off and get lost somehow? Should we head to the front of the store to reunite it with its missing sentence? While I think the use of this orphaned punctuation should be considered a misdemeanor offense, it points to a natural phenomenon about human interaction, especially the disembodied kind most common in the digital universe — when we communicate with each other, there are rhythmic expectations. When we want the rhythm of a conversation to be slower, but someone else wants it to be faster, the single question mark makes its grand appearance.
“I’m waiting,” it complains.
When starting a new relationship, deciphering these rhythms can be a challenge because the response time between parties can suggest very different things. If one party responds to a text message quickly, it might mean they’re interested in the relationship, or it might indicate that their device was simply nearby. Yet if someone responds to a text message slowly, it might indicate they’re disinterested in the relationship, or it might simply mean they’re preoccupied. The signals are unclear and they require interpretation.
If we’re honest, it’s probably impossible to know what someone’s response time actually indicates, but this doesn’t stop us from reading between the lines. But the problem with reading between the lines is that we simply end up interpreting or projecting. When we feel alone, we might imagine that our text was read but ignored, and when we’re preoccupied, we might feel smothered by a quick response back to us. While much of our communication has moved into the digital space, it remains timelessly true: new relationships have a way of tempting our projections.
It’s only after the relationship leaves its early stages that the conversational rhythms fall into place, and the uncertainties become clear. Familiarity with someone’s rhythms comes with time. Similar dynamics also exist within therapy. When the therapist and client are in the process of creating a new relationship — learning, in a sense, to dance together — the rhythms of communication are uncertain before becoming apparent. And while rhythms in a non-therapeutic relationship require time before becoming understood, therapists don’t always have the luxury of time. Fortunately, the therapist can learn strategies to remove these rhythmic uncertainties, and the process of understanding our clients can be accelerated. I certainly have.
The Rhythmic Uncertainties of Therapy
One effective way I have found to remove the rhythmic uncertainties in therapy is to be forthcoming about my own rhythms. Most of my clients have not met with me beforehand, so they don’t know the therapy rules — at least not mine. They don’t know if I take phone calls after 5pm, if I correspond on weekends, or if emails should contain intimate session details. Whatever my own therapeutic rhythms might be, it is my responsibility to make them explicit.
Another area where I have made my rhythms explicit is in my response time to phone calls and emails. Most therapists I’ve encountered choose a 24-hour window, while others choose 48. While I don’t think the timeframe itself matters too much, it’s important to pick a response time and stick to it. This is because when we stick to a consistent rhythm of communication, it elicits important questions about our clients.
“Jessica called me twice in the past 24 hours, is something wrong?”
“James calls me every day. What’s going on here?”
When I create a consistent schedule of responding to my clients, I create a baseline, and by holding my own behavior constant, it helps me to notice any deviations in a client’s behavior. If someone attempts to reach me multiple times within a single communication cycle, sometimes this deviation signals that I need to intervene. A client might attempt to make contact several times because their personal safety can’t wait until the end of a 24- or 48-hour window. Multiple missed calls can be flares shot into the sky.
In other instances, consistent attempts to contact me within a single communication cycle can indicate something much different. This behavioral rhythm often elicits an important question that each new therapist has to learn — and certainly, I was no exception. That question is, “what should be done when a client makes persistent contact and has no intention of slowing down?”
The Dependency Dance
One of the challenges of being a beginning therapist is working with highly dependent clients. While these clients are different in innumerable ways, they also share striking similarities. The stories that bring them to therapy contain universal themes.
One such theme I’ve noticed is that these clients experience a strong sense of helplessness, and as a result, they depend on others for excessive amounts of support. They don’t mean to, but they rely on their relationships to balance and guide them; they turn human beings into handrails.
The difficulty associated with this excessive need for support is often manifested through a dependency dance: a symbiotic cycle marked by ever-increasing client support, and ever-decreasing client security.
Here’s how the cycle has functioned in my own clinical work. Feelings of panic surge within the client, and in response, they contact their loved ones to help them de-escalate. Yet after the panic eventually finds its resolution, the inner turmoil soon returns, as does their need for support. From within the client’s subjective experience of the cycle, each time they’re de-escalated, they feel more convinced that they can’t de-escalate themselves. Receiving help from others unintentionally reinforces their feelings of helplessness. This increases the client’s experience of fear, and then this fear ushers the panic back in with greater frequency. It’s a panic trap.
As the frequency of their panic accelerates, so do their requests for help, and this creates fatigue in their support system. Eventually, and usually with great reluctance, their loved ones exit the dependency dance by either distancing themselves or ending the relationship entirely. Once these supportive relationships end, the client’s feelings of shame become overwhelming. With no remaining handrails in reach, they reach out for a therapist.
In my early days of practicing therapy, it took a process of trial and error before learning how to step into this complicated cycle effectively. My learning curve was steep and uncomfortable. My hope is that by sharing my early mistakes, that I can offer some modicum of guidance to fellow clinicians, both nascent and experienced.
Early Mistakes in Psychotherapy
When I first started working with highly dependent clients, there were three mistakes that I tried to avoid. The first was allowing the cycle of crisis-and-relief to continue inside of the therapy. If I allowed the client to implement their dependent style into our relationship, then the heart of their problem would remain unaddressed. I’d be providing de-escalation services, but this would reinforce their feelings of helplessness, and then their surges of panic would return more frequently. I didn’t want to contribute to the dependency dance.
The second mistake I hoped to avoid was connected to the first. I worried that if the cycle continued, I would undergo the same exhaustion that their support system did. These clients had a long line of exhausted people behind them, and I didn’t want to find myself at the end of that line. If I joined the dependency dance, I worried their exhausted support system would only be replaced by their exhausted therapist.
But the mistake that concerned me the most, the third one, was creating distance in our relationship too quickly. These clients often had important relationships recently ended, and they were bracing for rejection. They had been deeply hurt, and I worried that if I created distance in our relationship too quickly, their feelings of shame would be quickly reactivated. I didn’t want the shame they experienced in their previous relationships to be reexperienced with me.
I spent time thinking about how to simultaneously avoid these three mistakes. How could I elude the dependency dance, protect myself from exhaustion, and avoid reactivating their feelings of shame at the same time? This was hard. I felt anxious and stuck.
Each answer I came up with seemed unsatisfactory, and despite my best efforts, I made all three mistakes multiple times. I took phone calls after hours and scheduled extra sessions, and just as I worried, my client’s surges of panic became more frequent. No matter how I pretzeled myself, their need for my help only increased.
In other cases, I was too reactive. I was exhausted from being overly available with dependent clients in previous treatment episodes, and so I expressed my limits too firmly. These clients ejected from my office as if launched from a catapult before disappearing into the clouds. Their feelings of shame had reactivated, and they quickly terminated the therapy. I couldn’t blame them.
Eventually my mistakes brought me to a solution. I discovered that I didn’t need to choose between my clients becoming dependent on me, or more independent from me. Instead, I could do one before the other. I could first join the dependency dance, and then show them how to end it.
A Therapeutic Strategy Applied
I’ve come to believe that to help clients become less dependent on those in their lives, they must first be allowed to temporarily become dependent on their therapist. With this logic, and joining the client on their terms, I could work to change the relationship from the inside. Instead of telling a client to become less dependent on me, I could show them how to do it, and then they could then learn how to replicate this process within their personal relationships.
But what does temporarily joining the dependency dance mean in practice? Highly dependent clients will request extra sessions and phone calls, and so how available to make myself was the challenge.
There’s no hard and fast rule on this, but I think it’s useful to make ourselves available two additional times outside of our scheduled sessions. There’s a reason to settle on two times instead of one or three. If I make myself available outside of scheduled sessions for one time only, once I start to create distance from the client, it becomes harder to protect them from feelings of shame. These feelings of shame simmer just beneath the surface, and if I create distance too readily, this feeling can be brought to a boil. When this happens, the client’s disengagement from therapy becomes more likely.
Yet being available three times or more creates a dynamic that’s too similar to their previous relationships. If I fall into their old pattern for too long, the client isn’t working on ending the dependency dance, they’ve simply found themselves a new person on whom to become dependent. Yet by making myself available twice outside of scheduled sessions, I have the best chance of avoiding both negative outcomes: the client can avoid shame and early termination, and I can avoid becoming trapped inside the dependency dance.
Making myself available twice outside of scheduled sessions also allows me to structure two different conversations. In the first conversation, I can introduce strategies to help the client work through their feelings of panic, but I refrain from discussing their dependency. There’s not enough trust yet, and the risk of the client reexperiencing their shame is too high.
Instead, I can introduce grounding skills, breathing exercises, and other emotional regulation techniques. It’s important to introduce these strategies in the first conversation, because when their dependency is eventually addressed, I want to remind the client that they already have the mood regulation techniques that they require. More on this a little later.
But the first conversation is just as much about earning trust as it is about introducing emotional regulation skills. What I’ve learned is that when trust is low in therapy, my words must be delivered with more precision. Low trust lowers the margin for error. When clients are skeptical of my intentions or competency, my interventions need to be effective. The dart must hit the bullseye.
The good news is that the reverse is also true. When trust is high in therapy, the margin for error widens. The presence of client trust permits the absence of clinical perfection. My words don’t have to hit the bullseye, or the dartboard for that matter. It’s for this reason that I consider trust-building to be the therapeutic master-skill. It allows me to maintain my effectiveness while remaining imperfect in my practice. When I earn a client’s trust, inevitable errors are less damaging, and the prospect of client improvement despite my imperfections remains intact.
When I introduce emotional regulation skills in the first conversation, I’m also practicing this master-skill; developing trust by making myself available to the client. This is important because for the second conversation, the degree of difficulty increases. My clinical imperfections are more likely to assert themselves, and so I’m going to need a wider margin of error for what’s to come. This next dart is a little harder to throw.
The Second Conversation
Once I’ve built some degree of trust and provided strategies to help the client manage their feelings of panic, I need to exit the dependency dance the next time we meet. If I don’t, I run the risk of exhausting myself and reinforcing their feelings of helplessness. So how do I exit this dance without activating the client’s shame? I can do so by implementing these four steps:
Taking the Blame
Externalizing the Helpless Feeling
Triangulating Against the Helpless Feeling
Affirming that New Rules are for Next Time
Let’s explore an example of how this conversation might sound in a telehealth setting, and then we can unpack the steps therein:
Client: “- -”
Therapist: “You’re on mute.”
Client: “Oh, sorry. Can you hear me now?”
Therapist: “Yes, but now your picture is frozen — wait, now you’re unstuck.”
Client: “ – -”
Therapist: “You’re on mute again somehow.”
Client: “Sorry, how about now?”
Therapist: “You’re good.”
Client: “Wow, okay. Thanks for making the time. I’m feeling really bad, and I just need to talk about things with you again.”
Therapist: “Thanks for reaching out. I’m sorry things continue to be difficult. It sounds like these strong feelings keep rushing over you.”
Client: “Yeah, what should I do about it?”
Therapist: “That sounds really awful. So, I hate to sidetrack us before getting started, but would you mind if I shared something that I’ve been worrying about?”
Client: “Yeah, of course.”
Therapist: “I don’t doubt that these feelings are really difficult to experience, they actually sound physically painful. But I’ve been thinking since the last time we talked, and I’m worried about eventually making things harder for you.”
Step 1: Taking the Blame. When I start the second conversation, I can lean on the phrase “I’m worried about eventually making things harder for you.” There’s a reason this phrase can be helpful. As I’ve discussed, these clients have felt rejected in previous relationships, and their feelings of shame are just beneath the surface. Yet if I express concerns about the dependency dance, not in terms of our own personal difficulty, but in terms of the potential difficulty for them, I can reduce the chances of reactivating these feelings. I can help keep the shame beneath its boiling point.
Now is it possible that I’ll feel inconvenienced by making myself available for this second conversation? Yes. But is it helpful to share these feelings with the client? In this case, I don’t think so.
Perhaps the person-centered therapist will object, “But this isn’t authentic. You’re not demonstrating congruence!” That’s a valid critique. Sometimes there’s a tension between my intention to be helpful and my ability to be congruent. My private reactions aren’t always useful to my clients, and when faced with the choice of demonstrating perfect transparency or perfect sincerity, I want to prioritize sincerity.
While these two concepts might seem identical at first glance, I am careful not to confuse them. The word transparency comes from the early 15th century, and from the Latin nominative transparens. It translates to something like, “to show light through.” Transparency is a pane of glass from which nothing is hidden on either side. But the notion of sincerity means something entirely different. Sincerity comes from the 16th century, and from the Latin word sincerus which translates to something like “whole, pure, and clean.”
While I may not be able to maintain perfect transparency in each moment, I can always work to cultivate intentions towards my clients that are “whole, pure, and clean.” In this case, the disclosure of my own fatigue risks eliciting a shame response from the client, and if I’m to be helpful, avoiding this reaction is paramount. While it’s ideal to practice both transparency and sincerity whenever possible, in moments like these it’s better to prioritize the sincerity of my intentions over the transparency of my reactions.
After expressing that I’m worried about eventually contributing to the client’s distress, I can implement:
Step 2: Externalizing the Helpless Feeling. When implementing this step successfully, it sounds something like this:
Client: “Making things harder for me? I don’t feel that way. What do you mean?”
Therapist: “This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering if there’s this voice that tells you that you can’t manage these moments of distress on your own. My concern is if I talk through these feelings with you each time they come up, I’m agreeing with this invalidating voice. It’s as if the voice is saying, ‘You can’t do this by yourself,’ and I’m saying, ‘You’re right, let me jump in to help.’ Then each time you work through these feelings with me, it reinforces the sense that you can’t do it alone. But tell me what I’m missing.”
This intervention is more directive in nature and so it’s placed between therapeutic airbags, but to help clients approach their feelings of helplessness with more emotional safety, I can also use language that helps them externalize their feelings of helplessness. If I use the phrase, “there’s this voice that tells you…” this invites the client to think about their feelings from a safer distance. Here’s an example to demonstrate how this works.
Imagine hearing the following two phrases and listen for any differences in how you experience each statement. If it’s difficult to notice the differences while reading privately, it might be helpful to have someone read them aloud. Here’s the first phrase:
“You feel like you can’t do this by yourself.”
and the second one:
“There’s this voice that tells you that you can’t do this by yourself.”
Did you notice anything? The first phrase moves us into an emotional space and the second moves us into an evaluative one. This occurs because describing a feeling as “a voice” pulls the feeling out from the internal world, and places it into the world that’s external. An emotion is something we feel internally, but a voice is something we hear externally.
When I invite the client to think of their feeling of helplessness like it’s coming from the outside, this helps them step back from their uncomfortable emotional state. It creates space and emotional safety. This can make it easier for them to think about what they’re experiencing.
After I’ve taken the blame and externalized the feeling of helplessness, I can move into:
Step 3: Triangulating Against the Helpless Feeling. Let’s reenter the transcript to hear how this might sound:
Client: “I guess that makes sense. But what do I do about it?”
Therapist: “Well I think we could team up against this voice that says you’re incapable. I think we could create a practice arena for you to prove it wrong. If we can build some victories where you move through these times independently, then you can grow in your confidence to manage these difficult feelings. But please, push my thinking around here.”
When I externalize the helpless feeling in Step 2, I’m not only creating distance for the client to think about their feelings with more safety, but I’m also laying the groundwork for Step 3. These two steps work well together because by using the “the voice” intervention, I’ve increased the number of participants in therapy by one. Therapy goes from two parties (the therapist and the client), to three parties (the therapist, the client, and “the voice”). And once I’ve created this third party, I’ve created the opportunity for triangulation.
Now, triangulation typically carries a negative connotation and for good reason. It’s used to describe the process whereby two people inappropriately collude to exclude a third party. Triangulation is the reason groups of three are often unsuccessful in adolescent friendships; two friends grow closer to one another by excluding the third.
Yet in this case, the third party (the voice of helplessness) needs to be sidelined, and I can grow closer with my client by excluding it. I can initiate this benevolent triangulation by using the phrase, “we could team up.” This phrase prevents me from challenging the client’s feelings of helplessness directly, and instead I’m able collaborate with them against “the voice.”
That was Step 4: Affirming that New Rules are for Next Time, and this brings my four-part strategy to its conclusion. Here is the therapeutic dialog:
Client: “I hear what you’re saying, but I still don’t know what to do.”
Therapist: “Maybe we can start by reviewing what worked last time. This way I can help you find some relief today, but we can also figure out what to practice next time. Then when you steady yourself without me, you can push back against the invalidating voice that tells you that you can’t manage these feelings independently. What do you make of that?”
The rationale behind Step 4 is when I challenge the dependency dance, I don’t want to increase distance from the client in the same conversation. Instead, I can review the emotional regulation skills from the first conversation, but the client won’t attempt to manage their panic independently until its next occasion. This helps me demonstrate to them that changes to the relationship are not an expression of rejection. I’m not expressing my own need for distance, but instead, I’m creating opportunities for them to disprove the voice of helplessness. I’m not taking space from the client, but together, I’m creating space for them.
Now that I’ve discussed each step on its own and explored the internal rationale, I’ll provide a fuller sense of how this four-part strategy sounds with all four parts together. Here’s the transcript in its entirety:
Therapist: “I don’t doubt that these feelings are really difficult to experience, they actually sound physically painful. But I’ve been thinking since the last time we talked, and I’m worried about eventually making things harder for you (step 1).”
Client: “Making things harder for me? I don’t feel that way. What do you mean?”
Therapist: “This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering if there’s this voice that tells you that you can’t manage these moments of distress on your own. My concern is if I talk through these feelings with you each time they come up, I’m agreeing with this invalidating voice. It’s as if the voice is saying, ‘You can’t do this by yourself,’ and I’m saying, ‘You’re right, let me jump in to help.’ Then each time you work through these feelings with me, it reinforces the sense that you can’t do it alone. But tell me what I’m missing (step 2).”
Client: “I guess that makes sense. But what do I do about it?”
Therapist: “Well I think we could team up against this voice that says you’re incapable. I think we could create a practice arena for you to prove it wrong. If we can build some victories where you move through these times independently, then you can grow in your confidence to manage these difficult feelings. But please, push my thinking around here (step 3).”
Client: “I hear what you’re saying, but I still don’t know what to do.”
Therapist: “Maybe we can start by reviewing what worked last time. This way I can help you find some relief today, but we can also figure out what to practice next time. Then when you steady yourself without me, you can push back against the invalidating voice that tells you that you can’t manage these feelings independently. What do you make of that (step 4)?”
***
I’ve learned that while it’s understandable for the therapist to feel overwhelmed when working with highly dependent clients, it’s important to remember that these clients are living incredibly uncomfortable lives. It becomes even more important, therapeutically, to try to imagine their surges of anxiety, their loss of important relationships, and the sense that life is a spinning room. By working to understand what these clients experience in their emotional and social worlds, it becomes easier to provide support they’ve yet to experience. The real work then focuses on earning their trust, teaching them strategies to reduce their distress, and watching with admiration as they learn to exit the dependency dance themselves.
[Editor’s note: In the next installment of this five-part series, the author will address the challenges of working in the shadows of client suicidality]
Our Time is Up
When I arrived at Joan’s, there was construction going on. The elevator I had usually taken was being worked on, so I had to take the service elevator. I asked the doorman what was happening and he said they were making the elevator self-service and doing some redecorating.
“What will John [the elevator operator] do then?” I asked naively.
“He’s retiring. He was over 70.”
Sad I had not said goodbye to him, I frowned. I had seen him three times a week for years and had just taken him for granted. I guess I thought he would always be there.
When I rang Joan’s bell, she startled me by opening the door herself rather than ringing me in. Her face was ashen, as if all the color had been siphoned out and her eyes had small dark pouches under them. I had a feeling of foreboding; I could hear my heart pounding.
“Hi, Rose,” she said with as much of a smile as she could muster.
She opened the door to her office for me to go in and when she walked over to her chair she was limping. I didn’t notice it before because she was sitting in her chair the last couple of times I arrived for my sessions. I wondered what that could be about. Maybe she hurt her leg or needed a hip replacement.
She said, “Instead of lying down today, why don’t you sit up?”
Then I knew this wasn’t about her leg or her hip. Propping up the pillow against the wall under the Georgia O’Keeffe poster, I tried not to breathe, as if that would delay the bad news. I noticed the philodendrons by the window were brown around the edges; she must have forgotten to water them.
“I thought I hurt myself exercising at the gym when I first felt a pain in my side.” Her tone was calm and accepting; I could feel myself exhale. Her gray roots were showing, and her hair was flat on one side as if she had slept on that side and not taken a shower and washed her hair that morning.
“When it didn’t get any better in a few weeks, I went to the doctor, and he said it was probably a hairline fracture. He took an X-ray. Then he called me to tell me it wasn’t a hairline fracture — the cancer has returned. It’s metastasized and it’s cracked my bones in the hip and pelvis.”
I let out a gasp. “Oh, fuck!” My lower back tightened.
She went on unruffled. “I’m going to need a partial hip replacement and they’re going to put a pin in my hip. I won’t be able to walk for several weeks.”
“Will you come back after that?” I asked hopefully, like a child asking her mother if she will come home after she goes away for a trip.
She looked down for a moment as if she were avoiding my eyes. Still not looking at me, she said hesitantly, “No . . . I won’t be coming back. It’s terminal.” Then she looked at me and her eyes were wet with tears. Her shoulders were hunched as if she had given up on trying to sit up straight.
I struggled for breath as a waterfall of tears careened off my face. “How will I go on without you?”
I got off the couch and kneeled in front of her chair, putting my head on her lap and my arms around her. I was quiet; I just wanted to hold onto her.
She stroked my hair and whispered, “You will be fine. You’ve come such a long way; you’re such a good analyst and you have Stephen. You’ll be okay.”
“Joan, I love you true and blue and like glue. I hope you know that.”
“Of course, I do.”
I noticed a run in her stocking and suddenly realized I might be hurting her by leaning on her that way, so I got up and walked over to sit on the couch.
I wondered if Joan felt guilty leaving me in the middle. The problem is you never know what’s the middle.
I pondered the question out loud to Joan. “Maybe that’s why sessions are purposely set up to end at an arbitrary moment — to end in the middle.”
“What do you mean?” The lines around Joan’s eyes had deepened considerably from the last time I’d looked at her face closely.
“Well, they always end after 45 minutes no matter what’s going on in the session. I used to get so angry at you for that. It felt so heartless. It felt like you didn’t care about me.”
Joan laughed and said, “Yes, I remember.” Then she added, more seriously: “There are things you can’t control. We have to live with that.” Her arms were crossed as if she were hugging herself.
“But you seem so calm. You don’t sound angry. Why?”
“Well, you know . . . Of course, you don’t know, but my mother died of breast cancer when I was 16,” she said, knitting her brows. “I think I’ve always known this was going to happen. It’s been a time bomb ticking my whole life. It isn’t a surprise.”
I was torn between the pleasure at her telling me about herself and my compassion for her having spent her whole life waiting to die.
“How were you able to stand my anger at my mother when you lost yours at such a young age?” I asked.
She tilted her head as if she was considering the question, but then her face grimaced in pain when she tried shifting her body in her chair. “My mother never talked to me about her illness or about dying. My father died when I was 10 and there was never any discussion about it. My mother would say, ‘He’s dead, what’s there to talk about?’ And when she was dying, she never tried to help me, and my brother worked through the loss of her. She didn’t want to talk about it. So, I understood your anger at your mother.”
“So, you were angry at your mother too,” I said with raised eyebrows.
“Yes. Maybe that’s why your analysis has worked so well. I’ve always identified with you. Even rooted for you. My mother used to say, ‘You’ll break your arm patting yourself on the back.’ So, it’s been a struggle for me to feel pleasure at my accomplishments, but it’s been a delight to see yours. I feel so proud of you.”
She smiled at me again, but her eyes looked sad. “I’m afraid we’re going to have to stop now.”
An old part of me erupted for a moment — I bawled. “You mean stop forever?”
“Yes.”
The eruption was over in a moment. I didn’t want to cause her any more pain than she was already suffering from.
“Can I visit you?” I pleaded.
“I don’t know yet. We’ll have to see. Do you think you can bear that?”
“I don’t know. I guess I’ll have to.”
“Why don’t you wait a month so I can see how I am doing after the surgery and when I start the chemo. Then I’ll know better.”
“Okay.” I got up from the couch and looked into her sad blue eyes and said in a choking voice, “Goodbye. Please remember I love you true and blue.” Then I turned and walked out the door of the office.
***
I contained myself until I reached the street. Weeping turned into bawling by the time I got to Broadway. People turned to look, but kept their distance, walking past me quickly as if they would catch whatever I had. I thought about what I said to her. By then I knew I didn’t need to see Joan in order to ward off my sense of isolation and exile. I had Stephen and a growing practice, and I was feeling full and capable of nurturing. Joan and I had been talking about terminating my treatment soon anyway. I wanted to see her because I cared about her; I wanted to give her my love, but I had stopped feeling desperate for her.I thought about Frume Minkowitz and my guilt when I had to leave her in the middle of the semester. One day I walked out of my classroom at Brooklyn College and a young woman was standing in the hall with a baby in a snuggly on her chest and two toddlers holding her hands. She was wearing a sheitel and a long-sleeved blouse although it was a warm spring day. She looked familiar, but I didn’t know who she was.
“Rose?” Her large brown eyes looked intensely into mine, “I’m Frume.”
She had come to tell me she had not only survived the aftermath of my leaving her, but she had thrived. Her smile was radiant as she introduced her three children.
She said, “I’d like you to meet my children. This is Avram, he’s 3.” She raised her right hand to indicate the little boy with peyos was Avram. Then she raised her left hand to indicate the four- or five-year-old with the long pink dress and matching tights and said, “And this is Shoshanna.” She looked down at the sleeping baby in the snuggly and said, “And last but not least, this is Joshua.”
“Oh, my god,” I gasped and immediately felt embarrassed at the inappropriateness of using G-d’s name in response to her.
“I wanted you to know,” she said with a knowing smile, “that you changed my life, and I never forgot you. I had a rough patch for a while but now I have Shmule and our children and I’m very happy. I wanted you to know that.” A tear ran down her left cheek.
This excerpt is taken from "Our Time is Up" by Roberta Satow (2024) and published here with explicit permission of IPBooks.
The Pros and Cons of Remote Therapy: A Clinician’s Dilemma
The classic image of a therapy session is a therapist, a patient, perhaps on a couch, in a small room with a box of tissues between them. But COVID-19 changed all of that. Now, more often, therapists and patients are on screens, each logging on from different locations. As COVID-19 restrictions ease in medical environments, it is time to ask if therapists and their patients need to be in the same room for therapy to be beneficial?
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Changing Perspectives on Teletherapy
Prior to the pandemic, the thought of working remotely never occurred to me. Even if remote work had occurred to me, the fact that insurance only reimbursed for in-person sessions would have provided a significant deterrent. Four years later, I find myself of two minds when it comes to evaluating the pros and cons of remote therapy — for patients as well as for myself.
Rather than just relying on my personal feelings, I did some research into the effectiveness of remote versus in person therapy. To my surprise, I learned that patients prefer remote sessions more than therapists. As one patient said when I asked her why she prefers remote versus in-person sessions, she commented, “It’s like the difference between TV and live theater. TV is available when I want it, and live theater takes more effort — you have to get the tickets, find parking, etc.”
I appreciated the many benefits of being back in my office but most of my patients chose to stay remote. The convenience outweighed their desire to travel to my office, and they felt no discernible difference in the quality of the work. This created a dilemma for me as I weighed the cost of leasing my office and the ease of working from home against my personal preference for in-person sessions. Recently I made the difficult decision not to renew my office lease for financial reasons. Adapting to remote therapy has meant changing some aspects of how I practice.
In my mind, the greatest deficit of remote therapy is the lack of a physical presence in a shared space. When I was able to watch my patients walk from the waiting room into my office, I noticed how they carried themselves, their attire, and the mood they exuded. No longer having that opportunity online, I learned to be more specific in my questions about how people were feeling, and I look more closely for changes in appearance. Still, the intimacy of a therapy session cannot be replicated on a screen. Watching someone cry is not the same as being in the presence of someone crying. Nonetheless, I have found, to my surprise, some patients prefer sessions to be less intimate and find it easier to open up as a result. This may mean that the availability of remote therapy is capturing a new clientele for therapy.
But some patients are acutely aware of being alone, and thus find it harder to allow themselves to fully express their emotions during a remote session. I miss mirroring someone’s breath and using my steady gaze to offer comfort in person. Instead of being able to offer a tissue, I now wait as they go off-screen to retrieve one. I literally try to lean into my screen to provide a perception of being closer.
Being apart means many patients struggle to find a safe and private space like my office. Often patients are surrounded by distractions from their home, office, car, or wherever they are having their session. They find it is more difficult to shut out the world when we are not together in my office with cell phones off. Encouraging patients to make the effort to create a private space is part of the work of doing remote therapy.
Furthermore, patients tend to squeeze sessions in between other commitments, diluting the work. No longer having to take the time to get to my office, patients fail to prepare for their sessions or give themselves time to think about the session afterward. I encourage patients to build a buffer into their schedules, but realistically it rarely happens. I am guilty of this too; when I turn off my computer, I am home and no longer have my commute to process the day before resuming my personal life. I have changed my routines, so I have a clearer boundary between being at work and being at home.
Embracing the Future of Teletherapy
Despite these limitations there are important advantages to offering therapy remotely. The most significant gain from the availability of remote therapy is improved access to therapy for more people. Insurance coverage changed during the pandemic to include online sessions, which improved the possibility of finding a therapist. Initially this change suspended the need for the patient and therapist to be in the same state, furthering the potential pool of therapists. (That requirement has since been reinstated.) Finally, patients living in rural areas could find a therapist and have choices similar to those available to people in urban areas. Unfortunately, during the pandemic, demand was so high many people still suffered due to long wait lists. But over time, there is the opportunity for greater access and equity.In my own practice, during the pandemic I began work with a woman in her early 80s with physical limitations who could not access my office. The opportunity to meet with me over Zoom made it possible for her to do some significant grief work after losing her husband to COVID-19. Increased access to psychotherapy for a broader clientele is a plus for everyone.
Continuity of care can also improve when weather or travel are no longer impediments to having a session. Prior to remote work, patients had to cancel sessions when they traveled for business or had to attend to a sick child at home. I have found the ability to offer remote sessions particularly helpful with the new mothers in my practice who were experiencing or at risk for postpartum depression.
Some therapists have required patients to come back in person, while others, like me, have gone fully remote. Increasingly, therapists are working for companies which only provide remote sessions; they never establish an office. It behooves graduate school programs to adapt to this reality in their training of new therapists. It is also important that as a profession we do not create a two-tiered system, preferencing one form of delivery over another based solely on personal opinion.
As we live more of our lives online, the limitations of screens may not be felt as acutely by either therapist or patient going forward. New modalities of therapy may even emerge from this change in venue. But it is critical that the effectiveness and limitations of remote versus in-person therapy be studied. For example, people with social anxiety may request remote sessions when in fact in-person work would be more beneficial. When screening new patients, I take into account why they express a willingness/desire to be remote.
The key to a good therapy relationship has always been about fit. This equation used to be construed as the fit between the therapist and patient, but now perhaps we need to expand that idea to the room(s) where it happens.
Working with In-Law Problems in Couples Therapy
One of the most common problems I see as a couples therapist is trouble with the in-laws and its impact on the couple relationship. It can be hard enough for clients to deal with their own parents, let alone their partner’s parents, who may disapprove of them (openly or covertly), be protective of their child (or the opposite, treat their child in ways that make clients want to protect their partner), or feel threatening to clients or the relationship in some other way. Relationships can be tough, and family dynamics especially can be challenging to navigate; combining intimate relationships and family dynamics can pose its own struggles.
The Negative Cycle
Something I see often in my office is couples who struggle with how to handle it when an in-law offends. When their parent does something that upsets their partner, I often see a now-familiar and predictable pattern that I call the “That’s not what she meant” dance. When the partner is hurt, the son or daughter sees a rupture in the family; a slow unraveling of the relationship between their partner and their parent. They want harmony and for the family to get along. So, in an attempt to preserve the relationship between parent and partner, they invalidate their partner’s complaints. It could sound something like this (a dialogue I have seen in my office):
“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”
“She didn’t mean it like that, she was just surprised.”
“But it hurt.”
“You’re making too big of a deal out of this. Don’t worry about it too much.”
[Partner pouts and turns away (or explodes)].
The adult child above likely has good intentions. They hear that their partner is upset, and they want to help. They try to make things better by trying to tell them there’s no cause to worry. But if there’s one thing I’ve learned about the human experience from being a therapist, it’s that feeling understood is important to all of us, and especially aggrieved partners in scenarios like this. When I hear things like “It wasn’t like that,” or “There’s nothing to worry about,” clients feel invalidated and unheard. The partner here is not soothed, but instead left feeling misunderstood and frustrated. They likely long to truly feel that their partner “gets” them and has their back.
To help these clients avoid getting caught in this all-too-common pattern, I try to teach them to validate their partner’s struggles. If their partner says that they’re hurt by something, I encourage them to take that at face value and not try to talk their partner out of their feelings.
A Strategy for Reconciliation
Often, I see that my clients are hesitant to validate their partner’s hurt feelings when they involve the actions of a family member. They may fear that they’ll make the disharmony in the family worse, and that their partner will move further away from getting along with their parent.
In instances such as these, I try to let my clients know that they don’t have to insult their mother or father to validate their partner’s emotions and to show them that they make sense. Showing their partner that they understand why their hurt makes sense and are there for them usually restores harmony in the family, as their partner won’t feel as alienated or marginalized when they know that you are right there with them, and they are heard.
As often as possible, I encourage my client to try responding to their partner like this, with validation, understanding, and support:
“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”
“I’m so sorry to hear that, I can see why that hurts you. You put so much work into dinner and I know how much you love making people smile when they taste your food. And it was delicious. Is there anything I can do to be here for you right now?”
This response shows: I get it, I get you — and your feelings make sense.
Responding like this can help a client’s partner feel safe in knowing that they have someone on their team, and they aren’t alone in their feelings. This increased level of safety can soothe hypervigilance and make couples feel more comfortable and unified when it’s time to go see Mom and Dad, resulting in less tension and conflict.
How to Use Structured Writing to Help Clients Unclutter
The clock struck three and Mary was calling me on Zoom. Before I could say “Hi,” she was reading from a crumpled paper held in clenched fists. This was her weekly list of the topics that she wanted to bring to therapy. Her timing gained momentum until her words reached a breakneck pace. It seemed that I was witnessing a contest. Mary was like a game show contestant, reaching for the top prize that came with climbing to the top of her list of priorities.
Mary: The Gravitational Pull of Lifelong Habits
I waited until Mary finished reading, and then after taking a few deep breaths, began the arduous task of adding some modicum of structure to her list — rating the topics, determining their priority, and then talking out the prioritized topics in a bit more detail than she originally planned. Mary dutifully and enthusiastically jotted down notes corresponding to the topic at hand.
While rapport came easy with Mary and our conversations typically flowed, a seemingly interminable pause — you know, those that are unique to online therapy — Mary proclaimed, “I know, I know. I’m not ready to give up being the rescuer.”
“You think?!”
Before continuing, she gave me her usual comedic smirk and said, “But this is all real. I have a vitamin company that I’m running solo because…Um, well. It just happened. Sort of. Slowly.”
Knowing the answer, I asked in jest if Mary was still office manager at the commercial real estate company where she began working 15 years ago. Mary nodded. We turned back to her list. There were a few items that Mary also described as having “just happened.” These included volunteering to cook Thanksgiving dinner for her husband’s family and letting her sister-in-law stay with them for a long visit with an end date that was “to be determined.”
Prior to that session, Mary had been angry that her daughter had forgotten to place an order for groceries, making it necessary for Mary to stop and bring home dinner for the family on a very cold night after leaving the office. Initially, Mary regarded her anger as a simple and logical reaction to her daughter’s forgetfulness, but because there was already a template in place from an earlier clustering of items on her list, she finally seemed ready to identify another significant pattern of behavior she very much wanted to address, and hopefully change.
“My mother was always angry. She was the Lone Ranger, always putting out fires that we all set. My siblings and father, that is; not me! I did what I was supposed to. At some point, I became everyone’s helper. I guess I learned to do this when my mother became depressed.”
We eventually got to a point in Mary’s processing where she saw that there was a historical satisfaction she received from maintaining order by handling everything around her, instead of accepting the risks that came with engaging, or directly asking for the help of others. When others failed, as they invariably did, Mary felt anger. It wasn’t anger; however, at the perpetrator, but at herself because of her intractable belief that she had to then pick up the slack and failed to do so — and instead, outsourced. This rescue theme permeated all facets of her life.
Mary was circling items on her list that felt optional when she put her face in her hands. After some minimal silence, Mary described how she felt the first time she noticed her mother’s depression. “The sadder she looked, the busier I became. The busier I became, the less my brothers and father were doing. No chores or help around the house in any way.”
Through writing lists and seeing reality in print, right in front of her, Mary was able to appreciate the wide scope of her expectations of herself, and her role in continuing to be the rescuer to prevent the potential for disappointment from others.
Terry: Therapeutic Lessons in Self-Advocacy through Writing
Terry, aged 35, presented in a very warm wool blazer over a buttoned-up Oxford shirt that looked uncomfortable. His mannerisms seemed almost choregraphed corporate professional in such a way that made me think that he was working too hard at appearing polished. I believed that still waters ran deep with Terry, but I delayed my full impressions.
“I just can’t take my life anymore! Oh, no, not like that. I mean, I’m fine. Well, no, thanks to them, I am not fine. Or thanks to me, maybe. I could just leave, but then they need me, and I’m committed to seeing these changes through. I made a commitment. And I need the money. This is a huge opportunity. And, at the same time, this is no way to run a company and no way to treat a human being.”
Terry paused, looking at me almost apologetically. Wanting to normalize his expressive shouting, I nodded as if we were already in a working alliance and immediately went into establishing the presenting problem, before moving carefully into recent history. Terry’s upbringing seemed complex, and his expanded HR role at work which included dispute resolutions and public relations, seemed to mirror those early-life experiences.
In describing his days, Terry painted a picture that felt very much like a Pollock painting — taking meetings, picking up prescriptions for his uncle, being too tired to enjoy a weekend party, listening to a manipulative employee with a treacherous track record fabricate a story about discrimination, and finally, feeling financially burdened, depressed, alone, and coping with “a heart that feels like it’s doing summersaults inside my chest.”
As he frenetically laid out the complex intertwining of work and family-of-origin demands, once again, I had trouble catching my breath. Like a sports referee, I motioned for time-out, nodding slightly to offer Terry assurance that I wanted to understand everything, and to do so, I needed separation and space between each different subject. Granted, that’s not the effect that Pollock was aiming for, nor would we want to break down and bring order to his works, as chaos seemed to be the goal. But I explained to Terry that while the head-spinning menagerie of topics he was tossing onto the canvas of our session gave us a lot to work with, it would otherwise be helpful if we could indeed structure his topics and disassemble the inner chaos.
I’ve found that one of the many ironies in therapy is that the more issues are linked together, the more important it is to first separate them out. I’ve had good clinical luck by establishing traction with one issue at a time, usually the most current “hot topic.” The high voltage of that topic usually complicates and obscures other issues, regardless of when they arose in the client’s life. Without separating, wires cross, and I have frequently sat in an electrical storm of past and current issues as they collided in a dazzling and confusing Pollock-ian explosion.
Terry’s past did clearly contain some currency. He described being alone most of the time as a child, until his parents rented their basement apartment to his aunt and uncle. His uncle became his mentor. Terry emulated his uncle and grew up having two role models — his father and his uncle. Terry empathically described the contrast between his parents’ old fashioned work ethic of long hours and constant worry about the business, and his uncle’s more creative and impulsive risk taking. His uncle had a wild ride of achieving financial success after living for a time in the basement apartment, moving out and buying an enormous house on a fancy street in Brooklyn, only to lose everything 10 years later and wind up back in the basement, divorced, and working for Terry’s brother.
Terry’s formative years were spent being caught in a tug-of-war between his father and his uncle. His father wanted to hand the restaurant over to his son and his uncle wanted Terry to go to college. Terry did both, but through the years, he became the go-between for the two men. Unconsciously, he feared rejection from his father and carried this with a constant state of nervous energy and anxiety attacks, somatic digestive symptoms, and an obsessive monitoring of his health. His present work environment had some shared features of his family of origin homelife and ongoing sense of family-based obligations.
Terry was getting visibly angry within three minutes of our second session. He wanted to alleviate the sting from his recent reprimand at work, yet at the same time, he knew that he was in the right, and that his supervisor’s issues of paperwork falling through the cracks was 90 percent due to lack of administrative support and maybe 10 percent human error. Terry needed to fight back with professional decorum, but first, he needed to calm down. My suggestion was to disentangle the different items and then respond to each one — to himself — on paper, as preparation for communicating with his supervisor.
At first, Terry was irked, reluctantly pulling his laptop open and making a few nominal clicks. As we talked and Terry clicked, we created separate headings for each action item that was part of his entire merging of multiple job receptibilities. This master list with heading included multiple separate jobs that he had been unofficially asked to cover, without any new prospects for hire. Terry was pleased, and I was proud of him. As he gained clarity in the organization of his responsibilities, he also increased his personal conviction — his inner authority. Eventually, through his writing, Terry became fully prepared to meet with his supervisor. The meeting was without the previous subject of Terry being a remedial employee and failing to live up to expectations. Rather, this meeting was direct, goal-oriented, and successful.
The Positive Impact of Therapeutic Writing
In my experience with clients like Mary and Terry, I’ve found that when a client states facts on paper, they are also asserting the following:
1. They have the authority to interpret and define the facts
2. This authority is not subject to permission or approval from another
3. They have custody over the facts, as they are
4. They have the right to communicate these facts to another person, and doing so is not a betrayal or violation
Writing as a means of expressing feelings is well known, but the use of technical, terse writing can also be a valuable therapeutic tool. The tracking done in REBT and CBT therapy fits with clients when they are at a point of delving into activating events, beliefs, and consequences, but so often they also want to fully describe all the different scenarios they live out week to week. They want to take their therapist through a deep dive into the details of what transpired. This can often result in a confusion of ideas, goals, and plans, much like Mary and Terry initially experienced.
Technical writing can also be an effective means of helping a client work through the struggles of day-to-day life, including communication with others. Writing between sessions gives a client the opportunity for greater insight while deciding in advance of session time what is important to focus on. Sometimes, clients uncover a theme for the week as a direct result of writing. Whether a laundry list format or paragraphs, writing can fit easily within sessions on an impromptu basis. While the undesired feelings (dissatisfaction, grief or anger, or irritating tasks such as administrative responsibilities) do not get resolved through pen to paper or typing in a device, there is clarity through organization. This is similar to how balancing books doesn't make the red go to black, but often results in a feeling of ease.
Getting Organized: The Pre-Therapy Phase
After getting a baseline history and general understanding of the client’s concerns, there is a pre-therapy phase, akin to treatment planning. This phase begins by sifting through past and present to hit on the main problem of this moment. What is being experienced now that is problematic? Why is this problematic? What are the consequences? Is any of this problem optional? Could there be any benefits — even the kind of benefits that have more consequences later, such as avoidance? At about this point, I ask my clients to write down the words “Secondary Gains.” Some immediately Google it and some tell me the definition, as if on cue.
Once the main problem is identified, then the work of uncovering the various aspects within the problem becomes the next step. Technical writing is an ideal tool for this phase and can be a useful complement for therapy throughout the process.
The Top Card
My clients are accustomed to me saying that there is only one card at the top of each deck. Before selecting the top problem, it often helps to sort out problems into two basic categories.
In therapy, a problem is not always a separate entity, such as struggling with a recent promotion at work or difficulty adjusting to a new city. Rather, problems are sometimes complex and long standing, such as pervasive anxiety or depression or life patterns stemming from a background of trauma.
Often this pattern results in multiple struggles, where each struggle may seem like an independent problem, but each problem is part of a cluster of circumstances spurred on by the damaging pattern. In session, we take a sheet of paper and draw a line down the center. At the top of the page, we write a title on each side. On the left side is Problem Group A — Discrete Problems, and on the right side is Problem Group B — Overarching Patterns.
Problem Group A, for example, may be difficulty accepting a recent job loss, and Problem Group B typically shows up as a cluster of events or consequences linked to a combination of undesired habits, such as isolation, anxiety, and an endless state of resentment.
Problems from either category require teasing out and separating the different aspects. Aspects often include finding meaning in the problem and uncovering the types of environments and circumstances when the problem feels more present. There is often overlap between the discrete situation problems and the overarching pattern problems. But, even with this overlap, there is ultimately one card at the top of the deck and one situation or state of mind to home in on before delving into the others.
While this strategy may seem formulaic and concrete, I have found it very useful for clients like Mary and Terry, as they have tried, and successfully disentangled, prioritized, and addressed the problems that have plagued them. Doing so has also helped me to breathe a bit easier with clients who might otherwise pull me in the Pollock-like paintings of their lives.
Donald Meichenbaum on Coping with Loss and Traumatic Bereavement
Lawrence Rubin: Hi, Don. Thanks so much for joining me today. You are most widely known for your foundational work in developing CBT but it is equally important that our readers know that for these last 35 years, you have been the director of research at the Melissa Institute for Violence Prevention and Treatment in Miami, Florida.
Donald Meichenbaum: (DM) Thank you for the invitation.
LR: You had previously requested that my first question be about the tragic and unexpected death of your wife, Marianne?
The Irony of a Trauma Specialist’s Tragic Loss
DM: We were married 58 years. My wife and I were vacationing in Clearwater, Florida, escaping the snows of Buffalo, where our permanent home is. My wife was tragically hit by a car at a pedestrian crossing. You know they have flashing lights, and this is sort of a warning sign. She was hypervigilant about not trusting people to stop, so obviously she would not have stepped off the curb if the vehicle had not stopped. But for whatever reason, the vehicle continued on and hit her. And in fact, she was lifted by a helicopter from Clearwater down to the trauma center in Saint Pete.I had called her on her cell phone thinking that she was late because she had a Zoom yoga meeting that she usually attended. I got a male voice, and he indicated that she had been hit and taken by helicopter down to the trauma center, but they would provide me with a police car to drive to the trauma center. I got there and the trauma physician indicated that she had already died. I asked to see her, went in and she was covered by a sheet. I pulled down the sheet, and she was pretty messed up from the accident.
I’ve worked with head injured, so I’ve been involved in seeing such incidents. Remarkably, her hand was still warm when I caressed it. There was a chaplain sitting next to us and I asked her to take a picture of me holding her hand. I actually sent that picture to my daughter-in-law who made it into a pillow. So, it was a traumatic bereavement kind of situation.
The irony is that morning I was giving a Zoom lecture for therapists in China on how to cope with traumatic bereavement and prolonged and complicated grief. And by four o’clock that afternoon, I was living my lecture. So, one of the interesting aspects of all this, and I’d be happy to discuss it with you, is what is the immediate and more long-term impact on an individual such as myself, who is in some sense is an expert on the area of interventions — having developed cognitive behavioral techniques.
Interestingly, there are hundreds of these kinds of accidents, many in Florida, of people — for whatever reason, where the driver is not complying with the pedestrian crossing. And there are multiple accidents and deaths in this particular way. So, the issue of traumatic bereavement as compared to a kind of prolonged complicated grief is an issue that I have been preoccupied with. And moreover, I’ll just add this final note before we open it up for your further questions. There are two aspects that are really quite fascinating in the aftermath of such traumatic bereavement.
One has to do with dealing with the grief. And the other aspect that is not readily discussed by clinicians is the sequelae that follow the sudden death of a loved one. And I will give both you and the readers to this presentation, a keyword that will change your life forever. This is the most important thing you should take away from our discussion. And the one word that you need, Larry, that will change your life if you do not already have it in your repertoire, is “passwords.” If you do not have the password of your significant other who died in a traumatic fashion, you are screwed.
LR: You’ll lose access to everything.
DM: Yeah, right. So, at a moment of intimate repose for your listener, they should lean over to their loved one and say, “I love you, but do you know our passwords and how to retrieve them?” So, you know I can fill you in and turn this into a kind of therapy session? And tell you the kind of trauma events, both dealing with the aftermath of the loss of my wife, but also the police reports, the autopsy reports, the life insurance, the banking, all of the credit cards — everything that goes with it.And the interesting thing is, if you are a clinician, one of the things you do in helping me is assessing, what is the lingering impact of this, what was the aftermath like? But it’s unlikely that you would have done that and asked does your social life change, and then a whole bunch of other questions that I’ve put together. In fact, the lecture that I was giving that morning to Chinese therapists, that entire 80-page handout that I provided them with is available to your listeners.
So, if they go to Google – Meichenbaum, Donald, Melissa, Institute – they will be able to download my 80-page tool plus other items on how to treat individuals who have traumatic bereavement and prolonged and complicated grief. So, if there’s anything I say that might be of help, I’m glad for that. And moreover, if there are people who want to contact me, they could do so through the Institute.
LR: I’m fascinated by the one word that you said clinicians, spouses, partners, family members should know, which is “password.” What’s the significance of imparting that piece of wisdom of knowing your partner’s password? And how did it play out in your journey?
DM: To access a number of accounts, my life was such that my wife Marianne was a wonderful wife, a very competent person. She was an actress, and she was a June Taylor dancer. She looked after all of our finances. I’m not a very competent person other than psychology. I’m a really good psychologist. I know a lot.
But when it comes to life, she was what I would characterize as my surrogate frontal lobe. And therefore, I never knew how to run appliances or bank machines or any of these kinds of things, and she looked after it. So, to gain access to that information, you really need the passwords. Fortunately, I have four wonderful children who are competent and loving and supportive, and that helped a great deal. So, we were able to, over a lengthy period of time — trust me, it took more than an entire year — to settle accounts related to adaptive functioning and financial issues and the like.
I won’t trouble you and your audience, but to highlight how unfriendly, how totally unfriendly the system is, to the 1,000,000 people who lost loved ones due to COVID. You know, the 20,000 individuals who died by interpersonal violence. You know, the incidence of mass shootings and all the other kinds of episodes, you know, the 48,000 who have to survive the suicidal death of a loved one. So, this discussion is absolutely remarkably timely, let alone the loss of natural disasters. I mean, just think of all the people at Maui whose lives are just upturned, and the many wars and the like. So, dealing with loss, grieving, traumatic bereavement, and mourning has to be on the top agenda of every clinician.
Difficult Therapeutic Conversations
LR: Working with adult children of elderly parents, clinicians have to enter conversations about what their plans are with and for them. And it seems to really behoove clinicians to engage these clients about the possibility of traumatic loss and unanticipated loss without pre-traumatizing them. How can we do that?
DM: We have to remind ourselves that what makes us effective therapists is the quality and nature of the therapeutic alliance that we establish, maintain, and monitor with our clients. So, to answer your question, I would advise clinicians to not enter that discussion without the permission of their clients. If I were in that situation, I would say something like, “I recently had a personal loss and I had a lot of lessons that I learned. And I was wondering if you would be interested or willing for me to share those.” So, my notion of being a good therapist is always to solicit permission from my clients, no matter what it is I want to ask. The third thing I would do is to say that, “you should feel free if this is not a good time or this is what we want to do, to put you in charge.” Remember that we, as therapists, need to be person-centered rather than protocol driven.
So, it sounds like, Larry, you had a whole bunch of to-do tasks that you think this elderly client or loved one should go through, right? You said you don’t want to traumatize them. Well, I agree totally. You know, so treat them with the same respect that you would want.
LR: How do we have conversations with our clients who may not even have elderly parents, but who are aware that they live in a world where there are dangers around every corner. How do you help clients prepare for the unpredictable without pre-traumatizing them?
DM: I have a kind of style of therapy, and I’ve actually highlighted this. I just put together a legacy course on what makes people expert therapists. As it turns out, 25 percent of therapists get 50 percent better results and have 50 percent fewer dropouts. So, my legacy course is, what characterizes those 25 percent of people and how can I elevate clinicians to that level? I have a kind of interpersonal style of respectful curiosity. And I really want to convey that to the client and wonder if they’re curious as well.I might say things like, we live in — how should I describe it — precarious times. With the COVID epidemic, with unpredictable violence, with multiple disasters and I must confess that I personally wondered to myself, and I wondered if you wondered to yourself about, given the unpredictability of life ever occurring, are we and our loved ones prepared for that? I mean, that’s my style of interacting. So, what I’m doing in that is actually sharing the rationale, and I’m extending an invitation.
My client might choose to take that invitation or not. And moreover, if I am going to see that person again in the future, all I want to do is plant the seed, then I will be able to follow up. I would say maybe this isn’t the right time or I’m not the right person. But as I look around, I think it might be advisable. And even something as simple as knowing the password of your loved one might be a good starting point. So that’s my way of engaging people.
LR: As simple as that. Simple, but complete.
DM: The key, or perhaps the challenge, is to deal with difficult issues in a non-traumatic engendering fashion.
Lessons on Grieving through Personal Loss
LR: In what ways, looking back, has your own clinical work and research helped you in your journey of grieving?
DM: Now that I’ve talked about the sequalae, let me take a moment and talk about the grieving thing. One of the things that’s really important for your audience to know — and there’s good research by George Bonanno and others that in the aftermath of loss — is that whether it’s due to traumatic, violent episodes like this, or whether it’s due to more prolonged, complicated grief as a result of having someone who’s been ill for a long period of time; there’s an expectation and different kinds of deaths have different kinds of impact.The bottom line is you need to recognize that most people are highly resilient. If you look at the data, most people don’t develop prolonged and complicated grief. So, the key aspect is, what distinguishes those who do versus those who don’t? And I even wrote a book called Roadmap to Resilience, that examines this and deals with it. In fact, your audience is welcome, in honor of my wife’s death, to view this and also my legacy course in her memory. So that’s one way of transforming pain into something good that will come of it.
And in fact, the Roadmap to Resilience has been downloaded for free on the Internet by 45,000 people in 138 countries. So now, let’s get to the heart of your question. In fact, George Bonanno wrote a really nice book called The Other Side of Sadness, which I recommend. It’s a nice little extrapolation on the kind of resilience engendering behavior. Therese Rando has also developed a concept that I’d like to comment on, that she calls “STUGs,” Sudden Temporary Upsurges in Grief.”
And in monitoring my own behavior, since I’m a psychologist and good observer, I’ve tracked my own STUGs. These kind of substantial or sudden kinds of upsurges of grief. And there are two kinds of STUGs in my life that I’ve discovered that have important clinical implications. The first STUGs are sort of sudden and unexpected. A song comes up, an invitation comes up to go to dinner with someone who doesn’t know about my wife’s loss. A couple walks by holding hands and lovingly convey their intimate connection.
And that hits me in an unexpected way. I’m moved to tears, and I have a sense of loss and the like. And there’s nothing wrong with that. In fact, I’ve come to believe that each tear that I experience in loss is not only a reflection of the loss and the grief and how much I miss her and the like, but it’s also a tear of appreciation. Of how lucky I was and grateful to have her in my life all these years. And then, I would have never had this career and all that without her. I’m a cognitive behavior therapist, so the whole thing is not that you cry, not that you feel losses.
It’s what is the story you tell yourself and others about that emotion? Each of us, each of your readers of this interview are not only Homo Sapiens, but they’re Homo Narrans. That we’re actually all storytellers. And the nature of the story we tell will determine — I’m going to suggest — whether you fall into the 20 percent who develop prolonged and complicated grief, or you’re part of the 70 to 80 percent who, in spite of the loss, everlasting loss, your STUG is this kind of sudden reminder.
LR: Unexpected!
DM: I sort of expect them, but they come out of the blue, right? The other kind of STUG which is interesting is something that’s a reflection of a prolonged type of routine or activity that we would have engaged in. So, I’m in Cape Cod, one of the things we would do is go down and have our sunset drink on the beach. A saxophone player would often be playing in the background from their beach house, you know, some Cape Cod song that we would have toasted to, kind of thing.Or we have our favorite restaurant, or our favorite hike or something like that. And I’m now doing those activities on my own. There’s another really interesting aspect to this, and that is, is the person who’s surviving the death, male or female? Okay, so most of my social contacts here in Cape Cod, and in other places, are a derivative of my being a partner of Marianne. So, she had a remarkable social network. She was just lovable and likable. There wasn’t anyone who didn’t fall in love with my wife.
And when she died, those social contacts sort of evaporated. People sort of give you occasional email and a “how are you doing?” But you don’t get invited to the same social occasions or dinners or other kinds of activities, so your network is really an important issue. And the important predictor here, especially among men, is loneliness. Okay, and there’s a higher incidence of husbands dying soon after the death of their wife, about 30 percent and so forth, and having other kinds of physical ailments than the other way around.
And then you need to distinguish between loneliness and isolation. Some people choose to isolate — they like being alone and so forth. Loneliness is yearning for this. And so first of all, in the aftermath of both traumatic bereavement and in terms of the mourning process, that becomes important. The other thing that your readers should take away is that there are no stages of grieving. So Kubler-Ross and Ron Kessler’s stuff about going through stages has no scientific basis for it.
And not only do you not have the five stages, but the expectation on the part of the clinician that people need to go through stages, and the failure to do so is a sign of pathology, is indeed problematic and possibly stress-engendering. So, when people don’t get angry, okay, then it’s deniable or they can’t handle their emotions. And I had a pretty good cause to be angry. This happened in Florida, okay? So, the guy who killed my wife got fined 160 dollars and lost his license for three months.
That was the total consequence. Not only that, in Florida — this is a wonderful state to live in if you’re going to retire — you don’t have to have liability insurance on your car. Okay? All you need to do is pay insurance up to 10,000 dollars. The helicopter cost of taking my wife from Clearwater to the trauma center was 68,000 dollars. So not only do I have, look, how much time do we have? You want me to go on and on? So, what am I going to do? And anger we know, gets in the way of processing trauma memories. Of all the emotions, that’s the one you don’t want to give up to. And that’s the one that clinicians should ask about in the aftermath.
So, if you go to the handout that I have, I have put together the most important diagnostic questions that clinicians should ask. Yeah, I give workshops on grief, and I actually bring my pillow and tell people. And I ask, if I’m your client, Larry, what questions do you think you should ask me? You’re a gifted clinician. What do you think are the most important questions you should ask me to see whether I’m going to develop prolonged grief disorders? Because there are now effective treatments. Shearer and others have created really good cognitive behavioral interventions, when I go on and on and review all the literature. So, I can make this a two-way street. I could ask you, what question do you think you should ask me first?
LR: What comes to mind is, how has your life changed?
DM: Wrong question!
LR: Okay, I could probably guess 20 times wrong.
DM: No, no. The first thing you should ask is, “how long ago has this occurred.” Okay, if this happened like last week or last month, that’s different than if it occurred a year ago. Okay? You know, and then there’s a whole set of questions you could ask about the circumstances, like you did at the outset. Okay, so getting to the notion of how you handle this has a kind of implied judgment on your part that I should be handling it.So, am I going to tell you how bad off I am or am I going to say oh, it’s not that bad, right? So, you have to establish a good therapeutic alliance with me, where I’m going to be open and honest. You know, I have trust engendering things, so I don’t know what your agenda is. Anyway, go to my handout.
LR: I will. I will.
DM: Please, I didn’t mean to put you on the spot.
LR: It’s refreshing and intimidating at the same time. What other guidance are you offering to clinicians who maybe are sheepish about asking the questions, or will not openly receive or seek out clients who have experienced loss?
DM: The first thing — over and above the comment on stages — is that the field of psychotherapy is absolutely filled with bullshit. I wrote an article with Scott Lilienfeld called, How to Spot Hype in the Field of Psychotherapy. The next thing for therapists to understand is that the various therapeutic procedures are equivalent in outcome, and that there are no winners in the race. So that’s the next thing, just don’t believe the hype in these workshops where these people are saying that, “X, Y, and Z works better.”That traumatic bereavement is a common response, will lead to grief and mourning that leads to deteriorating performance is just not the case. So, the second thing that’s really important is that you need to ascertain from the client how to do therapy in a culturally and religiously, and gender-related kind of fashion. You need to ask the person — in my case, whether I’ve had other losses besides Marianne. You need to make me a consultant to you. Okay. And then you need to probe. How did I handle those? And is there anything I learned from them? So, you need to see me as a client as a resource person rather than someone you’re going to treat because you went to some workshop. Okay!
And apropos of the loss and transition website by Neimeyer and colleagues, they have a lot of techniques. Some of them are expressive. Some of these are customary activities that people engage in. So, you, the clinician, need to honor the way in which I want to cope with grief. Okay? And I recently went to a workshop by Mary Francis O’Connor who wrote a book on the grieving brain. And you need to recognize that some of the losses that people experience are natural and a reflection of love.
So don’t pathologize people’s grief or their coping techniques. If I want to avoid certain activities, I don’t go and get rid of the clothing and so forth. And there was a movie that Tom Hanks made that his wife produced called, A Man Called Otto. It’s a bit of a Hollywood version, but they did a really good job on talking at the gravesite. And doing the thing on the clothes. Here’s a wonderful thing that happens. When I cleaned out my wife’s closet, I found out that for the five years that we courted each other, we had written letters. And mind you, that was 1961. She saved all those letters. In 1961, a stamp was four cents. I read those letters as if she was present, each night I take out a couple. I’m now up to 1963, you know that stamps now cost $0.08 in 1963? Her presence, my storytelling, my doing this interview, my reading the letters, are all my own personal ways to honor her memory. The fact that I put the Roadmap to Resilience online for free in her memory.
If you go to the Melissa Institute website, if you’re interested, if you like this interview, go there and make a donation in my wife’s name. We’ve already raised 25,000 dollars for the Institute against violence prevention for her. I’m now in the midst of having done this legacy course of ten one-hour lectures on what makes someone an expert therapist, and then how to take those core principles and the transtheoretical behavior change principles and apply them to a whole host of diverse problems like grief and PTSD and anger and the like.
Each of those courses is only going to cost 150 dollars. Okay, that’s 15 dollars per CEU. All that money is going to go to the Institute in memory of Marianne. So, if you want more of what we’re talking about, track down this legacy course. If you do, there’s the likelihood you’ll be in the 25 percent group and you’ll be able to honor my wife’s memory. You get CEU’s for cheap.
The Role of Resilience in Healing through Grief
LR: You mentioned something earlier on, Don, about resilience as one of the really powerful predictors of how someone will move through their grief journey. Can you say a little bit about what a resilient griever looks like?
DM: In the aftermath of trauma or victimization, and with regard to whatever form it takes, resilience has been equivalated with notions of the ability to bounce back and with dealing with ongoing adversities. And it deals with the notion of personal growth. Margaret Stroebe and her colleagues have an interesting distinction within which people oscillate. That is, they have a variety of coping responses that are loss-oriented or restorative, and future-oriented. One of the things that’s interesting is that people can deal with it as a kind of Viktor Frankl type of observation.That people could deal with any kind of how in their life, as long as they have a kind of why in their life. Some sense of meaning, making purpose. This fits into my constructive narrative perspective that everyone is a Homo Narrans, or a storyteller. So, one of the things that becomes really interesting is how people transform their loss into some kind of effort to help others. So how did the Melissa Institute come about and my involvement therein? So, in the tragic killing of their daughter, Melissa, when she was at college in Saint Louis at Washington University, they have transformed the last 28 years – her loss — into a meaning-making activity.
You can go to the Trevor Project on suicide. You can go to Mothers Against Drunk Driving. There are numerable examples, I give multiple websites of how people have transformed their pain into something good. That doesn’t mean that you don’t continue to have an everlasting sense of grief. There’s nothing wrong with grief. It’s like any other emotion. The key is, what do people do with that emotion? Do they withdraw? Do they isolate? Do they become lonely? Do they use addictions? Do they self-medicate?
So, the key question is not, apropos of the resilience, or that people grieve. The fact that people are in touch with their grief is, in fact, a sign of resilience, right? It’s coming to, how do they honor? How do they memorialize? I deal a lot with returning soldiers. And the other kind of thing is that there are different kinds of losses. There’s loss of people, but there’s a thing called missing loss also. Like imagine people who have individuals who go missing in action. You don’t know if they’re dead right, or in Maui — you know, they haven’t found certain bodies. I mean, does that mean, is there more?
How do I, do I sort of get preoccupied and ruminate about the loss of my loved one, and how I wasn’t there? If I have guilt, shame, humiliation, if I have anger, if these kinds of negative emotions are that which drives me, then that’s the person, those are the folks who are going to be more likely to get stuck, who have hot cognitions and the like. So, you can talk about resilience being the absence of negative stuff, or resilience could be the restorative process on the other end. I don’t know if I’m getting close to your concerns, but…
LR: That resilience, and there are certain personality attributes and certain experiences that predispose people to resilient ways of being, and those people are probably in a better place to move forward in their lives after a loss.
DM: Here’s one of the things I failed to mention. The research indicates that people who have had a prior major depressive disorder are significantly more likely to develop prolonged and complicated grief. So, when I was asking the question, I ask, “Have you had similar losses in the past” and so forth? What we could do is look for vulnerability factors, okay, that are red flags as another tip. To see who would warrant evidence-based interventions, we’re pretty good.
If you look at my core task, there’s a whole way of how we, as therapists, do psychoeducation to educate people about grief. Or how do we help them develop various kinds of coping strategies? And how do we get them to follow through? The big thing is how do you get people who need help to want to come for help? And help them stay there? That’s the artistry of therapists.
LR: Is it more likely that those who have historically reached out to others for help, who have built lives that are rich in community, are just naturally predisposed?
DM: Well, a lot. There’s a fair amount of research by Camille Wortman and Roxanne Silver. Obviously, one of the building blocks for resilience is relationships. I mentioned I have four loving kids who really came to support, I have other people — professionally and others — who’ve come to support. But Wortman then really found a whole bunch of things that people do that are unproductive, that actually make people worse.
They have identified a variety of things that people provide support for, and actually make people worse. Like moving on statements. Things like, “You’re still a young, attractive, bright guy. You’ll find someone. How much longer before you die, You’ll be able to join him. This was God’s mission, He knew something.” So, there are lots of things that social support people offered, so that’s one of the questions you need to ask.
What, if anything, have people done or failed to do that you found helpful or unhelpful, right? Because you want to make sure that you, the therapist, aren’t doing something that I perceive as being unhelpful. So, if you’re a really good therapist, let your patients teach you how to do therapy. Don’t think just because you went to graduate school or took some workshop that you know how. Ask your patient, “What do you think is causing you to still have this lingering grief? And what do you think it will take to help you to move on? And what is it that I, the therapist can do to help you in that process?”
LR: You know, Bob Niemeyer suggests that therapists working in the arena of grief need to be what he calls the guide on the side, rather than the sage on the stage.
DM: Yeah. I like that. That’s a good metaphor. I like him a lot. I’ve read all his stuff. And, you know, my thing is, don’t be a surrogate frontal lobe for your patients. Don’t let the person’s emotions hijack their frontal lobe.
LR: And don’t, as the therapist, let your emotions hijack your presence in therapy. What about those therapists who themselves have had complicated losses, or unfinished business with their own children, parents, and spouses who have died?
DM: Well, I guess those therapists need to be honest with themselves and wonder how it impacts their therapeutic process. Those therapists need to be honest with themselves and decide whether, in fact, they need some therapy. That could help them deal with the issue. And the third kind of issue is, can they strategically use that self-disclosure in a way that facilitates or benefits the patient’s recovery? Rather than saying, you think you’ve got problems with your wife? You want to know what living with cancer has been like? And not only that, my father has Alzheimer’s, and now all of a sudden I have to listen to your shit, right?
So, you can judiciously, strategically say words are inadequate to describe what grief is like. I’ve been there myself. It’s not the occasion for me to share the details, but I want you to know I’ve felt the pain. Okay, I don’t know what the right words are, and you have to say it in an effective way. You can’t say, you think you got problems?
LR: In what way are you — are there any ways that you’re still practicing as a therapist now?
DM: I do a lot of consulting. I work with the head injured thing when people have cases, I train therapists who are doing supervision. I’m not seeing patients now like I did in the past, because I’m not in one place. I’m kind of a peripatetic clinician, so it’s hard to make a commitment to someone being there. I do some consultation with patients by telephone, since COVID.
LR: We could talk for hours Don and I do I hope we talk again. I appreciate your kindness and generosity.
DM: Thank you for the compliment and for inviting me on this journey.
©2024, Psychotherapy.net
Mapping the Heart Of OCD: Going Beyond the Conditions We Know
“The heart has its reasons of which reason knows nothing.” —Blaise Pascal
Capitalizing on Empathy in OCD Treatment
Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them what’s the best intervention for OCD, and you’ll get the same answer: Exposure Response Prevention (ERP).
ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their biggest fears and learn not to blink. Intending to conjure up their personal worst-case scenarios — the terror of harming a newborn child, the yuck factor of hands submerged in an overflowing trash can in Times Square, or entertaining the possibility that they just might be a psychopath — ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.
Although highly effective at providing relief for symptoms, ERP is a mind and behavior-oriented approach that misses the most astounding feature of the OCD tribe: their enormous hearts. People with OCD are amongst the kindest and loveliest clients with whom I’ve worked.
And it’s not just my own bias, research confirms this big heart. Recent studies found that individuals with OCD show higher empathy levels compared to healthy controls. They shared the suffering of others in both self-reports and in a naturalistic task designed to test empathy in real time. They also reported more distress over their heightened empathy and are more emotionally responsive and attuned to others compared to healthy controls.
Such responsiveness is at the core of what makes therapists so effective, and yet for those with OCD, it misses two crucial pieces: the self-compassion and self-advocacy to counterbalance a weighted-down heart. Therapist burnout shows it’s possible to be too empathic, but have we ever looked at OCD from this perspective? Maybe we should!
A behavioral approach gives little room to map this expansive OCD heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39-and-a-half-foot pole. Between one quarter and one half of people with OCD decline ERP, in some cases even before it begins.
I regularly take on the challenge of asking myself as a therapist: what more can I learn about this condition by entertaining something completely different? In the spirit of punk rock, what can I glean if I rebelliously take on the mainstream? With its one gold standard treatment, OCD begs the question: isn’t there more we can do to help OCD sufferers find their voice? Perhaps ERP is so popular that few have the audacity to question it. Maybe, as Pascal instructs, the heart has its own reasons. Such was what I learned with and through Kate.
Kate’s Therapeutic Journey
“I almost cried when I read your blog post,” Kate confessed during our first zoom meeting. A cinematographer based in LA, Kate was fast losing hope that she’d ever get past severe OCD that only relented, ironically, when she was on set. “I always thought that I was failing at OCD treatment, not doing it right. Like, why aren’t I strong enough to just sit through the anxiety? But when I read your work, I felt like treatment was failing me.”
Kate read my unconventional theory that OCD arises from an empathic and existential sensitivity that goes unnoticed and unsupported, and turns in on itself. That enlarged heart capable of so much love is also keenly aware of the chasm of loss set before us all. Is it any wonder that the majority of OCD sufferers worry that death might befall themselves or someone they love? Or that the ritual du jour might somehow stave off what we all wish to control? At its root, OCD is a keen awareness of the fragility of life and the myriad spells and incantations we use to hold on to it at all costs, even if we must lose ourselves first.
“My parents and siblings used to poke fun when I was little when I wasn’t ready to let go of my teddy bear like they all did when younger. I carried her everywhere; she was the sensitive heart nowhere to be found in my house. I hated that I couldn’t let her go, and even until recently, I felt that way about my OCD treatment. Why couldn’t I be fiercer and face my fears and just grow up? Why can’t I even do this ERP thing right?”
Kate felt guilty in therapy, too. She admired the OCD specialist who first gave her a diagnosis and regaled her with the promise of ERP. Finally, there was hope that OCD didn’t have to rule her world. If he had saved her — as she so often felt — why wasn’t she more appreciative?
As we talked together, it became clearer: feeling wasn’t on his radar. Her therapist didn’t listen or seem to care about all that sensitivity, and she felt rejected yet again alongside her teddy bear. “What does it matter what your obsessions mean?” he’d shoot back, as if to say, “get with the program, this approach isn’t going to get you anywhere.”
In conventional OCD treatment, obsessions are just noise in the system trying to distract from the most significant mission: full acceptance of uncertainty and ambiguity. While Kate always wanted to make meaning and find ever more intricate forms for her feelings, her therapist just wished she’d keep working hard and be satisfied with her progress. There was little room for her own authoritative and unique voice, all that good fire in her heart.
Kate could also detect something unspoken in her therapist’s heart: how much his identity seemed tied to one singular truth and how it rattled him to entertain otherwise. She vaguely knew something about herself — how she existed in the world — hurt him. But she never put those feelings into words. Instead, they metastasized into self-doubt, self-recrimination, and shame.
It clocked Kate in the face when she recognized her therapist’s philosophy in a meme widely circulating and praised on Instagram in the OCD recovery world: “OCD is just sound and fury, signifying nothing.” Borrowed from Macbeth’s famous line when the walls are closing in on his murderous exploits and he learns of his wife’s death (ironically, Lady Macbeth with her “out-damned spot!” is one of the most famous contamination OCD cases in literature), Macbeth’s phrase is one of horror, lamentation, and hopelessness. The world is a meaningless, obsessional march of tomorrow and tomorrow and tomorrow, a tale told by an idiot.
“What is wrong with me?” Kate wondered. “I’ve always been a failure in treatment just as in life.”
The middle daughter of a highly educated and successful family of Chinese immigrants to California, Kate constantly found herself on the outside. Family members pegged her as unable to let things go, and though they’d never outright say it, weak for not being able to be more driven and hardworking like the rest of the clan. “Even your work is all just fantasy,” her mother complained.
Kate’s sister had already long moved out of the parents’ house at 25 and was now in medical school, setting sights on buying her first home. Her brother, an IT specialist, always seemed to be able to fix just about anything. Kate was the anomaly, still living at home with her parents and never quite fitting into the alpha-driven landscape of her family’s California dreams.
“Why couldn’t she just enjoy the promise of all that beautiful California sunshine?” her father protested. Kate was always adrift in the riptides of her obsessions, what if she forgot the stove was on, burned the house down, and killed everybody’s nascent dreams along with it?
“It’s like I can never do what the mainstream wishes for me. Maybe that’s why I’ve gravitated to indie films so much. It’s my only refuge.”
“I’d reverse that. The mainstream has never really witnessed your profound heart. You have always tried to accommodate the mainstream — your family, your therapist, the world — but it has come at the price of who you really are. Your sensitivity has always been a part of what has made your vision so clear and full. It’s no accident that your OCD largely vanishes when your sensitivity is prized, as it is when you are working on films and the director gives you the go ahead to command what you need to get the right shot.”
Kate always had a whimsical and keenly observant view of the world, and it showed in her cinematography. She always knew which way to angle the camera not just to get the right light or best composition, but somehow, she evoked things out of objects and people that were somehow right there, but beyond them as well. Her prodigious talent landed her on projects that she most dreamed of; it was also one of the few places where she felt free from obsessional doubt.
“Because your parents didn’t see your sensitivity as a gift, it got housed in your own mind, and you had to protect yourself and them from its power. You sensed so much of what was happening in your environment but there wasn’t a place to communicate that. It becomes wild in our own minds, but we need relationships — and art — to tame it.”
Kate is in Good Company
Together, we joked about how many artists and innovators shared OCD and this unique sensitivity, if you were lucky, found a place to give it creative form. How Greta Thunberg, herself an OCD sufferer, marshals her profound sensitivity to the neglect of an entire planet into fierce advocacy to save us all from extinction. How young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis in The Fault in Our Stars and writes of Aza Holmes, the greatest young adult character with OCD in American literature, in his novel Turtles All the Way Down.
Like Kate, Aza seeks her own center. Is she just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself than she is lost again, spiraling about the possible infection she now has unleashed. Compelled to drain the pus and blood, Aza is a hostage of her own self-enclosed system of fear, love, and unboundedness.
The heart figures prominently in Aza’s story too. Her father, also a sensitive soul and unrepentant worrywart, mysteriously drops dead of heart attack while mowing the front yard lawn. Just as Kate is so aware of killing everybody’s dreams and truths in her life, Aza shares a moment of clarity with her boyfriend about the root of her OCD: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.”
“OCD is a sensibility of sensitivity, one that has an exquisite flame for creative possibility but when traumatically misunderstood and misdirected, it burns the house to the ground. If Gabor Mate specialized in OCD (Kate was a huge fan of this rock-star sage) he’d appreciate it with us too. OCD is more than just a biological glitch; nature and nurture are always in conversation, whether we choose to listen. OCD is trying to tell us more than even therapists are ready to hear. There’s interesting music in all that noise.”
Kate was accustomed to having her true interests and concerns fall on deaf ears. Her relationship with this therapist and with cognitive-behavioral therapy itself echoed her ambivalent relationship to her parents: while she was grateful for having been raised and financially supported by them, they minimized her interests as foolish and viewed her obsessions as just more evidence of her immaturity and self-absorption. Without a clear and secure sense of support from these relationships — her parents or her therapist — Kate relied on her own thoughts and rituals to hold her up.
And yet here was the rub! Untempered by any human relationship, these thoughts quickly became savage and cruel, expecting her to be able to live up to what her perfectionistic imagination could dream up: a world of all-or-nothing purity.
Kate suffered from paralyzing obsessions when out in public places, fearful that the looks of others somehow might cause her to implode. Triggered on subways, Kate left the NY film scene for California where she had more freedom to drive solo. But Kate never quite understood why her obsessions centered around this particular theme and not something else.
“It doesn’t really matter,” her old therapist used to say. That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep on going down the rabbit hole. It’s not to be trusted as your friend.”
But Kate, ever-so-fascinated by the motivations of the characters she tracked in the movies she made, knew there must be more. Obsessions had a funny way of both distracting and focusing us on the things we most feared and desired for a reason. Kafka’s Gregor Samsa didn’t turn into a bug just because he had some tic of the mind, but rather because he felt the alienation, oppression, and depersonalization of his family life and modern society combined.
Successfully Addressing the Heart of Kate’s OCD
We worked on a new kind of exposure response prevention, one that dialed down into all of her feelings and associations with her obsessional fear. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others around her. With her big heart, she was so tuned into the unexpressed fears and desires of everyone that there wasn’t enough room for herself. She sensed the fatigue in her parents, their loneliness for their home country, and their overcompensated worries about surviving. They had no idea that internally she was feeling for them, unconsciously trying to imagine every way she could help them control their fate.
She was compelled to avoid any places which might afford too much scrutiny — subways, planes, trains, long car rides— and wisely found the safest place to exist with complete freedom: behind the camera. There, she no longer was the stage for all the unexpressed feelings of others; she could now orchestrate them for her own artistic purposes.
I knew Kate was making progress in our treatment one day when she started our session rather abruptly, “I know you might want to talk more about what we only half-completed last week, but I don’t want to do that. This is what I need today.”
My heart swelled. I loved the grit, fire, and healthy aggression that I knew she needed to have to own herself, even if she risked temporarily losing me. When I expressed this, she was a bit dumbfounded, “You mean, it’s okay for me to ask this? I’m not screwing up your plan?”
“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger; it was Aza’s middle finger. She needed to say a healthy ‘fuck you!’ to the people she loved — her mother, her best friend, even her own OCD — and trust that she was entitled to it. That’s what you’re doing now, and I love it.”
For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.
Together, we found the heart of it, the mystery that constantly hovers somewhere between life and death, love and hate, and disaster and possibility. Like Aza Holmes, who had lost her father, her boyfriend, and her beloved Toyota Corolla Harold, Kate recognized the biggest truth of all: “To be alive is to be missing.” And yet, it’s in that unexpected place where Kate was found again.
A Foster Child’s Painful Visit with his Mother
The Child’s Family Visit through the Therapist’s Eyes
His eyes widened with welcome, and a quick smile flashed across his face when he saw me pull in. From that moment, Jason was a 55-pound human-guided missile speeding out the door when I came to transport him and his sister for their weekly family visit.
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Today he is dressed in a royal blue, short, sleeveless shirt rimmed with white. His shiny new soccer shoes and short white socks are in sharp contrast to his small, skinny, naturally honey-brown arms and legs which have been tanned an even darker color by the sun. His straight jet-black hair falls in a circular pattern around his face. He has a child’s small mouth and nose set in a fragile face. It is his enormous, soft, brown eyes fringed with long, black, velvety lashes that tell his story. His eyes are the mirror of the words his lips will not speak.
Jason is silent on the short drive to the office until he suddenly blurts out that he has lost a tooth as he proudly displays its previous location. I respond with excitement and ask if the tooth fairy paid him a visit. He is silent. When we reach the office, he is the first child out of the car, into the agency, and up the stairs to the therapeutic playroom where his mother is waiting.
He comes to a standstill in the doorway of the room. His eyes reach across the sea of two brothers and two sisters to connect with his mother. Helplessly, they look at each other, and with their eyes, express the pain they feel in separation, without words or touch. After a moment, Jason tenderly greets each of his brothers and sisters with a kiss and a hug. He receives no display of affection in return. There is no expression in his eyes or on his face when he has finished.
Jason doesn’t play with any of the toys but spends the precious minutes of his visit as a helper and a nurturer. He begins by straightening the toy closet. Standing on tiptoe, he arranges the toys, games, and puzzles. When he is finished, he sits with his hands folded and his little legs dangling over the sofa, watching his brothers and sisters play. When the visit is over, he helps them pick up the toys. Jason is a little old man in a little boy’s body at the tender age of 7.
Jason is the first child to hug and kiss his mother goodbye. His arms tighten around her neck as he buries his face in her shoulder. He lingers in this position until his siblings push him out of the way demanding their hug.
Jason steps back fighting off his tears. In the end he succumbs to his feelings. He turns his head to the side to hide the tears as he wipes them from his eyes with the back of his hand. Jason is the only child who cries when the visit is over.
Jason is quiet in the car on the way back to the foster home. He sits with head bowed so I cannot see the tears flowing. When we arrive at the foster home, he is the first child out of the car. He gives me a brief glance as he looks back on his way to the door. His eyes flicker for a moment with pain.
The Family Visit through the Child’s Eyes
I saw my mom and brothers and sisters today. When Vicki came in her little red car, I called to my sister, “Hurry, Christie, time to go see Mom. Race you to the car!”I beat her to the car by a long shot. Girls are so slow! I jumped in the car. I got the front seat! I buckled my seat belt. I wished Christie would hurry!
During the ride to the visit, I had so many questions I wanted to ask, “Why can’t I live with my mom? Why am I in foster care? What did I do wrong?” I did ask Vicki, but she said she didn’t know. I thought she just wasn’t telling.
I had a lot to tell mom. I couldn’t keep my surprise inside any longer, so I told Vicki. “See what I did! I lost my tooth!” I held my mouth open with my fingers so she could see the big hole where my tooth had been.
She had to look quick cause she was driving. She laughed and her eyes got really big. She asked me if the tooth fairy left me any money. I had never heard of a tooth fairy.
I wondered if mom would be there. She didn’t come last week. Nobody told me why. They said, “Ask mom!” Funny how grownups never give you a straight answer when you ask them questions!
I jumped out of the car when we got to the office. I ran up the steps to the playroom. I ran to the room and stopped really quick in the doorway. Mom was there! She got tears in her eyes when she saw me. I cried too, I was so happy to see her! I wanted her to kiss me and hug me. She couldn’t because she was holding a baby. She said his name was Adam, and he was my new baby brother! Daina, Katie, Jeff, and Christie came charging into the room. The moment was gone. There was no time for me. I was too late.
I love my brothers and sisters. I missed them, so I hugged them to let them know how much I missed them. They didn’t hug back. They didn’t know how because mom didn’t have time to teach them once the babies started coming. She was always too busy or too tired. I had to teach them hugging. I didn’t mind because I liked hugging. It only hurt a minute because they didn’t hug back. I am used to it by now.
I cleaned out the closet this week, like every week, hoping mom would notice me. Vicki noticed me and said something, then mom said something. I felt really special for a minute. The feeling would have lasted longer if mom had said something first.
When I finished, I went to sit by mom. I wanted her to ask me about school. She didn’t because she was too busy playing with Adam. She wasn’t supposed to be playing with Adam all the time. This was MY visit. I was mad and no one noticed but Vicki.
I got down on the floor to play with my brothers and sisters. There wasn’t anything else to do. Just when I started playing, Vicki said it was time to pick up the toys and say goodbye.
I helped put the toys away and turned to my mom. I put my arms around her neck and hugged her as hard as I could. I hoped if I held on long enough, they would let me go with her, or she would say something. Then the little ones pushed me out of the way to get their goodbye hugs and kisses. I gave up! I decided being the oldest meant being last, even if I was only 7!
I fought really hard to keep from crying on the way to the car and back to the foster home. I tried to hide my head when those dumb tears started falling. Vicki saw my tears. She reached over and stroked my head and neck. Her hand felt soft, and I felt better for a little bit. She said it was OK to be hurt and to cry. I wanted to ask if it had to hurt this much, but I didn’t.
When we got to the foster home, I beat Christie out of the car again. It felt good to be first. I’m not first very often. Vicki was watching me when I ran into the house. For a second, I couldn’t keep back my tears. I guess it was OK to let someone know I was a little boy inside, after all.
Virtual Treatment of Eating Disorders and the Importance of Human Connection
Be the person you needed when you were younger
-Ayesha Siddiqi
The Virtual World
I could never comprehend the idea of virtual eating disorder treatment. It would be so easy for clients to hide their food or engage in disordered behaviors behind a screen. How could I really connect? Especially with my young clients, I imagine them secretly watching Netflix behind the computer screen while I try and explore their deepest fears.
Cut to Covid! The world shut down, and my ideas on virtual treatment shifted as this became the new reality for all therapists. I have always worked with eating-disordered clients in one way or another since before I even completed graduate school. After working with eating disorders in community mental health, I started to burn out with the lack of support and knowledge in the field. As a recovered clinician, eating disorders are my passion and the reason I became a therapist. This is the population I want to work with, but this is also the most complex population which requires a complete treatment team and effective provider collaboration.
For my professional sanity — and to continue this career without burning out — I needed to shift gears and investigate a more supportive environment in which to treat eating disorders. The thing is: I live in a place where you must travel at least an hour to get to any eating disorder treatment center, which would mean I would have to travel at least an hour to work at one. While I was offered a position at one of these centers, I saw myself continuing the burn out with the commute and two young children at home.
As fate would have it, the treatment center connected me with their virtual eating disorder partial hospitalization program, which, as it just so happened, was hiring. I was still very hesitant but wanted to keep my mind open. I’d been through many treatment centers as a young teen — I know ALL the tricks. How could I help anyone, virtually? It was during my interview process that I came to the realization that there are many places where treatment is unavailable. What if this is the only treatment available to some individuals due to lack of transportation, living distances, or family circumstances? Would it have helped me as a teen if it were my only option? I must give this a shot. I must explore how I can best support this population virtually, because this is the only thing available to some individuals.
So, I made my decision to hop on the virtual train. It took some adjusting, soundproofing, and office plants to make the switch manageable — at least on my end.
The Young Anorexic Client
The sound machine is roaring.
Two boxes appear on my screen.
One screen showing my face, the other showing that of a new, adolescent client.
She is starting our program today after being discharged from a residential treatment center. I am meeting with her to introduce myself and complete a risk assessment. She admits that she is not thrilled to be on virtual, but that there are no other options near her. Her parents and treatment team are forcing her to complete this program. She admits to knowing that she needs it, and she is a minor, so her parents have leverage. She presents guarded, as teens usually do, waiting to see if I pass the obligatory therapist “vibe check.” I appreciate the honesty but notice the apathy in her voice. This is going to be a difficult client to connect with. I must learn how to connect with her.
Finding Connection
If I’ve learned anything about the virtual world, it is the importance of finding the ability to connect. Yes, it is more difficult virtually than when you are in person, but still doable. In fact, some people open up more through a virtual encounter because they feel safety in distance. New research has shown that the brain neuropathways activate more with in-person interactions. Which means I have to be more creative about forging a meaningful connection. (1)
Because the individual on the other side of the screen can’t get a sense of my “vibe,” and because a digital image of myself elicits different responses from neuropathways, I must rely on building rapport quickly.
I’ve learned the hard way, through moments of uncomfortable silence, that this sometimes requires talking about random teen trivia to get young clients to feel safe with me. My clients are experts in their life. I am merely a guest. The more my clients let me into their world, the more I can show them tools that will appropriately work for them. I have to meet my clients where they are at.
I find the best way to build trust is to find out their interests and build on that. That doesn’t mean I just pretend that I want to know about their interests. I mean taking the time to learn about them and ask deep questions. This helps me understand my clients and what treatment approach works best for them. My job is not to heal my clients. My job is to help them learn the tools to heal themselves.
Only with trust can a client effectively “buy-in” to what I am talking about regarding treatment. Why would anyone talk to me if I don’t feel safe? Building connections and creating a therapeutic alliance is about helping clients understand that you are a safe person.
Young teens are my favorite clients to work with. The most important part of effectively working with teens is to teach them to build connections that are stronger and safer than their eating disorder. The first safe connection might be with their therapist. The eating disorder is my client’s safest and most secure relationship. Which is why it is so difficult to recover from — it works.
The eating disorder becomes an entity of its own that protects the clients from trauma, rejection, fear, and most importantly has the capacity to numb. For clients with significant trauma or poor attachments, the predictability of this disorder is comforting. Ironically, it is providing them a mental refuge while slowly killing them. Accepting and understanding that the eating disorder has served a function for my clients is the most important starting point towards genuine connection. The eating disorder is my client’s biggest and most secure connection.
The Young Adolescent Client
The session starts the same.
Two screens.
Sound machine whirring.
I will call this client Abby.
Abby is hunched down on the floor with her laptop facing her. She is anxious and having difficulty sitting still as evidenced by a bouncing leg. This is not her first time in treatment. She has already told me she does not prefer virtual but has no other options at this time. By this point in our sessions together, we have discussed the usual eating disorder behaviors and worked on increasing Abby’s ability to talk back to the eating disorder voice. The ability to assist her in calling out the eating disorder is crucial. That means knowing how the eating disorder talks. Hint: it’s sneaky and insidious.
Since working together, what stands out about Abby is her increasing discomfort with the present moment. It is more than the eating disorder; I know the look of unresolved trauma. Abby is living in fight or flight. Her eating disorder being taken from her is forcing her to confront difficult traumatic experiences.
Abby started Cognitive Processing Therapy while in residential care but stopped it when the therapist realized she was not benefiting from the therapeutic intervention. So, what can I do here now virtually?
New research has shown that treating PTSD and the eating disorder at the same time yields better results for both. (2, 3) This is contrary to what was first taught to professionals about only treating one at a time.
I worked with Abby for some time, but Abby’s mother’s insurance eventually changed, and her parents no longer wanted her to participate in our program for understandable financial reasons (This is another aspect of eating disorder treatment that is complicated).
Abby will need long term therapeutic intervention for her complex trauma and the increasing severity of the eating disorder. Her motivation for recovery continues to wax and wane.
Let me explain what we were able to do virtually and how.
My work with Abby explored relationship patterns, boundaries, and the impact her trauma has had on her eating disorder relapse and recovery process. Abby learned evidence based therapeutic interventions to effectively talk back to cognitive distortions and her eating disorder voice.
And while all of this work was pivotal, I want to emphasize what got us there…
Soccer!
I know you are thinking. What is she talking about?
Hear me out. Gaining trust from my adolescent clients must come first.
The connection I made with Abby was as simple as soccer. Soccer was Abby’s motivation for recovery, soccer made her feel confident and alive. Soccer activated neuropathways in Abby that allowed her to feel seen by me.
All of the in-depth work that needed to be done started and ended with soccer. Ultimately all of the work that was done on a virtual platform started and ended with my ability to see my client and connect. In the end, my initial reluctance about working virtually with eating-disordered teens was largely unfounded. I would likely have encountered similar challenges had I worked face-to-face with Abby. It was the connection that built the bridge and soccer that reinforced it.
References
(1) Neuroscience News. (2023). Zoom conversations vs in-person: Brain activity tells a different tale. Neuroscience News, 27 Oct.
(2) Perlman, M. D. (2023). Concurrent treatment of eating disorders and PTSD leads to long-term recovery.” Psychiatric Times, Times, 17 Oct.
(3) Brewerton, Timothy. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. The Journal of Treatment & Prevention. 15(4). 285-304.