Category: Approach

Dialogue 1: How Do We Define Collaborative Writing?

Posted on by Psychotherapy.net Team

Editor's Note: In this “dialogue” between client (Daniel X. Harris) and therapist (Trish Thompson), the co-authors explore how collaborative writing that focuses on the therapeutic relationship can be a powerful tool for building trust, multiple dimensions, and humor. They also explore some of the ethical questions surrounding this kind of work and note that the entries do not always run sequentially, “as the themes they explore circle back and around, more like circuits of curiosity than a linear journal.”

Defining Collaborative Writing

Trish Thompson: Dan, so what do we mean when we say collaborative writing? Does it have to be writing with each other, or can it be writing to each other? Or can it be considered more broadly, including things like one-way writing about collaborative sessions?

Daniel X. Harris: This is an interesting question, Trish, and one (in my view) that is framed by disciplinary considerations. There are different ways of responding to it, whether you are coming from psychotherapeutic, autoethnographic, narrative writing or creative writing perspectives. One entry point might be the work of Jane Speedy, who is both an academic and narrative therapist. Her 2017 book, Narrative Inquiry and Psychotherapy, offers many responses to your questions. For example, Speedy offers, “My own interest in narrative research is very much as a collaborative co-inquirer, first in relation to the problems that have come to overshadow and shape peoples’ lives, and secondly in terms of re-telling these stories in writing” (1). Further, she defines “meaning-making as collaborative activities and “reality” as the space between people engaged in conversation.”

There is no hard and fast rule. It can mean a wide range of things, but if it is “collaborative,” I think there has to be that element of working together, not just reporting to each other what we have done individually or independently. For example, you have described using writing with other clients in which they write to you things between sessions. If you read those works and then you work on the content in their session, I would not consider that collaborative writing. If you both read your writings to each other, and change each other in that exchange, then for me that’s moving into the realm of collaborative. Or maybe, more accurately, that would be considered “interdependent” writing! Yalom (2) falls somewhere in there, I think. While I appreciate the efficacy of those approaches, and the many diverse ways in which writing is used in art therapy, I’m more interested in the mutuality of what we have done together. That to me is the “radical” bit: how can one part of a pair (the client) be helped by the therapist’s trained knowledge, through a multi- directional exchange that requires vulnerability and sharing from both sides? That’s truly collaboration.  

Thompson: Ah yes, I like what you are saying here. It makes me think about our writing process, particularly for this book, and the different ways we worked together. What about when we recorded a Zoom chat and then converted the conversation to text? Didn’t seem to make a heap of sense on the page. Technology at fault, surely! Our writing sessions were more productive — 45 mins of writing, screens off (I wonder if your dogs are at your feet?), and then sharing what we had written after. You had always written about three times as much as me, the words pouring out of you, capturing your experience so evocatively. But for me, it is slow work, as if I have to coax out reluctant words that are not sure whether they should show up in case they don’t get along together when they arrive on the page, despite my pleading! I remember telling you about my writing imposter syndrome, saying that there are so many great (much better) writers out there, what do I think I’m doing? And you said something like, “here is room for lots of writers to be out there.” That was so helpful to me.

Harris: Trish, what difference does it make to co-write for publication, rather than just as a therapeutic tool (and does that mean they have to be good writers)? 

Thompson: The first question I ask myself whenever I write something is, “who is the audience?”

This to me is fundamental in shaping the purpose of the words. Using writing as a therapeutic tool has its focus in deepening the shared understanding of the issues being explored in sessions. It is endlessly provoking in the material it continues to throw up. I am writing with a client at the moment, and the face-to-face sessions are so enlivened by the picking up of the threads of the email exchange, once they have also been through the reflective cycle. This client uses visual imagery to great effect in her writing, which I love and respond to. She says she loves how I capture and summarise her therapeutic journey so clearly. But this co-creation is done with little thought to skill or form, it is just about an illustration of our process that continues to build connection. But if a client/therapist pair are writing for publication, they are allowing others into the intimate space of therapy because they believe that what they have to say will be of benefit to others. It could raise feelings of vulnerability when imagining what are usually confidential words reaching the eyes of an unknown audience. I think if therapy writing is to be published, it would be important that the client and therapist can write well enough to convey meaning, create interest and inspire the audience (gulp!). The ethics of this issue are also touched on in Dialogue 3.

When Narratives Meet

We wonder how therapist narratives and different parts of them might enter the space and connect with the narratives/parts of the client? We argue that the meeting point/s of these narratives can be a catalyst for change in both the client and therapist. As Speedy states, collaborative writing between therapist and client, researcher and researched, can “take issue with the low- and high- ground positions in relation to “writing” and “research”… and to promote and encourage ideas of scholarship (alongside research) within the therapeutic domain as collaborative …” This problematisation of the unequal power dynamic that typically haunts both kinds of engagement is at the heart of this book.      

Harris: Collaborative writing doesn’t have to be of equal investment. Clients are looking for witnessing more than a therapist would. They don’t need the writing to witness/reflect them. It’s okay that what the client gets out of it is different from what the therapist gets out of it. Narrative therapy tells us that what a lot of the therapeutic work does, written or not, is bearing witness to someone’s pain or joy or hardship. Validating. It takes the experience from being in one’s psyche to being made real in “real life.” Validating the difficulty of an experience.

But what allowed Trish to accept that invitation? What allowed her to become playful in ways that I experienced as deeper, more or different than in the room? We agree there is something alchemical in the movement of being in, stepping out, looking. This is both a feeling and also is materially and spatially shown by the text and the comments down the side. We were doing that together. It wasn’t just Trish going to supervision and thinking about the therapeutic work.

It felt like there was a collaboration going on around what was going on. There was a shared analysis of what we were doing. Some therapeutic models absolutely flatten the hierarchy: the therapist is not there to tell the client what it “means,” or what to do.

What did it feel like for Trish? You don’t often get a client doing that. Reflecting on the last session, or the work, or where this was helpful – you invite it, but it doesn’t happen a lot. Therapists spend a lot of time wondering if techniques work or not. We have talked a lot about the tendency of therapists to workshop these questions with one another, but less so with clients. How would you know if something worked, if you didn’t ask the client?

This collaborative process speaks to something deeper in Trish, rather than therapist Trish. She doesn’t want to assume or believe things if they’re wrong. She wants to know. This kind of dynamic has been a long-term struggle for her, so the explicit-ness of the conversation in the writing (of the first article) really jazzed her because “the dialogue is open.” You get to know, understand, no matter how hard it is; so much better than wondering. We think that’s why Yalom did that exchange of, “I’ll write my version and you write yours.” He talks about how there are some moments he thinks are pivotal successes, but then the clients debunk that.  

Thompson: What I have particularly enjoyed in the collaborative writing with you, Dan, is the energy I felt when reading something you had written. I would then have a rush of ideas and start making connections – with things we had talked about in the past, with things that were happening in my life, or questions I wanted to ask you or other clients. And then in writing a response, something would click in me about my own journey in finding myself. The writing constantly challenged my self-perceptions.

May 2023: I have been reading your chapter Unstable Sense of Self. So many emotions came up for me. And then the anger came. People don’t see. People think they know better. And because of this you have to endure the experience of the deep knowing that comes from a life’s work of amazing “you-ness” being minimised, whether it is by psychiatrists or dramaturgs. God, who doesn’t want a play that makes you laugh and scares you shitless at the same time?  

“Taking Charge” as Collaborators and as Client/Therapist (29 November, 2020)

Thompson: I’m interested in the idea that as a therapist, I might have personal motives, desires and preferences. When I was studying for my counselling qualification we were drilled with the maxims of “do no harm” and “the clients’ needs are paramount” and that there in fact can be no personal gain for therapists. It is easy to understand this in the context of, say, not allowing a client to arrange to get you the best table at the restaurant they happen to work at, or free tickets to a concert through their connections. So, what about our writing together? You are right about a long-held desire coming to fruition. Not that I haven’t already written, having had three other articles published and many letters to The Age newspaper! The fact that the experience of writing our article has been so positive for both of us equally has felt like a relief. I have been thinking about how it might be for you to feel like my desire to write creates an obligation for you to meet this need. So, it seems like the arrangement is that I can meet your needs, but if you meet mine, there is an ethical problem. And yet you say that to see my excitement and investment is gratifying for you, and you don’t resent it. Not yet anyway. I wonder what might happen to make you resent it?

Harris: I can’t imagine that. I feel that we entered into this mutually – in fact, I suggested it.

Thompson: Dan, I knew you wrote for a living, and I remember when your email came through, suggesting we co-author an article about the process of arriving at the diagnosis of Borderline personality disorder (or BPD). A light inside me flicked on. Can this be something clients and therapists do together? Something about our therapeutic relationship suggested that it could work. Those many hours of therapy-built trust, and this would allow for a story to be told – not just from one perspective (be that client or therapist), but from both. We did due diligence around ethics (spoke to the editor of the PACFA journal, my supervisor and even the CEO of PACFA). Green light given. The writing allowed for a stretching, bending, flexing, and reworking of traditional client/counsellor dynamics and enhanced the work in possibly unexpected ways.

Harris: We tried writing separately, as Yalom and his client “Ginny” do in his book Everyday Gets a Little Closer (1974/1991). But eventually we returned to co-authoring in a shared Google doc that has satisfying interactivity and vibrancy. The fluidity of being able to write into the same document, and comment on each other’s and our own writing as we go, seems to form a big part of the “energy” of this new kind of shared work. (3). It also calls to mind the important work done by Wyatt et al. (4), who have offered an overview and history of collaborative writing (CW) in general, one that might be helpful to readers who are wondering how collaborative writing might be distinct from collaborative autoethnography, for example, or from narrative therapy, as we’ve discussed elsewhere in this book.

Thompson: I often think that the client-therapist relationship resists a definition that truly lands, no matter how hard we might try. An intimate partnership that grows and deepens over time, though it does not find representation in photo albums, social media posts, or at family dinners. But this relationship can be in existence one day, and not the next. When the therapy ends, chances are the client and therapist will not ever meet again. All that sharing, all that caring comes to an end when the decision is made that the work has been completed. The relationship is very contextual though; I know that people want to experience their therapist in a different way, whether that be as a person who will ultimately tell them what to do, or as someone who will help them feel differently about themselves. As a person-centred therapist, I know I resist taking on the role of the “expert.” Clients are experts of their own lives and I am there to hold the torch in a good spot so they can see more clearly what’s up ahead and choose the path.

Harris: I’m interested in what “expert” means to you. I love your ethos, but I also want to challenge you on your unwillingness to hold a position of power or expertness in the room or in this relationship. For example, when I was a teacher, I tried to do the same thing, but the students resisted it. They WANTED a parent/expert/person in charge. We were taught that it makes them feel safe. Maybe this is the same for the client in your rooms. Inviting clients into agency and power and self-determination and collaboration is one thing, but eschewing power or control altogether may be a bit disingenuous? I’m interested in what kinds of feelings it gives you to be “in charge,” and how you relate to those feelings and where they come from.

30 November 2020

Thompson: I have to respond to some pressing client issues in the next few days, so may not get back to writing till Wednesday, but I wanted to respond to this comment, as it is wonderfully provoking. I did not say I was unwilling to hold a position of power in the room, just unwilling to label myself “the expert.” I am very aware of holding power and in fact, recognise it goes with the territory. We are trained to understand this, and I think it is only in recognising it that you can be mindful of not abusing it. There are times I will be directive with clients, and even strongly suggest what should happen next. I agree that so often clients want to sink into the feeling of being held and directed by someone more powerful than them. I have also had the experience of wanting that myself as a client, from my own therapist. I am very interested in the power dynamics between client and therapist and think there is much we can write about and explore here. I note that you feel rebellious when Yalom uses his power in a paternalistic way, and it makes me wonder if that has anything to do with him inhabiting the role of “expert” to the extent that it takes the client into an infantile space. I know he doesn’t want to do that, but maybe that also goes with the territory of being a white male of his time and circumstance.

So, for me, what I reject about the expert stance is creating a vibe that puts me in a position of being “all knowing” and bestowing the answers from a superior position, creating some idea of the client having a deficit that I will “fix.” I have training, experience and skill which allows me the authority to occupy this role and do the work. I love the question around what “being in charge” means to me. I have often thought I am more comfortable with a second in charge role. I know I have leadership skills, have often been told that, and have also been in a number of leadership positions over my career. But as the youngest of four siblings (by a long shot) and older parents, I could never have been the “expert,” or “in charge” in a million years!

Thompson: You said to me that as a result of our writing the article together, you felt you trusted me more. Initially, I think I assumed that the trusting me more was about the fact that the writing went smoothly, and that nothing went wrong. Then I wondered about what it might have been like for you to read about my experiences of you as a client and to see my care in the words I offered. Not only that I wanted so much for you to be happy and fulfilled in your life, but that I saw you as vital and full of life. But now I am wondering more about the process we engaged in to produce the article. There was a spark that was ignited as we poured what was in our minds and hearts into the document. You would write something and it would create a flash of an idea in me, and then a rush of energy in trying to capture it in words. I think the same might have happened for you. There was a synergy that I don’t know we could have predicted, but maybe it was not so surprising, given the successful therapeutic space that we have created. We have been exploring the issue of the power dynamic in the client-therapist relationship. It is a strange beast because it seems like it is both needed and rebelled against simultaneously. Sometimes as a client you want me to take the reins and show you the way, and at other times you are aware that as you bare your life to me, I keep mine under wraps. You step into a vulnerable space, and I have a boundary that keeps me safe. And I want to offer sup- port and guidance but reject labels like “expert” and get cozy with terms like “fellow travellers.” Did our writing together even the score? For in that space, I saw you as the authority and looked to you to have the answers on how the work would come together. I completely trusted that you would take us to where we needed to be with this piece. Did you know that I trusted you result in you trusting me even more? 

Harris: Trish, I’m feeling the resonances of this co-authoring work with you in other places in my life. At the time of this writing, I’m also co-writing a chapter with one of my doctoral students, and co- supervisor, Julia and Elise. The chapter uses autoethnography to explore how our relationship changed during lockdown. Julia, the student, is talking about how previously she was trapped in a perfectionist student persona that didn’t allow her to share her mental health challenges, but through COVID, widespread attention to each other’s mental health in general, and us as supervisors sharing our own mental health challenges (to a degree), she has been freed to be “imperfect” and more open, thereby allowing a richer supervisory relationship. Sound familiar? In a material way, we even saw into each other’s homes through our online video sessions. A snippet, reminiscent of our conversations here:

Importantly, this turn to the personal and emotional in the context of the pandemic and consequent reduced hierarchies does not undermine Dan and Elise’s roles as supervisors, including as intellectual guides, advisors, and supporters; on the contrary, it creates a culture of care that enables Julia to further develop as a researcher by generating an ecology of empathic collaboration which fosters curiosity, connection, understandings, confidence, risk-taking, and expressivity. I love the resonances of this work we are doing as it truly does echo out into the other parts of my life. 

What Happens Underneath “What Happens”?

Thompson and Harris: Yalom and many others teach some foundational tenets: that the therapeutic relationship is a microcosm of out- side life. That whatever occurs between them, the focus and benefit must always be on the client, not the therapist. Yet Yalom also says therapists should let clients affect them, challenge them, even change them. For him, therapists must honestly and rigorously examine what it is they are bringing to this. So here we ask ourselves from both the client and therapist perspectives: Can/should we go beyond the Yalom client-centred writing, and if so, for what purpose? These questions are informed by our enquiry into the potential risks and ethical considerations identified in our creative collaboration, a challenge we have continuously held at the forefront throughout our practice together and throughout this book. Our boundaries required constant negotiation and adjustment. The foundations of our current questions in this section are underpinned by our discussions of how those risks were processed, and resolved. For example, sometimes our writing in our shared documents veered toward the therapeutic. In one case, Dan wrote about a dream they had had about Trish, and once we started to discuss it, we both realised it felt like it had crossed a line into the “therapy” space. We acknowledged it and moved back into a more shared enquiry.

Always in relation to these questions, we wonder together about the mystery of the therapeutic encounter. What hap-pens, and what happens underneath “what happens”? Common factors theory (5) suggests that the most important influence on therapeutic change is the strength of the alliance between therapist and client. Looking beyond technique and intervention (the old-school referents of mechanistic schools of psychotherapy), we instead look at what happened in the room with the two of us, and what has changed during and after the process of our collaborative experience as client and therapist.

The Power of Dialogue

 Harris: Hey Trish, what do you call a homeless horse with borderline personality disorder?

Thompson: Unstable.

We both love to laugh, and humour was there in the room but burst out even more unrestrained once we were “on the page.” It opened up new areas of exploration and trust, and helped us both relax a little as well, while we explored this new relationship. We started co-writing online during the 2020 Melbourne lockdown, while maintaining fortnightly therapy sessions, as face-to-face sessions had been prohibited by home isolation, and the humour was there from the beginning.

Thompson: Yalom (2002) talks about the therapeutic relationship between client and counsellor as being one of “fellow travellers,” So when you share your life with me, in all of its realness, I want you to experience the humanity that connects us to one another. And so, over the years, we’ve built a strong alliance, one in which talking about disorders hasn’t really figured (6). Hey Dan! How many psychotherapists does it take to change a light bulb?

Harris: Probably just one, as long as they take responsibility for their own change. This could be called having “a light bulb moment.” (3).

“We wonder together: what if we were writing a novel instead, or painting a picture? We’re writing about our therapy, not something else, so it reinforces the therapeutic relationship. We reflect on the fact that Trish is also a teacher and practice supervisor, and in those roles she encourages her students to be prepared to walk the talk, to consider the ethics of asking clients to go further than they’ll go themselves. 

We use many of the suggestions Yalom offers for calling attention to the bond between client and therapist including: doing process checks, inquiring about the state of the encounter during the session, me asking if Dan has questions for me. Through creative collaboration, the trusting here and now becomes multi-modal and multi-directional in ways that can offer new forms of corrective emotional experience.

Collaboration Extends to Co-Presenting

Harris: In May 2021, we were invited to co-present on our collaborative creative work at an art therapists conference near Melbourne, on the beautiful Morning Peninsula. We were well-prepared, drawing on our three already-published articles together, and having rehearsed. We were excited for the day. But the night before, I had this dream:

Dan’s dream:

So, we show up at Inverloch but arrive late for some reason – just before our session.

We are getting ready, and I have to go to the bathroom, and we are both fussing around and Carla is getting impatient.

All the participants are sitting at their tables, waiting for our “performance” to begin.

I take out my script but it’s not the right one – a previous draft. I ask you if you have yours and basically, we just spend a lot of time fussing around and you tell me I can read off yours, and then you say I can use your computer, etc., but all these versions of the script are wrong. Things are getting tense. The audience is impatient.

Finally, I say to you to just follow me. I start improvising, narrating that I don’t have the right script and narrating what we are going through out loud. Then I start blaming you – your script isn’t right either. Why don’t you know your script isn’t right? What are we going to do? You start laughing. I say, “don’t laugh out of nervousness, we need to do our show for these people.” It’s funnier than it sounds here.

The audience is not sure what to think. Eventually we do a series of audible asides and morph into a full blown “fight,” where we move around the room and then up to a semi-private space still in view of the participants. By now, we are arguing about the performance, and you are telling me I’m projecting and that this is the problem with doing standup with your client! The audience start to wander away, into the dining room for their meal, and we realise we need to re-engage them by asking for their help. I woke up and realised that we could perform therapist-client and that it might be funny but also instructive in a “‘show-not-tell” kind of way. I also remembered that I had done this with a student teacher in one of my first university classes. We pulled a prank where I went into class first and started complaining loudly about the teacher not being there, being late and getting the students kind of riled up, and then when Nick arrived, we were all difficult to control. He did some expert redirecting, and when it was finally calm, I would go up to the front of the room and say I was the lecturer and they always loved it.   

Thompson: I remember you telling me about this dream on the drive to Inver- loch. I thought it was hilarious and it got me imagining what we could do after we do the collaborative writing gig. We should so do stand-up comedy! I mean, how great would that be, telling insider therapy jokes and making people laugh and cry? Did I tell you that on the drive? I can’t remember if I said it or just thought it. And we had a great experience presenting to this gathering of art therapists, who were familiar and comfortable with our methods but also affirmed the radicalness of the reciprocity of our approach.

Harris: It’s challenging and at times risky work. Work that’s asked us both in different ways to re-examine the power of letting go: letting go of what we thought we were good at, who we thought we were … but the rewards are a powerful experience that is changing our self-awareness as both client and therapist.

Thompson: We have used a number of other writers in our shared work, including the meditation master and psychologist Tara Brach, and one of her favourite poets, yoga practitioner Danna Faulds. We ended our workshop with the arts therapists with the following poem by Faulds, called LET IT GO:

Harris: “Let go of the ways you thought life would unfold,
the holding of plans or dreams or expectations, let it all go.
Save your strength
to swim with the tide.  

Thompson: The choice to fight what is here before you now will only result in struggle, fear, and desperate attempts to flee from the very energy you long for.

Harris: Let go.
Let it all go and flow with the grace that washes through your days whether you received it gently or with all your quills raised to defend against invaders. 

Thompson: Take this on faith:
the mind may never find the explanations that it seeks, but you will move forward nonetheless.  

Harris: Let go,
and the wave’s crest will carry you to unknown shores, beyond your wildest dreams or destinations.

Thompson: Let it all go and find the place of rest and peace

Harris: and certain transformation.

 *** 

This material is taken from Collaborative Writing and Psychotherapy: Flattening the Hierarchy Between Therapist and Client (2024), by Trish Thompson and Daniel X. Harris, published by, and with the consent of Routledge. Buy the book with a 20% discount using code CWP23 here (discount valid from 1st December to 31st January): https://www.routledge.com/Collaborative-Writing-and-Psychotherapy-Flattening-the-Hierarchy-Between/Thompson-Harris/p/bo

My Romance with Narrative Letters: Counter-Storying Through Letter Writing

Posted on by Psychotherapy.net Team

How My Romance with Narrative Letters Began

From the second time I met with David Epston for supervision in December of 2003, learning to craft narrative letters became almost as important to me for learning to devise counter-stories as studying the verbatim transcriptions of my therapy conversations, which David had amended with his own questions. When I arrived at the door of David’s practice in Auckland on that December afternoon, he met me with these words:

“Kay, as chance would have it, Wally has just been meeting with me, and I wondered whether you would mind if he joined us for our supervision session today.”  

Before I had had time to find out who on earth Wally was or why David might consider it a good idea for him to join us, “Yes of course,” popped out of my mouth. Despite my consent, I wasn’t at all sure about the idea, especially as this was the first transcript of one of the therapy sessions I had brought to my supervision with David. I was more than a little nervous and already the paper I clutched in my hand was somewhat damp with perspiration.

As if it were not enough to be presenting my first transcript, my anxiety was heightened because I had “failed” my first supervision session a month earlier. I had made the grave assumption that our inaugural meeting would be given over to an introductory chat, preparing a supervision contract which we would sign, after which away I would run until we met for supervision properly. Surely this is how my experience told me supervision was always done? I should have known that just as David’s approach to therapy is uniquely his, so too would be his approach to supervision. At that fateful first session, when David realized that I had arrived empty-handed, he almost threw me out on my ear, but thankfully relented, settling for a firm reprimand and gifting me two more sessions in which to prove myself as a worthy supervisee. This second session had to go well, so the surprise presence of Wally was something of a curveball.

The warmth of David’s greeting slightly thawed the edges of my anxiety, and when Wally rose to greet me with his broad smile, generous handshake, and cozy, bear-like presence, I was somewhat soothed. Wally turned out to be Wally McKenzie, a veteran narrative therapist, famous for his practice in Hamilton, and for his narrative teaching on the Waikato University Masters Programme in Narrative Therapy.

“Hey, Kay,” David said as he caught sight of the pages of transcript in my slightly sweaty palms. “I can see you have brought a transcript!” David, overcome with what I soon came to know as his irrepressible and indefatigable excitement, slapped me on the back and before I knew it, he was reading the transcript aloud whilst Wally, chin in hand, listened with the ears of a seasoned therapist.

The transcript was of the second session with Wiremu and Mere, M?ori couple whose fourteen-year-old son, Edward, had found himself on the “wrong side of the tracks,” and had taken to joyriding with his mates. Rather than see his son risking the wilds of the “West Auckland hood” on his own, Wiremu had begun to join his son in his drinking and driving escapades, much to the distress of his wife.

When David had finished reading, a fevered discussion followed. Alternative questions zoomed around like silver balls on a table — first one from David, then one from Wally, rapidly followed by another from David and so it went on. Feeling that I was on something of a joyride myself, I held onto my seat and observed the narrative spectacle unfolding before me. With his usual aplomb, David then announced that he thought a letter was in order. “A letter,” I thought “What does he mean?” I soon found out. I left that day holding in my hand the gift of a two-page letter, feverishly crafted by David and Wally for this beleaguered couple and for their son, Edward.

The letter spoke of how the couple had stuck together through hard times. It acknowledged the injustices and struggles that their son had experienced, and spoke of how, despite his understandable anger, his attributes shine through in his care of his siblings and in other ways. The letter went on to invite Edward to join his parents in their commitment to put the hard times, together with mistakes they had all made, behind them. It spoke to his parents’ conviction that life could get better for them all and that they all deserved a break. It ended with an invitation to “stick together as a family,” and for their son to join them at the next session. Edward did not come with them when we next met. I began our session by reading the letter out loud to Mere and Wiremu.

Here is the beginning of my email to David written straight after my next session with Wiremu and Mere:

“When I read the letter to Wiremu and Mere, it was emotional for them both. Mere cried quietly. Wiremu began to talk about wanting his place back in the family and declared to Mere that he was no longer going to try to be a ‘mate’ to his son and instead would learn to be a father.”

And so that was how my relationship with narrative letters began, even if it might have been better described as an arranged marriage.  

Narrative letters have come to serve as extensions of sessions in my practice. Initially, they became the way in which I made up for what I judged to be mistakes in my conversations with people, or when I deemed that there was something missing from a conversation. As David once said to me with humility, “Kay, whenever I have messed up, I have always known that I could write a letter by way of apology.” While I am not immune from the need to write letters for such a reason, and I doubt if I ever will be, nowadays the purpose of my letters is almost entirely to add momentum to counter-storying. Sometimes they serve as counter-story “bombs” designed to explode the “Problem Story” between sessions.

Over the years, I have learnt how to write various types of narrative letters to serve different purposes. There are letters which act as a reminder of ideas discussed in a session; there are letters which serve to “keep the problem at bay;” letters which help to forge understandings and solidarity between the person, family members and friends; letters which recruit communities into a person’s life; letters which are written with a person to send to “a community of concern;” letters to respond to emergencies including life-saving letters; letters that I write with someone to another person or persons in their life to bring about changes in a relationship, and more. The letters that David has schooled me to write over many years have included all these intentions at times. However, despite the form of the letter, their purpose is always to give traction to an emerging counter-story. 

How My Romance with Narrative Letters Evolved

For many years (roughly between 2004-2010), I would submit draft letters to David’s “narrative eye” as regularly as I would submit transcripts. Letter writing became my way of wrestling with intransigent problems in the hopes that doing so would aid me and the people with whom I worked to find quicker and more clever ways to evade the Problem. Along with “mind maps” of possible questions, they were also my “drawing board” for my practice.

For some time, my letters would be impossibly long. I would go through reams of notes to find ideas and the germs of counter-stories themes that I wished to include. Mind-mapping of conversations would give me a picture of the story so far. The maps would lay out the different threads of possible counter-stories before me and make visible possible lines of enquiry to form the backbone of the letter. Sometimes lengthy letters were invaluable with complex problems such as anorexia/bulimia and attempted suicide, as they pulled together vital counter-story threads from sessions and juxtaposed the problem’s story and the emerging counter-story, laying each of them bare for all to see. Over the years my letters have tended to become a great deal shorter as experience has enabled me to glimpse the counter-story more keenly and resolutely. 

How I Compose Narrative Letters Today

Whenever possible, I write the letters immediately after a session. Letters written straight away have more effect because the conversation is still fresh in our minds (mine and my client’s) and in a manner of speaking, the Problem has less opportunity to displace the Counter-story. I put a limit on the time I will spend. Otherwise, I can become intoxicated with the emerging counter-story and a fifteen-minute letter can turn into a three-hour blockbuster. Rather than beginning by reading through my notes, I draft the key ideas of the letter in mind map form or by writing them down. I tend to find this easier to do on paper. Once I have a skeleton plan, I read through my notes from my sessions and circle or highlight key phrases. I then type my client’s words into the plan for the letter. As David has suggested, I aim for 40% of the letter to be in a client’s words, although sometimes this is too difficult or doesn’t ideally serve the purposes of the letter. The client’s words become the structure for the letter, arranged in a form that best “tells” the Counter-story. I then ruthlessly edit out whatever does not “move the action of the story forwards.” I then re-read and edit as I go.

Examples of Three Narrative Letters

I thought I would end with some examples of very different letters from my recent practice. The letters speak for themselves. In each letter you will see counter-stories unfolding.

This first letter is to “Leni,” a twelve-year-old girl who was referred to me through the Youth Health Hub, the community wing of the Child and Adolescent Mental Health Services here in Auckland. The letter was written after the second session. This is what her parents wrote on the referral form:

“As a family, we are struggling with Leni’s anxiety issues which have worsened since starting Intermediate School. It is getting increasingly difficult to get her to school as she worries about having to go to the toilet during class time, etc. We have talked to the school, and they are trying to work around the anxiety, but Leni gets extremely anxious when her school days involve any activities outside of her normal class (sport, drama, etc.). Normally, Leni becomes emotional during these mornings and refuses to go to school. We have managed to keep her attendance quite high, but we are usually emotionally drained each morning.

The anxiety over needing to go to the toilet so often is now affecting her out-of-school activities, and she is now refusing to go to her dance classes in case she needs to go to the toilet whilst she is at the class.   

Leni has always been an anxious girl, worrying about issues she has no control over. We are looking for strategies to help manage her anxiety. The whole family is struggling because of Leni’s emotional outbursts which seem to be increasing. We feel we need to help her before her next transition to high school.”

Dear Leni

“Dear Leni,

I looked at the date before I started writing to you and realized you had been 12 for a whole week! Do you think that you are noticing being 12 at all? Even though some people might only think of 12 as just being the number after 11, are you noticing that you are a little wiser and more mature than you were this time last year? If you are, are you noticing that you are more worry-wise this year than last? If you agree that you are becoming more worry-wise, do you think it is most unlikely that as you continue to mature and grow in your wisdom that the worries will ever worry you as much as they did when you were 11 or 10, or 9 or 8?

Anyway, I said I would write to you because I thought it would be good to collect up on paper all I have learnt from you about how you have been distracting and calming down the tiger worries. Leni, would you mind letting me know when we next meet if I have got anything wrong in my letter? Can I rely on you to let me know?

I am thinking that perhaps you haven’t realized how much worry-wisdom you have now. Do you think there might be some truth in that? I ask this because when we first met, I was expecting to find that the worries had really got the better of you. Instead, I discovered that you had been using your ability to ‘pick up on stuff,’ that your Mum told me about, and had already worked out that the best way of calming the worries down was to distract them. You told me about how you worked out that distraction was your best anti-worry tactic on your own and that compared to before, you were doing ‘quite good.’

Between you and me, I had to wonder whether I would be needed at all, and I got worried I might be out of a job. I thought to myself that if you just kept distracting the worries, there was a good chance that your strategy would pay off completely. I decided to hang on in there though just in case. I’ve noticed that worries can get pretty tricky so hoped I might still be of help in a backup kind of a way. After the first time we met, you told me that you had shrunk the worries down to about twenty centimetres from thirty centimetres and then the next time you shrunk them down to ten centimetres. I have to say that this made me think even more that you had become worry-wise and it might just be a matter of time before you got the better of them completely.

That first day we met, you also told me that you had worked out that talking about the worries made them stronger, and so you had stopped telling your Mum about them.

Keeping quiet about the worries had worked so well that your Mum even wondered if they had gone! You also told me about another anti-worry tactic you had devised — you had decided to go to a different toilet at school. I didn’t ask you why you did this and now I am wondering if you decided that this would confuse the worries because they were used to you going to another toilet? Is this why you decided to do this or was there another reason?

That first day we also talked about the worries as being ‘tiger worries’ because I got to wondering about whether the worries that have been bothering you come from the same place that lots of other people have told me that the worries that bother them come from. And truth be told, the worries that bother me come from. Do you think its possible, as we talked about, that they come from that old cave girl part of you which kind of got left behind and had not grown up over the centuries like most of the other parts of us have? People say this old, cave girl, cave boy, or cave man or cave woman part is a part we needed centuries ago in case there were dangers around like tigers because it helped us to run away from them or to fight them.

Some people also say that although the tiger worries are trying to protect us, they cause trouble and instead are ‘killjoys’ because there are no real tigers. So, there is nothing to get you to run from or fight and they end up running around in circles in people’s heads instead. Do you think that the tiger worries that have bothered you are like this? Do you think they might have been frozen in time and don’t realize that there are no tigers in Te Atatu (western suburb in Auckland)? Considering you are a very caring person, I am wondering if rather than being scared of the worries as much as you were, you have started to feel a bit sorry for them because they don’t know there are no tigers in Te Atatu and don’t know what to do except run around and around?  

Do you know the phrase ‘why re-invent the wheel?’ Well, I thought to myself ‘why re-invent the wheel’ because you had already found out that distracting the tiger worries worked. Do you remember how we thought that you might have a go at distracting the worries with fun and how last time we met you told me how you and your Mum had been spending time being silly and entertaining each other (and perhaps the tiger worries too) whilst you were waiting to go to school?

Do you remember that we talked about your dog Henry when he first came to live with you, and how he was scared and cried in the kitchen the first night? Do you remember your Mum telling me about how your brother had to sleep with him to stop him crying because maybe he thought he was all alone? Do you also remember how we talked about how your whole family went with Henry to dog training to teach him how to be calm and to behave?

When we talked about Henry, I got to thinking about how it might be a bit the same for the tiger worries. You agreed that maybe they needed training, so they understood that there are no tigers in Te Atatu. We then had a bit of a problem though because the problem with these tiger worries is that you can’t see them, so how do you go about training them and calming them? We thought about you getting a little furry tiger keyring to put on your school bag to remind you to calm and train the tiger worries. We agreed that maybe you could stroke the little furry tiger on your bag when you sensed that the tiger worries might be about to come along so that you could calm them down. Do you think that this is maybe where your caring nature comes in so handy?

I am so looking forward to finding out how you have been getting on with this new anti-tiger worry tactic.

Yours in anti-tiger-worrydom,
Kay

P.S. Did I spell Henry’s name right? I don’t want to offend him or you, so please would you let me know? Thanks.” 

After the letter, Leni continued to grow her anti-worry wisdom. We had two more sessions. She is now happily settled at high school. 

Dear Jasmin

The next letter was written to “Jasmin,” a 20-year-old Egyptian, Muslim, young woman after our third session. She had also been referred by the Youth Health Hub. This is what she had written on her referral form.

“I am a 20-year-old girl who is dealing with homophobic parents. They have disowned me, and I have been living all over the country for the last year. My mood is so low that I have been in hospital four times this year and the police have been involved in helping me as well. I’m currently unsure if I should accept my parent’s support and ‘be straight,’ or live with my girlfriend… and be sad? I don’t know.”

“Dear Jasmin,

Here is your letter! We agreed I would write to you about some of what we have talked about in the hope that this gathering up of the very different strands of our conversation might help you to see them more clearly, and to support you in your attempts to ‘anchor myself inside of the two worlds I am struggling to live in.’

I have been sitting here today, reading through the notes from all our conversations, pondering the ideas, thoughts, and feelings that we have talked about and wondering what to include and what to leave out for now. Would you please let me know if you think I have not made mention of something that is important to you or if I have got anything wrong?

Jasmin, when I think of you, I think of that first day we met and how we likened your being shunned and cast out by your beloved family to being a refugee. Jasmin, would you say that for as long as you can remember you have tried to live with a foot in New Zealand and a foot in the miniature Egypt of your family home?

When you were cast out because you were in a relationship with Anna, do you ever suspect that although this casting out was more dramatic that you could ever have anticipated, that sooner or later the tensions between being ‘a Kiwi’(colloquial term for a New Zealander) and being Egyptian, would have caused a rift between you and your family as you attempted to navigate the territories of both worlds at the same time? Has your love of Anna and your parent's refusal to ‘accept me being with a woman’ intensified and perhaps hastened the tensions that might well have burst through, and perhaps forced you and your parents apart at some point or another?

As you wrestled with the heartbreak and feeling ‘so very lost,’ you also wrestled with seemingly impossible dilemmas: ‘My parents say come home, but what is home? Is it worth choosing my family over my partner or my partner over my family? If they love me, why do they not accept me?’ We talked about how perhaps your parents’ love for you and Anna’s love for you are not loves that can be compared; how your parents’ love for you is not less than Anna’s love for you and Anna’s love for you is not less than theirs.  

We discussed how every culture has blind spots which render some other ways of living so alien that they either are not seen at all or are seen very differently from the inside than from the outside. Jasmin, do you think that same-sex love is so unfamiliar to your parents as an expression of love that, in fact, it does not appear to be love to them? Do you think that perhaps your love for Anna appears only to be a threat to the life that they believe will bring you happiness? If this is true, then is their casting out of you a misguided attempt to force you to choose the only way of life that they believe will bring you and your family happiness? Is it, in fact, a very awkward and confused expression of love?

Even though these are probably not dilemmas that can be resolved, we talked at our second meeting about ‘can I find a way of living in both worlds that is not a lie?’ Do you think it is possible, Jasmin, that this question may have come to seem unanswerable to you because you have been very understandably assured that there is a true way of living? If your love for your parents and their love for you is true, and your love for Anna and her love for you is true, then could looking through the lens of a ‘one truth’ be unhelpful? Would you be interested in playing with the idea of many truths? If so, then do you think it is possible that what is said or done in one world may possibly not belie what is said or done in another world even if they seem opposed at face value? 

Jasmin, what do you think of extricating yourself from ideas of ‘truth’ and asking instead different questions? For instance, what if you were to ask yourself: ‘If my family’s love for me and my love for them is true, then is it a lie to express my love to them in a way that makes sense within that world?’ ‘In their world, can I speak my love for them “in Egyptian ways” without pretending to love in the same ways as they do?’ ‘If my love for Anna and her love for me is true, then when walking in Anna’s world, can I “speak love” as a modern, gay, Kiwi?’

Although speaking more than one language of love could be nigh impossible if these worlds collide, do you wonder whether sometime in the future, it may be possible to traverse these two worlds even if it remains hazardous and delicate? If this means agreeing to the pact that your parent’s proposed: ‘To never speak of this again,’ do you think that they and you could find some kind of unspoken understanding that, just as you will not speak of your love for women, that they will not push you towards heterosexual love? Jasmin, would you forgive me if these ideas seem impossible to you? Do they seem impossible, or do you think that there may be some virtue in considering them?

Warm regards,

Kay”

I met with Jasmin for three more sessions. She went back to work full-time, and she began to find ways to navigate ways of seeing her parents and her sister whilst remaining with her partner. Previously, her parents had refused to see her, and they had no contact for a year. When I called her recently to talk to her about publishing her letter, she was going through a tricky time after a whole year of doing very well. She is seeing a counsellor at her university. 

Recent Developments

A recent development in my letter-writing has been my “four-letter-series" for young people, an idea invented from necessity when the mental health agency, which refers to me most of the young people with whom I work, recently had their funding reduced and consequently the entitlement of sessions was reduced from a possible five to eight to a maximum of four. As a way of reconciling this, I decided to shorten the sessions to 45 minutes and spend the fifteen minutes remaining crafting short counter-story letters.   

Dear Lucy

Here is an example of a letter quartet which shows the development of the counter-story between sessions. The letters are to “Lucy,” a 14-year-old young woman. Here is what Lucy’s General Practitioner wrote on her referral from:

“Lucy presents with low mood and social anxiety worsening over the last few months. She would really benefit from some counselling.”

Again, I will let the letters speak for themselves and tell you the story of our four sessions. The letters are each written one week apart: 

Letter after Session One

"Dear Lucy,

It was a real pleasure to meet you today! Here is the letter I promised. If there is anything that you think I have misunderstood or that I have missed out, would you please let me know when we meet? Would you also mind letting me know if there is anything in this letter which particularly interests you?

Lucy, we mostly talked about ‘the glass wall’ that seems to have appeared, separating you from others and the dreadful loneliness of life behind the wall. You told me how much you would like to be able to reach through the wall, and even that you might consider ‘letting people in more.’ As we talked, it was no surprise to me to find out that you have had your trust most hurtfully broken in the past, not only by other young people but by a teacher, an adult in authority, who should have known better. I suggested to you that just maybe the reason the wall suddenly appeared in high school might have been because your body remembered how badly and shockingly hurt you were in 5th form and leapt in to protect you with the wall. If this is indeed what has happened, then do you think that your body overdid it? In its attempts to protect you, has it left you out in the cold, and you have become a little rusty in the friendship-making department? Do you think that we might be able to teach your body that, slowly but surely it can allow you to risk getting a bit closer to people again?

At the same time as you have the gift of being able to enjoy your own company, do you think that you could give yourself permission to retreat into your own world whenever you need and want to?  

As you taught me more about your experiences, it became apparent that you have learnt a great deal from these past hurts. You have learnt to speak out and to stand up to authority. Would you say that the suffering has not all been in vain because by un-suffering yourself, you have learnt to look after yourself better?

Lucy, next time we meet, how about we start to talk about what it is that you would look for in a friend and then we can start ‘testing’ people around you (even if they are only people who would be lesser friends or acquaintances), to slowly find out if they are worthy of your time, attention, and friendship?

Warm regards,

Kay”    

Letter after Session Two

“Hi Lucy,

Good to see you today. So, here is a little account of what we spoke about today and some questions that we might both like to think about.

We began our chat today by reading the letter that I wrote to you after our first session. You looked very thoughtful as you told me that you agreed that the ‘wall had come up when I went to high school because I was going through puberty, and it made me more self-conscious.’

Lucy, if self-consciousness has grown with puberty, do you think it might also be possible that you might be able to shrink it back down again as you mature more?

Do you think that the difference between now and when you were little might just be that when you were little you didn’t need to learn how to be un-self-conscious (or out-going), it just kind of happened, but now as a young person, you have to learn how to do it?

We talked a little about how you made and kept friendships before the wall went up. You told me about a whole group of friends. Melinda was the person that you felt closest to. When I asked you what it would be like if the wall isolated you from others for the rest of your life, you told me that it was if you were ‘in a bubble,’ and if you remained in the bubble you would become ‘a hermit.’ You admitted that you really don’t want this life for yourself and if you did, you wouldn’t have come for counselling. Then, you told me something I found very interesting. You likened your friendships to an egg, telling me that ‘I only need one yolk and the others are acquaintances — they are

Beyond Neurosis: The Case for A Humanistic Approach to Illness Anxiety

Posted on by Psychotherapy.net Team

Not Just a Page in a Manual

In my client, Colin, I saw myself. He was, as I had once been, fixated on his physical well-being to the point that his hypervigilant behaviors had taken over and begun to negatively impact his daily life. He had put college on hold in his senior year and moved back home. He was consistently wracked with worry about his physical health even though he had no documented health problems. In session, Colin would constantly check his body, running his fingers along his neck to investigate for lumps or placing his hand across his chest to ensure that his heart wasn’t palpitating. He would often express the feeling that he was doomed to become horribly, catastrophically ill. He lived in constant discomfort and suffered persistent feelings of worry. I had been there myself.

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By the age of 30, I had visited numerous emergency rooms complaining of vague discomforts: heart palpitations, lightheadedness, shortness of breath, headaches, bladder pain. I’d be discharged each time with a clean bill of health, but I wouldn’t quite believe it. Often, I’d seek further care, visit other doctors and specialists, and ruminate and fixate on an impending health disaster that was surely just around the corner. I just couldn’t seem to accept that I was healthy; it was too risky. If I let my guard down, then the worst would happen.

It took a while, but I recovered. Therapy helped. So did a low dose of Prozac. I still got anxious about my health, but not to the extent that I constantly sought out care and lost myself in anxious rumination. But what about Colin? What would help him? When I began to think about what had helped me, I was surprised at how simple it sounded. I had found a therapist who didn’t make me feel crazy, irrational, or neurotic. He listened to me and never judged, even when I rattled off vague physical symptoms and the anxious conclusions I would draw from them, even when I told him I had scheduled yet another doctor’s appointment. He stayed with me.

But with Colin, I blundered. I told myself just listening wouldn’t pass muster, wouldn’t be intervention enough. So, I went clinical instead of human. I forgot what had helped me. I thought it would be helpful to show Colin the DSM criteria for Illness Anxiety Disorder. My thought was that he would read it and realize that he was being anxious and irrational in his worry and fixation about his physical health. I probably don’t need to tell you that this approach backfired. Though he never said it outright, Colin, I have no doubt, felt pathologized, invalidated, and judged. Therapy didn’t seem to be progressing, and Colin’s anxiety wasn’t getting any better. If I was truly going to help him, I had to pivot, and fast.

Moving to Where There is No Sky

At that time in my career, I was reading a lot of classic psychology texts and one that consistently resonated with me was Man’s Search for Himself, by Rollo May. In this book, May describes a young girl coming home from school after there had been a drill for students to hide from a nuclear attack. Once home, the young girl asks her mother, “can’t we move somewhere where there is no sky?” Eureeka. Colin and I both, while in an anxious state, desired to be somewhere where nothing bad could happen. If there was no sky, there could be no bomb. If there is no stone left unturned, there can be no surprises. So, if we check enough, if we fixate and protect enough, nothing bad can happen.

Call it “hypervigilance” or “neurosis” or “hypochondria” — whatever unhelpful psychological designation you wish to give it — it comes down to one thing: an anxiety-based behavioral response. When I would visit ER after ER, I was seeking a safe place where nothing threatening could happen. When Colin checked and rechecked his body for changes and symptoms, he was seeking a stasis where nothing bad could happen. When he returned home despite excelling as a college student, he was seeking a safe, nonthreatening space.

The little girl in Rollo May’s book is, to a greater or lesser degree, and in one form or another, all of us. When we are threatened, we seek safety. This response is human, though primitive; it is not, however, neurotic or maladaptive or irrational. Once I realized that Colin and I were no different than May’s young girl, my clinical mind softened, therapy began to expand, and change started to occur.   

Putting the Manual in the Drawer

I put my DSM in the drawer and began to talk to Colin about anxiety as a general concept. I reached for any metaphor I could find: “anxiety is like a smoke detector that goes off at the slightest wisp of smoke;” “anxiety is like a home alarm system that gets tripped when a strong gust of wind blows.” I wanted Colin to understand anxiety at its core. The therapist I mentioned earlier had done the same for me; I recall him explaining the “mammalian brain” and the concepts of “fight, flight, and freeze.” The more he educated me on what anxiety is and why it happens, the more in control I began to feel. Gradually, I became an expert on my own unique presentation of anxiety. And from there, I began to learn how to manage it.

I wanted Colin to experience this sense of knowledge and power in the face of his debilitating worry. If he could understand anxiety, he might feel less threatened by it. But beyond education, this required normalization. If Colin viewed himself as part of esoteric group of neurotics, he would assuredly continue to feel isolated with his fear. If, on the contrary, he felt a sense of commonality, he might be more willing to step out of his rigid fixation. So, we talked about physical health and how scary it is. We talked about it as you and a friend might talk about the weather or the football game. I left diagnostic language and pathology out of it and just talked with him about something we all have in common.

Then Colin said, “now that I think about it, this all started after the thing at the airport.” A few months before, at an airport, while preparing to fly home from college for a break, Colin had become dizzy. He didn’t quite faint, but he thought he might. His brain went into overdrive, telling him he was having a heart attack or a seizure or something catastrophic. Though he flew home, he shared that it was after this incident that his health-related anxiety had really begun to escalate. Anxiety had caused him to put his life on hold. He was looking to move somewhere with no sky. Colin’s newfound understanding of anxiety had allowed him to draw an important connection that he felt safe enough to share and that, ultimately, would help him begin letting go of his catastrophic worry. It wasn’t clinical language that allowed for this; nor was it diagnostic criteria — it was talking, sitting together, creating safe space.

Now we really had something to build on: there had been a stimulus, then a belief, then a behavioral response. Incredible things happen when we just listen, and Colin’s disclosure provided an opportunity. So, we kept talking. We talked about how things happen that scare us, how we have a cognitive response to these things then a behavioral response. I was careful never to call into question or to judge his response, but rather to help him understand the chain. It was making sense. I can’t say exactly that there was a breakthrough (this is, often, a myth of psychotherapy, as true breakthroughs are almost never moments of dramatic and triumphant epiphany), but it wasn’t long after that Colin started to come to therapy less often, began to report feeling less anxious, and began planning his return to college.  

More Than an F-Code

Nobody ever asked me for Colin’s diagnosis. He never asked me either and I owe him a great debt of gratitude for staying with me despite my wrongheaded decision to show him the DSM criteria. He gave me a chance to change course, for which I am eternally grateful. Colin was my on-the-job training in humanistic psychotherapy. Sure, I’ve read Irvin Yalom and Carl Rogers, but nothing can supplant real-life practice. Colin was pivotal in my recognition of the importance of humanizing rather than pathologizing. In retrospect, he was more important than any course I’ve taken, book I’ve read, or theory I’ve learned. He didn’t feel safe in his body but, over time, he felt safe in therapy, and that allowed his sense of safety to expand outward and to begin combatting his sense of worry. I realize now that my own therapy had afforded me the same opportunity. Once I felt accepted and safe, I was free to begin questioning my anxious thoughts and conclusions.

So, sure — on paper or to insurance companies, Colin might be the posterchild for Illness Anxiety Disorder (F45.21), but in a human sense, he is much more than an F-code. Because of a frightening stimulus, his unique form of anxiety attached itself to his physical health. Anxiety attaches itself to something for everyone — what it suctions itself to merely depends on our unique experiences. So, what does this make Colin, really? Is he neurotic or a hypochondriac? Or, simply, did he, like any human, become frightened by something frightening and want to protect against it? In protecting against the threat, he utilized specific behaviors in order to remain safe. These behaviors, no doubt, worked for a while, then they didn’t. I had done the same. You have done the same. If we humanize the experience, we allow for coping and healing. If we pathologize it, we impede coping and healing.

When we descend from our clinical and diagnostic “high horse,” we truly become Rogerian and “meet our clients where they are.” When I was seeking emergency care for a perceived illness, I was not an exotic specimen to be viewed through a clinical microscope. I already felt different and alien; the last thing I needed was confirmation of that belief. I needed to be understood, accepted, and humanized, not studied as though I was a fascinating case in the annals of abnormal psychology. Colin and I have this in common: when we felt we were being viewed through a clinical lens, we personalized our diagnosis and become resigned to it as an immutable fact. When we felt accepted and seen through a human lens, we became able to view our anxiety as a cloud in the sky rather than as the sky itself.

Questions for Thought and Discussion

  • What are your personal and clinical impressions about the author’s client, Colin?
  • Have you encountered clients with health anxiety in your own practice?
  • How does your own treatment approach with these clients differ from the author’s?
  • What might you have done differently with Colin?   

A Small Hope: Co-creating a Narrative of Grief – Part II

Posted on by Psychotherapy.net Team

Bringing Memories to Life

“I want to remember the precious times we had together in those last weeks but already they are fading and I am forgetting,” Claudia said with resignation. It was now a month after Tom had died and the conversation had just shifted from the challenges of getting through each day.

“Is gathering up memories of the precious times something that you might like to do in this conversation?” I checked.

“Yes, those last four weeks,” Claudia said through tears. “From when we were told in the hospital Tom was dying and decided to come home. In the hospital, I asked one of the nurses, ‘How long does he have?’ and she replied, ‘Maybe a week.’ As you know, however, he lived for four weeks… Tom didn’t ask how long he had to live but I wanted to know.”

“Would it be OK to ask… what was important to you that you asked for the nurse’s guess as to how long he had to live?” I added the word “guess” as no one ever definitely knows and that uncertainty is often unfamiliar to people.

Claudia’s voice broke, “I just wanted to know how long I had with him. I think I was just trying to get a clear view of the future.”

“Did you have any hopes for what a clear view might provide you and Tom?”

“I was thinking this is valuable time. It clarified that we wanted him to come home,” Claudia affirmed.

“In this decision to go home, what kind of valuable time were you and Tom hoping for?” (22)

“It meant he could see the changes in the girls. They are so young they change rapidly, especially Libby who develops in small ways every week. I knew that visiting in hospital is just not the same. Everything is different, distorted and not in their natural state,” she explained. Visions of hospital rooms with their lack of privacy and noisy nights floated through my mind. I tried to imagine visiting such an unfamiliar environment frequently with a baby and young child.

“What does it say about Tom’s relationship with Imogen and Libby that he prioritised noticing small changes in them even when he was dying?”

Claudia smiled. “He treasured and valued every little thing about them. He’s been quite good at appreciating small things for a very long time,” she answered, speaking of Tom in the present.

“Could you tell me a story of Tom appreciating Libby and the small changes in her perhaps? And then Imogen and what he enjoyed about her?” I was aware that I was collecting memories, not only for Claudia, but for her girls as well. Together we would build a document of memories she could keep. (23)

After Claudia had shared some stories, I became aware we had diverged from what she had originally said she wanted to discuss. “I notice we have moved away from speaking about the four weeks you said you wanted to focus on. Would you like to continue on this track or would you like to spend some time talking about the last weeks of Tom’s life? What would you like to do at this point?” (24)

“The last four weeks. It’s fading so fast. I’ve even forgotten subtleties that were routine to me, like giving him his morning wash, and that was something I treasured doing,” Claudia stated. I was glad I had checked. I didn’t want the conversation to end without it having been what she wished.

“Would asking you about treasuring his wash be a good place to begin?” Claudia nodded and sat back on the sofa. “Would you like to walk me through how you went about giving him his wash?”

Claudia began to recall previously unspoken details of the daily routine with me, inquiring into their meaning. Towards the end of collecting as many details as I could I asked, “When you were washing him, was there a particular way you touched him?”

“Yes. When he was moving less, I would give him a little massage, or I’d move his legs around. I could tell he liked it. After his massage, we’d put frankincense on his palms and the soles of his feet and he’d go, ‘Oh, Frank!’ and wiggle his fingers making a joke!” Claudia laughed.

“Did he keep his sense of humour even…”

Claudia’s words tumbled out in her enthusiasm. “Always, right up until that last night. A carer came for the night to help. When she saw Tom she said, ‘Still unresponsive,’ so he wriggled his eyebrows at me. It was our little joke! Frequently through the day I would wash his face and I’d say, ‘Would you like a cool flannel or a hot flannel to wash your face?”

“When you were giving him that choice… what was your intention?”

“He had very little control over his life. He deserved respect,” Claudia explained.

“What did you want him to know by giving him that choice and respect…and control?” In tender tones Claudia answered, “He was still just as valuable. Even though he couldn’t move or see much, he was still my Tom, he was still the same to me.” Moved by her love and respect I responded, “May I ask, what would have Tom noticed that would have told him it was you washing him rather than someone else and that he was still the same to you?”

“He would have felt my love in the way I washed him. I was given a choice of washing him or having a carer do it. There was no way I was going to let someone else do such a personal, private thing for him,” Claudia stated, flicking her hair behind her. (25)

“What were you valuing, do you think, when you prioritised this loving moment with him and protecting his privacy even as you were parenting two small children and doing everything else that was required of you?” I reflected on the exhaustion that comes with parenting very young children. Such a choice was not right for everyone. Claudia lowered her voice, leaning towards me as she spoke, “I wanted to protect his dignity and have that intimate time with him.”

“May I ask, what did you experience as meaningful in the relationship when you managed to get that time together and share love and intimacy?”

“It felt like this was why we had him at home. It meant I was the one changing his nappy… And I did feel proud and honoured that I could do that for him. It’s not something a wife normally does for a partner, but I guess it was a new intimate thing we could do where there were precious few of those new things.”

Struck by her ability to generate such a deeply loving experience in something so far from what couples ordinarily do together, I responded, “What does it say about you that you felt proud and honoured to do that care for Tom … that you could find intimacy in changing his nappy for him rather than seeing it as a chore?” (26)

Thoughtfully Claudia answered, “I think I understood what he needed. I understood the best way to do that for him.”

“What was it that you understood about Tom in those last weeks that was important to you both?” Claudia pondered. “We were able to slow things down a bit.”

“How did you do this slowing?” I wondered. Claudia spoke slowly as she considered, “Just focusing on little things. I’d go and get him milkshakes and I’d say, ‘So what flavour milkshake do you want today and where do you want me to get it from?’ It was treasuring very small decisions. I got great pleasure from him eating or drinking something and he got to make decisions and think about that milkshake and what he wanted. Life zoomed in and focused on those nice moments.”

“What did you know, Claudia, perhaps about living with such a serious illness, or about Tom, that had you recognising that making a decision about the flavour of a milkshake was worth treasuring?” I couldn’t help but notice her extraordinary sensitivity to Tom’s experience and I hoped that my questions might draw Claudia’s attention to her wise and gentle care.    

Claudia laughed. “Tom knew his own mind. I would never make that decision for him, particularly around food,” she said, reminding me that Tom was a skillful and passionate cook. “Choices in his life were dwindling. He didn’t have a lot of control.” She dropped her head for a moment, reflecting. Tears glistened in Claudia’s eyes as another thought occurred to her. “Tom knew how much it would hurt me when he went.” The tears gathered and a sob escaped but she went on speaking. “He didn’t want to go but most of all he was worried about me…” Claudia started to cry unreservedly. Her face reddened as more of her body joined the experience of grief. Rather than a break in the conversation, it was as if these tears spoke what words couldn’t as we reflected on Tom’s love for her even as he was dying. (27)

Quietly, I eventually asked her, “What were these worries Tom held for you?”

Claudia was barely able to speak yet she persevered, wanting to express what the emotion meant in words. “He just knew how hard it was going to be… he cared enormously about me being alone.”

We were quiet for a time as Claudia continued to weep.

“He was sad for himself and the girls, but he was really sad for me,” she eventually explained.

I thought about Tom worrying about Claudia even as he lay in bed so sick. “What does Tom’s compassion mean to you? …. that he couldn’t bear to think of you being on your own…that he cared so much about what might happen to you…?”

“It was a demonstration of how much he loved me,” Claudia choked out. “I usually cried,” she explained, smiling at herself through the tears. “I felt guilty every time I cried and got comfort from him but he’s the person I turned to when things were wrong. He said comforting me was something he could do.” She stared at me with her eyes wide waiting for my response.

“Do you have a sense of what it was to Tom that you chose him to seek support from?”

Claudia exhaled, “I think he was thinking about the time when he wouldn’t be able to support me, and he was doing what he could.”

“How would Tom have understood the way you saw him when you sought comfort from him?”

Claudia considered, speaking what seemed like newly formed thoughts. “He was my best friend, and we were there for each other. It didn’t change when he was sick. I think it was hard but very important for him. It allowed him to show support for me, I guess. He saw it as something he could do for me when he could do so little, when I was doing so much for him. I didn’t feel the need to protect him.”

“What do you know about Tom that you knew you didn’t need to protect him?”

“He was strong. He said he wasn’t scared of dying.” Claudia let out a big, long sigh collapsing in on herself in seeming resignation.

“Would it be OK to ask you one more question about the way you shared your grief together?” Claudia nodded.

“What did you know about the relationship that told you that talking would be best for it?” I wanted to bring forward Claudia’s knowledge of their particular relationship because I knew that this kind of talking wasn’t best for everyone.

“It’s what we’ve always done,” she readily replied.

Our time was coming to an end. After I summarised what we had been discussing, I checked with Claudia, “How has our conversation gone today? Has the experience of reflecting on the last four weeks connected you with anything that is helpful or important to you?” (28)

“I think it’s highlighted how we did it according to our values. That’s incredibly important to me. It eases the pain just a little to know that,” Claudia responded.

“How might you carry that knowledge do you think? That you did it according to your values?”

“I guess by carrying on doing that with the girls,” she replied thoughtfully.

“Perhaps we might come back to that next time if it interests you…. but could I ask you something else? As you reflect on the last weeks of Tom’s life, was there anything that happened that moved you a little closer to being the person you want to be?”

With some energy and perhaps surprise in her voice, Claudia answered, “Now that I talk about it, lots of things. Doing it our way and speaking up to make that happen. The way I was able to show him how much I love him through what I did. It was so hard, but I was there to support him die the way he wanted to do it. I hadn’t really thought about it before.”

Turning Towards Pain

Claudia and I met each week until I was scheduled to be away on leave. (29) Before I left, we planned who Claudia might turn to in difficult times for support and what she might do. Not long after I returned, we were once again sitting in her home. After greeting each other warmly, Claudia brought her cup of tea into the living room, and we sat down.

“We had a fortnight gap this time, how did that go?” I inquired.

Claudia let a rush of air out. “My sister said, ‘Have you seen your counsellor this week?’ And I said, ‘No we couldn’t make it. Sasha was away.” And she said, “I always know when you haven’t seen her.” I thought I’d be fine, but I’ve had a really awful fortnight.”

“What is it that you do differently in the week when you’ve had a chance to talk?” I inquired, but I was off track. (30)

“I was thinking about what it was that changed. You know how I was feeling numb? Well, I’m raw now. I can’t seem to stop crying…” Claudia’s voice broke, and she could no longer speak. The pain gathered and eventually she sobbed, “It’s all the time… just crying all the time. I’m right back to raw and where is he? And how can this be happening?”

I listened, feeling the echoes of her pain. (31)

Claudia bowed her head and tightly wound her arms around her body. It was as if she was holding herself together. “I’m right back there… and that lovely numbness… that I was feeling has just gone,” she stuttered through the sobs. “It’s horrible… just that relentlessness… And I went to see a clairvoyant and she was just ghastly. I think that tipped me over the edge a bit. I realised I had a lot of hope riding on it.” She looked up at me with wet eyes.

My voice was soft. “May I ask …what were your hopes in seeing the clairvoyant?” I wasn’t surprised Claudia had visited a clairvoyant. Many people search for connection with someone who has died through spiritual understandings they hold.

“I didn’t realise until afterwards that I was hoping that it would be for real. I would have got a feeling of peace knowing that he is somewhere and can be with us. I didn’t get that at all. I just felt duped. I was already feeling quite low but hopeful, I realised afterwards.”

“Would it be okay if I ask a bit more about these hopes?” Claudia nodded as she blew her nose. “Would you mind speaking a little about what you were hoping for?”

“That he’s somewhere…And he’s not just puff gone. That he is somewhere and sometimes, somehow, he is around…that’s what I really want to believe…I need a message to say, ‘I’m OK, I can never see you again but I’m OK…and I know you are OK.” It is one of the hardest things I think, the not knowing.” I reflected on how much not knowing there could be surrounding illness and death.

Claudia’s anguish layered her words as she again tightly encased herself with her arms. “I’m stuck in this awful hole…I don’t know how to go on. I just don’t know how to hold on. I feel like I’m clinging on to a ledge. I have to but I don’t know how to keep going and going and going…” (32) I tried to imagine the relentlessness of continuing on. Her words created a vivid picture of the ledge. I made sounds of empathy as I listened, a witness to her pain and sorrow. “How important was knowing where Tom is in this holding on?” (33)

“Very important,” she cried.

“Yeah… yeah…,” I replied, almost crooning in my compassion for her. “What would it have given you in the holding on?”

Claudia cried, hiccupping as she answered, “Some sort of peace that he’s OK…that he’s with us…and that I might see him again…It’s so hard. It’s not like breaking up with someone and you know they’re OK. Somewhere they’re alive…”

“Completely different,” I affirmed.

Claudia voice was husky, “I just can’t get my head around it. It’s the absolute worst that could happen to me…I’m really struggling…” Her tears took over and we paused, neither of us hurrying or censoring her expressions of grief. “…and I’m sure having less help this week is making a difference. The family have been away. I’ve actually been feeling OK with my parenting.”

My ears pricked up. “Yeah…?” We had talked a lot about the impact of grief on her parenting as Imogen and Libby were Claudia’s top priority. However, I didn’t want to move Claudia away from her talk of the struggle sooner than she wanted so I resisted asking a question and kept my query very small.

“We’ve found a routine and I’m not shouting. I’m not feeling desperate about those times,” Claudia told me with an energy that conveyed to me she might have a possible interest in speaking further about her parenting.

“Is this something you would be interested in talking about?” When Claudia indicated, she would like to follow this direction I continued, “What’s allowed you to be OK with your parenting especially when there is so much struggle?”

“I think routine has helped. It’s soothing. And I’ve got really, really good at filling in the time now. Those girls are bloody tired by the end of the day because I’ve worn them out. Like last Sunday, we went to the markets and met a friend for breakfast, then we went to a school children’s art exhibition which was a couple of hours and then we went out west to see another friend. We got home at 6 P.M.” Claudia sighed, sounding exhausted even by the thought of what she had just relayed to me.

While being so busy was not Claudia’s preferred way of parenting prior to Tom’s death, this was a survival strategy she was using. “I’m really tired but that’s how I cope. Just fill in every hour possible. It’s not because I don’t want to think because I like to think about him. It’s just the only way I can cope with the kids. It’s helped.”

I returned to the aspect of parenting Claudia was feeling good about and, remembering Tom’s belief in Claudia’s parenting, decided to bring him into the conversation. (34) “And what would Tom make of you doing your parenting in a way that you felt good about? Finding a routine and being more how you want to be with the girls. What would he be thinking about that?”

“He’d be saying, ‘I knew you could. I’m proud of you.’”

We both smiled. With a lighter voice I asked, “What might Tom have known about you that allowed him to know you could do it?”

“That I put them first…,” she replied as tears trickled down her face. “…That I’ll always look after them…” Intensity and what sounded like determination entered her tones of sadness “…and I’ll hold onto that ledge for them…hard as it is…”

“Is Tom under your feet helping to hold you up a bit too?” I asked, wanting to add his support if it was there.

“I don’t know…I hope so…He would if he could…if he can he will…I forgot about the rawness. It’s so horrible.” I nodded.

“It’s only three months since he died,” Claudia told me with emphasis.

“No time at all and yet perhaps a long time too. How would you describe it?” I reflected, slowly waiting for what else she might be about to share. Claudia replied, crying as if her heart would break, “No time and yet forever. It’s part of why I hurt so much. How’s three years going to feel since I saw him? And thirty years? I feel like I’m only living for my girls…to give them a good life…and not enjoying any of it myself. The hole just keeps getting bigger.”

“Is it hard to imagine that the hole might stop expanding and steady a bit? That it might be less gaping one day?” I said, offering a future possibility.

“I can’t…”

I nodded.

“Is your wanting to parent the girls so they have good lives…” I began to ask as I looked to connect Claudia to parts of her life that might help support her keep holding on. Her virtuous desire to care for her children in spite of the pain of living stood out to me.

Claudia interrupted me, staunch as always in her love of her girls. “I want them to have good happy lives, absolutely.”

“How would you describe a good, happy life for your girls?” I invited, seeking to connect her with a future for them that might be possible to envisage.

“Doing things that stimulate them and interest them with me…positive times with me and …being strong in themselves…able to weather some storms… and get enjoyment out of things…and finding passions. I want that for them but not for myself. I don’t believe in having that for myself. I can’t see it again. It feels like it’s all gone…”

We paused together for a time and Claudia wept. (35) “I feel like something in my soul has gone… an intrinsic part of me.” Her description touched me as I murmured a quiet acknowledgment. After a pause I added, “May I ask what part of your soul would that be?”

“All of my adult self…is connected to Tom. Everything I do and think is influenced by him and our relationship. All my memories of being an adult…are with him. The way I view things is because of him. It is lovely and I’m very glad. But it’s such a wrench.”

“Was your soul entwined with his?” I wondered. Claudia nodded. “And was his entwined with yours?”

She nodded vehemently. “I don’t know where he is! It’s just so hard.” Claudia’s body shook and she put her head in her hands. It was my turn to nod as we both acknowledged the hardness. It was so hard (36). As we sat there for a time, I considered Claudia’s disappointment with the clairvoyant and how it had made the pain worse.

“I wonder if we can think about that a little bit…if we could figure something out, away from the experience you had with that particular clairvoyant…”

Claudia laughed heartily through her tears, “…Who believes in herself even if she is a complete fraud. I can’t accept that he’s not somewhere or not existing.”

“What are your understandings of possible places or ways that Tom could be existing?” I asked. People I meet with often have very different ways of understanding death even if they identify as belonging to a well-known faith tradition. They also often re-evaluate beliefs they’ve held for a lifetime in moments of illness and loss. I can never assume I know what someone believes.

“That he is part of the energy, the finite energy of the universe… that’s scientific,” Claudia explained to me. I listened attentively as she continued, “Or he could be in a different realm or a different world which is potentially scientific as well.”

“… like a parallel universe?” I inquired, noting her tears had stopped. “Yes. Or in some heavenly place, someplace souls go where there’s peace. I’m sure there are other frontiers but those are the ones I think of…I want him to be conscious somewhere and aware of us. If I think about another world or a heavenly place, he would be conscious of us.” She stared at the sky out the window. “What would a sense of Tom’s presence give you?” Claudia returned her gaze to me. “I would know he’s with us, present in our lives”.

“Do you think you have any impact on that sense of presence or how that presence could be felt?” I inquired. Claudia looked at me quizzically. “Clairvoyant people say we do, don’t they? If we can be open to it or not open to it.”

“I don’t know…Can you influence the way you feel Tom?” I wondered curious.

“I don’t know. I’d like to,” she affirmed. I cast my mind back to a previous conversation. “When we met last time, you mentioned you had felt him.”

Claudia confirmed, “I felt him really strongly.”

“May I ask what you were doing at the time?”

“I wasn’t doing anything out of the ordinary. I was probably having a laugh which was unusual as it was maybe two or three weeks after he died. The girls were playing around so a bit of a lighter moment and I was laughing with Libby playing peek-a-boo.”

“Would it be possible for you to have faith in yourself even if you can’t have faith in the clairvoyant you met?” (37)

“I’ve tried very hard to separate those two. It’s where I came to on Saturday. I didn’t have a very good experience with her but that doesn’t mean it’s all out. I didn’t pin my hopes on just one person. I booked two clairvoyants. I’ve booked the other one for August and I’ve heard she is authentic and very good. I’ll keep that booking. I’m not giving up on it altogether.” Claudia sounded calm.

Laughing, she added, “I can spare another $120! If she’s good!” I laughed in response before inquiring, “What about your own experience of feeling Tom was with you?”

“It was very strong. But it’s very easy to doubt myself. That’s what’s hard I think,” Claudia explained. “I had another experience where I was looking for a necklace and I felt Tom very strongly. I was looking and looking and then I found it one day and I had a very strong feeling that Tom had helped me find it. I know that sounds strange. But it was such a strong feeling that I said, ‘Thank you Tom! That’s for Imogen.’ It just came out. I need more! Greedy, greedy!”

“When you feel Tom with you, what does that feel like?” I asked curiously.

“Normal! The old normal,” she explained with energy.

“How do you know he’s there? When he helped you find the necklace, what happened that told you that?” I wondered, keen to learn more.

“It just felt like everything’s OK again.”

“Ah.” I sat back in my chair.

“And I don’t have to have this new normal. Both times I just felt lighter and happier. This nightmare is over or maybe not what it seems.”

“If you met with another clairvoyant whom you did or didn’t find authentic, could anyone take away those experiences that you’ve had?”

“No. They’re authentic to me,” Claudia stated.

“You said you want more of them…”

In a sing-song voice Claudia interrupted, “I do!” She was grinning.

I returned her grin. “On demand!” I echoed in the same sing-song tones. Claudia laughed. (38)

“They felt authentic to me and I’m a big believer in going with your gut instinct. I’m quite in tune with those things. They felt real.” Claudia sat back looking steady.

"I drove back to the hospice some time later reflecting on the many understandings people hold about what happens to a person after they die." (39)

New Understandings

Claudia returned to work and, as the routine settled and time passed, the pain of Tom’s death intensified. As Claudia explained to me, “It is now not just days or weeks since I last saw Tom, but six months. The longer it is since I last saw my Tom, the more I miss him.” I wasn’t surprised as many other people have described a similar experience to me.

It was a rainy day. Claudia had finished breastfeeding Libby and had returned from laying her down to sleep. She walked up the stairs with a heavy tread and sat down. “It feels like we are now in a new normal. The new normal makes me so sad. I don’t want a new normal. I want the old normal. I’m feeling guilty; sad and guilty.”

I made a few acknowledging sounds as she talked, “It is so tough. Who would want this normal when comparing it to having a partner they loved alive?” I paused a moment as I looked at Claudia’s drawn face. “Would it be helpful to share with me some more about this sadness and guilt?” I continued, wondering if it might be useful to get to know th

A Week with Virginia Satir: The Gift

Posted on by Psychotherapy.net Team

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

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

A Retreat for Connecting and Growing

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

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

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

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

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

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

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

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

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

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

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

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

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

A Small Hope: Co-creating a Narrative of Grief – Part I *

Posted on by Psychotherapy.net Team

This story is dedicated by “Claudia” to “Tom” in memory of his loving ways.

I would like to thank “Claudia” for her generosity in joining me in adventuring into new territories. There would be no story without her.

I would like to thank Aileen Cheshire, Catherine Cook, William Cooke, and Peggy Sax for their insights and helpful suggestions, and David Epston for his editorial support.

Introduction

Grief can be excruciating. The pain of loss may be overwhelming at times and its duration and intensity can be a shock to many. However, it is not always so. Relationships are shaped differently and there are many possible stories that can be told of such an experience.

The following illustration of Narrative Therapy (2) was originally written as a therapeutic document for a woman who had been forced to contend with the death of her partner while she parented their young children. “Claudia” (3), as she chose to call herself for this article, was experiencing significant loss. At the same time, she was struggling to find compassion for herself. I hoped that if Claudia viewed herself in a story of our conversations, the narrative might lend strength to the new understandings we were co-constructing. Claudia was enthusiastic about the idea of co-creating such a document and after going through a careful consent process, we agreed that we would record our conversations and write a story from the transcriptions.

Our purposes for writing a story evolved. As time passed, Claudia wanted to share her knowledge of grieving with others. When we discussed the possibility of sharing the story with a wider audience, I hoped the story might show the unfolding of therapy, and in particular, narrative practices that companion a person (4) and invite them to explore new meanings of their experience.

I have therefore added footnotes to the story [Ed. Note: Please see the original article for these notes]. The footnotes explain more of what I was thinking as Claudia and I spoke, and why I asked particular questions. They also include some thoughts on narrative practice with people who are suffering as they live with loss. You may choose to read the story and the footnotes together or separately.

For those of you who are interested in experimenting with writing a story, in contrast to other forms of therapeutic documents, please see an earlier paper I have written on writing narrative therapeutic letters. I have described the process of story writing and some of the possible benefits within that paper.   

A Cupful of Time Folded in with Love

“It’s urgent,” the community nurse told me solemnly. “Yesterday, Tom was told he was bleeding internally by the doctor at the hospital. When he heard nothing could be done to stop it, he asked his wife Claudia to take him home. Understandably, they are reeling; this has all happened so fast. We’ve offered counselling support and Claudia has agreed. She’s asked if you could ring after 10 o’clock so you don’t wake the baby from her morning nap.”

I walked back down the hallway towards my office reflecting on what it might be like to receive such news. Just after 10 o’clock I telephoned. Claudia answered. “Hello, it’s Sasha speaking. I’m one of the counsellors from the hospice. I understand you might be interested in meeting up with me. Have I got that right?” Quite often people have another understanding from a referrer, so I was tentative to give Claudia space to say what she wanted. (5)

“Yes, that would be great,” she replied.

“How would tomorrow suit you?” I asked, thinking of the urgency of the situation.

“Look, it’s very kind of you. I know it’s Friday tomorrow but it’s going to have to be next week. I’m sorry. I promised our five-year-old, Imogen, I would bake a cake with her tomorrow. It’s her birthday and I promised,” Claudia apologised in a rush.

“Are you the kind of mother who honours promises?” I asked with a smile in my voice. (6)

I heard Claudia let out a long breath. “She’s been looking forward to it all week.”  

Warmly, we now began to make a time to meet up. In the back of my mind, I was thinking about Claudia prioritising a promise to her daughter when she was possibly having the worst time of her life. Images of baking with my own young daughter many years ago floated through my mind. I wondered, “What might Imogen remember of this time when her Daddy was dying and when promises were kept to her five-year-old self? What might she say about the way she was cared for by her Mum at such a terrible time?” I also appreciated Claudia’s ability to put me off and say what she wanted. I was well aware it wasn’t easy to delay health professionals, especially to honour the wishes of a child.

I looked forward to meeting Claudia and Tom, and learning more about them.

A Surprising Renewal

I parked the hospice car down the road from the house, worried that the signage on it might communicate to the neighbours something Claudia and Tom wished to keep private. It wasn’t the anonymous unadorned car I usually drove. A young woman opened the front door of Tom and Claudia’s home and, as I looked at her animated face, I realised I knew her.

“Do you remember me?” she asked, wide-eyed, as if she could hardly believe who she was seeing.

“Yes!” I replied, flooded with memories. It was nearly 20years since Claudia and I had last seen each other. Her father had been dying at the time and Claudia was caring for him. I was working as a counsellor in a university counselling service and we had met together across the last 18 months of her father’s life. I easily recalled Claudia’s devotion to his care at a time when her contemporaries were more focused on parties and the opportunities study could provide them.

I walked further into a room that had ushered in many unfamiliar health professionals over the prior week, full of gratitude for this chance reunion and hopeful that it might make some difference for Claudia and Tom.

Claudia invited me to come into a bedroom for some privacy and together we sat on the bed. She was dressed comfortably in shorts and a T-shirt with her long, fair hair tied back off her face. Clothes that would be practical for parenting work and caring for Tom, I thought. There were dark circles under Claudia’s red, lidded eyes, easily visible because of her fair skin, and her face had a hollowed appearance in spite of her warm smile.

Claudia explained she had been up all night with their baby who was sick, and on top of that she herself had toothache. “Somehow, I am going to have to fit in an appointment with a dentist, but I don’t know how I’m going to find the time,” she exclaimed, throwing up her hands in dismay. After talking further, Claudia led me into a small, darkened room to meet Tom. He lay on a single bed unmoving and silent. Claudia touched Tom gently and he turned his head towards us. “This is Sasha,” she said. Tom looked up at me and we exchanged a greeting.

I sat down on a chair facing Tom while Claudia ignored the other chair which was placed near his pillow. Instead, she sat on the floor with her arm resting on Tom’s shoulder. Tom’s skin was a faded tan colour, suggesting to me he had once spent considerable time out of doors. In response to my greeting, he slowly shifted in the bed with jerky movements. Once he had settled, I leaned forward looking at him. “Tom, it’s lovely to meet you.”

He was a tall man I guessed, with fair hair and a kind face, softly lined around his eyes and mouth. “I’m aware talking can take a lot of precious energy. Is this an OK time for the three of us to talk together, or would you rather we spoke another time? I want to do whatever best suits you and Claudia. I can easily fit in either way,” I offered, smiling warmly at him.

“I’d like to talk for a bit. I won’t last long. We’ve been looking forward to it,” he responded, glancing at Claudia.

“When you find yourself beginning to tire, will you notice and be able to let me know?” I inquired, thinking I would need to be alert for any signs I was extending the conversation longer than he could comfortably manage.

“Claudia will know. She’ll tell us both.” Claudia nodded, her face soft and relaxed.

“Thank you.” Sitting back in my chair, I made myself comfortable while I looked from Claudia to Tom. “Illnesses have a way of taking over people’s lives and yet people are so much more than the illness they are living with. Would it be OK if I asked you a bit about yourselves and your lives before all this happened?” (7)

“Gosh it’s so nice to be asked that,” Claudia exclaimed. “It makes me feel like I matter, we matter. Tom’s a teacher and you probably noticed the garden. He grows plants from seed and often ones that are good to cook with.”

In a faltering voice Tom contributed, “Yeah… I’ve taught younger age groups and I love to garden and cook.”

“Food is very important in this house!” Claudia laughed.

Tom quietly added, “In the last year I’ve worked tutoring from home … it’s been ideal with me having cancer.” I considered asking Tom about how he lived with cancer but decided to pursue getting to know them more a bit more first. Claudia continued the conversation in a lively manner sharing with me stories of her work and interests.

“Tom, if I were to know Claudia as you do, what might I come to appreciate and respect about her?” (8)

Tom looked at Claudia as he answered me. “I love Claudia very deeply. She is kind. Really kind. I saw that from the first. She is honourable and dedicated to the people and things she believes in. Her loyalty is like none other and there is nothing I wouldn’t share or confide in her. Claudia is a wonderful, loving mother. Knowing that makes it easier for me to be sick because I know I will be leaving the girls in her care.”

“Could you tell me a story that illustrates some of these attributes you love and appreciate in Claudia?” (9)

Tom spoke of the care Claudia had given her father as he was dying. “She will always have your back,” he told me.

“What difference has Claudia ‘having your back’ made to you?”

“It has given me a whole new life that I wouldn’t have had without her. It’s meant I can be myself and pursue my interests. It has meant I have had the joy of becoming a father.”

Claudia responded by clasping Tom’s hand. “I love you so much,” she whispered.

After I asked Tom a few more questions, I turned to Claudia.

“Claudia if were to get to know a little of the Tom that you love so much, what might I come to respect and appreciate about him?”

“You’d appreciate his authenticity. Tom is real. He has a wicked sense of humour too! He’s always polite but he doesn’t suffer fools.”

“Would it be OK to ask you for a story of Tom’s authenticity and his wicked sense of humour?” I grinned at Tom and his eyes twinkled in return. Claudia launched into some stories with enthusiasm. Tom lay back quietly enjoying her words.

As the conversation progressed, it turned quite naturally towards the cancer and what they had been going through. I looked over to Tom and inquired, “What do you give weight to in your days as you live with this cancer?” (10)

“My family, being a father, I like to be involved with the girls,” Tom confided. A small smile emerged on his face. Tom tried to raise himself in the bed but, before Claudia could help him, slipped back down and, seeming to give up on a sitting position, rested his head on the pillow. When he looked comfortable again, I asked, “Could you help me to understand a little of what it means to you to be a father?”

“I love it! I wasn’t truly happy until I was a Dad. I took one look at Imogen, our eldest, and I fell in love.”

I was aware Tom’s words might carry meaning that could be passed on and retold down the years, perhaps providing solace for his girls.

“Could I ask you about this experience of falling in love?”

Contentment seemed to flow over his face for a moment, relaxing the lines as he contemplated my question. “Sure. I didn’t know what happiness was till Imogen came along. She made my life complete.”

“What did Imogen’s birth give you that has you experiencing this sense of completion and happiness?” I responded smiling.

Tom pondered, “I think it was a proper purpose….”

Claudia joined us. “…Being parents connected us to what’s important…I think Tom’s found a role that really fits him. He’s a good father.”

Tom’s quiet voice gained strength and the corners of his eyes turned up. “…And then Libby was born and I felt overwhelmed with wonder.”

“What had you overwhelmed with wonder when Libby was born?” I asked, collecting stories again. (11)

“Libby having her very own personality and the way she could let her feelings be known,” he responded with a chuckle. Claudia joined in, “He sent me a message when I was at work that said, “Baby does not want to sleep in the bedroom today. She was very vocal on the matter!” Claudia laughed. “Tom always appreciates her strength of character and being able to understand what she’s trying to say.”

Enjoying their delight, I responded, “What is important to you both that the experience of parenting has connected you to?”

“Our values and beliefs,” Claudia told me. Tom nodded, meeting Claudia’s eyes. “What we treasure.” I was keen to ask them more about their values and beliefs, but I didn’t know how long we might have for our conversation. Tom was likely managing fatigue and so I decided to pursue another path. I would return to the detail of what they treasured at a later date.

“Would it be OK to ask how this giving weight to what you believe in and treasure shapes your experience of living with cancer?” (12)

“It’s given us good times, wonderful times in amongst the hard stuff. The girls make each day worth living for,” Tom answered.

“We spent one morning just watching Libby learn to roll,” Claudia laughed.

Our laughter was cut off by sounds of crying from the room upstairs followed by shuffling as Tom’s mother walked quickly to attend to Libby.

Claudia tilted her head as she listened for signs Libby had been soothed. Tom stilled listening as well. “How will I do it without you?” she whispered, looking back to Tom. Tears began to flow down Claudia’s face. Stifling sobs, she rested her head on Tom’s chest and stretched her arms out as if to cradle the entire length of his body.

“I’m still here now. I’m still here now,” he crooned, patting her back.

“How will I raise the girls without you?” Claudia reiterated.

“I trust you. You will do a good job,” he said, trying to placate her. Tom continued to pat Claudia’s back in the age-old rhythm of comfort. I remained quiet, touched by her pain and his attempts to console her. (13)

After a time, I asked him, “What is it that you know about Claudia that allows you to trust her?”

Tom began to describe his faith in Claudia, gently patting her back all the while he talked.

“Could you tell me a story that illustrates this trust you hold for Claudia and her parenting?”

Tom expressed his admiration for Claudia as a mother. “She always puts the girls first.” He told me stories of her kindness and her beliefs about mothering, explaining how important their shared parenting beliefs were to them. As he spoke, Claudia listened silently, intent on his every word.

“How might you like to carry these beliefs you share forward so Imogen and Libby might know something of what is important to you as a couple and as a family?” I responded.

Claudia suggested they create a family charter that recorded their values. (14) Tom was enthusiastic about such a project and together we discussed what might be included in the document.

I checked with Tom as to how his energy levels were at regular intervals. Mindful that it is hard to send someone away, when I noticed his eyelids start to droop a little, I began to bring the conversation to an end.

“How has this conversation been going? Have we talked about what you hoped we might or have I taken us off track?” I checked.

“It’s been good,” Claudia said.

“Thanks. I liked talking,” Tom said warmly.

Claudia showed me out a few minutes later.

A Small Hope

Over the following week I heard that Tom had stopped eating and was now unable to leave his bed. The nurses told me that Claudia had insisted no one speak to her about his symptoms or deteriorating condition.

At the end of the week I went to see Tom and Claudia as we had arranged.

Claudia and I sat outside in the garden at an old wooden table. Tom was inside sleeping, too sick to talk. The garden provided a quiet private place away from the activity of the household as the extended family all worked together to care for him and the girls. Tired, harrowed faces had welcomed me and in the heavy movements of the family, I thought I could feel unspoken sadness weighing down their every step.

Claudia looked up as the leaves ruffled in the moving air. “It’s been a better week.”

“When you look back on the last two weeks, do you have some ideas about what has contributed to this week being better?” I asked, incorporating her words into my question.

“I’ve stopped looking ahead,” Claudia replied. Not wanting to presume what Claudia meant, I responded, “May I ask, where do you look when you’re not looking ahead?”

“No one can know exactly what’s going to happen, can they?” Claudia replied. “Now I only think about today and I have some hope.”

“Could you help me to understand a little of what this hope (15) is to you?”

Claudia paused, bowing her head.

“It is only a small hope,” she said in a quiet voice as if confessing something. “…To be with Tom, for another day or maybe even a few days.” Claudia looked up at me with tears gleaming in her eyes.

“May I ask what difference this small hope makes to you?” I replied, moved by the humility of her hope.

“It means I’m not crying all the time. I sat by the window and told Tom what I saw outside. We spent some time talking quietly together once Imogen was at school. I made him a little something for lunch and we sat together. He told me being together like that was ‘perfect,’ and he has never said that before.”

“As you look out the window describing the view to Tom, what does this small hope do that has Tom finding your time together perfect?”

“I can enjoy the moment and he feels that. It helps me forget what is coming,” Claudia explained.

“When you spend these moments that the small hope has given you, what has been made possible that hadn’t been there in the week before?” I knew that the week before had been distressing for them both.

“Close time together. Over the past few months, we’ve been arguing because of the stress and that isn’t us,” was Claudia’s reply.

“How did you come to find closeness in sharing the view from the window and talking and bringing Tom food?”

Claudia told me with eagerness now edging into her voice, “It’s what we’ve always done together, enjoyed the simple things. We like to enjoy those things that money can’t buy.” Claudia continued telling me stories illustrating this.

“What else do you do in the day that speaks to the closeness you share as a couple, and as parents together, and brings you closer to Tom?”

“Gardening,” Claudia readily answered. “I feel close to him when I do his garden and I will keep doing it. I just couldn’t do it before. I was too shocked. Now I have some hope and it gets me through the day.”

“How important is this hope in keeping you close to Tom and getting through the day?”

Firmness was in her voice as she stated, “Very, very important. It means I can enjoy some time with Tom and that is the most important thing to me. The time is so precious. And I don’t want to cry every minute.” We carried on talking about how Claudia and Tom were enjoying the window of time they still had together when Claudia confided, “Did you know I’ve stopped the nurses telling me about Tom’s symptoms?” She glanced up at me and paused, “Maybe that means I’m in denial, I don’t know.”

“What sort of talk are you encouraging or hoping for when you halt discussion about Tom’s condition?” I asked.

Her reply tumbled out. “I know what’s coming…I just want a little longer, just a little longer with him without thinking of that. It’s always there in the background but I don’t want to go there before I have to.”

I could easily understand why Claudia might want to protect the hope that was allowing her to savour time with Tom. To me it was not denial of his approaching death but rather embracing what was most important to her — close time with Tom before he died.

I left that day not knowing when Claudia and I would next meet. The uncertainty Tom and Claudia were living with made it difficult for Claudia to plan. We had agreed she would call me when she next wanted to meet.

The following week I heard that Tom was dying. The hospice nurses were visiting daily and every effort was being made to keep him comfortable.

One morning I arrived at work early. I sat down at my desk noting the light was blinking on my answerphone. I punched in the numbers to access my messages. There was just one. One of the hospice community nurses had called to let me know Tom had died. “Claudia would like to see you,” she said.  

“Such a lot has happened since we last met. Would you like to talk about the last fortnight or is there another place you would rather begin?” I asked, seeking to create some space for her to guide me as to how she wanted to begin our conversation. I didn’t know how talking about Tom dying would be for Claudia or what language she preferred to use. (17)

Claudia spoke slowly contemplating her words as if they were transporting her back in time. “I moved Tom back into our room after I saw you. I’m so glad I did. It was much nicer for him.” She smiled tenderly. “I lay beside him on the bed that last week as he was dying. I told him over and over, ‘You’re loved and you’re safe.’ It was just him and me when he died…” Claudia paused, her eyes staring unfocused. Returning her attention to me she resumed speaking. “The family had left for the evening to give us some time alone together, but I called them when I realised he was dying. They came straight back. In the end, he died like he’d wanted.”

I imagined Claudia reassuring Tom with her love. “May I ask… what difference did it make to Tom to feel loved by you as he was dying?”

Claudia sat back in the sofa. “I guess he could bear it. He’d had a tough childhood because he was different, and he was bullied a lot. But when he died, he had a family. He was loved. He had all the things that were really important to him.” She glanced at a photo of Tom and the girls on the wall. I too looked at the picture of Tom holding Libby while Imogen wrapped herself around his legs.

The slow pace and rhythm of my words matched Claudia’s as I returned my entire attention to her and expanded my previous question. “What did it mean to Tom to have a family and to be loved as he was dying do you think?”

“Everything. A chaplain visited Tom at the hospital just after we heard the news he was going to die. The chaplain asked Tom, ‘Has it been a good life?’ and Tom said, ‘Yes. It has been a good life.’ It comforts me to think that. He always said he’d got a life through me he’d never expected to have.”

I leant towards her as I replied, “What was it that he got from his relationship with you that made his life good?”

“He said he learnt new things. He became a father. He said because of our relationship, he got to have a life he wanted but never imagined having.” Claudia’s body stilled and her mouth turned down. I responded tentatively, “Would you mind sharing with me a little more about this good life that your relationship gave Tom?” I hesitated. “Might Tom have said it was a longed for life?"  

“It was a longed for life,” Claudia replied emphatically. She wrapped her arms around her body as if to hug herself and began to recall how she met Tom and the friendship they shared. The words came out quickly matched by the tears that fell from her eyes. After a few minutes of talking, Claudia slowed, releasing her arms from her body, and sat back on the sofa. “He said he’d always been on the outside and never felt like he belonged. It all changed for him when we were together. We both valued friendship and loyalty and it built our relationship.”  

I was spellbound by what they had given each other. “People mean many things when they talk about friendship and loyalty. What were yours and Tom’s understandings and how did they show in your relationship… that had Tom moving from feeling on the outside to stepping inside and experiencing belonging, friendship, and love…a longed for life?”

It was a long question and I said it slowly with expression. Claudia stared at me attentively. Eagerly she replied, “We had each other’s backs. Even if we didn’t agree, we always loved each other. We respected our differences and opinions. Our love was always there even in the way I cared for him. When Tom got sick, he said it changed how he dealt with having cancer.”

“How did this love you shared and the loving ways you cared for Tom influence how he lived with the cancer?” (18)

Claudia leant towards me, seeming oblivious to anything other than what she was about to express. “It meant he could go on enjoying his life. We were good at loving each other. We both changed and grew because of the relationship. I will never have another like it. It kind of gives me more to hold on to, and I keep saying to myself how grateful I am for my relationship with Tom, but it’s also so much more to lose.” Claudia lowered her voice, her passionate tones fading rapidly, and almost whispered, “I’ve been on the edge of a cliff for so long knowing there was a chasm ahead of me. I know I’m falling into it now but there’s this numbness. I hate it. It disconnects me from Tom. It’s like this isn’t real and it is.”

I reflected on the enormity of such a loss and Claudia’s ability to express gratitude at such a moment. “When you’ve had such a special relationship which both gives you more to hold on to and more to lose, how do you understand this sense of numbness?” Claudia nodded when I gave weight to the words “more to lose” and then replied hesitantly, “It’s an anesthetic. My body being kind maybe.”

“What does this sense of numbness speak to about the relationship you have with Tom and the magnitude of the loss do you think?” I wondered if the numbness was an expression of their close connection, and the magnitude of the loss Claudia was experiencing.

Claudia straightened her back and lifted her chin. “Tom dying is bigger than any loss I have been through before. Other people I have loved have died but nothing compares to this. Nothing!” She uttered the words emphatically as if arguing with an unseen audience. Then, making eye contact with me added, “Does that make sense?”

I nodded as she spoke, reflecting that she was in a much more informed position to speak of this than I was. “Losses are not the same, relationships are different, and circumstances are different. Would it be OK to ask what it is that contributes to Tom dying being an incomparable loss, the biggest loss you have ever experienced in your life?” I wanted to fully acknowledge her experience. (19)

Claudia wriggled back on the sofa unfolding her arms. Her chest rose as she took a deep breath. “He has been the most important person in my life. He is my best friend. I don’t want to forget.” I remembered h

Awareness: Attunement, Access, and Affirmation

Posted on by Psychotherapy.net Team

The key is to focus in on the intuition you do have, to pay attention to ways that you may be using it in your life, in your profession, in your interests, and in your dreams….
—Mona Lisa Schulz

Flowing into the Psychic Mind

Awareness of the diamonds contained in the psychic mind allows you to affirm its vital resources and attune to its ongoing flow of information. As Dr. Milton Erickson taught, we all have the ability to access and utilize the resources of the unconscious mind. The first step is to understand how to tune in and recognize the precious gems of intuitive wisdom. In understanding the use of the ACE schema, it’s important to remember that each step contains dynamic concepts made up of ideas and processes, characteristic phenomena that you can come to understand and learn to develop. Let’s start with the phenomenology of the first concepts of the schema:

A: Access, Attune to, and Affirm your natural psychic gifts.

I have identified six key phenomena of the first “step” of the ACE schema: accepting, absorbing, dissociating, listening/sensing, receiving, and interpreting, aka “reading.” As you study and use ACE, you may identify even more phenomena. I suggest that these features, although presented as linear, will overlap as you develop your intuitive skills. Let’s start with awareness and acceptance that psychic ability is part of our human makeup — that it is a valid way of receiving knowledge, and that it can make you a better clinician.

Becoming absorbed into the inner mind is something we all do on a regular basis. Absorption is as natural as spacing out in front of the TV, intently focused on playing a game on your computer, or relaxing in a hot tub. Meditation, progressive relaxation techniques, prayer, and hypnosis all involve the quieting of the mind, a kind of “zoning out” that creates entry to a state of inner awareness. When thus absorbed in a state of mindfulness, one is somewhat dissociated, less consciously aware of what is going on in the outer environment, more deeply and narrowly focused on one’s chosen object, and more deeply attuned inside.

Although this type of deeper attunement often happens spontaneously, you can actually learn how to become more consciously tuned to your inner world by practicing the felt experience of being in a receptive state. Your preferred method of stilling your mind can be a practical and useful way to enter a state of receptivity; however, a relaxed state is not mandatory for accessing intuitive knowing. Intuition can also be available when you are in a state of sympathetic arousal due to some exciting situation, positive or otherwise, including the variables of a therapy session when intuition may be extremely helpful. As will be demonstrated shortly in the case of Tom, access to intuitive knowing can be a go-to consultant when you are immersed in the variations and variables of a clinical experience.

Listening, Sensing, Receiving, and Interpreting

Take a moment to think about a time when you “just knew” the right thing to say or do in a session. Was it a fleeting thought of intuitive wisdom that helped you formulate an effective intervention, or a hunch about a correct diagnosis? Can you recall times when after following a gut feeling, you congratulated yourself on the way your clinical acumen could just “sense” what was needed?

As a therapist you probably already have a pretty good sense of how to “read” people, how to interpret and be guided by minimal cues. You may be adept at imagining contextual aspects of others’ lives by noticing small details of word choices, postures, and expressions. Observations such as these and similar experiences of knowing are examples of sensing, listening, receiving, and interpreting, some of the phenomena of attunement and access that are pivotal to the magick of clinical creativity.

Consciously putting yourself into a receptive state for intuitive knowing can make clinical insights, ideas, and interventions more available, and make you more creative. As you become familiar with the way your mind receives information and what related sensations occur in your body, you can memorize and anchor the felt experience of cognitive, emotional, and sensate phenomena of your receptive state. Practicing in this way will help you develop psychic “muscles” that you can flex with fluidity and authority. You will become better equipped to help clients access their own unconscious resources with greater trust and comfort, and less guilt and shame.

Welcoming Wisdom with Easy Attunement

If you choose to use your psychic wisdom to improve your clinical work, you may or may not hang out a flashing neon hand at an amusement park. However, after reading this book, you might decide to try your hand (or your mind) at an intuitive consultation, also known as, a psychic reading. In fact, doing intuitive readings can be fun and, as I have found, can also be very useful for certain clients and certain situations.

In whatever way you choose to utilize your intuitive ability, the following short script can be used to practice attunement and access. This can be done anywhere, and with practice you will become adept at recognizing and welcoming the way psychic knowing emerges into the wisdom of your conscious mind.

Choose a comfortable spot. Close your eyes if you wish or gently let them go out of focus or be blurry.

Gently breathe and when your mind is quiet in the right way for you, take a little deeper breath and count down slowly from 10 to 1. By inhaling gently and exhaling smoothly, you can realize how easily your body can settle and your mind can be free to roam into the unconscious mind and receive guidance.

Pay gentle attention to your breathing, feeling tension leaving your body, and in whatever way feels right to you, notice the way your mind is becoming receptive to images, ideas, and sensations. Good.

If unwelcome thoughts come in, return attention to your breathing or counting, continuing to pay attention to what comes in and give yourself permission to let go of what is not welcome. Very good.

As you continue to breathe normally and rhythmically, you can trust that you are entering a receptive state that is just right for you.

Now, without struggling or attempting to reach a conclusion, you can imagine allowing your senses to receive information as thoughts, feelings, impressions, somatic sensations and intuitive hunches enter your mind. Affirm that you will realize which ideas will be most useful. All you need to do is to notice. Good.

If there is a specific issue you wish to resolve, you can project your problem onto your mental screen. Visualize possible courses of action and potential outcomes. Allow your mind and body to imagine scenarios and metaphors that later you can consider for possible solutions. Excellent.

When you are ready, reorient your senses to your current circumstances. Affirm that your psychic mind has intelligence you need for all situations. You can remember whatever needs to be remembered or forget what needs to be forgotten.

When you’re ready, take a gentle breath and come back feeling refreshed all over. As you go forward, your psychic mind can offer continuing intelligence that may come as a subsequent hunch, a feeling, a metaphor or in some other form that you will realize. Affirm that this is so. Good job.

When we include guidance from our intuition during a therapy session, we are better able to help the patient attune to the unique resources of their own psychic mind. The case of Tom offers an example of the way in which insight from the psychic dimension gave me access to an idea for utilizing Tom’s intuitive potentials for neurobiological and physiological shifts, and actual somatic and emotional improvement.

The Doctor Makes a House Call: The Case of Tom

A grandfather and a retired businessperson living with HIV, Tom is down-to-earth and practical. While he might not appear on the surface to be a candidate for a psychic healing session, Tom’s health issues, his familiarity with my integrative, intuitive work, and our solid therapeutic alliance opened an opportunity to help Tom with his anxiety.

Having seen Tom through HIV diagnosis, stabilization on medical protocols, and successful recovery from several other serious health issues, I was only mildly surprised when he announced: “My doctor found bleeding during the sigmoid exam. I’m doing my best to manage the anxiety, but I’m scared, and there are a few weeks before the definitive procedure. I’m keeping busy, taking care of the grandkids, and going to the gym, but I can’t shake the feeling that this might be it.”

Given Tom’s ongoing health issues, I realized that his “This might be it” was very frightening. It was not my job to provide concrete answers or reassurance, so where would I go with “It?” At moments when there are complex intricacies, such as in Tom’s situation, I think of Dr. Erickson’s permission to utilize everything. Or as Jeff Zeig says to be in a “state of readiness” to use whatever the client brings as well as what comes into the therapist’s mind.

In what seemed like only seconds, my mind was filled with ideas. I could not give concrete information, but could I offer Tom something to relieve his anxiety, to tamp down his sympathetic nervous system? It occurred to me to venture outside the traditional box. If not specifically curative, the approach might be soothing for Tom. In the intuitive flow, memories of my great uncle came to mind.

Handsome and over six feet tall, with a strong jaw and a steady, reassuring stride, Uncle Abe had been a doctor in the city where I grew up. When I was a little girl, Uncle Abe made house calls, arriving confident and authoritative with his stethoscope and his otoscope (and a cache of lollipops tucked into his black bag). When deep in diagnostic considerations, Abe’s cheek muscles gave a teeny twitch. Uncle Abe’s presence, his gentle, caring reassurance, and our knowing we would get to pick a lollipop left my sister Gini and me feeling better and trusting we would get better.

Over the many years since Uncle Abe had been gone, I had often channeled him as a healing spirit guide. Now, perhaps a psychic visit from Abe could help Tom. Because Tom was aware of my psychic work, I felt fairly sure he would be open to having my uncle make a channeled house call. I hoped that an uplifting experiential moment might provide an alternative mental and emotional focus that could comfort Tom and replace any obsessive thinking about this latest health issue.

I asked Tom if he would be open to a visit and a healing from Uncle Abe. Intrigued, he agreed and settled into the couch as I induced a gentle hypnotic trance. Seeing Tom responsively absorbed, I said:

“I am inviting my spirit guide Uncle Abe to join us now.

“I welcome you to picture him in your own way, and when ready, imagine Uncle Abe gently placing his hands on your shoulders. As you feel his touch in your way, you may notice a shift in your breathing and a deepening awareness of sensations in your body.”

“I feel warm all over,” Tom responded. “I feel something like a gentle pressure around my pelvic area. It’s comfortable, healing, and warm. It’s okay.”

“Good,” I affirmed. “Now you can continue to breathe normally, just noticing this warm, healing sense of Uncle Abe’s presence and his placing his hands on you. Spend a few moments imagining and sensing in your body the way Uncle Abe’s hands can elicit feelings of comfort that can spread into any part of your body. In a few moments I will welcome you to return gently from trance, coming back refreshed and able to remember these feelings. You can memorize the way it feels to have healing hands laid upon you, and you can bring back these impressions any time later, as you desire.”

Coming back, Tom reported his anxiety to be relieved and his sense of hope improved. I asked him to call me after his procedure.

When the call came, Tom’s bright “Hello” said it all.

The doctor, actually somewhat surprised, had found no evidence of bleeding or pathology. He had pronounced that Tom was fine.

“I think it was that session we had with your uncle!” Tom asserted.

And I’m not sure I would disagree. Who knows really? Was Uncle Abe really there or was it the psychic wisdom in Tom’s own mind that could feel the healing power of imaginary hands the way you can taste an imaginary lemon?

I explained it this way to Tom: “Uncle Abe served as a channel for the psychic, somatic intelligence inside of you. Your body and your mind were the real medicine men. With your psychic mind allowing the felt sense of Uncle Abe’s touch, your body experienced whatever healing was in the imaginary hands, drawing on your body’s innate capacity and intelligence for improvement. Now as you absorb the memory of this experience into your mind/body, you can call upon Uncle Abe’s psychic medicine as many times as you wish.”

Dynamic Magick: Putting Ideas Together

Whether the vast resources of the inner mind are called the unconscious mind, the wise mind, the intuitive mind, or the psychic mind, the mind-that-knows is a font of wisdom and a vital feature of your enterprise as a clinician.

By listening, sensing, receiving, and reading you will have greater insight about what is going on with the client, what is happening within yourself, and how to best intervene in a given session. You will become more effective at helping clients choose more effective coping options, increase stress management capacity, experience problem-solving epiphanies, find relief from self-defeating patterns of thinking and behaving, and increase creativity.

Herb Dewey taught me to use psychic ability as part of counseling skill. Herb loved the drama of the magick, which he called the shmaltz or the pizzazz. And he was serious about the counseling, about helping others in an accepting, non-threatening, and non-shaming way. Similarly, Milton Erickson put great value on respecting all messages from the client and never taking away choice.

My intention is to utilize everything I have as a therapist, including aspects of psychic arts along with clinical skills in every session, based always on the needs, beliefs, and personal maps that a client brings in. Whatever your objectives may be, utilizing your intuitive abilities can empower the therapeutic magick that will motivate your clients to heal from inside out.

If it is your goal to help clients use their own inner resources for mental, emotional, or behavioral healing, why would you not want to attune to and access the healing wisdom available from your own intuitive mind? And why would you not want to use everything you have available to help yourself be more therapeutically effective and help your clients feel better?

As you affirm and access the breadth and depth of your psychic knowing, you will become more attuned to the unique personalities, personal world views, and therapeutic needs of your patients as they absorb and integrate the wisdom you offer. The following short excerpt from the case of Emily presents another example of utilization of the psychic mind.

Emily Tunes In

Trying to manage a large men’s store while dealing with a variety of personal health and family issues, Emily had been in a chronic state of high velocity distress. However, on this particular day she surprised me, coming into the office with light and lively steps. And she was laughing.

“I was at my wit’s end last week at the store,” Emily reported. Remember how we channeled my mother when my husband was sick? Well, I decided to channel you! I imagined sitting with you here in the office, but I switched it. I made me you and you me. Then I put you into that place in the inner mind where you, or I, or both of us could just let it all go, like we do when we have a good laugh together. So, what I am saying is that it was just like the time when John was in the hospital. Remember how we pictured him having no blood clots — and the doctor was surprised that the ones they thought he had had gone away? Remember how upset I was? You had me channel my mother and she told me that I was going to be able to handle everything — and I did handle it.

“Well, this time when the store was crazy, I channeled you and you said I could handle it. And it worked, I handled it all — and I feel great!”

***

Intuitive attunement and receptive access each have a particular phenomenology. In the same way, conscious contemplation of unconscious resources and cultivation of the experience of receptivity will make you even more adept at tuning into and accessing the virtually limitless flow of information that comprises your psychic mind — and your own brand of magick.

This essay appears as chapter 7 in, Other Realms, Other Ways: A Clinician’s Guide to the Magick of Intuition, published by Iantella books, and reprinted with the permission of its author, Bette Freedson.?  

Effective Family Therapy Using Football Metaphors

Posted on by Psychotherapy.net Team

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

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

Shifting Therapy to a Focus on the Family

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

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

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

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

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

Family Therapy as a Game of Football

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

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

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

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

Family Response to Therapeutic Intervention

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

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

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

Questions for Thought and Discussion

What were your impressions of this therapist’s intervention?

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

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

When the Therapist Turns Out to be Human

Posted on by Psychotherapy.net Team

A Therapist Looks Inward

This year has been one that has proven challenging career-wise and personally. While these challenges have offered opportunities for growth, reflection, and introspective experiences, they have arrived at a point in my career as a therapist I had never anticipated. This has been the place where I have questioned my professional identity to the point that it affected my competence and well-being.

A large part of my therapeutic identity resides at the intersection of my race and gender. With much pride, I relish identifying as a Black female therapist because it gives me a unique lens of empathy, therapeutic alliance, co-regulation, and strength in my approach to psychotherapy. So, when that identity became weaponized against me in the therapy room, I wondered how that would influence my trajectory as that Black female therapist providing mental health services to clients of intersectional identities.

If They Knew I Was Black Beforehand, Would They Want Me as their Therapist? 

Racial encounter experiences with clients often stick out in my mind and linger, leading me to wonder how many uncomfortable clinical experiences fellow Black female therapists have had like mine. Having a name that one may consider “white-passing” with a “different accent,” I often found my racial and ethnic identity a point of curiosity for new clients, particularly White clients. A few showed overt shock on their faces when they saw I was Black. Over a period, however, I have arrived at the more useful question, “If they knew I was Black beforehand, would they still have moved forward with having me as their therapist?”

A supervisor at that time called on me and a colleague with whom I had recently seen a new family for an initial co-therapy session. She told us that the parent of the identified child client expressed her desire to change therapists along with accompanying discomfort — without apparent or stated reason. My supervisor immediately expressed support for us knowing that race had to do with the parent’s choice. The atmosphere of the room was filled with laughter to “ease” the intensity of the discussion; however, at the same time, that faux lightness felt belittling to me and my own personal and professional struggles as a Black woman.

Following that early encounter with the parent of the “distressed” child, many similar experiences have occurred. These included clients requesting to change therapists due to me being “direct,” “challenging,” “a woman,” and many other reasons that had racial overtones which could easily be missed due to the ease with which these issues could be missed.

These common microaggressions directed at me as the therapist can and often have been difficult for me, as I suspect they can be for fellow clinicians in similar circumstances. I have always considered my primary role to be one of providing a brave space for clients to work towards a better and more improved mental health trajectory — while considering, when necessary, our racial differences.

I recall a former White client whom I had been seeing for a year expressing to me her desire to change therapists because my accent was not “American enough” for her. This came after a year into our work, which I thought was going well. I quickly — perhaps too much so — expressed that while I was American-born, I had not been raised in the US.

I wondered what being American enough really meant, knowing once again I was experiencing racial discrimination and prejudice. Experiences like these have often traveled alongside me. These particular clients are blind spots, as I attempt to re-focus, or perhaps shift the focus to the basic, familiar, and comfortable principles of therapy, at the clinical expense of dealing with the racial issues head-on, in –the moment.

The Importance of Community for Black Female Therapists

My road to growth, acceptance of vulnerability, and wisdom as a mental health professional has been paved by the nurturing, direct, and protective guidance of other Black women. Through their lessons and guidance, I have come to appreciate the importance of community for Black female therapists.

When I think of community, I think of phrases like safety, transparency, guidance, mutuality of goals, productivity, culture, support, open-mindedness, and encouragement. If any of these notions are also useful to other Black female therapists, then more communities need to be established for therapists with marginalized intersectional identities.

Psychologist Ariane Thomas has highlighted the importance of community for her professional growth as a private practitioner and educator. She stated, “My career started with Black women taking care of me and mentoring me into the roles that would distinguish my career as a private practitioner and educator. Two incredibly important Black women ushered and mentored me into those roles, and I will be forever grateful to them both. I have found that in both roles, I've come to the point in my career when I'm able to pay it forward. I take great pride in my ability to support and mentor young Black women entering the field both as an educator and as a clinician.”

Thomas expressed the importance of paying it forward for other generations of therapists like me and Aisha Popoola, who shared her views with me on the pressure on Black female therapists to present as role models. She said, “Being a minority in the field, I often feel the pressure to serve as a role model for aspiring Black mental health professionals, and I also want to be the best at my job in order to prove my competence as a therapist.”  

The complexity of how Black female therapists show up in the therapy room is further proof of the importance of community for Black female clinicians. Having this sense of community as a clinician is particularly important in validating the core shared, and often very challenging, experience of navigating the professional demands of the work world.

Clinician and now clinical educator, Laura Dupiton, has often raised awareness of the impact of professional growth not taught in graduate school. She said, “none of my diversity courses gave me a blueprint for holding space for someone who questioned my humanity. Learning how to hold space and boundaries that protected my personhood was pivotal to my work.”

My Boundaries Come First

Author therapist Nedra Tawab described boundaries as “expectations and needs that help you stay mentally and emotionally well.” Establishing professional boundaries as a therapist is hard enough, let alone as a Black female therapist. I have often been faced with personal and societal expectations to be cooperative, pleasant, and easily available to my clients. However, when my boundaries have been violated, and I have asserted their importance by setting limits with clients around what I will and will not accept, strong, and often negative reactions ensue.

Such was the case with a recent therapeutic encounter I had with a White client that centered around microaggression. When setting the boundaries and expressing expectations that my client respects my racial identity by bringing awareness to the insensitive and prejudiced remarks she made, I was initially met with resistance and the expectation to appease her. I felt it necessary in that moment to provide unsolicited, and more than likely unwanted racial psychoeducation.

Laura Dupiton referenced the stereotype of “The Mammy Myth,” which portrays the Black woman as subservient and happy to first meet the needs of her superiors. Laura stated, “As a supervisor and professor, being in a position of power challenged me in new ways. I was surprised to be met with entitlement, an expectation for me to be lenient and nurturing despite unethical behavior or not meeting basic expectations. I was expected to play the role and stereotype of the Mammy. This process unlocked more of a need for me to create new boundaries and expectations for myself as a leader.”  

The importance of setting a tone from the beginning of treatment as well as in work environments is expected for the Black female professional. Clinician Aisha Popoola explains, “I have learned that from the outset that setting clear and transparent boundaries with clients regarding session times, communication channels, and the scope of therapeutic involvement is always helpful. And consistently upholding these boundaries can help maintain a professional and structured therapeutic relationship.” With such stereotypes as the Mammy Myth, setting boundaries has often proven to be difficult in my experiences as a Black female therapist

The Power of Genuine and Affirming Intersectional Identities

When I asked how each of these women would describe their Black woman experience as therapists, I was met with colorful descriptions, such as a learning experience that comes with navigating stereotypes and biases, microaggressions and racial stress, trust and rapport, representation, and role modeling, and balancing professional and personal identities. Other descriptions have included “paradoxically sacred, powerful, heartbreaking, and terrifying,” and “a charmed experience that is different now than it was then.”

In my experience, some factors that contribute to this “paradoxically sacred, powerful and terrifying” experience, come from the interactions that occur between intersectional identities of me, the therapist, and those of my clients. A complicated example would be a BIPOC cis female, disabled, Christian therapist from a high socio-economic background, working with a White, non-binary, Seventh-day Adventist client from a low socio-economic background.

Ariane Thomas shares the power of genuine and affirming encounters of intersectional identities in the therapy room as she stated, “I think race, gender, and all our intersectional identities if incorporated genuinely and with affirmation into our work, can only enhance the relationships we have with clients. It is also essential that we work to find power within all their identities. I cannot imagine expecting a client to bring about change in their lives if I believe their race and gender render them basically powerless”.

She further states, “What has surprised me most that I was not taught, but that I now teach, is that in the process of engaging with a client in a way that celebrates and affirms all the identities we bring to a relationship, I learn and grow as well. I believe that in the protected space we create in a therapeutic relationship, it is important to value those aspects of our identities as strengths and sources of power”.

What Thomas highlights here is the need to recognize humanity even in professional relationships like that between the therapist and client. It is important that Black female therapists as well as others with intersectional identities be given the same respect as that which is afforded their clients. I have personally experienced collective growth between my clients and me in the therapy room which has led to a stronger therapeutic alliance and productive clinical work. 

A Most Challenging Clinical Experience

More recently, I suffered from a therapeutic experience I believe to be common among the Black woman’s struggles at work and in career-driven environments: downplaying her value to make others comfortable, proving her competence and ability to navigate explicit racist or sexist encounters.

Following this experience, I began struggling with self-doubt, motivation, imposter syndrome, and my commitment to being the best culturally sensitive and competent therapist I could be. I quickly realized that well beyond being a clinician, I was human, which led me down the path of exploring how race, racism, and discrimination happen to the therapist in the therapy room. Through that experience and that of other respected Black female therapists, I examined the importance of community, boundaries, and the impact genuine and affirming intersectional identities play in the Black female therapist’s experience.  

As I sat during my session with my long-term client with whom I had built a strong therapeutic alliance, I experienced a chilling feeling; one I liken to feeling “small.” I sat and listened as my client recounted the difficulties and challenges of being a White woman from a middle-class family with nothing more than an undergraduate degree. She made comparisons between herself and other White colleagues whom she described as more privileged; hence, why she was more deserving of financial and professional promotions than other colleagues, including the Black ones. Additionally, she expressed feeling tired of jobs that required her to serve racially marginalized communities and stated that she has given back as much as she could.

I sat in disbelief at what I was hearing, recounting the recent incidents I had with this client where my boundaries as a Black therapist were not respected. I noticed that it became difficult for me to engage in further conversation with this client about the presenting issues that brought her to therapy as my own ruminations and feelings of just experiencing racial prejudice and ignorance came to the surface. I thought it was fortunate for this client, with whom I had a longstanding relationship, to be able to raise this racially charged topic, and in doing so, bring to their awareness the bias and ignorance in their remarks. I soon learned that I was wrong!

I took what I thought was a golden opportunity with her to say, “I am currently struggling to be present in session with you as your therapist because I could not move past some of the offensive statements that were previously said about your Black colleagues. As a Black woman who happens to be your therapist, I must bring that up with you as it is currently clouding my judgment and making it difficult to be professional.” In all honesty, I felt small, shocked, hurt, and responsible for what was happening. While trying to hold my tears and hide my fear, my immediate thought was to put my client’s needs first despite her negative reaction to me pointing out what was going on.

This client went on to respond defensively and immediately dismissed and minimized my feelings as she expressed, not understanding why I would feel triggered by the statements she made about deserving more professional benefits than her Black co-workers. She consistently put the responsibility on me to explain to her why my feelings and experiences of her racial ignorance were valid. The more I felt spoken down to, the more fear I experienced. As I tried to make sense of the interaction while remaining professional, I began experiencing physical symptoms like a headache, tightness in my chest, chills, and stutters.

I expressed to her that I needed time to process what I was experiencing with her, as it would be unfair as her therapist to carry on our work in light of this therapeutic rupture. And this rupture, I believed, was directly due to her failure to recognize and take ownership for making remarks that were racially ignorant and biased — and that hurt me deeply. The conversation became slightly heated as she persistently asked me to tell her that she was not a racist and often made apparent attempts to induce guilt because I “[was] the ‘therapist’ in the situation.” I recall stating that despite being a therapist, I was also a human being with real marginalized experiences that often led me to feel unsafe, and that I was experiencing those feelings in session with her.

I had to make the difficult decision to terminate my relationship with her, but not before and without seeking comfort and encouragement from amazing Black female supervisors who validated my experiences of guilt, responsibility, emotional dysregulation, and anxiety.

Some other experiences I had following this incident were a lot of doubt in my competency as a professional, hyper vigilance with other White clients, low mood, lack of motivation to be diligent in my work, and struggles with controlling emotional responses. Overall, as difficult as this experience was, it led me to a reflective season that birthed “the human therapist.”

After much-needed supervision, time, and education, this client and I were able to mutually terminate our professional relationship. In addition, she seemed able, or at least willing, to take accountability, which highlighted the growth she experienced in our work. It helped teach me the importance of forgiveness — even during racial encounters — and reiterated that in therapy with her, it was not about being right or wrong, but on making intentional spaces to learn from one another to be better humans.  

Using A Holistic Approach to Therapy with Clients Experiencing Chronic Illness, Disability, and Mental Health Challenges

Posted on by Psychotherapy.net Team

Prevalence of Chronic Illness/Disability in the United States

The presumption that “typical” abilities and wellness encompass the norm is a viewpoint that pervades United States policies, infrastructures, and societal expectations. The reality is that the majority of the US population grapples with chronic illnesses and disabilities, challenging the conventional definition of “normalcy.” While many associate illness with isolated incidents, dramatic and prolonged interruptions in otherwise regular lives — along with the prevalence of chronic conditions — indicates that illness is, in fact, more typical of the human experience than not.

According to data from the Centers for Disease Control and the Rand Corporation, over half of Americans (51.8%) contend with at least one chronic condition, whether physical or mental. Some estimates are that 42% of the population faces multiple chronic conditions. By comparison, according to the European Council of the EU, one in four, or 25% of European adults live with a chronic illness/disability. These statistics not only reveal the widespread impact of chronic illness but also emphasize the need to shift cultural perspectives surrounding health and ability. To be absolutely clear, in the United States, chronic conditions are the norm, not the exception. In his recent book “The Myth of the Normal,” Gabor Maté challenges prevailing notions of normalcy and underscores the ubiquity of trauma and illness within the diversity of human experiences. Exploring biopsychosocial aspects of chronic illness and disability, Maté exposes fundamentally unhealthy cultural constructs that shape our understanding of what it means to be “normal.” Moreover, in response to an unhealthy environment, Maté asserts that illness is a valid response. His work resonates deeply with my practice, as it highlights the importance of acknowledging the sequelae of trauma in the vast spectrum of human existence.  

As a Clinical Rehabilitation Counselor, my training encompasses both the medical and psychosocial aspects of chronic illness and disability. Moreover, my own personal journey as a cancer survivor and someone diagnosed with Crohn's disease enables me to meet clients from a perspective of lived experience. This experience underscores the importance I place on applying a comprehensive holistic approach to mental health in the context of chronic conditions many of my clients experience. My work in a small group practice specializing in supporting clients with trauma, chronic illness, and disability is a testament to the prevalence of such experiences.

Within my caseload, 95% of clients navigate the challenges of multiple chronic physical and mental conditions, often relying on state-subsidized insurance for healthcare. Among these individuals, approximately 60% identify as female, 25% as gender fluid or transgender, and 15% as male. Their narratives underscore the multifaceted nature of dependence and autonomy across various dimensions of life. From physical and financial to emotional and sexual realms, the complexities of living with chronic conditions influence every aspect of their existence.

For individuals grappling with chronic illness, the connection between past trauma and present health challenges cannot be overlooked. More often than not, these clients report elevated Adverse Childhood Experiences (ACEs) scores, revealing a complex interplay between past trauma and present health challenges. My integrative approach encompassing trauma-informed care, empathy, empowerment, and holistic healing includes attention to my client’s experience of their body. Attention to physical sensations including interoception and proprioception, breath, movement, and reflex patterns, allows me to guide them towards a path of resilience, self-acceptance, and well-being. Recognizing the intricate threads that weave together past experiences, present struggles, and future aspirations creates a space where my clients feel heard and equipped to navigate the complexities of their health journey with resilience and clarity. 

Relationships and Chronic Illness/Disability

One of the prevailing challenges faced by individuals with whom I work who have chronic illness and disability shows up in power dynamics within close relationships. Dependence on a partner for various types of support including financial and logistical, coupled with chronic pain and the struggle to balance gratitude and self-worth, can erode an individual's sense of agency. For those grappling with conditions such as Crohn's disease, fibromyalgia, multiple sclerosis, or rheumatoid arthritis, the unpredictability of their conditions makes planning for the future a daunting task. As a result, vacations, celebrations, and even daily routines are frequently disrupted. The demands of work often deplete their energy, leaving their partners to shoulder the responsibilities of managing a household and caring for children. The strain on intimacy and sexual relationships adds another layer of complexity.  

Partners of those with chronic illness and disability experience their own set of challenges, leading to feelings of frustration and helplessness. Their desire to provide support can transform into a sense of powerlessness as they navigate the complexities of medical interventions, lifestyle changes, and emotional well-being. The dynamic between partners can quickly shift from a place of caring support to caregiver exhaustion and burnout, a source of resentment that creates a cycle of mutual dissatisfaction.

In my therapeutic practice, it is not uncommon for clients to request involving their partners in sessions. Drawing from my unique perspective as someone who navigates a chronic illness while also being a partner to someone with health challenges, I provide insight that resonates with their experiences. This shared understanding fosters open dialogues that explore the intricacies of relationships within the context of chronic conditions.

One poignant example underscores the profound impact of childhood experiences on an individual's journey. A client shared a harrowing memory of their father monitoring their food intake during meals — threatening punishment if they exceeded a prescribed number of bites. This history of food-related trauma has woven itself into their present struggles with Small Intestinal Bacterial Overgrowth (SIBO), a condition marked by pain, diarrhea, gas, and bloating due to bacterial overgrowth in the small intestine. While the impulse to connect trauma to illness is compelling, the client's journey also involves a series of infections necessitating antibiotic treatment over time.

This client’s partner, in their well-intentioned efforts to support, inadvertently triggers their traumatic memories when attempting to manage the client’s food choices. The need for a restrictive diet as part of SIBO treatment further compounds their emotional turmoil, fostering feelings of deprivation and punishment as they strive to heal. Addressing this intricate interplay of trauma and health within the therapeutic space requires a delicate balance.

In a joint session involving both the client and their partner, I employed empathetic communication to navigate their complex dynamic. While acknowledging the partner’s genuine desire to provide assistance, I simultaneously asserted the client’s agency and authority over their own body and treatment. Employing the metaphor of the client as the “captain of their ship,” I emphasized that their body is their vessel, and they remain firmly in control. This approach is of paramount importance, particularly for individuals who already feel a sense of bodily discord and lack of control.

Additionally, it is helpful to recognize the partner’s role in the client’s healing journey. Acknowledging the partner’s commitment to honoring the client’s autonomy becomes an act of spiritual significance, aligning with their broader values. This dual recognition — empowering the client’s autonomy while honoring the partner’s supportive stance — fosters a therapeutic environment that not only addresses the physical aspects of chronic illness but also attends to the emotional, psychological, and relational dimensions.

In another case, my client grappled with chronic Lyme Disease within a relationship plagued with communication challenges, describing their partner as “unresponsive.” When they came for a family session whose purpose was to help them talk about the ramifications of her disease, I realized her partner was very likely on the spectrum. Though not his counselor, I was able to introduce both of them to this possibility, explain how this might be contributing to their difficulties, and help him connect with a counselor of his own.

Finances, Work, and Future Self in Chronic illness/Disability

For those clients navigating a chronic condition on their own, their lives are often precariously situated on what feels like the brink of financial ruin and collapse. With chronic pain or with an unpredictable condition exacerbated by stress, work is a double-edged sword. On the one hand, it may confer some security, sense of accomplishment, and self worth. On the other hand, it may aggravate certain illnesses by contributing to stress and may prevent people from qualifying for federal or state aid.

Most of my clients with chronic illness have applied for disability and are on their second or third appeals. They hang in a limbo where making money can compromise what little chance they have. Barring paralysis or a progressive condition, their chances of receiving disability are slim to none. These clients often seek work they can do from home. They are unwilling to take on student loans because of the precarity of their health. Some earn a living from piecemealing several jobs.

Whenever possible, I try to coordinate care with vocational rehabilitation (VR) services offered by the state which helps people find and obtain work suitable to their strengths and limitations.  

In one case of a client with chronic depression and difficulties which led to him losing his job, I advocated for him to receive a neuropsychological evaluation. Both the client and I felt he was on the spectrum. This enabled him to receive help from VR for job placement and support. By helping him find work that made use of his strengths while limiting his interactions with people, his depression improved along with his self-esteem. Whether living with a chronic physical or mental condition, it is important to remember everyone has strengths as well as limitations.  

Moreover, chronic illness, disability, chronic pain, and trauma can profoundly alter one’s sense of self. As mentioned earlier, the challenges posed by unpredictable and intermittent conditions make it challenging for individuals to plan for their future. This absence of foresight can have far-reaching consequences, undermining clients’ ability to envision a future version of themselves — a capacity often taken for granted. This lack of future-oriented thinking leaves clients susceptible to a multitude of setbacks, affecting their physical, mental, reproductive, financial, and educational well-being.

The ability to manage finances is a skill, yet those who lack both financial resources and a sense of their future self tend to make choices that perpetuate their financial struggles, leading to increased poverty. I’ve come to understand that these clients find it difficult to delay immediate rewards for a future date. Without a clear vision of their existence in the next 5-10 years, they prioritize immediate gains, which is understandable.

A client who was in the foster care system and spent a period of time houseless in their teens worked in the food service industry. Though experienced, their lack of formal education meant they often worked under managers with a degree but less actual experience than they had. Frustration with poor management led to frequent job dissatisfaction. Chronic but unpredictable illness limited their ability to work more than 25 hours per week. This kept them stuck in tip-dependent but ultimately unsatisfying work. Their dissatisfaction influenced their feelings about work in general.

During a period of unemployment, I encouraged them to explore alternative options. It became clear that they had only the barest sense of how much money they actually needed to cover expenses. A critical therapeutic intervention involved helping them create a budget in order to more accurately assess the benefits of a job that offered no tips, but more hourly pay. Even at 25 hours/week, they stood to cover their costs better than with sporadic food service work.  

To arouse clients’ sense of possibility, I lean on existential humanistic and Buddhist psychological teachings. None of us knows when we are going to die. People with long-standing conditions, both physical and psychological, live long and productive lives. To come to terms with having a finite amount of time with no sense of how much time is left is an essential human challenge. My clients experience grief over unlived possibilities. These feelings must be acknowledged and included. One client whose career was interrupted by an ependymoma (a spinal tumor that recurred twice) has grappled not only with ensuing disability from the spinal tumor, but ways she never took her career seriously even before the onset of the disease. Often disease itself becomes a catalyst for deeper exploration and participation.

Wellness Culture, Community, and Chronic Illness/Disability

Our culture’s pervasive and inescapable preoccupation with fitness, appearance, and social status is another hurdle facing people with chronic illness or disability. Research has demonstrated the undeniable mental and physical benefits of engaging in exercise and community. But for those who struggle with chronic illness and disability, these arenas are often outside their reach. These clients find themselves frequently isolated by the exigencies of their illness.

Socializing requires energy, and in the face of household or work demands, friendships fall by the wayside. The COVID pandemic resulted in yet another barrier for people with chronic illness and disability who are at risk of more serious infections. For those with mobility issues, opportunities to exercise are limited. One client with Cerebral Palsy receives only 6-10 sessions of physical therapy per calendar year.

Part of providing holistic therapy is helping clients discover ways to include movement and connection in their daily routines. As an example I work with severa,l clients affected by Ehlers Danlos Syndrome (EDS). EDS is a genetic condition that affects collagen, our body’s connective tissue. It ranges from mild involvement that creates hypermobility in the joints, requiring avoidance of extreme movement practices, to so severe it can cause heart and other organ failures.  

I frequently incorporate QiGong movement exercises in sessions, or I provide clients with short videos to follow. QiGong, a 4,000-years-old mindfulness based movement practice used throughout Asia for health maintenance, healing, and longevity, has been shown to mitigate pain, lower cortisol levels, and improve self-efficacy perceptions. The movements are gentle enough to not strain the body, yet require focused attention. They can be performed standing, seated, or supine. 

For those clients who are housebound much of the time, the need for community is often met by online connections. One client maintains an active online presence and connects through advocacy and providing education about their condition. For a trans teen client attending online school however, face-to-face interactions with peers is missing and contributes to their feeling alone. Like many people his age, he’s reluctant to learn to drive, and though he has applied for many kinds of work, he’s not been able to find employment due to his age. These circumstances compound his isolation. Group therapy has sporadically met those needs, but isolation remains a significant issue for those with chronic illness.


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In my personal and clinical experience, addressing the mental health needs of individuals with chronic illness and disability requires a holistic and empathetic approach. As a therapist, I have found it essential to challenge prevailing cultural norms, advocate for the acceptance of diverse abilities, and provide a safe space where clients can explore their unique journeys.

At the outset, chronic illness and trauma can feel like burdensome lead, weighing down the spirit and clouding our sense of self. The challenges posed by these experiences may appear insurmountable, the darkness can be overwhelming. Yet, it’s in the crucible of adversity that a profound alchemical process unfolds.

In essence, the alchemical journey of turning lead into gold mirrors the transformative power of the human spirit when faced with chronic illness and trauma. It reminds us that within the depths of our struggles lies the potential for profound growth, healing, and the emergence of our most radiant and precious selves. By fostering open conversations, cultivating self-advocacy, and nurturing supportive relationships, I, and hopefully fellow clinicians reading this, can empower their clients to embrace their identities and navigate the complexities of life with resilience and grace.