A Man, A Car, and a Metaphor

John was a warrior in every sense, long-returned from a battle that most had forgotten. But John remembered, in all ways a soldier can—in slow motion. Every skirmish, every battle, and every slight upon his not-so-triumphant return from a not-very-popular war left its indelible mark on his body, his spirit, his life. Most of all, John’s body kept the score, tallied in sleepless nights, unyielding fits of agitation, anger, and sadness, and unsuccessful alcohol-laden attempts to subdue his demons.
 

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I met John during the practicum semester of my doctoral training at a local VA outpatient center. John didn’t say much, which was both a relief and source of frustration. Looking back, I’m not sure what I could have offered, but I believed that I should have been able to connect better. Afterall, I was young, energetic, and optimistic. He was just the opposite—haggard, tired, and deeply worn. Yet, he came to every type of therapy group we offered, showing up in every imaginable weather condition in his 1964 Chevy Impala.

Back then, I didn’t appreciate the metaphor because I was too caught up in trying to figure John out from a literal perspective. Had I known then what I know now, I would have spent my time with John hanging out and chatting in and about his car, rather than trying to break through or ply my nascent clinical skills.

That white Chevy Impala, ironic in this case given the swiftness, beauty and agility of its namesake, was what car enthusiasts would call a “beater.” Simply, a “beater” is an older, high-mileage car with more than its share of dings, dents, and duct tape that still works. It gets from here to there without splash, without head-turning (except perhaps for the noise and smell it leaves in its wake). It is a utilitarian object.

Beaters work…until they don’t, at which point they are typically too costly for the owner to repair. And therein lay the metaphor which I wish in retrospect I could have appreciated. For that car was the mechanical and aesthetic embodiment of this enigmatic war veteran. John, like his Impala, had been patched together and just kept running, until they didn’t.

Halfway through my practicum, we learned that John and his car died within days of each other. And you can only imagine the theories and rumors that spread as quickly as a car fire. Was it suicide following the demise of his trusty metal steed? Did he go first, and the car had the metaphysical prescience to call it quits soon after? Did they go together? Was it a suicide pact between old friends? In hindsight, we never found out, but John and his Impala certainly left us wondering, and created a poignant metaphor that I carry with me and that forms the template for my interest in client metaphors.

***

My own steel and iron metaphor turns 50 this month. I know, who celebrates the birthdays of their cars, let alone someone who identifies as a parent, university professor, clinical psychologist, and purported adult? Well, I do, and I hail my 1972 Volvo 1800E, born a half-century ago in Sweden, soon after transported to the U.S., and raised by its foster owner for a decade before finding its way to Tom, its previous forever-parent of 35 years. Tom loved the car for personal reasons that I never did discover but had lost his passion after the passing of his daughter. Two subsequent strokes made it virtually impossible for Tom to get into the car, let alone work under its hood or dashboard (which requires Houdini-like contortionist skills).

I had seen my first 1800 at age 7, when after chasing a ball into the street (perhaps a tad impulsive of me) I found myself face to face with what appeared to that sci-fi-fed child to be a spaceship. Flash forward 60 years to that boy grown to manhood who now stands before his own spaceship with the same sense of marvel and admiration for this beautiful object. And therein lies my metaphor.

While getting into and out of my car reminds me that I am no longer that nimble 20-year-old (or even 40, 50, or 60-year-old, for that matter), I am young and dashing when we are in motion together (or at least so I delude myself). We (or more likely it) turn heads, draw curious questions and leave people wondering, “Hey what is that thing?” Together, we are enigmatic, mysterious and interesting, perhaps just a little bit sexy, but most definitely ageless. There is always a glitch du jour around the corner to remind me that aging is messy and sweaty, and both mechanical and organic maintenance require diligent effort that has dividends in a sense of vitality and efficacy. And to add to its appeal, both metaphoric and literal, I recently brought my 1800 to its first European classic car show and enjoyed the social aspect of that gathering of fellow automotive metaphorists.

***

So today I think of John, the man, the car, the metaphor, and I thank him, as I do all clients whose lives are sometimes more poignantly appreciated in metaphoric rather than literal terms.

In the Same Leaky Boat: Being a Parent and Therapist

I have some new career goals that have been taking a great deal of my attention and time lately. They’re exciting, but intense and demanding. I also have two little ones tugging at my clothes at all times. Sometimes I feel split in a million directions with my time, my attention, and my emotional and physical energy. I wonder why I’m working so hard and why it never feels like it’s enough (and feel that it’s all my fault). For what? Where did I get these ideas of what it means to be a successful parent and a productive therapist/business owner? And why do I feel so alone in all of it?

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When I’m reviewing my photo reel on my phone at the end of a day (a modern habit any parent will attest to doing), an unconscious smile on my face as I scroll through my kids’ smiling goofy faces and chubby limbs, I often feel content, relieved to some degree. I made it through another day.

But I also feel guilty and like I’m falling short, sad that I’m always hurried and tired. I feel worried that I’m not soaking up the time with my small kids thoroughly enough, whatever that means. “They grow so fast!” we’re often told, as if that’s a helpful thing to hear when we're already crushed under the weight of perfectionism, guilt, a barrage of unrealistic goals and expectations, financial burdens our parents were not saddled with, and a list of other maddening external constraints.

I know my clients feel this, too. I work with many new parents and I think frequently about how best to support these clients—the ones with babies and toddlers, who feel barely human, disconnected from themselves, like they’re forever flailing, convinced they’re failing at everything.

Caroline, for example, is a client I’ve been seeing since the spring of 2020. It took a pandemic for her to feel justified in reaching out for help. When we first started working together, her baby was four months old. She had recently left her job (after a brief return following a mere eight weeks of maternity leave) to stay home with her daughter. She’d like to work again, to connect with aspects of her identity that feel distant right now, but the cost of childcare is nearly equivalent to her former salary. Additionally, she found that her workplace was too inflexible about scheduling and not supportive of pumping.

Caroline has no family nearby, and the pandemic pushed her further into introversion and isolation. She has no real “tribe” or community of other parents with which to commiserate, share information, or get her out of the house. She scrolls Instagram and feels inadequate when she sees the slim bodies of celebrity and influencer moms, the perfect plates of cut up fruit and toast for babies, the inventive sensory activities, the families out in the world doing fun things, the informative posts from child psychologists, or the quotes from other mothers that are meant to be inspiring but just reinforce her sense of failure and defeat.

She spirals into panic when she thinks something might be wrong with her daughter’s development or health. She feels responsible for carrying the weight of all of the researching and decision-making regarding various aspects of care for the baby. Her husband doesn’t see or appreciate the mental labor and intense pressure she puts on herself to make sure their daughter is fed, clothed, entertained, and developing appropriately. Their relationship has suffered significantly.

Caroline feels beaten down and trapped. All the days bleed together, and there’s nothing she really looks forward to. She loves her baby and feels connected and attuned to her but is not enjoying motherhood in the way she had hoped, which makes her feel tremendously guilty.

Sometimes we’ll be in session and all of a sudden, the baby appears, finishing up a nursing session I didn’t even know was occurring off screen. Caroline will stroke her daughter’s back while she gazes off exhaustedly and says, “No one prepared me. No one told me how hard this would be.”

We’re in this boat together, me and my clients. It has a ton of holes, and we’re constantly exhausting ourselves scooping out water with our feeble buckets and trying to keep ourselves afloat. But the truth is we didn’t build this boat. We also didn’t break it.

The more I work with clients like Caroline and go through my own experiences balancing work and life with small children (an intense phase I’m aware will be over before I know it—I don’t need the reminder), the more convinced I am that our self-blame and the pressures we put on ourselves are absurdly misplaced.

When I take the time to question the metrics I use to evaluate myself and their origins, I start to see the cracks in a society that by design provides little support to parents (mothers especially) in the workplace and beyond, reinforces impossible standards through social comparison, and isolates us from support and community (to say nothing of the deeply problematic inequities baked into all of it). We are not doing anything wrong. The system itself is broken.

And recognizing this, making this mental shift of externalizing some of the perceived failure I experience, allows me to be a bit kinder and more realistic with myself. The more that I acknowledge how broken the system is, the more I can comfortably eschew its standards.

When I’m with clients like Caroline, struggling in similar ways with expecting too much of themselves and feeling the pressure to do everything (and do it “right”) and to enjoy every second of parenthood, I can invite them to examine the larger context of these expectations. I can affirm and normalize slowing down, practicing acceptance, and embracing rest and self-compassion as an act of defiance and empowerment.

We have done enough. We are doing enough. Let’s just float for a bit.

Costumed Authenticity: Building Trust in LGBTQ+ Telehealth

He was the kind of client who liked to sneak in jokes to relieve his own anxiety. A deflector. The kind of client who is openly gay, but emotionally closed. In telehealth sessions he rarely looked at the camera, or even the screen. His thoughts were off in the distance. He had a lot to say, but it was going unsaid. Or, more accurately, he had a lot to share, but it wasn’t being verbalized.

Social camouflage can be a powerful survival mechanism. While it can lead to compartmentalizing social identities, it’s important to value a client’s need for safety. In fact, if there’s anything I’ve learned from my LGBTQ+ clients, it’s how multifaceted identities open up progressively through tiers of trust. Codeswitching is common, as is reserving whole aspects of personal identity for those who actually appreciate it. This can make it hard to trust anyone, especially a mental health professional.

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Even amongst the LGBTQ+ community there is no guarantee of acceptance, requiring camouflage just as much within the rainbow as outside of it. Pansexuals and omnisexuals may tell people they’re bi because it’s more commonly understood and socially accepted, just as bisexuals may tell people they’re gay. Genderqueer, genderfluid, and agender people may generalize themselves as queer or nonbinary rather than get into the specifics of their actual identity. Likewise, there are many nuanced facets to being a transgender person, but there’s no chance of talking about that with someone who’s unfamiliar with even the most basic Trans 101 terms. Yes, a client may talk about their sexuality or gender identity with a therapist, but at what level is the conversation? Tier one? Tier two? Tier ten?

In the back of my mind, I found myself relating to his bemused smile and his coy silence. But how could I, as his counselor, create enough safety in a telehealth session for him to share more of his unspoken authenticity? Or, at the very least, another side of himself?

I’ll be the first to say that telehealth has more than a few problems, yet having a small window into the client’s home is a game changer. I’ve had some clients proudly take me on a video tour of their house, and others who actively hid their home environment. Getting to see someone’s sanctum of comfort, or playground of self-expression, is an honor that should not be taken lightly. Yet when a client doesn’t know how to talk about themselves, a little curiosity about their external environment can go a long way.

In the background of his bedroom was a sewing mannequin. When I asked if he sewed, he laughed and said he was better with a hot glue gun. Then, when I asked what he’d been working on, there was a second of hesitation. A second of hope, mottled with the fear of rejection. The natural prelude to authenticity.

No, he wasn’t a Drag Queen. He was a Drag Cosplayer, who spent a small fortune every year transforming himself into sci-fi and fantasy characters to attend massive conventions. And he walked a fine line, in heels no less. He didn’t fit in with Drag Ball Culture, and he was sure most Queens would call him a nerd. On the flip side, not every conventioneer appreciates a cross-dressing cosplayer. Here was courage and shame in the same costume. Here was cognitive dissonance. He kept all his social media accounts private but had hundreds of people take pictures with him at every event. He was an anonymous celebrity.

This disclosure segued into a conversation about his favorite anime characters and, most importantly, why they were his favorite. People are drawn to certain fandoms for key archetypal reasons, because they resonate with a specific character, or universe, or story arc. Fortunately, I happened to grow up in the height of America’s anime revival, so I recognized not only his characters, but also his attention to detail. After that, I was updated on the status of his latest costume for the next two months. It turned out he had a soft spot for manic female antiheroes who are vibrant, loud, and completely over the top.

It takes time to build rapport. As therapists, we are outsiders, approaching each tier of privacy like a gate. It’s not enough to say friend or foe. For this client, I had to not only know the password to be let in, but I also had to speak the language. It’s because of this that I encourage therapists to take an active interest in their client’s media. Dive into their music scene, or favorite book series, or television show, or movie fandom, or video game community, because there you will learn a hidden language.

So I asked him if, in our next telehealth session, he would be willing to show up in character, and he laughed, and cringed, and said he’d have to think about it.

My next session was with Haruko Haruhara, from the spastic anime masterpiece FLCL.

My next session was with my client’s shadow, imagination, and feminine inspiration, and this time, they looked right into the camera.

A Walk in the Park

It seemed like any other day, nothing too challenging, I hoped—a walk in the park. Well actually, it was a jog in the park, my favorite place to run…woods, roots, rocks, mud, water. It was just enough of a challenge for this aging body. As I launched (actually lurched) forward for my run, I caught a fleeting glimpse of a couple trying to cajole their young child into a nature walk. “What a nice thing to do with a child,” I thought as I rounded the first bend. But apparently this child had a different view on the situation, because within seconds, he was screaming his displeasure at the top of his lungs, while his powerless mother offered all sorts of appeasements before landing on, “Alright then, I guess I am going to take you home and put you to sleep.” Her way of throwing in the towel and expressing perhaps her sense of powerlessness.

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Within less than a quarter mile, I had that Swiss Family Robinson fully assessed and the child thoroughly diagnosed. I was quite proud of myself. “What a masterful clinician,” thought I. Even in spite of the fact that I have largely retired from clinical practice and play therapy, I still had it.
Well, the jog ended; I had made it through yet another humbling reminder of my age but figured, “A little (understatement) joint pain, inflammation and blanket of mosquito bites are a small price to pay for the privilege of making it through another run through the wild.”

As I turned the corner of the park’s field station, who did I see standing before the opening and closing door of the elevator, proudly pushing buttons, but young Robinson, or the howler monkey I had heard upon entering the woods. But he wasn’t howling and instead was fully engaged, if not enthralled, by the mechanism of the elevator apparatus, or perhaps the power he wielded over the beast by pushing the button. His parents were doing their best to patiently indulge him in his fascination while trying, once again, to rein him in. “Two more times, and then you can take one ride in the elevator, and it will be time to go home,” they offered the boy, who paid absolutely no attention to them.

As you might imagine, I couldn’t restrain my inner-clinician, who had already channeled Virginia Axline, and said to the boy, “You really like that elevator,” upon which he took my hand to lead me into the mechanical maw of this beast he had tamed- although that might have been my projection, not his. “Ah, taking the hand of a complete stranger,” now that is diagnostically important, so my unsolicited assessment deepened. I gently released his tender but firm little grip and stepped back as he continued, unabated, his elevator play. I believe that in that moment, mom was embarrassed and quickly apologized for her child, something that in retrospect I believe she was accustomed to doing.

I piped up, “I could tell from his screaming a bit ago that he didn’t want to walk in the woods, but he sure likes playing with the elevator.” Mom and dad were on board with this unfolding in-situ play therapy session and said to me, “You sure seem to know a lot about kids, do you have grandchildren?” Ouch!!!!!

I felt like saying, “Hey, young people, don’t you see this sweat on my body…I have just vanquished the wilderness trail with my blinding speed and god-like endurance” (I probably ran a mile), but decided to restrain myself. We turned our attention back to elevator-boy, who was now jumping with glee and flapping his hands, trying to verbalize his enthusiasm in words, clearly a challenging developmental task for this sweet, sweet little boy, whose only failing that day was his choice to endlessly engage with this predictable machinery rather spend a minute walking in the muddy, bug infested, woody and sensorially-overwhelming uncertainty of the woods his parents so wanted him to enjoy.

My parting words to the young couple was not affirmation of the obvious diagnosis, but something along the lines of, “It’s so wonderful that you encourage his fascination with the elevator….encouraging any fascination in a child is a good thing.”

Perhaps they were saying something equivalent to “Who was that masked man?” as I hobbled away, or at least that’s what I hoped. And while part of me wanted to turn back around and ask if they’d had their child assessed for autism, I didn’t think that level of intrusion was necessary or appropriate. I was pretty sure that I was in the ballpark on my assessment, but I wasn’t there, or being asked, to render a professional opinion. Maybe it was enough that this “elder-seeming” man they met in the park was kind to them and their child.

Psychodermatology: Understanding the Mental Health Component of Skin Conditions

There is a relatively new subspecialty within dermatology that is of interest to therapists. Psychodermatology, the study of the connection between the “mind” and the skin—or an understanding of the psychosocial context of skin diseases—is giving many patients a new lease on life. While we’ve always known that there is a connection between mental health and certain skin conditions, we’re now finding that this connection runs much deeper than scientists first believed. For example:

  • Among patients with disfiguring, chronic skin conditions, the prevalence of psychiatric disorders is 30% to 40%.¹
  • Significant stress and anxiety have been reported in 44% of patients before the initial flare of psoriasis, and recurrent flares have been attributed to stress in up to 80% of individuals.²
  • The prevalence of psychiatric disorders among patients with skin conditions is greater than in patients with brain disorders, cancer, and heart issues combined.³
So, what can psychotherapists do to recognize patients who could benefit from seeing a psychodermatologist or drawing connections between their skin conditions and their mental health? Continue reading for tips to guide your recognition and treatment of psychodermatologic conditions. How to Identify and Treat the Symptoms Symptoms to look for in patients include any skin condition, including severe acne, eczema, pruritus (itching), psoriasis, vitiligo, and others, that may arise at the same time as particular mental health challenges. If you notice a skin condition, ask your patient to tell you about it. Find out what makes it worse or better and when they notice flare-ups. You have to become a bit of a detective at first until you can teach your patient how to start connecting dots for themselves. Certain patterns may be obvious, while others will require further investigation. But once you discover a connection between the brain and skin, you can dig deeper to better understand the nature of the connection. The goals of psychodermatology are:
  • To investigate the emotional impacts of a patient’s skin condition,
  • To help the patient work through these emotional impacts,
  • To reduce the threats posed by these emotional impacts,
  • To help the patient develop coping mechanisms for if and when a recurrence occurs
With patient-centered approaches to explore the patient’s feelings, concerns, and experience regarding the impact of their condition and with cognitive behavioral therapy, you can begin to reveal a clearer picture of what stimuli and stressors contribute to the physical manifestations of a patient’s emotional condition. For example, suppose you have a patient who you’re treating for depression and social anxiety. During one therapy session, you notice eczema on the back of your patient’s hands. You enquire—just as you would when assessing any physical behavior. Your patient discloses that ever since they started a new job, their eczema has gotten worse. Armed with this new information, you can have your patient jot down when flare-ups occur and bring their notes to sessions with you. Together, you can collaborate to spot patterns, which can help you create a timeline. From here, it’s time to focus on healing from the inside out. Working with Other Health Professionals While many conditions can be eliminated through psychotherapy alone, patients experiencing any of the above symptoms often benefit from an interdisciplinary approach. Many dermatologists understand that while they can treat the physical manifestations of a patient’s mental health condition, patients often also need mental health professionals, like psychologists, psychiatrists, or psychiatric mental health nurse practitioners, to target the source of the skin condition. One good strategy may be for therapists to seek out partnerships with dermatologists in the know.? Also, if you see patients who suffer from compulsions or skin conditions, such as skin picking or hair pulling, which you know have a psychological component, referring them to a psychodermatologist can be especially productive. While any dermatologist can prescribe drugs to treat the physical skin condition, working with someone who understands the deeper connection can be the ticket to deeper healing for particular patients. Ultimately, psychodermatology is all about improving quality of life by healing the skin condition and enhancing the patient’s emotional state. When we give our clients the tools they need to find true healing from the inside out, we show them that the journey to healthy skin and mental stability is a path they can walk. Case Application Glenda, a 21-year-old-woman, was referred to my office by her dermatologist because of anxiety that heightened when asked questions about her visibly red, scaly and raw-appearing rash on her hands and forearms. She insisted that she must be allergic to the soap she had been using and possibly the prescription cream that her primary care physician (PCP) had prescribed. Glenda had been examined by her PCP for her rash three times over the past few months and diagnosed with contact dermatitis, allergic dermatitis, and possibly eczema. Her PCP also prescribed a steroid cream and instructed to wash her hands with hypoallergenic soap and apply Aquaphor healing ointment daily. Glenda’s dermatologist took a thorough medical history and asked her about having repetitive thoughts that may be causing her distress. Glenda started to talk about the stress she has been experiencing over the past year due to COVID. She talked about staying up late at night worrying about getting infected with COVID and spreading it to others. She began to wash her hands multiple times a day. She shared that she had always frequently washed her hands, but now felt compelled to carry out a hand washing ritual—hand washing, turning the cold water on and off four times, then washing her hands, scrubbing until she counted to 30, turning the cold water on and off four more times, then applying hand sanitizer and rubbing it into her skin for 30 seconds. Lately she had been washing her hands every half hour and had been applying extra hand sanitizer to make sure her hands were clean, since washing her hands made her feel less anxious about getting COVID. She believed that carrying out this ritual had the additional benefit of protecting her family. At that point, the dermatologist explained that her skin rash and anxiety were interconnected, prescribed a hand ointment that promoted healing, and referred her to my outpatient mental health practice for an evaluation. After taking her medical and psychological history, I asked Glenda “What is your story?” to provide her with an opportunity to construct her personal narrative and share her experiences and beliefs about her current psychosocial circumstances. She opened up about her repetitive hand washing behaviors and worries about COVID that “hijacked” her brain. As a first-line intervention, cognitive behavior therapy for OCD directed at her behavior (compulsions) and cognitions (obsessions) made good sense. Sessions with Glenda included cognitive restructuring, psychoeducation, imagery exposure, self-monitoring, relaxation training, coping skills development, and self-care to alleviate her OCD-related distress. Relapse prevention was used to reduce the occurrence of initial lapses and to prevent any lapses that might escalate into a full-blown relapse. For homework, journaling was used to help Glenda identify harmful patterns of thoughts, emotions and actions and to develop techniques to help her better cope with uncomfortable feelings.

***

The collaboration between two specialties, dermatology and mental health, enabled this patient to have her psychological and physical needs treated holistically and simultaneously.  References: 1.  Goldin, D. (2020). Concepts in Psychodermatology: An overview for primary care providers. The Journal for Nurse Practitioners, 17(1), 93-97. 2.  Jafferany M. (2007).Psychodermatology: A guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry, 9(3), 203-13. 3.  Ghosh S, Behere R.V., Sharma P, & Sreejayan K. (2013). Psychiatric evaluation in dermatology: An overview. Indian J Dermatol., Jan;58(1), 39-43. 4.  Azambuja R. D. (2017). The need of dermatologists, psychiatrists and psychologists joint care in psychodermatology. Anais brasileiros de dermatologia, 92(1), 63–71.

Overcoming the Pernicious Chronicle

Therapy stagnates when patients doggedly chronicle the events that have occurred since their last session or when they use all their therapy time to recite their grievances, bewail the injustice of their situation, and air their resentments. The therapy, in short, fails to fulfill a treatment plan. The misuse of these sessions can lead to “interminable” outcomes, where patients continue to catalog their problems but do not modify or alter how they deal with them. The therapist can be caught up in this paradigm, resigned to listening and sympathizing without making any meaningful headway in helping these patients recover.

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Worse yet, the therapist may become comfortable with this covert contract: “If you tell me your troubles and adventures, I’ll listen and make occasional wise remarks, I’ll even offer you some advice, but little will change in your life due to our therapy. You’ll be comforted, and I’ll be compensated.” This arrangement can go on for years, even decades, and only end if the patient can no longer pay, by the death of either party, or by the therapist’s retirement. A colleague of mine used to refer to these patients as “psychiatric annuities.” To him, they were an income stream providing steady payments that would support his earnings “forever.” The patient will never reach the therapy’s goals (if indeed there ever were therapy goals!) and instead become so dependent on the therapist that their lives will be diminished instead of enhanced by their treatment.

Some therapists feel comfortable with this long-term arrangement. Sessions with these patients are predictable and require little or no effort. They might even grow fond of this long-suffering patient and wouldn’t want to trade for a new case with all its uncertainties and hard work. And they’re getting paid for little or no work. If asked, these therapists might argue that they are providing “Supportive Therapy.” This rationalization adds insult to injury: The patient is incapable of change? Are they so damaged they need a weekly boost from a therapist to tell them how to live their life? Does the therapist need a therapy-dependent patient, hanging onto every word, to boost his or her own self-esteem? What is being supported? The status quo?

A real regard for the patient’s benefit, not to mention simple professional ethics, requires that all of us resist the siren’s call of these cases and, instead, interrupt the chronicle, reinstate active treatment, and forego the insidious pleasure of these unworkable, so-called supportive arrangements.

The Pygmalion Effect and Treating Incarcerated Individuals with Severe and Persistent Mental Illness

For as long as I can remember, I’ve always been fascinated by locked doors; what does society do with the individuals it tucks, or perhaps sends away, and why are they sent away to begin with? Prisons and psychiatric hospitals were always talked about so ominously, and as a young child I remember thinking, “I need to know what goes on in there.” Fast forward to the year 2015, when I signed an offer to begin working as a correctional social worker. I had spent the last year working in a correctional facility as an intern and made the decision that working in corrections was where I needed to be. I’ve always had a passion for mental health, and when I was offered a position in a psychiatric correctional unit, I knew I had to take it.

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Upon walking onto the psychiatric unit that first day, I knew instantly that I’d found my place. This place, this “unit” was just the opposite of what I expected it to be and believed as a child they were. It was painted with bright colors, residents’ art was on the walls, groups were running, and security and mental health staff members were working together to provide treatment to the men on the unit. The air on the unit was lighter—residents were able to joke with staff and clearly felt safe in this niche of the prison. I had always hoped a program like this could exist in corrections, and somehow I was lucky enough to stumble into this in one.

***

“I never thought it would work,” Melvin* said. This is a line I’ve heard Melvin repeat time and time again in our clinical sessions as he reflected on the birth and development of an innovative psychiatric unit where he resides inside a correctional facility. Melvin is a long-standing community member in the unit, and his role is anything but benign. He and a few other permanent residents serve as institutional memory—not only do they keep the mission of the unit alive, but they also keep the cultural expectations and norms of the unit thriving.

It may be tempting to think the culture of a unit inside a correctional facility to be harsh, ruthless, and violent; but with the right balance of residents and staff, the most astounding transformations can be seen—just ask Melvin. Melvin, an individual living with psychotic illness who walked onto the unit upon its inception, will be the first to tell you he never thought a structured mental health unit would survive in corrections. Having lived a life riddled by poverty, substance use, abandonment, dual-diagnosis, and trauma, it is not surprising Melvin ended up in an institutional setting. When he first arrived onto the unit, he appeared hardened and unreachable and had just returned from a hospital trip due to an injury inflicted during the throes of a psychotic episode. “Ya, I used to sit in the corner over there (referencing the group treatment room) and just stay silent all group, purposefully choosing to stay uninvolved.” Melvin is honest in his reflections that he didn’t think a unit could exist inside a correctional facility without strong-arming, victimization, and prison politics. He didn’t know then the power of the Pygmalion Effect.

The “Pygmalion Effect”¹ describes the way individuals present themselves in a manner akin to the expectations set before them, whether they are positive or negative. The psychiatric unit where Melvin resides was able to cultivate the expectation that individuals residing on the unit would drop behaviors typically seen in the prison culture (intimidation, bullying, violence) and promote ideals such as asking staff for help, utilizing town halls to address community issues within the unit, and speaking honestly about their lives in group treatment. The vulnerability and effort to curb well-developed criminal tendencies it took residents like Melvin to exhibit was extraordinary, and over time the unit has become what Melvin describes as a “safe place” and “my family.” Although staff may have initially brought forth these ideals and stayed dedicated and consistent to the mission of providing treatment rather than simple stabilization, the therapeutic and pro-social culture of the unit now comes directly from Melvin and other long-term residents. The “Pygmalion Effect” tends to be cyclical in nature and is seen daily in this psychiatric unit. The staff members show unconditional positive regard and a belief that typical prison behavior and defenses can be dropped in the unit because the residents are much more than their prison sentence or mental illness. The residents, in turn, begin to believe themselves to be individuals who are worthy and can contribute to the world through human connection. This spreads amongst the men through groups and psychotherapy, and eventually, the entire unit is finding positive ways to support one another along their journeys with mental illness, recovery, and imprisonment. The “Pygmalion Effect” has allowed for something uncommon to occur in a correctional environment—people are actually getting well, not just stabilized.

****


Here we are in 2021, and I now hold my doctorate in social work and am the director of this unit in which I whole-heartedly believe. The evolution of the unit has been extraordinary to watch. In an interesting way, we’ve grown together. I started working in the unit as a conditionally licensed professional, left and explored other avenues of corrections, and then returned as a fully licensed professional completing a doctorate program. As I’ve gained my clinical footing and found my stride, I’ve watched the men on the unit do the same. The residents who have been on the unit since its inception, such as Melvin, have gone from being acutely ill to now being peer mentors on the unit. Throughout these years on the unit these men have developed self-esteem and practiced being able to trust; skills they struggled with for most of their lives. If this is what happens in six years’ time, I cannot wait to see the growth that occurs within the next six.

1. Chang, J. (2011). A case study of the “Pygmalion Effect”: Teacher expectations and student achievement. International Education Studies, 4(1), 198–201.

Relief or Change? Which is the Most Meaningful?

Jack, a forty-three-year-old insurance executive, was referred to me by his family doctor for help with severe panic attacks that had suddenly begun for reasons that were completely unclear to both of them. Jack's symptoms were disabling and resulted in his missing work for several days before his initial appointment with me.

In the first session, I listened to him describe his difficult breathing, chest pains, sleeplessness, occasional choking episodes, along with his fear of losing complete control and “going crazy.” He told me that he has always been an anxious person and had contemplated entering psychotherapy for several years, but never actually did…until now.

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The initial consultation with Jack was, in my view, a mixed success. According to Jack however, it was “an unbelievable success.” We were able to quickly identify the sources of his current anxiety symptoms, which almost immediately provided him with some much-needed relief. We began to outline some of the likely goals of the ongoing therapy he was “very happy to be starting, finally,” and for which he eagerly arranged his next appointment with me.

As the session wore on, I began to feel concerned that the initial and speedy benefits of this first session might have implications for Jack's ability to fully engage in the challenging, ongoing work of psychotherapy, something I believed he needed and from which he could derive greater benefit than immediate symptom relief only. I became especially concerned when Jack described his first session as “maybe the best hour of my life!” and described me as “undoubtedly, the best therapist in America!” That's when I thought, I probably will never see Jack again.

As it turned out, Jack did attend his second session, and a third, and described the continuing benefits of the work thus far. He was hardly symptomatic, felt “great,” no longer thought that he was “losing it,” and was wondering whether or not he really needed therapy after all. Somewhat surprisingly, he asked me to tell him what I thought he should do. In order to help Jack figure this out for himself as much as possible, I did what any therapist worth their stripes would likely do as a first response to such a question: I asked Jack to try and decide independently of my input, so that we could both learn something about his attitudes, thoughts, and feelings, rather than have him simply react to mine. My input followed and consisted of my ideas about the differences between relief and change, with the latter, obviously, being the more ambitious pursuit and perhaps the more durable. I also was mindful, as always, that for some people, relief may be all they want or need. Not everyone wishes to or has the wherewithal to undertake a full course of psychotherapy, especially if they are not in active distress.

After a meaningful conversation about his dilemma, i.e. to stay or to go, Jack decided that he was quite happy with what had occurred and chose not to pursue further therapy at the time. He asked for and received assurance that my door would always be open, and we both acknowledged that we may or may not ever see each other again. He left describing himself as the “three-session wonder.” I later heard from his physician that he was doing quite well, with no further panic attacks. It led me to wonder whether or not I should revise my thinking to include the fact that sometimes and for some people, relief is change, and not necessarily something less or less meaningful.

Redesign Your Mind in an Instant

Wouldn’t it be lovely if you were able to help clients make real, significant, lasting changes right on the spot, just by providing them with a certain frame and by inviting them to do a little on-the-spot visualizing? I have. You can.

Philosophers from Marcus Aurelius to the Buddha concerned themselves with the idea that “you are what you think.” Nowadays, this age-old notion is typically explored using ideas and techniques from cognitive-behavioral therapy. These ideas have resonated for many of my clients and have been quite useful in our therapeutic work. But there is an important next step to take.

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By providing clients with the metaphor of “the room that is your mind,” I have helped them visualize “the place where they think”—really, “the place where they live”—and help them instantly change and upgrade that “place.” This simple metaphoric frame has created powerful, on-the-spot results.

In a very few words, I explain to my client that it is in their power to redesign and redecorate the room that is their mind. Then I move right onto giving some examples of what that redesigning might look like: adding windows so that a breeze can blow through, reducing inner claustrophobia; adding a calmness switch, producing immediate calm; adding an exit door, out of which repetitive, obsessive thoughts can be scooted; or repainting the walls a bright color, so as to reduce the experience of sadness.

What is rather amazing is that my clients “get” this idea instantly. They have often said that no one had ever invited them to picture their mind room before and that, without knowing it, they had been waiting for this invitation.

I was recently chatting with an interviewer about my forthcoming book, Redesign Your Mind, in which this technique is described. Even as we were speaking—even as he was asking me questions and I was answering them—he was doing this redesign work. I could tell. Then, suddenly, he smiled and said, “I’ve just repainted the walls in my mind room and I can feel the difference.” The brain is brilliant at this sort of thing, if it is presented with the invitation and offered even just the briefest of explanations.

A few days later I wrote to the interviewer, whom we’ll call John, and asked him to share his experience. What had that felt like, spontaneously doing that work right on the spot? How was it that he had done that work without my hinting or suggesting that he do it—had his own brain instantly “decided” that it was imperative that he try out the idea and paint those walls a new, bright color? Did the change that occurred feel real and significant, even fundamental? Had the change lasted?

John replied:

“The effects I experienced when you began to explain this to me were quite profound and instantaneous. It was straightforward. You told me I could put anything into the ‘room that is my mind’ such as a ‘calmness switch’ that could be flipped whenever I needed it. I pictured a red light switch, and when I flipped it, I immediately became calm, and felt it both mentally and in my body.

“You helped me construct my ideal living room, and when I painted the walls, I immediately began to experience pleasure in the color. I put large, clean windows in the room, some open so that the breeze from the beach made the flowing white curtains dance. I felt calm and joy and peace in my body, as well as my mind. And it’s not just about calm. There's a breastplate in the corner that I can don to immediately feel courageous and ready to take on the tasks I need to.

“There's also a free speech platform I can mount when I want to privately engage in any thought exercise. And there’s a back door to exit the room. As a person diagnosed with PTSD, I can utilize this to help reframe my perceptions of past events, heal, and press on with the tasks associated with my goals in life. Thank you. Thank you.”

Clients immediately brighten up when I discuss this with them. There is something amazingly invigorating about the idea of redesigning one’s mind. Maybe it puts folks in mind of magazine ads of beautiful rooms that have stirred them and moved them. Maybe the metaphor strikes them as achingly right. Maybe their “inner architect” or “inner designer” is suddenly engaged. Or maybe it simply matches their felt experience, that there is a place where they go and that they can change the look of that place—and their experience of that place.

Rather than having to arm-wrestle negative thoughts to the ground, dream up thought substitutes, or do any of the blocking, disputing, reframing, substituting, or other heavy lifting techniques from cognitive-behavioral therapy, a client gets to smile a little and laugh a little as she zips right off to her mind room. There she can change the furniture, replace her usual bed of nails with an easy chair, install a pressure release valve for immediate stress relief, or do something else quick, brilliant, and useful.

I have found this “redesign your mind” technique very helpful in addressing many challenges clients bring to our work. For the client who lacks confidence and who is having trouble speaking up, she can be invited to create a Speaker’s Corner (like the famous one in Hyde Park in London) where she can practice saying important, dangerous-feeling things in complete safety. Whether the issue is depression, anxiety, addiction, procrastination, healing from trauma, or loneliness—whatever the issue may be—there is bound to be some simple subtraction or addition she can make to her mind room that will immediately change the thoughts she thinks and her experience of life.

I invite you to look into this technique, and perhaps into your own mind room, and even, perhaps, the one you inhabit with your clients.

Less Treatment, More Therapy

"Yo, call me back ASAP!,” read the text message from Carl, a 20-year-old man who has self-identified as a gang member for the past seven years and who has struggled with anxiety and depressive symptoms, alongside antisocial personality traits.

I had an impulse to explain boundaries to Carl but decided against it. I knew that a dispassionate instructional ACA-type lecture would be distancing—especially via text.

Carl has been in counseling with me for three years as a requirement of his probation. He is a member of a local gang who has mentioned how his affiliation got him into trouble while growing up. He also shared his initial fear of telling me he was in a gang because of how I might “react” to him. I maintained a neutral position.

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Gangs were part of the social fabric of Carl’s youth—I, too, was gang affiliated. Thus, I was personally familiar with that life, but I believe that it was because I have historically been the only Black male therapist in most of the psychiatric settings in which I worked that I was often given complex and challenging cases. This often meant working with male gang members and other males who had been charged with sex offenses (perhaps a story for another time).

I returned Carl's call because I was concerned that he had done something inappropriate with which I could help him. I was also mindful of my own insecurity. I felt as though little progress had been made in our work. Carl was also inconsistent with taking medication prescribed by his psychiatrist and in attending sessions with me. Yet he constantly told me how much he “appreciated” working with me. I viewed his text as a plea that might allow me to do something meaningful with him. I hadn’t gotten his message quite yet.

Carl answered the phone on the first ring. “I am sorry about the capital letters in my text, I don't want you to worry about me. Do you have time to talk?”

He went on to say, “I need some therapy right now.” Carl mentioned that after a domestic dispute with his girlfriend, she had been considering leaving him. “I don't know why I'm so angry” and “I wish I could get over this anger,” Carl cried.

This was refreshing and far different from Carl's usual sessions, which he tended to begin with a detached, “I'm doing good. I am safe and in good health.” Eventually, I came to realize that after being in both penal and psychiatric institutions, he was used to giving knee-jerk responses to risk assessment questionnaires. After his pleasantries, there was always a laborious discussion of his video game adventures. Today was different, although I did not understand how at that exact point.

Instead, I felt anxious in that moment. This may have been my own internal reaction to Carl's sense of anxiety. However, I also felt a strong inclination to capitalize on Carl's plea for help and felt as if I needed to come up with a clever “intervention.” I had to strike while the iron was hot. Should I use CBT? I could re-emphasize the cognitive model to Carl and how his distorted thinking contributed to his ongoing patterns of anger. No. Carl had already admonished me in the past for using “big words,” referring to clinical jargon.

Maybe, EMDR?! Could some eye movements mollify his intensity? While I am trained in both interventions—and believe they have some merit—I thought it might be better to just shut up and let Carl talk.

After a while of silent sobbing, Carl exclaimed, “I think I know what this is.” He paused.

“I used to be soft” in grade school, he went on, and after years of bullying he stood up for himself. “That's when I learned that I could fight,” said Carl, his voice cracking as he held back more tears. Carl mentioned that after a while, he learned to become the aggressor as a preemptive way of sending a message that he was a formidable opponent.

I felt stuck. Was now the time for an intervention? I fought against the impulse. Instead, I simply asked, “How do you feel now?” Carl shared that he had felt a little better and that he was glad that he could “get this off my chest.” Ironically enough, almost immediately after this revelation, the call dropped. The call dropping likely saved me from myself. I had an urge to say, “I just want you to know that you're not that little boy anymore.” I probably heard this line somewhere from a supervisor in the past. I do not actually believe it. Carl knows full well that he is not the little child who was bullied, although he might still feel like it.

I wish I could say that Carl no longer expresses anger in an unhealthy manner. I believe that it will take more than one 45-minute session for that. However, I do trust that the session was meaningful to him (and in retrospect, to me as well). He appreciated that I listened to him. I appreciated that the session felt like real therapy. It involved all of the ingredients that make therapy special: attunement, minimal encouragers, brief re-statements, warmth, empathy, compassion, the list goes on.

While still a relatively new clinician, I find myself frustrated and impatient with the mental health industry. In my brief time practicing, I have noticed that I am encouraged to quickly create and implement rigid and concrete treatment plans with goals and objectives that might say things like “decrease frequency of anger by 30% by such and such date.” I am not saying we should abandon these measures. They have a place. However, it creates a false sense of urgency to “do” something in sessions in lieu of “being” myself.

I have been in my own therapy for a few years. A secret that I have not shared is that I would cringe if my own therapist held rigidly to one treatment modality. I appreciate that she is flexible and willing to meet me where I am. However, the issues I often bring to counseling pertain to deeper questions I have about the contradictory elements of life. I do not know if the cognitive model can get me through that.

It is seductive and somewhat satisfying to have a ready list of tools and interventions that I can provide to clients. It makes me feel smart and prepared. It is not as sexy to promote the tried-and-true skills that have been empirically validated. As a disclaimer, I am not saying I reject these treatment modalities. If that were the case, I would not have spent 80+ hours learning them after graduate school—I think. I am simply saying that I should not disregard the elements of psychotherapy that have, time after time, proven themselves effective in my work with clients.

I founded a clinical think tank centered on helping gang-affiliated adolescents. It began in New York and expanded to Denver. Over the four-year course of mobilizing clinicians to research evidence-based interventions to help this population (there are none), what keeps coming up are the same principles that work with Carl.

I am reminded of how fascinating it is when I ask clients what they find helpful about working with me. I almost never hear anything about a specific intervention. What I do hear is that I am “kind,” I am “engaging,” I “relate well” with them, I am there for them during difficult times, I am “real,” and other similar sentiments.

As I look back at my three years with Carl, I can see that I have been unfairly critical of myself. I had viewed our relationship as ineffectual up to that moment I discussed at the outset of this essay. I focused on select symptoms (i.e., anger) and his inconsistency in coming to sessions (I told myself that if I were a better therapist, he would not miss sessions and he would be less angry). However, I mistakenly dismissed the fact that he often expressed his appreciation for me and had adamantly refused to work with anyone else in the past. I also ignored the fact that someone who defines themselves as “solid as concrete” is capable of being vulnerable with me.

Carl appreciates me because I strive to connect with him. For the past three years, he has known he has at least one person who doesn't view him as just a gang member or someone who is antisocial. He can look forward to my showing a genuine interest in him as a person as opposed to probing for tendencies that may deviate from the norms of society.
It is my hope that fellow therapists seek to be human with their clients prior to employing so-called standardized interventions in a reactive, knee-jerk fashion. Perhaps more of a focus on therapy and less on treatment protocols will allow for the true healing power that comes with the relationship, which I thoroughly believe is the element that heals.