Category: Blog

The Upward Arrow and the Golden Rule

Posted on by Psychotherapy.net Team

My client Leslie sits across from me, her shoulders slumped. She has come to me for help with her marriage. Despite having a core of love for each other, for many years Leslie and her wife have been sharing mutual recriminations and dismissals of each other’s feelings. Their marriage has moved through time like a net, trapping resentments. We’ve been focusing on a moment when she complained to her wife about a critical comment her wife made about her in front of their kids.

I ask her the “Miracle Cure” question to clarify her goal in today’s work. “Let’s imagine that a miracle happens, and you got exactly what you wanted out of this session. What would that look like, what would be different?”

“She would see that I’m right, and she’d apologize,” she responds quickly.

Like so many people who say they want to improve their relationships, Leslie is stuck in blame. She is having a hard time conceiving anything that could help the relationship beyond having her wife do the changing.

As Dr. David Burns (1) has pointed out, a stance of blame is incompatible with healthy intimacy. When we blame, we fall into distorted thinking patterns and place all the badness and problems on the shoulder of the other person. In doing so, we cast ourselves in the role of victim, powerless to effect any changes that would move us to our goals. But the problem goes further than that. Relationships are reciprocal—when we approach someone with blame, they will naturally respond in kind. The Golden Rule is fundamentally a self-compassionate one: treat others as you would like them to treat you…because, well, what comes around goes around.

But how to help Leslie feel that with her heart, and not just in her head? In previous sessions, I had validated the hurt behind her wish and then redirected her, reminding her that her wife wasn’t asking me for help and that any changes need to come from Leslie herself. But today, I encourage her. I call this line of questioning the Upward Arrow, akin to the technique called the Downward Arrow. In the Downward Arrow technique, we ask a person why a negative thought is upsetting, which leads them to make contact with the negative beliefs that underlie the thought. In the Upward Arrow technique, by contrast, I ask my patient to elaborate on her wish for her wife to acknowledge her as right and apologize. The goal is to help her make contact with the healthy longings that underlie the problematic wish.

At first, she is confused by my line of questioning. She closes her eyes and shakes her head. She has a hard time imagining her wife apologizing. I encourage her to keep going, even if she draws a blank at first. She makes another try, but her anger and bitterness reemerge.

“She never listens, she’s always poo-pooing my feelings.”

I redirect her gently back to the task at hand. “Yes, you’ve felt so dismissed by her. See if you can put those thoughts aside for a moment. Instead of thinking about how badly she has been treating you, let yourself think about what you’d most want to hear from her. You said you’d want her to see that you are right and to apologize. That makes so much sense to me—can you elaborate on that? What would that mean to you, why is that important?”

“Well, it would mean she understood me. We wouldn’t have to keep arguing all the time. I wouldn’t have to keep defending myself.”

“Yes, that would be so much better, wouldn’t it? And can you keep going? Why would you want that, to not have to argue and defend yourself?”

A look of sadness crosses her face, and her eyes moisten.

“I could let my guard down, and relax, and just tell her how I was feeling. I could just be myself with her.”

“That would feel so good, wouldn’t it? To just be able to be yourself, without worry.”

“Yes,” she softens, “that would be such a relief.”

“And what would it be like to be with her, if she apologized to you, and you were feeling able to just be yourself?”

“We’d be on the same team. We’d be able to work together instead of fighting with each other. We’d be better parents.”

 “Close your eyes for a moment and really imagine that. What would that feel like, in your body, to be with her like that? What sensations do you have?”

“I feel calmer. My chest feels more open. I feel like I can breathe.”

Can you see what is happening here? She is starting to self-regulate, using her own imagination. She doesn’t need her wife to say exactly the right thing—with a little guidance she can bring herself to this state of mind. She has woken up to her own self-compassion using an idealized image of a partner.

I bring her out of the visualization and check-in. She’s still enjoying a feeling of ease.

“And you know what is cool?” I ask her. She tilts her head, inviting my answer. “You came to this state without her having to be different. You didn’t need her to say the right thing to be able to feel this sense of ease. This is something you created in yourself.”

“Yeah,” she nods. “Just imagining being treated this way allowed me to relax and be less defensive.” She widens her eyes as she realizes something. “And what is also interesting is that I feel more warmly toward her.”

“When we started this conversation, you said what you most wanted was for her to see that you are right and apologize.”

She gives a short laugh. “Yeah, that would be nice, I guess. But what I want more is for the two of us to be on the same page.”

She pauses, then continues. “What if I accept that she’s feeling hurt and defensive too? If I treat her the way I want her to treat me, maybe she’d relax and be more open to working this out.”

“I think you have just articulated a famous rule,” I notice.

“A golden one!” she says with a smile.

References

(1) Burns, D. (2020). Feeling great: The revolutionary new treatment for depression and anxiety.
PESI Publishing and Media.
 

The Quarantine Void: A Reminder of the Central Role of Being

Posted on by Psychotherapy.net Team

COVID-19 has radically arrested the ethos of American life as hundreds of millions of people have been forced out of their jobs and into their homes. This loss of everydayness has inevitably set into motion an involuntary reflection of what constitutes a meaningful life. In the emptiness of this pause, traditional American values of progress, work ethic, and profit have become eclipsed by the felt importance of human connection and meaningful engagement. I, along with my clients, have begun to realize that the jobs, activities, and tasks that once filled our daily schedules were partly distracting us from truly living our lives.

In my clinical work, I’ve noticed that the pressure my clients have felt to constantly be doing something with their lives has paradoxically hindered their ability to “be” in their lives. This emphasis on doing has led to lives that seem externally busy, but feel internally hollow. The slowed-down and socially-distant world of quarantine has inevitably exposed this absence of being. However, the acknowledgement of this existential void also contains a powerful opportunity for change. The pandemic has offered the pause needed for my clients to better understand the difference between being and doing so that familiar maladaptive patterns do not follow them into a post-quarantine future.

The doing mode is characterized by future-focused actions. My clients occupy this mode when they see their reality and decide that it needs changing. The American dream is a glorified example of the life-changing power of the doing mode. Its underlying belief, that a strong work ethic is the key to unlocking an idealized future where all of one’s dreams will come true, is deeply rooted in America’s emphasis on doing. The central fear is that laziness, a term used to describe any action or experience that is not firmly rooted in the doing mode, will jeopardize progress, which is seen as the ultimate ideal.

The doing mode has created astonishing advancements in technology, while also providing the modern world a multitude of successful ways to orient towards practical problems. However, problems continually arise when doing is seen as central. Doing does create potential frames for practical living, but it doesn’t do the living for us. My clients are realizing that they must be in their lives if they hope to acquire what makes their lives worthwhile. As the classic saying goes, we are human beings, not human doings.

The being mode is characterized by present-focused experiences. My clients occupy this mode when they are experiencing their reality without the desire to change it. The being mode redefines the term laziness as existence itself. Existence doesn’t desire to change, judge, or label itself. To exist is simply to be. The being mode lets go of progress for the life-giving sacredness of the present moment. As the current pandemic forces my clients to bear witness to the present moment, their emptiness and suffering are reminding them that their vitality, center, and reality are found in their willingness to regularly cultivate moments of feeling, or being, truly alive.

This dichotomy between being and doing emerges frequently in the therapeutic setting. My clients typically attempt to satisfy their being needs with the investigative, externally-focused aspects of the doing mode. For example, a middle-aged woman set up an intake with me due to her desire to learn coping skills to manage symptoms of her anxiety. We began treatment by discussing diaphragmatic breathing, mindfulness exercises, and grounding techniques. However, I kept my attention centered on her unspoken being needs by noticing the possibility of their existence during each session. Over time, she came to realize that her anxiety wasn’t a problem that needed to be fixed. Rather, she learned that her anxiety was a reactional fleeing from her deeper unmet emotional needs. As I provided a space for these needs in session, she began to realize that her emotional pain was valid and worthy of being heard. Her ability to receive my validation of her pain in session, represented by her sobbing, motivated her to share these experiences with others outside of the therapy room. Her anxiety dissipated and was no longer needed as an alarm call as she received validation within herself and from others. She cured herself by choosing to allow for love.

An emphasis on the doing mode also tends to pull my clients towards relying on external objects rather than internal states for solutions to their problems. For example, a man in his early twenties reached out to me to help treat the anxiety and depression he started to experience after the death of his best friend. He explained that his house was also robbed shortly after his friend’s death, which resulted in his deciding to pick up more hours at work to make up for the loss. However, he continued to pick up extra shifts even after he had financially recovered from the robbery. He told me that he just wanted enough money to feel safe, but that desire quickly turned into an addiction. As we compassionately explored the possibility that money wasn’t helping him fill the void of his grief, he slowly began to allow himself to acknowledge his being needs. He gave himself permission to inhabit the pain of his grief, represented again by sobbing, which allowed him to begin to let go of the anxiety and depression he endured from his belief that money would cure his pain. As he continued to inhabit his grief by being present with his pain during our time together, his anxiety and depression eventually faded altogether. He also decided to change careers to pursue something more meaningful and authentic to his interests. Being with his grief gave him the chance to replace the external intentions that harmed him with the internal sources of meaning and connection that eventually healed his broken heart.

My responsibility as a therapist is to persistently attend to the heart of my client’s experience, while choosing not to get distracted by their attempts to flee the being mode. I’ve learned that I must continually be willing to point my clients back to their being, so they can learn to stay with themselves to find healing. Explaining the difference between being and doing to my clients has also helped to increase their understanding of which mode to implement in any given situation. My therapeutic hope is that their decision to voluntarily inhabit the being mode will provide them an ability to act authentically when the time for doing naturally emerges in their lives. This hope has expanded to a general belief that those individual decisions will then have a positive ripple effect on the greater world as a whole.

As an example, I worked with a middle-aged man who used alcohol as a means for expressing the being needs that he didn’t feel important enough to express without it. However, he tended to express them with rage and accusations due to the impact of the alcohol. He also had a strong tendency towards co-dependency and self-negation, which often resulted in anxiety and depression. After a year of my attuning to his being needs in the safety of the therapeutic environment, he finally felt ready to soberly share his needs with his wife. His fears of sharing were not irrational, for he was forced to stand his ground in the relationship for almost a week to undo the patterns he had created during the previous years. However, after the week ended, his wife came to him and apologized for not validating his pain and suffering. He was amazed by how much better she treated him after his sharing. He was also surprised to notice his anxiety and depression becoming replaced with a deep sense of grounding and hope. Even his children started treating him with respect. They took better care of the home, attended to their responsibilities, and even began asserting their own desires to have a better relationship with their mother as a consequence. His wife became more vulnerable and loving with him and their children as well. This butterfly effect of positive change extends well beyond the family sphere, as my client continues to share how his shift in orientation is positively impacting his relationships with friends and coworkers. I continue to be amazed at the positivity and love that extend outward from each of my clients’ willingness to authenticate the importance of the being mode by inhabiting its transformative power.

COVID-19 has given my clients the chance to reorient toward being. In turn, their shift in orientation has reinforced my belief in the significance of the being mode. However, the gravity towards doing is a powerful force. My clients and I hope to remain mindful of the importance of letting go of the need to do something (to become better, safer, stronger, happier) to allow ourselves the opportunity to inhabit the nourishing depths of our being. My therapeutic aim is that my clients and I resist our need to change the present moment, so we can be brave enough to embody it. Increases in vaccination distribution and reductions in positive COVID-19 cases are beginning to present the possibility of returning to a new normal, but the pull towards doing will follow in their wake. How my clients and I choose to respond to this new normal has the power to restore the centrality of being, along with our shared humanity, or bring us back into the dizzying energy of a doing-centered world.

Being Black and a Clinician During 2020: A Trainee

Posted on by Psychotherapy.net Team

It is now the year 2021. Vaccines have been released. People are getting vaccinated. And yet, the death toll from COVID is still staggeringly high, particularly in the United States. 2020 was a year that humbled many of us, and as a Black graduate psychology trainee, I was no exception. To say that 2020 was a “hard” year is almost facetious. The truth of the matter is, for many people, particularly those who look like me, 2020 was a series of struggles at the hands of two pandemics, one that was novel and the other that was not. To be frank, 2020 was arguably disproportionately more difficult for Black people than any other group. Black people living in the United States were hit harder than any other group by COVID-19 (1). If this were not bad enough, the main culprit of these disparities was systemic racism. While a more thorough explanation of the factors attributable to systemic racism that made Black people more susceptible to COVID-19 infections and subsequent deaths is not within the scope of this piece, it is important to note that factors such as minimized access to healthcare, food deserts, and results of housing inequality over the years contributed to this trend.

Along with the detrimental effects of systemic racism and COVID-19, the pandemic of systemic and structural racism also manifested through televised, media-streamed reports and depictions of brutality against Black people. Names and stories of individuals such as George Floyd, Ahmaud Arbery, and Breonna Taylor (among others) incited global unrest and placed a spotlight on the undervaluing of Black lives. As a Black person living in America, this was not surprising. And yet, I’d be dishonest if I said that a video of a Black man crying for his mother with a knee on his back didn’t take my own breath away.

Considering the totality of these factors, the question becomes: where does this leave Black clinicians? I identify as an African American woman, and I am currently living, learning, and working in a part of the country that has not always been welcoming or kind to people who look like me. Throughout my training as a clinical psychology graduate student, many of the training experiences I have valued the most were when working with racial/ethnic minority clients, particularly those identifying as racially Black. For me, it was interesting to see the nuances of the Black lived experience manifesting through my clients. However, 2020 very explicitly placed a spotlight on the struggles associated with these lived experiences.

In their candid ethnography-based article, Lipscomb and Ashley (2) provided a direct look into the struggles of working as a Black clinician in 2020. While it is not within the scope of this blog to give the totality of their narratives, a few important points stuck out: 1) as Black clinicians working in 2020, the authors felt overwhelmed, 2) the authors felt challenged to mitigate countertransference in providing space to validate the feelings of their Black clients while managing their own feelings, and 3) the authors felt uncomfortable at times with their White clients’ desires to share their sentiments regarding the racial injustices of 2020. While it would be unrealistic to insinuate that these authors or myself know and can speak to the lived experience of all Black clinicians working during 2020, I feel a commonality between my own experiences and those of the authors.

As a clinical doctoral trainee, the trends Lipscomb and Ashley found amongst themselves almost feel exacerbated within me. As many of the readers of this blog might know, operating as a graduate student trainee is often plagued by holding opposing positions. For our clients, we are regarded as “authorities” on mental health, though we are only students, learners, and supervisees in the eyes of our supervisors. We are encouraged to develop and cultivate our professional autonomy and identities, but are also frequently and subtly (or sometimes not subtly) reminded of the hierarchical structure of higher education. As a Black graduate student trainee, these juxtapositions often feel jarring and have felt increasingly dissonant throughout 2020, as civil unrest and health care disparities have become blindingly apparent. Admittedly, I resonate very strongly with both the COVID-19 and racial injustice pandemics. To plainly illustrate this point, I faced the unfortunate reality of losing my grandmother on the same day in May that the story of George Floyd went viral.

At the time of my grandmother’s passing, I only shared the news with a limited number of faculty within my program, but, as things tend to do, the news spread. Whereas faculty members and some student colleagues were reaching out to me with condolences for my grandmother, hours later they were contacting me again with gingerly worded messages attempting to lend support in the wake of the civil unrest following George Floyd’s murder. While well intentioned, the onslaught of messages felt emotionally, mentally, and psychologically overwhelming. The dual pandemics also affected me as a Black trainee in my clinical work. With my Black clients, I struggled with allowing them the space to articulate their hurt, pain, and fear, while also validating them and not allowing my own feelings to seep into my clinical work. This is something that I have since become better at reconciling, but it at times felt like a hard barrier to overcome, particularly during the late summer months.

I have a client with whom I have been working for about two years. She also is a young Black woman, and we have found throughout our work that we tend to be extremely aligned personality-wise. After my grandmother died this past summer, I took two weeks to return home and be with my mother, who after the death of my grandmother had just lost her last remaining parent. What this meant is that when my client was struggling with the fallout from the death of George Floyd, I wasn’t there. When I eventually returned, despite our having a treatment goal that we were working on, I entered the virtual session (another thanks to 2020) and could see that she was visibly distressed. She began speaking about the topics we’d listed on our treatment plan, and I responded by gently stopping her and asking if she needed the space to just be Black and “feel.” In that moment, the client visibly deflated and became emotional. For 50 minutes, we spent the session with me listening and providing affirmation. I did not try to guide the session. While I’ve been taught that guided processing is an often-effective therapy tool, I did nothing of the sort. I let the client be Black, in a space with another Black woman who intimately could understand and validate what she was feeling. I won’t pretend I’m not potentially biased, but I’d argue that session was one of the most impactful sessions I have had with that client in our two years working together.

In concluding this blog, I leave a few takeaways for fellow clinicians and a quote I was particularly moved by from the Lipscomb and Ashley article.

  • For Black clinicians: It is important to create your own spaces for self-reflection and emoting. This could look like having your own mental health professionals you can engage with to process your feelings (I have one, and let me tell you, that level of being able to just “be” is unmatched).
  • In working with Black clients: As noted by Lipscomb and Ashley, “there are no words to heal the pain of systemic racism, oppression, and racialized trauma…” (2). Be kind, graceful, and validating of the lived experiences of Black people you might be professionally engaging with.
  • In working with majority group clients who might want to discuss racial injustice: One of the hallmarks of effective therapy is creating a safe therapeutic space. Fear of making mistakes, expressing microaggressions, or in some other way making blunders when discussing racial injustice could impact the ability for White clients to engage and benefit from therapy. Considerations should be made to transparently, directly, and yet compassionately, address these topics.
  • For Black trainees: Give yourself grace. Graduate school is often an isolating experience for Black trainees. Being one of the only Black people in a field that prides itself on empathy and emotional intelligence is often a hard feat, particularly during times of civil unrest. Take time to engage with your communities of support, and don’t feel bad about taking breaks from engaging in sympathies expressed by majority group colleagues and faculty.
  • For majority group individuals engaging with Black clients, trainees, clinicians, and/or colleagues: Validate. Don’t try to assuage guilt or get caught up in “saying the right thing.” Listen and affirm. Also understand that while your attention might be uniquely piqued to race issues in 2020, for Black people and other people of color, racial injustice is a generational lived reality. Your current sentiments are appreciated, but continued engagement and investment on your part to these matters would be appreciated even more.
  • For the field at large: There are no evidence-based models, manuals, or diagnostic criteria available to guide work with Black clients living through COVID-19 and exacerbated racial injustice. This places even greater importance on the role of therapists of color during these times and highlights the notion that work should be done to recruit, acquire, and retain more therapists of color moving forward.

“…Black people can only heal as much as the larger society allows for them to; as long as injustices continue, Black individuals cannot fully heal” (2).

Reference
 

(1) Yancy, C. W. (2020). COVID-19 and African Americans. JAMA, 323(19), 1891. doi:10.1001/ jama.2020.6548

(2) Lipscomb, A. E., & Ashley, W. (2020). Surviving being Black and a clinician during a dual pandemic: Personal and professional challenges in a disease and racial crisis. Smith College Studies in Social Work, 90, 221-236. doi: 10.1080/00377317.2020.1834489 

The Four Brahmaviharas and the Quiet Inner Voice

Posted on by Psychotherapy.net Team

My patient, whom I’ll call Andrea, is a lovely woman in her 60s. She wakes at 4 am each night, stomach clenched with worry about her adult son, who just left his job without a clear plan for his next move and appears quite depressed. My patient leans her head against her hand, and through the video screen, I can see the worry lines tight across her face. She is terrified that he has made a terrible mistake in leaving his job, and she is fighting the urge to micromanage his every decision. “Feeling his pain is so much worse than feeling my own. I just want to make it stop,” she tells me. She and her husband have been at odds about the situation—he tells her she worries too much, and she thinks he isn’t worried enough. “I am all alone in this.”

We explore her good reasons for feeling anxious through a “Positive Reframe” exercise, which comes from TEAM therapy, developed by David Burns. In this exercise, we explore how painful negative symptoms can be useful and can reflect our most deeply held values. “It shows I’m paying attention, it keeps me vigilant about the situation,” she reflects. Indeed, she has been very proactive about helping her son find a good therapist and has been brainstorming with him about leads for a new job. She identifies the values that underlie her worry—“Seeing his pain hurts so much because I care so much about him. But I know my reaction pressures him, and that’s not helpful. I just want him to be happy!”

Most recently, Andrea and I discussed the Buddhist concept of the Four Bramaviharas or the “divine abodes.” They are 1) Metta—loving-kindness or goodwill, 2) Karuna—compassion, the awareness of the suffering of others and the desire for it to stop, 3) Mudita—sympathetic joy in the happiness of others, and 4) Upekkha—equanimity.

When she examines her underlying motivations, it is clear that Andrea is manifesting Metta for her son. She wants him to be happy. She is also demonstrating Karuna, compassionate awareness of his suffering and desire for it to stop. And by coming to see me, she demonstrates both Metta and Karuna for herself: she recognizes a need to bring things into balance and bring down the level of her suffering, which she can see does not help either of them.

She finds this part of our conversation helpful: “It’s a good reminder that I don't need to believe all the things my mind tells me, like that I’m not a good mom. I’m feeling pain because I care about him, not because I’m doing something wrong.”

“And what about the thought, ‘I’m all alone?’” I ask her. “Could there be a kinder way to speak to yourself?”
“What do you mean?”

“Well, what if instead of saying ‘I’m all alone,’ you said, ‘I’m with myself’?” Changing the words we use is an example of one of Burns’ cognitive methods, the “Semantic Technique.”

She looks up thoughtfully as she tries that on. “My first response is that I don’t really want to be with myself. No wonder I feel lonely! It’s interesting to imagine being ‘with’ myself.”

“Are you willing to try that right now?”

She nods.

“Go ahead and turn your attention inward. When you think about your son’s suffering, what comes up for you?”

Her face tightens into a grimace. “I feel a strong tightness in my chest—right here,” she gasps. I feel a swell of admiration for her as she stays with the difficult sensations.

“That’s great, keep going. What else do you notice?”

She falls silent. “Yes,” she says finally. “I have a teacher who says, ‘the wise voice is quiet.’ When I listen more carefully, I hear a voice that says that what my son needs is this, what’s happening right now, this kind of being-with. I can’t fix his depression or make him find a job. But I can be with him. And I can be with myself.” She smiles. “If I’m listening to a wise voice, I’m not all alone, am I?”

We sit together in silence. Then she continues, “I feel less helpless and desperate. His depression, my anxiety, they are part of being human. It’s okay.”

She has hit upon the fourth Bramavihara—equanimity. The willingness to be fully present with things as they are. Equanimity acts as a natural brake on compassion and our tendency to become preoccupied with the feelings of others.

“My teacher has taught me an equanimity prayer,” I offer. “I call it ‘a mother’s prayer’. I’ve found it helpful in parenting, if you’d like to hear it.”

“Sure,” she replies.

“It goes like this: ‘Things are just as they are. Joy and sorrow arise and pass away. Your happiness depends upon your intentions and your actions, not upon my wishes for you. I love you, but I cannot prevent your suffering.”

“That’s nice, I like that.”

“I added a line: ‘I delight in your capacity to make your own decisions, even if I don’t agree with them.”

She laughs. “Oy. That’s a tough one. What if his decisions are making us both miserable?!” She pauses and answers her own question. “I understand. I want him to be his own person, and he has to figure out his life from his own experience.”

Mudita, the third Bramavihara, fills us with sympathetic joy in the happiness of others, even if we did nothing to create it.

“I’m grateful for all the times my parents let me make my own mistakes, I suppose I can take pleasure in his being able to do the same. I guess I know what I’ll be practicing this week.”

***
 

And so, by sitting with herself, Andrea weaves together the message of the four Bramaviharas, guided by the wisdom of her quiet inner voice.
 

What the APA Apology Means for Black Psychiatry

Posted on by Psychotherapy.net Team

On January 18, 2021, the world of psychiatry experienced something historic when the American Psychiatric Association acknowledged and issued an apology for their part in a history of racism¹. There is no doubt it was time for this monumental moment, which markedly took place on this year’s celebration of Martin Luther King, Jr. Day.

This apology doesn’t erase all of the history that is behind it, and it doesn’t solve everything that may come. Yet after the history that has led to the APA’s need for an apologetic statement, this is an important step forward. This is a milestone for Black psychiatry and for all of us, really, in the African American community. I believe it may even deserve its own place in the history books.

For Black American, the history of our country has been paved with injustices, many of which have had a lasting effect on every facet of mental health, from assessment to treatment. The trauma of the African American community goes back many generations to slavery. The history behind the need for the APA’s apology goes deep into our past and can still be seen in the current practice of psychiatry². Going back all the way to the very beginning, the necessity of this apology is painfully clear.

The roots of racism in the psychiatric field go back a very long time. Diagnoses of mental illness were used to justify the view of Black slaves as inferior human beings. A supposed mental illness invented by Samuel Cartwright called “dysaethesia aethiopica” was used to explain a slave’s “laziness” and disinterest in their forced lifestyle³. In those days, the work of mental health professionals was only used to harm Black Amercians, not help, as it is meant to do.

The APA was meant to be an institution that kept racism from being fully actualized. The organization should have been there for the mental health support of all Amercians. Instead it was founded on principles that allowed Black patients and White patients to receive separate and vastly different levels of quality in care. It should be clear who was given real support, and who was left to suffer.

Time and time again, injustices were suffered by the Black community, and APA was among those who remained silent. Again and again, the mental health of Black Americans was both damaged and neglected while society stayed silent. Racism remained an issue within American psychiatry and someone should have spoken up, but APA didn’t.

APA repeatedly did not support civil rights legislation meant to improve psychological conditions for Black people. They neglected at the most crucial of times to do anything more than offer mere consolation to the people who were really hurting. Regardless of how widespread race-related inequality was at the time, the APA has missed many opportunities to speak up before this recent apology.

This history has piled onto the state of mental health for Black patients today, and it is about time that we hear the APA take accountability for its actions and inaction. Racist beliefs were integral to the damage that has been caused in the long history of Black psychiatry in this country. African Americans were declared biologically inferior, and that bias never fully went away. From Cartwright’s categorization of an entire race of people as simple and lacking emotional complexity, to the still very recent disproportionate diagnosis of schizophrenia in the BIPOC (Black, Indigenous, and People of Color) community?, systematic racism runs through the field of mental health and has done so for a very long time.

The APA’s apology is a small step in the right direction. The damage done has been far too great, but this is not insignificant. Truly, it represents something incredible. Mental health treatment is so important for people, especially for those in the Black community. This is the work that helps people heal from trauma and address the disorders and mental struggles that make everyday life difficult. With the apology we have received from APA, we can gladly find ourselves so much closer to reaching what the mental health system in this country should be.

What this represents is hope. We have made it a great deal forward, and now we can continue to find hope for better in our future. On the day that I saw this apology, I celebrated, not just for the moment itself, but for what this means for what may come. While I’m glad for the APA’s apology, I’m excited to see more medical organizations stepping up to do the same. I have hope that this is only the beginning, and that this apology truly represents a positive move towards improved mental wellness in our community.

References
American Psychiatric Association. (2021, January 18). APA apologizes for its support of racism in psychiatry. American Psychiatric Association. https://www.psychiatry.org/newsroom/news-releases/apa-apologizes-for-its-support-of-racism-in-psychiatry.

American Psychiatric Association. (2021, January 18). Historical addendum to APA's Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry. American Psychiatric Association.
https://www.psychiatry.org/newsroom/historical-addendum-to-apa-apology.

In 1851 a scientist “discovered” a disease that caused slaves to run away, this was the prescribed cure… (n.d.). Watch the Yard. Retrieved 16 March, 2021, from https://www.watchtheyard.com/history/drapetomania-dysaesthesia-aethiopica/.

Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World Journal of Psychiatry, 4(4), 133–140. https://doi.org/10.5498/wjp.v4.i4.133

Termination: A Process by Any Other Name

Posted on by Psychotherapy.net Team

My client, a psychologist by training and fellow traveler through COVID’s unforgiving landscape, had initially visited with me because of anxiety and his growing difficulty managing it. Accustomed to a take-charge style that centered around scanning his environment for potential threats to his family, he had grown tired, not just of the challenges COVID presented, but from the sheer effort and energy it took to manage his anxiety. The details of our work can be found in a recent blog I wrote, so I will fast forward to the later portion of our time together when we began reviewing the path forward for him (and us)—life after therapy.

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As we reviewed his progress, it became clear to both of us that he had made significant gains in managing anxiety, breathing a bit more into his life and enjoying moments with his wife and children. All of this without the pressure that came from constantly scanning his inner and outer worlds for threats and subjugating himself to a harsh inner list-maker. His goals were being addressed and he was making significant changes and progress. The time for planning an ending to our work was approaching, so I broached the subject.

The conversation quickly pivoted to the word “termination,” and although I had used it numerous times with past clients and in my teaching and writing, it suddenly felt quite leaden rather than a natural part of the therapeutic process. Perhaps because I was particularly fond of this client, termination felt like a loss and triggered my own attachment issues and deeper existential concerns around loss.

I considered each of these and sought the wisdom of those who had come before me in order to move more comfortably into this uncomfortable space with my client (and myself). From a developmental perspective, termination suggested a separation/individuation process that, while inevitable and painful for some clients, was a harbinger of growth. From a traditional analytic perspective, termination followed resolution of the transference, awareness of defenses, strengthening of the ego, and a lifting of repression, while more contemporary analytic theory favored a more natural progression in the relationship between therapist and client. Jung believed that termination reflected the client’s awareness of a new philosophy for living—an awakening—and as such carried a more growth-oriented valence. Anchored in a more positivistic appreciation of the role of therapy, humanistic theory suggested that the final phase of treatment focused around movement towards growth and accomplishment. Finally, from a more pragmatic and behaviorally-oriented perspective, termination is the logical and planned conclusion to a predictable, scientifically-grounded, ends-oriented intervention.

And then I came across an interesting article (Maples & Walker, 2014) that reviewed and critiqued the label “termination.” I liked what these authors had to say because they, like I, had considered that termination and its historical associations and connotations were weighted down by historical attempts to find just the right name for the final episode of the therapeutic relationship, and that most of these attempts had resulted in a negativistic perception of termination, mostly around loss. In response, they proposed the concept of “consolidation,” which suggested a normative process centered around the stabilization, strengthening, and reinforcement of therapeutic gains—a preparation for the client’s journey ahead without the therapist.

All of these concepts, particularly the latter, made sense but left me wanting more. I sought something a bit more post-modern: a collaboratively derived and meaningful frame for this particular moment in the therapeutic portion of my client’s journey with me in therapy.

***

So, in our most recent session, I asked my client, “what would you like to call this phase of our work together?” And he simply said, “I’d like to call it the comfort zone!”

Seemed simple enough, but I sought clarification. What did this actually mean? His response was “I’ve gotten to a place where I am comfortable with myself.” There it was! My client was not deeply immersed in labelling this latter phase of our work, nor was he reflecting on our separation. He had done what he came for. The simplicity of his “comfort” was comforting to me because our work, and I, had helped him find his way there.

What’s in a name? Everything, as long as it is of the client’s making.

References

(1) Maples, J. L., & Walker, R. L. (2014). Consolidation rather than termination: Rethinking how psychologists label and conceptualize the final phase of psychological treatment. Professional Psychology: Research and Practice, 45(2), 104-110.

The Thought Process Underlying Perfectionism and How Therapists Can Help

Posted on by Psychotherapy.net Team

As I listen to my clients describe their “maladaptive” ways of functioning, I usually discern adaptive elements in the patterns they perceive as dysfunctional. This surprised me at first but doesn’t anymore.

It is as if their symptoms have a point, and the problem is that they have taken this point too far. If so, the solution is not to reverse the problematic way of functioning but to dial it down into a more moderate range—a smaller and more readily attainable goal.

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But not necessarily an easy one. Research indicates that black-and-white thinking lies at the root of many mental health problems. Thinking in simple binaries makes it impossible to dial behaviors down because, if it’s not black, it must be white—there is nothing in between. There are many examples of this pattern, and perfectionism is one.

Perfectionism is a schema that recognizes just two categories of performance: perfect and unsatisfactory. There is nothing in between.

Perfectionism doesn’t work. Research indicates that it is associated with low self-esteem, depression, eating disorders, and, ironically, poor productivity. Nonetheless, perfectionism has a valid purpose: it can be rewarding to strive for high levels of performance.

Kirsten was a middle-level manager who looked successful from the outside but suffered from anxiety that was mostly related to her job. She worked long hours but said she was always behind. She had nothing but critical things to say about her performance, although she acknowledged that her evaluations were more than satisfactory. I also noticed that Kirsten frequently disparaged her performance as a therapy client: I found what she said quite clear, but she often interrupted herself with comments like “That didn’t make sense” and “I’m all over the place in the way I’m telling you this.”

Replacing Binaries with Spectrums

The alternative to black-and-white cognition is to think of psychological phenomena in terms of spectra. The spectrum relevant to perfectionism concerns personal standards for performance. The question is: what is good enough? Here is the continuum of possible answers:

1———-2———-3———-4———-5———-6———-7———-8———-9———-10
Horrible      Bad      Mediocre      Okay      Good      Excellent      Perfect

Clients with whom I have worked vary in how they answer this question. Almost none think that performances in the 1-3 range are good enough, but then variability kicks in. Some are content with performances that are below average but halfway decent, and standards range from there all the way up to perfectionism, with lots of gradations in between. I ask clients to mark the point on the scale that represents their answer to this question. Fractions and decimal points are often given by perfectionistic clients, who like to be precise, and Kirsten’s answer was 9.3

In black-and-white thinking generally, spectra are chopped into dichotomies. The two halves might be very unequal in size, because the dividing line might not be anywhere near the midpoint. We can understand clients’ thinking at a deep level by asking ourselves the question, “at what point does the client dichotomize the continuum?”

In black-and-white thinking about performance quality, perfectionists divide the continuum with a cut-point so close to its end that almost all of the spectrum is viewed as representing failure, with just a thin slice for success. On the above spectrum, the cut-point would be between 9 and 10. This lop-sided dichotomy results in constant failure experiences; it helped to explain why years of positive performance evaluations and promotions had not ameliorated Kirsten’s feeling that she was barely keeping her head above water as a professional.

To provide a visual illustration, I draw an arc over each side of the binary, label the large one “failure,” and label the small one “success.” This diagram illustrates the onerous nature of the standards by which perfectionists evaluate themselves.

The Goldilocks Zone

I generally try to help perfectionistic clients moderate their standards, but at first the idea of doing so makes many of them anxious. Their fear of lazy laxity may be so strong that it propels them to the opposite end of the spectrum: perfectionism.

Kirsten acknowledged that she strove for near-perfection in her approach to tasks, but her understanding of the problem was not that her standards were too high but that her performance level was too low. She said, “I need to strive for perfection to improve. If I start going easy on myself, I’ll become lazy and do even worse.”

This fear is the result of dichotomous thinking: if standards are not perfectionistic, they will be loose and sloppy. The solution is to replace this binary with another spectrum:

1———-2———-3———-4———-5———-6———-7———-8———-9———-10
Lazy slacker      Easy-going      Average      Conscientious      Perfectionistic

This diagram shows that perfectionism itself can be understood as an extreme on a spectrum of self-evaluative standards that vary in stringency. This spectrum maps onto the previous one—it is about how good a performance must be to be considered good enough. Again, I ask clients to mark their point on the scale. (Kirsten gave herself a 9.2.)

When I help clients move beyond black-and-white cognition to think in terms of spectra, possibilities open. Rather than making either/or choices, clients can learn to think in nuanced ways about the personal standards they would like to have—not too low and not too high.

Not a Point but a Range

This spectrum shows that perfectionism is not so much a bad thing as too much of a good thing. Perfectionists are not wrong to value high standards, but they take a good idea too far.

I have found that it is not necessary to reverse high standards, but only to adjust them toward moderation. Nor is it necessary to adopt the standards of the average person. The solution is to move into the Goldilocks Range, which is an area around the midpoint of 5.5, say between scale-points 4 and 7, or even 3 and 8.

Previously perfectionistic people usually feel most comfortable around scale-points 7 or 8, and Kirsten was no exception. We had some careful discussions about the difference between excellence and perfection and about how a person could be conscientious, exacting, and achievement-oriented without being perfectionistic. I validated the value of high standards and made it clear that I was not suggesting she become easy on herself and satisfied with mediocre work. The modest but important changes she made preserved her rigorous, hard-working style but moderated it enough to allow some flexibility and satisfaction. Her anxiety level decreased, and she began to enjoy her job for the first time.

This post focuses on perfectionism, but the spectrum strategy applies to a wide variety of mental health and relationship problems, as described in my book, Psychotherapeutic Diagrams. I have found that clients generally function best when they move from the extreme end of a spectrum into the part of the Goldilocks Range that is closest to their original style. For example, aggressive clients become assertive, anxious clients become cautious, and oppositional clients become independent.

A small- to medium-sized adjustment usually changes a maladaptive style into an adaptive version of itself and transforms a problem into a strength. My clients are glad to discover that resolving their difficulties does not require them to become a different kind of person. I ask clients to mark the point on the scale where they would like to be, and the distance from their current position is usually about 2 scale points; this makes the goals of therapy seem quite attainable.

There is a big practical problem with perfectionism: People have only limited amounts of time and energy, life has many aspects, and being perfectionistic about some aspects means short-changing the others, because there are only so many hours in a day. The goal of living a well-rounded life requires us to give up perfectionism.

***

Trying to reverse clients’ habitual ways of functioning can feel like swimming upstream, with opposing currents such as genetics and long-term histories—difficult factors to overcome. When clients realize that the changes they need are not dramatic or wrenching, and a 2-point adjustment on a 10-point scale could change them from an unhappy perfectionist to a hard-working, conscientious person, they feel more relaxed and optimistic, and so do I. Thinking in terms of spectra has brought my therapeutic efforts into accord with my clients’ natural styles and made our work together more harmonious.

References

Shapiro, J. P. (2015). Child and adolescent therapy: Science and art (2nd ed.). Wiley.

Shapiro, J. (2020). Finding Goldilocks: A guide for creating balance in personal change, relationships, and politics. Amazon.com Services.
 

Tokophobia: Recognizing the Multifaceted Fear of Pregnancy and Childbirth

Posted on by Psychotherapy.net Team

“The pregnancy test was negative,” Gretchen recounted through tears. Her tears were not a straightforward reflection of disappointment and longing, as one might assume. They accounted for a complex stew of relief, guilt, and shame about the relief and fear of this ongoing cycle that was proving to be torturous and emotionally exhausting due to Gretchen’s unmanageable anxiety.

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Gretchen and her partner had been trying to get pregnant for several months. Having a biological child was something they both very much wanted. Each month, in the weeks leading up to a possible positive pregnancy test, Gretchen would be excited about the prospect in theory, but utterly terrified about the reality. She often had panic attacks, was inundated with worries about the ways pregnancy and childbirth can go wrong, and was physically repulsed by the idea of a human life growing inside her. The idea of pregnancy made her feel trapped—the state being inescapable and the thought of that, unbearable.

Even before trying to get pregnant, Gretchen had struggled for years with tokophobia, an intense fear of pregnancy. Her extreme difficulty with managing even the process of trying to conceive reinforced Gretchen’s belief that she certainly couldn’t handle an actual pregnancy.

Another client, Octavia, had also been struggling with tokophobia, although hers looked quite different. In our most recent session, she was also in tears. After hooking up with a man she’d gone on a few dates with, Octavia had “spiraled” for days after. “I just couldn’t stop thinking that I’d somehow gotten pregnant,” the notion of this outcome intolerable to her. She was consumed with fear, despite the fact that they hadn’t had sex, let alone gotten fully undressed in their encounter.

Octavia recounted to me the hours she’d spent researching obscure ways of getting pregnant and the repeated phone calls to friends and family seeking reassurance. She knew logically, somewhere in her brain, that it was impossible and felt embarrassed, but Octavia couldn't shake the fear. In the end, she cut things off with the guy.

***

Pregnancy understandably creates a certain amount of anxiety (with a whole extra layer heaped on top given current pandemic circumstances), but for some, the concept itself prompts excessive fear, strong physical responses of anxiety and repulsion, and behavioral avoidance that is debilitating and outside the norm.

Tokophobia wrecks a person’s ability to move forward with their life goals or get close to people—or allows them to do so only under extreme and unrelenting distress. Both Gretchen and Octavia exist in a state tinged with deep pain and impairment—a life not quite lived.

Unfortunately, although this phenomenon is widely experienced, it is not thoroughly researched. There are some, but not enough, comprehensive studies and little in the way of specific treatment guidelines. People are suffering and likely not getting much help—or even realizing that what they are experiencing has a name.

In the literature, tokophobia is broken down into two main types: primary (fear of pregnancy/childbirth without having direct experience) and secondary (fear following a traumatic pregnancy or childbirth experience). In doing more reading and reflecting on my clinical observations of clients like Gretchen and Octavia, I came up with the following distinctions, or subtypes, with the idea that each requires a tailored therapeutic approach, and therefore it’s important to make the distinction.

  • Reluctant: A person with tokophobia who wants to get pregnant
  • Avoidant: A person with tokophobia who avidly does not want to get pregnant and experiences obsessive and extreme worry as well as significant OCD-like avoidance and compulsions.
  • Ambivalent: A person with tokophobia who is uncertain about whether to pursue pregnancy.

For an avoidant tokophobic like Octavia, it wouldn’t make sense to delve into the meaning and source of each of her thoughts or try to dispute each specific worry, when an approach like Exposure and Response Prevention (ERP)—the most effective treatment for OCD—is more likely to ultimately bring some relief. And while it is tempting to treat Gretchen’s reluctance as ambivalence, helping her explore alternative options for growing her family, she is clear in her conviction, but unequipped to manage her physical and psychological anxiety.

Most importantly, I think our job as therapists when working with a client with tokophobia is to 1) take it seriously and 2) conceptualize and treat it appropriately.

My sense is that those struggling with phobic fear of pregnancy and/or childbirth typically feel dismissed, confused, and ashamed (related either to the fact that they feel such fear and aversion to something they expect “should” come naturally to them or to their avoidance and rituals that they recognize as embarrassing/extreme/out of touch with reality).

So when I encounter a client with tokophobia, I often say something like, “Yes, this is a real thing, you are not alone, and furthermore, we can take steps to reduce the shame and nudge you towards the life you want.”

I can offer legitimacy to their experience and compassion to their suffering, while paying attention to the distinct ways tokophobia can manifest person to person. Clients like Gretchen and Octavia don’t have to feel so isolated or hopeless.

The Secret Sauce for Mixing up a World-Class Psychotherapy Blog

Posted on by Psychotherapy.net Team

This won’t sound very scholarly, but for me, the best part of high school began after school let out for the day. It was then I would rush to a small hamburger stand within shouting distance of my home and order a burger, a Cherry Coke, and an order of fries. Just the thought of it is still enough to make me salivate like Pavlov’s dogs. Classical conditioning is not quick to dissipate. Truth be told, both the fries and the burger were just a tad above average. But OMG—and everybody agreed—the sauce was to die for. Virtually every single customer requested burgers and fries with double or even triple sauce. The sauce tasted like catsup, BBQ sauce, and salad dressing combined on steroids. What made the sauce so darn jaw-dropping good? Well, quite frankly, nobody knew. It was a secret. No surprise. The containers behind the counter had the labels removed. For many years after graduation our high school’s yearbook and even the local papers would “reveal the recipe for the secret sauce.” But there was only one problem: every year and every article described a different recipe. Worse yet, about the time I received my high school diploma, this tiny eating establishment, which would hold all of five or six customers on a good day, closed- up shop. A few former employees stepped up to the plate revealing recipes that were too vague to muster up the secret sauce. Sadly, I don’t have the recipe for the secret burger and fry sauce, but I do have the secret sauce for creating a winning psychotherapy blog, and it works nearly every time. And unlike the sauce, the mixture of ingredients need not be perfect. So if you’ve been wanting to serve up your insights but haven’t been sure of how or where to start, I’ve got a recipe for you. Often a little story like the one you just read is a great way to begin. But here are some of the best ingredients that I have mixed into my own recipe. Ingredient #1: Begin with a compelling title. Consider my first-ever blog for psychotherapy net. It was titled, It’s the Psychiatric Meds, Stupid. I wanted the reader to be saying, “What in the heck is Rosenthal talking about? Are psychiatric meds good or evil? I absolutely, positively, need to read his blog and find out.” Direct marketing experts discovered years ago that an advertisement or press release with a good title is more likely to be read than a terrific document with a weak title. Why would a blog be any different? Hint: It isn’t. Some other titles from my own trophy closet include: Alcoholics Anonymous Founder Bill Wilson’s Long-Lost Treatment Paradigm. In case you haven’t read the blog, I’ll guarantee you he wasn’t pushing merely the merits of Alcoholics Anonymous. Nope. In fact, I explain to the reader in the first few sentences I am going to tell them something they don’t know. If you think about it, entertainment aside, isn’t the entire purpose of reading a blog to learn something you don’t know? An excellent question to ask yourself is: Will the reader learn something new from my blog? The ideal answer is yes. Titles with numbers can be powerful attention grabbers. My blog Conduct Therapy Sessions Like Ellis or Rogers in 7 Days or Your Money Back is a great example. The word “how” or the words “how to” are some of the best words to use in a blog title. Imagine combining these words in a title and teaming them up with a number, such as my blog Gone in 60 Seconds: How to Handle a Mental Health Workshop Heckler. And believe me, I’m not the only blogger with killer titles. This site is inundated with bloggers who created world-class titles. Surfing the site for just seconds revealed 20 Seconds: Coming Out to a Client, by Alex Stitt, and Closing the Deal: The Art of Selling Yourself to New Clients, by Robert Taibbi. Ingredient #2: See what everybody else is writing about, and then write something totally different. Indeed, you can write about what is trending or popular and often this will work well. The problem is after an exceedingly short period of time the topic is totally covered in a traditional fashion by a host of bloggers. When this occurs, why not take the road less traveled? Even if you are covering a traditional or trendy topic, why not cover it in an innovative fashion? In my blog In Search of the Perfect Private Practitioner, I weave in the story about the pitfalls in my own private practice. Had I created a blog titled My Private Practice, readers might have been recommending it to others as sleep therapy, or more likely would have never read it at all. At one point in my career, I penned over 20 pieces for a publication in our field. My secret sauce, if you will, was I never wrote a single entry about a mainstream topic. Topics that are historical, or have not been covered in years, often work well. Case in point, my blog The Gloria Films: Candid Answers to Questions Therapists Ask Most showcases a landmark psychotherapy movie shot in the mid-sixties, or roughly the time Ford was releasing the Mustang. Ingredient #3: Write the blog in your own voice. When I entered the field of psychotherapy, I not only wanted to become a great therapist, but I also wanted to become an accomplished writer. Some of my therapeutic literary heroes included Albert Ellis (who originally wanted to write the Great American Novel), Andrew Salter, Lewis Wolberg, Jay Haley, Gerald Corey, and Arnold Lazarus, to mention just a few. I thus began to emulate their writing style. But there was just one problem with my strategy. If somebody wanted to read Ellis or Corey they would pick up something penned by these experts, not something cloned by yours truly. The very best advice I can give you is to merely write your blog as if you are talking to a friend over lunch or a latte. As yes, this could be virtual during COVID. My college students often verbalize this principle in a more eloquent way. “You know, Dr. Rosenthal, when we read your books, articles, and blogs, we know you really wrote them. They sound exactly like you in class.” Ingredient #4: Whenever possible, use a trick or so-called surprise ending. In my blog It’s the Psychiatric Meds, Stupid, you will discover that perhaps it wasn’t the psychiatric meds which impacted my client and why. In my aforementioned In Search of the Perfect Private Practitioner blog, you will discover that maybe . . . just maybe . . . the perfect practitioner wasn’t so perfect after all and why it mattered! In my blog centering on Bill Wilson, I revealed near the conclusion of the blog that on his deathbed Wilson did not want to be remembered for Alcoholics Anonymous, but rather for a treatment paradigm unknown to most readers. (Hello: read the blog, did you really think I was going to spill the beans without your reading the blog? No spoiler alert here, therapy fans!)

***

Try on these four ingredients, add a pinch of your own creativity, and I look forward to reading your blog in the very near future. So how will you begin your first blog? Hmm. Try this. “Well, when I was in high school there was a great burger joint nearby, and they had the best BBQ sauce I had ever tasted” . . . or maybe not.

The Queen’s Gambit and Me: The Surprising Similarity Between Therapy and Chess

Posted on by Psychotherapy.net Team

I was mesmerized from the first frame of The Queen’s Gambit, a Netflix mini-series about a Kentucky orphan girl in the 1960s and her passion for chess. Thoughts of the show colonized my thinking for the three days it took me to get through its seven episodes. I loved it, it intrigued me, and I cared deeply about the characters. It was a perfect jewel. But little did I know how those seven hours would change my life.

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I don’t remember how it happened, but a week or so after the final credits rolled, I started to research chess. I’d never played before and didn’t even know how the pieces moved, so I typed “chess for beginners” into YouTube and curiously, like Alice, fell down the rabbit hole.

I find that I’m dreaming about chess these days and have started to see chess tactics and strategy in everything. I’ve been a psychotherapist for thirty-five years and it's become clear to me since I started playing how a course of therapy conforms, in many ways, to a chess game, with its well-defined opening, middlegame, and endgame.

The first few therapy sessions, when you’re learning about your new client, are like the opening. You start slowly and respectfully, using moves that you’ve used many times before to get a feel for the person sitting across from you. You’re getting situated, knowing that you’re at the very beginning of an important relationship.

For example, I start the first session with my new client, Isabelle, with the opening move I’ve used so many times before—a variation of the question “What brings you here today?” Everything is possible at this point, and I have no idea where this exchange will take us.

During this opening phase, I’m getting a sense of the pacing. Will she jump right in with a cascade of emotion (making dizzyingly fast moves) or sit quietly waiting for me to ask questions (establishing a pensive introspective pace to the “game”)? In this case, holding back and very reserved (not making risky moves), 28-year-old Isabelle explains that she wants to improve her relationships. She’s on pause with her boyfriend, who has not treated her well, and is wracked with indecision about whether to go back to him. She doesn’t trust herself. But when asked her biggest goal in life, she says she wants to meet the love of her life.

A session later, in a latter part of the opening, Isabelle tells me about the struggles she faced in childhood. I learn that her much-loved mother, whom she describes as an angel on earth, suffered mental health problems that were so severe that when she was eight and her parents divorced, she was sent to live with her father’s parents. They were very strict remote old-fashioned immigrants who did not speak English, and she did not speak Italian. She rarely saw her mother and felt alone and abandoned.

More complexity is introduced in a later session as Isabelle reveals that no matter what has happened in her childhood, she’s determined to build a wonderful future and has enrolled in a course to become a life coach. With this goal in mind, at the turn of new year, she’s started to eat more healthily, is trying to exercise, and has incorporated a meditation practice into her day.

In this part of the therapy, the middlegame, I’m searching for patterns. It’s both a science and an art. Isabelle relaxes, and story after story comes spilling out. I’m receiving reams of information and have to make continuous decisions about which pieces are vital to attend to and which not to “take.” I could focus on a tantalizing piece of information that Isabelle shares (capture a knight that’s available to take but which won’t advance my position), but I have to make sure not to make a move unless it contributes value. There’s no doubt that I could chase the pieces all over the board, but I need to develop a plan that will guide my choices.

Over time, the essential issues are brought into focus and, in the endgame, many of the peripheral bits have been eliminated so that only the primary core issues remain. There are fewer pieces on the board, but every one is vitally important. We’re narrowing our focus on the need for Isabelle to forgive herself for having left her mother, who later died of cancer, and working on helping her develop a deep well of self-compassion. The search for the love of her life will have to wait until she’s very comfortable with the love of herself.

Isabelle is not, of course, my opponent, and a course of therapy is certainly not a process of win or lose, but I like to think of strategizing how to help my client in her struggle (our chess game) as the mutual challenge for both of us. The pleasure of checkmate comes from feeling that we’ve shared a profound experience together resolving something important, and that now Isabelle and I can celebrate that positive change has happened in her life.

I've found that there have been many surprisingly meaningful aspects about life during the pandemic, and discovering chess is certainly high up on my list. I smile when I think about it and look forward with anticipation to the next game. Where it’s going to fit into my uber busy life, I’m not sure. But for the moment, hey, set up the board and let’s play!