Category: Blog

Every time I opened the door to Jane, I instantly recognized her odour. This used to rattle me at the very beginning of our work together, but after a few months I barely noticed it and simply opened the window to air the room after her departure, almost automatically as part of a familiar routine. She smelled of a neglected child, of sad days spent in unwashed pajamas and binge-eaten lonely meals. Jane was in her late 30s, and the main reason for her being in treatment was her feelings of shame. This is what I, as a therapist, thought, but if Jane were to explain it herself, she would have probably mentioned her anxiety and the emotional disappointments of being single and lonely in a foreign city. At least, this is what she had told me a few years ago as we first met. We had been working together for a few years, and I had grown to like her a lot. She was a bubbly, intelligent woman with an acute sense of humour. We would often laugh together at one of her jokes, and her face would lighten up in a beautiful transformation. Despite these qualities and her professional achievements as an international school teacher, Jane thought less of herself and battled with a feeling of deep inadequacy. In the first months of therapy, we explored her early history at length, to realize that her two parents had never been able to attune emotionally to her. Jane felt constantly unsafe around them, as they would suddenly explode in unhinged fights, often in public spaces such as a restaurant. This would leave their daughter paralyzed with embarrassment. For years, she had hoped that somehow her parents would get out of their bubbles, entirely occupied as they were by their respective work and their arguments, and that they would notice her presence and her suffering. Jane was an only child, and she could acutely remember her constant feeling of loneliness and despair. She would also be constantly torn between feelings of hurt and anger. Her parents would hardly notice, and when they occasionally did, the response was frustration from her mother and indifference from her father. “I feel like I am stuck in a cold shower.” Hearing her murmuring that, I tried to imagine myself naked and exposed to freezing water, unable to escape and paralyzed with confusion. Jane had been living in this frozen state, her development seemed to have been stopped by the cold shower of her parents’ emotional misattunement, their indifference to her childhood needs. I am horrified by accounts of adults who stop their child’s tantrums by placing them under cold water. Not only does it dismiss the child’s anger, but the wet, shivering child is made to feel shame as a result of this treatment. When parents are unable to cope with the overwhelming emotions that their child cannot yet process, it eventually pushes shame onto the child about this powerlessness. This is probably where Jane was stuck — swollen with indignation and overwhelmed by shame. No wonder she had been avoiding showers. Despite some steady friendships, Jane felt lonely and often dismissed or rejected by others. More than once, we reflected on which of her behaviors allowed or invited other people to push her away. Jane was starting to realize that her constant readiness to get angry and to lash out was not helping her interactions with others. She also knew that her stubbornness about not wanting “to make [herself] pretty” for men had trapped her in a place where she felt unattractive. She avoided all forms of exercise and was putting on weight. But what about the smell? Was it some unconscious strategy to put off others, especially potential intimate partners? Not unlike some insects, which have evolved to develop the capacity to produce a very unpleasant smell when threatened, Jane had learned how to keep others at arm’s length. Her conscious desire for a romantic relationship had not outplayed the unconscious fear of being pushed back under the cold shower by somebody unable or unwilling to give her what she needed. At the end of every session, as I would be opening the window, I was wondering whether I should finally tell her about the smell. This risk-taking on my side could open a royal road for exploration of her shame; or at the very least it would push her to change her hygiene routine for the better. But how could I? Pointing out something so potentially shameful could make her flee the therapy room and undo the work we had been doing. Jane was mostly avoiding any situation that would expose her — such as taking on more rewarding projects at work, or physical intimacy. This constant avoidance had saved her a lot of embarrassment but had also contributed to her feeling stuck. I hoped that by facing her shame together, we could help her to develop resilience. In order to get out of the cold shower, she had to take action and change things that had made her feel bad about herself — exercise more, take better care of herself. Jane had been an unhappy but steady user of online dating apps. The rare times she had made it out with a man had ended up with the same scenario: the man either fled after the initial drinks, or they both got drunk and had sex in her messy studio. In the latter scenario, the denouement would always be the same — she would never hear from the man again. This had been the worst and most hurtful part of it all. To be ghosted by these individuals that Jane actually despised served as a constant reminder of her unworthiness — sending her back to the cold shower. She would get out of each dating experience wounded, and it would take her a few months to recover enough strength to give it another chance and take the risk again. No matter how many hours we spent analysing and unpacking her experience, no amount of awareness or insight seemed to help her change the flow of her lonely and unsatisfying existence. I was still pondering about the whole body odor dilemma when Jane came to a session more deflated than usual. She crumbled into the armchair and stayed silent. I recognised her “cold shower” look. She confirmed: she had just gone through another failed attempt at dating. “This was horrible, absolutely horrible,” she cried. My heart sunk. I felt hopeless myself and probably as defeated as her. “What happened?” “This… jerk told me that he was turned off by my smell.” My first reaction was to console her, to hug her, to reassure… but I resisted the temptation. Not now. Not yet. “This is very hurtful. I am sorry this has happened.” Was I? Not really, as this insensitive and probably drunk stranger had done what I was unable to do. He had liberated me from this burden. Was this a therapeutic opportunity? “Do you think this might be true?” “What? That I was stinking?” “Yes, that you had not showered that day?” Jane kept silent for a while. I could see that she was divided between her childish desire to get angry and storm out of the room and the trust that we have built over the years. “I actually had not. My shower is broken… it has been for a while. I cannot get myself to call the landlord, he hates me… I cannot deal with the plumber in French…” Jane’s defenses crumbled all at once; her anger, her intellectual polish, and her sense of humour, everything disappeared, and what was left was the little girl struggling with shame. This feeling was terrifying but somehow, we stayed with it for the rest of the session. We sat with her humiliation together, and Jane had an opportunity to learn that I still liked her despite her body odour, that her shower could be repaired, and that we actually all smell. We were even able to finish with a laugh about us smelly creatures. This incident became a turning point in Jane’s therapy. The insensitive but honest feedback from a failed date turned out to be an unexpected therapy gift. We recovered slowly; after a few weeks, Jane could talk more openly about her body shame. Then, she was finally able to get jogging shoes and try to run her first mile. Eventually she started feeling better about herself and her sense of self-worth became less dependent on others. Jane seemed a little more content with her Parisian life. I felt sad the day we said goodbye. As she had left, I automatically started opening the window… before realizing that the only smell she had left behind was one of a very light, citrusy perfume.

Over the course of my 28 years as a therapist, I have told many patients that therapy is like putting puzzle pieces together. It was a metaphor that most of my patients seemed to like and accept. Like most of us these days, I have extra time due to living with the stay-at-home orders, so I recently purchased a jigsaw puzzle to help manage my anxiety and to enjoy my new-found leisure time. As soon as I began to solve the puzzle, I realized that the metaphor was much more nuanced and complex than I had considered when offering it to my patients. I will elaborate. Seeing What’s There When it was delivered, I first looked at the final product on the box cover. I immediately wanted to solve the puzzle, so eagerly opened the box to see the pieces all jumbled together. I instinctively dumped them scattershot onto the table and turned them all face up. Therapeutically, this represents the jumble of loss, confusion and pain that brings patients into therapy and the awareness that something needs to change. Although we are careful not to dump all the pieces out at once, it is important to help patients take these jumbled pieces of their lives, turn them face up and begin to sort them out. With awareness, patients can better their situations, improve their relationships and lead more satisfying lives. For example, for your patients who have found themselves in a series of unsatisfying relationships, the assemblage is asking questions like: “Is it the people out there that are the problem, or is there a common denominator?” “Do your partners possess negative traits?” “Or perhaps do you bring out those qualities in your partners?” If not clarity, then at least direction may begin to emerge at this point in treatment. Identifying the Borders Next, I had to find the pieces that made up the edges of the picture. What are your patients’ edges, and how do the contours of their lives impact them and others? Here, we can use the term coined by Heidegger (which Binswanger introduced into psychology) called Dasein: Each individual’s being-ness in the world. The three types of being-ness are umwelt (interpersonal relationships), mitwelt (engagement with the immediate environment) and eigenwelt (relationship to the self). The three types of engagement constitute all our thoughts, feelings, attitudes, mental images and more. Where your uncompleted puzzle sits is where their physical, emotional, and psychological boundaries intersect with others, consisting of their connection to the world (welt). Identify and Group the Colors I next had to identify the various colors and textures as I grouped them together. I organized the green-yellows into one section and separated the purples, reds, and blues into others. After the colors and textures had been grouped, continued refinement occurred. I next noticed pieces that composed new colors and textures that I hadn’t seen before. Lighter brown pieces constituted a tree, whereas darker brown ones were the roof of the house. In therapy, this is the process of identifying your patients’ feelings, thoughts, attitudes and overall behavior, as well as clarifying the expectations, patterns, and challenges in their relationships. In fact, discovering existing and previously unseen colors may be likened to recognizing your patients’ ways of being in their relationships. There are aspects of their personalities and ways of thinking and feeling that we can help them to identify. How do they treat their spouses within various contexts, such as when they’re stressed out or in a bad mood, and how does their partner’s behavior impact their emotions and self-image? What is the degree of honesty, rivalry and satisfaction with their friends? What is their attitude about their jobs? Conversely, what is the impact of their attitude (sense of safety, optimism, and fulfillment) and self-image (pride, shame, love, or indifference) on others? Consider the following examples of discovering new colors vis-à-vis interpretations: “I see that you became angry, but I’m wondering if you also felt hurt.” “Is that vulnerability you’re experiencing?” “You felt abandoned when your partner walked out and you followed him from room to room. Was it a response to panic?” As another example, we might help them learn that they are actually not afraid of conflict when all this time they thought they had been. That’s because conflict exists before the first word is spoken. If a patient’s spouse wants their child to have a play date, but your patient is concerned about her not feeling well and would rather she stay at home, that’s the conflict. What they are actually afraid of are the consequences of bringing up the pre-existing conflict. Do they expect (and receive) anger, the “silent treatment,” or rocking an already rocky boat? Another example of further clarification and nuance is when patients tell us they’re shy. “Is that always or in certain contexts – parties, public speaking, or on a first date?” This process can help them reduce their blanket “I am” statements and add new facets to their self-image. Find the Adjacent Issues As I continued with my puzzle, I recognized which sections were next to one another. The corollary to therapy is illustrated in the continuing example about conflict. When patients don’t bring up conflict with their partners, they “hold” the conflict 100%. In fact, their partners may not even know there’s a problem. Therefore, a risk of not acknowledging the conflict is the possible adjacent issue of harboring resentment and living with continuing victimization (which can be very powerful). “I never get what I want.” “I can’t believe how selfish she is.” There is almost always a previously unrecognized issue that lays next to one that they are aware of. The challenge is to recognize what they are and how these adjacent sections fit together. Tolerate and Accept Emotions There were times when I felt overwhelmed when doing my jigsaw puzzle: “This is too hard.” I was also hopeful — “I can do this”; frustrated — “Did they include all of the pieces?”; uncertain — “Will I finish it?”; and accomplished — “I did it!” We are, in a sense, emotional managers for our patients, helping them to self-regulate as they piece together the often difficult experiences of their lives and the underlying feelings. It is important for our patients to tolerate and ultimately accept a wide range of feelings. The goal is not to “get rid of” anxiety, for example, but to reduce its duration, intensity and frequency (the “DIF”) as they increase their emotional tolerance. Consider Process What are you and your patients thinking, feeling, and imagining as your patients figuratively put the pieces of their lives together? The how of therapy is the therapeutic process — everything from the relationship, the way therapy is experienced, what happens within the sessions and the acknowledgment that there are two points of view in the room. The process also incorporates the tribulations, joys, sorrows, frustrations, and hopefulness that we each bring into every encounter. And then there is the possibility that the final product of our therapeutic work may not resemble the image or may vary considerably from their expectation of the goals they brought into treatment. The act of working out their puzzle might have altered the final product. The Full Picture While working on my own jigsaw puzzle, I realized that the metaphor of therapy as a jigsaw puzzle is not as simple as I used to suggest to my patients or even realized myself. To help them solve their puzzles, we (and they) must look at the many aspects of their lives; to sort out the jumble into a coherent picture. As we help them through the process of laying out the pieces, finding their edges, sorting and organizing by color and content, they hopefully will learn to look for and at the bigger picture — how they developed certain patterns of behavior, coping strategies and ways of relating to others. They will come to see themselves more clearly and accept themselves more unconditionally, develop and refine facets of their identity and gain insight into who they are. In these ways, effective therapy — like solving a puzzle — is both a demanding and rewarding experience. But unlike the static and store-bought jigsaw that comes in a box, the puzzle of therapy is fluid, and the final product not always available on the box top.

When a patient reports their history, we listen for content as well as the emotions associated with their recollections. With a discerning ear, we also consider the reliability of their narrative. Even if a patient is not a good historian, it does not mean they’ve lied. There are many reasons patients don’t report an accurate history.

One reason that I find particularly interesting, which you’ve likely encountered if you’ve worked with long-term psychotherapy patients, is the shifting of narratives, stories that change over time. This is not necessarily unreliable reporting. Emotions associated with narratives change with life experience and with that so does the recollection of the events.
Memories, then, are as much a representation of the present as they are of the past. What we hear when we listen to patients’ reports of their past experiences not only gives us history but also offers a window into present emotional states.

For example, my patient Beth reports depressed mood, anxiety and feeling that her life is harder than everyone else’s. In the difficulties of her present life, she remembers a man from her past who she dated on-and-off for a couple of years. This is a good example, because I was seeing Beth in therapy while they dated, so I’ve been privy to her emotions while she experienced the relationship as well as her retrospective examination.

At the time, she had described constant frustration and upset at his lack of emotional availability. Her sessions were filled with lamentations about him and about the relationship. I had the sense that she was cornering him and being overly demanding, because I also experienced that in our therapeutic relationship. But she was unable to withstand any relational analysis at the time. It was too soon in our therapy, and she did not yet have the self-esteem and emotional resilience to tolerate that level of painful introspection.

But years after their breakup and with continued therapy, looking back, she remembered a different man, one who was kind and generous, and who wasn’t unavailable, but rather one who was focused on building his career. She longed to go back to that man – the one she didn’t date. She believed that man would reduce her life difficulties. The sessions over the last couple of years have been dripping with nostalgia for the life she didn’t lead.

If memories change, then perhaps nostalgia is a longing for the life we only see in retrospect. If so, how do we help patients let go of regrets for things they couldn’t have understood at the time they happened? How do we help them understand the role of the life they didn’t lead? And even deeper, how do the unlived lives of people close to us influence our own journey?

I’d been tossing these ideas around for a long time, especially after working with patients who presented with trauma symptoms who had not experienced any clear traumatic event but whose parents did. Listening to their narratives, I heard a similar theme: they absorbed their parents’ trauma when they were young children, mostly when it was communicated without words, when the heaviness was felt but not discussed.

I decided to write a novel exploring these psychological and philosophical questions using characters to gain insight so as not to be limited by the frame of psychological constructs. The book, called Before the Footprints Fade, explores how our memories change with life experience, how we often long for the life we can only see in retrospect, and how we sometimes want to go back to things that had remained unrealized. It also delves into how the unlived potentials of our loved ones can become part of our own struggles and journeys.

How are we influenced by the roads not taken?

In each of us and all the people we know, there are an infinite number of unlived lives; each choice opens some doors and closes others. I wanted to show how this translates intergenerationally, because sometimes patients’ distress begins with the unprocessed feelings of the previous generation.

So, for one of the characters in my book, the father’s choice to give up the saxophone and take a more reliable career path to raise the family became something he felt responsible for. His father’s unlived life becomes part of his journey. It’s greater than just the unspoken expectations from his parents, too. He then struggled in his personal life to shed what others wanted from him, so he could become who he truly was.

Another example is my patient Damon, whose parents’ implicit statements about his success led him to be an overachiever. When he began therapy, despite his tremendous ambition, he had little emotional connection to his pursuits. “It all felt empty,” he had told me.

Eventually, he was able to recognize that his relentless motivation was fueled by a need for validation and the label of “success” rather than any meaningful connection to the work itself. It became an unconscious quest to live out what was expected of him, rather than what he might have wanted had he felt the emotional freedom to choose. Complicating this was the fact that expectations were not obviously stated, making it hard to separate his unprocessed emotions from those of his parents.

Exploring the unlived lives of our patients’ parents and the implicit communications of these unlived aspirations can be very helpful when stuck with a patient, particularly when there is a lack of vitality connected to how they are living or pressure surrounding imagined expectations.

And as I learned from writing Before the Footprints Fade, “You never go back the way you came.” Once we’ve learned, once we’ve grown through life experience, the road back looks different. We are different.

We spend time with our patients exploring their past in an effort to help them better understand themselves in the present. With insight and ego strength, with psychological growth, the emotions associated with memories change. Therefore, we can also understand present emotions by listening to stories about the past.

Perhaps it’s not quite accurate to say that youth is wasted on the young. Wisdom can only come from making footprints, not from following them. We can only be where we are because of where we have been. We can only see our youth through the eyes of nostalgia. If we want to help patients live fulfilling lives, with meaningful and integrated intentions, with emotional freedom, then we must consider the influence of the roads not taken. We want to explore and understand them, realizing that though they may never have actually happened they still – like footprints – can leave a deep impression.

*Beth and Damon’s names were changed to protect their anonymity.
 

Uh oh, it’s happening again. Another session where my patient, a man in his 30’s, has taken over the session. I sensed this might be an issue from our first intake visit, which extended into a second session because of our mutual tendency to allow him to speak in long-winded answers. And here we go again – 20 minutes into our session and I’ve barely gotten a word in edgewise. I take an audible in-breath and lean forward in my chair, signaling that I’d like to speak. He responds with a small nod, but at the same time speeds up his words and raises his voice, effectively saying “no” to my bid for a turn. We’ve been through this cycle enough times that I’m feeling rather trapped – my choices seem to be either to shout him down or fall silent. On the one hand, this isn’t a good thing. He’s not going to get any help if he doesn't let me participate in the conversation. On the other hand, falling into this pattern is exactly what needs to happen. He’s come to see me for help with his relationship with his wife, who complains that he interrupts her all the time. I can almost see the thought bubble above his head shouting, “Help! Stop me!”

Healthy relationships offer opportunities for the joy of conversational “flow.” An excellent conversation can have the charge of two soccer players passing a ball back and forth down the field or the grace of a figure skating pair. The two parties read each other’s non-verbal communications, sensing when to move forward and when to shift to support their partner’s motion. In conversation, the “silent” partner is active in the role of listener, sending feedback signals in the form of nods, reactive facial expressions and all of those wonderful listening noises: “uh-huh,” “mmm,” “oh?” “I see,” “yes,” “go on.”

People can fall out of conversational cooperation by either talking too little or too much. Some people offer excessively terse “closed down” answers when discussing emotional content, obliging the listener to work hard to draw them out. Others tend to speak with excessive length or over-complexity, in ways that can be hard to follow and difficult to interrupt¹.

Traditionally, the culture of therapy has been to let patients talk. Psychoanalysts famously say almost nothing. But failing to address conversational imbalance is a huge missed opportunity. Helping patients recognize and shift a problematic default tendency is an important part of therapy – both because conversational collaboration is a key part of the working relationship, and because the therapeutic dialogue serves as an in-vivo training opportunity in collaborative behavior. What is tricky is to do this in a way that is encouraging rather than shaming².

“Allan, can I stop us for a moment?”

He looks at me somewhat surprised, for I’ve raised my voice a bit louder than usual in order to get his attention.

“Sure?” he says a bit dubiously.

“I’ve noticed something happening between us, and I was wondering if we could take a look at that together because I’m thinking it’s an opportunity for us to communicate better.”

“What do you mean?” He’s flinching as if anticipating a harsh blow.

“There have been a number of times I’ve had something I’ve wanted to offer you, but I haven’t been able to find a way to break into the conversation. I’ve noticed feeling a bit frustrated, and also sad because I don't feel as connected to you as I’d like to be. I’m wondering if you’ve noticed this, too, and if you’ve felt anxious or frustrated with how we’ve been connecting.”

I can see him physically expand, as though about to let out a flood of thoughts, but he stops himself. He speaks slowly for the first time.

“I was afraid you were going to criticize me for interrupting you, just the way my wife does. I think I’ve been worried all along that you have been silently judging me, and ironically I think that makes me talk even more so you won’t have a chance to hurt me.”

“It sounds like I was on the mark about your feeling anxious in our relationship – and that you’ve been feeling that anxiety for good reason, because you were picking up on my unspoken frustration. It’s really cool that you noticed that. It feels awkward to talk about this, but at the same time, I’m excited by the opportunity we have to shift things, so we can have a better connection.”

“But I don’t know how to stop interrupting or even to talk less. I don’t feel like you really get me, so I have to give you all the details. Like, I mean…”

I raise my hand and smile. “Is this an example where you wanted to add in more details so I’d understand?”

He nods.

“Could we try something?” I ask, “I wonder if this might be a ‘less-is-more’ situation. Would you be willing to let me guide you a bit? I’m thinking that if you give me a little more space to talk, we might actually communicate better and ironically, you might feel more understood.”

“I already feel more understood since you stopped me to talk about this.”

Together we agree on a plan for me to raise my hand when I’d like to talk so we can practice a more back and forth dialogue. He recognizes that this shift away from telling every story in completeness is going to be uncomfortable for him, but he sees what he stands to gain.
Two sessions later, things are already starting to look different – he’s still a talker, but we’ve gotten ourselves in rhythm, and we’ve gotten down to work tackling his communication difficulties with his wife.

“Wow!” he tells me at the end of a particularly good session. “We had a real back and forth going there. That was actually a lot of fun! I’m so glad you stopped me!”

References
Gratitude to Dan Brown’s work on fostering collaborative behavior (see his book Attachment Disturbances in Adults, Norton, 2016)

Gratitude to Dr. David Burns for his method “Changing the Focus” demonstrated here (see his book Feeling Good Together, Crown Publishing Group, 2008.)
 

“We scheduled his next appointment, and I took payment for the session. I turned to open the door to my office as I always do, and I said take care and that I would see him next week. As he walked past me, he turned back and said, ‘You know, tattoos are a choice, and God did not choose for you to have tattoos.’ He just kept walking. I was shocked. It was unexpected. I didn't know what to say; it happened so quickly and quite literally in passing. It was not in a hateful tone at all.”

So began a spontaneous and unsolicited conversation during my counseling internship class – I always offer students the opportunity to reflect upon their previous week’s sessions, whether seemingly innocuous or salient. In this instance, one of the interns hesitantly brought up a clearly uncomfortable moment at the end of a recent session with a teenage adherent of the Church of Latter-Day Saints. His departing remark took her quite off-guard in the moment and led her to process whether she might have better served this young man by concealing, rather than exposing her tattoos.

What seemed apparent to me was not whether she should or shouldn’t conceal her ink (her agency did not explicitly prohibit exposure of tattoos), but that this was a unique teachable moment both for her and her young client, but also for me, as her clinical supervisor.

I did not want her to roil in shame and guilt over the concern that she might have somehow hurt the therapeutic relationship and this client, leaving him avoidably confused. Had she just covered up! I wanted to create an atmosphere of both acceptance and challenge, in which she could explore the relationship between choices she made as a clinician and person and the impact of those choices, whether intended or not, upon her clients. And I knew the rest of the interns were listening for lessons they could take from the conversation, as they reflected both upon this specific situation and those with their own clients.

In those moments, I was both the supervisor, cognizant of seizing the lessons inherent in that teachable moment, but also the therapist, reflecting on similar moments I have had with my own clients at the self-doubting and shifting intersection of self-concealment and self-exposure. I, too, am visibly tattooed, at least if I roll up my sleeves, which I most invariably do when working with clients, both literally and figuratively. I wanted what I have learned on my road to becoming a therapist to be useful to these nascent clinicians. I also did not want to force them down my road, even if I could.

Over the next week, I reflected on that conversation, wondering about its impact on this particular intern and the group. In the next group supervision, she offered the following:

“Dell [a fictitious name] did come back to counseling, and he actually brought up the subject of my tattoos and his faith before I could even close my office door! He said after he left, he immediately felt bad for the way he approached the subject of my tattoos and that he thought a lot about it and was concerned I wouldn't see him anymore, as he said he enjoyed our time together and that I was incredibly helpful. He said when he left he started thinking about why people get tattoos and what they mean to them. He came to the conclusion that for some people, tattoos are as meaningful to them as his CTR ring (Choose the Right, which is a saying in the Church of Latter Day Saints). He asked if his conclusion about tattoos was true and what mine meant to me. I said that I could not speak for others with tattoos, but that mine meant very much to me.

I described them as time capsules, memories, a reflection of me; stories, and that they mean very much to me, just as his faith does him. I told him there was no need to apologize, and I appreciated his kind words. I also applauded him for taking the time to reflect and educate himself about the subject, as I will not be the only human he encounters with tattoos. I also told him that I thought a lot about what he said and that I researched a lot about the Mormon church, so I could have a better understanding of his views. We agreed that this new understanding of one another strengthened our professional relationship and that we both learned from one another and in working together.”

My supervisee impressed me with her expanded world and self-view, one that was broad enough to take in all visitors to that intimate space of therapy. She closed by saying, “I learned how tolerant I can be, when something I love and cherish is judged so quickly and harshly, and that people have the capacity to grow and open their minds to differences even when their religions may not agree.”

I was honored to be part of the learning process, initiated by my clinical curiosity and desire to guide my interns forward on their own journeys. Indelible impressions were made on all.
 

After the last COVID-19 patient has been discharged and the intensive care unit beds are empty, the world will declare the crisis over. Politicians and pundits will begin to talk about mistakes made and try to lay blame. They will finger point and bluster about why it got as bad as it did and declare it wasn’t their fault.

Store shelves will be full of products again. There won’t be a run on toilet paper or hand sanitizer or sanitizing wipes. People will have parties and weddings. They will have celebrations just because they can. Many businesses that were forced to close will reopen, many people will have jobs to go back to, and nearly everyone will breathe a sigh of relief that it is over.

Family members will gather to mourn their dead, to hold each other and cry, to process the guilt of not being with their loved ones as they died.

Doctors and nurses will start to process their own trauma. The trauma of watching patients die alone, of their decisions about who got the respirator and who didn’t, and of knowing their colleagues died from this virus due to lack of protective equipment. The trauma of holding the phone for a patient and witnessing the last goodbye before that patient is put on a respirator.

Those who survived this virus will wonder if they passed it to anyone else before they even knew they were contagious. Some will know they passed it on, and they will wonder if any of those people died.

Things will eventually get back to the way they were before this virus took over our lives in ways we never could have imagined and barely comprehended

People will enter my therapy office trying to find a way to fit this unprecedented event into their life story. There will be guilt and regret and pain and fear. And grief. So much grief. The trauma will continue for months and years to come because trauma is a time bomb with no visible timer.

The trauma of this pandemic does not end when the acute crisis is over. That is when it truly begins. That is why I am the last responder.

As I listen to the ever-increasing number of infected and dead, I know my work hasn’t even begun. I will celebrate when the intensive care unit beds are empty and when we can hug each other again.

Life will start to return to normal, but things won’t feel quite the same.

I’ll take a deep breath. And then another.

And then, I’ll get to work.
 

Clinicians are currently in the same predicament as their clients. They are struggling with similar pandemic-related challenges, and many of the go-to interventions aren’t available right now due to social distancing. Clients feel isolated and lacking in social support and, while social media offers some respite, friends and family might not be able to offer the client what they need due to their own challenges.

While this can feel a bit hopeless to clinicians, the answer lies not from without but from within: television, once thought of as the bane of social connection, gestures towards part of a potential solution. As long as clients have a television, internet access, video games, comics or books, they are just moments away from potentially meaningful attachments. Parasocial relationships are the one-way relationships people have with objects of their affection — both real public figures and fictional characters. We prefer to call these relationships Fandom Attachments, as the fans are experiencing the benefits of attachment to their celebrity/fictional heroes. These relationships can be incredibly healing. They offer the additional benefit of play — an outlet for the imagination.

There are few positives that the pandemic has provided, but one is the destigmatizing of Fandom Attachments. Culturally, these attachments are often looked down upon as being childish (in the best of times) or pathological (in the worst). However, during this time of isolation, the usual narratives surrounding fandom’s lack of importance, simply don’t hold. Where else can someone go? Who else can they see? The pandemic has given people permission to play in this realm.

But it isn’t sufficient simply to advise a client to go watch television. The awareness of Fandom Attachments might be new to clients and they need support from their psychotherapist on how to interact with this new form of attachment and play. First, the clinician will want to ask clients if there are any fictional characters or (non-fictional) public figures with whom they feel connected. Clinicians should prepare themselves for a broad range of answers. Beyond mortal and superheroic/supernatural figures, some attachments might include YouTube makeup artists, Twitch streamers, reality TV stars, actors, and fictional characters from any media.

Once the client has identified a Fandom Attachment, this is an opportunity for the use of Therapeutic Fanfiction skills. The clinician has the opportunity to become curious about the reasons for the attachment––just like in any relationship. What draws the client to that person/character? What is the feeling they get when they are “together?” How can/does that person/character support them during this time? And, just as the clinician always does, listen without assigning any judgement to what the client discloses. The client is sharing an important relationship and source of meaning. Depending on the answers to these questions, a treatment plan begins to form.

Let’s explore the case of Audrey (name and details changed). Audrey presented for therapy six months ago due to profound anxiety. She was making excellent progress in reducing her anxiety through interacting with friends and taking regular yoga classes. Unfortunately, due to the pandemic, she couldn’t work, and her yoga classes weren’t meeting. She lives with roommates who caused her some distress, but this distress had become intense, as she felt she couldn’t get away from them due to the pandemic. But she felt trapped when she stayed in her room to get away from them.

After some inquiry, I (Justine) discovered that Audrey felt an attachment towards the television series Twin Peaks, and particularly the character of Agent Dale Cooper. Audrey found “Coop” to be comforting and full of sage wisdom, like “Every day, once a day, give yourself a present. Don't plan it. Don't wait for it. Just let it happen.” I wondered aloud if Audrey could give herself the present of time with Coop away from her roommates. This sparked joy for Audrey, who responded that she would love to spend time with him, and that maybe she could have Coop’s favorite meal — coffee and cherry pie — while she watched. I affirmed this and said that we would check in on her “date” with Coop at the next session.

Social distancing and the ensuing quarantine challenges us all in numerous ways. As clinicians, if we can think beyond our scope and get creative with our clients, we can help them use the power of play and Fandom Attachments to foster resilience and weather the storm. There are so many unknowns during this time, but, taking Dale Cooper’s lead again, what we can offer our clients is this: “I have no idea where this will lead us, but I have a definite feeling it will be a place both wonderful and strange.” 

A woman dreams of a knock on the front door and she opens it to find no one there. But something compels her to look down, and there is her son, lying dead. A man dreams of a dragon who is so large and so angry, he has the sense that it will overwhelm not only him, but the entire world. Its shadow passes over him but then grows so large it seems to obliterate the sun… I dream of a woman who jumped up onto a high platform, gracefully and lightly, yet with her balance tipped slightly back. And I watch in horror as she begins to fall gracefully to what I am sure will be her death.

In times of crisis like these, it is very common to have more intense and frequent dreams, and for the dreams to represent our deepest fears about the crisis. So, it comes as no surprise that many people, my clients included, are reporting more frequent dreams of death and of large, inexorable forces, so much bigger than they are.

One of the beautiful counterforces to all of this dread is the wonderful way people are coming together to offer mutual support. For example, on the Jung Platform, an online classroom disseminating practical ways to apply Jung’s ideas, Robert Bosnak is offering a free Friday-night Spooky Dreams Café as a gathering place for those who want to share their disturbing dreams. For an hour, Bosnak has been doing speed-dreamwork with participants and plans to do so for the duration of the crisis.

I offered my dream of the falling woman to the group. She is a friend of mine whose immune system is compromised, so in this dream there is some of my palpable concern for her as she is someone who would likely not survive a coronavirus infection. The dream also put me in direct contact with the feeling of watching a tragedy from a distance, seeing clearly what is about to happen, but without any way to intervene.

Bosnak asked me to embody first the supple and lithe way that my friend leapt onto the platform. And then I was guided to feel into the immense gravity of the fall, sucking my upper body backwards into my chair. I felt paralyzed. As I held both places simultaneously, I felt pulled apart. But in between, in my chest and belly, I felt an opening, and some heat. This is my practice, Bosnak said, to feel that heat.

In my own dreamwork practice, I work in a similar embodied-experiential way, but the steps I offer come from focusing, a practice philosopher/psychologist Eugene Gendlin developed as a way to gently inquire into our own felt sense of any situation. I have applied this method to trauma work and nightmares and have found these steps offer surprising ways to help my clients manage overwhelm and safely metabolize frightening feelings and dream images.

One of the ways to work with dreams in a focusing way is to embody the helpful images in the dream as a resource, in much the same way we help our trauma clients become resourced before going into any deeper work with their trauma. For example, with the man who dreamt of the dragon, I asked him to imagine he was the dragon, and from that vantage point, he was filled up with immense power and agency. And, as I often do with nightmares, I asked the dreamer to continue the dream from where it left off, as if he pressed the ‘play’ button on the final dream image. Typically, nightmares wake us up at their most frightening place. In this imagined dream ending, the dragon began to fly higher and higher until its shadow was a mere speck on the surface of the earth.

Imaginal ways to manage overwhelm

The overwhelming sense of powerlessness is a common dream theme right now because it is how so many of us are feeling. One thing that we often do in focusing, whether with day-world feelings or looming dream images, is to find a way to make them smaller, more manageable. We might find the right distance from our dream dragons (i.e. much further away) or shrink them down to the size of a mouse in our mind’s eye. What we are feeling in response to the coronavirus is a sampling of the collective dread, and this is more than one person can ever manage. Another way to work with such images is to ask clients to sense how much of what they are feeling belongs to them alone. It is usually a much smaller piece.

One more way of titrating the enormity of a crisis is to limit it in time — to just this present moment and the next one. For example, when I sensed into the immediate feeling I had about the helpless sadness in my falling-woman dream, seeking the right next step, it was clear what I needed to do. I called my friend and was reassured that she is fine and being extremely careful not to expose herself to any risk. I have also felt moved to use my particular skill set to help reduce some of the collective dread. I wrote an article for first responders (and anyone else suffering from nightmares) with some suggestions about what to do. I have opened a number of dream sharing groups and remote therapy sessions for front-line workers. I am using the ways I know best to help reduce collective anxiety one person and one dream at a time. The fire in my belly, borne of helplessness and fear, is being put to good use. And the man who dreamt of the dragon said his dream has changed, and now the dragon is a sentry, watching for early warning signs.
 

 In the 90’s, Scott Miller and Barry Duncan developed the Client-Directed, Outcome-Informed approach to psychotherapy (CDOI). More recently, Miller along with other clinicians and researchers, developed Feedback-Informed Treatment (FIT), while Duncan developed the Partners for Change Outcome Management System (PCOMS). These innovations in the field center on the idea of understanding and honoring the client’s voice; to understand how they are experiencing the therapeutic process and relationship and to give them agency over the course of treatment. This body of research demonstrates that client feedback increases retention rates and improves therapeutic outcomes. The implication of this new research, for those of us who want to provide best practice to our clients, is to leave the beaten path of rigid model adherence to be client-directed and feedback-informed. Understandably, this may not be as easy as it sounds.

For some clinicians, leaving the useful guardrails of model adherence may feel like following a rabbit trail. After all, we are practitioners of evidence-based models, models shown to be effective in producing positive outcomes for clients. Many of us were taught in graduate school that best practice is synonymous with model adherence. It is the model and how well it is delivered by a clinician that heals people, right? Hubble, Duncan, and Miller discussed the eye-opening common factors of their research in their book Heart and Soul of Change. They showed that the psychotherapy model only has a minimal impact on client change, as opposed to the therapeutic alliance and extra-therapeutic factors, which have the biggest impact. By way of implication, we must consider that clinging too tightly to a model may not ultimately serve the client. That putting all our eggs in the model basket may not constitute best practice. That we need to follow a client when they stray from the path — to follow a rabbit trail — in order to discover the true nature of their issue. And that we need to embrace rather than shy away from the paradigmatic tensions between rabbit trailing and model adherence. How can a therapist hold the reins of these two stallions running in opposite directions and not be torn asunder?

Advantages

What are the advantages of rabbit trailing? A client may need to rabbit trail so as to feel in control of the therapeutic process. We want our clients thinking, “This is MY therapy.” We certainly do not want clients thinking, “This is HER therapy.” Treatment is enhanced when clients feel a sense of ownership over the therapeutic process.

It has been my experience that a segment of clients seeking therapy do not know the nature of the problem that is holding them back. Therefore, a journey of rabbit trailing and discovery is necessary in order to identify the true nature of their problem. Additionally, clients’ initial presenting problem may indeed be a genuine problem, but not the true or core problem. Again, rabbit trailing may be necessary to explore the depths and discover what is holding them back.
Rabbit trailing also feels very organic. Think for a moment how odd our profession is. We sit in a room waiting for people to come and tell us their problems for a concentrated period of time. The relational dynamics active in counseling are unlike anything our clients experience in their daily lives. So, if the counseling process could feel more natural and organic, and less artificial and cold, all the better. The relationship between client and therapist can develop; you and the client are in the dark, together, searching for the answer that is right for the client. Rather than a regimented process where you are doing something to the client, rabbit trailing is an exploration, collaboratively done by client and clinician.

Rabbit trailing allows for issues of the “here and now” to be addressed. If strictly following model protocol, a client’s true issue may not be addressed till session 5, or 6, or 7. Clients may not have that kind of time. Or, rather, they may not stick around for you to get there. And, to be honest, a single model may not be enough. Rabbit trailing allows for other models to be integrated into the course of the treatment as it seems useful and appropriate for what the client needs in the moment.

Cons

What are the disadvantages of rabbit trailing? Some clients may need the regimented approach and may not do well with rabbit trailing. We’ve probably all had those clients who show up for session and look at us, waiting for us to “do” therapy. And hey, I get it. Between patient and physician, that’s kind of how it works. The patient shows up, and the physician does something to them to make them better. There’s a logic to the approach that’s carried over from the healthcare system, and I’ve done it too. So, if that’s what the client wants and needs, then let’s give it to them and walk them through the model.

Rabbit trailing could certainly devolve into weekly check-ins, versus working on something substantive. There is a place for a systematic, step-by-step approach, otherwise, therapy could deteriorate into putting out fires and never truly working on the issue causing the fires. In other words, rabbit trailing could fall prey to chatting and socializing rather than doing serious clinical work.

Rabbit trailing may lack consistency and accountability. For example, with the model adherence approach, there is assessment, intervention, homework and exercises, and then follow up. If a client didn’t do their homework, rather than getting distracted or moving on to a new topic, the reasons why they didn’t do the homework need to be addressed. Addressing those reasons could enhance treatment and client outcomes. With rabbit trailing, you may be ping-ponging issue to issue, week to week, and not keeping clients accountable.

Sam

A father brought his 15-year-old son, I’ll call him Sam, regarding concerns of depression and anxiety due to his divorce with his wife. Sam, he didn’t have much to say about his parent’s divorce. He felt like it happened a long time ago and it didn’t really bother him. He felt like no one believed him and he didn’t have much else to say. Sam seemed uncomfortable and was slow to open up. As sessions progressed, I felt the urgency to connect with Sam and make it comfortable for him to share. I remembered Sam mentioning he wanted to buy and fix up a car. I asked him if he had bought a car yet, and he said he had and was planning on fixing it up, but it would cost a lot of money to do so. He went on to say he felt conflicted; he wanted to get a job to earn money for the car, but that would mean he couldn’t play sports, which he felt okay about because, even though he loved sports, playing in front of other people overwhelmed him with performance anxiety. We weighed the pros and cons of both options and concluded that Sam really wanted to play sports but was paralyzed by performance anxiety. I mentioned to Sam that I had a number of ideas and strategies that could help with his anxiety, at which he became very excited. From that point on, Sam was open and engaged in therapy. Following Sam’s rabbit trail led to the discovery of his performance anxiety and his hidden motivation to resolve it. I was then able to utilize CBT and standard methods to effectively treat his anxiety.

Holding the Reins

Hopefully, weighing the pros and cons of rabbit trailing has answered the question, is it possible to hold the reins of BOTH model adherence and a client-directed/feedback-informed approach? I believe an awareness of the upsides and downsides of both model adherence and a client-directed/feedback-informed approach will allow us to synthesize the best of both worlds. We can operate from a model, loosely, and allow for clients to stray from the beaten path when they need, bearing in mind clients’ need for accountability.
 

A few years back, I remember being deeply impacted by Richard Louv’s “Last Child in the Woods: Saving Our Children from Nature Deficit Disorder.” In it, he lamented the disconnection between children and nature, reflected on the impact of that disconnection on not only children but adults, and offered corrective suggestions. His book resonated with me, as I have, since as far back as I can remember, found comfort, grounding and meaning in the natural world. From early childhood, I seemed to understand the importance, power, beauty and violence of nature – both physically and metaphorically.

This understanding often informed my teaching and clinical practice, whether it was explaining reproduction to students by observing it in the lush woods surrounding my university, or discussing life, death and the cycle of being by accompanying clients on nature walks. Invariably there were lessons abounding in the trees, the sky, the animals we might accidentally encounter along the way, and in the rich and symbolic discussions we had around issues related to birth, death, divorce and aging. Metaphors accompanied us on those walks, and with them opportunities for painful and pleasurable but always poignant insights.

These experiences came rushing back to me recently when, on a hike through the woods along the Blue Ridge Parkway in North Carolina, I once again pondered deeply about the natural world, and my place in it. I couldn’t help but notice that although the trees and shrubs were gray-brown reminders of yet another brutal mountain winter, all were at the same time in bud, with the local birds busily building their nests and feeding their young. Several days before that walk and upon our arrival, it was 78 degrees, and the local teens were cliff jumping into the frigid river below — in bathing suits. Two days later, there were 4 inches of snow on the ground. It is now back up to a welcoming 60 degrees. The schism and dynamism is dramatic and inescapable. The promise of life and rejuvenation is everywhere. As Jeff Goldblum’s character in Jurassic Park said, “Life will not be contained.”

In these moments of existential absorption and awe, I am not quite able to free myself of the very reason for my mountain hermitage. It was to seek higher ground, quite literally, from the densely populated and sweltering heat of South Florida. Surely, the virus would not find us here.

While my body, as far as I know, has not been impacted by the COVID invader, my mind is not free of it. I am well aware of the suffering this pandemic has wrought, and that countless others do not have the luxury or the privilege to escape to higher ground — of any sort. But there it was, my perfect metaphor! Life abounding in the very same world racked by so much suffering and death.

Is it hope that springs eternal or that eternity is to be found in Spring, a time of nature’s rebirth? How perversely ironic that, in the Western hemisphere at least, this scourge coincides with nature’s reawakening.

I don’t delude myself into believing that thoughts such as these can heal, but in those moments in the woods, I felt hopeful and wondered if there could be a therapeutic value in connecting others to nature during this most difficult time. We have all been advised to stay home and safe, going out only for essentials and, when and where possible, exercise. What if, just what if on those walks we are being asked to take, wherever they may be, we look for it! Look for signs of Spring. A weed pushing up through cracks in the cement, buds on a plant thought long asleep or even dead, the dance of clouds in a blue sky, the breath of warm air in an otherwise cool breeze, the warmth of the sun, the cleansing rain.

My rose colored glasses have long ago been trampled by the passage of years, and I am no longer in the prime of life, but I do look ahead and I do look to Spring and I do think about tomorrow and hope that this musing is useful for you in some small way, whether for yourself or for your clients who are struggling to balance meaninglessness with meaning, death with life and despair with hope.

Spring, and with it, hope, is there. Look for it! Nature will not be contained, nor will human nature.