Category: Blog

I walked into the grocery store Sunday morning after a relaxing run. As soon as I came in the doors, I saw the headline of the newspaper in bold letters reporting that New York was in a state of emergency. Anxiety coursed through me. Earlier that same morning, I’d had a phone session with a patient who was becoming increasingly anxious due to news of the spread of COVID-19. She was starting to feel like she couldn’t leave the house.

New York City has been empty, comparably speaking. In a somewhat eerily quiet Midtown — where the crowd can make brisk walking a challenge — on Tuesday afternoon, I couldn’t help but be reminded of the days following 9/11, where in place of the vitality and determination that usually fills the streets of Manhattan, there was tense anticipation, like a cloud hanging over the city, just waiting for rain to pour down. And in both cases, no one had an umbrella to protect them, not even psychotherapists.

We are the ones who are to be containing anxieties, speaking to people about their fears, the trauma, not feeling protected. We’re supposed to comfort and soothe and help people use whatever resources they have to cope.

I have worked with trauma patients ranging from rape to incest to emotional abuse to people suffering after 9/11. I’ve worked in the prison system with perpetrators who were also victims. I’ve listened to stories that were utterly terrifying, heartbreaking, even some so bad they seemed unbelievable. Most of us know these stories and most of us know how to listen and allow difficult emotions into the room. We know how to contain them, which helps patients feel comforted.

A supervisee many years ago, working with her first incest survivor, asked me how she could empathize with something that was so foreign to her. I suspected that the content made her uncomfortable. Stories of incest can be very painful to hear and it’s natural that we have feelings about them whether we know the experience personally or not. Empathy, we had discussed, comes not necessarily from identifying with circumstances, but more so from relating, understanding and being with the patient in the difficult emotions associated with the traumatic experience.

We’ve all left sessions and been deeply affected by patients’ stories, their emotions, their experiences. But most of the time, we can separate their distress from our own personal lives.

But how do we as clinicians do this when we are immersed in the same traumatic environment?

Trauma is anything that fractures our sense of safety. What if our sense of safety is also compromised? When we are also inundated with information that traumatizes us, how do we help others?

It is important to be informed and updated, but the way the information about COVID-19 is being presented on some media outlets, and the amount of it, is creating an environment of hysteria, one we need to be able to step out of in order to provide effective care.
People are more likely to be pinned to the news when they feel unsafe, because it gives the illusion of control over an unsafe environment. But at the same time, the flood of news causes more trauma; so, the reaction to feeling traumatized is to look for comfort by reading information that’s being presented in a way that is more traumatizing. It’s so insidious, most people don’t even realize what’s happening to them or that there are things they can do to minimize the emotional impact.

In this way, it is a type of micro-trauma — small, subtle, consistent tears that break down our psychological resilience and resources, causing depression and anxiety, as well as psychosomatic symptoms.

So, what do we do to help?

The hard truth is that we were never safe to begin with. Our environment is always precarious. Of course, worldwide devastating events make us more aware of this, but it’s always there to some degree: anything can happen and everything can change — in an instant. I think as clinicians most of us know this. Most of us have found ways to accept this reality and to cope with it. Under normal everyday circumstances, the use of some denial is adaptive.

I find myself returning to this truth as I try my best not to be caught in the frantic energy naturally evoked when a state of emergency or pandemic is being announced everywhere and news that’s meant to inform the public is terrifying people. The headlines that capture attention, like NEW YORK IS IN A STATE OF EMERGENCY, are traumatizing people.

Reputable sources post their information more quietly. If you go to the CDC website, the information is written in calm, clear language, and is not meant to alarm people or cause hysteria. It’s meant to inform.

What we can do is to help people see where they do have control. The CDC advises us to practice good hygiene, to wash our hands, cover our mouths when we sneeze or cough with a tissue, practice social distance, be vigilant. These are things we can do. These are ways that we DO have control. Worrying is not going to change anything. But we can change our behavior in a way that is helpful.

When there is a global trauma such as this, our powerlessness over circumstances is highlighted to such a degree that healthy denial breaks down. We must help our patients focus more on areas they can control. Show them that they do have power over some things. There are things they can do. We must contain and redirect.

Additionally, we will be more equipped, emotionally, to handle whatever is presented by our patients if we decrease the amount of time we spend consumed by information that’s just making us feel more helpless. Being aware that too much news is a maladaptive attempt to cope with an unsafe environment is part of our role as mental health professionals. We so often talk about self-care being important. In this case, not drowning in news is part of this practice. We can’t change what’s happening, but we can adjust how we respond so that we can help others do the same.
 

As a therapist in private practice, along with having five years’ experience as a bereavement coordinator in hospice, I can attest to the complexities around end-of-life caregiving, both for the family and the professional.

Whether the loved one is at home or in a skilled setting, the burden of care can be overwhelming. Regular folks are suddenly confronted with medical decision-making, legal considerations, financial questions, not to mention the actual day-to-day interaction with the loved one who is dying. To add to that, the caregiver will likely have a job, family and other obligations.

When they are overwhelmed by the physical and emotional toll of their responsibilities, caregivers often show signs of anticipatory grief: anger at the exhaustion, frustration at the never-ending demands, shame for wishing it were all over already, helplessness at not being sure what they should be doing and sadness at the way time is running out.

How do we begin to work with these clients?

Making Sense, Making Ritual

As an existentialist, my focus is around making sense of that which is unknowable. I find one of the most effective ways to help caregivers to find meaning during this time is to uncover significant joys, rituals and mementos. I have found that singing the songs of youth, making meals that bring back memories, or even sitting together watching birds to be ways caregivers with whom I have worked are able to connect with their loved one at the end of life, and that can help them move towards a place of acceptance after the death.

During the last weeks of my dad’s life, we read through a well-loved book of bad and bawdy jokes from the vaudeville years. Even when he could no longer understand the meaning, he would laugh at the inflections of his daughters’ voices, his muscle memory recalling something deeper. Years later, I keep that book.

Once death has taken place, the transitional period during which the loved one shifts from physical to spiritual presence is an important phase of healing¹. Rituals have been used effectively for years in religious and cultural ceremonies and by therapists who understand that creating unique ways to honor the departed aids the grieving process. So, recognizing the unique characteristics of the individual while they are living and highlighting these attributes and delights can help to make this transition easier for the caregiver following the loved one’s death.

For intuitive clinicians, this is a fantastic opportunity to think outside the box with the client. Tattoos, animal totems, reimagined articles of clothing, and connection through natural elements are frequently utilized by clients with whom I have worked, but it doesn’t need to stop there.

One client struggled with letting her father go until we created a ritual around visiting their favorite golf course, where she buried some of his golf balls. Unorthodox to be sure, but it helped her immensely.

Dealing with Dementia

The cruelty of dementia has no bounds; robbing the family of a loved one inch by inch before the body has time to react. It is a harsh twist of nature, and it can be very helpful to recommend a support group for those struggling to come to terms with this very personal and unjust theft.

When counseling a caregiver whose loved one’s deterioration is both painful and frustrating, I have found it important to help them to acknowledge that they are no longer dealing with the lucid and logical person they once knew. This is often the hardest part for these caregivers: accepting that logic is no longer accessible, nor is the person that they love and who loved them. The caregiver cannot make them remember, change their newfound (mis)beliefs, help them reason or provide assurances that relieve their anxiety.

The caregiver’s role becomes one of simplifying, calming, redirecting and comforting. Many elderly with dementia understand in the beginning what is being lost, and the frustration and fear is obvious. The caregiver can be reminded to acknowledge the pain, recognize the magnitude of their loss and just be present.

Some form of suspicion or, at the extreme, paranoia, is frequent: Why did you take my car keys? Who's paying for this apartment? Why can't I have my checkbook? That isn't my signature on that document! Where am I? Where is my husband – what have you done with him? As heart-breaking as this can be, the caregiver needs to intentionally practice patience and calm in the face of the storm.

I have suggested to these clients that they join in the world that is real for their loved one; since they simply cannot tell reality from fanciful thinking, dreams or stories they've been told, asking them to recall what the loved one cannot recall often causes great embarrassment and frustration.

It may be helpful for caregivers and their loved ones to remember some tips for better communication:

• Memory may be better at certain times of the day; later in the afternoon, confusion may increase, a phase called "sundowning"
• Talk about broad topics, not specifics
• Phrase questions in a way that they don't feel anxious if they don't know the answer
• Don't correct or contradict their memories, even when they are wrong; just join them in their world
• Engage with touch, sight and body language
• The loved one may not be able to follow stories or movie plots; consider reading simple, shorter stories

 This kind of psychoeducation is important for those who are going through this lonely journey. As therapists, we must be able to validate and normalize with the client. Competency in serving clients – both family members or professionals – means knowing about the dying process and being able to walk alongside them during this transition. Being aware of the types of dementia and their different impacts on individuals can help bring understanding to bewildered caregivers.

While one elder was in the latter stages of Alzheimer’s she would continually try to “elope” (leave the secured facility without permission). Her daughter, in an effort to find humor in an otherwise dreadful situation, took to lovingly referring to her as “Houdini.”

Boundaries and Self-Care

Caregivers who are anticipating the demise of their loved one experience the full range of emotions, from sadness to guilt to rage. In my work with caregivers and their dying, I have found that no matter the dynamics of the relationship, guilt and self-recrimination are real. Most of these clients I serve replay the “If only I had…” mantra after the death; this has been the norm for me. The idea of having to balance self-care with the real needs of the dying is hard and there is no absolute.

In the course of my own clinical experience with these clients, the need to deal with caregiver burn-out is often great and it becomes critical to remind them that we cannot pour from an empty bucket – if they have nothing left to give, they cannot truly help. Recharging the batteries enables others outside of the immediate sphere of loss to relieve the caregiver or provide assistance. As counter-intuitive as this seems, asking for specific requests can provide a way for those in the life of the caregiver to be and feel useful rather than burdened and helpless. Suggesting the client make a list of chores or needed help can stave off burnout and help the client to maintain some sort of emotional and physical balance. Counselors should encourage reaching out whenever possible to support services such as neighbors, family, friends, religious or civic groups.

When my young cousin was dying of cancer, her parents and husband were with her every day. As the illness had impacted her speech, she was difficult to understand, so visiting could be anxiety-producing. Her lasting gift to her friends, however, was asking for certain foods – bringing her a smoothie, mashed potatoes, ice cream – made us all feel that we had contributed to her comfort.

Final Thoughts

Hospice work became a passion for me when I sat with my cousin in her final hours; I came to understand that there was a great honor and privilege in companioning the dying and their family members at the end of life. As I learned through that work and my own family’s losses, the medical community provides much care to the dying, but not so much support for the caregivers. I was inspired to write Take My Hand: The Caregiver’s Journey, after following blog posts by a friend caregiving for her mother. Her experiences underscored that caregiving can be the loneliest job and reaching out provides comfort.

The gifts I have gleaned from this soulful work have been a true blessing of sharing in moments of insight, joy and incredible grief. To hear the stories of youth and the weariness of decline has enabled me to experience the full scope of life.

References:
Wolfelt, A. (2015). The paradoxes of mourning: Healing your grief with three forgotten truths. Ft. Collins, CO: Companion Press.   

“Acceptance is such an irritating word! What the hell? One is supposed to ‘be okay’ with all the crap that happens?”

I am sitting with my patient who pounds his fist with frustration on his thigh. He works long hours, has a terrible commute, is a single parent, and to top it off, his autoimmune disorder is flaring up and his joints ache. He’s in the middle of a ferocious divorce. In the evenings he is exhausted. The sink is piled high with dishes. Instead of cooking, he orders takeout, which he and his kids eat in front of the TV. He feels terrible. He consoles himself with Instagram and ice cream. Too much ice cream. He’s gaining weight. He wants my help in changing this habit.

“I should be able to get the dishes done. I should be able to cook a meal for my kids! And I shouldn’t be eating like this!” He drops his head. “I can tell myself that I need to change my habits, but it won’t happen. I won’t do it.” He puts his hands over his face. “It shouldn’t be this hard.”

Acceptance means to be okay, even when things are really crappy. Not just to be okay, but to be okay with the crappiness. To lay aside that powerful word “should” and stop demanding ourselves, or the universe, to be different than we are. My patient and I both know in our heads that something positive lies in this direction, and we are both feeling rather mutinous about it. My resistance to acceptance has been that it implies approval, like getting accepted into college. It feels almost offensive to be asked to send a thick welcome envelope to some craptastic aspect of life.

But what if we ease into it? Might that not be a little easier? One dimension of acceptance is to see things clearly, accurately, as they are. We could make that a first step, and call it “acknowledgement.”

A dear mentor, George Haas, founder of Mettagroup in LA, turned me onto one of those wonderful Buddhist lists. This one breaks suffering into three categories:

Type 1: We grow old, get sick and die. The same is true for everyone we care about.
Type 2: We don’t get what we want, we have to put up with what we don’t want, and when we get what we want, it doesn’t last.
Type 3: The subtle, constant, ongoing irritation that nothing is exactly the way you want.

My patient is experiencing a solid dose of all three types of suffering. Oddly, when I share this with him, we both start to laugh.

“Right. I’ve got a chronic illness and I’m tired and in pain when I come home. I have a demanding job with a hard commute. I’m in the middle of a hellish divorce. And I always get to the end of the bowl of ice cream.”

He relaxes and starts to cry. After a bit, he wipes his tears.

“And I really, really like ice cream. I guess it’s kind of silly to say this shouldn’t be hard.”

Maybe we are ready for step 2: “appreciation.” Appreciation is defined as “full understanding, recognition of worth.” Nothing is perfectly good. Is it not also true that nothing is perfectly bad? Can he gain a more balanced awareness of his experience?

He starts to give it a try, and immediately wrinkles his nose. “Eww.”

I nod. “Mmm, yeah. Not quite there yet, huh?”

“No. My life looks pretty dingy compared to the glow of the better life I could be having.”

We just sit and breath together for a few moments. He leans forward.

“But I know that life is imaginary. And for all of its glory, that perfect life casts harsh and inescapable shadows. And compared to many people in the world, I have it pretty good.” He closes his eyes gently this time, reflecting on his life as it is.

“I’m tired, and this is hard. The reports at work that no one reads. The grim faces on BART [Bay Area Rapid Transit]. My aching elbow and the way my skin feels rashy.” He takes another breath. “I got a seat on BART today.” Another pause. “I listened to a podcast about megalodon sharks. My middle daughter will get a kick out of that. I really, really love my kids. If I didn’t feel tired, I’d probably be trying to get them to do something ‘educational’ instead of just hanging out with them. We are having fun watching Star Trek together.”

He looks up at me, and smiles.

“Maybe I’ll improve my habits. I hear dark chocolate is pretty tasty. And I could get a plastic bin for the sink so at least the crap on the dishes can soak while I’m not doing them. I can be okay with that.”
 

On January 11, China announced its first death from the Coronavirus. On January 13, the WHO reported a case in Thailand, the first outside of China, and Japan's health ministry reported a confirmed case. The WHO said later on January 23 that the outbreak did not yet constitute a public emergency of international concern and there was no evidence of the virus spreading outside of China.

I was concerned enough to bring face masks and antiseptic wipes in case people were coughing on the plane, but on January 24, my husband and I boarded a plane to Sydney, Australia. A couple of people were wearing masks on the flight, but not many. I didn’t put on a surgical mask, but I wiped my food tray and arm rests with the antiseptic wipes. While we were in Australia and New Zealand, we kept hearing that the virus was spreading.

When we returned from Sydney on February 26, the Japan Airlines lounge was not serving food; the staff in the lounge walked around spraying disinfectant; and the flight attendants all wore face masks. More than half the people on the flight were wearing masks as well. My anxiety about the virus increased exponentially.

On my first day back to my office, my first patient, Rosalind, asked me about my vacation and then turned to her anxiety about the Coronavirus. She said she had ordered a carton of Lysol and Clorox wipes; she took her shoes off and washed her hands upon entering her house. Her son had a doctor’s appointment at a hospital and she wasn’t sure if she should cancel it. She asked if I was scared because I’d just been on a plane returning from vacation. Since she has an anxiety disorder, I thought it was important to help her separate out her internal reality from the external reality, but it was not easy.

“I understand why you are concerned. There is a danger of the Coronavirus spreading and it makes sense to wash your hands frequently and use Clorox wipes. But I think it’s important to try to separate the reality of the virus and your internal anxiety.”

“Yes, that’s exactly what I need to do.”

“While it’s important,” I continued, “to wash your hands and use antiseptic wipes and try to avoid crowds, it is also true that most people who get the Coronavirus don’t die from it. Elderly people with underlying medical issues are the most vulnerable.”

“Yes, people with respiratory problems. Yes, I’m not elderly and in perfect health. Yes, that helps.” She took a deep breath.

After that session, I felt conflicted. On the one hand, I didn’t want to frighten my patients or subject them to my anxiety. But, on the other hand, I needed to protect myself as well as my patients. I walked around the office with a can of Lysol and sprayed all the door handles. But I needed to model a way of coping with a frightening reality that neither denied it nor exaggerated it. I decided to put Clorox wipes in the waiting room with a note saying: “Please wash your hands or use one of these before coming into the office.”

When Rosalind returned the next day, she remarked on the Clorox wipes and said it made her feel safer. She thanked me for doing it. I felt good about it; I felt I’d found the right balance between keeping the office safe and without unduly frightening my patients.

But then Florence came to her first appointment. She told me that while I was on vacation she had found out she had cancer! I was stunned. But she seemed calm about it so I strained to keep calm. She told me the story about what had led up to the diagnosis and then turned to another subject.

“I visited my mother in her nursing home over the weekend and it was fine. Everything seemed normal. My son Ronnie went on Sunday and spent 45 minutes there. It’s a good thing we went because on Monday morning, they started a ‘no visitors’ policy.” She laughed.

I felt a rush of anxiety. She visited a nursing home? I was frightened for her because she is in a compromised state, and also because she could now be spreading the virus!

I didn’t question her decision to visit her mother, and I didn’t point out that she put herself in a vulnerable position. But I felt anxiety running through me — for her, her son, and for me. As soon as she left, I walked around the office spraying Lysol on all the door handles.

So what is my conclusion? I do not have any answers, because dealing with the Coronavirus is a work in progress. We have to feel our way. I think I have to keep walking the fine line between keeping my office safe for my patients and myself and not letting my anxiety get the best of me. But as it spreads, patients may not want to use public transportation or they may get quarantined. I will offer phone sessions if either of those things happen. At times like these, it’s good to talk to our colleagues and commiserate about how to handle this crisis and others like it that we may encounter. 

Ghost (verb) – Definition: to end a personal relationship with someone suddenly by stopping all communication with them. What’s your first reaction to ghosting? Would it be to judge unfavorably the person who ghosts as disrespectful, unable to face and deal directly with conflicts, or, at the very least, impolite and ill-mannered? This judgement may very well be deserved. For example, in online dating or after an in-person date with someone they initially met online, a person may choose to ghost rather than deal with the discomfort of having to say they are not interested in continuing the relationship. The person “ghosted” is left without even comprehending (at least for a while) what has actually occurred. More questions than answers remain, and it is difficult for the “ghostee” to not take it personally. There are, however, situations in which “ghosting” is done as a means to protect oneself from pain, or for reasons of safety – and I say this with some authority having lived these experiences. In groups or organizations, when leaders act without awareness, or are unable to acknowledge their painful colonial history, they often repeat marginalizing certain groups of people. Those who identify with the marginalized may then disengage or “ghost” the group, knowing that the group will be unable to acknowledge or meaningfully process their deep collective hurt and pain. In situations of extreme domestic abuse or violence, it may be in the person’s best interest and safety to ghost the abuser or manipulator, in order to escape from the danger and for self-protection. Might the notion of ghosting apply in therapy? As therapists, we must keep in mind and entertain all possible reasons when a client ghosts us and doesn’t return to therapy. Although it is not very common to have clients ghost their therapist, I have had clients who have let me know by email that they will not be continuing therapy–a milder, kinder version of ghosting, but a breakup nevertheless. To my chagrin, at times clients have refused to take up my offer of a termination session, even when offered without charge. As in all breakups, the one broken up with, (in this case, me, the therapist) is left asking the question: “Was it me or was it them?” I have often thought about and at times agonized over what I could have done to prevent this sudden rupture in the therapeutic relationship that now seemingly has no chance of repair. Clients with abusive, traumatic histories place enormous trust in us as therapists when they venture to explore their painful pasts in our presence. Money is an often emotion-laden topic that is fraught with different associations and meanings to different clients. One client negotiated a low fee with me due to her many ongoing medical issues and treatments. During the course of therapy, I learned that this client was a millionaire who had inherited a great amount of wealth. We processed her experiences of scarcity and shame of having grown up in poverty. After many months of therapy, I brought up the issue of her current low fee and raised the fee by $20. Clearly, I had not processed adequately how that landed with her, as she ghosted me after that session and did not return to therapy. She also did not return my phone calls or emails, where I acknowledged my mistake and requested an opportunity to repair the pain caused to her. As a therapist, I take full accountability for what transpired between us, and I hope this client is able to process and work through her issues around money with someone else who holds her conflicts and predicaments with abundant compassion. Only in one case of ghosting have I felt truly taken advantage of. This was when a relatively new client suddenly stopped therapy just after I tried charging their credit card on file for the four sessions attended that month, and the credit card was no longer valid. Did I learn anything from that? Probably not, as I still charge clients only at the end of each month using their credit card on file. Here are some steps I now take to minimize the chance of ghosting, or should I say abrupt therapeutic termination:

1. End of session feedback: At the end of each session, I take a few minutes to ask and go over with the client how the session was for them, especially whether there was something said (or unsaid) by me that needs clarification or that didn’t feel right to them. This gives them the opportunity to bring up the issue, so I can address it directly, rather than them not feeling understood, or worse, when a developmental trauma is reenacted in session and the client misperceives the interaction. In most cases, when a client abruptly decides to end sessions, it is usually related to an attachment trauma’s being reenacted in some way, where the pain is too much for the client to bring up in session.
2. Need for closure: I tell the client at the initial session, and often throughout the course of therapy, the importance of a planned termination, or at least a single dedicated termination session. I also tell them that while it might seem easier to terminate abruptly rather than bring up a difficult issue directly with the therapist, a relationship grows stronger after an intentional repair by the therapist after a therapeutic rupture; I model this whenever possible.
3. Offer a termination session at no charge: When a client lets me know that they are no longer going to continue sessions, I always offer a termination session at no charge. Even if the client does not take me up on the offer, it conveys to the client my interest and care for them, and that I am available and open to taking responsibility for repairing the rupture between us.

When a client decides to terminate abruptly and does not want a termination session, I let them know that they can always contact me in the future if they have any questions or would like to come in for a session. I also provide referrals to other therapists. In some cases, it is simply not the right time for the client, and I have had clients return to therapy, sometimes years after they had abruptly ended sessions. I am learning to accept the “ghosting” of clients gracefully and to let go–it is what it is.

I sat there quietly while she held a gun pointed directly at me. I have had clients express displeasure at a comment or suggestion. I have had clients call me unflattering names for various reasons, none due to professional impropriety, just projected anger. These I could handle. But a gun? That was never part of training. So, I sat and talked quietly, invoking all thoughts of Mariska Hargitay on Law & Order as she would talk people off the ledge. At that moment, I was kind of wishing for my own ledge to jump from. Most evenings, I was the last one in the clinic, a small cluster of offices housed in a large, out-of-use hospital in North Hollywood. No security guards, no under-the-desk emergency buttons. Just me, a drug addict and her gun. I had initially and officially met with her one time, when she was mandated to therapy to learn that her 3-year-old son, who had been in foster care since he was born, was soon to be adopted. While I was just an intern at the time, it was my legal responsibility to deliver the news in as benign a way as possible, but to make sure the information was delivered. It was my first and, I assumed, last time meeting this woman. She stormed out and that was that – or so I thought. She reappeared on the evening upon which her child was officially adopted, brandishing a weapon and blaming me for not stopping the process of placing her child. I talked and waited and talked and waited and then, just like on an episode of SVU (Special Victims Unit), some hours later she got lazy and put the gun on the desk. I immediately grabbed it, pushed her to the floor (note I had never held a gun in my life) and called 911. I was soon safe, and she was soon gone. I had subsequent contact with neither her nor her child, but took a firearms course shortly after this event. The clinic, now defunct, immediately hired a full-time security guard who was always close by. Those of us who are in the business of caring for others do not often think that we will be placed in harm’s way for trying to help – and certainly not by way of gunpoint. While the client may be angry at the system, another person, or a circumstance, we do not think that beyond some verbal outrage they will take it out on us. Naïve! According to a 2016 survey, nearly three in four psychologists have been harassed at some point in their career, with over one in five threatened, and one in seven stalked (1). Now there is cyber-stalking, easily accomplished via a website, email, Facebook, or other avenues of social media. According to the National Association of Social Workers “therapists often deny or minimize feelings of risk to themselves” (2) and do not recognize the red flags of potential harm. An early experience in which I was stalked emanated from a red flag that no professional, seasoned or otherwise, could have anticipated. I had been working with a gay client who had been raised by very devout Seventh Day Adventist parents who made her go to a church that clearly preached against her “blasphemous ways.” She was angry her entire life. She was angry towards a slew of therapists just because she was an angry woman. She was that much angrier by the time she got to me. On the night she threatened to end her life but described no specific means for doing so or timeline (so that I could report her), I suggested she take herself to a reputable Adventist Hospital. It just never occurred to me that I said the ‘A’ word (Adventist). To say that she unloaded on me is an understatement. The sheer volume and intensity of threatening phone calls, emails and texts was unnerving, to say the very least. Until they finally and abruptly stopped. I deeply apologized for my lack of sensitivity (it seriously never crossed my mind) and gave her a way to find a new therapist. I must say that when she threatened my license for what I thought was an honest and caring attempt to help her, I did not exactly feel all warm and fuzzy. But I did assist and then blocked the client from further contact. I am not an insensitive therapist. I am, in contrast, perhaps too sensitive and have been willing to take a chance with potentially dangerous clients even when my antennae are up. However, I have also increased my vigilance in conducting the initial phone consultation. I now request written consent to contact any prior therapist. As one who began this career working in drug and alcohol rehabilitation clinics, I do not decline addicts but insist that they are sober when I see them and note in the therapy agreement that they sign that they will be terminated if I suspect otherwise. But I also have a private office where often there are no others around. I am not perfectly safe, and I know that. But I try to carefully assess the level of risk before taking certain clients; at least, as best as I possibly can. I know I will not always be correct in that initial assessment and may turn away clients who would never have done me harm. Like so many in our profession, I continue to feel drawn to take care of others before taking care of myself. But I have learned, and am no longer quite so trusting when considering red flags, be they great or small.

References

(1) Storey, J. E. (2016). Hurting the healers: Stalking and stalking-related behavior perpetrated against counselors. Professional Psychology: Research and Practice, 47(4), 261–270 (2) Lonner, R., & Licht, M. (2018). When a client threatens the therapist: Guidelines for mitigating risk. Retrieved from https://naswcanews.org/when-a-client-threatens-the-therapist-guidelines-for-mitigating-risk/

Shortly after my arrival in graduate school, I was placed under the clinical and research auspices of the late Nathan Azrin, the consummate and rightly-heralded applied behaviorist of his day—a direct intellectual descendant of B.F Skinner. And if that wasn't quite enough to dazzle a wide-eyed and eager young psychologist-to-be, I also had the pleasure of witnessing and partaking in both informal hallway and structured classroom discussions between Dr. Azrin and Dr. Leo Reyna, who was cut from similar behavioral cloth. I was truly in the presence of genius(es)—awed by their ability to converse in the seductive and reductive lingua franca of behaviorism. They could just as easily reduce the most complex pathologies to their simplest linear roots, as they could map out elegant therapeutic strategies for ameliorating the most challenging intra and interpersonal dysfunctions. I and my fellow graduate students, acolytes at the doorstep of the temple, basked in the piercing light of their reductive brilliance, mesmerized by their ability to explain and treat all.

Fast forward from that young psychologist-to-be to the now-grayed-clinician and clinical educator who has long ago left behind the certainty of singular theories and unidimensional interventions. Flash forward from that youthful and devout clinical ideologue to the pragmatic and prescriptive eclectic who has worked in venues as diverse as state psychiatric hospitals and youth foster facilities, with clients equally diverging in age, background and pathology, and with methods ranging from play therapy to CBT. No longer do I trust the promise of theoretical purism, and even less those who promise to part the clouds of clinical uncertainty with a simple wave of their empirically-informed manuals. In the therapeutic relationships I trust; far less in the techniques that I use.

***

And then came Phillip. Of all the grad programs, in all the towns, in all the world, he walks into mine. Phillip is a behaviorist through and through, capable of not only talking the behavioral talk but apparently walking the behavioral walk. He is facile and fluid with the principles and techniques of behavior modification, having come to his graduate training with several years’ experience on the ABA (Applied Behavioral Analysis) front lines with children and adults with developmental and neurodevelopmental challenges. While he can also sprinkle his classroom polemics with the names and theories of non-behavioral luminaries and their practices, he nevertheless remains a behaviorist to the core. Behaviorism makes sense to him. Clients’ problems filtered through a behavioral lens make sense to him. The seductive simplicity of the model and its practices give him a weapon with which to battle what he seems to most fear—relativism and uncertainty.

While I appreciate Phillip’s need to anchor his thought and practice in a widely accepted theoretical and applied modality, I am concerned with his rigidity. While I was awed in my own professional youth by world-class behaviorists who made it all sound so easy and whom I desperately emulated while I found my own clinical footing, this graduate student gets under my skin, and I am not exactly sure why. Is it because his cock-sureness smacks of as-yet unearned arrogance and privilege, or because his seeming clinical precocity is so unsettling to his classmates, who themselves are struggling to find their own theoretical footholds? Is it because his rigidity reminds me of my own all those years ago? Or maybe it is because he is so energized and zealous, while I have lost touch with those feelings over years of clinical practice. What about the possibility that this is a (not-so) simple case of supervisor-supervisee countertransference? Perhaps it is a little bit of each of these.

I am not quite sure what my role is with Phillip, as his clinical supervisor and mentor. Is it to be the empathetic clinical mentor supportively guiding him along his own chosen path? Is it to be the provocateur, challenging him to take a few steps away from his cherished beliefs, at least long enough to consider other ways of conceptualizing cases and building treatment plans? And what to do with my growing feelings of annoyance with Phillip? Do I express them directly with him, seek out clinical supervision, or simply jot down these thoughts for you, fellow clinicians and clinical educators, in hopes that doing so will give you the opportunity to ponder similar questions when confronted with your own version of Phillip?

***
 

I must confess that I still do privately find behaviorism attractive, and its explanatory promises and practices enticing. I have quietly used its methods over the years at select times with specific clients, more so children, but prefer to view and present myself as a clinician and clinical educator who is comfortable with relativism and uncertainty and the ever-unfolding and inexplicable mysteries that are part of the psychotherapeutic relationship. Oh, that it were so simple!
 

She enters the office and takes her position: feet curled into the chair beneath her, fingers gently petting the soft pillow on her lap, eyes fixed on me. Waiting.

He sets his phone to vibrate, puts it in his bag on an empty chair within reach. A water bottle is placed next to the tissues on a side table. He adjusts a pillow to support his back and settles into the chair, his eyes focused halfway up the wall to my right. Waiting.

Others greet me with a handshake or hug, offer comments about the weather and the commute, or immediately pay for the session. The rare iconoclastic types who sit in different chairs on a regular basis and vary their routines, are almost equally predictable.

These behaviors are attempts to settle into the space and ultimately, to help with the transition into the challenging work of psychotherapy. Getting comfortable is often the way we prepare to be uncomfortable. I have my own patterns of greeting and then settling into a session, serving much the same set of purposes. Similar patterns are evident at the end of each session as we transition back to the outside world, re-engaging with those familiar parts of ourselves essential to navigating daily challenges.

After all, we are creatures of habit, custom and ritual. It is within our predictable routines that we feel most at-home. To change patterns of behavior demands that we tolerate being at risk and vulnerable. If attachment theory has taught me anything it is that human beings need to feel a strong connection with a safe home to effectively take risks beyond that home.

Therapy is always a risky venture. By crossing the threshold of the therapist’s door, the client is rolling the dice, and the wager – what they could lose – is far costlier than the therapist’s fee. They are opening themselves up to discomfort in the hope of increasing their joy. It is a risk I would never advocate a client take in a game of chance! When we (those without a gambling problem, of course) play the slots and lose, that loss stings for a moment but typically has no lasting impact on our lives. The money lost is not needed to pay the mortgage or feed a family.

The client, however, is not gambling with funds set aside for entertainment. The client risks upsetting the order of their life, and when a session is over, they may not be able to leave that upset behind in the therapist’s office.

Fortunately, the odds of hitting the therapeutic jackpot are astronomically greater than in any game of chance! Such games demand the player surrender to the whims of fate, while therapy engages the will and empowers the client. The payoff is not merely a means to happiness but is itself joyful.

I bring to my work knowledge, understanding and professional discipline. I also bring my ego. I like to think of myself as a creative person. Conversation has always been an artform for me that entails engagement, insight and the capacity to recognize and articulate the connections between things. What experience has taught me and reinforced over the years is that these artistic/creative qualities can all be great assets in psychotherapy, but they are rarely enough to ensure a positive outcome for my clients.

In fact, creativity, I have had to admit, can also be an obstacle to the client’s progress. I may be intellectually and emotionally excited by a reframe or interpretation, absolutely convinced that it is a useful and applicable intervention, and yet it might, in practice, be a disruption or even give rise to a therapeutic rupture. The creative intervention, born and delivered primarily as a product of my own enthusiasms, can be out of sync with the client’s immediate safety needs—implicitly inviting a change that is not yet supported.

Creative people tend to push against boundaries. They look for the rules that can be fruitfully violated. An artist recognizes the utility and value of structure, but regularly seeks opportunities to depart from it in service of expanded artistic expression.

A returning veteran was referred to me for EMDR treatment to address PTSD stemming from his deployment. As we progressed through the early stages of EMDR (engagement, history gathering and psychoeducation) we identified many interrelated issues, and it soon became clear that the client and I had been collaborating in trauma-related avoidance. I had engaged in lengthy discussion about current issues, many of which I artfully linked to trauma symptoms, justifying my delay in initiating the active ingredient of EMDR: bilateral-stimulation (BLS). Finally, in a session that began with the client’s earnest description of a recent loss, I stopped myself from responding with exploration. Immediately, I asked him to identify his emotions and their somatic expression. We then utilized BLS to process and reduce his reaction. By session’s end, building upon confidence born of that success, the client was willing to directly address the traumatic deployment, and I was ready to stick closer to the EMDR format. Both therapist and client require comforts to perform optimally in therapy. The therapist’s comforts, however, must also promote the client’s comfort and progress. An appropriately applied Evidence Based Practice (EBP) should help to ensure this balance, providing a structure for the clinical process and containment of the unpredictability that accompanies the untamed winds of creativity.

The similarities between the client’s self-comforting behaviors and what, to my artistic self, may appear to be repetitious patterns of intervention, may in truth be central to the EBP’s effectiveness. What I judge to be lacking in the organic intimacy found in unstructured dialogue, may in fact meet the client exactly where they are at and provide them with an essential component of their own empowerment: predictability.
I strive to maximize the predictability of a structured approach in my practice by initially disclosing the structured elements of the therapy (duration, participants, session-to-session structure); sharing the rationale of the EBP; consistently using the same relevant terminology; and regularly utilizing the same measures. Working with an EBP or other structured therapeutic methodology allows me a far greater opportunity to make therapy transparent than when I am working in less structured ways. Increased transparency promotes collaboration and helps the client take ownership of the outcomes.

The habits and behavior patterns exhibited at the start of each session remind me of how challenging therapy can be for the client, and how difficult change can be for us all. Creating opportunities for client change demands a therapist’s creativity and willingness to take risks along with the client, who is willing to be set off-balance and to persevere through discomfort. That capacity to endure is rooted in underlying structures that provide the foundation for security, safety and autonomy.
 

Group practices are taking the field of outpatient psychotherapy by storm. In just the last five years, thousands of group practices have started in all corners of North America. The dream of passive income, coupled with the somber realization that a full solo practice does not yield enough money to pay for college, retirement and the lifestyle that most practitioners desire, has fueled this rise.

As someone who has run a group practice for 20 years and has coached over 200 psychotherapists in starting and growing one, I see both the promise and pitfalls in this trend.

At the first naive glance, group practice seems almost too easy. If you have a successful solo practice, you know how the therapy game works. So you hire a good therapist, give them an office and a few referrals, sit back and rake in the money. Hire a few more, and more money rolls in while you bask in the sun or stroll along the beach.

Not so fast. The reality is that group practice is a complex, dynamic beast that challenges you in ways that a solo practice never will. It requires the owner to simultaneously juggle numerous plates, while still performing therapy during the early stages of growth, sapping your time and energy. Group practice also demands that you learn a bevy of new skills. For example, you need to learn how to hire, manage and evaluate clinical and admin staff (and fire them when necessary), manage the irrational projections staff throw at you as the resident authority figure, expand your marketing, track much more complex metrics, develop a profitable compensation model, stay current with the latest ethical issues and clinical strategies and, finally, develop a work culture that people enjoy working in.

I know many group practice owners like myself who have mastered these skills and currently employ staffs of twenty or more clinicians, generating revenue over $2 million per year. But these tend to be group practices that have been around for at least five years.

As a group practice owner, I am always balancing three things: referrals, office space and clinical staff. The dirty little secret of group practice these days is that with its exponential growth, finding and keeping good clinicians is MUCH more difficult than ever before. The best clinicians already work in other group practices or have their own solo practices. One measure of the competition for good clinicians is this: the number of ads for therapists for group practices on job sites such as Indeed.com has increased tenfold in the past four years.

The new kids on the block may find themselves competing with practices that offer a host of benefits such as healthcare, retirement accounts, paid vacation and paid trainings for an increasingly limited pool of qualified clinicians.

So what can you, as a newer or existing group practice owner, do if you want to expand? Here are five specific strategies that can help:

1. Develop an internship program – there are still many pre-licensed clinicians who need hours and are hungry to learn from an experienced, successful therapist. You can pay them less than a licensed clinician, and if they like working for you, they will often stay on after they are fully licensed.
2. Stress the benefits of joining a newer group practice – it’s exciting to be part of something new, to be able to have an immediate impact on policies and procedures. If you join a larger group with 20+ clinicians, all of that will have been established years ago, and you will have very little say in what happens.
3. Use your personal network of colleagues to find therapists – don’t forget your friends and colleagues who know many other therapists in your community. Personal introductions that build on your experience in the field can be an invaluable way to attract new staff members.
4. Develop a unique specialization that is not commonly served in your community. Many group practices are one-stop shops that serve a general range of clients. Practices that specialize in one or two niches can attract clinicians who already are — or want to become — experts in a particular clinical specialty.
5. Promote your practice to people who are working in low-pay agencies that have endless paperwork and hours of boring meetings. These people are often seasoned clinicians who are thrilled to make more money and work with higher-functioning clientele.

Group practice is here to stay, and when done correctly, can fulfill the dream of an affluent lifestyle, meaningful work, and providing help for thousands of people in your community. But without solving the staffing problem, this dream will remain a distant fantasy.
 

Michael is a first-generation Chinese immigrant who requested to see me for counseling. When I met with him, I could sense dejection, fear and abject shame as he shared his wife’s desire to divorce him. By all accounts, Michael is an upstanding citizen. By Asian standards, he is a success, having immigrated to this country to start a successful business. He has provided financially for his family. He expressed bewilderment as to why his wife would want to divorce him, as he felt he had done everything possible to sacrifice for the greater good of his family.

While his therapy involved exploring some of the relational patterns that might have led his wife to feel like she was unappreciated, much of our work centered around reflecting the pain and grief he was or might be experiencing.

In one of his early sessions, Michael described having panic attacks while sleeping, waking up sweating and having a hard time breathing. He would also rhetorically ask, “What am I to do next (if she divorces me)?” and “I can’t accept this!” He described his mental state prior to seeing me, saying, “Two weeks ago I was in a dark place, depressed and felt empty.”

I immediately inquired about suicidal thoughts, and he acknowledged passive thoughts of suicide (i.e. thoughts without any concrete plans). I brought up the concept of a safety plan which would include calling 911, calling me and/or going to an emergency room. He said he could contract for safety by calling 911, but I was not convinced he would do it and felt he was just saying that to appease me.

Beyond the main current precipitating factor for suicide (upcoming divorce), I also asked him about protective factors by directly saying, “What’s keeping your alive today?” He shared about wanting to be here for his youngest son, who’s 10 years old.

Michael was mild-mannered and not openly emotionally expressive of his pain in session, although he acknowledged bouts of crying spells at home. He also described a life that appeared isolated and lonely. Playing golf for hours at a time by himself is what he described as his means of coping. It made me worry as he lacked an emotional support system.

While he denied suicidal thoughts in the following weeks, his physical symptoms increased in intensity (i.e. panic attacks and feeling like the “sky is going to fall”). Since Asians are much more comfortable talking about somatic issues than emotional ones, I recognized that he might still be trying to assess the extent to which he could trust me. I gently probed and educated him that his thoughts of “not sure if he could go on” were indeed considered passive thoughts of suicide. He was unaware of this and expressed the belief that feeling suicidal was simply when one had concrete plans.

During this time, I continued to press Michael to determine if he had friends, colleagues or others in whom he could confide about his upcoming divorce. Because of shame, it took a long time before he could even share this with his own parents. He eventually opened up to one friend, which I believed was a courageous first step towards openly expressing vulnerability. He told me that if he felt suicidal, he could and would likely be able to reach out to this friend. I remember feeling relieved that there was at least one person in his life whom he trusted.

***
 

This case example demonstrates the delicate balance that therapists must tread when working with cultural shame and suicide. Over the years, I have learned that despite the shame Asian clients may feel about their lives and related suicidal thoughts, we must be bold enough to directly engage in these conversations.

In the general suicide literature, precipitating and stressful life events include divorce, death of a loved one, job loss and physical health problems. For Michael, it is no different. While divorce is mainstream in America and Caucasians may see this as simply another loss from which to recover, Asian clients may view this quite differently. As Asian identities revolve around familial ties and their place in the family, divorce can propel an Asian into a painful and shame-filled world where he/she may feel ostracized not only from their family, but from the greater Asian community, including friends, colleagues, churches and extended family relatives.

Michael is somewhat atypical in the sense that his thoughts of suicide occurred in mid-life, compared to those aged 20-24 years old, when suicide is the leading cause of death among Asians. However, what links Michael with other Asians is their centuries-old viewpoint on mental health and cultural shame. Shame is what Asians learn to avoid in any form throughout life, so going through a divorce is considered highly shameful. The belief that they have shamed their family and ancestors leads some to feel they have so disgraced their kin that they must hide oneself (physically and/or emotionally) or atone for their actions by ridding themselves from society by suicide.

In the context of younger Asian Americans, shame can emanate from perceived failure in academics (not getting high enough grades), poor career choices (pursuing a less financially secure occupation), or relational mistakes (dating or marrying someone the parents object to).
The fear is far more than one of disappointment, and is instead the concern over outright abandonment. There are innumerable stories of Asian parents disowning their children for not abiding by their parent’s dictate. Even if this were not a reality, the very fear or perception that this threat exists could lead one to suicide, depression, addiction, isolation and a host of other maladaptive coping behaviors.

In addition, mental health is viewed as a weakness, and talking openly about anything emotional such as sadness, disappointment and the stress of various life events is discouraged and rarely emulated in traditional Asian families. Stoicism is desired and the notion of physical touch and verbal affirmation can be seen as coddling.

Even suicide is viewed very differently among traditional Asian cultures. Some view suicide as an opportunity to atone for their misdeeds in this life and return honor to their families. In this regard, there are even extra incentives to die by suicide, including restoring the family’s reputation as well as those of the ancestors. It also can be seen as spiritually elevating oneself, since those who die by suicide become free of criticism.

All this is to say there is much work to be done in the field of mental health and outreach as it pertains to Asian Americans. If you’re working with Asian Americans in any capacity, be aware of their nature to minimize negativity and emotions that are regarded as shameful.
Clinicians should be mindful of life events that Asian clients deem so shameful that suicide becomes an option (job loss, divorce, bankruptcy). Because Asian shame is endemic to the culture, you also have to be wary of the client’s support system (or lack thereof). Is your client isolating from friends, peers, or relatives? Does your client struggle with emotional intimacy and fear that if someone else (besides the therapist) knew of their struggle, they would be abandoned?

Regardless of your therapeutic modality, when working with Asian American clients it’s imperative to find ways to reframe therapy from a shameful, stigma-inducing event to one where the client is working towards health, wellness and growth.