Category: Blog

On Holding Your Tongue

Posted on by Psychotherapy.net Team

We therapists have all been guilty of this one: holding forth when we should really be letting our client have the floor. I recall many cringe-worthy moments as a nervous new therapist, going as far as talking to my clients about the theory behind what they were experiencing, convinced they would be as fascinated by this as I was. Fortunately, I was empathic enough to pick up on their blank stares and restrain myself.

I am currently in the process of doing a qualitative study on the common factors in working with dreams. This is relevant because of what I’m finding in the data around dream interpretation. In short, don’t do it! What modern dreamwork methods suggest is that even if you have a jaw-droppingly brilliant sense of what your client’s dream is about… don't, especially if you have something amazing to say, the best thing to do is keep it to yourself!

Why hold back? There are a few good reasons. First, because we may not actually be right. Dreams are multi-faceted and only the dreamer really knows what they are about. My wonderful interpretation may fit the images tidily and still not have any relationship to the client’s dream. Also, I’ve found that if my take on the dream is not a fit, my less assertive clients will do their best to see my point of view and contort their dream into the Procrustean bed I’ve made for them.

Another reason to hold back my brilliance? This is the main reason: because if I don’t, I rob the client of their own thrill of discovery, the excitement that comes when they unlock the meaning of the dream for themselves. Not only will the client’s interpretation be better-timed because the realization comes when they are clearly ready to have it, but also, the insight or experiential shifts made in the process will stick because they are the dreamer’s own and there is strong emotion attached to their discovery.

Despite what I just wrote, on occasion, if I feel I really must offer my pearls of wisdom about a dream, I have learned to do so tentatively, and back off immediately if I get that telltale blank stare. I may be right, and the timing may be wrong. Or I may be way off base. Either way, the best interpretation is the one that comes from the client. After all, I don’t want them to walk away from therapy thinking, “Wow my therapist is so smart, how can I manage without her?” Rather better is when they walk away with a sense of mastery and confidence about their own ability to read into their dreams and their life.

That said, good dreamwork like good therapy, should be highly collaborative. We all tend to have huge blind spots around the images that come in our dreams; so playful and respectful curiosity can help guide the dreamer to find their way through the complexity of their dream world. You can also use a device from the dream interview method that suggests you play really dumb and ask the dreamer to explain their dream images as if you are from another planet. The words they use for me-from-Mars often give a sense of how the image may be a metaphor for something in their life-and what they say is never predictable. If they dream about a dog and I say, “I’m from Mars, what’s a dog?” the answers could range wildly: from a dangerous beast with big teeth to my best and most loyal friend.

In the common factors research into dreamwork, of the 14 dreamwork methods I analysed, only psychoanalysis still advocates for interpretation by the dreamworker. All the rest advise strictly against it and suggest instead to encourage the dreamer to engage with their dream experientially and allow the dreamer’s sense of what the dream means to emerge. When I’ve had the self-discipline to do that, so often I have been amazed by the creativity and insight from my clients, and the unexpected places they went with their dream images, that I’m glad I held my tongue. 

Shame Part 2: Shame Proneness

Posted on by Psychotherapy.net Team

Megan came into session and sat down. Her eyes wandered around my face, but didn’t meet mine when she said, “I did it again. I went back to him.”

“Tell me,” I said, leaning forward.

“I’m a – a loser. I can’t stay away from him even though he’s bad for me.”

Megan had come into therapy after failing to sever ties with her most recent boyfriend, Tim, a man who repeatedly left her feeling emotionally abandoned and worthless. She reported a history of tumultuous intimate relationships that consistently left her feeling lonely and dissatisfied.

Tim was no different. Every time he dismissed her or invalidated her, it tore a little more of her heart out. Worse yet, it confirmed her inner fear: She was worthless and no one would ever, could ever love her. Trying to repair fractures to her self-esteem, she would search for the next man to love her, only to find herself in another relationship where she felt dismissed and worthless.

This isn’t unusual. It’s certainly a story I’ve heard variations of many times as a psychotherapist. Megan, who was thirty-five years old, reported that she had been going through this cycle since she was a teenager. She felt hopeless that she would ever find the stable, loving relationship she so wanted. I felt it as soon as we started our work together. Shame.

In my last blog post, I discussed the shame that entered the room in early sessions, when patients began exposing themselves. Megan’s shame was more complicated. Normal shame is transient, but for Megan, her inclination was to experience shame in all ambiguous situations. This proclivity has been assigned various names. I like to call it shame-proneness, which is the term June Price Tangney, one of the leaders in research on moral affects, (shame and guilt), named it.

When Megan came into situations that naturally elicited self-assessment, her emotional response would be feeling bad, small, defective. Self-esteem is a cognitive evaluation of the self; shame, on the other hand, is an affect, and therefore, permeates the entire self, spilling into every crack of someone’s being, coloring all their experience-darkly.

On some level, Megan believed that she deserved poor treatment from men, causing a repetition of the very pattern she was trying to stop. No matter how hard she tried to find a different outcome, she was always confronted with the same feelings of shame. Thus, the narrative – I am bad – that she desperately wanted to change, perpetuated itself.

Megan explained that she went back to Tim during the week when he promised it would be different, only to be left again. This was the fifth time she went back only to be left.

“He threw me out.” Tears trickled down her cheeks. “See, I’m weak. I’m a failure at everything. I’m never going to find what I want. It’s me.”

Her feeling bad about herself in the Tim situation pervaded other aspects of her life. That is, she felt bad all around, not just in relations to Tim.

I knew I had to help her see how her self-perception created a type of self-fulling prophecy. So, I reminded her of what we had been working on. “Remember what we talked about?” I often use psycho-education with patients, even when I’m working more psychoanalytically as I usually do with a shame-prone patient. I don’t find that keeping the nuances of therapeutic work undisclosed helps, especially for patients who feel so exposed already. It’s like throwing them outside in the cold without a coat, alone.

Megan and I had discussed shame. She knew that it tied back to early experiences of emotional neglect and abuse, where she unfortunately heard messages that she was bad and wouldn’t be anything different, ever.

“I remember, that just makes me feel worse. I should know better by now,” she whispered. This is where shame is so tricky; it’s very hard to intervene without evoking more shame.

I addressed her experience in the room. “We knew it would be hard not to go back if he called. Intellectual insight comes before the emotional connections that make change easier. You are working very hard to undo a narrative that took years to build. It takes time.” I leaned forward, again. “Remember, what we talked about last session, during the break from Tim.”

“Yes, I’ve – gosh, I can’t believe I forgot.” She pulled out her phone and showed me a schedule of all the workouts she had done the last week. Megan had been very athletic. I encouraged her to go back to exercising.

I wanted her to feel her strength and resilience. I wanted her to find her value in her activities. One of the most effective ways to help people combat these shame narratives is to help them access and activate their natural strengths, the parts of them that weren’t fostered, because no one acknowledged them when they were younger.

It’s our job as clinicians to discover these natural endowments and cultivate them for all of our patients. Shame-prone patients need more help figuring out what they are and more time to develop motivation.
Megan smiled as she showed me what she had accomplished that week. I saw pride glowing in her eyes. I observed it with her. “What are feeling?”

“I feel good.”

I smiled, thinking that we had found a space for Megan that was shame free. “What’s it like to feel good?”

“It’s something I knew I wanted to feel, but I could never quite find.”

“Now that you know what it feels like, it will start to get a little easier. Be hopeful.”

“I am.”

*Megan is an amalgamate of patients suffering from shame-proneness.
 

Shame Part 1: Walls are Fears Disguised as Safety

Posted on by Psychotherapy.net Team

The wind blew in strong gusts, howling and shaking the windows. Tracey pulled her cardigan tighter, then rubbed her arms with her hands. “I hate strong wind. It feels like the walls are going to come down.”

Interesting, I thought, we’re getting closer. This described exactly what was happening in the room.
Tracey and I had been working together for four months but had barely scratched the surface. She discussed work-related stressors and dating. She would go into detail about the many men she dated, but she never described her feelings. I wanted to know more about her inner life, but I felt her guardedness. She had a wall up. And I had to respect it.

Walls are fears disguised as safety.

But why are they there in the first place? When patients come in, but have trouble disclosing, this is the question.

We call it defensive structure or defensive mechanisms or resistance, this wall. We have words, but one I rarely hear that is significant, is shame. My dissertation topic involved a thorough analysis of shame and I have continued my research. Every time I’ve presented on the topic, students and established clinicians alike ask the same question: “Why aren’t we having classes on shame?” It’s important.

Shame is the deepest and most painful affect, as it involves an evaluation of the entire self. Whereas guilt assesses what we do- “I shouldn’t have done that”, for example; shame evaluates the entire self: “I shouldn’t be that.” Guilt says, “what I did is bad.” Shame says, “I am bad.” Shame pervades our sense of self – entirely.
Shame also involves the real or imagined perception of another. It’s the reason why infants and toddlers will run around nude without feeling exposed. They haven’t reached the developmental stage where they recognize themselves in the eyes of others.

The essence of psychotherapy requires that patients come in and reveal their innermost self, layers of secrets, elaborate fantasies. We are asking them to tell us the very thoughts and feelings that are usually hidden, because we don’t want others to see. Shame inevitably arises as the bricks come down and the patient feels exposed.

For patients like Tracey who have never been in psychotherapy before, this is often even more difficult. Additionally, unresolved shame creates more psychotherapeutic challenges. Unresolved shame (which I will discuss in the next blog), develops when injuries to the self occur over and over; any type of emotional abuse will leave people with some unresolved shame, which is woven into the very fabric of their identity.
In a lecture I had given some time ago, a psychodynamic student asked if I thought it was our own shame that made us avoid discussions of shame. I hope not. We need to afford patients the luxury of a safe room, where we are sensitive and cognizant of the shame that naturally arises as disclosure increases.

I had to help Tracey feel safe enough to slowly remove the bricks she felt were loosening. I went with the metaphor. “What do you imagine would happen if the walls came down?”

“I dunno.” She crossed her arms tighter.

“Are you feeling that right now, like the walls are coming down?”

She diverted eye contact, picking at a string on her shirt. “I don’t want you to think I’m crazy. I feel crazy sometimes.”

I leaned forward. “I know this is hard. Everyone that comes in here feels like their thoughts are crazy. I have thoughts sometimes that others might think were crazy. It’s normal.”

She looked back at me. “You do? But you’re a doctor.”

“We all have ideas and thoughts and fantasies that feel bad or scare us sometimes.” Small self-disclosures to normalize the situation and show patients that we are also vulnerable to emotions helps ease shame-ridden angst. Also, keeping the dyad collaborative instead of hierarchal reduces shame.

“I have thoughts like that all the time.” She placed her hands over her face. “There are things that I’ve never told anyone before. I know I should tell you, but it’s very hard.”

“I know it is. Maybe we can start with what you’re afraid I will think.”

“OK,” she said with a small smile. I felt a few bricks had come down as I acknowledged her shame. I knew that the more we discussed her fear, the safer she would feel to explore what was behind the wall. It would be two bricks down, one back up, but at least we were finally at a start.

*Tracey is an amalgamated example of patients during early sessions struggling with shame. 

Teen Heroes with Feet of Clay: The Dilemma of a Pop-Culture Psychotherapist

Posted on by Psychotherapy.net Team

Recently scanning the Internet, I was dismayed although sadly not particularly surprised by the glaring headline which read “Demi Lovato rushed to hospital for possible overdose.” My first response was “damn, poor kid!”

The next flurry of thoughts closely paralleled my own varied life roles. The father in me remembered my kids’ shock upon learning that this same celebrity, former Disney actor/singer used to cut herself. The pop-culture author in me reflected on the writing I’ve done around superheroes who are often deeply flawed characters. Finally, the teen therapist in me wondered once again how to bring the stories of popular culture icons like Demi Lovato into the therapy room. As examples of the challenges and pitfalls of high achievement and celebrity? As cautionary tales to those who would model their lives and mold their dreams in the images of superstars? Or simply as examples of people more alike than different from them, who struggle to regulate anxiety, depression and the accompanying demons by using, cutting and killing themselves.

Heroes abound in popular culture, exceeded only by those who have fallen hard and as such are in no short supply. As I watch the 2018 Tour de France, I remember Lance Armstrong’s substance-enhanced fall from grace. As I read more deeply into the life of Demi Lovato, I think about Justin Bieber’s near-death automobile escapades, Britney Spears’ seemingly unending brush with the dark side and the terrible fate that Heath Ledger, aka the Joker met; not to mention the myriad music legends whose lives were cut short by their own hands- Kurt Cobain, Whitney Houston, Michael Jackson and the artist who will forever be known as Prince.

Just today, a soon-to-be twenty-year-old asked me (in my professorial role) a poignant question about adolescent identity formation. A question she would like to have asked her developmental psychology professor, I believe she was reflecting on her own journey to personality coherence on the road to adulthood. We concluded together that there are many influences that shape who we are and who we become during our formative years, not the least among which are popular culture figures both great and small, evolved and base, and those who succeed and ultimately who fail…terribly.

In his book, Breaking through to Teens: Psychotherapy for the New Adolescence, Ron Taffel encourages all those who work with teens to be familiar with popular culture and its many and often strange inhabitants. He challenges clinicians to regularly assess their PCIQ, or popular culture IQ. As a therapist who specializes with children and teens, I couldn’t agree more strongly. I worked with a troubled seven-year-old who had been alternately diagnosed with ADHD, oppositional defiant disorder and conduct disturbance. He taught me about the struggles Japanese anime character Naruto faced, and in so doing provided me key insights to helping him. And it was the tortured relationship between Darth Vader and Luke Skywalker that assisted me in my work with a depressed and alienated adopted pre-teen. Each of these pop-culture characters, regardless of their fictional origins, struggled in very real ways.

So, the next time you have the opportunity of working with a child or teen who identifies with a figure of popular culture–whether fictional or non, elevated or fallen; be prepared to explore the meaning of that identification, whether positive or negative. And be prepared, as I have learned, to sit patiently at the intersection of that client’s and their hero’s relationship in order to gain a deeper understanding of your young client as they wrestle to make sense of themselves, the world around them and the characters within it. Lessons abound.  

The Healer that is Hurting

Posted on by Psychotherapy.net Team

Life’s a beach, or so I’m told. Paradoxically, death may draw many apt analogies from this image.

This summer, my work was humming along to the tune of vibrant pulsing music, much like a beloved beach getaway. My client load, lightened by family vacations, left breezy spaces in my schedule for unpacking course development and writing projects that had been tucked away for a while and for unfolding new ideas I had been eager to examine in the full light of day.

The sun shone brightly down as I played with the projects like beach volleyballs in the ocean, keeping each in the air with my respective co-teachers and co-authors until they skidded across the water before me with large splashes of inspiration, ready to be passed, set, and attacked in turn with greater intention.

And then, I woke up one morning this week to an email informing me that a buddy of mine who has been battling brain cancer for more than a year is now in end-of-life care. In cruel and rapid succession, thirty minutes later, I learned by telephone that my mother-in-law died peacefully in her sleep the night before, after her own two-year fight against cancer. Despite the battles my loved ones had been fighting, the news of these events was both sudden and unexpected, like going for that ball in the water and falling off the sandbar that I didn’t even know I was on into the depths of the ocean, scrambling to find solid footing again.

Anticipatory grief was launched from the American side, where my buddy is from, and was amplified by the full force of the shipwreck of my mother-in-law’s passing on the Swiss side, where I now live. It has been two and a half years since my last family loss, my maternal grandfather, my last grandparent. I remember that it hurt to lose him – an enormous, ocean-sized bucket full – but I had forgotten how ravaging grief feels in the moment it is felt. Until now.

Grief is often described as coming in waves. I had forgotten how bone crushing and soul squelching the break of those tsunami-sized waves feels until I received news of these recent events. Gasping. Sobbing. Roaring. Crashing. Crushing. Overtaking. Undertowing.

The former lifeguard in me recognized the drowning person’s combat, wordless and writhing under the weight of the wave of grief, struggling to keep her head above water, breathing in fits and spurts. Time is different in that space and place, seemingly at a standstill in the struggle to get to the surface, to figure out which way is up again. Until grief, finally deciding to subside… leaves the body limp and devoid of form or feeling, like seaweed tossed upon the shore both as an afterthought and as a reminder of the power of the wave that has (temporarily) receded.

I am still on this sober beach, lying on the sand in the ebb of the tide in the interim between my mother-in-law’s death and burial, her demise and our ceremonial remembrance of her. I am experiencing the void of losing her and the unbearable anticipation of the loss that I know is still coming – the next hard wave that will hit when I want to pick up the phone after work to pass the commute home in her company – only to realize that I will never be able to do that again. I am also in anguish about what I cannot see coming – how I will react to the funeral rites I will experience for the first time as a family member in Switzerland. I have attended funerals here before, but not for someone within my family.

Despite my full integration into this Swiss society I’ve called home for over a decade, the subtle differences in rites and rituals here contrast from those of my home Appalachian culture and signal my otherness, and aloneness, to me. Certain differences in the timing of things and in how the ceremony is performed are culturally and painfully dreadful to me, like skidding against hard rocks at the bottom of a crashing wave without choice or conceivable resistance to the process.

Thus, documenting my feelings, resonances, and imaged analogies while I am still in the throes of fresh grief will serve to remind me, the healer that is hurting, that it is important to let people feel what they feel, to ask them to describe their resonances in whichever directions their sensations take them, to explore what grief and loss mean to them and how it is expressed in their culture(s), and to bear witness to their pain and struggle without trying to fix what is ultimately unfixable.

I will sit with my pain and accept it as the old acquaintance it is, letting it accompany me on this voyage to the beach and home again in the full consciousness that the length of this journey is unknown and impressible. I will also bear in mind that, at some point, I will not remember it as vividly as I feel it in this moment, and I will try to take some small comfort in that. I will eventually be able to feel the warmth of the sun again, despite its continued shining. And, when I sit as a counselor with grieving families, I will not soon forget – and will never minimize – the impact of the roaring waves of grief that cover them until their seas eventually calm again, even if just temporarily.

A Barbie in Paris

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Barbie girls do not visit my therapy room that often.

This one was from a Fashionista kind – perfectly blond and dressed up for a lunch in town with her equally well-groomed girlfriends on stilettos.

This is the unkind thought that crossed my mind as I opened the door and greeted her. I felt bad; a spark of shame made me smile a bit more broadly to her than I would usually do. How could I reduce this person to a soulless doll? Nadia (no, she was not called Barbie) was probably suffering – otherwise why would she be here?

She was a Russian-American living in Paris. Her parents had immigrated to Texas when she was eleven; and this is where she had grown up – she stressed at the very beginning of our session. She felt American and preferred to speak English with me, if I did not mind. I did not.
Her English was perfect indeed, with a subtle Southern twist.

Ignorant of my inner thoughts about her, she sat down, crossed her long legs and kicked off:

– I hate everything here.

This was a rather unusual beginning. My American clients are typically fascinated about Paris, though, sometimes, this initial idealization turns into disillusionment or frustration about the French administration or widespread snobbiness.

– Everything?
– Yes, I hate French people, I hate French food…
– Is there anything you might like about Paris?
– Nope.


She sounded certain; the frozen frown on her perfect face confirmed this commitment to disgust. I believed her feeling. She looked fed up with trying to fit into a place she did not belong to.

The only reason Nadia was still living in France was her French boyfriend.

At first she had found the idea of following this Frenchman to Paris rather appealing. Her Texan girlfriends were finding it exciting, they could not hide their envy. This sat well with her – she was into fashion, and Paris was the place. She could picture herself working for one of the luxury brands, wearing a Chanel jacket and some fine jewelry…

Who was this man? How did he connect with her? What did he appreciate in her apart from her looks?
I did not get much out of her: he was rational, well-organized and made good money.

Is it ever possible to love someone and completely dislike the culture this person belongs to? Having loved France and a French man for twenty years, I naturally doubted that, but Nadia’s story was different: they had met in her step-motherland, the US, and her knowledge about France was limited to Hollywood movies and her mother’s dream to visit Paris, an impossible fantasy during Soviet times.

But Nadia was not interested in philosophical questions. She made it clear – she just wanted me to tell her that “her feeling was normal” and would pass with time: should she stay and give France another chance, or return home? She was desperately homesick.

Was this place rejecting her? Probably. This had been my first reaction after all – Paris is not to welcoming Barbie girls – its well-known lights can be disappointing and lack the promised glamour. My own Frenchness, acquired through hard work, had rejected the way she was exhibiting herself.

She stubbornly rebuked my attempts to enquire into her relationship with her original home, Russia. She did not have much recollection from her first years of life there, and had never given it much thought. She insisted on being happily American. Could it be that her current exposure to another strong culture was threatening her American identity?

Working on this is possible in long-term therapy and can be painful at times. I suggested that, as long as she was ready to commit.
Nadia was resisting taking any responsibility for the flaws in her relationship with France, she just could not do anything else than hating the country, the people, or the food here.

After going in circles for an hour, we did not manage to move an inch beyond this initial point. I sat there in front of her, moving closer to the realization that I could not help her without her cooperation.

When I finally closed the door behind her, I felt exhausted and relieved. My guess was that she would not be coming back. I felt used by her, and as result mildly ashamed.

Shame is a tricky but always informative feeling.
What was it about? Maybe this shame was something Nadia was experiencing deep down under her tight red top, under her perfectly tanned skin?

Reflecting on our session, based on the very little she had shared with me about her past, I could imagine the young Russian girl brought by her parents to a new and probably alienating place. She had mentioned that the first year had been hard – children at school mocking her for her wrong clothes and wobbly English. But she was a tough kid, and soon enough she had joined the group of the ‘popular girls’. This had come with a cost – losing weight and learning how to play totally new and strange sports among other things …

Thinking about this teenager dealing with her new immigrant condition that she had not chosen, I could finally feel some compassion.
Here in Paris, the adult Nadia was certainly feeling as inadequate as the younger Nadia during her first years in America. The fact that this time she was the one making the choice to move did not make it any easier.

My intuition was proven right – Nadia never came back, neither did she follow up on our unique encounter. This happens rarely, and every time it does I am left with more uneasy questions than answers. Did I fail her somehow? Should I have done something differently or was I simply not the right therapist for her?
Even now as I am writing about Nadia, I feel an uneasy feeling, a mild embarrassment about failing to connect with her, to feel for her more in the moment. Had I been able to connect with the young Russian girl, ridden by the feeling of being too different from other truly American kids, would it have gone any differently? Perhaps her Barbie-like façade was the only way she had found at the time to fit in, to belong. How desperate she would have been to fit in to adapt her own personality to this caricature of a perfectly American girl. Had she played with foreign-looking Barbie dolls as a little girl back in her native Russia?

Most probably I will never find answers to these questions, and as any other therapist, I had to learn how to deal with such frustrations and uncertainties – they are part of my job.

I hope that one day Nadia is safe enough to get in touch with her shame about her imperfect origins. After all, she chose to contact me – a Russian become French, rather than one of the many American psychotherapists in Paris. Maybe a well-hidden part of her wanted to connect with her ‘shameful’ roots; but for now this part was too small and too insecure. I had to accept that and hope that in the future she will give therapy another chance…
 

What Do a Mango Tree and Child Therapy Have in Common?

Posted on by Psychotherapy.net Team

I am from Brooklyn. While a tree might have grown there for someone else, it certainly did not do so for me. A few shrubs here and there, some weeds poking up in the cement cracks perhaps, but nothing more verdant than that. I was thrilled, upon moving to my current home in Florida to have a mango tree on my property.

Everything I ever needed to know about therapy I’ve learned from that mango tree…but more about that in a bit. Each year like clockwork, the tree blooms, fruits, sheds and ultimately yields. And each year like clockwork, I worry that for a variety of reasons, it will not actualize its mission. And each harvest season, I must remind myself that this magnificent living thing has its own rhythm, its own wisdom and needs me there simply as a witness, unassuming caretaker and gentle guide.

In similar cyclical fashion, right around this time for the last two years, I received a call from Jamie’s parents. “Hi Larry”, says Tom, Jamie’s dad, “Jamie just finished 4th grade and asked to see you; he misses you.” Tom went on to describe how his creative, playful and precociously intelligent and self-aware child had flourished and evolved despite the challenging climate of public school. Now, a rising fifth-grader, Jamie was again expressing anxiety over leaving the familiar landscape of fourth grade.

I first met Jamie when a mere sprig of a second-grader, who at the time was nervous at home and at school, fearful of making mistakes, prone to clashes with his parents and the occasional classmate as well as very sensitive to criticism. Our therapeutic play was at his pleasure, not my design, as I believed a client-centered approach best fit his growing needs. I trusted that through his drawing, role-plays, arts-and-crafting as well as popular culture-based story telling that he would play out exactly what he needed to express; and that my non-directive feedback would provide whatever additional insight he might have needed.

It was now two and-a-half years later, and there stood Jamie in the middle of my therapeutic playroom, surveying all the possibilities before him. Without flinching, he quickly went to work; reminding the bobo doll who was boss, animating a group of hand puppets in lively conversation about fears, worries and confidence, and finally turning to me saying “I’m done, let’s go talk to my parents about why they brought me here.”

And so it was! This little mango tree named Jamie told me exactly what he wanted and needed, reminding me of my role and its limitations while imparting a simple lesson that applies to mango trees and child therapy alike. Trust in their wisdom, potential to grow and ability to tell you exactly what they need. The measure of the bounty will be its own reward.  

Burning Out After Jumping In: Reflections From the F

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Some days, I question why I became a social worker. Other days, I wonder why I chose to work at an inpatient psychiatric facility for the past two years of my life. Coincidentally, these last two years were my first years in the field post graduate school. The reason I find myself working at an inpatient facility is a much less dynamic mystery—I was hired straight out of grad school by the hospital I did my first-year internship with. I remember it vividly. I was nearing graduation with a mountain of student loan debt, armed with an Ivy League education and ambition to help others. Secretly, I was crippled with anxiety about exiting the comfort that being in school provided. So, like most people, I jumped at the first job I was offered. Mystery solved.

However, wondering why I became a clinician is a recurring thought. Sometimes I find myself pondering the motivation behind my entire career path. On other more hectic days, I gravitate towards the more stress-fueled variety of that question: Why the (expletive) did I choose to dedicate my life to helping others who, more often than not, don’t want my help?! Why am I swimming in debt to provide services to patients who would rather do literally anything than attend my groups?

It occurred to me recently—can this be burnout so early in my chosen career? Is it possible to be burned out after two years of practice? Apparently so. Okay, so, we’ve established that I’m burned out. The question now evolves to—what do I do about it? I engage in self-care daily. I have a beautiful horse that I ride as much as possible; I have a wonderful husband who supports me in every way; I journal; I participate in mindfulness; I play with my dogs, I don’t take work home with me. But, on the worst, most chaotic days—that’s not enough.

If I’ve learned anything from my years on this planet—what’s right for one is not right for others. I don’t presume to have the answers for anyone but myself. Though, I know I’m not the first to wonder if it’s too late for a career change because I just can’t take anymore (just a side note—I’ve investigated essentially every profession that does not deal with other living human beings). So, I’m not sure if this is the “right” approach, but here’s what I’ve determined: burnout is eased by the days that a patient says, “thank you.” Okay, that’s ridiculously simple and people are rolling their eyes thinking, “Yeah, someone says thank you and then all your stress and compassion fatigue just vanishes?” Definitely not.

But, today a patient walked into my office. Uninvited… sure!, but “come on in” I said! He said to me, “When I first got here, you made me nervous because you are a smart woman. But, I have to tell you that I’ve learned so much from your groups. You have a heart of gold and have helped me more than you know.” This person then proceeded to recite ideas that were shared in my groups and was applying them to his particular situation. He illustrated how certain topics helped him in specific ways throughout his admission. I won’t pretend that this interaction erased the layers upon layers of burnout hovering over me like an aggravating, stress filled cloud. But, I can say with confidence that this conversation reminded me why I became a social worker. This five-minute discussion is the answer to the recurring question: why did I enter this field?

Burnout remains a mystery to me. I know I haven’t introduced an unfamiliar idea into the narrative around this subject. Though, if you’re anything like me, and you feel like you’re doing as much self-care as one human can possibly do yet continue to feel dread as you pull into the parking lot at work—then gratitude is the sprinkle of motivation essential to putting the car in park and carrying on with the day. And maybe it is just enough to keep me moving forward into this new and strangely rewarding career.
 

The Acronymization of Psychotherapy and Mental Illness

Posted on by Psychotherapy.net Team

According to the New York State Office of Mental Health (I randomly chose New York because it is my birthplace), an acronym is a “pronounceable word formed from each of the first letters of a descriptive phrase or by combining the initial letters or parts of words from the phrase.” Actually, this definition was news to me because what I’m really referring to in this blog is an “initialism”, which according to dictionary.com, is “a set of initials representing a name, organization, or the like, with each letter pronounced separately.”

Oh hell, what’s in a definition anyway and what does this even have to do with psychotherapy, or mental health for that matter? Let’s PTC…. pause to consider. Sorry, I couldn’t help myself.

Psychotherapy acronyms such as EFT (Emotionally Focused Therapy), ACT (Acceptance and Commitment Therapy) and REBT (Rational Emotive Behavior Therapy) share a certain mellifluence. They roll gently from our tongue and offer no mystery to the audience, who instantly knows exactly what complex forms of treatment they represent. Psychotherapy initialisms such as DBT (Dialectical Behavior Therapy), CBT (Cognitive Behavior Therapy) and CCPT (Client Centered Play Therapy) are a bit harsher on the oral musculature, but like their grammatical half-cousins leave no one wondering about the nature of the clinical intervention.

Psychopathology acronyms like SAD (Seasonal Affective Disorder), GAD (Generalized Anxiety Disorder) and ADD (Attention Deficit Disorder) leave us with the comforting knowledge that we have adequately captured the complexity of psychopathology with a catchy shortcut. In parallel, psychopathology intialisms such as OCD (Obsessive Compulsive Disorder, BPD (Borderline Personality Disorder) and PTSD (Post Traumatic Stress Disorder), while a mouthful in their own right, equally assure us that we “know” the person who sits before us in the consulting room.

I understand the essential reason for acronyms and initialisms in place of their parent terms. They are lexical placeholders; stand-ins for their meatier counterparts that ease communication between diagnosticians and psychotherapists. They are helpers. Or are they?

I think that these otherwise well-intentioned substitutes rather than simplifying, actually obscure, obfuscate and trivialize both psychotherapy and those struggling with psychiatric disorders. Instead of conveying meaning, they commodify the human experience and trivialize psychotherapy. They scientize and sanitize the pain and complexity of human suffering while creating the illusion that the complex and often unpredictable dance of psychotherapy is easily measured and fully understood. These reified and abbreviated pseudonyms, these shallow masks of meaning mis-cast light rather than illuminate, hide rather than reveal and hurt more than they help us to understand.

The solution in my not-so-humble opinion. Call them like they are. JSN! Just say no to acronyms and intialisms and resist the downward pull of simplification and commercialization in the place of understanding and compassion.  

When Your Client Dreams about You

Posted on by Psychotherapy.net Team

Things were not all good between my client and me, but I had no idea. She showed up promptly and consistently, seemed to like me, at times even told me how much the therapy was helping her. Yet she often seemed uncomfortable, preferring to fill the session with detailed accounts of her life rather than engage in the directly experiential way I like to invite. My role became that of a witness, a compassionate listener for sure, but rather a passive one. I thought, okay, this is our dance-step.

Then she brought the following dream: I was cleaning her house and had done rather a cursory job of it. The house was still so incredibly unkempt she had rolled up her sleeves and was tackling the lion’s share of the job herself. Later I show up with a flashlight and am opening up rooms she never visits, illuminating darkened corners.

The metaphors here are pretty darn obvious, so I won’t belabor them. If we read the dream as a commentary on the therapeutic relationship, I am clearly getting a mixed review – leaving her to clean up her own house because I’ve done such a bad job of it, but also encouraging her to look into areas (inside herself or in her life) that she would otherwise not visit.

What I love about this example is that the dream becomes the vehicle for the client to comment on the therapy process in a way that she would never have done otherwise. I try hard to level the playing field, be open and immediate with my clients, invitational, friendly, casual – in all ways endeavor to make the therapy relationship feel safe enough for clients to say anything. But often it’s only through dreams that I hear truly honest commentary on the things that don’t sit right with them about my job as their therapist.

This argument for listening to dreams extends further. In my personal experience as a client, I have found dreams open up avenues I would otherwise not walk down. The unflinching honesty of dreams at times makes me cringe – they are like that good friend who will tell you when you have spinach in your teeth or have behaved badly.

The most profound therapy session of my life was precipitated by a dream. I was born very premature and in the germ-phobic mid-60s, so I was kept sealed off in an incubator, touched only as needed for the first six weeks of my life. I had another near-death experience as an adolescent, when, convinced I was invincible, dove under a waterfall and then got carried deep underwater by the powerful current, nearly drowning before I resurfaced.

I had a powerfully scary dream that wove these two events together, and because I was seeing a Jungian analyst at the time, naturally I brought the dream to our session. We revisited the dream material, re-entered the dream, sketched it… but all this did was underscore the profound sense of aloneness contained in the dream. Then my therapist asked me to re-enact a part of the dream where I reach out and no one is there. In that moment, he grabbed my outstretched hand firmly and looked me right in the eye, reaching back across the years to provide a firm supportive presence to that lonely baby and that teenager. It was so unexpected it sent a kind of shock wave through my body.

This profound moment had ripple effects that ultimately shifted my sense of self and relationship. Yet I would not have brought the topic up had I not had that dream. I have now been working with dreams, my own and those of others, for more than 20 years. Sadly in that time, I have seen dreamwork fall out of fashion. I am hoping the examples offered here show that dreamwork is not just some quaint antiquated practice but one that has current relevance: we all dream about things that are deeply authentic and that are too often left out of the therapeutic conversation.