Category: Blog

Navigating Client Loneliness in the Digital Age with Therapy

Posted on by Psychotherapy.net Team

I’ve noticed a striking paradox in today’s digitally connected world: loneliness persists despite the abundance of online connections. Many of my clients grapple with profound feelings of isolation, shedding light on the intricate relationship between technology and loneliness. As digital interactions increasingly shape our social landscape, it has become important for me to delve into the possible underlying connection between loneliness and digital habits of my clients. By examining this paradox, I have been better able to support them in navigating the challenges of modern connectivity while fostering their interpersonal connections and well-being.

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Nurturing Non-Digital Relationships through Therapy

Social media and messaging platforms often create a superficial sense of connectivity, where likes and comments substitute for meaningful face-to-face interactions. Moreover, the pressure to maintain a curated online presence can amplify feelings of inadequacy and isolation. Excessive screen time and reliance on digital communication can hinder the development of deep, authentic relationships, ultimately contributing to a sense of loneliness and isolation. Understanding these detrimental effects of hyper-connectivity on social well-being has been crucial for me as a clinician working with clients who have been impacted in this way.

I’ve come to realize that while virtual communities offer a semblance of connection and support, they often pale in comparison to the richness of genuine, in-person relationships. Online interactions lack the depth and intimacy of face-to-face encounters, leading to a sense of emotional emptiness. Additionally, the curated nature of online personas can create a distorted perception of others, fostering feelings of inadequacy and isolation. Excessive reliance on virtual interactions can thus contribute to anxiety and depression.

In my clinical work, I’ve witnessed the pervasive influence of the fear of missing out (FOMO). This hyperconnected lifestyle often leads to a sense of emptiness and disconnection from the world around them. However, amidst the frenzy of digital connectivity, the concept of the joy of missing out (JOMO) offers a refreshing perspective. By consciously choosing to disconnect from digital distractions, my clients can potentially create spaces for meaningful real-life and interpersonal experiences. I have strived to promote awareness of these concepts and to empower my clients to prioritize meaningful off-screen/offline connections.

Case Applications

I recall working with Sarah, a 32-year-old marketing executive, who presented with profound loneliness despite her extensive online network. Spending hours each day immersed in social media and messaging apps, Sarah sought validation through digital interactions. However, despite the illusion of constant connection, she felt increasingly isolated from genuine human interaction. Through therapy, I remember supporting Sarah as she acknowledged the detrimental effects of hyper-connectivity on her social well-being.

Sarah’s treatment plan focused on dismantling her curated online presence, moderating her excessive screen time, and reducing her reliance on digital communication. Together, we explored alternative ways for her to nurture meaningful relationships offline. I emphasized the importance of face-to-face encounters and encouraged Sarah to connect with a limited group of friends in real-life settings.

In a similar manner, I supported Michael, a 28-year-old Latino construction worker, who experienced feelings of emptiness and isolation despite his active participation in online communities. Raised in a tight-knit community, Michael valued deep, meaningful relationships rooted in face-to-face interactions. However, his demanding work schedule limited his social opportunities, leading him to seek connection through virtual means. In therapy, I recall reflecting on Michael’s cultural values and exploring strategies for fostering authentic relationships offline.

Recognizing the importance of developing culturally relevant social skills to navigate interpersonal interactions, I suggested incorporating extended family members into Michael’s treatment plan. We discussed the idea of using role-playing exercises with his relatives to simulate real-life scenarios and practice social interactions within a familiar cultural context. By engaging with his extended family in these role-playing sessions, Michael gained confidence in initiating conversations and building rapport with others while staying true to his cultural heritage. These sessions provided Michael with valuable opportunities to develop his social skills in culturally relevant contexts, ultimately empowering him to forge deeper connections within his community.  

***

Technology presents a double-edged sword in the fight against loneliness. While it offers innovative solutions for connection, it also poses challenges, contributing to the erosion of traditional social structures. By promoting digital interventions that prioritize authentic connection and well-being, I hope fellow clinicians can empower their clients to navigate the complexities of loneliness in this complex digital age.

Questions for Reflection and Discussion

What is your opinion on the author’s view of technology and loneliness?

What has your clinical experience been with clients who have chosen digital over live connection?

In what ways does the author’s position resonate with you personally?  

Creating a Safe Therapeutic Space for All Feelings

Posted on by Psychotherapy.net Team

Yesterday, after a long silence, my client suddenly asked me, “did I offend you?”

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Where did that come from, I thought to myself. She had historically been so agreeable — almost too agreeable. I often wished she would occasionally say something offensive. I let these thoughts percolate as I considered how to proceed. I am trained to think twice before answering a question directly. Questions are fodder for the therapeutic process. I decided to delve deeper by responding with a few questions of my own. “How would you know if you did? What would it mean to you if I felt hurt? Have other people suggested that you’ve been offensive to them?”

A Therapist’s Secret Wish

I don’t let her know about my secret wish that she offer something offensive about me. Afterall, this was her process and I want to be careful not to project my feelings onto her, lest she become disagreeable to fulfill my aspirations for her instead of her own. That would defeat the entire purpose. Despite my success at navigating the conversation, my desire to be the recipient of a nasty comment did not abate. Perhaps I sound like a masochist who enjoys reveling in the psychological pain of being insulted. You might be thinking, is this a repetition compulsion? She should’ve gone to therapy to face her traumas not become a therapist to reenact them. Or maybe others would call me a martyr who sacrifices her own need for respect to keep her clients happy with her. She sounds Codependent. Is she in this for the right reasons? You might wonder.

I definitely do not have a penchant for pain. When someone insults me, I do not like the way it feels. Despite my best efforts to hold them back, my eyes often fill with tears in response to even a minor slight. Like most humans, I protect myself valiantly when I feel judged or criticized. Were I, in actuality, to be a martyr for the sake of keeping my clients happy, it would actually be pretty devastating to hear negative feedback. It would mean they weren’t happy with me. Wouldn’t that defeat the entire purpose of the sacrifice?

Here’s the thing; I’m no masochist and I’m definitely not a martyr. However, I am invested in my clients. I believe that for my clients to heal, they need a space where they are free to say and be whatever and whoever they want — including offensive. I might be a sensitive person, however, when I’m in my therapist role, my feelings are only welcome if they are in service of the client. If they aren’t, I set them aside to work through later.

In my experience, clients don’t come to therapy to be rude or offensive, especially toward the therapist. They certainly don’t want to be perceived as an ingrate by someone whose job definition is to help them. They are often ashamed of their selfishness and deny it, not only in the therapy room, but in their lives. But here’s a little secret; if they leave part of themselves outside, then part of them won’t heal. For therapy to work, they need to give voice to all their thoughts and feelings, especially their most shameful ones.

As a therapist, it is my responsibility to make space for the repressed voices of my clients. Good therapy grants permission to express what, outside of therapy, might be labeled socially inappropriate. Lack of this permission can reinforce ineffective patterns of repressing feelings and increasing shame.

The therapeutic challenge comes when, in instances such as this one, my own feelings are at stake. It’s relatively simple to support a client when their complaints are about “other things.” However, when their pain might be related to me, even if I had no intention to hurt them and despite the feeling that they are nitpicking, I feel obligated to face the Herculean task of supporting them just the same. Indeed, this selfless endeavor may be the most important and impactful act of therapy. If I can respond to an insult with curiosity, receive negative feedback without defensiveness, and authentically validate the valid, then I am giving my clients full permission to shamelessly express themselves. I cannot think of a better way to convey unconditional acceptance. But don’t get me wrong, I’m not giving permission for people to act how they please. Actions need boundaries. However, in therapy, I believe that words don’t and that words shouldn’t, even if and when those words are offensive.

***

So, as I think again about yesterday, I hope I can find a way to convey this message, “no, dear client, you didn’t offend me, but I hope that one day you feel strong enough to take that risk. And when you do, I will not abandon or reject you. Instead, I will be honored that this vulnerable and precious part is finally brave enough to join us in session.”  

Questions for Reflection and Discussion

In what ways is the therapist’s attitude in this essay similar or dissimilar from your own?

How do you address situations where your client offends you?

In what clinical circumstances might you NOT address a client’s offensive behavior?  

Reflections on Clinical Techniques for Working with Loss

Posted on by Psychotherapy.net Team

In the “helping profession,” it is easy to talk about how we handled our successes, but seldom do we openly speak about the failures, the ones who got away. The people who leave treatment and don’t come back, or the ones who take their own life. How do you reconcile this?

Losing Clients in Therapy

I remember sitting in a training group run by one of my mentors — the topic was treatment failures. He said clients come and go, and that few therapists get through their career without experiencing the death of a client.
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The Ones Who Come and Go or Don’t Come Back

Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.

On the Death of a Coworker

At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.

Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.

Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.

On the Death of Clients

True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.

The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.

In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.

The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.

I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.   

The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.

I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!

Questions for Reflection and Discussion

How have you dealt personally and professionally with losing clients?

How might you have avoided a particular client’s unexpected departure from therapy?  

What are your thoughts about attending a client’s or their family member’s funeral? 

How In-Person Sessions Create Space for Clients Unspeakable Truths

Posted on by Psychotherapy.net Team

Many of us have not gone back to in-person sessions even though the Covid epidemic has passed. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on long business trips or had some other compelling reason that made them unable to come in person. But beginning in March 2020 my practice transformed — all phone (or in a few cases video) sessions. After two years of living in my “weekend” house, I sold my office in New York and accepted the fact that my practice was going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.

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Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.

John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.

A Revealing Therapeutic Interchange

[Therapist’s thoughts]: I am aware that Sharon’s crotch is in full view. She does this often when she is wearing a skirt. I am trying not to look at her crotch while she is talking to me, but I have the impression that she is not wearing underpants. I think to myself that perhaps she is just wearing dark underpants. I start to question myself. Am I really seeing her genitals? Yes, I am. How should I handle it? If I ignore her exposing herself to me, I will be doing what her mother did — acting as if she is not a female with genitals. On the other hand, I know that however I say it to her, she will be mortified and furious at me. In the past, I felt the mortification would be too much for her, but this time I feel this is much more directly sexual than her sitting this way in the past.  

“Are you aware of how you're sitting?” I asked.

Sharon immediately put her knees together.

“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”

“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”

“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”

“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”

“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”

“You mean it doesn’t matter if your crotch is exposed or not?” I asked.

“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”

“You mean you feel like there’s nothing between your legs?”

“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”

“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”

“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”

“You didn’t offend me. But I think exposing yourself is a way of telling me something.”

“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”

“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”

“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”

“What about underpants?”

“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”

“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”

“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”

[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]

[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]  

“You mean your mother was masturbating in front of you,” I said.

“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”

[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]

*** 

Sharon’s traumatic childhood experience would not have been unearthed if I was talking to her on the telephone or video (which is face-to-face). On the phone or on video, she would not have been able to engender in me the same confusion, self-doubt, anxiety, and denial that she experienced as a child; she would not have been able to communicate the unspeakable truth. Telephone sessions may be useful for many patients, but for those who enact rather than verbalize their early experiences, it is not optimal.

Questions for Thought and Discussion

What are your impressions about this author’s clinical approach with this client?

Might you have done or said something different under these circumstances?

How do you address uncomfortable situations like these in your practice?  

Postmodern Play Therapy: Helping a Child Overcome their “Trouble Energy”

Posted on by Psychotherapy.net Team

When I was deeply entrenched in research, writing, and play therapy practice that incorporated superheroes, I learned about the importance of the origin story — the backstory narrative. It is no different in the context of this article, which is about what I call “postmodern play,” a term I use to describe play-based interventions rooted in Narrative Therapy. As a brief but related aside, I had just finished a book on the use of superheroes in counseling and play therapy when I was contacted by MSNBC to come on air to discuss what they, NOT I, called Superhero Therapy. When I sat excitedly in front of my television that night to watch myself, I noticed a chyron beneath my image that said, “The APA does not endorse Superhero Therapy.” Fifteen minutes of infamy, I guess.

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Ironically, I had never used the term, “Superhero Therapy” in my writing, nor did I profess my clinical work with superheroes to be evidence based. And so, it is here! The APA will never endorse postmodern play, nor will it ever attain evidenced-based status. And I aspire to neither.

But, as Irvin Yalom suggested in his Gift of Therapy, nonvalidated therapies are not (necessarily) invalidated therapies. So it has been for me, and postmodern play. In my child therapy work, particularly involving play, I have noticed that positive changes in the child’s world, both inside and outside of the therapy space, could often be explained by some of the core principles of Narrative Therapy, one of the postmodern approaches to therapy — which also includes Brief Solution-Focused Therapy. These core principles included a(n):

  • Strength-based orientation rather than one based on deficiency
  • Focus on the child as an agent of change
  • Externalization of the problem
  • Collaborative orientation to treatment that includes parents and teachers
  • Author-editor relationship between therapist and child
  • Future orientation that draws upon past successes
  • Articulation of preferred identity through storying
  • Personalization of outcome measures
  • Understanding that children have islands of competence

Channeling Trouble Energy in Play Therapy

As an example, I recall 8-year-old Liam, who came with his parents for help with “his” problems of stealing food, his mother’s jewelry, and temper tantrums — exclusively at home when he was confronted with his misdeeds. Born in Asia, Liam was adopted in early infancy and seemed to be progressing nicely through his developmental journey. But something was happening that was giving rise to this relatively new spate of behavioral problems. During the intake, the parents and I wondered together if the racial/cultural difference between him and his parents was contributing to an emergent and distressing sense of “otherness” — they rarely, if ever, discussed the adoption, Liam’s origin story. We wondered if he was trying to process the loss inherent in the adoptive process, stealing as a way of filling a gap. We wondered if the marital tension between them was creating a bed of unrest and insecurity for Liam. We wondered!

When Liam came to my office the following week, I was met by a very poised, articulate, and interesting child whose vigorously shaking leg suggested that deeper currents of emotions ran just below the surface of this very seemingly contained boy. Drawn in by that current, I wondered aloud about the “energy” in his leg, and asked in what other parts of his body does he sometimes feel such energy. He played right along and said how sometimes that energy goes to his stomach, and sometimes arms, and together, we called it “body energy.” We explored this body energy when it started and whether he liked it, whether it got in the way sometimes and what he typically did with it once it appeared.

From there we launched into a conversation of other possible types of energy that he had, and as I asked him to describe some of his interests, which included history and origami, I asked him if he could label that energy, to which he responded, “art energy and learning energy.” A bit later in the conversation, when our conversation turned to the concerns his parents had around his stealing and angry outbursts, he quite spontaneously came up with the notion of “trouble energy.” I asked him to pick a colored piece of Play-Doh and show me how big trouble energy could be in his life, and he offered an apple-sized ball of Play-Doh in his little hands. That was the sum total of our intake and treatment plan.

The clinical work in the following weeks consisted of:

  • Play therapy with Liam using the sandtray to act out play out scenes of family separations and reunions
  • Playful conversations about trouble energy in his life, and what he wanted to do with it and its influence
  • Liam sharing his vast knowledge of world history and “trying” to teach me origami
  • Discussing simple behavioral methods for the parents to use when Liam expressed anger and took things
  • Collaboration with his teacher around additional sensitivity to his needs, and
  • Occasional family drawing time during which Liam and his parents expressed themselves freely.
  • Referral of Liam’s parents to a marital counselor which they happily agreed to.

I never doubted that Liam was content with allowing trouble energy to rule his life, and I always had confidence that his parents and teacher could and would work together to support him and bring out the best in him. As a tip of my hat to readers who might be wondering, “well, what was your outcome measure(s),” I offer the following which is Liam’s depiction of trouble energy at the time of our last session at right, in contrast to trouble energy at the beginning of our work, at left.

I also offer the words of David Nylund, speaking at the Pan Pacific Brief Therapy Conference in Japan in 2001, regarding outcome measures in a postmodern, narrative play therapy context. He said, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person is able to reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”

***

My work with Liam and his family was complete, satisfactory to all involved. His tantrums subsided, the family re-visited and openly discussed the story of his adoption, and his feelings about it, and the stealing ended. I trust that my description of the work adequately captures the core principles and methods of what I call postmodern play therapy. Chyrons not withstanding!

Questions for Reflection and Discussion

What are your impressions of this author’s work with Liam?

In what ways have you found narrative therapy to be helpful?

What about this approach do you find interesting? Helpful?

Ink Therapy: Harnessing the Power of Vintage Self-Help Books

Posted on by Psychotherapy.net Team

My dad was an avid reader, visiting the library weekly as well as purchasing new and used books. As a teenager, I spied a vintage copy of a 1957 work titled How to Live with a Neurotic: At Home and Work and snuck it into my tiny bedroom.

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A Very Brief History of Self-Help Literature

I couldn’t attain complete privacy in my room, shared with my brother, due to the 6-foot barbell we stored under the bed preventing the door from closing fully. But seriously, for the most part who needs privacy when you have weightlifting to focus on?

I discovered the book was written by Albert Ellis, a New York clinical psychologist, and I thought his ideas were monumental. I made up my mind right then and there that one day I would write my own book and interview Ellis. Indeed, many years later, when Ellis was 89 years young, I did, and the interview was much more intriguing than I ever could have imagined. But I digress. 

As a graduate student, I came across his name again, only this time he had teamed up with another clinical psychologist, Robert A. Harper, to pen a 1975 edition of A New Guide to Rational Living. The word “new” was added to the title since the original version was released in 1961. The book outlined how to use Albert Ellis’ Rational Emotive Therapy or RET (now Rational Emotive Behavior Therapy or REBT) to enhance happiness in everyday life. 

Simply put, I thought it was hands-down the best self-help work I had ever read. It turned out I was not alone in my opinion. The head of the publishing company, Melvin Powers, a lay hypnotist and self-made millionaire, whose picture graced the book cover along with his wife, agreed. Powers, one of the premier publishers of paperback self-help literature, said in the foreword, “it may well prove the best psychotherapy book for layman ever written.” Powers ended the foreword with, “You have my best wishes in reading a book that I think will remain the standard for years to come.” (Don’t you love it when others concur with your opinion?)

If the book had an Achilles heel, it was that the text might have been a little too complex for the average person to understand. But an answer was right around the corner.

Enter Wayne Dyer, a counselor educator at St. John’s University, who, after studying Ellis, created an easier-to-comprehend and much more popular book titled, Your Erroneous Zones in 1976. According to some estimates, 100 million copies have been sold! Behind the scenes, a controversy brewed with Ellis claiming Dyer stole his ideas and gave him no credit in Erroneous Zones. Dyer became one of the most popular lecturers and a guest on thousands of television and radio talk shows worldwide.  

The bottom line is that these classic 60s and 70s bibliotherapeutic works are still a goldmine for clients in 2024 and beyond. As I often quip, “Good counseling and self-help never goes out of style.” I have often heard therapists assert that the 1960s and 1970s were the golden age of self-help.

Self-Help Guidance for the Next Generation of Therapists

A few other gems from the era you could suggest as bibliotherapy to assist your current clients could include:

The blockbuster and often provocative 1964 transactional analysis (TA) text Games People Play by the founder of the theory, former psychoanalyst Eric Berne. Or another TA flagship work, I’m OK – You’re Okay, by psychiatrist Thomas A. Harris in 1971.

Taking this theme a bit further, Muriel James and Dorothy Jongeward wrote Born to Win: Transactional Analysis and Gestalt Experiments in 1971, integrating the work of Fritz Perls into the equation. TA made psychotherapy and self-help fun using words like Parent, Adult, and Child, in place of analogous and confusing Freudian terms such as Super-ego, Ego, and Id.

As a final example, clients who wish to blend psychology with spirituality could benefit from M. Scott Peck’s 1978 The Road Less Traveled.  

One unique feature of the books from the era is seemingly that they crossed the invisible line between textbooks/professional literature, and self-help or so-called pop psychology. To put it another way, these works, and many others like them, were as at home in a graduate counseling, psychology, or social work class as they were in the hands of people outside of the mental health field struggling with marital issues, addiction, depression, anxiety over public speaking, or many other challenges of everyday life.

In embracing the timeless wisdom of vintage literature, our current clients can unlock a treasure chest of insight from the past. It’s not just about self-help, it’s about tapping into a reservoir of wisdom that transcends time, offering guidance and solace to all who seek it.

Questions for Reflection and Discussion

How have you used self-help books with your own clients?

Which of the author's favorites have you used either personally or professionally?

What other newer self-help books have you found useful in your practice  

Advice for Young Therapists: A Long View

Posted on by Psychotherapy.net Team

I am in my 70’s and still working full time as a psychotherapist. Psychotherapy has been my career, and never simply a job. It represents who I am and has never simply been a way of making money.

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The world in general is always confounding, and the field of psychotherapy can be perplexing as well. There are so many schools of thought, treatment approaches, new ways of practicing therapy, and the potential of radically new types of intervention on the cultural horizon. I have become increasingly interested in how beginning clinicians feel that they fit in, and where and how they develop their personal and professional skills.

A Veteran Therapists Offers Wisdom to a New Generation

As I approach the late phase of my career, I feel a desire to share viewpoints and learned lessons with beginning therapists, regardless of their age. As a veteran therapist, I think it is important to pass the baton, and share key concepts that might clear some of the potentially confusing path forward.

As a therapist, I have strived to help my clients strengthen and broaden the range and the quality of their personal relationships and their active involvement in the world. Too often in therapy, the arrow of attention points inward on the individual, assisting them to forge their own way through the challenges of life. While that is often a right and necessary focus, it is not a complete view of the role, or the potential, of therapy.

I have learned to help clients focus that arrow outward towards relationships, skill acquisition, the assuming of roles, and building up the clients’ productivity and sense of purpose. It has never been solely important for me to help the client be better within, but also better with others, and better able to effectively contribute themselves to the wider world.

In writing this, I hope that early-career therapists participate in the development of psychotherapy, not simply in their own practice. Learning new techniques along the way is certainly important, but I have always valued the importance of filtering their value through tried-and-true perspectives and approaches.

I can’t overstate the important contributions of three particular therapists. Carl Rogers (On Becoming a Person: A Therapists’ View of Psychotherapy), Viktor Frankl (Man’s Search for Meaning), and Erik Erikson (Life Cycle Completed) have provided me with a firm foundation for a therapy career, and a yardstick against which to measure the value of newly emerging ideas.

Carl Jung suggested the therapist should learn everything, then forget it when they sit down with the client, but that learning should not be limited to the theories and history and techniques of psychotherapy. I have come to appreciate the importance of mythology, religions, folklore, theater, poetry, and literature — each of which have become resources in my personal and professional development. Absorbing the wider context of art and culture through history has helped me to view the client and their relationships in new ways. Yes, the dynamics of the psyche are important, but so too is the client’s (and therapist’s) place in the dynamics of a long and vibrant history of human culture and creativity.

The great 13th century Italian poet Dante, wrote the three-volume masterpiece “The Divine Comedy: Inferno, Purgatorio, and Paradiso.” At the beginning of the first volume, Dante becomes lost in a dark wood, midway through life’s journey. He was guided and tutored in his subsequent trek by the ancient Roman poet, Virgil, who is said to have represented human reason.

Lost in a dark wood during one’s journey. Talk about a universal experience! Life can be so complex, and so difficult at times — both client and clinician can find themselves lost on their respective journeys. Many of my clients have come to me for guidance and tutoring in their journey through the thicket of their hardships.

I have come to seek wisdom in my work as a therapist, as someone able to blend art and reason in my effort to accompany others through the descents and ascents of life. As a psychotherapist, I aim to guide and educate others through their darkest troubles, and towards recovery, and/or attainment of their fullest capacity for love and a purposeful place in this wide world.

Questions for Thought and Discussion

What impact does this author's words have on you as a person and as a clinician?

What have you learned thus far in your professional journey that you might want to pass on to others?

In looking back, what life's lessons have you brought into the therapy space?  

The Elder in Exile: Psychotherapy with Older Adults

Posted on by Psychotherapy.net Team

A frustrated and depressed nursing home resident recently described the facility as “a place where unwanted elders can be exiled.” Through our therapy conversation in that session, he came to acknowledge that he did have problems with his memory and his health, and that his facility residence was reasonable — even though unwanted — and was not a rejection by his son. “I know he’s only doing what he thinks is right for me.”

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The Emotional Plight of the Nursing Home Resident

Many residents of nursing homes view their predicament as a rejection, or an exile, or an imprisonment. Many blame family members for the situation and try to pull the heart strings of loved ones in efforts to get them “to take me home.”

Many adult children weep as they speak with me about the conflicts they feel over the placement of their mother or father in the facility. Daily care at home with family is desired by all, yet available to only a few.

The older person living in the nursing home may feel a loss of home, family, their former roles, and too often, their sense of the value of their life. Some older people feel not only cast out by others, but inadequate due to the infirmities of their advanced age and their medical problems.

As I speak with seniors in psychotherapy at nursing homes, I discuss the specific aspects of their situation and seek to place some of their experience in a broader cultural and societal context. For example, I talk of ways that “the Elder” has traditionally been venerated in human societies.

Whether sitting around a fire in the cave, or in a small tribe, or a simple village, it has been the Elder who others looked to for history, stories, and advice. The younger members of the tribe or clan or family came to the Elder to learn the lore and lessons of their people. Others listened to and memorized the stories told by the Elder, and those stories they passed along when they, in turn, became an Elder.

The older nursing home resident might feel adrift from their family and their former life, but the value and the lessons of their life endures, and the sharing of their personal stories — whether in life-review therapy, with family, or with others at the facility, is a key part of reclaiming and affirming the value of their experience.

I encourage residents to share their stories with me and others in their life. I point out and affirm the dignity and value of the person’s journey through a long life. I speak to seniors of ways the society has changed, and how elders might not socially be held in the respect that their lives deserve and have earned.

Some people have suggested that nursing homes ought to have daycare programs attached to them, for the mutual benefit of old and young. But I think that it might be more productive, and developmentally appropriate, to have programs for troubled teens associated with nursing homes. Then, a teenager might share her problems about a relationship, her parents, school, or a career choice, and the senior might be able to understand and share suggestions, relate anecdotes, and offer guidance that might be helpful and in line with the long history of ways younger persons have been helped and guided by the wisdom of the Elder.

“Okay, but I don’t know if I really am wise, and I have all kinds of problems,” an elderly lady said as we discussed these ideas one day. I point out that throughout the long history of human life, the Elder who others looked to and venerated, likely also experienced problems with balance, and with short-term memory, and with urinary incontinence; but that did not erase the value of what they could contribute to younger generations.

It is important to share the stories of one’s life. As we age, we might become less active, and we might forget some of the recent events, but we might retain long-term recall of long past events and situations and relationships — and the sharing of those stories can enrich the understanding and the development of the younger person.

A nursing home sponsored a program a few years ago in which all the staff wore a round metal pin labeled “I’m a Future Senior Citizen.” That program enhanced the awareness of younger workers about the aging process. We each may now be, or may later be, senior citizens. Aging does not invalidate the adventures and lessons of a full life. A key task for the elderly person is to share their tales, and that is as it ever has been, and should be. And one of the most valuable tasks a therapist can undertake with the elderly is to give them the opportunity to share their story. 

The Benefits of Making Metaphors Meaningful in Psychotherapy

Posted on by Psychotherapy.net Team

“Nature cocks the hammer and experience pulls the trigger,” said the presenter. Everyone nodded, in seeming understanding, that in the context of the presentation, eating disorders, too, are more complicated than learned behavior. Grinning at this clever metaphor, I slipped it into my back pocket for when the nature-nurture discussion would invariably arise in my abnormal psychology class.

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Metaphors, as figures of speech, have various conversational and literary roles. They also offer powerful therapeutic opportunities for clients that, in my experience, have ringed unconscious bells and helped them to make connections and draw important conclusions. I have always enjoyed using them in treatment, particularly those moments when a well-chosen metaphor has breathed new life into a therapeutic relationship.

Fred: Testing Therapeutic Waters

Fred was a 25-year-old graduate school student studying earth sciences. He sought therapy because, according to his girlfriend, Heather, he was “in a funk again.” Heather, who accompanied Fred to his first session, also pointed out that he never spoke to her about how he was feeling during these “funks,” which strained their relationship. Overall, the couple had a lovely relationship, but periodically, particularly when school and work stress billowed, Fred lapsed into one of these brooding episodes, which could last days.

“Fred,” I began, “I see you just listening in over there. What do you say?”

“Why should I let my crap bother other people? It’s hard to explain when that happens, anyway. I’ll deal with it,” explained Fred, providing common “logic” often exposed in couples’ work.

“God! You think keeping your stuff to yourself is protecting me somehow,” cried Heather. “I don’t know what’s going on with you when that happens, and it hurts that you’re unwilling to let me in or at least try to talk to me. Now we’re in a therapist’s office. It doesn’t help me to see you suffer.”

To test the waters, I asked Fred what it was like listening to Heather say that. He leaned on the arm of the couch with his forehead in his hand, remaining reticent. Clearly there was room for improved communication, and I had to figure out how to provide Fred with a new perspective to help the couple gain momentum.

During a subsequent session, Fred looked particularly tired and noted that he “felt like deadwood” that afternoon. Noting his “dead” reference, a metaphor that took advantage of Fred’s interest in earth sciences took shape that might illustrate the benefits of communicating emotions.

As the session took shape, I awaited an opportunity to capitalize. The metaphor goddesses were with me, for Fred commented that his classes were draining him.

“Surely,” I began, “you’ve had a class studying the world’s great bodies of water,” getting Fred’s attention.

I continued, “You know, the Dead Sea and the Red Sea are both fed by rivers teeming with life, but nothing survives in the Dead Sea. Do you know what makes the difference?” Fred sat quietly, considering the query, and shrugged. “The Dead Sea has no outlet,” I finished.

Looking up, Fred, nodding, reflected, “It isn’t flushed out, so stuff stagnates and dies.”

The bell was rung, and the message was clear. He was periodically stagnating like the Dead Sea because he was not expressing his emotions and dealing with his conflicts, contributing to his “deadwood” feelings. In the rest of the session, Fred was able to start reframing the consequences of his internalized emotions and why communicating them was important.

Beth: Metaphors to Guide Diagnostic Conversation

While I have found metaphors to be therapeutically useful in guiding patients to new understandings, sometimes patients have used a metaphor to help me understand their experience. While I would never diagnose someone based on a metaphor, I have used them to guide diagnostic conversations.

Beth was a 31-year-old professional who sought therapy because she had been feeling increasingly moody and exhausted over the preceding few months. After being checked for Lyme, low iron, thyroid complications, and other medical causes, her physician suggested Beth meet with a therapist.

“I feel like I’ve been living on an emotional rollercoaster” she described in our first meeting. While more of an analogy than metaphor, I thought there might be a way to capitalize on this poignant description.

In my clinical experience, “emotional rollercoaster” is a common way that clients, or those in close relationship with them, have described the experience of bipolar disorders or borderline personality disorders. I have had to be cautious; however, not to jump to conclusions in instances like these. Afterall, jumping from a roller coaster can be hazardous to clinical health (I couldn’t resist). “Beth,” I replied, keeping with her description, “I don’t spend much time in amusement parks, but I know there are all different sizes and intensities of coasters. If your emotional experiences were actually a roller coaster, how would you describe the one you’re on?”

Chuckling at the idea of trying to guide me along, she explained, “It’s not fast with steep hills and loops,” she began, “but sometimes I feel totally unbalanced and like I’ll fall off, like my head’s just not on straight.”

“Tell me more about that ‘head not on straight’ description.” Beth shared that she frequently just couldn’t gather her thoughts and focus well, as if “nothing wants to germinate in my mind.” It took extra time to think things through, especially at work where critical thought was involved. Beth added that, at home, she felt lazy and zoned out much of the time, even if she might want to do something. “It’s exhausting,” she signed.

“That doesn’t sound like much motion; a roller coaster moves,” I observed. “What’s the emotional ‘ride’ you initially mentioned?

Beth continued, “Well, most of the time, I feel unenthused and tired, but I get irritated so quickly and can stew on something. It could be how I hate feeling like this. It might be at a friend I’m on the phone with and they don’t silence their dog in the background. It’s so annoying and rude! I’m just mad, and that irritates me more because it doesn’t feel good, and then I’m exhausted again.” Beth detailed that it often happened daily or just a couple times per week.

It seemed her mood changes were generally reactive and short-lived, superimposed on withdrawal and malaise. After more interviewing, she failed to describe anything indicative of the moodiness ever spiking into hypomania/mania or having psychotic symptoms. The fatigue, slow cognition, lack of enthusiasm and dysphoric mood that Beth described was indicative of someone who had been depressed for months. And there it was!

***

I have come to appreciate that planting a good metaphor is like cultivating the flower instead of pulling out all the weeds.

Finding Ways to Communicate with Clients About Their Symptoms

Posted on by Psychotherapy.net Team

Some nursing homes tend to have few, if any, residents with major mental illnesses. There are other facilities that have many residents with a mental illness, and those are the nursing homes where I prefer to work.

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Many of the clients I see for psychotherapy have a long history of mental illness. Few, though, report having been educated in helpful ways about the symptoms of their condition. When education has been presented, it may have been in technical language that might be perplexing or off-putting for the client. Finding ways to communicate effectively and sympathetically with a client requires artful attunement to the inner experiences of that person.

A 50-year-old lady with a diagnosis of anxiety, described her symptoms as “sweats, shaking, very nervous, and feeling pulled away from things.” A 72-year-old lady movingly described depression as “a heavy something that weighs on your brains, and you can’t think beyond that feeling — until someone helps bring you out of it.”

Asking someone to describe the symptoms of a mental health condition can be a helpful way to begin the process of deepening and clarifying their self-understanding. It can also be helpful to use some of the language and concepts of the client as a starting point, while avoiding sole reliance on technical jargon about mental illness. I’ve found that many clients have developed a defensive deafness to such language, anyway.

Helping Clients Understand their Symptoms

One way that I approach conversations with clients about their conditions and symptoms is through an exploratory series of questions:

How do you know when you are experiencing depression, (anxiety, bipolar symptoms, difficulty telling the difference between things real and unreal)?

How do others know when you are feeling depressed (anxious)?

Do you sometimes feel depressed, anxious, or have mood changes, or have maybe unreal experiences and others don’t notice?

What might others need to pick up on to recognize when you feel depressed, anxious, or afraid?

In general, individuals experiencing anxiety and/or depression may be interested in and receptive to education and discussion about their symptoms.

Yet many persons with a schizophrenic illness might deny the condition and rationalize the symptoms — due to stigma and shame, and due to limited capacity for logical reasoning. “I don’t have schizophrenia, I’m psychic; I get psychic attacks,” suggested Martha, who, nonetheless, is sometimes willing in therapy to directly acknowledge her schizophrenia, and her peculiar experiences as being symptoms.

Therapeutically educating a client about symptoms of schizophrenia might start with distinguishing things that are subjectively real from those that are objectively real. We might discuss inner perceptions and beliefs that may be real subjectively but may not be objectively real. Some already feel as though they live in a separate and inward world, somewhat apart from others.

Recently, I have begun experimenting with using a Venn diagram of three overlapping circles to illustrate differences between subjective and objective experiences. The first circle, on the right, is labeled as the client’s inner, or subjective world. In that circle are listed several of the specific symptomatic experiences already discussed in therapy, that the person might confuse as being real. The second circle, on the left, is labeled as the outer, or objective world. The overlapping middle circle represents the client and me in therapy, looking into each world to make connections and distinctions. Here is a compilation of some selected items from the right-hand circle for five clients: psychic attacks, mind-boggling thoughts, curses and accusations made by voices, paranoid thinking, anger, depression, anxiety, my make-believe world, messages received from the TV or radio or unseen persons. The list in the left-hand circle would include the facility, medical and psychiatric diagnoses, and related care and treatments.

I draw arrows to show, for example, how the experiences in the inner world circle are symptoms of the psychiatric diagnosis in the outer world circle, and how medications and psychotherapy from the outer world circle are intended to address the symptoms. Clients have shared poignant responses to lessons learned from this approach.

Cameron said, “This helps me understand mental illness. I feel relieved when we talk like this. I get it mentally, about what’s going on.”

Betty said that “Nobody ever told me this. It makes me understand what’s going on in my head better.”

“That means we’re on the same page, I appreciate that,” suggested Martha. “You understand what it’s like for me.”

Richard said, “Sometimes I think it’s real, and sometimes I don’t; it’s hard to tell. It relieves my mind when we talk about it.”

Donald said that “I’ve gotten a lot more mature and rehabilitated talking to you, Tom. I just don’t know what to say sometimes. It’s a big thing for me to get up to this level of reality. It’s your words that make me feel I’ve turned.”

For multiple reasons, it can be difficult to educate people with schizophrenia about the psychiatric nature of their subjective experiences. I had the impulse to try the Venn diagram with one client, and his response encouraged me to try it with a few others, as well.

***

I don’t use this approach with all clients, as some may be too delusional at the time to experience benefit. The people I have tried this with each showed some willingness to question the validity of their unusual subjective perceptions and beliefs. So far, I have only tried this approach with these five clients, and I have been pleasantly surprised, and touched, by their responses. Other therapists may wish to experiment, as well, with this simple, yet promising technique.

Questions for Thought and Discussion
What is your reaction to this therapist’s approach to explaining symptoms to clients?
What methods have you used to help clients understand their psychiatric symptomatology
With which clients might this approach be effective? With which others might it not?