Category: Blog

Psychotherapy Training on Steroids: Remote Live Supervision

Posted on by Psychotherapy.net Team

Note to readers: This blog is dedicated to exploring new training tools and techniques to help us become better therapists.  May we all become “supershrinks!"

Learning a psychotherapy technique can be like a romantic tragedy.  You go to the workshop, fall in love with the technique (and occasionally the presenter), and go home with fantasies of all your therapy cases getting unstuck.  On Monday morning in your office, however, everything falls apart:  you can’t remember the techniques (despite the post-its), you can’t do them correctly, or, even worse, you do the interventions perfectly but the client responds totally differently than how the clients in the presenters’ videos responded.  Sometimes I want to yell, “No, you are supposed to cry when I say that line, and get angry when I say this line!”

Most training and supervision lacks the most important variable in therapy:  the client.  The best training occurs in an actual therapy session.  I want to know what techniques to use with my client, not the client in the case reports or videos.  But what if the expert I want to learn from lives across the country, or I don’t have a one-way mirror room?   Now, thanks to internet, I can bring him into my office.

I would like to share a new method of supervision that has been made possible by recent technological advances.  “Remote live supervision” allows a supervisor to observe a therapy session over the internet and give feedback to the therapist in real time.  The technology is inexpensive and easy to setup.  This new method has promise to greatly increase the accessibility of top-quality supervision and training across the field of psychotherapy, as therapists will no longer be limited by geographic distance. 

Specific instructions on how to set up the remote live supervision for both PCs and Macintosh computers, along with a discussion of technical issues, can be found here.

Combining the video of the therapy session with the transcript of the supervisor’s moment-to-moment comments makes for a powerful training tool, as trainees get to see the actual results of following (or not following) the supervisor’s interventions.  Another option for training is group video, where a team of trainees can observe a remote live supervision in real time.

I do remote live supervision with Jon Frederickson, MSW, to accelerate my learning of Intensive Short-Term Dynamic Psychotherapy (ISTDP), an affect-focused therapy effective for healing trauma, anxiety, anger, relationship problems and somatic symptoms.   One aspect of ISTDP that can be challenging for trainees to learn is how to identify and address the automatic, unconscious behaviors clients use to maintain an emotional distance between themselves and others (including the therapist), such as rationalizations, talking in hypothetical terms or being vague.   In a review of my work, I found that I was missing my clients’ distancing behaviors, and many sessions could go by without a significant emotional experience or change for the client.  

Of course, the client is not the only person in the therapeutic dyad who can unconsciously create emotional distance.   Colleagues in a consultation group helped me identify my own pattern of unconscious emotional distancing, especially when working with male clients who were emotional distant or angry.   However, I was unable to translate this insight into change in the therapy room.

Through remote live supervision I have been able to get immediate, moment-to-moment identification of distancing behaviors, by both the client and myself, in real therapy sessions.  Live supervision can be very challenging, especially when it addresses my own avoidance.  It is, however, extremely effective: Jon’s real-time feedback has resulted in multiple breakthroughs of sustained, heavy grief and character change in clients for whom therapy had previously been stuck.

If you have a new psychotherapy training technique you would like to share on this blog, please email me.

Rules for a Good Relationship

Posted on by Psychotherapy.net Team

1. Never go to bed angry.
Stay up all night yelling and screaming. After the way your partner behaved, he doesn’t deserve to sleep.
 
2. Don’t jump in to help when your partner is telling a joke
–unless, of course, you can tell it much better.
 
3. When fighting, take a time out.
That will give you a chance to come up with more devastating putdowns.
 
4. Don’t interrupt your partner.
You need to have all the facts in order to show her how totally wrong she is.
 
5. Don’t mind read.
Your partner might be thinking awful things about you that you don’t want to know.
 
6. Don’t dump out all your stored-up complaints.
Keep a few in reserve so you won’t be caught with nothing left while your partner still has four or five.
 
7. Restate your partner’s message.
Let him see how truly irrational it is.
 
8. Make “I” statements, not “you” statements
–except when nothing but a good “you” statement will do.

9. Don't say "always" or "never"
–except when you need it for added emphasis when your partner won't admit how totally wrong he is.
 
10. Don’t raise your voice.
You can have so much more effect by speaking softly between clenched teeth.
 
11. Don't  try to change your partner
–except, of course, for the few things that really do need changing. In fact, make a list.

Suicide During the Holidays . . . Not So Much!

Posted on by Psychotherapy.net Team

We've all heard it on a local or national television or radio station, "And when we return after the weather, we'll examine the tremendous increase in suicide during the winter holiday season."

Well that's great, except for one small thing: It doesn't exist. In fact, the direct opposite is true.  The suicide rate generally hits a peak during April and May.   The National Center for Health Statistics placed November and December as the months with the lowest daily rates of suicide.

All major holidays with the possible — notice I said possible — exception of New Years have lower suicide rates than other days of the year with Thanksgiving and Christmas posting extremely low numbers.  Now you will invariably think I am wrong because on Christmas Day some poor soul will take his life and the media will showcase the suicide on the front page of the newspaper. Chances are you will also see it as the top feature story on the local five o'clock news. Keep in mind, however, that if this tragedy occurred on any day that wasn't on a holiday the story would appear on page 54 of the paper next to the classified ad for a Basset Hound in search of a home . . . if the story appeared at all.

The adept therapist will conduct suicide assessments everyday of the year.  Key clinical hint: If you wait until you hear Elvis singing Blue Christmas to start asking client's if they feel suicidal, then you've endangered the lives of your clients for approximately the first 340 days of the year.

What if Its All Been a Big Fat Psychotherapeutic Lie?

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In the early 90's I developed a classroom exercise to teach my students an important academic lesson. This is one of those experiential exercises where the professor feels holier-than-thou because he or sheknows the outcome in advance. First, I placed the students in groups of two's and asked one of the students to play the part of the helper while the other played the part of the client who tells a real or fictitious problem.

Next I pulled the helpers into the hallway. During the first trial the helpers were merely instructed to give the clients advice, suggestions, ask lots of questions, be extremely directive, and provide psychological interpretations. There was absolutely no empathy, warmth, or relationship building . . . I repeat no relationship building.  This session was a strict Rogerian's worse nightmare.

I then gave the helpers and the helpees about a five or ten minute session together. I then pulled the folks playing the helpers out in the hall once more and explained that during trial number two they were forbidden to give any advice, interpretations, or suggestions. They were also told not to ask the person playing the client any questions. Instead, they were merely instructed to be totally nondirective, paraphrase, reflect, and make statements that conveyed a high degree of empathy. Using the same partner with the same problem, the students were given another five minutes together.

Next using a scale of 0 to 100 (in which 0 is terrible, 50 is average, and100 is perfection) the students playing the part of the client were going to rate their helpers. Needless to say, I knew that the clients would rate their helper higher during trial two; except for one thing: it didn't happen!  The ratings for the first session devoid of empathy were significantly higher.  In fact, it was a blow-away landslide in favor of the directive approach. Say what?

I mentally scratched my head and made a joke out of the whole experience, convinced the results in this class were merely an anomaly. "Listen," I told the class, "I knew you guys were strange, but I didn't know how strange." I then explained that exercises in class often do not parallel what transpires in the real world of therapy.  Secretly, I also told myself that these were undergraduate students that most likely didn't do the interventions correctly.

There is only one problem: I have now been doing this experiential exercise (switching the order of the trials) for approximately 17 years and I can't remember a single trial when the relationship building non-directive approach won when I looked at the results for the entire class! And while no self-respecting researcher would be impressed by my experimental rigor, they would be impressed by my N; over 1000 individuals have now participated in my therapeutic scenario. Since the aforementioned first trial I've added grad students, probation and parole officers, guidance counselors, therapists in training seminars, and therapeutic supervisors, to the rank of participants.

How can this be? Many, if not most, research studies insist empathy is the most important trait for a counselor. I nearly always use what I consider a Rogerian, person-centered, non-directive, heavy on the empathy approach during my initial sessions with a client even if I plan to switch to more directive interventions during subsequent sessions. Heck, it has to be true, it says so in most counseling books, including some I have penned! So what is the explanation for these seemingly contradictory results?

1. Well, there's the rationale (or should I say rationalization?) I've been giving to my classes and in seminars for years now; simply that students and workshop participants are not like real clients and this exercise would turn out differently if we used real clients. In other words, the folks in my classes or seminars are training to work in the field or they are working in the field and therefore believe in suggestions and advice . . . no empathy necessary! The problem with this explanation is that often students are real clients, otherwise we wouldn't have college and university counseling centers.  In the case of therapists, many do seek treatment from other helpers. Indeed, if my armchair experiments are on target then relationship building, non-directive, empathy laden initial sessions, should not be used with those in the field or folks planning to go into the field.

2. Students, grad students, or helpers in the field don't really know how to perform person-centered, Rogerian slanted interventions. Maybe it's just too complicated. Although this is theoretically possible, the eminent psychologist Ray Corsini once told me that Rogers confided in him that he could teach anybody to do client-centered therapy in two weeks.

3. The paraphrasing, reflecting, and rating responses on an empathy scale paradigm we use to teach this approach actually bears little or no resemblance to what Carl R. Rogers was actually doing with his clients. Hmm that's certainly conceivable. Or . . .

4. What if it has all been a big fat psychotherapeutic lie?

As for me, well at this point in time I guess I must admit that despite a wealth of experience and knowledge, I remain a psychotherapeutic agnostic. You decide.

Bids for Emotional Connection in Couples Therapy

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John Gottman’s concept, “bids for emotional connection,” is practically a complete theory of relationships in itself. Hearing the word “bids,” we picture partners reaching out to each other in a variety of ways. Gary Chapman, in his book, The Five Love Languages, lists five such ways: words of affirmation (“That situation was delicate and you really handled it beautifully”), touch (“How about a hug?”), quality time (“Let’s get a babysitter and make a reservation at Chez Alouette”), gifts (“This scarf was so gorgeous, it had your name on it”), and acts of service (“Why don’t you take a nap while I do the cleaning up?”).
 
Partners make bids to create, increase, maintain, and re-establish connection. Arriving home at the end of a day, we ask: “How was work today?” Noticing that our partner is preoccupied, we say, “What are you thinking?” Sensing something amiss, we send out a probe: “Are you upset with me about something?”
 
“Bids” are the active ingredient in a relationship. Gottman shows how people make bids in the fine grain of everyday life, often without knowing they are doing it: “Did you hear about…,” or “You’ll never guess what my sister told me today.” A lot is going on all the time in the form of these little signals that partners are often unaware of sending. These signals—these bids—are nonverbal as well as verbal: a wink, a smile, a shoulder rub, a gentle shove, or a mutual look of understanding about a friend’s quirks. What matters, Gottman suggests, is not depth of intimacy in conversation, or even agreement or disagreement, but rather how people pay attention to each other no matter what they talk about or do. What matters is the quality of attention, as my partner, Dorothy Kaufmann, puts it.
 
What the person making the bid wants, of course, is a positive response (“Oh yes—tell me. Your sister always has such a special angle on things”). What that partner doesn’t want is an angry response (“Don’t bother me; I’m not finished with the paper yet”) or no response (grunting in acknowledgement and continuing to read the paper). Borrowing terminology from Karen Horney, Gottman labels these three responses turning toward, against, and away.
 
Gottman’s major point is that repeated failure to turn toward in response to our partner’s bids leads our partner to stop making bids. The relationship sags and both partners feel lonely. Couples frequently find themselves in a devitalized relationship without knowing how they got there. Turning away or against their partner’s bids for emotional connection is how they got there.
 
Susan Johnson’s Emotionally Focused Therapy can be viewed in these terms. She focuses on the traumatic effect of having our bids for emotional connection rejected or ignored (our partner turns against or away), resulting in our being afraid to make further bids and, instead, attacking or withdrawing (turning against or away) in turn.
 
If turning away or against is a problem, shouldn’t we try always to turn toward? Perhaps. But forcing ourselves to be nice when we don’t feel nice also leads to devitalization or to a buildup of resentment that culminates in an explosion. And we may not always be able to turn toward; the impulse to turn away or against may be automatic or overpowering. Furthermore, the original bid might have been made in a manner that provokes a negative response—that is, it might have been offered anxiously, demandingly, reproachfully, or failing to take account of what the other is doing or feeling at the moment. Gottman says that temper tantrums may be bids in some situations.
 
But maybe we can create a vantage point above the fray—a platform—from which to report that we have turned away or against. We can say, “I know I’m over the top.” Or, “Wow, you don’t deserve my snapping at you like this.” Or, “I know I’m lousy company at the moment; I’m caught up in writing this thing.” We would be bringing our partners in on our concern that we are not doing right by them. We would be turning toward by acknowledging that we have turned away or against.
 
But it is difficult to be self-reflective in the heat of the moment. It would be easier to go to our partners later and say, “I was so focused on making that last paragraph work that I hardly said hello when you came in last night. I feel bad about it.” Or, “I hate how irritable I’ve been lately, and I’m sure you hate it even more.” Or, “I know I gave you a tough time when you made me those perfectly wonderful eggs this morning. I must have been still fuming over that comment you made Saturday.” Or “I keep forgetting that when you blow up like that it’s because you’re hurt.”
 
We would be making a bid to reconnect after having previously ignored or rejected our partner’s bid. We would be reconnecting in the act of talking about how we had been disconnected. We would be talking intimately about not having been intimate—which is perhaps the ultimate intimacy and the fullest way we can join.

Methinks Jay Haley Hit the Bulls Eye

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My client began her session with an interesting saga. In an attempt to improve her health she began each day by ingesting a nutritional drink that was loaded with nearly 100 superfoods. Since I personally take enough vitamin and mineral supplements a day to capsize a small battleship, I was all ears. Unfortunately, my client lamented that the supplement seemed counter-productive. That is to say, instead of having unlimited energy, she was nearly falling asleep at the wheel on the way to work. The client was quite savvy when it came to nutrition and therefore hypothesized that the product was excellent, but it needed more protein.  In other words, the high carbohydrate formula was the problem.

Truth is always stranger than fiction and the very next week — as if the supplement company had a bug or a webcam in my office — they released the identical drink in a high protein low carb version. Problem solved? Well to use the oft-quoted phraseology of our times: not so much. The client reported that she was dragging through the morning just as bad as ever. Her dilemma was solved quite by accident when one day she discovered she was out of her superfood protein drink and thus she began the day with a banana and a slice of white devitalized bread and a low-tech multiple vitamin. (Sheer blasphemy, incidentally, for nutritional zealots like myself or my poor client.) The verdict: She had boundless energy and felt terrific. After that day she continued with the banana/bread regiment with excellent results.

Along these same lines another client was telling me about how he became very serious about his golf game.  The golf pro felt his swing was sound but he almost fell over laughing when he saw my client's antiquated clubs. The pro promised to set him up with some serious equipment. The irony, however, was that his his golf game suffered markedly when he began using the new high-tech, super high price tag, custom fit clubs. My client became somewhat obsessive and in the years that followed and he secured club recommendations from golf pro after golf pro and purchased set after set to no avail. Finally, one day, just as a joke, he pulled out his early 1970s aluminum shafted clubs and shot the best round he had in years.  He decided to stick with the zero tech clubs of yesteryears and his game continued to improve.

Like most therapists, I have literally heard hundreds of stories like this including:
• Men who gave their wives flowers or compliments based on the recommendation of some self-improvement expert, an Oprah approved bibliotherapeutic work, or a well-credentialed psychotherapist, and the relationship deteriorated.
• Parents who followed the behavior modification instructions to reinforce their child's behavior and saw the behavior stay the same or perhaps get worse.
• Clients who were told to wear orthotics in their shoes to take their comfort to a whole new level and now had pain in their feet or legs that never existed prior to wearing the devices and
• People who jogged extremely long distances every day to "do something good for themselves and to ward off old age" and now look considerably older than their peers (yes, there is even some scientific research that seems to be backing up this one) . . .  to name a few.

So what in the world is going on here? At least for me, the riddle was solved in an instant when I attended a lecture of Jay Haley's several years before he passed away. An audience participant asked Haley to spell out what caused most people's discord and Haley remarked, "The solution to the problem is the problem." I'll leave it up to historians of psychotherapy to discern whether Haley really came up with this on his own or whether he lifted the idea from the great Milton H. Erickson or perhaps Gregory Bateson.

In any event, the key point is that often, the very strategies that the client is using to make his or her life better are at the root of the problem. But I ask you: How often as therapists do we investigate this dynamic? In all probability, it is not nearly enough. We like it and get excited when clients seemingly do good things. Nevertheless, the message to take back to the therapy room is that something that appears positive is not always positive. The protein shake, the orthotics, and giving a spouse flowers could be the culprit. Most of us would never suggest that the client give up the protein shake, or perhaps stop complimenting a spouse. Instead, many therapists will gloss right over these behaviors and look elsewhere for the root of the problem. In essence, The solution to the problem — even when it appears to be a good one — can the problem. Jay Haley hit the bull's eye. Now it's your turn.
 
 
 

Working with the Unemotional in Emotionally Focused Therapy

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It is pretty clear from research that focuses on how change happens in therapy, that emotional engagement is essential for significant change to occur. This is true in individual therapy (for example, research by Castonguay and by Beutler ) and it is certainly true in couple therapy (research by EFT therapists like myself). So what happens in an intervention like Emotionally Focused Couple therapy when one person emphatically denies or avoids emotion? The Boy Code insists that men are at their best when they are strong and silent. So, it is not surprising that male clients tend to deny their emotions a little more often than their female partners.

Process of change research and over 30 years of the clinical experience of numerous EFT, suggests that in fact, this does not seem to be a problem in EFT. Men who are described as “inexpressive” by their partners at the beginning of therapy seem to do very well in EFT. Now why is that?

First, it’s because as EFT therapists we have a map for emotions. For example, there are only 6-8 emotions that everyone on this planet can read on another’s face and assign a similar meaning to. The main difficult emotions that come up in couple therapy are reactive anger, sadness, shame and fear of rejection and abandonment. If you understand emotions, you can help people make coherent sense of them. Once you and your client find the order and logic in an emotion, it is much easier to deal with and work with. Emotions are the most powerful music in the dance called a love relationship and EFT therapists learn how to shape that music and use that music to guide partners into new dance steps.

Second, EFT therapists are emotion detectives. They know emotions are wired into our brains and they have simple, safe, systematic ways of helping folks access and explore them. So, Jim will say in session 8 of EFT, “I used to think I was just frustrated, angry in these fights with my wife; but now I see that mostly I am afraid. It’s a relief to get this – to understand my own feelings and to be able to ask my wife for reassurance rather than stomping around the house in a huff or zoning out and withdrawing into my loneliness.”

Third, tuning into your emotions, especially your fears and longings and shaping these into new messages to your partner WORKS. It is what securely bonded folks naturally do. It pulls our partner close to us and this connection sparks little floods of the cuddle hormone, oxytocin, in our brain. The calm contentment and a sense of belonging that oxytocin induces is the ultimate reward for our kind – little bonding mammals that we are.

When folks tell us, “I don’t have emotions”, we know that this person is working very hard and stressing out his body to suppress his feelings, so we gently explore how and why he does this. He always does it out of fear to avoid being overwhelmed, feeling helpless or ashamed, getting rejected or abandoned. The trouble is that when you shut down your emotions, you shut others out and then you are ………… all alone. No-one wants that. So if you show folks another path to take and support them, they will take it. Even people who do have to shut down as part of their jobs, firefighters, policemen, marines and surgeons respond to EFT. Even traumatized partners who swim in the turmoil of emotional storms learn to order those storms and use their emotions to tell them what they want and need and so find direction in their lives and with their partner.

The traditional route to change in psychotherapy is the haloed “corrective emotional experience”. Without this, any therapy is just an intellectual mist that evaporates once a strong emotion hits. The EFT experience is that even the most seemingly “unemotional” among us respond to corrective emotional experiences of being reassured and treasured. Who can resist this ? Who wants to?

Why a Therapist Should Care About a Clients Favorite Brand of Shampoo

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When I was a youngster my father owned a company that manufactured shampoos and hair conditioners.  His bestseller was the original Rum & Egg Shampoo, a product he invented himself.  Now here’s where the story gets a little humorous (or perhaps not so humorous depending on your vantage point).  We would routinely receive correspondence from folks who just loved the Rum & Egg . . . heck, they thought it was the best darn shampoo on the face of the planet.  In fact, they’d go a step farther and trash another brand or two of Rum & Egg and say something like, “Why can’t Brand X or Brand Y make Rum & Egg like yours? The product they manufacture is pure junk.”

These folks wanted the original Rum & Egg. Anything else was a poor copy of the real thing. Now you might be thinking that we were patting ourselves on the back for making such a great product. Well if that’s what you thought then hold onto your horses because I haven’t gotten to the punch line yet.  Moments after the first call we receive another telephone message. This time it would be from an irate customer who would be ranting and raving about how inferior our product was, “Why in the heck can’t you guys make a decent Rum & Egg Shampoo like Brand X or Brand Y?  I’ll even send you a bottle of their brand so you can see how good the competition’s product really is.” 

These folks had invariably seen the Brand X or Brand Y advertisements that stressed that their rum and egg products clearly surpassed the original formula. And send us a bottle, they did!  Now what the aforementioned dummies (um excuse me, I mean customers) didn’t know was that most of the time it was the exact same stuff!  Let me put it in a different way.  We’d fill a thousand bottles to the brim with Rum & Egg and some bottles would get our label, others Brand X, and others Brand Y, Z or whatever.  We never had a clue which bottles received which labels. Hello folks: you’re all buying the same stuff . . . it's called a private label product. Often the same shampoo or conditioner would even be made under the same name with ten different colors, ten different brand names and ten different perfumes.  (Sorry to disappoint you, but in cosmetics generally the most expensive part of the product is the package and the perfume, in that order.)

But this principle goes way beyond hair care products. At one time made in Japan meant junk, but that’s hardly been the case for the last twenty years.  Now Japanese always stands for superior quality . . . or does it? A few years back researchers took models of automobiles and VCRs that were sold either with US nameplates (Dodge or RCA) or Japanese badges (Mitsubishi or JVC).  Like the shampoo saga, the products were actually identical. Customers were given the Japanese brand and the American issue and told to rate them. Perhaps you’ve already guessed that the products sporting a Japanese label – never mind that in reality they were the same – were rated much better.  Consumers made comments like, “The Japanese model just rode quieter,” or “the picture and the sound were markedly better.” Had you performed the experiment in the early 1950s the products with the US nameplate would surely have won by a landslide. 

Now what does all this have this do with the art and science of psychotherapy?  I thought you would never ask. A number of years ago I was at a conference where one of the top-guns in the world was not only lecturing but was going to perform therapy with a real client for the audience. Since I was the program coordinator for an agency I brought several of my therapists with me. Anyway, Mr. Hot Shot top-gun therapist was kind enough to perform a therapy session for the audience. He spent most of the session yelling and screaming at the poor client. One of my therapists leaned over and said, "You'd fire us if we ever talked to a client like that. Well, wouldn't you?" I didn't answer.

When the brief session ended a counselor in the audience raised her hand and asked the client a question, "What would you think if you walked into an agency or private practice and the therapist treated you like this?" "Well," the client admitted, "I would think it was a bit odd or perhaps totally crazy." The counselor in the audience was now extremely perplexed. "But I don't get it. You seemed perfectly happy and even impressed when Dr. so and so just did it." "Oh that's different," replied the client. "I know he's one of the greatest therapists in the world. He did it for some complex theoretical reason. He knows what he's doing."

I leaned toward the therapist at my agency and whispered, "Yes, I would have fired you." So here's the quintessential question: If you said exactly (I mean precisely word-for-word) what a well-known therapist said to the same client would you get the same results? Since a world famous therapist is one heck of a placebo the best answer is: not on this planet.  Therapists, quite frankly, are a lot like brands of shampoo, electronics, and  automobiles.

Receiving Gifts in Psychotherapy

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What does your ethical code say about accepting gifts from clients? Is it ethical to do so? If you’re a psychologist, social worker, or marriage and family therapist, you’re probably not sure. That’s because your official code doesn’t address it. Surprisingly, there’s not a word about gifts in any of the codes pertaining to those disciplines. And yet, virtually every mental health practitioner has, or will, face a situation where some client offers a gift of some sort at some time in the course of their treatment. So what do you do? Do you have a well thought out approach or policy to guide you when a client is standing in front of you with an offer of a gift?
 
The truth is that most practitioners don’t have a clear idea of what type of gift would be acceptable, if any. Those who work in an agency or hospital setting might simply adopt the policy their employer already has in place, but those in private practice need to develop their own guidelines or they might find themselves one day standing face to face with a smiling client who is offering a small, or large, token of their appreciation, and who is wondering why there is a such a long pause going on.
 
Would you accept a poinsettia plant at Christmas time that your client brought as a gift for your office waiting room? How about a plate of cookies at Easter for you and/or your staff? Or a packet of special seeds for your garden since you once talked about growing and nurturing in an earlier session? Or a picture a child client drew for you, or a lanyard she made for you in her crafts class? How about frequent flyer miles? Or cologne? Or an item of clothing for your birthday? Or underclothing?
 
Surely you drew a line somewhere along that list of choices. Maybe right at the beginning or maybe at some point along the way. But why? What went into your decision to say, “That one’s not acceptable”? Why did you reject it? What factors did you consider?
 
The one major code that addresses the issue is the American Counselor Association Code of Ethics. It advises counselors to consider the therapeutic relationship, the cultural context, the value of the item and the motive of both the client and the counselor involved in the transaction when dealing with the issue of the appropriateness of the gift (ACA Code Section A.10(e)). Those are all excellent considerations that should bear on your decision of whether to accept or reject the offer.
 
We might, however, add to those factors at least three more: age and gender of the client, and the timing of the offer. For example, if a six year old boy brings a bouquet of flowers he’s picked for his 40 year old female therapist the situation is markedly different from the same bouquet coming in the hands of a 45 year old male client. Motive and intent would not appear to be the same in those two instances.
 
Also, the timing of the offer can be critical. Is it at the end of a successful treatment regimen, or is it at the outset? Saying goodbye with a token of appreciation would seem more straightforward at the end than at the beginning treatment in terms of motive, intent and the therapeutic relationship.
 
So putting together the ACA list of factors of therapeutic relationship, cultural context, value and motive, and adding the age and gender of the client along with the consideration of timing, should give you enough to think about when deciding whether a gift is appropriate or not. But it would be wise to do your thinking before you hear your client say, “Here, I brought this for you”.

Memories of Stonehenge, 1984: Conference of Women Family Therapists

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In the summer of 1981 I was traveling around Ireland with Lynn Hoffman who was at that time- and for a great many years- a tremendous supporter of the work of a numerous others in family therapy. She was at that time especially supportive of therapy teams in many different places in the world and was telling me a good deal about all the creative women she had run into in her travels. I began to think about the need of women mentors in our field and what a good mentor she was to so many others herself, including two Irish women to whom I became very close: Nollaig Byrne and Imelda McCarthy. By the end of our trip I had hatched a plan to bring together women family therapists for a conference. I approached my friend Betty Carter, who agreed it was a great idea and asked if we could present it to her group: The Women’s Project (in which her compatriots were Marianne Walters, Olga Silverstein and Peggy Papp). I agreed and soon met with them to discuss the idea. They were, much to my surprise, not enthusiastic and decided against the idea. For some reason, they could not see the value of a meeting of women in the field. They were not the only ones. Virginia Satir, Mara Selvini, and Cloe Madanes were all negative about the concept when invited, and Lynn herself said she could not see the value of it and did not in the end participate.

In any case, I went to my handy-dandy sisters, Froma Walsh and Carol Anderson, who I knew would support the concept and we decided to do the conference together. I knew of a wonderful hotel in Ridgefield Connecticut called Stonehenge and we decided that would be our venue. It had space for a meeting of about 40 people so that was the number we decided on. We then began the planning through networking. We contacted women we knew or whose work we knew of and asked them to recommend others they knew and through that method of networking we eventually had a wonderful group of very impressive women family therapists who agreed to come to Stonehenge to share work, personal experiences and ideas for 3 days in September of 1984. It was a most impressive group of women- the outline of presentations and discussion emerged pretty organically as I remember from different ideas presented by various women. One that stood out particularly for me was Ellen Berman’s presentation of the “Glory-Work Ratio,” a presentation in which she proposed that we as women often under-sold ourselves when invited to do a presentation and would agree to meager terms, happy to be included and not realizing how much work, time, and energy were entailed in such presentations. She recommended that we always sleep on any invitation and not agree to it for at least 24 hours, by which time we might have had a chance to decide how much effort should be expended for what return. We all laughed, recognizing how many times we had found ourselves traveling to faraway places for micro-fees, while the men in the field commanded much larger honoraria, even when they did not prepare for the presentation.

Another highlight for me was a comment by, I think Kitty LaPerriere, still one of the unsung heroes of our field, who said at dinner on Saturday night how amazing it was that for so much of our lives we women always wanted a “date” on Saturday night–which meant with a man—and here we were and we all seemed to want to be where we were at that time and in that place and were so fine with it! We had amazing experiences hearing new voices from the field and also from experienced senior voices. the Women’s Project had decided to participate and even sponsored the welcoming cocktail party on the opening night of the conference and all of them shared many of their experiences as women breaking the glass ceiling of our field.

There were also difficult issues and discussions about why our group was almost all white and how could we do it differently—how could we change our thinking so we could become a more diverse group of women. For me the struggles with how to deal with the intersection of race and gender took many more years—many years to appreciate that we could not discuss gender without taking race into account at the same time. And the intersections of race and gender , along with class and sexual orientation—which have become such important parts of our conversation in the decades since that time—were just in their infancy and not well understood or dealt with. In the years since I have learned a lot about the naiveté and inaccuracy of trying to consider gender by itself rather than within the larger cultural contexts of race, ethnicity, religion, class, and sexual orientation.

At the same time that we made many mistakes in our efforts, there was something amazing that happened for many of us at that meeting, I think. From that point on when we saw each other at other meetings there was a sense of solidarity and of collaboration and support:we had acknowledged to each other at that meeting how isolated we often felt, competing with each other for the attention of the men in the field, and how much of our sisterhood we lost in that competition process. And we came to stand by each other better, to help each other out informally with writing and presenting and thinking about the research and clinical practice of the field. I think wee listened better to each other after that—I know I did, realizing how often I had not really appreciated the other women in our field.

In the years after that we held one other Stonehenge networking meeting (1986) and then an international networking meeting of about 100 amazing women in Denmark a few years later, where, once again, we relied on networking as the organizing principle, learning from each other about other voices in the field. And at that international meeting with women from as far as Israel, Japan and Africa, I remember being totally in awe of the amazing women presenters, one after the other, who taught us about ourselves and each other and how to think more creatively about families and about their experiences trying to be family therapists in different contexts. I think these meetings helped many of us develop our voices in the field and I am grateful to all the women who participated and shared their stories and their work in those earlier days of our field.