Category: Blog

Avoiding the Adverse Impact of Electronic Communication in Couples Therapy

Posted on by Psychotherapy.net Team

Although it is nearly impossible to break communication habits in the Internet age, I have had numerous therapeutic instances where clients only dig themselves deeper relational holes by attempting to resolve interpersonal issues by texting and messaging their partners. The nuances of tone, emotional body cues, facial expressions, and the imperfections of language that are a normal part of face-to-face interaction, are lost through these digital mediums. The result is often an exacerbation of ongoing communication difficulties. Through my informed voluntary consent at the outset of therapy, I make my position about texting and messaging outside of the therapy hour very clear. Because clients frequently do this, my informed consent includes these statements for reasons that will become clear in the cases below, but also because SMS creates the expectation of an instant response, which I am only prepared to provide in an emergency. I also encourage clients to deal with emotional issues with each other in person, or at least by phone. In this way, the nuances of non-verbal communication and precise language can be more readily perceived, clarified, and addressed.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Case Examples of Electronic Communication Gone Wrong

Brian and Samantha, a couple in their forties who had lived together for two years, presented the problem of frequent arguments over both trivial and deeper issues. These tensions regularly escalated into withdrawal, name-calling, and impulsive criticism, with old resentments resurfacing. I worked with the couple on the basics of communication, problem-solving, and behavior exchange, and explained the role of lingering resentments. They did well with practicing and understanding these issues, but resentments still lingered, and comments flared up.

After six sessions of rocky and frustrating, ungratifying conjoint therapy, I received copies of text exchanges between them. They each sent me the copies they received without their partner’s knowledge in hopes of proving to me the other’s abusiveness — ignoring my informed consent provision. In one thread, Brian apologized for commenting at dinner that a glass was dirty, saying that he was merely making an observation, not a criticism. Samantha replied, “If you don’t appreciate all I do for you, when you never do anything around the house, you can do it all yourself!” Brian then attempted to clarify his intent, to no avail.

I replied to Brian by text, indicating that my informed consent stated that I do not use the internet for emotional content such as this, and we could discuss it further in our next conjoint session. In their next “post-text debacle” session, Brian did not bring it up out of embarrassment. They continued for six sessions, working on the resentments that surfaced and terminated with improved overall skills; I never found out whether they were able to resolve past resentments.

In another case, I worked with a disgruntled individual client, Belinda, who was in a severely dysfunctional marriage with her wife, Lucy. Her goal was to obtain recommendations for dealing with the anger she felt for several reasons. I explored them cognitively and emotionally, having her align her values with her behaviors. Belinda sent me pages of exchanges going back eight years in which Lucy had historically berated her for everything she resented. Seemingly, Belinda wanted me to agree that she had indeed been emotionally abused.

When Belinda directly expressed outrage at home, Lucy said she “didn’t really mean all that,” to which Belinda told her she could not take it back and they should consider divorcing. In the next session, we explored her situation, and I told her that moving forward, I could not take an additional hour to go over all the comments her wife made in those electronic exchanges but could instead help her to consider some resolution of the contempt and disconnect she felt. I advised that they see a couple therapist, either myself for a 1-2 session consultation, or another therapist. She seemed to have a better understanding of her resentment and how to control it.

***

In looking back on these two cases, I understand the widespread use of texting and messaging in today’s electronic world. Although I discourage clients from using it to discuss emotional issues, I cannot prevent them from doing it, either interpersonally or with me. I believe it’s important for therapists to set an example — and boundaries — by not using electronic media for intimate communication.

Using Play Therapy (and Movies) to Heal Attachment Wounds in a Young Child

Posted on by Psychotherapy.net Team

A Troubled and Troubling History

Peter was four. He had just started Head Start programing when his mother announced she was pregnant. It seemed almost immediately after that Peter became non-compliant with any authority. He experienced a disturbance in sleep and appetite, withdrew socially, refused to wear a seatbelt in the car, and misbehaved in public until his mother had to bring him home. Peter hit, bit, threw things, broke toys, and screamed to get his way, and developed an excessive need to be in control.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

More alarmingly, Peter engaged in harmful behaviors, riding his bike across the street in front of traffic, running over a two-year-old with his bicycle, putting a pillow over his mother’s head telling her to die, and deliberately putting toys on the floor to make his grandmother fall.

Peter’s mother reported that at eight months of age, he had rolled out of the bed, resulting in an ER visit and a report of suspected child abuse. During that ER visit, Peter’s grandmother was asked to help restrain him while they took X-rays, which revealed a broken knee cap. DCFS took custody of Peter and charged the mother with neglect. He spent two days in the hospital and one night in a foster home before being returned to his mother.

I concluded that Peter’s school referral and his mother’s pregnancy had triggered the medical trauma, separation, and attachment issues that were contributing to his behavioral and emotional difficulties. In that assessment, I identified several issues for treatment, including (1) intense fear and anger at separation from attachment figures, (2) inconsistency in setting limits/boundaries and consequences for misbehavior, and (3) the use of behavior, rather than words to express himself. At the time of developing Peter’s treatment plan, I noted that his favorite act of defiance was to run outside in his birthday suit (naked). Our first task in behavior management was to have him put on his underwear before his appointment began!

Growth and Understanding through Play

Peter’s mother and grandmother were nurturing and invested in his growth and development, as well as my support team during our home play therapy visits. Books, toys, and movies were abundant in the home. Working with children, I had come to understand that they find comfort and a sense of security in the predictability in movies. Peter was no exception and movies were frequently playing when I arrived.

Using a client centered approach that incorporated themes from movies his parents had allowed him to watch like, Honey I Shrunk the Kids, Titanic, and Jaws, Peter was able to process his experience and communicate very aptly the chaos he felt both internally and externally. He would play these movies, or parts of the movie during appointments, while he built his creations, including his parents and myself with his toys, and then act out the scenes. I saw the parallels between the movies and his life experiences.

He built an elaborate shrinking machine in the living room which, I believe, reflected his feelings of being totally overwhelmed with his world and the multiple changes he was experiencing. As he adjusted to school and the birth of his sister, his shrinking machine became smaller and disappeared.

Titanic reflected the family’s chaos during the time his mother worked away from home, which took her away for extended periods, and other times resulting in her return home after Peter was in bed. The grandmother was left to assume all parenting and childcare responsibilities. Peter would rewind and replay the moment the ship would break in half and sink into the ocean in a perfect parallel to the absence of his mother. He wore out the tape! His mother quit the job.

The presence of Peter’s grandmother in his classroom as an aide helped to heal the attachment wounds that had occurred during his early infancy. She took him to school, remained in the classroom and brought him home. As Peter adjusted to the structure and routine of school and gained confidence in the return home, he became challenged by the learning process and his desire to learn took precedence over his misbehavior. Both parental figures read to him and the social stories of The Bernstein Bears, and his ability to understand and apply what he heard helped him adjust to new and changing social situations.

Peter became able to verbally express his dislike for his sister but never intentionally attempted to hurt her. He would simply pick her up and move her, even when she would unintentionally destroy one of his play creations. One of my repetitive phrases during appointments was “Use your words!” Feelings of resentment disappeared when he was able to use his words and tell his mother and grandmother he did not like his sister because she was messing up his creations. They in turn made more conscious efforts to keep her away from his projects, and to listen when he used his words.

In his play around the themes from the movie, Jaws, Peter was the captain of an imaginary boat in shark infested waters. He brought all the people and things important to him into the boat, his mother, grandmother, sister, and me to protect us. He acted out the shark attack addressing his fears about his safety and nurturing needs. He would replay this scene many times. As the boat became bigger and bigger, the shark infested waters grew smaller and ultimately disappeared. So did his disruptive and aggressive behavior.

***

Peter was phased out of treatment. His mother and grandmother were learning that withholding his movies could quickly bring misbehavior under control, while their nurturance, consistency, and attention to his safety and security needs helped to strengthen and support his positive and social behaviors. Peter was able to play with new friends and enjoy all of the experiences of school.

How to Use Narrative Therapy to Help Clients Locate Alternate Stories

Posted on by Psychotherapy.net Team

As a practicing psychotherapist, I hear a lot of stories. These stories are, without fail, complex, nuanced, and multidimensional. But, often, clients come to therapy with a singular focus on only one element of their larger story. In narrative therapy, the term is “problem-saturated” story. Part of my work as a therapist is to guide clients to widen their lens beyond this problem story and recognize that many of their stories are actually a story within a story (within a story). The act of locating these missing story parts and creating an alternate narrative is a way to alter the problem-saturated story and to clear the way for a new, more accurate, and helpful story to emerge. I enjoy little more than when a therapeutic opportunity presents itself — it feels like a gift. So, when John, a 76-year-old gay man, shared his story with me, it came with a giant bow on it: here was a perfect opportunity for a narrative therapy approach. John’s story began like this. It felt as if he had spent his entire life being “sneaky,” and feeling remorseful for what he described as his “untrustworthy ways.” As he began to share his life story, however, a very different story presented itself.

A Secreted Life

Born in the late 1940’s, John grew up in a small rural town where conservative and traditional values around relationships and marriage prevailed. His parents, both uneducated immigrants, neither understood nor accept homosexuality. When John, in his teens, shared his preference for men, his parents agreed that he should not be permitted to remain in their home. Though they apologized years later and expressed regret for rejecting him, John had difficulty letting go of their implicit message that being gay was something to be ashamed of and, therefore, secreted. The telling of this “thin version” of the story, as narrative therapists call it, seemed to offer multiple therapeutic opportunities. First, we could explore where this story originated. In this case, demographics, social norms of the time, and institutionalized beliefs were what Stephen Madigan might term the “undergrowth” of John’s narrative. Next, we could investigate if this was, in fact, John’s narrative or someone else’s. Parenthetically, clients often “inherit” or are burdened with others’ stories which they take on as their own. In this sense, they become colonized. Getting back, it was, without question, a story his parents had told and not necessarily a story John believed, though he had introjected and accepted it. This is, in essence, what narrative therapy is about; an honest investigation of the stories we tell ourselves. Once clients have investigated these narratives, they are free to begin challenging them, updating them, and cultivating new, more compassionate self-stories.

A Therapeutic Path Forward

I saw my role as guiding the investigation into John’s story. In one therapy session, I asked him to tell me about life as a gay man in the mid-1960s, when he was in his twenties. He replied, “well, we had to be careful.” “Even sneaky?” I asked. He smirked, understanding where I was going with the question. “Well, yes, sometimes we had to be sneaky,” he conceded. We began to discuss how that behavior that John had so automatically viewed as “bad” was, actually, a product of the times, the geographical area, and the social climate. John went on to describe how he found community with other gay men and with straight people who were accepting of his lifestyle. Missing story parts were coming to the surface and alternate story was emerging. John’s “problem story,” for a long time, had been: “I was sneaky. That was bad and therefore, I was bad.” It was now morphing to sound more like this: “I had to behave a certain way at a certain time for reasons that were out of my control.” This is the way uncovering alternate stories works. The more he started telling and revising his story, the more he began to recognize that there was far more to his tale than the theme of ‘badness.’ Musing aloud, John drew a conclusion: “so I guess I wasn’t really sneaky. I was just finding a way to live my life.” “The life that was right for you,” I added. Be clear that in this session, John and his story did the bulk of the work, not me. I merely guided the conversation using a narrative questioning approach. Armed with a new story, John slowly shed his previous negative self-label. More than that, he began to view himself as an asset to humanity rather than as a stain on it. He explained that he had discovered a new fondness for sharing his story with younger generations so that they could understand how his generation’s struggles had helped pave the way for the greater level of inclusion that LGBTQIA+ people experience today. The alternate story ended up being much for helpful to John and to those he shared it with than had been the long-standing problem-saturated story. When clients tell me they are “just rambling” or “going off on a tangent,” I often explain that it is necessary for me to understand their story — and all of its elements. What they may see as rambling, I see as vital to my comprehension of their story. The same way I would struggle to understand a novel if I read only a few pages, I would not fully comprehend a client’s life story if I was given only a few facts. Narrative therapy, for me, is an exercise in wholeness; it encourages clients to stand back and look at their lives from an expansive, panoramic vantage point. From a higher plateau, clients begin to identify story parts that had been obscured and to cultivate a more complete telling of their lives. Part of the honor I experience as a psychotherapist is that I am often welcomed into a client’s story. I can give back by helping my clients to see their stories as important, valuable, beautiful, and nuanced…as are they.

A Healing Journey: Developing Coping Skills in the Face of Trauma

Posted on by Psychotherapy.net Team

She had lived in a major city for years and felt confident and secure in her ability to negotiate public transportation. During the pandemic, she worked from home, like a large portion of the global population. Emerging from that dark time, as people returned to work, so did she. Barely a month back on the job, she was pushed against the wall by a man in the subway, had her purse snatched by a man outside a drugstore, was physically assaulted by a man in a pedestrian walkway that connected her neighborhood to public transportation, and intimidated by a man standing behind her at the pharmacy.

All these events occurred within her neighborhood, an upscale complex near an inner-city transportation hub. The final straw was a shooting incident in a public area she had to negotiate to connect with public transportation to work. Paralyzed with fear she withdrew to the safety of her home behind an iron gate and security cameras. If she ventured from the home, it was with Uber or her husband. She had lost her sense of safety and security. Working from home during the pandemic was safe for her, and returning to the office was not initially a problem. But in the shadow of these frightening events, she began experiencing obsessive thoughts, sleep disturbance, hypervigilance, flashbacks, difficulties concentrating, depression, and anxiety. She reached out for help via telehealth and with the devoted support of her husband, treatment began. In a short period of 11 months working with her, she was able to reclaim her sense of safety and security, and her confidence in negotiating her environment. She was to call that 11-month period, “The journey.” Her name was Sarah.

Preparing for The Healing Journey

Upon initial assessment, my strategic plan was to stabilize Sarah in the face of this crisis, reduce her symptomatic behaviors, evaluate her coping strategies, develop a de-sensitization plan, and incorporate EMDR into the process.

My first step was to remove the pressure of traveling to work so we could begin to address her anxiety as we began to focus on treatment. Fortunately, her employers were very supportive, only asking for documentation to process her request. She was the driver on this journey, so I sent her the document for approval before sending it to her employer. Sarah said when she saw the document, she cried because someone finally understood what she was experiencing. Her anxiety and mood instability diminished with the approval of her medical exemption to work from home.

I typically conceptualize symptom management and coping skills as “tools in the toolbox.” If they are willing, I ask clients to draw a picture of their toolbox and to put their tools inside it. This activity makes an internal process feel more real. I suggest that they add tools as we go along.

At the onset of treatment, Sarah preferred not to use medication. She already had many skills, resources and supports in place. These included her friends, work environment, pets, cooking, reading magazines, gardening, music, exercise, walking, yoga, and art. She and her husband were taking a self-defense program, and he had already purchased a handheld pepper spray for her, which she never left home without. Her husband was her strongest support, ally, and partner in the treatment process, working the plan with her from beginning to end.

During treatment, Sarah was able to share the trauma narrative by describing each incident that occurred. The first step in her desensitization was to describe the walk between her home and the transportation link. Next steps were to have her husband video record the walk for them to watch together which they did, several times.

One month after her first appointment, we discussed using behavior modification and progressive desensitization. Her homework was to develop the plan. She was to work the plan at her own pace, which she did eagerly, logging the steps as she took them, her physiological responses, feelings, and thoughts. We would discuss her journal entries in treatment, and she would modify the plan as needed, especially when barriers and roadblocks seemed insurmountable.

Addressing the Clinical Obstacles

Sarah’s environment provided unanticipated challenges that put her coping skills to the test. Multiple such incidents occurred in their neighborhood; a man fleeing from the police jumping into their backyard while they watched, a shooting in the lobby of a theater before they arrived, teenagers rioting over the weekend, and a man riding a bike in the neighborhood being attacked.

Initially, and each time one of these events occurred, Sarah’s symptoms would briefly re-emerge. During those times, we explored the incident in detail, and how she and her husband responded. We were able to reframe her responses as correct and resourceful choices. She began to recognize that different environments and events required their own unique, rather than blanket responses.

When Sarah did encounter either internal or external obstacles, she would modify her response accordingly, an example of which occurred around her visit to the local drugstore, which was frequented by vagrants. Everything in the store was under lock and key, and customers had to ask for help. During this particular instance, Sarah implemented what we called the “fire drills.” This involved visiting a same-named drugstore in a “safe” neighborhood, and recognizing that it was not the store, but the neighborhood that elicited fear and anxiety. Sarah and her husband concluded the environment they were living in was changing and no longer safe, and that it was time to make a change. Sarah was soon able to apply a related strategy to coping with her fears associated with the tunnel where one of her earlier traumatic experiences had occurred. We successfully added EMDR to her treatment plan.

We had been preparing for termination and scheduled our final appointment. When she came on-line for that session, she excitedly proclaimed, “You are not going to believe this.” She then detailed how she and her husband decided to take the subway home one night after leaving the theater, in front of which there was a protest.

Realizing that while many of her initial fears were justified, Sarah had re-gained control of her life and put her traumas behind her. She had completed her journey both literally and figuratively! She shared her final art project with me, which was a graphic reflection of her healing journey. A masterpiece in every sense of the word; it was being framed as we concluded our work, and was to hang in her new home, as a trailhead of sorts for the next phase of her journey.

The Pros and Cons of Remote Therapy: A Clinician’s Dilemma

Posted on by Psychotherapy.net Team

The classic image of a therapy session is a therapist, a patient, perhaps on a couch, in a small room with a box of tissues between them. But COVID-19 changed all of that. Now, more often, therapists and patients are on screens, each logging on from different locations. As COVID-19 restrictions ease in medical environments, it is time to ask if therapists and their patients need to be in the same room for therapy to be beneficial? 

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Changing Perspectives on Teletherapy

Prior to the pandemic, the thought of working remotely never occurred to me. Even if remote work had occurred to me, the fact that insurance only reimbursed for in-person sessions would have provided a significant deterrent. Four years later, I find myself of two minds when it comes to evaluating the pros and cons of remote therapy — for patients as well as for myself.

Rather than just relying on my personal feelings, I did some research into the effectiveness of remote versus in person therapy. To my surprise, I learned that patients prefer remote sessions more than therapists. As one patient said when I asked her why she prefers remote versus in-person sessions, she commented, “It’s like the difference between TV and live theater. TV is available when I want it, and live theater takes more effort — you have to get the tickets, find parking, etc.” 

I appreciated the many benefits of being back in my office but most of my patients chose to stay remote. The convenience outweighed their desire to travel to my office, and they felt no discernible difference in the quality of the work. This created a dilemma for me as I weighed the cost of leasing my office and the ease of working from home against my personal preference for in-person sessions. Recently I made the difficult decision not to renew my office lease for financial reasons. Adapting to remote therapy has meant changing some aspects of how I practice.

In my mind, the greatest deficit of remote therapy is the lack of a physical presence in a shared space. When I was able to watch my patients walk from the waiting room into my office, I noticed how they carried themselves, their attire, and the mood they exuded. No longer having that opportunity online, I learned to be more specific in my questions about how people were feeling, and I look more closely for changes in appearance. Still, the intimacy of a therapy session cannot be replicated on a screen. Watching someone cry is not the same as being in the presence of someone crying. Nonetheless, I have found, to my surprise, some patients prefer sessions to be less intimate and find it easier to open up as a result. This may mean that the availability of remote therapy is capturing a new clientele for therapy.

But some patients are acutely aware of being alone, and thus find it harder to allow themselves to fully express their emotions during a remote session. I miss mirroring someone’s breath and using my steady gaze to offer comfort in person. Instead of being able to offer a tissue, I now wait as they go off-screen to retrieve one. I literally try to lean into my screen to provide a perception of being closer.

Being apart means many patients struggle to find a safe and private space like my office. Often patients are surrounded by distractions from their home, office, car, or wherever they are having their session. They find it is more difficult to shut out the world when we are not together in my office with cell phones off. Encouraging patients to make the effort to create a private space is part of the work of doing remote therapy.

Furthermore, patients tend to squeeze sessions in between other commitments, diluting the work. No longer having to take the time to get to my office, patients fail to prepare for their sessions or give themselves time to think about the session afterward. I encourage patients to build a buffer into their schedules, but realistically it rarely happens. I am guilty of this too; when I turn off my computer, I am home and no longer have my commute to process the day before resuming my personal life. I have changed my routines, so I have a clearer boundary between being at work and being at home.

Embracing the Future of Teletherapy

Despite these limitations there are important advantages to offering therapy remotely. The most significant gain from the availability of remote therapy is improved access to therapy for more people. Insurance coverage changed during the pandemic to include online sessions, which improved the possibility of finding a therapist. Initially this change suspended the need for the patient and therapist to be in the same state, furthering the potential pool of therapists. (That requirement has since been reinstated.) Finally, patients living in rural areas could find a therapist and have choices similar to those available to people in urban areas. Unfortunately, during the pandemic, demand was so high many people still suffered due to long wait lists. But over time, there is the opportunity for greater access and equity.  

In my own practice, during the pandemic I began work with a woman in her early 80s with physical limitations who could not access my office. The opportunity to meet with me over Zoom made it possible for her to do some significant grief work after losing her husband to COVID-19. Increased access to psychotherapy for a broader clientele is a plus for everyone.

Continuity of care can also improve when weather or travel are no longer impediments to having a session. Prior to remote work, patients had to cancel sessions when they traveled for business or had to attend to a sick child at home. I have found the ability to offer remote sessions particularly helpful with the new mothers in my practice who were experiencing or at risk for postpartum depression.

Some therapists have required patients to come back in person, while others, like me, have gone fully remote. Increasingly, therapists are working for companies which only provide remote sessions; they never establish an office. It behooves graduate school programs to adapt to this reality in their training of new therapists. It is also important that as a profession we do not create a two-tiered system, preferencing one form of delivery over another based solely on personal opinion.

As we live more of our lives online, the limitations of screens may not be felt as acutely by either therapist or patient going forward. New modalities of therapy may even emerge from this change in venue. But it is critical that the effectiveness and limitations of remote versus in-person therapy be studied. For example, people with social anxiety may request remote sessions when in fact in-person work would be more beneficial. When screening new patients, I take into account why they express a willingness/desire to be remote.

The key to a good therapy relationship has always been about fit. This equation used to be construed as the fit between the therapist and patient, but now perhaps we need to expand that idea to the room(s) where it happens. 

Working with In-Law Problems in Couples Therapy

Posted on by Psychotherapy.net Team

One of the most common problems I see as a couples therapist is trouble with the in-laws and its impact on the couple relationship. It can be hard enough for clients to deal with their own parents, let alone their partner’s parents, who may disapprove of them (openly or covertly), be protective of their child (or the opposite, treat their child in ways that make clients want to protect their partner), or feel threatening to clients or the relationship in some other way. Relationships can be tough, and family dynamics especially can be challenging to navigate; combining intimate relationships and family dynamics can pose its own struggles.

The Negative Cycle

Something I see often in my office is couples who struggle with how to handle it when an in-law offends. When their parent does something that upsets their partner, I often see a now-familiar and predictable pattern that I call the “That’s not what she meant” dance. When the partner is hurt, the son or daughter sees a rupture in the family; a slow unraveling of the relationship between their partner and their parent. They want harmony and for the family to get along. So, in an attempt to preserve the relationship between parent and partner, they invalidate their partner’s complaints. It could sound something like this (a dialogue I have seen in my office):

“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”

“She didn’t mean it like that, she was just surprised.”

“But it hurt.”

“You’re making too big of a deal out of this. Don’t worry about it too much.”

[Partner pouts and turns away (or explodes)].

The adult child above likely has good intentions. They hear that their partner is upset, and they want to help. They try to make things better by trying to tell them there’s no cause to worry. But if there’s one thing I’ve learned about the human experience from being a therapist, it’s that feeling understood is important to all of us, and especially aggrieved partners in scenarios like this. When I hear things like “It wasn’t like that,” or “There’s nothing to worry about,” clients feel invalidated and unheard. The partner here is not soothed, but instead left feeling misunderstood and frustrated. They likely long to truly feel that their partner “gets” them and has their back.

To help these clients avoid getting caught in this all-too-common pattern, I try to teach them to validate their partner’s struggles. If their partner says that they’re hurt by something, I encourage them to take that at face value and not try to talk their partner out of their feelings.

A Strategy for Reconciliation

Often, I see that my clients are hesitant to validate their partner’s hurt feelings when they involve the actions of a family member. They may fear that they’ll make the disharmony in the family worse, and that their partner will move further away from getting along with their parent.

In instances such as these, I try to let my clients know that they don’t have to insult their mother or father to validate their partner’s emotions and to show them that they make sense. Showing their partner that they understand why their hurt makes sense and are there for them usually restores harmony in the family, as their partner won’t feel as alienated or marginalized when they know that you are right there with them, and they are heard.

As often as possible, I encourage my client to try responding to their partner like this, with validation, understanding, and support:

“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”

“I’m so sorry to hear that, I can see why that hurts you. You put so much work into dinner and I know how much you love making people smile when they taste your food. And it was delicious. Is there anything I can do to be here for you right now?”

This response shows: I get it, I get you — and your feelings make sense.

Responding like this can help a client’s partner feel safe in knowing that they have someone on their team, and they aren’t alone in their feelings. This increased level of safety can soothe hypervigilance and make couples feel more comfortable and unified when it’s time to go see Mom and Dad, resulting in less tension and conflict.

Ethics or Protocol: Children Must Take Priority

Posted on by Psychotherapy.net Team

A friend offered me the opportunity to join her in her practice, which I gladly did based on my knowledge of her values, beliefs, my love of what I do, and awareness of my weaknesses in marketing and billing. I brought my 20-plus years of clinical experience across inpatient, outpatient, and community mental health settings, which included my skills in assessment, documentation and play therapy into practice.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

I was happy as a clam doing the clinical work, receiving a regular paycheck, and leaving behind the hassle of finding clients for myself. In terms of emotional demands on my employer, I was a non-complainer, and my needs were few. I asked for little and consulted enough to keep her informed of significant treatment issues.

An Ethical Dilemma Arises

As the practice grew, so did my employer’s need to be outside the office, and in her place, there were protocols. One of them was that no written document was to leave the office without her review, which included all letters, reports, and clinical summaries. Clinicians had deadlines and due dates on the documents which left the office, which did not always coincide with her ability to review and approve them. I understood the need for this system with new employees and interns, and that with multiple employees, that was a lot of reviewing. After all, that is what supervisors are for! But as a seasoned professional, I was not new to the field, and I knew my way around documentation and ethics.

I was treating a court-related, post-divorce father with three children, who traveled out of state for visitation with their mother. It was a 10-hour drive. A Guardian Ad Litem, who also happened to be an attorney, was assigned to the case.

The mother had been asked/ordered to participate in treatment and met once with me along with the children. In that meeting, she expressed her resentment and never returned. The father, nanny, and I were sure that the children were being abused and neglected. The children were telling the father, nanny, or myself stories of inconsistent care with meals, medications, sleeping arrangement, and transient care and supervision outside of their mother with other extended family members.

We were documenting the children’s emotional state and physical condition prior to, and after their visits with the mother. I was working with the children individually, as a group, with the father, and/or the nanny, after visitation with the mother to further support the need for intervention to stop the visitation. The judge continued to order the visits for lack of evidence and threatened the father with jail time if he didn’t comply.

We were documenting signs of abuse and neglect; refusal to give medication for a documented health condition, untreated medical illness, injuries, abnormal bruising, weight loss, sleep disturbance, and neglect. The children were scheduled to travel out of state for an extended three week stay. The father was under a court order to send them and severely stressed by the prospect.

In my clinical opinion the children were in danger if they were sent out of state for an extended visit like this. I felt the need to inform the Guardian Ad Litem. The deadline for the childrens’ next departure was rapidly approaching.

At that moment in time, my employer was consulting out of state and not due back until after the children’s impending departure. I fully understood the importance of protocol that the employer had set in place, but there was so much more at stake here than protocol. There was the children’s safety, health, and wellbeing, not to mention my legal liability, that of the agency, and my ethical reporting responsibility. While many reports had been filed in the past, there was not enough hard evidence to file a DCFS report or stop the visit.

I had prior authorization to communicate with the Guardian Ad Litem. I wrote the letter to the Guardian Ad Litem expressing my concerns, and the reasons. Based on experience, I knew my employer would not review the letter before the deadline for the visit, even if I sent it through email. The internal debate was emotional but brief. I sent the letter to the Guardian Ad Litem, and put a copy in the file, knowing it could cost me my job. The children needed to come first.

Because of the court order, the father sent the children to their mother. I did not hear from the Guardian Ad Litem, who did receive it via email, before the scheduled departure. The children survived the visit. Shortly after their return, one of the children disclosed sexual abuse, giving the court enough legal grounds to end visitation. The mother’s parental rights were terminated. The father re-married, and all three children have been formally adopted by his new wife. The children are thriving and progressing developmentally, despite their challenges.

As for my employer and I; we parted by mutual agreement.  

Politics on the Couch

Posted on by Psychotherapy.net Team

I practice in the Boston area, the bluest part of a very blue state, Massachusetts. In the wake of recent world events — Trump’s election, mass shootings, and limitations on access to abortions — most of my patients have until now assumed, not wrongly, that we are aligned politically. For the few whose politics differ from the majority here, they have come to trust that I am open-minded enough to hear their positions without compromising our relationship.  

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

It is a long-standing cliché that therapists answer a question with a question. Typically, if patients ask me direct questions, such as whether they should take a new job or get divorced, it is easy for me to parry the question back to them. But some patients’ tolerance for this practice has waned as they want me to make explicit my position on the war. To them, a position of neutrality or silence feels unsafe and, for some, even immoral. As the war has continued, patients’ positions have shifted somewhat but the intensity of their feelings has not lessened.

Existential and moral questions have always had a place in therapy as people struggle to reconcile concerns about the meaning of life. But in the last decade, patients frame wanting to share their feelings with me in the context of feeling safe. Therapy sessions were meant to be “safe spaces” long before that term became part of the vernacular. Promises of privacy, confidentiality, and acceptance are the backbone of establishing a therapeutic alliance and, with rare exceptions, are guaranteed. But, for some of my patients this war shook their sense of what it means to feel safe in some fundamental ways and that has translated into wanting me to agree with them.

Inviting Politics into the Therapy Space

Days after the attack on Israel by Hamas, a patient started his session by saying, “I need to talk about the war, but I feel so afraid of being wrong, I just keep my mouth shut.” He went on to discuss how limited his understanding of the Middle East was and the pressure he felt to take a side. He knew his silence was not read as neutral and that his friend group wanted to know where he stood. 

He also questioned whether my silence was actually neutral, and worried that I too would think less of him for not already having a position. “What do you think?” he asked. “I want to hear how you are talking to your friends.” He hoped I would share my position to model for him what a cogent answer might sound like. Rather than satisfying his request, I chose to discuss strategies for having effective difficult conversations and support his right not to know how he felt at this moment in time. It was a meaningful interchange if not wholly satisfying for him.

Another patient vented her fury about her friends whose beliefs on this topic did not align with her own. She saw the potential for this issue to rupture relationships which had stood the test of time through many other challenges. Now she wanted my help, but she expressed grave concern that I would be unable to understand her position since I am not Jewish.

Despite our long history, I wondered if our relationship would survive this difference. Even though I appreciated the amount of distress she was living with, it pained me to think that given the current state of affairs, the fact that we have different backgrounds could limit her trust in me. We are both choosing our words carefully and I check in with some frequency to see how she is feeling about our relationship.

I have a number of patients who are college faculty members or students, and the heated debates on campus came roaring into my practice. Questions about the positions leaders were taking on their campuses and the implications for future career choices were on the minds of these patients and those who are parents of college-aged students.

Patients with younger children raised questions about how much to discuss the war with their children and how to keep their children safe from hate speech and potential violence. There was a general sense of people feeling unmoored and frightened. Taking time to understand the personal connections to this world event became a dominant theme over the course of many sessions.

Most of my patients do not belong to a religious community. I am by no means an expert on Middle East affairs, nor is that my role. For those who feel devastated or set adrift by current events, they look to me for answers and reassurance that I cannot give. Furthermore, in this day of AI and polarized news feeds, people do not know where to turn for information they can trust. At the same time, they want something more than equivocal answers from their therapist.

A weekly therapy hour cannot solve the problems of the world, but good therapy can promote mental health. The goal of therapy is not to shut the world out, but to help people manage feeling overwhelmed by the world. As the challenges of the world continue to come into the therapy hour, I strive to maintain the therapeutic connection. I might not always pass the litmus test, but I am hopeful that my efforts to encourage patients to empower themselves, improve their skills at having difficult conversations, and increase the number of places where they feel safe to share nuanced feelings will mitigate some of the damage done by this war.  

A Foster Child’s Painful Visit with his Mother

Posted on by Psychotherapy.net Team

The Child’s Family Visit through the Therapist’s Eyes

His eyes widened with welcome, and a quick smile flashed across his face when he saw me pull in. From that moment, Jason was a 55-pound human-guided missile speeding out the door when I came to transport him and his sister for their weekly family visit.  

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Today he is dressed in a royal blue, short, sleeveless shirt rimmed with white. His shiny new soccer shoes and short white socks are in sharp contrast to his small, skinny, naturally honey-brown arms and legs which have been tanned an even darker color by the sun. His straight jet-black hair falls in a circular pattern around his face. He has a child’s small mouth and nose set in a fragile face. It is his enormous, soft, brown eyes fringed with long, black, velvety lashes that tell his story. His eyes are the mirror of the words his lips will not speak.

Jason is silent on the short drive to the office until he suddenly blurts out that he has lost a tooth as he proudly displays its previous location. I respond with excitement and ask if the tooth fairy paid him a visit. He is silent. When we reach the office, he is the first child out of the car, into the agency, and up the stairs to the therapeutic playroom where his mother is waiting.

He comes to a standstill in the doorway of the room. His eyes reach across the sea of two brothers and two sisters to connect with his mother. Helplessly, they look at each other, and with their eyes, express the pain they feel in separation, without words or touch. After a moment, Jason tenderly greets each of his brothers and sisters with a kiss and a hug. He receives no display of affection in return. There is no expression in his eyes or on his face when he has finished.

Jason doesn’t play with any of the toys but spends the precious minutes of his visit as a helper and a nurturer. He begins by straightening the toy closet. Standing on tiptoe, he arranges the toys, games, and puzzles. When he is finished, he sits with his hands folded and his little legs dangling over the sofa, watching his brothers and sisters play. When the visit is over, he helps them pick up the toys. Jason is a little old man in a little boy’s body at the tender age of 7.

Jason is the first child to hug and kiss his mother goodbye. His arms tighten around her neck as he buries his face in her shoulder. He lingers in this position until his siblings push him out of the way demanding their hug.

Jason steps back fighting off his tears. In the end he succumbs to his feelings. He turns his head to the side to hide the tears as he wipes them from his eyes with the back of his hand. Jason is the only child who cries when the visit is over.

Jason is quiet in the car on the way back to the foster home. He sits with head bowed so I cannot see the tears flowing. When we arrive at the foster home, he is the first child out of the car. He gives me a brief glance as he looks back on his way to the door. His eyes flicker for a moment with pain.

The Family Visit through the Child’s Eyes   

I saw my mom and brothers and sisters today. When Vicki came in her little red car, I called to my sister, “Hurry, Christie, time to go see Mom. Race you to the car!”
I beat her to the car by a long shot. Girls are so slow! I jumped in the car. I got the front seat! I buckled my seat belt. I wished Christie would hurry!

During the ride to the visit, I had so many questions I wanted to ask, “Why can’t I live with my mom? Why am I in foster care? What did I do wrong?” I did ask Vicki, but she said she didn’t know. I thought she just wasn’t telling.

I had a lot to tell mom. I couldn’t keep my surprise inside any longer, so I told Vicki. “See what I did! I lost my tooth!” I held my mouth open with my fingers so she could see the big hole where my tooth had been.

She had to look quick cause she was driving. She laughed and her eyes got really big. She asked me if the tooth fairy left me any money. I had never heard of a tooth fairy.

I wondered if mom would be there. She didn’t come last week. Nobody told me why. They said, “Ask mom!” Funny how grownups never give you a straight answer when you ask them questions!

I jumped out of the car when we got to the office. I ran up the steps to the playroom. I ran to the room and stopped really quick in the doorway. Mom was there! She got tears in her eyes when she saw me. I cried too, I was so happy to see her! I wanted her to kiss me and hug me. She couldn’t because she was holding a baby. She said his name was Adam, and he was my new baby brother! Daina, Katie, Jeff, and Christie came charging into the room. The moment was gone. There was no time for me. I was too late.

I love my brothers and sisters. I missed them, so I hugged them to let them know how much I missed them. They didn’t hug back. They didn’t know how because mom didn’t have time to teach them once the babies started coming. She was always too busy or too tired. I had to teach them hugging. I didn’t mind because I liked hugging. It only hurt a minute because they didn’t hug back. I am used to it by now.

I cleaned out the closet this week, like every week, hoping mom would notice me. Vicki noticed me and said something, then mom said something. I felt really special for a minute. The feeling would have lasted longer if mom had said something first.

When I finished, I went to sit by mom. I wanted her to ask me about school. She didn’t because she was too busy playing with Adam. She wasn’t supposed to be playing with Adam all the time. This was MY visit. I was mad and no one noticed but Vicki.

I got down on the floor to play with my brothers and sisters. There wasn’t anything else to do. Just when I started playing, Vicki said it was time to pick up the toys and say goodbye.

I helped put the toys away and turned to my mom. I put my arms around her neck and hugged her as hard as I could. I hoped if I held on long enough, they would let me go with her, or she would say something. Then the little ones pushed me out of the way to get their goodbye hugs and kisses. I gave up! I decided being the oldest meant being last, even if I was only 7!

I fought really hard to keep from crying on the way to the car and back to the foster home. I tried to hide my head when those dumb tears started falling. Vicki saw my tears. She reached over and stroked my head and neck. Her hand felt soft, and I felt better for a little bit. She said it was OK to be hurt and to cry. I wanted to ask if it had to hurt this much, but I didn’t.

When we got to the foster home, I beat Christie out of the car again. It felt good to be first. I’m not first very often. Vicki was watching me when I ran into the house. For a second, I couldn’t keep back my tears. I guess it was OK to let someone know I was a little boy inside, after all.  

Psychotherapy with Dissociative Identity Disorder

Posted on by Psychotherapy.net Team

“I call them the persons of my mind, my “pers,” Robin said, in reference to the split personalities she experiences due to trauma. “I talk out loud to them and I find it therapeutic, but I try to be careful because I know it can bother my roommate, and other people,” she said.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

The Long-term Consequences of Trauma

Robin had suffered severe trauma years earlier, and subsequently was diagnosed with Dissociative Identity Disorder, with associated psychotic symptoms (voice-hearing and delusions).

She currently resides in a nursing home, where she receives care and treatment for a painful chronic medical condition that she keenly understands may be a terminal one. She also receives psychiatric medications, and she meets with me for psychotherapy.

Robin is intelligent and articulate, and able to think in rational and logical ways. The psychotic and dissociative features have a common origin in her traumatic experiences. Addressing split personality issues is only a part of the scope of our therapy conversations, yet will be the focus of this blog.

Robin had experienced much psychiatric care over the years, and she was fluent with professional terminology. I did not begin to directly address the split personalities, or pers as she calls them, until a trusting therapeutic rapport had been well established, and only after she had initiated comments that were directly including the pers in our conversation. We then began to discuss the therapeutic goal of reintegration of the personality fragments into the self, and to include the pers in conversations.

Robin would tell me how the pers were listening to and reacting to comments I was making, and she would convey questions they raised. “They like the way you talk to me, and to them,” Robin said.

Robin would sometimes mentally gather the pers so they might participate in our sessions. I would speak in a teaching way about the trauma she previously experienced, about the fragmenting impacts of trauma, and about ways that dissociative features could have a protective effect — at least at the time of the trauma. I would explain that the so-called split personalities were actually all parts of Robin, and that one purpose of therapy was to help them all come together again as one person.

“There is only one Robin,” I said. “There are no other persons or personalities inside of you that are not Robin. Parts of you, Robin, might be experienced as if being separate — but only because of the psychologically explosive impact of trauma. The task of healing is a gathering up of the parts into the whole — of learning to recognize and identify with those thoughts and feelings and memories that have seemed peculiarly different, due to shattering troubles.

Some pers would argue or complain to or about Robin because, “they feel frustrated being stuck in this nursing home, and they want to be out in the world doing things. They get mad at me because I can’t easily move or walk.

“I can feel the pers moving in my body, and sometimes others come in and enter the pers, and I can feel them in my body, and I don’t really know who they are or what they want,” Robin remarked.

We would talk about the pers as aspects of Robin’s own feelings — that she feels frustrated being ill, and restricted to the nursing home, for example. We spoke of how the “others” were Robin’s as-yet unfamiliar, or unconscious, thoughts and feelings, and that her bodily sensations were ordinary visceral elements of emotions (but feelings numbed by suffering for Robin or pushed away from awareness to the point of seeming to be other than self).

When her subjective experiences were considered as unfamiliar elements of her own thoughts and feelings, Robin could glean new understandings about the complexity of her reactions.

When providing psychotherapy to someone with dissociative identity disorder — like Robin — I have found it important to keep in the front of my mind, and for the client, that this is one person; one unfortunate person, yet one quite resilient and remarkable person. Robin suffered great misfortune, yet she has been quite resourceful in her coping and her capacity for growth. Her well-being has been served by our careful, gentle, and sustained reconsideration of her internal experiences, with the aim of “bringing it all back home,” as Bob Dylan said, or returning the many parts into the one whole.