As is true in the lives of clinicians outside of the office, asserting and maintaining clear professional boundaries is essential clinically, ethically, and personally. I have found it not only helpful, but often critical to help my clients gain awareness of the limits in our professional relationship, not only for their safety but for my own. As to be expected, my clients have tested these boundaries, sometimes in minor and other times significant ways. Regardless of the size of these crossings, I have always found their navigation challenging. If their behavior inside of the therapy room is in some way a reflection of similar behavior outside of those walls, then I would like to think that by setting boundaries, I have been helpful in their personal relationships. I’d like to share an instructive experience I had several years ago.
Category: Blog
The CORE Approach to Therapy: Helping Jennie Find Resilience
A 58-year-old CT scan technician at a local hospital, the youngest of three sisters, and a recovering alcoholic, Jennie came to therapy four months after healing from surgery to repair an atrial septic defect, one of two major congenital holes in her heart. The repair of one of the major defects, and other secondary repairs had been done during Jennie’s childhood. When we began her treatment, Jennie was about three months into a second episode of sobriety after a relapse prior to heart surgery.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
As Scott Miller’s research into therapeutic effectiveness has taught us, the relationship is the key variable in virtually any modality. With this in mind, I decided to utilize the CORE method with Jennie to develop a safe, trusting context in which a strong therapeutic alliance could develop. The method offers a schematic guideline for the utilization of intuition as a curative dimension, particularly in the treatment of trauma. The model is comprised of four components.
Connecting in a caring climate of calm and comfort
Orienting toward strengths, including inner wisdom
Resourcing resilience, evoking awareness of capacity
Establishing strengths that endure, including symbols and metaphors
Connection
When Jennie first came to therapy, my intent was to attune to her and to her story in a way that would communicate a sense of being heard and clinically “held.” My intention was to create an atmosphere of positive regard in which Jennie would experience acceptance and, with her nervous system sufficiently regulated, feel safe enough to address past painful memories and traumatic events of the past. My strategy was to build a connection with attunement to Jennie’s frame of reference, her beliefs, and her presentation and language, to create a context in which Jennie might better understand events of the present.As our alliance flourished, I would look for opportunities to offer trance, possibly with a lengthier induction, but maybe a short absorption, in which Jennie might find latent or cut-off resources she could apply in future situations. In this way, I was able to help her to identify and integrate new resources in the service of managing her emotions and behavior in future situations.
For the first two sessions, I mostly listened to Jennie’s story, affirming the trials and problems she revealed. In doing so, I gently guided Jennie to express as clearly as she could what she hoped to get from her therapy. Although I didn’t know at first, or even at the start of any particular session how exactly I might utilize methods of hypnosis and trance in combination with ideas arising from my intuition, I hoped that the strength of our connection, characterized by validation of both Jennie’s struggles and her strengths, would ultimately lead her to recognize and absorb a belief in her own resilience and achieve her clinical goals.
I trusted that as I listened to Jennie’s story with compassion, attuned with an empathic gaze, and validating responses, that I would pick up both overt and minimal cues of what was most important for her. I also believed that as I scanned the impressions arising from my clinical observations, I would recognize cues for what might be needed to help her learn to recognize and shift into a state of calm when sympathetic arousal overwhelmed her emotional boundaries, and what points would stand out for me for utilization of trance.
It did not take long for Jennie to come to her goals. She wanted to deal with cumulative stress that would “pile up” and lead to “rage that can get out of control.” During exploration of her major life stressors, Jennie reported a difficult under-staffed work setting as well as on-going communication problems in the family of origin which included at the time a terminally ill brother-in-law and misunderstandings between herself and her two older sisters, Naida and Meg, that often involved the oldest sister’s daughter, Marcia, a niece who was close to Jennie in age and whom Jennie considered a close friend.
Although Jennie’s life partner, Tony, was dealing with a terminally ill mother, this added stress in Tony’s life was not causing conflict in their life together. From all reports, this primary relationship appeared to be a stable area and an island of support for Jennie. Clearly, she was more likely to be triggered into anger by relationship disturbances with her siblings or with coworkers when differences of opinion resulted in disagreements and distorted perceptions.
Such interpersonal static would cause Jennie to question her understanding of a situation, trying often with difficulty to determine her part in the problem. Often, the aftermath would be distance from her niece or from a sister or might form resentments toward a co-worker that could affect her morale and threaten her sense of competent efficiency at her job.
While Jennie reported no incidents of physical violence toward anyone with whom she would get angry, she expressed high motivation to learn to refrain from lashing out and making disagreements into larger issues that would disrupt contact with her sisters and leave her feeling bereft and disappointed in herself.
These types of painful emotional episodes reminded Jennie of the dysfunction and traumatic chaos caused by alcoholism in her family of origin. She wanted to understand how the old images, left-over impressions, and painful memories of the past affected her in her relationships now.
In the service of self-differentiation, Jennie longed to understand her personal role in these painful experiences. As therapy progressed, Jennie became even more consciously motivated to find strategies for reducing the emotional/somatic arousal that would break through her conscious intent to refrain from lashing out.
Orientation: Toward Strength and Inner Wisdom
My realization was that an inner wise intelligence was available for utilization as part of problem solving, and in this case, specifically for healing trauma via re-association of cut-off strengths and resources.It seemed both clinically and intuitively advisable to consider orienting Jennie toward her strength and helping her to access via her intuitive, inner wisdom. Jennie, I intuitively hypothesized, would benefit from an approach that would utilize trance and also provide some solid stress management skills. Both the intuitive and the practical would serve to guide Jennie toward the resources she wanted for managing both her emotions and her behaviors, particularly during interpersonal stress and conflict. Like every feature of CORE, intuition would be best accomplished with the CORE features of an approach that would access the non-conscious processes of the intuitive dimension of mind to remind Jennie of strengths she had already used in her life, and access dormant and latent strengths that were, for the moment, dissociated from a consciousness plagued by conscious as well as subliminal memories from her past.
First Intuitive Impressions
As therapy began, so did both overt and minimal cues as well as intuitive impressions. My first initial postulation, based on Jennies wide, welcoming smile, was that she had relational resources she was evidencing, but not fully aware of. I sensed based on the way she connected on screen, face-to-face, eagerly listening to what I chose to say, that Jennie might be open to the focused attention of hypnotic trance, with or without eyes open. While later this proved to be true, at first it was more of a hunch as she was readily beginning to let me know her by revealing a background history of emotional neglect, family conflict, and multiple complex losses, as well as the recent operation to correct a congenital heart defect.It did not take long for a certain current situation in Jennie’s work life to give me a chance to test out my hypothesis. The idea for the experiential moment came intuitively in the third session. I was working on two channels, the intuitive and the clinical, listening to Jennie, and paying attention to her non-verbals. I was also scanning my own hypotheses. As I was also sorting out clinically what direction I might go in next, Jennie’s narrative gave me the inspiration, an intuitive idea.
Resourcing Resilience
I was able to guide Jennie toward the realization that inner strengths existed and could be available — in this instance, using a brief trance and metaphor, as well as a dissociative moment in the service of integration of strengths.Jennie revealed that in the imaging department, a complaining and underperforming co-worker was “driving me crazy!” (I was now in intuitive territory). Extremely conscientious in her work, Jennie could feel her anger brewing and escalating as the co-worker’s poor work ethic and performance was leaving her overwhelmed and frustrated. Jennie was adamant that she did not want to lash out or do anything to cause problems for herself at the job, as had happened in other situations in the past. She wanted some help to calm herself so she could cope in a different way.
“Just ignore this person and go about your business,” might have worked for some people, but Jennie’s anger was deeply embedded in her emotional and operational self. I intuited that reaching her non-conscious intuitive mind was the way to go.
“I am so angry when I go in and I see her! I feel like I am just a bitch!”
In that moment, I remembered her history of conflict with two older sisters who had blamed Jennie and called her a bitch! I also knew Jennie had not just a broad smile, but a way of seeing the world with humor. How to externalize this self-denigrating sense of herself was the intuitive question — the answer came quickly and surprised me with its humor and potential to utilize Jennie’s sense of humor — without formal trance. I also knew that I was going to trade in what had felt like a positive alliance.
“Jennie, I have this idea and you can tell me if it seems too odd. (She agreed to hear the idea) Have you ever seen a spray perfume bottle?”
“I just happen to have a very fancy one,” Jennie replied.
“What if you imagine that it is filled with a perfume called “Eau de Bitch?” And you can imagine that you can spray it all around when you go into work, so you know it’s just in the air and it’s not in you!”
Now chuckling, she said; “I love that idea!” I’m going to do it!
Evoking Endurance
“Well, let’s take it one step further, okay? You could also have another imaginary bottle that could be for you. This one could be sprayed in the air like an air cleaner, or on you like perfume. This one could be called “Eau de Calm.”Now fully belly-laughing, Jennie reported that she was actually going to use the real spray bottle for “Eau-de-Bitch.” She later sent me a picture of the bottle and reported at the next session that not only did she no longer feel bothered by the co-worker, but Eau-de-Bitch could also be a go-to when she was upset by her sisters.
***
Over time, using intuition in my work, and teaching others how to use this psychic dimension of mind, I have learned that although people might understand the concept of what intuition is or can be, may clinicians want something more concrete about how to utilize intuition in the clinical setting — or in life.
[Editor Note: “Jennie” has given the author permission to share her story on psychology platforms for teaching purposes.]
Containing The Adult ADHD Fad — With a Rejoinder from ChatGPT
A sad and fairly ubiquitous aspect of human fallibility is that we are extremely suggestable suckers for fashion. Psychiatry is no exception — its history is littered with recurrent fads. The specific details vary, but the pattern is always pretty much the same.
Dangerous Psychiatric Fads
- Charismatic promoters identify a new and plausible diagnosis; do some second-rate research suggesting it “exists,” write a lot of papers, and give a lot of workshops and conferences.
- Media picks up the story, sensationalizes the “new findings,” and transforms lousy evidence into a vital new discovery.
- Whenever a potential pill treatment is available, Pharma marketing goes into an extravagantly financed, high-gear marketing mode — enthusiastically hyping the diagnosis and the medication in every possible venue.
- Benefits of the new diagnosis and treatment are widely publicized; risks and harmful unintended consequences are neglected.
- Primary care docs are especially targeted because they do most of the prescribing of psych meds, have the least training, and aren’t given adequate time to do careful evaluations.
- Patients are seduced by drug ads to “ask your doctor” about the diagnosis and the pill to treat it. “Asking your doctor” usually results in getting the medication.
- These familiar patterns of fad development are now greatly speeded up and given immediate worldwide distribution via social networking on the internet.
- Diagnostic rates rise exponentially in a very short time.
Cold Hard Psychiatric Facts about ADHD
Why The Explosion of ADHD Rates in Kids? We are in the midst of a 30-year fad of excessive diagnosis of childhood ADHD. Rates have tripled to about 10% — partly because DSM definitions have gotten looser — mostly because of aggressive Pharma marketing to MDs, parents, and teachers. How Do We Know That Rates of ADHD are Wildly Exaggerated in Kids? Studies done in a dozen countries on millions of kids have returned a remarkably consistent and disturbing result. All over the world, the best predictor of ADHD is the child’s birth date — the youngest kid in the class is almost twice as likely to get an ADHD diagnosis than the eldest. There is only one possible interpretation of this powerfully robust finding: ADHD is being wildly over diagnosed — we have turned simple immaturity into a mental disorder. Does ADHD Ever Occur in Adults? Yes, of course — because many kids don’t outgrow their ADHD symptoms once they become adults. The rate of persistent ADHD into adulthood varies widely across longitudinal studies — but probably about half the kids who have a childhood ADHD diagnosis continue to have clinically significant symptoms in adulthood. When the symptoms do persist, they usually become milder with age (especially true of hyperactivity). Can ADHD Ever Have Its Initial Onset in Adulthood? The simple and very important answer is an empathic NO! By definition, ADHD has to have its onset in childhood. This requirement is absolutely necessary in order to distinguish true ADHD from all the many other causes of inattention and hyperactivity in adulthood. Why Is ADHD So Often Overdiagnosed in Adults?- Almost all mental disorders and almost all substance addictions can perfectly mimic ADHD since they can cause its two classic symptoms — hyperactivity and trouble focusing attention.
- Real or imagined attention problems are a very common complaint among perfectly normal people.
- Getting an ADHD diagnosis is a gateway to legal speed — desired for performance enhancement, all-nighters for school tests or work assignments, recreational purposes, or for sale into the extensive secondary ADHD pill market.
- Careless diagnosis and prescribing by MDs.
- An inevitable consequence of overdiagnosing ADHD in kids is overdiagnosing ADHD in adults.
- Promotion via drug companies and social networking.
- Meds used for ADHD are usually quite harmful if the person’s symptoms are due to another psychiatric disorder that has been missed — especially bipolar disorder, depression, schizophrenia, eating disorders, or anxiety disorder.
- Overdiagnosis of ADHD results in over-medication with drugs that cause harmful side effects and can lead to or worsen addiction.
- There is now a huge secondary market for ADHD meds, especially on college campuses.
- There is also a
nationwide wide shortage of ADHD meds for patients who really need them — because the meds are so often prescribed for those who don’t or diverted to the illegal market.
- Rules out the possibility symptoms are caused by another psychiatric disorder, substance use, drug side effect, head trauma, or another neurological or medical illness.
- Determines that the symptoms had their initial onset in childhood — adult onset of symptoms rules out ADHD.
- Ensure that symptoms are severe and persistent enough to cause clinically significant distress and impairment. Most people worry about their ability to focus — this is not sufficient evidence to diagnose mental disorder. Many people have transient episodes of inattention or hyperactivity due to everyday stress — this is also not adult ADHD.
- Consider the risk of malingering to get legal speed for performance enhancement, recreation, or resale.
Bottom Line
Most of what looks like adult ADHD is not adult ADHD. Distractibility is ubiquitous in the general population — most of it is normal; sometimes it’s caused by another psychiatric or medical problem or substance use. People who didn’t have ADHD symptoms in childhood should not be diagnosed with ADHD as adults. ADHD drugs are unsafe except when carefully used for accurately diagnosed ADHD. They are currently in short supply for appropriate use because they are so often used inappropriately. ADHD drugs are useful when appropriately prescribed for the few, but harmful when carelessly prescribed for the many. It is past time to stop the adult ADHD fad before it gains even more traction. The harm caused by the adult ADHD fad is great, both for the individual and society. Easy access to legal “speed” has created a large illegal secondary market of diverted pills. ADHD drugs have become the campus recreational drug of choice at parties and the performance-enhancement drug of choice for all-nighters during finals week. Legal speed can cause many medical and psychiatric adverse effects, and emergency room visits for complications are skyrocketing. The Drug Enforcement Agency and the FDA are now trying to contain the epidemic — but their efforts are too little/too late. The adult ADHD fad will be stopped only if clinicians and patients fight against its seduction and insist on more careful diagnosis and cautious treatment.ChatGPT Asked the Same Question
[Editor’s Note] Once again, Dr. Frances’ granddaughter posed the same question to ChatGPT with the prompt: “What are the dangers of diagnosing ADHD in adults and how best to avoid them (in 500 words)?” “Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in adults comes with its own set of challenges and potential dangers that need to be carefully considered. While accurate diagnosis can provide individuals with the appropriate interventions and support, the risks associated with misdiagnosis or overdiagnosis are significant. To avoid these dangers, a comprehensive and cautious approach is crucial. Dangers of Diagnosing ADHD in Adults- Misdiagnosis: ADHD symptoms can overlap with those of other mental health conditions such as anxiety, depression, or even medical conditions like thyroid disorders. Misdiagnosis can lead to inappropriate treatments and exacerbate underlying issues.
- Stigmatization: An incorrect diagnosis can lead to stigmatization, where individuals might feel labeled or misunderstood. This can negatively impact self-esteem and overall mental well-being.
- Overmedication: Misdiagnosis may result in the unnecessary prescription of stimulant medications, which are commonly used to treat ADHD. These medications can have side effects and may be harmful if taken without a valid reason.
- Self-Fulfilling Prophecy: Once diagnosed, individuals might attribute all their challenges solely to ADHD, overlooking other contributing factors and hindering personal growth and development.
- Masking Other Concerns: ADHD symptoms might overshadow coexisting conditions like learning disabilities, which require specific interventions. Treating only ADHD could leave these underlying issues unaddressed.
- Comprehensive Assessment: A thorough evaluation by a qualified mental health professional is essential. This should include a clinical interview, medical history review, and collateral information from family members or close associates to ensure a comprehensive understanding of the individual’s history and current challenges.
- Consider Differential Diagnosis: Since ADHD symptoms can mimic other conditions, it’s crucial to explore the possibility of comorbidities. This might involve additional assessments, screenings, or consultation with specialists.
- Longitudinal Perspective: Assessing symptoms over time helps differentiate between chronic ADHD-related impairments and situational factors that might be causing temporary difficulties.
- Multimodal Assessment: Utilize a combination of assessment tools, such as self-report questionnaires, cognitive tests, and behavioral observations, to gain a holistic view of an individual’s functioning.
- Functional Impairment: Focus on the degree to which symptoms interfere with daily functioning in various domains, including work, relationships, and personal responsibilities.
- Psychoeducation: Educate individuals about the diagnostic process, potential pitfalls, and the multifaceted nature of their difficulties to prevent over-identification with ADHD symptoms.
- Second Opinions: Encourage seeking a second opinion, especially if the diagnosis or recommended treatment plan feels uncertain or uncomfortable.
- Collaborative Decision-Making: Involve the individual in the diagnostic process and treatment planning. Discuss the potential benefits and drawbacks of medication, therapy, and lifestyle modifications to make informed choices.
- Holistic Approach: Address physical health, sleep patterns, stress management, and other factors that can impact attention and focus. Sometimes, lifestyle changes alone can lead to significant improvements.
- Regular Follow-ups: Periodically reevaluate the diagnosis and treatment plan to ensure they remain appropriate as the individual’s circumstances evolve.
***
Afterword from Dr Frances
The response from Chat-GPT is remarkably good, especially considering that it took it one second to produce while my piece took 90 minutes to write. But ChatGPT did leave out two critical issues:- The requirement that ADHD cannot, by definition, be diagnosed in adults unless symptoms were present in childhood and why this is so critical.
- The societal impact of the adult ADHD fad.
When Clients Ask, “What Do You Want for Me?”
“What do you want?”
We therapists are constantly asking people some version of this basic question.
- What are you wanting to be different?
- What are your hopes for yourself?
- This difficult circumstance being what it is (and beyond your control), what do you want to be able to do in the midst of it?
- This difficult person being who they are (and beyond your control), how do you want to relate to them?
- What needs to happen?
- What do you want?
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
And people respond:
- I want to feel less depressed.
- I want to leave my marriage.
- I want to stop drinking.
- I want to feel happy.
- I want to feel more connected to others.
- I want to be less reactive and controlling.
Therapists Must Listen for What Clients Really Want
These answers become the guiding force that frames and energizes our work together. And as therapy progresses, and we keep asking “what do you want?” the answers and the focus of our work shift and deepen. “I want to feel happy” becomes “I want to interrupt my ingrained habit of always looking for what’s wrong.” “I want to feel more connected to others” becomes “I want to feel more connected with myself.” Or, “I want to be less reactive and controlling” becomes “I want to learn what it takes, and do what it takes, to feel safe in the world.” And beneath all these answers, beneath the “what do you want?” question itself, is one of the deepest questions of all: “What’s worth wanting?”
So, we keep asking, over and over, “What do you want?” And following our clients deeper and deeper.
Recently, a client turned the question back on me. I’d asked her some version of the question, and she’d responded with a thoughtful litany of hopes for herself and her life. But then she paused, tilted her head, and asked, “What do you want for me?”
Sometimes, of course, people ask therapists (and others) to guide and direct their lives because they lack confidence in their own inner compass. Perhaps they grew up with parents who sheltered them or micromanaged them, and they weren’t given space to grow that confidence. Or perhaps they entered adulthood trusting themselves, but a lot of things have gone wrong, and they’ve come to doubt themselves.
We therapists are careful about giving advice for lots of reasons, but this is one of the main ones: we don’t want, in an effort to help someone through a hard moment in their lives, to send a meta-message that we believe they can’t think and judge and make good choices for themselves. Quite the opposite: we want to respect and nourish people’s trust in themselves, their power to know what’s needed, and their capacity to choose and to act.
This woman, however, had demonstrated these abilities many times, in session and out. She was insightful, intuitive, and brave. So, I did not hear her question, “What do you want for me?” as a flight from responsibility: “Tell me what to do.” I heard it as healthy curiosity: “Tell me how you carry me in your heart.”
And so, I paused, took a breath, listened inside, and said to her: “I want you to be happy and powerful.”
I paused again, to see what else might be there. And I’ll pause with you, too, to say that, by “powerful,” I don’t mean CEO powerful or politician powerful. I mean the ability to gather and concentrate our energy, to plug the leaks that dilute us, and live from a strong and regulated stream of force.
I continued: “I want you to be faithful to who you are and what you know. So many people, you included, have been gaslit — by their parents, by friends, by their employer, by religion, by advertisers — and end up not able to trust themselves and their inner GPS. I want you to be a deep witness to the truth of yourself and your experience, to hear what your mind knows and, even more, what your body knows and what your intuition knows. And I want you to be able to live from all that.”
That was all. I paused and gave her space to absorb what I’d said and, if she wanted, to say how it had landed in her. She looked at me quietly, and I imagined she was doing exactly what I’d just said — listening to herself, weighing the truth of my words against the truth of her own knowing, and welcoming whatever she found trustworthy.
Then she said, “Thank you. I like that.”
And I said back, “Thank you. I like it, too.”
What I liked was twofold. It was, firstly, the experience of connecting with her, which I found deeply nourishing. And secondly, it was the sense I had that, spontaneously and concisely, I’d just articulated my view of what I hope happens for people who talk with me in therapy. I’m hoping they will grow in consciousness and in power. I want to help people witness the truth of their life — their outer life and their inner life — and, based on what they witness, to exercise agency, freedom, and choice.
I’ll close by asking you, therapist or whoever else you are, when it comes to the people you care for, what do you want for them?
How to Use Inference and Speculation for Psychological Assessment
Is it possible to conduct a psychological assessment and to offer treatment recommendations without ever communicating directly with a client? At the very least, aren’t interviews and history-taking minimum requirements to reach such important conclusions?
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
I experienced just such a dilemma when I was asked to provide temporary services at a nursing home in Boston. Thinking it an otherwise easy task, I was soon faced with impossible barriers to communication and was not able to conduct a full assessment — at least not in the traditional way. As it turned out, I could only privately speculate on what might lie beneath the limited information available to me at the time. As therapists, when faced with this type of perplexing clinical situation, it is natural to ask, “What else must be true for this to make sense?”
Psychological Assessment with Limited Information
The facility management were dissatisfied with the work of a prior psychiatric service provider. They wanted continued treatment services for residents already receiving them, an audit of the documentation done by the prior provider, and a review of all residents to identify who might need or be able to benefit from behavioral health services.
This was an old brick building in a residential neighborhood that was now a Catholic nursing and rehab facility, serving the needs of a diverse population. One unit was fully populated by American-Vietnamese citizens, half of whom were Catholic, and half were Buddhist. The TV and newspapers were in the Vietnamese language and there were many staff persons who spoke both English and Vietnamese. On several occasions, a bilingual staffer sat in to translate for my interview with a resident.
One day, I pulled out a new chart from the rack at the nurse’s desk and began reviewing the information. I sat next to the nurse and asked if she thought I could provide meaningful service to this resident. The nurse shrugged her shoulders and said, “They just want to know if each person might need psychiatric medication or anything else you provide.” So, I continued to read through the medical record.
This resident had been a single mother of one son, living in Vietnam during the war. According to the record, she had been “deaf and dumb” from birth. Current records described her as having advanced dementia. How might I communicate with a person whose native language was Vietnamese, yet who had major speech and hearing impairments throughout her life, and who was now incapacitated by dementia?
I walked down the hall to a day room where Mrs. Tran was seated in a wheelchair, wrapped with a colorful crocheted blanket, and her nurse’s aide sat quietly beside her. The aide was keeping an eye on Mrs. Tran and on a few other residents across the room watching TV.
I smiled and introduced myself and my role, and made comments to Mrs. Tran, even though I knew she was deaf. I gently placed my fingertips on her forearm as I spoke to her, yet she continued to sit unmoved, with her eyes closed. I asked the aide if Mrs. Tran was sometimes communicative, but the aide explained that Mrs. Tran did not make eye contact or display any direct type of communication.
“Does she show some communicative responses if you hold or stroke her hand?” I asked.
“No, not really,” the aide said.
“How was it to care for Mrs. Tran?” I asked. The aide smiled and spoke of her affection for Mrs. Tran. She enjoyed taking care of her.
“She’s never a problem,” she explained, and added that Mrs. Tran’s son was a frequent visitor, and that he would bring in things that might be needed for his mother’s care, and that he would often assist with feeding his mother.
Clearly, I could not document an assessment, but what personal speculations might help me peer behind the cloud of the unknown surrounding her history?
As it turns out, Mrs. Tran may have been a remarkably capable, resilient, and praiseworthy individual. She might have even had enormous emotional intelligence and social relationship skills. As a young, single mother raising a son during wartime, and burdened by severe speech and hearing impairments, she might have also been especially effective in connecting and somehow communicating with others in the “village” that it must have taken to successfully raise her son, get him to the United States, and help him obtain his education and develop a full life. The loving attachment and close involvement of her son seemed a clear testament to the success of those conceivable efforts.
But all that I was able to formally and ethically document was that Mrs. Tran was stable and quite well cared for, and that no psychiatric interventions were needed. I was satisfied with that outcome.
Questions for Thought and Discussion
How did the author’s account impact you as a clinician? As a person?
What might you have done in this circumstance?
Do you agree or disagree with the author’s conclusions?
Brief Therapy with Single Mothers: The Transformational Alchemy of Metaphor
Psychic Schemas and the Phenomenology of Being a Single Mother
There are over 9 million single mothers in the USA. Therapists working with these women hear stories of abandonment, disempowerment, loneliness, hopelessness, victimization, rage, and unrelenting stress.
Disturbing perceptions and emotions such as these, and the distorted interpretations that result, may, but more likely and typically, solidify into psychic schemas characterized by deeply embedded patterns of distorted thinking, dysfunctional reacting, and compromised coping.
Psychic schemas, themselves free of valence, can be understood as internal vehicles serving as repositories for what the individual notices, perceives, and catalogues — including feelings, thoughts, sensations, actions, experiences, and the ever-changing states of the Self. The way these phenomena of living are perceived — through thought, memory, imagination — and the linguistics of the internal narrative, provides the personal schema with its phenomenology, its valence, and its meanings.
As with any individual, what gets introduced and accepted into a single mother’s schema will affect how she thinks, what she feels, how she continues to live her life, and how she views herself. Her existing schema will influence content that continues to be incorporated. The phenomena that become absorbed will affirm or refute negative cognitions, support or refute distorted thinking, validate or dissipate painful emotions, increase or decrease stress, and affect choices of action, including decisions about the mother’s parenting — and about her sense of self.
Through listening to the single mother’s stories, and recognizing her interpretations about them, the therapist can become aware of and assess the possibilities for creatively crafting metaphors that can elicit cognitive shifts, emotional transformations, and behavioral change.
The Transformational Alchemy of Metaphor
The unconscious mind embodies a powerful potential to transform negatively charged schemas into more positive ones that embody uplifting themes and hopeful interpretations. The quiet mind, combined with the evocative and rhythmic language of hypnosis, can fuel a subconscious shift that can reduce stress, increase ego strength (including parenting skill), transform confusion into clarity, decrease stress, and increase a sense of strength and wellbeing.
Used in conjunction with trance, the mother’s personal metaphors become powerful tools that can reach beyond the didactic to tap the unconscious mind’s potential for reframing and restructuring the phenomenology of the single mother’s psychic schema. This potential to redirect focus, shift internal states and create change in the bio-psychosocial-emotional substance of the patient’s psychic schema constitutes the transformational power of metaphor.
Metaphors (and their cousins, simile, allegory and parable) contain rich sensual imagery that can gently and poetically focus attention to perceptions that can shift self-states and move patients toward changes they desire. When used with techniques of trance, such as tempo and attunement, metaphors drawn from patients’ stories constitute a power-filled therapeutic tool for anchoring change and growth in the body-mind with stability and durability that can successfully lead to increased resilience and coping strength.
Using brief, simple, and effective techniques, therapists can assist the single mother in imaging and identifying with new metaphors drawn from her own personal story. In trance, this “sympathetic identification” with new and transformed metaphors can lead to increased confidence, more solid self-esteem, greater ego strength, and a more integrated core of Self. When this positive enhancement becomes incorporated into the psychic schema, the psychosocial-emotional benefit to the mother can also benefit the health of her children.
In the following narrative, my work with “Queen Esta” demonstrates the way in which a carefully crafted metaphor has the power to shift the meaning of a personal and create a stronger sense of Self.
Queen Esta’s Story
“I just left my husband of 30 years!”
That was how Esta introduced herself, at the age of 83, knowing that she could have a future. Esta wanted to understand why she had spent thirty years with a second husband she did not love. To Esta’s credit, she had the wisdom to realize that at this critical turning point, it was important for her to understand the greater span of her life in order to accept her choice to leave her marriage.
As Esta’s story unfolded, it became clear to both of us that Esta’s acceptance of her current choices had everything to do with looking at a different piece of her story. Long before there were social supports and the stigma had faded, Esta had been a single mother. Esta soon came to realize that understanding the impact and meaning of her single motherhood would hold a key to the answers and comfort that she was seeking.
I discovered that Esta had married her first husband in the early 1940’s, shortly before he went into the service and, “when I was too young to know what love was.” The new husband had come home on leave and had left Esta again, pregnant. Esta’s husband was not pleased with the news. When he told her that he wanted her to have an abortion, she agreed it was a very good idea. “I did have one,” she enjoys saying triumphantly — “and it was him!”
After dismissing and divorcing her husband, Esta found herself a single mother of a very young son. In the mid 1940’s, widows, especially war widows, had some acceptance, but single motherhood was not as socially integrated as it is today. How had Esta coped? What had been her resources? Even so many years later, Esta did not fully comprehend how strong she must have been to grapple with the social context of the day and the great difficulties and isolation that single mothers faced.
As single mothers in every era must, Esta had to deal with her own fears and insecurities and raise her child at the same time. Esta had done both successfully, but she did not see the strengths she had drawn on or realize that they could add to her resilience in the present.
During her son’s early childhood, Esta had called upon her inner and outer resources. She had relied on her parents to take care of her little boy while she worked long hours, often traveling alone overnight. She remained mindful and grateful for the help she was getting from her family, feeling fortunate that she had this support. In this way, Esta did not see herself as a victim, but rather cultivated an attitude of acceptance that gave her strength to keep going.
“Esta,” I asked her, “Wasn’t it terribly hard to be a single mother in those days?”
“Yes, it was.” She assured me. “I did what I had to do, but there were others harder up than I was, with no families to help.
“What is the secret of this positive attitude you had?” (She still has it into her 90s!)
“I believe in God.” she said unhesitatingly. “This was the path he chose for me, and I had to accept that. I felt grateful to have my son. He was so precious, and my mother and father loved him as if he was their own. I accepted my decision to divorce and trusted that this was what God wanted for me. So, you see, I was lucky.”
As Esta continued to examine her life story, she came to realize that more than luck had been at work. She was able to see her courage and the intuitive wisdom that gave her the courage to banish husband number one. Finally, she could entertain the idea that there was also deep wisdom in her choice of husband number two. At a point where she no longer had family support, was weary from her grueling job, and had no financial base, Esta had married a man who could, and would, support her and her son.
Esta was now able to make sense of her past and present choices, comforted by knowing that they had been logical, born from a positive impetus. With this knowledge, she was able to accept the sadness of never having had the romantic union, but Esta was relieved of the stress caused by disappointment and regrets, and feelings of well-being replaced disappointment and regret.
Once again, Esta had “done what I had to do.” Realizing how strong she had been in the past helped Esta to see that her decision to leave her current husband was coming from an authentic core part of her Self which knew what was right for her now as it had in the past. As she achieved this wisdom, Esta’s feelings of sadness and self-doubt were replaced by a sense of well-being and an appreciation for her experience and her maturity.
In the throes of her single motherhood, Esta was too immersed in survival to see what she was accomplishing, and the era of self-help and therapeutic support had not yet dawned. Now, so many years later, ready to look back and see her success as a single mother, Esta embarked upon a review that allowed her to know how inner wisdom had directed her to cope and survive. Esta told me about the love of her life, a young man who had died before they were able to be married, almost 50 years ago.
Esta recounted the depth of that old grief, and how difficult life became then, and again when her parents, on whom she had so depended, died. Through all these losses, Esta had kept her sense of humor, her belief in God, and the persistent effort to give her son a good life. She maintained her dedication to him even to the day when this son, now a man, asked for her blessing to follow his destiny 3000 miles away. “My heart broke.” She told me. “But what could I say? This is what he wanted, and I wanted him to be happy.”
As she reviewed the events that required such pervasive and abiding courage, Esta was able to acknowledge that, indeed, life had been hard for her. She affirmed that trust in the will of her Higher Power had enabled her to embody the healthy attitude that had been with her into her 90s. When Esta started therapy, she was no longer the young mother with a little boy to bring up.
However, it meant the world to Esta to transform her doubts of having wasted her life into a view of herself that affirmed her strength, and the deep abiding soul Wisdom that guided her so many years ago, when she just “Did what I had to do.”
When asked how I should identify her in my book, Esta requested that she be called “Queen Esther.” Partly, she says, because Queen Esther in the Bible was a wise woman and a survivor; and partly because now Esta saw herself as “Esther,” a modern Queen, courageously having raised a boy into a good man.
Esther told me that she knows that the difficulties she faced as a single mother helped to make her into the Queen she is. She knows that she made choices from an inner truth that directed her to do the right thing.
Queen Esther was then, and will always be, truly a Soul Mother.
This story is excerpted and adapted from Soul Mothers’ Wisdom: Seven Insights for the Single Mother, by and with the permission of its author, Bette Jonas Freedson, and that of its publisher, Pearlsong Press.
Critical Tips for Building and Maintaining Your Private Practice: Avoiding Self-Defeat
Over my consulting career with mental health professionals at various stages of their development, I have offered critical guidance about the development and maintenance of their private practices. I have also learned a great deal about why so many of them struggle in these efforts.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
All of us who see clients privately have likely heard stories about why some left treatment and came to us, or why they did not return to the former psychotherapist. In the process, we have also hopefully learned why we were chosen to be their therapist as opposed to others with whom they have consulted.
Successfully Managing Telephone Contact with Clients
There are many ways in which clinicians — often unknowingly — defeat their own interests in the course of building and maintaining their private practices. One of these is the difficulty managing and handling telephone contact with prospective clients. New clients who were given several names of therapists have reported to me that one of the reasons they came to see me was that I was the only one who returned their phone call, or that I returned their call on the same day, rather than two, three, or more days later. I am astonished every time I hear this.
Another familiar comment I’ve fielded surround concerns the “phone-side manner” of the therapist who does return the call: “Unfriendly,” “Cold,” “Abrupt,” “I felt like I was bothering them,” “Didn’t really seem to want to answer my questions,” “She sounded to me like I must sound to the salesperson who calls me at dinnertime,” and more. It seems that some therapists are not any more comfortable talking with strangers than prospective clients are comfortable talking with us.
Prospective clients who have been sent to us by a known referral source may simply be calling to make an appointment as instructed. For many others, however, that initial phone call is a fragile moment that may have been delayed for some time. This is a first opportunity to engage the client and establish a positive initial connection. Many prospective clients who feel uncomfortable or even put off during the first call will never make it to the first visit with that clinician. Some potential clients call to arrange an appointment and save their many questions for the first visit.
Other prospective clients, especially those who are ambivalent, fearful, or who are seeking help under duress, require answers to their questions on the phone before ever coming in for a session. How this conversation is handled by the therapist might well make the difference between a new client and a non-client. If a therapist is uncomfortable with a prospective client needing a lot of information during the first contact, it might be evident and affect the quality of the encounter. Some callers ask difficult questions that must be handled sensitively, e.g. “What is your fee?” “What is your orientation?” “How long will it take?” “Should I bring my spouse?” And my favorite: “Now that I’ve told you a little about my problem, do you think you can help me?”
Many therapists seem to struggle in answering questions about their fee. There is probably no really safe or “good” answer — at least on the phone, and especially for clients who have issues or conflicts about paying for psychotherapy. Some therapists try to dodge the question by saying that they do not discuss fees on the phone and attempt to postpone the fee discussion until the client agrees to come in. The caller may find this answer evasive and permanently end the encounter. With a direct answer, arguably a superior response, the therapist runs the risk of an abrupt end to the encounter. The prospective client may be comparison shopping and the stated fee may eliminate a therapist right away or the client may make an appointment and then not show up.
It is important to remember and utilize the “rules of engagement” we all learned many years ago. The first phone contact is, possibly, the beginning of treatment. It is essential that the clinician is attentive, receptive, steady, ready to be of service, and generous so that the person contemplating therapy feels recognized and accepted sympathetically as a person in trouble.
I have always conducted the first session as a courtesy, i.e., no fee. This, I believe, accomplishes a few ends. For one, it conveys that the possible treatment is not all about money — especially helpful to therapy “virgins” who have seen too many Woody Allen movies. Second, if, for whatever reason the relationship is not going forward, there is nothing owed for what will not be an ongoing experience; and third, if I choose not to accept an individual as a new client in my practice, they are relieved of having to pay to hear me decline and explain why.
The Importance of Client-Centered Office Space
Some therapists are not sufficiently mindful of the impact that their office — their physical space — has on their clients and what that space conveys, especially new clients. One client told me that the main reason she elected not to work with someone with whom she had consulted, “There was a large spring protruding from the couch I was invited to sit on. The couch was in terrible disrepair and so was I. I was afraid that the broken couch might be a metaphor of some kind, so I decided not to go back.” Another oft-heard complaint concerns inadequate soundproofing, and, in the case of some home offices, too many personal distractions that interfere with a sense of privacy and optimal concentration.Some clients have spoken of their confusion and upset about not having been given clear instructions about how to locate the office and, once there, which door to enter, whether to ring the bell, and what to do when the therapist may be running late and does not immediately respond to their arrival. Sometimes the issues that we see as insignificant have a profound impact on our clients. If one agrees that a first session is often a particularly anxiety-arousing event with a more-than-likely vulnerable prospective client, then therapists should do everything possible to ensure that the journey from phone contact to first visit is as smooth and reassuring as possible.
The office bathroom can be another problem area. Client observations have included such things as broken toilets, no toilet paper, general hygienic neglect, and broken locks or no locks at all to ensure privacy. To some clients, some of these things may be hardly noticed, but to others, these moments have significant impact and may influence or determine their feelings about continuing the relationship itself. This is generally more of an issue with new clients. If one agrees that the therapeutic cathexis is likely to be to the office as well as the clinician, then appreciating the importance of an attractive, appealing, “holding (office) environment” is crucial.
Tips for Communicating with Referral Sources
One of the most common complaints I hear from those who consult with me for private practice help is that certain referral sources have stopped sending clients for reasons unclear or unknown. Curiously, some private practitioners resign themselves to the loss and quietly regret it without ever inquiring why.Referral sources expect to be acknowledged and thanked when they send a client to your practice. They also like to be informed about the disposition of their referral and some appropriate and discreet information about how the person they sent to you is doing. When I was building my practice many years ago, I sent referral sources a one-page statement entitled, “My Treatment Approach,” (see addendum to this article) which enabled them to understand how I conduct the initial evaluation and what the client would be experiencing when they came to see me. Feedback over the years was quite positive. Some referral sources sent work my way citing this document as unlike anything they had ever received from a psychotherapist marketing a practice. I also sent referral sources articles that I had written, kept them abreast of changes to my practice. In this way, I maintained contact with them if they were considering sending a new client my way. When I have not received any referrals from a traditionally active referrer, I inquire why. Sometimes the answer is as simple as, “you just didn’t come to mind,” so my call or e-mail inquiry served to reestablish my presence.
How to Handle Termination
The problem for many clinicians here, it seems, is when a client announces a desire to end the treatment when they are ready, and their therapist is not. This is an unfortunately mishandled moment in many treatment relationships that often sours or ruptures the relationship — at times, irreparably. Some clinicians simply cannot let go and, rather than explore the client’s desire to terminate as the treatment issue it is, they wind up angrily challenging the client and becoming an adversary, rather than remaining a valuable ally. This sometimes leads to an abrupt severing of the relationship and the client will not return. He or she may seek a new therapist or, worse, may be reluctant to seek therapy again.***
We are all very busy mental health professionals who, at times, run the risk of losing sight of the issues that have impact on our clients. Our interpersonal skills and sensitivity to client needs must go beyond the essence of the therapeutic contract. Attention to the areas of practice discussed above and the ways in which we represent ourselves has significant impact on the treatment and demonstrate respect and appreciation for the people in distress who have chosen to share their lives with us.
Addendum: My Treatment Approach
After making empathic contact, I conduct a mental status examination to arrive at as comprehensive an evaluation as possible in the initial hour. I assess motivation, capacity for insight, flexibility, frustration tolerance along with an understanding of the presenting problem and symptom constellation. I attempt to see how affects are handled, thoughts are presented, what mood is prevalent, and how well or poorly I am related to. Resistances are initially bypassed while attempting to ease the person into the therapeutic encounter.I arrive at a psychotherapeutic diagnosis and develop a preliminary formulation of the goals of continued work. This formulation includes an understanding of what a person is seeking in his life and what seems to be blocking his or her progress and achievement. An informal “contract” is negotiated which serves as a blueprint for the therapeutic work ahead. There is early interpretation of the transference, where appropriate.
The above is done to determine whether interventive efforts should be directed at nurturing, maintaining, enhancing, or modifying inner capacities; mobilizing, improving, or changing environmental conditions; or improving the fit between inner capacities and external circumstances.
Questions for Thought and Discussion
Which of the author’s suggestions resonates most strongly with you? Not at all?
Which of his observations have you struggled with in your own practice development?
Identify three changes you can make to enhance your practice
The Costs and Benefits of Virtual Reality in Psychotherapy
Learning to Weather a Patient’s Emotional Storms
Edith typically experienced a fire-hose intensity in the flow of her emotions. She would dye her hair in bright colors, and these colors changed almost as often as her moods. She could be washed over by waves of anger or sadness. She frequently stormed in rage at her caregivers in the nursing home, or on the phone with her son. During psychotherapy conversations, her anger often dissolved into tears. The symptomatic features of her Bipolar I disorder were like a flashing neon sign on her forehead.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
Part of the therapeutic work with Edith’s case was to educate the staff that her dramatic and unpredictable swings of mood from manic to depressed and her sometimes rapid speaking were elements of her illness. Edith would also verbalize sharply critical comments to her caregivers: “You don’t even care, you don’t listen, what do you get paid for, anyway!” I thought it was important to help the staff to appreciate how reacting with strong personal emotions to her symptomatic behaviors might provoke even greater instability. They were taught to maintain a sense of role boundaries, avoid personalizing her actions or comments, establish clear expectations for daily care, set limits on unreasonable or unacceptable behaviors, and see how those steps would add to the effectiveness of their care and to their professional satisfaction.
The Pain of Virtual Rejection
One morning upon greeting Edith, I was assailed with, “My fiancé dumped me!” As I sat down, I thought, “what fiancé?” She’d not been in a relationship. Edith had a tablet computer and spent many hours playing a virtual reality game. Her avatar was a slim and pretty lady who owned a florist shop and was a personal fitness trainer. As she was interacting that morning with the male fiancé avatar, another female avatar approached and claimed that he was her boyfriend, and the male character “virtually” walked away with the other female character.
In response to our conversation, Edith was able to acknowledge that she had designed her avatar as an entertainment, and a partial fulfillment of things desired yet not available in her present life. But she was unable, at that moment, to realistically distinguish between herself and her fantasy avatar, or to distinguish her emotions from those she projected onto the avatar. The stress of the situation triggered a psychotic episode for Edith. She experienced a loss of ego-boundaries.
I consulted with team members at the facility about ways to manage Edith’s care and treatment. Psychiatric hospital care was not indicated because she made no threats to herself or to others, and an involuntary admission might add to her sense of rejection from persons and supports available to her at the home. Safety checks every 15 minutes were unobtrusively put in place, and staff would make frequent, brief contacts to help her regain her sense of self and her composure. Privately, I wondered if one day I might need to develop a therapy avatar and enter virtual reality settings to conduct therapy interventions.
Four years later, I worked again with Edith at a different nursing home. She had been living in an apartment and was helped by home-based care providers. She’d become ill with an infection, went to the hospital, then to the nursing home for further care prior to discharge home. Since I last worked with her, Edith had experienced significant diminishments in her eyesight, her memory, her mobility, and her overall functioning. She did not remember having worked with me in the past. As we sat for therapy one morning, Edith said that she’d been trying to compose and memorize a poem, because she could not write due to visual loss.
She dictated the poem, and I wrote it down so she could bring it home with her. In her poem, Edith was confronting the many losses she’d experienced, and additional ones she anticipated. Her poetic reflections were sorrowful yet realistic and reasonable given her situation. She showed no indications of psychotic symptoms and was no longer using a virtual reality game. “I know it’s getting darker for me,” she said, “But I just have to face it.” Her medical condition had worsened over time, yet she showed an improved psychological ability to deal with her circumstances. Edith was also more comfortably willing to rely on people in her life who provided helpful services.
***
Postscript: Virtual reality systems are playing an increasingly prominent role in entertainment, education, business, and in the treatment of mental illnesses. Will the use of virtual reality be a positive influence in all cases, or might it be risky or possibly harmful for some? Might virtual reality headsets be a sort of psychosis-induction device for some vulnerable people? How will we as psychotherapists better understand how risks and benefits of virtual reality might vary for different people? Time, experience, and research findings will help guide our future steps. But we can at least proceed with a sense of caution, as well as curiosity about potential new and helpful approaches.
Questions for Thought and Discussion
How might you have clinically addressed the situation with Edith and her virtual fiancé?
What are your thoughts about the use of AI in psychotherapy?
Would you like to gain familiarity with AI in therapy? If so, what kind and for what purpose(s)?
Using the Filipino Practice of Shared Inner Perception in Psychotherapy
Pakikiramdam (Shared Inner Perception)
Shared Inner Perception is the essence of the Filipino core value of Pakikiramdam. It is the sensing and attunement that occurs when people interact. Although I speak of it within a Filipino cultural context, many other collectivistic cultures share a similar value. And from an ancestral anthropological viewpoint, we were all collectivistic at one point in our histories.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
Pakikiramdam is a Filipino core value that is antithetical to the Western philosophy of directly stating what one feels or needs. The word “stating,” makes all the difference. Through Pakikiramdam, the Filipino — usually the immigrant or in the first-wave generation — is able to state or communicate far more without words than is typical or even comfortable for those solely dependent on the literal word for communicaion.
In mixed-generational or mixed-racial families, these two styles of communication often clash, leading to instances where the intent of the speaker becomes lost on the listener, while the listener feels out of touch with the speaker. In my clinical experience, this scenario often plays out in therapy with Filipino clients, leaving members of the family feeling unheard, mis-heard, or unvalued. If the therapist is not keenly attuned to the client, whether Filipino or not, the potential for miscommunication multiplies.
Shared inner perception in the therapy room starts with deep listening. It is using the therapist’s gift of intuition, attunement, collaborative projection, and co-transference. When the intuition channel of the therapist is clear, it’s like a light shone on a map that the client possesses. When the intuitive channels are unclear, ridden with ideologies and blind spots that belong to the therapist, intuition is instead like a broken compass, taking the client somewhere he intends not to be.
Pakikiramdam’s language relies on watching, listening for, and sensing non-verbal cues; paying attention to what is not said as much as to what is said. This includes paying attention to changes in vocal inflections, subtle facial and bodily movement, breathing patterns, and subvocal sounds, such as tsk, tsk, tsk.
This is not an uncommon scenario:
Ricky, a Filipino American son asked his elderly mother, “Do you want me to pass by your house before I head straight to work?” “His mother replied, “Oh no, just go right ahead.” And so the son did. A few days later, he realized that his mother experienced Tampo (having her feelings hurt, although not completely angry or upset, by someone they care about). Why?
Here’s the other part of the conversation from the mother’s perspective:
“No, just go right ahead. Oh, by the way, I remembered I have to call the plumber because I can’t flush my toilet. I had a stomachache yesterday, I guess I used too many toilet papers. Now, I don’t have a single roll. Gosh, I need to go because my neck is starting to ache holding onto the phone. Bye.”
It would’ve been more useful for the son if the mother had clearly and directly articulated her needs, even though he did repeat his request to her to stop by. Let’s explore this scenario.
Self-Soothing Versus Collective Coregulation
The “rules” for communication in individualistic and collectivistic cultures differ widely. Individuals and family members in cross-generational, or mixed cultural/racial families often experience scenarios similar to that of Ricky and his mother.Systems of care in a particular culture are influenced, in large part, by the self-soothing strategies that are part of that culture’s value system. In America, grandparents can babysit their grandchildren but more formal out-of-home, out-of-family care, like daycare or school, provides American families with the stability and consistency of care that the parents need to manage their livelihood and parenting responsibilities.
In non-Western, collectivistic societies, cooperative care is the social norm, through which children are raised by non-family “trusted-others.” These informal resources allow primary caregivers to pursue much of the same goals parents have across cultures, that is, to pursue economic opportunities and navigate parenting with ease. In these collectivistic cultures, Filipino included, parents emphasize the importance of being part of a system, which includes relying on others and being someone to rely on.
In the Filipino culture (in the Philippines), preparing and rehearsing children to read non-verbal cues are taught almost instinctively by adults from birth. The words, iyak-iyakan (pretend crying), galit-galitan (pretend being mad), sakit-sakitan (pretend being hurt), may be used in a playful, teasing way with young children so they can read real situations when they arise.
I had the interesting experience of a being a kindergarten teacher both in the Philippines and in America. The stark difference in the use of teasing as part of the group dynamics with children and the adults was notable.
Teasing is defined as making fun of someone in the English language. While I am neither proposing or advocating for teasing, I am referring to a type of teasing where someone who is teased can tease back. In fact, this is not an uncommon strategy of parents in the Philippines to teach their children to tease back playfully when teased. In this instance, the teasing becomes a communal act, as does the soothing.
It’s also not uncommon that such teasing can be used to lighten up an embarrassing moment. For example, if a child trips in front of his friends, his friends might start laughing, not as a way to ridicule him entirely but to elicit laughter so that child does not feel embarassed. Again, rather than burdening the fallen child with soothing themself, that burden is shared by the group and soothing becomes an act of community based on that groups ability to sense or intuit that child’s distress.
Shared Inner Perception in Parenting
In the following illustration, I contrast the Filipino and American orientations to the goals of parenting..png)
The American parent’s goal is to teach their child to self-regulate, to be independent, and to be self-sufficient. In the individualistic, nuclear family system, there simply aren’t as many helpers that can assist in informally raising the child. A good child is one that can self-soothe, articulate their needs, and do things on their own.
.png)
The Filipino parent’s goal is to teach their child to enter group settings successfully. This means teaching children to read non-verbal cues, including watching for subtle changes in facial and bodily movement, as well as tone of breathing and voice. A good child is one who can collectively receive and give coregulation, can share their space, and do things with others.
To contrast self-regulation, coregulation, and collective coregulation (a term I made up to explain this phenomenon), I’ll use the umbrella metaphor:
In individualistic culture, it’s essential that an individual learns to build and toughen their own umbrella so that when rain comes, they won’t be drenched. This is self-regulation. When the rain turns into a storm that surpasses the umbrella’s protective capacity, the individual may seek the company of other umbrellas. After all, two umbrellas are better than one. This is coregulation.
In the therapy room, when trauma, or a client’s deepest hurt, is akin to the rain that turns to storm, deep attunement to that client’s need for the protective umbrella, so to speak, of the therapist becomes crucial. Self-regulation yields to coregulation.
Shared Inner Perception in the Therapy Room
Returning to Pakikiramdam, shared inner perception values the following for the purpose of connecting with others: Pangangapa (to grope), Pagtatantiya (to estimate), Tiyempuhan (to wait for the right time), Tiyakin (to ascertain), Pagsusuri (to investigate), Pakikibagay (to deal with), Pakikisakay (to catch/ride on), Timplahin (to blend or season to the right taste), Singhot (to smell or sniff).It would be daunting to rely on the therapist’s intuition as a treatment plan. Intuition without a framework can put that therapist in a position of a guru who must rationalize that they were only following their intuition when they have led a client to themselves.
A useful tool is a sense of wonderment which gives way to collaborative projection. In that, the therapist’s projection is likened to a doctor who is giving an intravenous injection. The doctor has seen many veins, good and unsuitable candidates for a shot; they project based on their professional experience. When they finally choose a vein, that projection is essential, and yet they watch for a slight twitch and nuance because only the client can tell that a good vein is actually good.
The therapist who diligently engages in the practice of observing their clients can begin to wonder about the subtle unspoken reactions and changes in their client that serve as guiding cues for therapeutic involvement and intervention. This process of wonderment is not the same as interpreting, since the therapist must constantly check that their projections are in agreement with the client’s and not the other way around.
Shared inner perception is an openness to co-suffering, not just as a mere strategy for treatment but as a human experience that the suffering and the witness (therapist) are both touched by what was shared in the therapeutic relationship. As the client grows in therapy, so does the therapist and vice versa. It is a thread where the beginning and the end are indistinguishable.
It is a dance to take the experience of the client at face value, leaving space that there may or may not be more. In other words, that a no response from a client may be a camouflaged yes and a yes, a polite way of saying no. The therapist who hones their shared inner perception skills doesn’t read their clients like an x-ray, but understands that the x-ray may reveal very different results depending on how it is held.
Final Thoughts
Marco Iacaboni’s research on mirror neurons and the process of co-internalization distinguishes between the self and the other, suggesting that our neurobiology puts us “within each other.” In this vein, interpreting facial expressions and social exchanges becomes a mirroring process, a thread that connects both the therapists and the client, and not merely a strategy “done to” a client.Although the concept of Pakikiramdam in this article was introduced through the Filipino cultural lens, its tenets are not exclusive to this culture. In addition, its therapeutic use is not reserved for this population. There are modalities in the Western culture that purport a similar framework to healing.
For example, J.L.Moreno’s work on psychodrama encourages therapist spontaneity and flexibility. The other characters in the drama can utter words that the protagonist (client) dare not speak, giving timely voice and necessary silence when appropriate.
Various other modalities rely on creative expression — the sand tray, movement, art, and music — all become powerful mediums through which to explore healing without tripping into the trappings of language that often mean different things to different people. Language in all its forms, spoken and otherwise, is at the heart of the therapeutic communication.
****
The therapist, therefore, listens deeply like a dancer listening to the rhythm of a tune for the first time, aligning her moves to the serenade of the music. Every beat counts and every beat missed becomes an opportunity to recalibrate the dancer to waltz back to the therapeutic relationship.
The Symbolic Healing Power of Traditional Coping Strategies
Why do coping strategies help to resolve psychological symptoms? I once assumed that this question had a simple answer, but I have found over the years that the answer is much more complicated. There is a hidden depth to this question that is both mysterious and life-altering.
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
As a therapist, I regularly offer an assortment of coping strategies to help my clients cultivate symptom reduction. The empirically grounded strategies that I most commonly provide include breathing exercises, grounding techniques, mindfulness practices, and/or distress tolerance skills. My clients typically report these techniques to be effective physically and psychologically. Despite their positive impact, I often wonder how exactly these coping strategies work — beyond the obvious, that is!
How Coping Strategies Work
The apparent reason for the success or failure of any coping strategy is its potential to effect visible or discernable change in behavior, thought, and/or feeling. However, I have often found both in my personal life and clinical work, that there is a deeper symbolic process contributing to these outcomes.
For example, I love to run simply because it makes me feel better. While the science suggests that running promotes neural growth, creates a reduction in inflammation, stimulates new activity patterns in the brain, and releases endorphins which help to regulate mood, sleep and energy levels, these are not the reason why I run.
I run because it “carries me to a new place,” beyond the literal, that is. Symbolically, this seemingly simple, mechanical activity “opens me” to new paths and possibilities within my own internal experience. It reorients and centers those parts of myself that have gone astray. I return to who I truly am when I’m running, and I am never the same once finished. If, once I begin running, I’m angry, my feet can stomp out my frustration. If I’m anxious, my body can unwind, working through its tension. Beyond the positive, physical outcome, these symbolic gains are what keep me going, so to speak.
Along similar symbolic lines, I often de-clutter my home when my thoughts feel cluttered or chaotic. Sometimes, however, I forget to attend to this symbolic process, getting lost in the physicality of de-cluttering. In those moments when I should be focused on the symbolic, I feel too distracted by the misguided pressure of the physical act. In instances like this, and in retrospect, I often wonder how much more benefit I would gain if I were to better recognize and then enter more intentionally into these symbolic processes.
Transforming Act into Symbol
In a similar way, I often wonder if my clients are missing out on the full benefits of their coping strategies by not paying attention to their symbolic healing potential. For example, one of my client’s daily practice of journaling became much more effective when he began to intentionally symbolize the words he wrote as thoughts that were finally “leaving his mind.”This particular client initially presented with “stress” related primarily to his inability to let go of the future-oriented worries that regularly “pulled at” his attention. These thoughts typically intensified in the quiet of the night as he obsessed over the demands and possibilities of the next day. These thoughts made it impossible for him to fall asleep, which left him fatigued and even more worried the next day. Over time, this cycle solidified into a holding pattern that dominated his life, making it impossible to freely move forward.
I asked him to write down his worrisome thoughts before bedtime to externalize them. Initially, he found it difficult to banish these thoughts to paper, so he stopped trying. The action didn’t seem powerful enough to help. The full benefits of writing down his worries made sense only when he intentionally embraced the symbolic process by truly experiencing his worries leaving him through the embodied process of writing.
He also expressed the need to add a symbolic ending to the process by crumbling and tossing away the worry-laden paper into a small trash can that he set up in his nearby hallway. While he considered other symbolic acts including storing the paper in a designated box, shredding it, or setting it on fire, the act of tossing it away made the most sense to him. Over time, the journaling practice extended beyond the original act and into his everyday activities so he could experience a more complete sense of separation from the worries that had previously dominated his life.
Bridging the Gap Between the Physical and Symbolic
My clients and I find that the physical and symbolic need to be explicitly paired in order for the coping strategy to work most effectively. For example, I had another client who was struggling to experience the full advantages of diaphragmatic breathing. Despite the research suggesting the many neurophysiological benefits of this activity, she wasn’t experiencing them.As it turns out, this client had struggled with anxiety for most of her life, incessantly shopping for and trying on coping strategies in search of “the one” that would finally “fit” and bring her relief — hobbies, relationships, etc. Over time, we realized together that the “real” cause of her unrelenting distress was the fear that she would not be able to endure “standing still” and being in the moment. Searching for, trying on, and then discarding technique after technique was an illusory quest, denying her peace in the moment.
Together, we discussed this disconnect, and I suggested that she take a small step towards stillness by intentionally pairing a pleasant feeling (one she wanted to bring into herself) with every inbreath, and an unpleasant feeling (one she wanted to release from herself) with every outbreath. She chose to breathe in peace and breathe out anxiety. She came to the following appointment excitedly celebrating the positive effects of this modification to her breathing practice. The simplicity of the assignment, and her willingness to literally and symbolically “breath into it,” helped to override her deeper fears of being fully present, reduced her anxiety, and freed her to more fully and deeply engage with life.
Both clients provide striking examples of the transformative power of symbolic acts for enhancing the efficacy of otherwise traditional and mechanical coping strategies. One of the major benefits of the symbolic process is how easily accessible it can be for clients. The benefits await clients willing to engage with the limitless possibilities that symbolism provides.
For example, taking a shower may help me to wash away the shame that is held in the body. Pulling weeds can help to eradicate negative thoughts that keep “popping up.” Simply locking the front door to one’s house is a symbolic gesture that offers a sense of safety. Every moment, every act, every thought contains the possibility of actualization. The quest for symbolism, whether in or outside of clinical space, is an endless call to adventure.
This call is also a call to more fully enter into the mystery of this human experience, and to participate in the world with a fuller sense of awareness and being. Personally, these symbolic processes enrich and transform me on my own personal journey to feeling fully human. They help me to not only cope with my own day-to-day challenges, but more importantly, they pull me into a much deeper participation of healing that continually restores my own love and appreciation for life.
Professionally, I remain eager to deepen my engagement with the symbolic so that I can help guide my clients toward transformative experiences, regardless of the troubles they present. Whether they “write out” their distressing thoughts or “breath away” their anxiety, I admire their willingness to entertain and benefit from venturing into the symbolic with me. I am also amazed by and find beauty in their commitment to do so. I am fully committed to offering all my clients these symbolic pathways they can use in and outside of my office and consider this a fundamental aspect of the therapeutic process.
Questions for Thought and Discussion
What are your reactions to the author’s premise of the importance of symbolism in healing?
How have you used this process with your own clients?
Which clients with whom you currently work might benefit from this strategy?
How have, or might you use this symbolic process in your own personal life?