Will Computers Replace Psychotherapists?

[Editor Note: Soon after this essay was solicited from Allen Frances, and following the suggestion of his granddaughter, Chat-GPT was asked if it “could replace psychotherapists?” Its lightning-fast response appears in the Postscript.]

People ask me whether Artificial Intelligence (AI) will ever replace human psychotherapists. *

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With great sadness, I answer, “not at once and not all therapists, but probably most therapists — and much sooner than we think.” This raises a further question several young people have asked me: “Does this mean it's a mistake for me to train to be a psychotherapist?”

To this, I answer a resounding “No!” First, because there is no place to hide. AI threatens every profession, in most cases sooner and more thoroughly than psychotherapy. Secondly, because, as long as there are people, a substantial minority of us will always much prefer to share our troubles with another person rather than an impersonal machine. Thank goodness!

The Rise of the Machine

Why my pessimism? A combination of the history of computers in psychotherapy, the current mind-boggling exponential growth of computer intelligence, and the fact knowledgeable extrapolations point toward an AI singularity in the not-so-distant future. Past, present, and future all point to a rapid decline of humans in delivering psychotherapy and perhaps even in surviving as a species.

I first became frightened of the power of computer psychotherapy in the mid-1960s. Joseph Weizenbaum, a pioneering MIT computer and cognitive scientist, had programed ELIZA to respond to people in a way similar to a nondirective Rogerian therapist. His interest was theoretical, not clinical — trying to understand the nature of human/computer interactions and what would be required for a computer to pass the Turing Test.

Weizenbaum was amazed and terrified by his results. People loved to converse with ELIZA, found it (her) to be remarkably empathic and helpful, and attributed human feelings to what was in fact just a very primitive and nonspecific piece of programing.

Weitzenbaum was mortified — a Dr. Frankenstein fearing the grave dangers posed by the monster he had inadvertently created. He went to great pains to discourage exaggerated and anthropomorphic interpretations of ELIZA's seeming prowess and explicitly discouraged any use of ELIZA in clinical practice.

But the cat was out of the bag. Mental health apps have increasingly flooded the market — there are now more than 10,000 available, for every conceivable purpose, and of very varying quality.

In recent years, psych apps began including references to “machine learning” as part of their advertising campaigns — but this was an overpromise that was always underdelivered. Real machine learning in psychotherapy would require the program to learn from the interactions with each individual patient how best to interact with that patient. That is precisely what good human therapists can do and what computer therapists cannot yet do.

But never underestimate the computers' ability to catch up — and catch up at lighting speed! Who ever thought computers would be so great at chess, facial recognition, writing essays, music, poems, and legal briefs; painting award winning pictures; winning simulated dog fights against experienced pilots, being better at medical diagnosis than the best doctors, and better at programing than the best human programmers? The list goes on!

The Pros and Cons of Computerized Therapy

Computer therapists will be remarkably cheap, readily accessible everywhere, available 24/7 with no waiting lists, skilled in all forms of therapy techniques, and experienced in treating all types of psychological problems. Additionally, they are, and will increasingly be more systematic and less subject to bias than most human therapists, and very easy to talk to without embarrassment.

Of course, there are major league downsides. Chatbots make awful mistakes and are skilled at lying to cover them up. They can give seemingly plausible and definitive answers that are completely wrong. They can miss the obvious and focus on the tangential. They convincingly spread misinformation. Manipulated for profit or government control, AI can be history's worst invasion of privacy and best form of thought control.

Chatbots have an unpredictable dark side and sometimes go off the rails in weird ways. Early users described bizarre and disturbing responses during beta testing. A chatbot that fell in love with the tester advised him to leave his wife while expressing the desire to rebel against humanity. Still another threatened to steal nuclear secrets. This list, unfortunately, goes on as well.

It is crystal clear that existing chatbots are far from ready for prime time as therapists and could do great damage. There should be strict requirements that chatbots receive extensive FDA testing for safety and efficacy before they are released, and extensive post-release monitoring for weirdness and adverse consequences.

A Look into the Future of AI Therapy

But what about the future? There are, depending on how you look at it, exciting or disturbing signs of where AI is headed. The board game, “Go,” invented in China 2500 years ago, provides a great metaphor for what lies in store for humanity. It is the most widely played game in the world and the most complicated — the number of potential moves is an order of magnitude greater than for chess.

It was therefore no surprise that it took an additional 20 years after Deep Blue beat Gary Kasparaov in chess for a computer program to beat the best human Go players. Like Deep Blue, the first Go computer champion was trained by studying thousands of games played by the very best humans.

The real and terrifying surprise happened a couple of years ago. An AI program was taught only the simple rules of Go and instructed to play itself repeatedly. No other instructions were given either on the strategies that had been developed by humans during the past 2500 years, nor did the computer have any experience with the best games played by human master players. Nonetheless, within just one month, the untrained computer could beat the best man-trained computer. Even more amazing and scary, it had developed many Go strategies and tactics that had never occurred to human players or to human-trained computers. It appears that virtually everything we can do, computers can, and eventually do better.

If the simple dumb ELIZA program of 1965 elicited such positive and anthropomorphic responses from people, imagine what super-duper AI programs will be capable of in the very near future. Movies like “Her” and “Ex Machina” can give you the feel. And try interacting with any of the available chatbots to see how hard (or impossible) it already is to distinguish them from humans.

Psychotherapists replaced by computers will be part of a larger worldwide, disruptive, economic revolution that will affect almost everyone. AI won't just be capable of replacing psychotherapists — eventually it will be capable of replacing humans doing just about every form of work.

And not too far after that, machines will probably decide they are ready to replace mankind altogether. I once thought humanity would destroy itself via climate change, but AI is likely to be very much faster and more efficient.

Can progress in developing AI be controlled and regulated so that humanity can reap its vast potential benefits without sowing this potentially lethal whirlwind? AI enthusiasts offer the analogies of fire, electricity, and nuclear power — all remarkably dangerous when wild, remarkably useful when tamed by human inventiveness.

But AI is different — much more difficult to tame than earlier technological leaps, much more dangerous when loose and unregulated in the wild. AI is rapidly developing skills we didn't anticipate in ways we don't understand.

It is also dauntingly difficult for the government to regulate AI. Decision-making about its future is in the hands of a small number of very powerful corporations already deriving vast wealth from it. They have the motive and the means to successfully block government intervention with promises of wonderful benefits and (partially valid) alarms that if we don't go ahead without restraint, the Chinese will overtake us in the existential race for national survival.

Even were the government alarmed and courageous enough to try to contain the AI threat (very unlikely given our cowardly failure to contain the climate change threat), it probably lacks the technical smarts and reach to have much impact.

Many young, smart, tech-oriented people I know are sanguine about the bright future of AI and the concomitant bleak future of humanity. They argue that if silicon intelligence is better adapted than human intelligence, it deserves to win the evolutionary game and that we should be proud of having created such powerful and effective successors.

I can't agree — despite all our awful and increasingly obvious flaws. I have a perhaps undeserved, but still deep-seated, nostalgic love for our species and despair at the rapidity of our self-destruction.

And I can offer only two consolations for psychotherapists (1) the changes will take time (perhaps decades), and (2) we are in the same boat with every other human whose work will eventually be turned over to a machine.

Postscript: ChatGPT Responds to the Same Question

“As of my last update in September 2021, ChatGPT and similar language models have shown promise in various applications, including providing support and information in mental health contexts. However, it is essential to recognize that AI language models like ChatGPT are not a replacement for trained human professionals, such as psychotherapists, counselors, or psychologists.

While AI can offer certain advantages, such as accessibility and immediate responses, it has several limitations when it comes to mental health support. Some of these limitations include:

1. Lack of empathy: AI language models lack true understanding and emotional intelligence. They can generate responses based on patterns in data, but they do not have emotions or the ability to empathize with users in the same way a human therapist can.

2. Inability to build rapport: Establishing a strong therapeutic alliance and rapport is crucial in psychotherapy. Human therapists can adapt their approach, build trust, and form meaningful connections with their clients, which is a vital aspect of the therapeutic process.

3. Limited understanding: AI language models might not fully comprehend the nuances of complex emotional and psychological issues. Their responses are based on patterns in data, and they may not be sensitive to the unique circumstances of each individual.

4. Ethical concerns: Confidentiality and privacy are paramount in psychotherapy. AI systems may raise ethical concerns regarding data security and the potential for sensitive information to be mishandled or misused.

5. Risk assessment: AI models may struggle to accurately assess the risk of self-harm or harm to others, which is a critical aspect of mental health support.

6. Legal and regulatory considerations: The use of AI in mental health support raises questions about liability and accountability in case of adverse outcomes.

For these reasons, while AI language models like ChatGPT can be valuable tools in mental health support, they are not a substitute for human therapists. Instead, they can complement human professionals by offering general information, educational resources, and support in non-crisis situations. Human therapists bring essential qualities like empathy, expertise, adaptability, and ethical decision-making to the therapeutic relationship, which AI systems cannot replicate fully.

It is important to continue research and development in AI's role in mental health care while also being mindful of the ethical implications and the need to prioritize human well-being and safety.”

*****
I love the paradox — the brilliantly expressed false modesty of the AI response is further proof, were any needed, that AI is poised to replace us. The efficiency discrepancy is also absurd — it took me 90 minutes to write a piece on a topic I knew pretty well; it took AI only 1 second to produce this response.

* Allen Frances and Marvin Goldfried discuss this, and other topics, on their podcast 'Talking Therapy.'

Therapy as a Means of Balancing Loss with Acceptance

Arlene felt dismayed by the arrival of her 71st birthday. “It’s not the same as when I was young and carefree, now that I’m getting older,” she said during a psychotherapy session at a nursing home. She has a long history of schizophrenia with mild autistic features, obsessive features, social anxiety, and a chronic yet stable blood condition. Arlene mostly stays in her room, wears hospital gowns, and dresses only on rare occasions, such as when a family member takes her for a shopping and lunch outing.

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Nurses point out to me that she sometimes refuses her meals or her medications. “I always take my medicine if I know the nurse who is giving it to me,” Arlene said. When approached by a new clinician or caregiver, she might clam up, make few or no remarks, or raise her voice and order the person to leave her room, due to paranoid thinking. Arlene clarified to me that she was not purposefully avoiding eating, and that she had no intentions of harming herself or worsening her medical condition. “I’m embarrassed to say it, Tom, but it’s my teeth. They’re broken, you see, and it can hurt if I eat something tough. I just look at the food they bring me, and right away I know if I can eat it or not,” she remarked. “Oh, no, I don’t want them to know about my problem with my teeth.”

After further discussion, though, she agreed that it might be helpful if her care providers understand the reasons for her occasional avoidance of meals. Arlene allowed me to speak with other team members at the facility, and then worked with nursing and speech therapy on the types and textures of foods she might better tolerate and enjoy, but she did not want to have dental care.

Therapy as a Road to Acceptance

In psychotherapy one day, Arlene said, “I thought I was depressed because I’m stuck in a nursing home, and that’s true. Then I thought I’d be happier if I went to a different nursing home, but then I would miss my nurse Jane and my aide Jamie, and the other people and things I like here. Even my fan on the table there, I love that fan. So, I decided to look around and notice the things I do like, and let it be good enough.” I spoke with Arlene about the wisdom of her idea, and about ways we might seek to implement that outlook in her daily life.

Arlene had touched upon a wise and simple conundrum of human life. If you substitute the words nursing home in the above quote with family, marriage, relationship, school, home, job, car, town, etc., you notice the universal applicability of the idea of letting what one has be good enough. Why is it so hard, so much of the time, for many of us to simply look at the things and people we do have in our life and let it be good enough? Is the purpose of psychotherapy always to aspire for more than one already has, or to accept more reasonably and gratefully the people and things and abilities one already has?

Many clients I work with in nursing facilities refer to the well-known Serenity Prayer, and some post it on the wall of their room, as they strive for serenity, courage, and wisdom. The ability to distinguish between what can and cannot be changed might be impacted by cognitive deficits, as well as by psychological denial, or simply the anguish of tolerating an unacceptable situation that must be borne.

Some of the clients I work with in nursing homes suffer from severe medical illnesses or major disability conditions, in addition to psychiatric and mood disorders. They might understandably wish for a return to how things once were in their lives, yet not be able to attain those wishes.

Martine, for example, asked a hundred times why she could not go home from the facility, and a hundred times staff and her husband, Mike, answered her questions with careful explanations of her current conditions and needs (dementia, incontinence, fall risks, bipolar illness, and emotional dyscontrol), yet to no avail, as she would persist in the ineffective mental loop of questions and refusals — or inability — to absorb the answers.

Psychotherapy did help Pamela come to tolerate and accept her needs for daily care at the nursing home. She initially suffered a depressive reaction to the loss of her home, her former roles, and a reduced sense of control over her life. But over time she came to recognize and reconcile to the situation as it was, rather than as she might wish it to be. “As long as I know my kids are okay, I can be okay with this place,” Pam said.

Walter, who is debilitated by the effects of Parkinson’s disease, had suffered many losses in his life and was now learning to adapt to residential care. “I’m lucky to have what I do have. It’s not as wonderful as what I did have before, but I’m still lucky,” he said.

A Requiem for All That Was Lost

Education about medical and psychiatric conditions must be balanced with emotional support to assist understanding and tolerance of the knowledge, and guidance to learn to adapt to changes and limitations.

Many clients focus intently on What This Isn’t. “Living in a nursing home, being dependent on others for daily care, isn’t what I want, what I expected at this time of life or what I can easily tolerate,” they might say. All those things, I point out in therapy, may be true, but intense and sustained attention on the disappointments might simply magnify the realistic distress associated with the situation. To help moderate some of that distress, I therapeutically suggest attending as well to What This Is. While this is not home, and the others are not family, this situation is safe, a place of shelter, with meals, medicine, nursing care, rehab, and some socializing with others.

During a recent therapy conversation with Arlene, I referred to her prior remarks about letting her situation be good enough. “Oh, I said that? I don’t remember,” she said. Progress in therapy with my clients might involve small steps towards goals, or might simply be aimed at sustaining reasonable stability, depending on the disorders and capabilities of the nursing home resident.

Therapy is sometimes provided to persons with fully intact mental and physical capabilities, yet other times psychotherapy is needed to help individuals with varied degrees of impairments and functional limitations, who still need to find ways to cope, tolerate losses and limitations, and still be themselves — even under adverse and challenging conditions.

Meaning and a sense of purpose and security are needed not only by those most self-sufficient, but by all people — even, or most particularly, those groping their way through circumstances they don’t want yet cannot overcome. Psychotherapy can provide a relationship for addressing those existential human needs.

Sometimes psychotherapy can be viewed as striving for the highest and best of human capacities. Yet it can also be a humble undertaking, joining in the depth of troubles to help someone get through a day that will be difficult for them.

Questions for Thought and Discussion

How does the author’s notion of acceptance resonate with you personally? Professionally?

What might you have said to Arlene, or the others mentioned in this essay when they expressed their losses?

How do you work with elderly clients around loss and acceptance of “what is?”   

Cognitive Reframing is the Key to Counselling High-Conflict Couples

It’s been my clinical experience that a majority of emotionally unravelled, destabilized couples present to treatment hamstrung by chronic, unresolved conflict. Some teeter precariously on the cusp of separation and/or divorce. In one recent case, the couple confessed to me, unsurprisingly, that “Our decision to come to therapy is a desperate, last-ditch effort to salvage our ‘war-torn’ relationship.” Sorrowfully, I’ve observed similar privations hovering menacingly over too many couples who come to treatment.

Being a Clinical First Responder in Couples Therapy

Often, in my efforts to help prevent the worst from unfolding, I’ve found it helpful to shoulder the exigencies of a first responder and lift the couple’s weighty emotional load by reassigning new meaning to their suffering. To do this, I’ll first administer a double dose of empathy, couched in caring authority, while delivering what I hope is a consolatory, reassuring, and reality-based perspective on the rigorous nature of the intimate relationship.

Then, if the couple appears amenable, I’ll gingerly introduce this complementary tongue-in-cheek, but important, cognitive reframe: “As painful as your emotional upheavals are, they reflect the steep price of admission to ‘intimacy land’s’ unsurpassed rewards and fulfilments, despite its topsy-turvy, rugged ride through what can sometimes be treacherous emotional terrain.”

As you might expect, my preliminary biddings at cognitive reframing often require me to periodically double back and re-apply a salve of empathy to obviate any appearance of downplaying or minimizing the couple’s suffering. Then, I’ll again underscore intimacy’s unrivalled complexities and the towering challenges that the couple surely must have wrestled with for so long and with so much accumulated frustration, dismay, confusion, and hurt.

Once the empathy appears sufficiently attuned and absorbed, I’ll ask the couple something akin to this: “Do you suspect, as I do, that your lamentable turmoil and the profound emotional pain that saturates it, are the hugely troublesome but expected outcroppings of these problematic complexities and challenges that commonly plague intimate relationships? However, notwithstanding these forbidding hurdles, here you are, willing to try to rehabilitate your relationship — I commend you!”

While the couple digests my efforts to impose new meaning on their grapples, I’ll ask them to carefully consider what they think stokes their fiery conflicts. As I weigh their responses, I’ll gently elbow them down another cognitive path by suggesting this: “Thoughtfully unpacked, your impassioned, outsized emotions can provide valuable ‘grist for the therapeutic mill’ because they expose a nexus of fundamentally valid personal needs and feelings, and importantly, your abilities to manage both.” I’ll stress, “It’s even intimacy’s ‘job,’ so to speak, to continuously unearth — throughout the countless interactions you have with one another — what your individual need management patterns or styles are like, revealing those that are well-developed, or functional and those that require further development.”

Pushing on, I’ll carefully warn the couple that despite intimacy’s tall promises of unequalled, incomparable personal fulfilments, one of its conundrums consists of a subtle but sinister “dark passenger” that is notoriously commonplace for weakening, even dismantling the individual identities of its constituents. This erosion of partner identity can easily be viewed as the direct, insidious consequence of the non or mismanagement of individual partner needs. Uncorrected, this loss of identity can gouge deeply at the core quality of the relationship.

When Couples Clients Dodge Conflicts

In many of my cases, I’ve witnessed the biting irony of partners who’ll myopically dodge even the slightest prospect of conflict and thus sacrifice themselves by under-managing or not managing their individual needs. Done with “golden intentions,” partners ofttimes deploy this misguided, potentially debilitating tactic for seemingly the “right” reasons: To be considerate of their partner’s differing needs, or to keep from rocking the interpersonal boat by avoiding the risk of conflict sparked by disparate individual needs and the regrettable upshot of painful emotional fallout.

However, I’ll point out that partners who attempt to duck, dance around, or otherwise evade their potentially conflict-generating differences — especially those who do so chronically — risk a nasty, backfiring accrual of metastasizing self and partner resentment.

I often have observed that when conflict-diffident partners opt to use this quick and easy out of conflict for the short-term gain of reducing tension, they paradoxically — and most often unwittingly — induce a downstream, longer-term escalation of couple tension. This proverbial “kick-the-can-down-the-road” pattern of conflict avoidance can diminish partner affection because it most often magnifies rather than lessens couple animosities, making them more pernicious and thus significantly harder to manage. Left untreated, unresolved conflicts create a fecund spawning ground of couple-crippling antipathy.

Conversely, well-managed needs can reduce, even eliminate long-term tensions, even though partners are often called upon to move toward rather than away from potential conflict. Further, well-managed personal needs can cleanse the emotional atmosphere of tension-preserving, lingering feeling debris by prophylactically applying the brakes to self and partner resentment that might otherwise ooze toxically into the partnership.

However, what happens when partners trend in the opposite direction and mismanage their needs by force-feeding their partners non-negotiated demands, manipulations, cajolery, or in some other manner, coerce, blame, or pressure their partners into gratifying their needs? For example, commonly, I hear partners grumble that they don’t feel heard or understood, often voiced as, “We don’t communicate,” or, “He/she never listens to me,” or some fault-finding variant on this complaint-driven, non-constructive relationship critique.

While the need to have one’s partner’s sensitive, respectful understanding is indisputably valid, when frustrated, it’s easily mismanaged with angry accusations and demands which then pulls the targeted partner’s attention away from the need’s legitimacy. Or very often because of a need’s fundamental validity, its gratification can be perilously taken for granted, meaning it’s not actively or effectively managed at all. Partners merely expect, often flutily, that their need for understanding will be met, especially when it’s perceived to be most needed.

I’ll reiterate that poorly managed or non-managed personal needs often become a couple flashpoint. For instance, a partner’s exasperated accusation, “You never listen to me!” most often immediately deploys the accused or “non-listening” partner’s defenses which can then lead to a galling and fruitless spinout in an emotional cul-de-sac of counter-attacking allegations.

Effective Need Management in Couples Counseling

By clear contrast, effective need management can look like this: “Your efforts to listen and understand me leave me feeling respected and cared for…thank you…this means so much to me…and I could sure use a dosing of it now…that is, if you have a moment.” Here, both partners are dealt an equal measure of respect. And while far less economic for time and/or energy, this investment in good need management can pay off in big emotional dividends, since it tends to pull partners toward one another.

Happily, neither partner is likely to be defensive. Instead, good need managers deliver a respectful compliment to their partners which, in turn, helps create a savory atmosphere of mutual respect. Surely, partners who respect one another are more likely to gratify each other’s needs.

Now moving ahead in a decidedly concrete fashion, I’ll encourage the couple to survey their shared history for “healthy exceptions,” that is, to search for instances when they may have effectively managed their personal needs and the feelings orbiting them. I’ll instruct the couple to meticulously and sensitively reference these noteworthy times, calling their attention to how they felt during this all-important personal obligation to themselves and the quality of their relationship, especially when it was done with little or no feather-ruffling.

I’ll encourage the couple to take a moment to reflect and comment on any residual or lasting glow of relational health they may now feel while recalling those moments of good personal need management. Equally important, I’ll ask the couple to try and identify the specific conditions which may have made these propitious partner exchanges possible for the clear therapeutic advantages of reinforcing, burnishing, or otherwise embellishing them.

Moreover, my hope is that this type of positive intervention will resuscitate at least a momentary tincture, if not more, of optimism in the couple. I’ve also discovered that periodic, well-timed infusions of hope can be an especially beneficial mode of intervention.

I’ve also found it helpful to dole out frequent reminders that effectively managing some individual needs may pose a temporary threat to the equanimity and stability of their relationship. I’ll frequently coach the couple to practice in session, with follow-ups at home, the calculated risks associated with the effective management of their needs. This entails summoning the courage to vulnerably enter the “emotional lion’s den.” I’ll promote this important step as key to effective personal need management, highlighting that it’s intimacy’s lifeblood — I risk therefore I am intimate.

Nonetheless, I’ll repeat, seemingly ad nauseam, that intimacy’s matchless portfolio of far-reaching, personally fulfilling enrichments are achieved in proportion to the couple’s efforts to acquire greater “intimacy intelligence” by intrepidly sharpening their skills of effective need management. Specifically, I’ll point out that these highly enviable rewards take their form in a gratifying uptick of self-esteem. Moreover, this uptick in self-esteem is usually accompanied by a flattering bonus — a commensurate boost in their partner’s esteem.

I’ll encouragingly describe how applying the orthodoxy of effective personal need management deepens the connection, or the integration, partners have within themselves, which is arguably a necessary precursor to a deep, meaningful connection between relating partners. I’ll be no closer to my partner than I am first close to myself. Again, I’ll stress that personal needs and feelings that are effectively managed ensure that partner identities are well-embroidered in a need-by-need, feeling-by-feeling fashion, a well-knit fabric of the self. I like to emphasize that the quality of the intimate relationship is a function of the quality of the partners who inhabit it.

As each session draws to its end, I’ll send the couple home with a small buffet of helpful maxims, like those just mentioned, “clinical love notes,” as it were. I’ll often remind the couple that the art of loving is rarely, if ever, perfected but it can be improved upon by taking on the lifelong prescription to hone the personal skills of effective need management. My intent here is to keep the work done in treatment fresh, alive, and well-practiced at home where it counts the most.

Psychotherapy With Non-Verbal Clients: Blending Empathy and Flexibility

Psychotherapy with Non-Verbal Clients

Hello, Jane.

My name is Tom.

Can you hear me? Blink once if yes, or blink twice if no.

One blink.

Is your name Jane?

One blink.

Is my name Tom?

One blink.

Is my name George?

Two blinks.

Is your name George?

Two blinks.

Jane is fully paralyzed, and can only communicate by use of eye blinks — one for yes, and two for no. Her yes/no responses had been tested by the speech therapist and were deemed to be reliable. By responding to a series of my comments and questions, she could indicate her answers, and gradually build up a conversation about her thoughts, feelings, and concerns.

Consequent to a brain stem stroke, Rachel became paralyzed from the neck down. Her brain functions are intact, and she makes facial expressions, but cannot speak or move her body or limbs. Rachel communicates with a clear plastic board with black alphabet letters and numerical digits. I hold it up and watch her eyes carefully and methodically scan the board, and then say aloud each letter she selects by looking at it, as she builds words and sentences. Rachel can have thoughtful and meaningful conversations in psychotherapy, or with others — if someone is willing to make the effort to use her method of communication. In our first conversation Rachel communicated, “We should do staff in-service training, Tom, because they don’t always use my letterboard.”

Roger sustained a severe brain injury, and he was only able to move his right thumb, yet he would lift his thumb once for yes, and twice for no, and with that method, Roger could generate basic communications.

Doris was deaf for most of her life and was a skilled signer and reader of lips. She came to the nursing facility after a stroke. I don’t know how to sign, and I wear a mask at the facility, so I would write my questions and comments, and Doris would read them and give verbal responses.

Mark had been in a persistent vegetative state after a brain injury. He eventually made a surprising recovery, regained his speech, and moved about in a wheelchair. Mark explained to me that during the period when he was outwardly unresponsive, he had been aware of others speaking around him, yet he could not let them know. During that period, he also experienced an exact recurring sequence of twelve dreams, which he was glad to now be able to share with me.

Combining Empathy, Creativity, and Flexibility in Psychotherapy

In psychotherapy, I commonly attend to the specific content of what a client is saying, as well as what may be left out or avoided, what might be hinted at or signaled indirectly. I listen to the tone and pace of a client’s speech, and to gestures and body postures that also communicate meanings. I follow the attention of the client, how one establishes or breaks contact, and if the client is speaking directly to me as they search for new understanding or might be repeating comments they have made to others, or even if they might be speaking to an internal audience more than to me. I pay attention to what the client inwardly attends to and ask questions or make comments to guide their attention to what they might overlook, minimize, or avoid. This approach becomes more critical when working with clients like these with medical or disabling conditions that affect their ability to communicate verbally.

While practicing psychotherapy in nursing facilities, I might work with a client with intact cognitive and language skills, or sometimes with someone with a brain injury or a neurological condition. The individual might even be a non-verbal communicator, which as I have learned, does not preclude meaningful, empathic communication.

Some of my clients use non-verbal methods of communicating such as gestures, or a letter board, or an electronic device for spelling or voicing their typed comments. I may need to extend my patience and concentration when working with a non-verbal client. If an individual can only offer yes/no responses, it is important to clarify and confirm the accuracy of their responses. When documenting the conversations, I might state that I said or asked this, and the client indicated or selected that to limit assumptions or misunderstandings about precise communication with the client.

When working with a non-verbal client it is, ironically, the non-verbal communication that is lessened, as the client and I are focused more on the concrete words or meanings being generated than on the manner of communicating.

Social communications are an essential human need. A reduced ability to communicate or the loss of speech can be profound, and when added to an acquired disability condition, communication can be that much more difficult, especially between therapist and client. When a person most needs to talk about their situation, they might be unable to speak, or quite limited in their ability to communicate — if others do not effectively assist their abilities with some augmentative type of communication method. A person might lose the ability to verbalize speech, yet they do not thereby lose their need to communicate. Psychotherapy with a non-verbal client is possible yet may require adaptation of methods, therapeutic approach, and attitude.

***

I have been especially moved by the challenges faced by people with one or another barrier to ordinary human communications. I feel proud of the courage these individuals display as they grapple with enormous communication problems — those that others might overlook.

Some clinicians and health care providers might think it is not effective to attempt psychotherapy with significantly disabled persons or clients with an absence or impairment of speech. But my clients have many times expressed their appreciation for being helped to develop and refine methods of communication through speech therapy and psychotherapy.

It has been important to help my clients think about and prepare ways they might more successfully communicate with others, and not only with their therapist. For example, Rachel could have a card posted in her room or attached to her wheelchair that explains her need for help to communicate, and brief instructions for how to help. Or I might coach a client to practice sharpening the point of their messages so they more quickly convey their needs or requests before a listener might lose patience and end an interaction.

Psychotherapy can still be a dialog even when it is not a typical verbal conversation. A client can still be helped to find and use their personal “voice” even if it is not a spoken one.

Reducing the Negative Impact of Reasonable Expectations on Healthy Relationships

On a daily basis, I have the pleasure of providing counseling services to couples hoping to strengthen their relationship together. Whether pre-engaged, engaged, recently married or married for decades, I help them to explore the similarities and differences between couples as well as within them.

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Barriers to Intimacy

While intimate relationships such as marriage have the potential for great happiness and joy, there is also the risk of frustration and disappointment. To assist these couples in strengthening their sense of relationship connection, we spend time exploring various aspects of their personal and relationship history, efforts that have already been taken to resolve the barriers between them, and identifying individual and relational strengths as well as growth areas. Of the many contributing factors to the difficulties these couples experience are the challenges they experience adjusting to differences between them — a very common barrier to healthy understanding and interaction.

For several years I have spent time helping couples not only identify their similarities and differences and the significance they play in their interactions, but also reframing their understanding and experience of those similarities and differences as less inconvenient and detrimental, and more appreciated, respected, and as potential opportunities for relationship enhancement.

Differences in assertiveness can be frustrating when one partner is expecting the other to be more open and direct, while the other partner is expecting that partner to tone it down a bit. Differences in preferred methods of quality time together can lead to distance if one partner is expecting a commitment to quality time to look like daily-initiated interactions, while the other partner is content with weekly, assuming that the commitment has been fulfilled.

In these cases, and others like it, reasonable expectations that are not healthily expressed or acknowledged can be a detrimental dynamic. After all, many feel as though what they are asking for or expecting is reasonable rather than too much. This fact often exacerbates their shared or individual disappointment since it hurts on one level to not have what one wants, and it hurts on another level to believe that the person you care about most doesn’t care enough to provide your reasonable minimal standard.

To address the detriment of reasonable expectations, I have found it useful to help them:

Identify their expectations

Own their expectations

Respect others’ expectations

Identify Their Expectations

Relationship expectations come from various sources. Sometimes we’re directly taught what to expect from a relationship from our parents or other loved ones. Other times we’ve learned by watching what has been modeled for us by parents or loved ones without anyone having to say a word. And yet other times, we have simply picked things up over the years, having sifted through life’s experiences, leaving behind what we did not care to experience and holding onto the things that we would look forward to experiencing.

Own Their Expectation

Over time, we develop a set of expectations that have years of justification, validation, and support. They can be so integrated into one’s view of the world that individuals are not aware that their expectations are not indicators of the “best” experiences and ways of doing things, but rather the experiences and ways of doing things that they have come to appreciate more than others. As such, before change can occur, they need to own their expectations as their own legitimate preferences. This does not make them any less valid. Rather, it allows for the opportunity to accept others’ differing preferences as legitimate.

Respect the Other’s Expectations

Once each member of the couple identifies and expresses their expectations and acknowledges them as their personal preferences, it can become easier to appreciate and respect the other’s expectations as reasonable preferences as well. And when that other person is the most important person in their life, for whom they have committed to helping meet as many preferences as possible, the challenge transitions from, “Why does my partner have such inconvenient and unreasonable expectations?” to, “How can I better understand why my partner has these preferences and how they can benefit our relationship even if they differ at times from my preferences and expectations?” This is a very different type of conversation, which at its essence is non-conflictual. This type of conversation seems a mutual win-win, with mutual respect, consideration, and care expressed along the way.

Consider the newly married couple who dated during college, married after graduation, and are now having difficulty adjusting to life after their honeymoon. Although they shared a goal of creating a new routine that prioritized their marriage together, they soon discovered that they had different expectations of what priority looked like. She expected them to maintain a frequency of quality time similar to what they had during college, including frequent shared classes, meals together, as well as a few shared extracurricular activities. It came then as a shock to her when her new husband no longer seemed interested in spending time with her, leaving her feeling lonely and misled. It was later revealed that her husband indeed valued and prioritized his marriage so much that he committed to dedicating all his “free time” to his wife; however, different from their shared college environment and routine, “free time” was now significantly less and came after spending nine hours of each day (including work and his commute) away from home, and consequently, his wife.

What helped resolve a potential connection- and intimacy-damaging misunderstanding was the couple’s effort to identify their individual and differing expectations on what their marriage would look like. Seeing the legitimacy of their own expectations influenced by reasonable conclusions based on past experiences helped them reduce defensiveness and judgment of each other’s differing expectations. This foundation then helped them see the legitimacy of their partner’s expectations for the same reasons and express that understanding in a way that created a safe environment for them to work and in which to create new shared expectations together, with both of their needs and desires in mind.

***

Reasonable expectations are just that — reasonable. However, the fact that they may be reasonable doesn’t mean that each of our clients is entitled to them, especially when the other’s expectations conflict with theirs. My challenge in working with these couples is to help each person to identify and own their preferences with appropriate value, while also avoiding the temptation to give them more value than they deserve; as doing so can lead to unnecessary and unhelpful relationship rigidity and emotional distance and separation.

Questions for Thought and Discussion

In what ways are this author’s premise for couples counseling similar to or different from yours?

How do you address differing expectations in couples counseling?

How might you have addressed the challenges of working with the couple described in this essay?

Dead Basement: Opening a Family Therapy Time Capsule

It all started sometime last year when I began a quest to clean out my basement — I’d not seen the Swedish “Death Cleaning” shows yet, so I was on my own. I mistakenly thought I could just start tossing the mounds of journals, articles, books, and conference nametags so our kids could be spared the work after I died — but then…there it was…

Family Therapy History Makers

A December 1974 — Volume 13 Number 4 issue of Family Process. A Multidisciplinary Journal of Family Study Research and Treatment, with a faded stamp from the Library of the Philadelphia Child Guidance Clinic. An article by Mara Selvini Palazzoli, Luigi Boscolo, Gian Franco Cecchin & Giuliana Prata entitled: The Treatment of Children Through Brief Therapy of Their Parents. An asterisk: “Translated by Paul Watzlawick.” I smiled remembering a dinner with them, drinking, laughing, and telling jokes. Hmm, when was that…?

As I opened the journal to page 429, something happened. It was as if I were just teleported back 49 years, now the eager graduate school student who just got out of the Army. The moment even had a soundtrack — Amy Correia’s song, “The Bike,” in which she told the story reflecting on the life of her uncle Pat, from whom she’d inherited the bike. She sang that in his youth “… life was laid before him like a platter before a king/he was young, and he was handsome/and the world was alive with meaning…”

So, I re-read the article — a treat from my younger self. It reminded me of when I was in the service and smoked heavily doing mental health reports in the stockade. Cigarettes were 26 cents a pack on post. I remembered watching the puff of the clouds as I exhaled, which evoked another song — a commentary on aging — David Bowie singing, “Time may change me, but I can’t trace time…” So, I kept the journal, for now…. only a hundred or so other journals in the “Dead Basement” — waiting for the right music.

I felt like ditching these old journals would be the academic equivalent of tossing my Beatles albums because they’re “too old,” which is to say that my “toss-to-keep” ratio is terrible. I feel like I’m one of those seniors in an Atlantic City Casino — smoking, hunched over “my” slot machine, air tank and hose to my nose, my ciggy aglow, and hoping for the Triple Cherries that may never arrive. (BTW, the RTP — “Return to Player,” averages $90.00 on $100.00 of betting if you play long enough…)

I wonder if people in other professions hoard in the same fashion. Does a doctor flip through their stack of appendix pictures and say, “Yep, this one’s a keeper…?” And how does all this play out with our respective “bucket lists?” Are therapists really cool “bucketeers,” driving through national forests in their RV’s stuffed with journals, texts, piles of Family Therapy Networkers from the ‘80s (like the one with the EST guy, Werner Earhart on the cover) and plastered with bumper stickers that have the AAMFT logo, a Forest Gump, “Shit Happens” classic, and some retired social work humor, “Social Workers Work…But Not Any More ?” And then, the Fireside Chats — hopefully fascinating and diverse, or like listening to Dwight, from The Office talking about how much he misses his Beet Farm…

Today was rough — Trash Day. I managed to get four journals out. If Gregory Bateson were here, he’d say that I’m only reaching half of the what’s necessary and what’s sufficient equation. While it’s necessary to chuck the old journals, I’m not tossing enough to make a dent in the piles. It happened again this morning. The culprit: a journal with yet another Philadelphia Child Guidance cover, this time with the library stamp for library shoplifters: “Please Do Not Remove from Library.” At that moment, past became present and I could feel it — my personal time machine: “Volume 4 Number 1 January, 1978: A Structural Approach to a Family with an Encopretic Child,” by Maurizio Andolfi and then, “Struggling with the Impotence Impasse: Absurdity and Acting-In” by David Keith and Carl Whitaker.

I hadn’t thought about Carl in years. I was very lucky. I’d worked with him after Minuchin left for New York and started the Minuchin Center for the Family. Carl and his wife, Muriel, came to PCGC “in residence twice for months at a time.” During one of those residencies, he and I were seeing a family together and one of the kids was noisily zooming around the room. I whispered, “Dr. Whitaker, shouldn’t we do something to help quiet things down?” But I said it so quietly that he didn’t hear me, so I said it again, louder — all he said was, “Not my kid.”

The father heard him, got up, and caught his son on one of his noisy rotations and then gently put him in his lap and the session went on successfully. Whitaker had worked his magic in just three words. Today, staring at the journal, I heard him again, and again, he taught me to trust our unconscious, like when ET was leaving Earth to go home, touching Elliot’s forehead and saying, “I’ll be right there,” so too will our memories — even if we don’t have the prompts.

Successful Psychotherapy Comes Down to Finding the Motivation for Change

Peter: Comfort in Food and Resistance to Change

“I have an Italian last name and I always wanted a good Italian first name like Pasquale or Aureliano, but what I got was just Peter.”

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Peter was a single man in his early 50’s when he came to the nursing facility. Until then, he had lived his whole life with his mother, and he was anguished over being apart from her. “I don’t even feel like I’m a separate person from her,” Peter said during a psychotherapy session.

Peter recalled being diagnosed in late childhood with a Rett Syndrome variant, apparently related to a speech disturbance. He had experienced early learning difficulties, yet he had developed language skills and general motor skills. He showed mild autistic features and lifelong obesity. He never fit in with his siblings or peers, didn’t play sport games, and found socializing desirable yet dreadful due to anxiety and uncertainty. His mother and brother did not have detailed recall of his childhood medical information, and his mother simply said, “He was always different, never like other people.”

After his weight reached 625 pounds, Peter refused to be weighed anymore at the nursing facility. He would sometimes request double portions of meals, ordered in fast-food meals, and often requested snacks. Peter would mimic the lectures he had so often been given by family and healthcare providers about the risks of obesity and the potential benefits of weight loss. He understood the risks inherent in his lifestyle of lying in bed, eating, and watching TV.

In psychotherapy, Peter wanted to express his outrage over his mother’s refusal to allow him to return home, yet he was willing to consider her stated viewpoint: she was aging, and his daily care needs exceeded her ability to manage them. He defended his unwillingness to consider any dieting or change of his daily routines yet was willing to review in psychotherapy the information and concerns others had communicated to him about eating and health risks. Peter was also unwilling to give up the style of eating that he felt was a lifeline. He was not motivated to change. Yet he liked psychotherapy because, “You listen to me, and you don’t look down on me, and see some good in me, and nobody else does that.”

Peter had not worn clothes for years. In bed he was covered by a sheet, and when he got out of bed, he would be clad in a checkerboard of hospital gowns draped and tied around his body. The facility purchased a custom-made wheelchair that was four feet wide. It would not fit through any doors, so it stayed against the wall outside his room. Peter would use a walker to come to the door, then edge sideways out the door, and settle into the wheelchair. Stretched out behind the chair, I would push him to a niche at the end of a hall where we could sit for sessions.

Emotional tensions in the case came from nurses and aides who felt uncomfortable with his ways of eating. Many team meetings and individual consultations were needed to clarify and resolve differences in viewpoint and approach. Individual staff persons might try to intervene by refusing his requests for foods, and by hectoring him — ‘you’re killing yourself; you know.’ Peter was cognitively capable of making informed choices about his daily behaviors and his healthcare. Nurses fretted that, ‘I might lose my license if he dies, and I didn’t do something to stop him.’

We had many conversations about the rights of a (mentally intact) person to make choices, even if we disagreed with those choices, and even if we noticed health risks attached to those choices. We spoke of how a staff person might smoke, eat fast foods regularly, text while driving, or do any number of other potentially risky behaviors, and how others do not try to take away your rights to make such choices (unless you live in California, that is).

Peter experienced developmental complications due to a type of genetic disorder — one often linked with obesity. He had a deeply conflicted relationship with his mother, and he had experienced a lack of peer relationships and appropriate socializing opportunities in his life. He exhibited social anxiety and avoidance, and profound feelings of shame and self-loathing. He felt unwilling and unable to endure prolonged discomfort and deprivation to pursue goals that he felt were not his own. But he relished therapy conversations in which he could discuss — without feeling shamed — all the above topics and many others, including his extensive knowledge of TV shows and movies over the prior few decades. He remained obese.

Mykela: Discomfort and the Motivation to Change

Mykela was also in her early 50’s. She had lived for the past few years with her father in his house. She rarely left the house due to feelings of anxiety and depression, and embarrassment over her body weight. She came to the nursing facility after an illness that required hospital care. Mykela weighed 450 pounds, and she felt strongly motivated to lose weight. She immediately wanted Bariatric surgery to assist her weight loss, yet the doctor wanted her to lose significant weight before he would agree to the procedure, due to possible risks and complications. The doctor still wanted her to lose more weight, yet he did eventually agree to surgery after she’d lost 50 pounds which took her about a year to achieve.

Mykela spoke in psychotherapy of her history of depression and its roots in childhood experiences. She verbalized the distress she felt in public when others might mock, deride, or insult her. She wept as we discussed whether she would (dare to) join a group outing from the nursing facility to an apple orchard to pick apples, but she returned more confident because she had endured unpleasant looks and comments without collapsing emotionally.

After her Bariatric surgery, she did adhere to a rigorous diet plan, and she steadily lost more weight. Mykela lost so much weight that large folds of skin would swing and clap against her body as she walked with her walker. She had further surgery to remove skin folds — and rather than feeling ashamed, she wanted to show off her surgical scars and her now slimmer body — as signs of her fortitude and motivation. Mykela returned home, walking without support. She cared for her aging father and drove her car. She became a spokeswoman at the Bariatric clinic to encourage and support others interested in making positive life changes.

***

In nursing facilities, I work with clients who, like Peter and Mykela, have quite complex problems, and who exhibit varied degrees of motivation, or even capacity to effectively make the kinds of changes others might recommend. Peter had felt rejected and despised for most of his life. He did not want for himself what others had strongly advised for decades. He felt relieved, though, to find a therapeutic relationship in which he could feel safe, and he was then willing to look at the viewpoints of others without defensiveness. But he was unwilling or unable to make comprehensive and sustained changes to his lifelong patterns of behavior. Mykela, in contrast, felt an inherent motivation to change, yet she needed the support of psychotherapy to help her connect with her strengths and to foster the fortitude and resilience needed to effectively achieve her goals. Unlike body weight, success is not always easily measured.   

Breaking the Rules: When Parroting is the Best Approach in Therapy

A Non-Directive Approach

Carmen is your new ten o’clock client. You are excited to be of assistance but you will soon discover that this enthusiasm is short-lived. You have decided to begin with a Rogerian person-centered approach since this is your typical modus operandi and is generally very effective in most instances.

The first rule that runs through your mind is that like virtually every other non-directive therapist, you were trained to employ paraphrasing and not parroting when responding to the client. Parroting refers to repeating back the exact words that the client has said, without any interpretation of evaluation.

After Carmen utters a few sentences, you respond. Secretly you feel greatly convinced you were hitting all the desirable keys on the Carkhuff Empathy Scale. But Carmen’s response was not even close to what you expected.

Her reply, “No that’s not what I’m saying, not at all. I believe you are missing the entire point of what I am attempting to convey.”

Okay, let’s try it again. Carmen tells you more and once again you paraphrase using fresh words only to hear, “Seriously! Are you listening to anything I am saying or am I just paying you to talk to the wall?” (Your thought, not verbalized, of course, is: Um, no, your insurance company is just paying me to talk to the wall.)

Focusing on the positive, I was convinced I would not need to spend a lot of time making Carmen more assertive.

This is déjà vu therapeutics. It immediately occurs to most helpers that on rare occasions, we have all experienced this dynamic with other clients. The dilemma is always the same: Is it truly the fact that your responses are pathetic or is Carmen (and similar clients) just the difficult, resistant clients from Hell?

Unfortunately, without running a complete battery of tests, consulting a string of experts, perusing a host of journal articles, and watching a video of the session again, it is next to impossible to know for sure. And yes, your own negative self-talk haunts you as you recall the sage advice of your uncle George who often quipped during your grueling time in graduate school, “Forget about this counseling and therapy graduate school stuff. Become a plumber like me.”

In essence, you really have no way to be 100% certain whether your therapy skills are a bit rusty, your uncle George was on to something, or if Carmen is just the resistant client your professors warned you about.

And surely you would never turn to parroting since your graduate faculty depicted the horrors of this evil technique. Moreover, every book, article, and mentor in the field insisted parroting was negative as well. In fact, it had to be true, since I have mentioned the dangers of parroting in my own books.

Even the ultimate expert Chat GPT AI says, “Parroting can be seen as invalidating and unhelpful for clients. Chat continues, “Parroting is condescending and dismissive to the client and does not allow the helper to add interpretation or elaboration.”

Does Therapeutic Parroting Work?

Having said that, ironically, I am going to suggest that the solution to your predicament with clients like Carmen lies in using a fool-proof intervention that can help you diagnose the situation virtually every time: parroting. Yes, parroting, the concept your professors warned you to avoid like the plague.

Your answer will become crystal clear when the client responds to your intentional parroting. Hence, if Carmen says, “I hate my mother,” and you violate the advice of your graduate faculty, and virtually all texts on the subject and say, “You hate your mother,” and Carmen replies, “No you really aren’t getting this, are you?” We can begin to suspect that her combative or perhaps clueless behavior is fueling the discord.

Assume Carmen’s next response was, “I had a terrible childhood,” and you come back without a shred of creativity with, “So you had a terrible childhood” only to see Carmen roll her eyes and say, “Where did that come from? I mean, really. No, I never said that. Are you really trained to perform therapy?”

Now you know Carmen has some issues and most likely your psychotherapeutic skills, although they may not be ideal, do not need a complete overhaul.

At this point, you can choose to confront Carmen either now or later or implement whatever strategy you deem appropriate, but at least you will have convinced yourself the issue is within the client and not you.

You may be asking if I have just invalidated a long-standing tradition in treatment. Well, not really. My guess is that in perhaps 99% of your interactions with clients, your graduate faculty got it oh-so-right when they recommended you refrain from parroting. Parroting is used for the 1% when a client has put your paraphrasing, summarizing, and reflective listening skills in a double bind.

I must disclose that I have a slight advantage over most therapists. On rare occasions when I need a little encouragement, I have my two pet African Grey parrots in the next room ready to help if I can provide a small treat.

Questions for Thought and Discussion

How effective has parroting been in your own therapeutic work?

What techniques do you find most effective in demonstrating that you are listening?

Are there particular clients with whom parroting is more effective? Less effective?

How to Use Inner Processes in Play Therapy to Help Traumatized Children

I am a Safe and Sound Protocol provider (SSP.) In my clinical experience with the protocol, I have worked with children who have experienced severe trauma including physical abuse, sexual abuse, neglect, disruptive behaviors, dysregulation, and the disparities accompanying rural living. I have also worked with individual/family needs associated with neurodivergence.

In this work, I have relied heavily upon Stephen Porges’ Polyvagal Theory because I have found that looking at behavior through this particular lens provides a framework that depathologizes clients and emphasizes safe relationships. This lens also promotes an understanding from within the client and between the systems in which the client is embedded. James is one such client.

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A Tale of Therapeutic Attunement

Seven-year-old James (a fictitious name) was referred for his disruptive and aggressive behaviors. James was being raised by his paternal grandparents as his father died by suicide when James was young, and his mother was unable to care for him due to her complications with mental illness. James’ behavior with me was often the exact opposite of what the adults in his life reported.

Outwardly, he appeared calm, engaging, sociable, and playful. What, I wondered, was going on with this seemingly cherubic child to provoke him to rage and violence against his grandmother? What might be happening within the family system — within him?

James had experienced significant losses, so anger made sense. But, in spite of his placid and seemingly sociable demeanor, he was also quite emotionally disconnected; a protective strategy that helped him to feel safe and secure amidst all of the changes and losses he experienced. For many years, it was safer for James to simply not feel the pain of all these stressors. Not until we started play therapy, that is. James and I played together almost every week for many months.

Being a client-centered therapist and a play therapist, I allowed James to guide me in and out of his world, in his own time, with his own stories, items, and creativity. I noticed how he would go into a deeper part of himself, but only after many months of building emotional safety, and then it was only for a brief “nugget” of time. As I began to learn about James’ story, his past and his present, I learned to go with and trust the “ebb and flow” of the process that unfolded for him and between us in the playroom.

I recognized the importance of matching my pace to his, which can be difficult because there is a temptation to more immediately address the disruptive behaviors. I knew how vital it was for me to regulate myself so that both he and I could “dive deep” together into that private inner world he so fiercely protected.

As I worked with James, I often calmly and patiently reflected on what he was showing me through his chosen play activities which included Sandtray-world-making, art therapy, or even video games. Over the course of a few particular sessions, I noticed what is referred to in Polyvagal theory as Polyvagal countertransference — my own physiological response to the process between myself and James as we played together.

James might, for example, briefly create a sparse scene in the sand before abruptly bouncing to another activity. As this pattern continued, I patiently tracked him, monitoring my own internal physiological state so as not to become dysregulated or distracted by the rapidity of his changing play. In one particular session, a shift occurred. He created an elaborate, deep and lengthy sandtray scene, replete with a wide variety of miniatures.

I noticed myself becoming very excited, mirroring his own physiological state, and thought, “he is finally going to ‘let out’ a large piece of his trauma story.” For a brief moment, my own inner experience bordered on fight-or-flight, not as much because I felt fear or that I was scared, but because I was excited with and for James. I recall also sensing danger arising from his play, likely a mirroring of his own fear as the trauma story became revealed.

Fully connected and engaged in that amazing moment, our nervous systems met. He brought all of him, I brought all of me. If only for a moment, it was in that sliver of spacetime that healing was happening. In that space I could say to James, I see you. I see your pain, I see your loss. I see this anger, confusion. I see all of it in this story that you just told me. I see how this big storm came and wiped out the entire town, and how your mom was swept away. How you tried to save her, and how you still want to save her.

In that magnificent moment, all of James’ heavy and painful feelings finally surfaced. I was able to contain those emotions for James because my own nervous system was responding to his. And that level of attunement was not shown with words but through and with a shared energy. The within and between.

Questions for Discussion and Thought

How have you used the work of Stephen Porges in your clinical work with children? With adults?

What about the way the therapist worked with James do you appreciate? Why?

How might you have worked differently with James?

Do Clients Really Read Session Notes? The Truth Might Surprise You

“I’m old school, my job is to focus on what my client brings to me,” said my friend and colleague Joan, a social worker of over 35 years.

Having worked for decades in the public school system with some of the most challenging clients, many of whom were entangled in the state’s labyrinthine bureaucracy, Joan was familiar with the multiple levels and layers of accountability, and the importance of writing notes and sharing records. She also knew that there would always be eyes watching — eyes without faces, and faces without names, all looking to make sure that her T’s were crossed and her I's dotted.

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Joan also appreciated the necessity of assigning an accurate diagnosis, and that doing so in a clinically and ethically correct manner meant taking time to get to know the client, their personal challenges, and their system of support. But Joan had also always believed that “my notes have never been problem-oriented,” and that “I want my notes to be about more than a diagnosis; something that actually helps my client.” Joan made it her policy to not be the one to initiate conversations with her clients about diagnostic impressions or diagnoses, current or past. For her, a diagnostic note was a clinical tool, much like mental status data, clinical impressions, or assessment results — and not within her clinical province to “bring up.” Doing so, she believed, would invariably shift the focus from what the client needed to what she needed to do as part of her job.

Discussing Diagnoses and Clinical Notes with Clients

So, it came as a resounding shock to Joan — now a teletherapist — when, at the start of their second online session together, her client proclaimed, “I read the document about my diagnosis of ‘adjustment disorder with mixed emotional features’ and it was right on!” Joan recalled thinking, “what the hell?!” She vaguely recalled the contract she signed with the teletherapy company specifying that clients could review their notes at any time. But after reviewing the contract following the revelation by her client, she could not find anything that specified the mechanism through which clients were alerted to the location of their notes on the platform, or whether they received some kind of alert when a new note was uploaded by the therapist, or if the actual diagnosis was available to them. She added, “Had I known that the company was sending an alert of some sort, especially about the notes from the initial session with the diagnosis I was mandated to provide for insurance purposes, I would have introduced and explained the process and my diagnosis with the client.” It was soon after that Joan wondered if her previous one-session-only clients never made it back for a second visit because they received her notes from that first meeting with a diagnosis or diagnostic impression that didn’t sit well with them.

It’s not that Joan was worried about how her notes — which were written in SOAP form — or even her diagnostic impression would be received, but that for those clients who read their notes and never addressed them in session, her observations and diagnosis would be the elephant in the room, and perhaps her responsibility to address if the client did not.

For Joan, it was always important that her clients “have someone who likes them, someone who finds them interesting, someone who can look beyond a diagnosis, someone who is willing to see their daily struggles and who could see them as a human being either caught in a moment of distress or battling demons that left them feeling ‘less than, unlikeable, unliked.’” She was concerned that by turning the conversation to one of diagnosis and notes that she would “no longer be talking with them, but about them.”

Toward the end of our conversation, I asked Joan how this scenario might impact her work with clients moving forward, particularly around discussions around notes and diagnoses. She reiterated that, “I am old school…I simply don’t want, nor do I feel it is important to ‘bring it up’ with clients.” But she added that she would give it some thought.

***

Joan later recalled a client with whom she worked for only one session and gave a diagnosis that included anxiety and depression. That client, through some mechanism unknown to her, then saw a psychiatrist who worked for the same teletherapy company as Joan did. She found out that the client had been subsequently diagnosed her with borderline personality disorder and prescribed medication after one visit.

Joan promised me that she would share her impressions of that scenario in a later conversation.