Category: Population

Finding Ways to Communicate with Clients About Their Symptoms

Posted on by Psychotherapy.net Team

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

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

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

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

Helping Clients Understand their Symptoms

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

***

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

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

Terminally Ill Pediatric Patients and the Grieving Therapist

Posted on by Psychotherapy.net Team

When asked about the favorite aspect of my (dream) job, I could talk for hours. I feel passionate about working in a pediatric hospital setting with chronically ill children and their families. Each day brings new challenges. I enjoy inpatient and outpatient sessions, parent consultations, family work, collaboration, and advocating for this population any chance I get.

On the contrary, when asked about the least favorite aspect of my job, my response is far less glowing and enthusiastic. I work with children from various departments within the medical center, including oncology, cardiology, trauma, and solid organ transplant. It is inevitable that I encounter children who are terminally ill. I will never understand why children die. Experiencing the death of a child is the most painful part of my job, and it will never make sense to me although logically, I know this happens. On the other hand, I feel honored to be a small part of the most vulnerable time in a family’s life, and to walk alongside them in their journey of grief and loss. Helping a family and their child during end-of-life care is arduous work. It has been impossible for me to not be deeply impacted working in this arena.

I will never forget the first patient with whom I worked that received a terminal diagnosis. I was an intern completing my graduate work. Because I speak Spanish, I was privileged” to work with more challenging cases. I remember sobbing to my mentor at the time, not understanding how a child could die. In response, my mentor neither chastised nor criticized me. She agreed with me and mourned with me. She supported me through that experience and reminds me even to this day that we are human. That support has stuck with me as I continue to mourn the deaths of children with whom I work.

When I was first asked to write a post related to working with terminally ill children and their families, I hesitated, perhaps not wanting to open old wounds and visit the pain that comes with this kind of work. But as I’ve experienced more child deaths over the years, I wanted to share my thoughts and feelings and am humbled to share my stories.

The Dying Child

The dying child has a variety of emotional, physical, and spiritual needs. They have questions and often want information about what is happening to them. The child who is terminal often feels unsafe and understandably anxious. One word I’ve frequently heard, particularly from the parent, is “brave.” In my experience, many parents of terminally ill children find inner strength in the strength of their own children. I remember one child who was aware of her prognosis comforting her parents, reassuring them that she would be “okay.” She arose each morning and worked hard to remain connected with her parents, family, and friends. I also try to remember, even in the face of their strength, that these children are scared. As I have discussed with many families, fear and bravery can, and often do co-exist. For me, bravery is moving forward even in the face of fear.

To Tell or Not to Tell

A glaring ethical question is whether a child should be told they are terminally ill and that they will die. In my experience, many medical providers and members of the psychosocial team believe a child should be informed of the severity of the diagnosis; whereas parents often do not wish for their child to know. Many parents believe children will “give up” if they are aware of the prognosis. To the one, children often know something is very different or not right. They may be confused and desire open communication to understand what is happening within their own bodies. It is my job to provide caregivers with this information and connect them to the Child Life department if they would like guidance regarding how to tell their child. It is not my job, however, to advise them on what to do or impose my own beliefs. The decision is ultimately up to the parents.

The Dying Child’s Family

The families with whom I’ve worked represent a wide range of cultures, faiths, religions, abilities, and beliefs. It has been imperative for me to work with them through a very focused lens of acceptance and understanding of end-of-life issues so that I can be as useful as possible. When learning about a family’s culture, it has been important to know and appreciate the family’s beliefs about the afterlife as this has guided me when discussing their child. Faith can be an important coping skill and protective factor when a family receives news of a terminal diagnosis for their child. However, challenges may arise because of a family’s faith. I have met with Christian caregivers who struggle with the balance of faith and science. Many worry that preparing for end-of-life care, such as transitioning to hospice, considering a DNR, or planning the funeral indicates they are not “good Christians.” Connecting families to spiritual care has been crucial when the family’s faith is important to them.

Families are often faced with challenging decisions regarding end-of-life care. Many parents process these decisions with the child’s therapist. Some parents worry that focusing on the child’s quality of life and reducing seemingly futile treatments will be perceived as “giving up.” I have often worked with caregivers who struggle with the continuation of treatments that are painful, and sometimes even agonizing, for their child. While they want what is best for their child, the decision to extend that child’s life can be tortuous.

Complex and anticipatory grief can make the adjustment to a terminal diagnosis that much more difficult. It is challenging for caregivers to be fully present while still grieving the impending loss of their child. In addition, siblings are often overlooked as a necessity for the dying child’s care. I recall the family of a dying child with whom I facilitated sibling play therapy. My goals during sessions were to connect with each child and help them connect to each other. During those sessions, the child with the terminal illness often felt ill and lethargic. The sibling first requested that the patient play with her in many ways. However, as sessions progressed, the sibling learned to allow her sister to lead. For example, instead of two chefs working at a restaurant, the sibling was the chef who served the tired patron a meal. The ability for families and siblings to find strength to cope always amazes me.

Hope vs. Denial

It is not uncommon for me to receive proclamations from the child’s medical teams that the family is in denial about their child’s diagnosis. I will never forget sitting down with a particular mother to discuss her child and family. She said, “I know what the team thinks. They think I don’t understand what is happening. I understand. I am just choosing to have hope. Hope in a higher power. I know my child’s doctors do not have the last say. I have hope that God will heal my child.” Hope is not denial. Hope is an adaptive and positive coping skill that bolsters a child and family during outstanding hardship.

The Challenges of Working with Dying Children

I was fortunate to be surrounded by deeply empathetic people during my internship, when I first experienced the death of a child patient. Since that time, I have met many medical providers who have been able to build an emotional tolerance for this kind of work out of necessity to care for their patients. I have always been thankful for their skill at addressing the physical and medical needs of these children and their families.

As a therapist, however, my role is to attend to the emotional needs of the family — their strengths and fears along with, of course, their presenting concerns. I have learned the importance of allowing space for all feelings, including my own, when a child’s death is imminent or has occurred. I used to believe I was not able to grieve the loss of a patient. My grief meant nothing compared to the limitless grief of the family, friends, community, and bedside staff. However, I quickly and poignantly came to see the disingenuousness of this belief. I have learned that the only way I can be fully present for the child and their family is by remaining firmly anchored in my own humanity and vulnerability.

I have certainly heard words like compassion fatigue, secondary trauma, contagious emotions, and empathy trauma bandied about, and how any of these experiences can lead to burnout. One extreme challenge I’ve experienced when meeting with a terminally ill child and/or their parents has been the pressure of meeting with a healthier patient immediately afterward. I will never forget receiving news a patient with whom I had worked for years died two minutes before a session with another patient. I still question whether I was able to offer unconditionally positive regard to that second patient as I struggled under the weight of what had happened moments before. Shifting those emotional gears was a challenge.

Over this and related experiences, I have had to learn ways of grieving to avoid burnout. Showing my own humanity and vulnerability within the boundaries of safe relationships and work friendships has made me a better therapist and afforded me an outlet for my own emotions. I remember working with a chronically ill child for over a year who received a terminal diagnosis. As her illness progressed, I transitioned to working with her parents. I learned to never schedule a session with another family or patient directly following these interventions. After these emotionally dense and intense sessions, I would schedule five minutes to cry. I would shut my office door and have a few minutes to allow myself to experience these heavy feelings and an emotional release. I have learned that by allowing myself to grieve, experience, and understand my own humanity, I have become a more empathic person. This has, in turn, allowed me to continue to work with this population and alongside grieving families.

Guilt and Perspective

There are several challenges and, not surprisingly for me, blessings when working with this population. One glaring emotion I often experience is guilt. When leaving the hospital for a vacation or holiday, I must inform the families of newly admitted patients that I will be gone for a few days. Many families say, “Have fun!” or “Merry Christmas!” The typical “you too” does not suffice in this scenario. The extreme guilt I felt as a young therapist was overwhelming. Then, with two healthy pregnancies and subsequent maternity leaves, and now, with two healthy children, I am often surprised by waves of guilt. Over the years, these waves have decreased in size and duration. I know I have a role to fill to support these patients and families, which will be impossible if I continue to focus on the guilt I feel.

On the other hand, I feel deeply grateful to work with these patients and families. Their strength and steadfastness are astounding. In addition, this job fills me with immense amounts of perspective. I recall a mother saying to me, “I don’t know how you do this — choose to come to work with these sick kids every day.” I replied, “I don’t know how you do this — show up for your family every day with vulnerability, strength, and support.”? Small arguments at home or my childrens’ typical tantrums seem so manageable when compared to the hardships families I work with endure. This often leads me back to guilt. It has taken me years to focus on the perspective and honor I feel instead of allowing guilt to overcome me. I realize this helps me be a better therapist for the children and families with whom I work.

Countertransference

Another challenge I’ve encountered when working with this population is countertransference. Loss prompts memories of past losses, with each new one potentially amplifying the pain of those that have come before. This has been extremely challenging for me when working with dying children, especially when I think of my own children. I recall working with a family whose child was nearing the end of her life. The parents and family wanted to make new memories by visiting Disney World, Six Flags, Disney on Ice, and birthday parties. I found myself planning with the parents during parent consultations ways to motivate their child to want to attend these events.

The child wanted none of these outings, instead choosing to remain home and stay close to her parents and siblings. In looking back on that episode, embarrassingly, I wondered if the child was exhibiting depressive symptoms. I naively believed that it would be to everyone’s benefit if she did those things with her family. During a subsequent parent consultation, I suddenly realized I was pushing my own agenda. I mentioned this to parents and that this was not what their dying child wanted. In that moment, I realized the potential power and influence of countertransference when working with dying children and their families. Therapy and supervision are key in instances such as that one.

Boundaries and Self-Care

I’ve always valued the importance and recognized the challenges of maintaining boundaries when working with this population. Our mission at Children’s Health is “making life better for children,” and I genuinely strive for this every day. However, I have encountered specific ethical dilemmas necessitating clear boundary setting. These have included coming in on a weekend or evening when a child is not doing well or nearing the end of their life, wanting to buy gifts or necessities for families who are struggling, attending funerals, crying in front of families, or sharing information with others outside of work. While buying gifts and sharing information outside of work lie within strict ethical parameters, attending funerals, coming to work when not scheduled, and crying with families lie more in the ethics shadows. Attending patient funerals is a particularly challenging ethical domain. Many providers simply do not attend funerals, while just as many others do. It has been important for me to determine if harm might befall the family if I attended their child’s funeral.

Showing emotions to family members is also a sticky issue. Many therapists have been told “don’t cry in front of families!” I have openly teared up with several families.

Therapist as Advocate

Over the years, I have discovered the importance of advocacy. If the patient expresses certain wishes, such as knowing details of their medical/health status or having friends nearby, I share these with the family and medical team when appropriate and after discussing this with the child. My role as advocate has also included helping the caregivers understand their child’s desires. As with the example of the client and her family mentioned above, I helped parents see their child’s perspective and, in turn, meet her needs during the end of her life. We were able to focus on the goal of togetherness and provide her with feelings of safety and connection the way she wanted. This was a difficult shift to focus not only on what the family wants but want the child desired. Legacy building through memory making is yet another form of advocacy, which can be built into the (play) therapy.

Postscript

Working with children who are dying has been emotionally strenuous yet deeply gratifying work for me. Staying present in my feelings while being fully present for the child and family has been particularly challenging. Utilizing rituals to remember and honor a child has been a helpful tool. Our hospital hosts a memorial service each year for employees to grieve patients who have died. Others plant a seed or add a bead to a bracelet for each child who passes. I choose to keep mementos given to me by patients and consider how each child impacted my life and changed me as a clinician. Moving forward is one of the hardest challenges for me as both a clinician and person. I have learned the absolute importance of surrounding myself with others who understand my experiences working with this population.

Coming Full Circle: Helping a Young Couple Through Their Grief

Posted on by Psychotherapy.net Team

A Matter of Death in Life

After seeing my last patient out, the sun in the back-office windows faded into twilight, darkly illuminating the autumn leaves. I began to feel weekend-ish, looking forward to a long, relaxed walk with Charley in the park, and the single gin and tonic with two limes, which I allowed myself on Friday evenings. As I put the day’s session notes on the desk, I saw the light blinking on the answering machine. One of my grad school colleagues and friend, Ben, sounded mildly upset.

“Hey Liz, I don’t know if you could see someone over the weekend, but a friend of mine just lost a baby to what they think is SIDS. They have a three-year-old son. They’re in shock and want to talk to someone about how to handle it with the kid. I thought of you immediately. It’s kind of urgent. Call me back.”

I sat quietly, letting this request wash over me. Was this a little too close to home, me aged 3 with the dead brother? But this felt urgent to me, as it was my story. Then with certainty and a whole-body-resolve, I thought, I could be of help. I dialed my colleague back.

“Liz? Hey, thanks for calling back.”

“Sure. Give me some details.”

“Upper-middle-class family. Lives on the west side. Dad seriously Type A. Mom too, but she has an arty vibe. The dad, Mark, left early for work this morning and when mom got up later, she thought it was strange her one-year-old daughter Bonny hadn’t woken her up. Claire, the mom, found the baby blue and not breathing in the crib and called 911. Claire tried not to panic, because Angus, the three-year-old, was up. Angus saw the cops and the medics and watched as the baby was taken out of the apartment. I think Claire was really freaking out too. Mark called me — he is a friend of my brother’s — after the baby was pronounced dead at the hospital. He is worried about his wife and his son.”

“I can see them tomorrow morning before yoga. Nine?”

“Sure.”

“Did the father describe the three-year-old’s reaction at all?”

“I think he is usually pretty rambunctious but after it all went down, apparently the kid has refused to talk and is very subdued.”

“Got it. Why don’t you just call them back with the time and give them my name, the office address, and my cell number in case by morning they change their minds. I assume they can afford a full fee?”

“Definitely,” Ben responded. “Great, I knew you were the person for this.”

“Thanks.” I hesitated and then said, “I think I am too.”

Ben was a good guy. We had bonded over leukemia; Ben got sick with it in adolescence and had been able to tell me about that experience. This helped me to know what it may have been like for my brother. Sometimes the universe is a sticky web. We get stuck in with those we need to know.

As I hung up, I realized I was somewhat daunted by the intensity of this referral, but felt it was necessary I take it on. What will I learn by touching the rawest parental grief over a lost child? Would I learn something about what my parents really went through when Jim died, or what I went through then too?  

The weekend feeling vanished, but I was still up to mixing my gin and tonic.

The next morning, I knew I needed to be centered and calm. Before my shower, I breathed in the roses on the terrace and then gave Charley’s belly some extra rubbing. As Charley and I walked to the office, I kept my awareness on what I could take in through my senses: the silver-grey concrete, the smell of traffic, the feeling of my foot hitting the pavement, and the cool morning air. I would have to steady my own feelings, so my own ancient grief did not disrupt what the family needed to bring to me. I had been known to get tears in my eyes when my patients were in pain.

At the office, Charley snoozed under my desk, and I settled into my buttery soft leather shrink chair. I kept working to find the right emotional space to work from — calm, steady, receptive. I didn’t get to stay put long when the outer doorbell rang. Game on.

A Sense of Helpless Defeat

I tried to softly smile as I greeted them. “Hi, I’m Liz Tingley. Please do come in.”

The father shoved out his hand and said, “Mark McNitt. This is my wife, Claire Holm.” They were in their late twenties, both tall, the woman quite thin. She was blond and the man’s hair had a reddish tint. They wore jeans, he with a jacket and button-down shirt. She had on a light-colored linen sweater, her long blond hair held back from her face in a ponytail. Their expressions were somber. Neither looked like they had slept.

I studied her face, pressed lips, red, swollen dull eyes. This plummeted me back to my own mother’s dark hole eyes the morning after my brother died, the look that made me back away so as to not get sucked all the way into her blackness. I felt a muscle in my neck tighten.

Stay in the present, Lizzie.

“Please come in,” I repeated, gesturing toward the adult patient chairs on one side of the room. Mark took his wife by the hand, almost depositing her in the first seat.

Type A alright, but protective too. She needs that now. That memory of my father pulling my mother to him, as we left the hospital where they learned Jim would die, reverberated in my head.

“Ben only told me a bit of what’s happened to you,” I said as I sat back. I made eye contact with each of them slowly, lingering a bit with Claire, her eyes tearing as she met my gaze. “Just tell me where you are.”

Mark reached over to hold Claire’s hand. He spoke first. “In shock, really.” Claire nodded.

“Yes. And it will take a while for that to wear off,” I said softly and paused. “Do you want to tell me about it?”

Claire nodded. “It was a usual morning, except that we had been out late to friends for dinner with both kids the night before. We put the two of them down for bed about an hour or so later than usual. So, in the morning, when I didn’t hear Bonny stirring, I didn’t think anything of it.” She broke down, sobbing. Mark put his arm around her.

She must be feeling guilty, like if she had checked right away, the child might have lived.

“You had no reason to think it wasn’t normal for her to sleep in a little.”

Claire nodded as she sobbed. She pulled herself together. “Angus was playing in his room. I could hear him. So, I put the coffee on first and then went into Bonny’s room. She was lying on her side, with her head in an odd position. When I touched her, I knew something was wrong. She was blue. I screamed, grabbed her up, and called 911. They had me try to clear her airway and do mouth to mouth. When the paramedics got there, they took over. They took her away and I called Mark to meet them at the ER.” She looked down, her voice tapering off to a whisper and then she stopped.

Mark finished the story. “She was already dead,” he said. “The EMTs told me that at the hospital.” In a monotone, he continued, “They let me see her.” He teared up too but bravely went on. “They told me it was an unexplained death and they had to investigate. They called the Agency for Children’s Services and the cops. They’ve kind of been at the house since.”

Claire continued, “They said it’s a ‘SIDS-like’ death, but she was too old for SIDS.” She was trying to hold onto her tears but couldn’t. “She was nearly a month premature, but she had caught up at her one-year check-up. She seemed so healthy.”

“Yeah,” I said, trying to match my tone to hers, this inexplicable crazy fact of her dead baby.

“And Angus,” Claire again began to cry, with a panicked tone.

“That is why we are here, Dr. Tingley, to figure out what to do for him.” Mark sat up straight in his chair, ready for instructions.

Inwardly I groaned. They couldn’t fix this for their son, or for themselves any time soon, and I could see that at least Mark wanted a solution now. They were going to have to live in grief with him and themselves for a long while.

“Yes, let’s do talk about Angus. But let’s not go too fast to him. Before I can share what might help you with him, I want to know more about how you are experiencing today and yesterday. What has this been like for you?”

Claire sat back in her chair, with an air of defeat. “Devastated. And I feel a cascade of things. Exhaustion.”

That’s it, the sense of helpless defeat when you can’t protect your child. Though no one’s fault, it feels like a parental failure. I decided this was not the moment to elaborate this. What agency they had left they needed to carry them through the next few days.

Mark too leaned back in his chair, looked at his wife, and then made piercing eye contact with me. I held his gaze, to reflect the pain I saw on his face. Mark added slowly, “I didn’t know something could feel this bad.”

“Those feelings for you aren’t going away for a long time. And there is a lot to get through,” I replied.

“I know they just have to do their job, but I feel like both the cops and the social workers are very suspicious of us,” Claire reported.

I nodded.

Mark jumped in. “We know we didn’t do anything to cause this. The autopsy will show that. They just have to follow up.” Claire hung her head.

“You want to know how I am?” Mark continued, his tone now angry. “I am so mad. Not at the cops, but this is so unfair. Cosmically unjust. And Angus is suffering.”

Ah, he is trying to protect his son, because he “failed” to protect his daughter. 

“It is,” I said with emphasis, “Completely unfair.”

Mark met my eyes again and a tiny sliver of real connection seemed present, but he was rushing to solve the problem at hand, his son’s trauma from this abrupt death of his sister. “So, what can we do to help Angus?”

I decided to work with his wish for some answers. “What has been his reaction so far?”

Claire grimaced. “I’m not sure what he was doing when I found her, and I was screaming and trying to breathe life into her. He came out into the living room when the EMTs arrived. He looked spooked. And my son is usually a little bit of a tough kid.” Here she smiled just a bit.

Mark added, “He is usually a little bit oblivious and is very active, in his own world.”

Claire went on, “After they took Bonny away, he started to cry and asked where she was going. I feel like I came to my senses then and told him she was sick and going in the ambulance to the hospital and that Daddy would meet her there. He seemed to take that in. I said Sandy, his babysitter, was coming while I went to the hospital too. He asked me to stay with him but then I left him with Sandy. She was reading to him when I went out. We didn’t know what to say when we came back, with Bonny dead.” Claire started to sob uncontrollably.

I sat, looking at them both, trying to generate warmth, allowing her strong affect to flow and for me to receive it. Mark went over to hold Claire, his eyes wet too. Finally, Claire’s sobs receded, and she sat up, grabbed a tissue from the table next to her.

“How does it feel to let it out?” I asked.

She smiled faintly. “It’s not like regular crying. It doesn’t get any better if you let it out or hold it in.”

“Yes, the grief is intense, and it won’t go away altogether, ever. It may, with time, be less intense.”

She nodded, then continued her description of Angus’s reaction to the chaos. “When we got back, Angus was not himself. He clearly knew that something was terribly wrong. He won’t talk now, not a word. And he is not his usual bundle of energy. He kind of just sits there.” Claire paused. “What should we say?”

“It’s hard to know how to explain this to him when you can’t explain it to yourselves,” I replied. Both parents looked so utterly sad, helpless, and young. “I don’t know what you should say exactly, but we can think about it together. It has to be honest. You have to say that she is dead, that her heart and brain stopped working, and that she is never coming back. Do you have any religious views that you want to give him about death?”

They glanced at each other and then said, “No, not really,” simultaneously. That was a good sign; they were attuned to each other. That could go a long way to help them get through this.

“Has he ever stopped talking before?” I asked.

Mark shook his head. “He did have some pronunciation problems and he’s had some speech therapy but no, he’s never stopped talking before. Though he is an action kind of kid usually.”

“How old is he exactly?”

“Three and a half.”

That gave me an idea of how he thought. Concretely. And with probably slightly underdeveloped narrative skills given what else they were saying about his language. It might be hard for him to participate in creating a coherent story about this.

“Okay. Basically, what I said before goes to the main point, to let him know that Bonny is dead.” I watched to see how they would react to this clear statement of the reality. Mark minimally flinched but I went on. “Angus will not understand death at his age. I always recommend the book The Dead Bird by the lady who wrote Goodnight Moon. It is simple and direct. You can read it to him over and over if he wants, to help him understand.”

Mark took out his phone and made a note of the book. “I will order it when we leave.”

I continued, “And even though you tell him once that Bonny is dead, he will likely need to hear it more than once, because he will understand it differently than you think he does. I mean, cartoons make sense to kids; when the guy gets run over and then he pops back up. Permanence doesn’t mean the same thing to preschoolers as it does to us.”

Both parents nodded.

“Don’t force him to talk but keep talking to him. Empathize with his state of shock. Label his feelings, including confusion. Children often regress under stress. His language sounds a little vulnerable. It’s not surprising that he might lose that. He might regress in other ways too, toileting for instance, or not being able to sleep alone.”

Mark almost chuckled. “Claire had him in our bed last night, and he had been in his own room for more than a year.”

“I had to be sure he would make it through the night, Mark,” Claire said, distressed.

“I understand completely,” I replied. “And it was wise. He needs your physical presence more than anything, and to the extent that you can, your emotional presence as well. Children are most reassured by their parents. You need to help him feel safe. Mark, can you be okay with that for now?”

“Of course. Claire, I didn’t mean…” She nodded at him.

Different Ways of Grieving

“One part of this, as you try to manage what Angus needs, is to allow each other to need things that might be different. There is a lot of research suggesting men and women often grieve differently.”

Claire asked, “What do you mean?”

“Let me ask Mark. When are you going back to work?”

“Oh, I’ll want to get back in a couple of days. I can’t imagine sitting around like this for very long.” Claire looked horrified.

“That is what I mean. To feel useful and in the routine can often feel like healing to men. Often, women find they just need more time together. And that conflict can be misunderstood by both. I wonder, Mark, if you really will want to get back to work so soon, and if you will be able to meet your need to do that and balance what Claire and Angus might need.”

Mark looked at his wife. “We can talk about it, of course.” She smiled for the first time.

“When we have the funeral, should Angus be there?” Claire asked.

“Yes, unless there is some compelling reason elsewise. But you need a back-up plan, in case he is disruptive or very upset, or you feel you can’t grieve as you need to with him there. Someone who could take him out and could bring him back. It has to be someone he knows and trusts. Though he won’t understand all the nuances, he will be a part of saying good-bye to his sister, with you and family and friends. That’s what matters,” I said.

I could have cried right then. I had succeeded in pushing my past out during most of the session, but something felt very big, pressing down inside of me, my own emotional exhaustion at trying to hold them and me at the same time. They were hurting and it hurt to see that, to feel the hurt with them, as I suggested what they do for Angus. Why couldn’t someone have said these things to my parents? Why? But I had to push that question away for the moment. I still had work to do.

“This is, not to sound clichéd, a process,” I continued. “It is going to take time. The goal with Angus is to help him have a story to tell himself about this time and about his lost sister, a story that will become part of his life story, that helps him feel that it is coherent and hangs together. To do that, you are also going to have to be willing to be with him over time and to talk about your own sadness and grief and confusion — of course in a modulated way when you can — so that he feels you all together.”

Mark let out a big sigh. “That fits with so much of my gut instinct, but already I can see that Claire’s mother wants to take him out to her house in Westchester, so we have time to cope and make arrangements. But I want him with us. Don’t you Claire?”

“I’m not letting him out of my sight for more than five minutes,” she answered forcefully.

“Is he close to his grandmother?” I asked.

“Well, yes and no. She travels a lot, but when she is around, she is super fun with him.”

Grandparent as playmate. Not what this kid needs right now.

“Some of that will be fine, but more as time goes on. You will deserve breaks sometimes, but now he needs you. As best you can, give him that,” I said softly. Both were quiet for a moment, and I saw Mark disconnect and return to some state of shock.

“I think this is enough for now,” Mark said. “You have given us the start, a preliminary road map. Claire?”

Claire nodded, tearing up slightly, and said, “Thank you Dr. Tingley. I feel like I have some better ideas about helping Angus.”

“I’m glad it feels helpful. It’s going to be a tough row to hoe, but I think you have what it takes to get it done. And remember, like always with parenting, taking care of yourselves is also a way to take care of Angus.” I made full-on eye contact, first with Claire and then Mark. “And remember I am here. Call if you need more.”

Claire bowed her head at me as they stood. Mark shook my hand.

When I returned to my chair, I let the tension of holding myself together through the session evaporate. Silently, I still felt all the same terror, confusion, sadness, helplessness, and anger as Mark and Claire, but I knew I had done decent work with them. I also thought, as Ben had said, that I was the perfect person for this — on many levels. It wasn’t just my 40-plus years in the field, working in childcare with toddlers, where I lived with children’s everyday tears and frustrations, or the career in academic developmental psychology where I learned the research that supported work with young children, or even my time as clinical psychologist, where I found a theoretical frame and the tools to connect with and manage pain and growth. It was all of that combined with my own experience of early loss, that brought me here to be able to do this job, this day. That felt satisfying.

There was another feeling, too. Gratitude. These two grieving people had come to me, trusted me, taken in my empathy and knowledge. I was honored they had let me in at such a time in their lives.

A circle was complete. My career began because I wanted people to take the emotional experience of young children seriously, as my parents had not. I had just done exactly this for Angus. This small child, whom I’d never even meet, allowed me to finish what I started, unconsciously, so very long ago, saving myself, and all the children I had touched in my career, from the denial of their young children’s grief and pain and the aftermath.

A quite different sensation took hold: I am done. I will not be compelled to do this work anymore. My mission is complete. I could work, but I didn’t have to, the compulsion gone. I slumped down, exhausted, and exhilarated. Was there time to get to yoga?

Postscript: I did not see the family again but heard from my colleague that they had relocated to Vermont and had another child. I also did not give up the practice of psychotherapy but now see many more adolescents and adults in my practice.

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

Posted on by Psychotherapy.net Team

A Troubled and Troubling History

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

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

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

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

Growth and Understanding through Play

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

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

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

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

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

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

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

***

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

How to Use Narrative Therapy to Help Clients Locate Alternate Stories

Posted on by Psychotherapy.net Team

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

A Secreted Life

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

A Therapeutic Path Forward

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

Ethics or Protocol: Children Must Take Priority

Posted on by Psychotherapy.net Team

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

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

An Ethical Dilemma Arises

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

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

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

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

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

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

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

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

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

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

A Foster Child’s Painful Visit with his Mother

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

The Family Visit through the Child’s Eyes   

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

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

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

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

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

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

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

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

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

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

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

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

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

Psychotherapy with Dissociative Identity Disorder

Posted on by Psychotherapy.net Team

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

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The Long-term Consequences of Trauma

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

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

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

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

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

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

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

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

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

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

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

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

Virtual Treatment of Eating Disorders and the Importance of Human Connection

Posted on by Psychotherapy.net Team

Be the person you needed when you were younger

-Ayesha Siddiqi

The Virtual World

I could never comprehend the idea of virtual eating disorder treatment. It would be so easy for clients to hide their food or engage in disordered behaviors behind a screen. How could I really connect? Especially with my young clients, I imagine them secretly watching Netflix behind the computer screen while I try and explore their deepest fears.

Cut to Covid! The world shut down, and my ideas on virtual treatment shifted as this became the new reality for all therapists. I have always worked with eating-disordered clients in one way or another since before I even completed graduate school. After working with eating disorders in community mental health, I started to burn out with the lack of support and knowledge in the field. As a recovered clinician, eating disorders are my passion and the reason I became a therapist. This is the population I want to work with, but this is also the most complex population which requires a complete treatment team and effective provider collaboration.

For my professional sanity — and to continue this career without burning out — I needed to shift gears and investigate a more supportive environment in which to treat eating disorders. The thing is: I live in a place where you must travel at least an hour to get to any eating disorder treatment center, which would mean I would have to travel at least an hour to work at one. While I was offered a position at one of these centers, I saw myself continuing the burn out with the commute and two young children at home.

As fate would have it, the treatment center connected me with their virtual eating disorder partial hospitalization program, which, as it just so happened, was hiring. I was still very hesitant but wanted to keep my mind open. I’d been through many treatment centers as a young teen — I know ALL the tricks. How could I help anyone, virtually? It was during my interview process that I came to the realization that there are many places where treatment is unavailable. What if this is the only treatment available to some individuals due to lack of transportation, living distances, or family circumstances? Would it have helped me as a teen if it were my only option? I must give this a shot. I must explore how I can best support this population virtually, because this is the only thing available to some individuals.

So, I made my decision to hop on the virtual train. It took some adjusting, soundproofing, and office plants to make the switch manageable — at least on my end.

The Young Anorexic Client

The sound machine is roaring.

Two boxes appear on my screen.

One screen showing my face, the other showing that of a new, adolescent client.

She is starting our program today after being discharged from a residential treatment center. I am meeting with her to introduce myself and complete a risk assessment. She admits that she is not thrilled to be on virtual, but that there are no other options near her. Her parents and treatment team are forcing her to complete this program. She admits to knowing that she needs it, and she is a minor, so her parents have leverage. She presents guarded, as teens usually do, waiting to see if I pass the obligatory therapist “vibe check.” I appreciate the honesty but notice the apathy in her voice. This is going to be a difficult client to connect with. I must learn how to connect with her.

Finding Connection

If I’ve learned anything about the virtual world, it is the importance of finding the ability to connect. Yes, it is more difficult virtually than when you are in person, but still doable. In fact, some people open up more through a virtual encounter because they feel safety in distance. New research has shown that the brain neuropathways activate more with in-person interactions. Which means I have to be more creative about forging a meaningful connection. (1)

Because the individual on the other side of the screen can’t get a sense of my “vibe,” and because a digital image of myself elicits different responses from neuropathways, I must rely on building rapport quickly.

I’ve learned the hard way, through moments of uncomfortable silence, that this sometimes requires talking about random teen trivia to get young clients to feel safe with me. My clients are experts in their life. I am merely a guest. The more my clients let me into their world, the more I can show them tools that will appropriately work for them. I have to meet my clients where they are at.

I find the best way to build trust is to find out their interests and build on that. That doesn’t mean I just pretend that I want to know about their interests. I mean taking the time to learn about them and ask deep questions. This helps me understand my clients and what treatment approach works best for them. My job is not to heal my clients. My job is to help them learn the tools to heal themselves.

Only with trust can a client effectively “buy-in” to what I am talking about regarding treatment. Why would anyone talk to me if I don’t feel safe? Building connections and creating a therapeutic alliance is about helping clients understand that you are a safe person.

Young teens are my favorite clients to work with. The most important part of effectively working with teens is to teach them to build connections that are stronger and safer than their eating disorder. The first safe connection might be with their therapist. The eating disorder is my client’s safest and most secure relationship. Which is why it is so difficult to recover from — it works.

The eating disorder becomes an entity of its own that protects the clients from trauma, rejection, fear, and most importantly has the capacity to numb. For clients with significant trauma or poor attachments, the predictability of this disorder is comforting. Ironically, it is providing them a mental refuge while slowly killing them. Accepting and understanding that the eating disorder has served a function for my clients is the most important starting point towards genuine connection. The eating disorder is my client’s biggest and most secure connection.

The Young Adolescent Client

The session starts the same.

Two screens.

Sound machine whirring.

I will call this client Abby.

Abby is hunched down on the floor with her laptop facing her. She is anxious and having difficulty sitting still as evidenced by a bouncing leg. This is not her first time in treatment. She has already told me she does not prefer virtual but has no other options at this time. By this point in our sessions together, we have discussed the usual eating disorder behaviors and worked on increasing Abby’s ability to talk back to the eating disorder voice. The ability to assist her in calling out the eating disorder is crucial. That means knowing how the eating disorder talks. Hint: it’s sneaky and insidious.

Since working together, what stands out about Abby is her increasing discomfort with the present moment. It is more than the eating disorder; I know the look of unresolved trauma. Abby is living in fight or flight. Her eating disorder being taken from her is forcing her to confront difficult traumatic experiences.

Abby started Cognitive Processing Therapy while in residential care but stopped it when the therapist realized she was not benefiting from the therapeutic intervention. So, what can I do here now virtually?

New research has shown that treating PTSD and the eating disorder at the same time yields better results for both. (2, 3) This is contrary to what was first taught to professionals about only treating one at a time.

I worked with Abby for some time, but Abby’s mother’s insurance eventually changed, and her parents no longer wanted her to participate in our program for understandable financial reasons (This is another aspect of eating disorder treatment that is complicated).

Abby will need long term therapeutic intervention for her complex trauma and the increasing severity of the eating disorder. Her motivation for recovery continues to wax and wane.

Let me explain what we were able to do virtually and how.

My work with Abby explored relationship patterns, boundaries, and the impact her trauma has had on her eating disorder relapse and recovery process. Abby learned evidence based therapeutic interventions to effectively talk back to cognitive distortions and her eating disorder voice.

And while all of this work was pivotal, I want to emphasize what got us there…

Soccer!

I know you are thinking. What is she talking about?

Hear me out. Gaining trust from my adolescent clients must come first.

The connection I made with Abby was as simple as soccer. Soccer was Abby’s motivation for recovery, soccer made her feel confident and alive. Soccer activated neuropathways in Abby that allowed her to feel seen by me.

All of the in-depth work that needed to be done started and ended with soccer. Ultimately all of the work that was done on a virtual platform started and ended with my ability to see my client and connect. In the end, my initial reluctance about working virtually with eating-disordered teens was largely unfounded. I would likely have encountered similar challenges had I worked face-to-face with Abby. It was the connection that built the bridge and soccer that reinforced it.

References

(1) Neuroscience News. (2023). Zoom conversations vs in-person: Brain activity tells a different tale. Neuroscience News, 27 Oct.

(2) Perlman, M. D. (2023). Concurrent treatment of eating disorders and PTSD leads to long-term recovery.” Psychiatric Times, Times, 17 Oct.

(3) Brewerton, Timothy. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. The Journal of Treatment & Prevention. 15(4). 285-304.