Reflections on How to Live with Hardships in Life

The central question of my latest book, Shh…it Happens: So What? Reflections on How to Live with Hardships in Life is: How do we go on when life refuses to grant us peace? Some pain lingers like an old debt; some wounds never fully heal. Perhaps wisdom lies not in overcoming, but in learning to carry what cannot be undone.

Pain Isn’t Meant to Teach Us Anything

I’m not sure how this idea could serve as a therapeutic tool. But through my work with Holocaust survivors, and others who have endured severe trauma, this perspective has gradually become something I deeply believe in.

Shh…it happens is often all we can say when life falls apart, and when we recognize that some things defy response. There is no clever comeback to death, no simple answer to betrayal, no quick fix for what breaks us. Shit happens—and not just once, but again and again, in forms both visible and hidden, personal and global, trivial and devastating. No one is immune. No life is spared from it.

Our culture doesn’t like that. It wants action and solutions. There’s a constant stream of advice: stay strong, be positive, find the silver lining. But what if we can’t? What if we’re not ready to move on, let go, or come to terms with it? What if all we can do is sit with it?

This is not a call for despair. It’s a call for honesty.

For decades, I’ve sat with people in pain—clients, friends, family, and myself. I’ve witnessed how quickly we rush to make sense of the senseless. We reach for explanations, spiritual frameworks, psychological theories, anything to tame the chaos. We want to believe that suffering has a purpose. That it fits into some larger arc of redemption.

But what if it doesn’t? What if some pain isn’t meant to teach us anything? What if the most human, most courageous thing we can do is to stay with the discomfort, without turning it into something else?

That’s the heart of what I’ve come to call a “so what?” philosophy. Not as resignation, and certainly not as indifference. It’s not a shrug—it’s an act of quiet resistance. A refusal to force meaning where there is none. A willingness to sit in the shadow of what has happened and say: This is real. I don’t understand it. But I’m still here.

Lessons from Experts in Survival

We are meaning-making creatures, but not everything in life offers us meaning. Some events simply are: A child dies. A diagnosis lands. A future dissolves. No explanation makes it right. There’s only the living with it.

And in that living, there’s something else—not healing, perhaps, but presence. A kind of dignity that doesn’t come from overcoming pain, but from carrying it honestly.

The “so what?” stance is not about dismissing what matters. It’s about letting go of the pressure to be wise, composed, or productive in the face of grief or absurdity. It’s about recognizing that we don’t have to justify our sadness or spin our suffering into virtue. We can just sit with it. Let it be part of our story without needing it to be the whole story—or the final word.

There is no clean arc to follow. No perfect lesson to extract. There are only fragments—of reflection, of feeling, of thought—offered here as a kind of companionship. No system. No stages. Just a shared recognition that life gets messy, and sometimes the best we can do is to pause, to breathe, and to say quietly: So what?

Because that’s where we begin again—not by solving the pain, but by making space for it.

While working at The Israeli Center for Mental Health and Social Support for Holocaust Survivors and the Second Generation (AMCHA)—a treatment center for Holocaust survivors and their families—I was granted a unique opportunity to learn from the very experts of survival. These were individuals who had endured the unimaginable, who had lived through horrors that seemed to defy the capacity of the human spirit to endure. It was, in many ways, a privilege—a rare chance to ask the question I had long pondered: How did they do it? How did they manage to survive the unspeakable, to continue living in the face of such loss, such devastation? What I learned, however, was that survival did not come without its own unrelenting cost.

The survivors I encountered—each with their own story, and their own scars—made every effort to continue their lives without being constantly haunted by the atrocities of the past. And yet, the memories had a way of returning, uninvited and unavoidable. They surfaced with all their accompanying emotions—grief, anger, fear—relentless in their return, like waves crashing against the shores of their minds. These memories could not be erased; they lingered, embedded deeply, despite all efforts to forget them.

Most survivors, however, showed an unusual degree of psychic strength, overcoming the effects of their harrowing experiences, their losses, and their exile. Yet, there was a minority, a clinical minority, whose wounds—those invisible scars—remained raw, continuing to affect them for years, even decades, after the war. The weight of those emotional scars lingered beyond what anyone might have expected. I tried to capture these findings, these complex realities, in my 2009 book, Holocaust Trauma—a humble attempt to summarize what I had witnessed, and what I had come to understand.

Perhaps the most telling description of endurance during the war happened during the death marches of the Holocaust. Prisoners were forced to march from one camp to another under brutal conditions, knowing that those who fell behind—too weak or too exhausted—would be shot on the spot. Every step they took was an act of defiance against a fate that seemed inevitable. The advice to “take one step at a time” finds its most literal and harrowing expression here. It’s a mantra we often hear when life feels unbearable: “Take it one day at a time.” It urges us to confront today’s pain, today’s hardship, without being consumed by the unknowable weight of tomorrow.

These aren’t stories with happy endings. They don’t offer neat resolutions or triumphs to celebrate. They are about enduring the unendurable—about surviving not because there is light at the end of the tunnel, but because continuing is the only option left.

I used to visit an elderly woman who had survived the Holocaust and once asked her gently, “And how are you today, dear?”

“Oh, you know,” she replied, her voice tinged with weariness. “Ups and downs, as always.” She paused. “I had hoped to put it all behind me, to find some peace. But it seems the past refuses to let go. It haunts my dreams, a persistent shadow.”

Her words, simple yet profound, laid bare the depth of her emotional turmoil. I had heard her recount her experiences during the war countless times, and there was no need to articulate what weighed on her mind. The past, an unrelenting burden, had etched itself into her being—a scar that even time could not heal. And yet, we must continue to live with what cannot be changed, carrying the weight of the scars as we navigate forward. It’s not about fixing or erasing the pain but learning to coexist with it.

Some shit doesn’t pass. It lingers, not as trauma in the clinical sense, but as residue. A faint tension in the body. A change in tone. A silence that settles into the corners of a room. We move on, but something in us stays behind.

We learn to live with this residue, not by resolving it, but by tolerating its presence. That doesn’t mean being passive. It means not turning away.

There’s a common belief that pain must be processed, worked through, or healed. And sometimes that’s true. But more often, we simply carry it better. We learn to contain what cannot be erased.

Containment isn’t control. It’s not about suppressing emotion. It’s about holding what’s there, without being overwhelmed by it. Like sitting with someone crying—not trying to stop them, not analyzing—just staying present. That’s what we do with our own pain, too.

To “come to terms” with suffering doesn’t mean to conquer it. It means to walk alongside it, to acknowledge its presence without letting it consume us. Perhaps then, we may slowly release our futile struggle to control the uncontrollable and begin to find peace in the messiness of life. As painful as it is to admit, this struggle isn’t separate from life. It is life. Suffering forces us to confront something deeper: who we are, how we endure, and the meaning we choose to create in the shadow of the unbearable. Some people rebuild. Some collapse. Most of us do something in between. We adapt. We patch. We find new ways to carry the same weight.

That’s what I mean by recycling shit—not transforming suffering into something beautiful, but giving it a new function. Letting it fertilize something else, even if we never asked for it.

Pain leaves a mark. But it also leaves material. Emotional scraps, memories, truths we didn’t want but now can’t ignore. If we’re lucky, we find a way to use them. That doesn’t mean we’re grateful for the suffering. It means we don’t waste it.

Some people make art. Others grow more tender. Some become fierce protectors of others who suffer. Some just endure—and that’s enough. Repurposing doesn’t have to be dramatic. It can be as quiet as waking up and doing the dishes.

I’ve seen people repurpose pain into humor, into music, into silence, into stubborn survival. Not because they’re brave, but because the alternative was to fall apart. Pain, when recycled, becomes part of who we are—not a scar to hide, but a seam in the story.

There is no promise here. No redemption arc. Just a reminder: pain changes us. And in that change, something new may form—not because the shit was good, but because we lived through it.

Recycling is not erasing. It’s carrying forward what cannot be undone, in a way that no longer poisons everything it touches. It’s not transformation. It’s a continuation.

The Contained Mess

We often speak of recovery as if it were a return, but most of us don’t return. We don’t go back to who we were before the shit happened. That version of us is gone. What we do instead is re-cover—layer over the wounds, stitch the fabric of life back together, however unevenly.

This is the heart of what I’ve come to believe: we don’t get over things. We don’t transcend. We carry, adapt, and make space. We contain, not in the clinical sense, not in the tight management of emotions, but in the old sense of the word: to hold. We become the container for the life we didn’t ask for. We hold the brokenness, the anger, the absurdity, the beauty. Sometimes it leaks. Sometimes it’s too much. But somehow, we stay upright.

For me, writing has been an exercise in containment. I’ve tried to reflect, not resolve. To stay with the mess long enough to see what it might become. And yet I wonder whether the act of writing is its own attempt at control—a way of taming the chaos with sentences.

Maybe this, too, is part of my own shit.

Still, I believe in the value of sitting with it. In not turning away. In saying, even when no answers come, I am here. This happened. I’m still breathing.

The world doesn’t need more advice. It needs more truth and more people willing to say: I don’t know what to do with this pain. But I’m willing to hold it.

That’s where these reflections end. Not with clarity or healing. With a container of shit, and the quiet hope that it holds.

This essay is a condensed version of the full book: Shh…it Happens: So What? Reflections on How to Live with Hardships in Life. The full version explores each of these ideas in depth, with stories, personal examples, cultural reflections, and philosophical insights. It’s not a manual, but a companion. A place to pause, to reflect, and to feel less alone in the shit we all face.

Shaped by Experience: What a Brain Bleed Taught Me About Therapy, Grief, and Presence

From the Ashes of Crisis

Alone in the ICU, tethered to machines and unable to see my family due to COVID protocols, I realized I was about to learn lessons no textbook could teach. I never imagined that a single medical crisis could teach me more about therapy than years of clinical training––surviving a brain bleed during my final semester of internship turned the ICU into the most intense classroom of my life.

Some nurses became my anchors; others showed me what I never wanted to become. I learned lessons about presence, compassion, and patience that no textbook could offer. My neurosurgeon was like a balm for my fears. Some nurses offered calm steadiness when everything felt terrifying. Others were brusque or cold, teaching me just as powerfully what I want to avoid in my work.

Even months into recovery, lingering symptoms—burning headaches, balance issues, heightened sensitivity—forced me to slow down. I had to set limits. As my internist said bluntly, “Focus on yourself.” This is advice we all need to hear sometimes—especially when life feels overwhelming. That process of slowing became a gift: I learned how to sit fully in stillness, tolerate uncertainty, and meet suffering without rushing to fix it. And humor? It can diffuse suffering. I realized it can be a quiet lifeline, reminding us of our shared humanity even in the darkest moments. The following lessons about presence and patience became especially relevant in my work with clients navigating profound loss.

Sitting with Grief: Aaron’s Story

Aaron came to therapy shortly after losing his partner in a sudden and tragic accident. The shock and anguish he carried were crushing. In the early months, he found ways to honor his partner’s memory through personal rituals that gave him small moments of connection, purpose, and meaning.

I drew on my own experience with vulnerability and life-altering uncertainty to simply sit with him, without judgment or pressure to “fix” his grief. Sometimes, just being present felt like the only thing that mattered. Over time, we explored the idea of growing around grief, which lifted some of the pressure to “get over it” within a certain timeframe—pressure that Aaron sometimes felt from his family, who were anxious for him to move on. Healing, we discovered, doesn’t erase loss—it expands around it, letting life continue alongside the grief.

Slowly, Aaron began to imagine a future where his partner’s memory stayed with him, while leaving room for new relationships, moments of joy, and perhaps one day having children—a future shaped by both love and remembrance.

Shared Vulnerability: Duncan’s Story

Another client, a young adult in their twenties, came to therapy struggling to access emotions after a loved one had died about a year and a half earlier. At first, they couldn’t cry and often felt numb, as if the grief had shut down their ability to feel. Over time, they learned to open to vulnerability, explore deep questions about life, and celebrate meaningful milestones.

Later, a sudden and tragic medical crisis, similar in intensity to my own brain bleed, involving a close family member shook them to the core. Sitting with their grief stirred my own memories of helplessness and survivor guilt. In the past, I might have redirected those feelings in the name of “professionalism,” but now I could simply bear witness—being fully present alongside their suffering.

Silence became a space where emotions could surface. Through that silence, Duncan was able to access feelings that had previously felt blocked. For me, as the therapist, the long bouts of silence were challenging, yet holding that discomfort became part of supporting him. For this client, it allowed grief to breathe, tested trust, and revealed the quiet power of shared human vulnerability. My steady presence, sometimes wordless, reinforced that being truly present can matter more than saying the “right” thing.

Takeaways for Readers

  • Presence is powerful: Sometimes simply being there matters more than advice or solutions.
  • Grief has no timeline: Healing is nonlinear, and growth can happen around, not just after, loss.
  • Shared vulnerability fosters connection: Authentic empathy strengthens bonds, both in therapy and everyday life.
  • Humor can coexist with hardship: A gentle laugh can remind us of resilience and shared humanity.

Just as I learned to sit in the stillness of an ICU room, tethered to machines yet alive, I now witness grief and healing unfold—messy, nonlinear, and profoundly human. In therapy, and in life, the greatest gift we can offer one another is simply to be present.

Therapy, for me, is about ensuring no one feels alone in their suffering. My ICU experience didn’t just shape my approach—it deepened it. I show up with attunement, patience, and care rooted in lived experience, creating space where clients can meet their own pain with courage, curiosity, and even a little laughter.

Rebuilding Connection after Grieving the Loss of a Desired Relationship

The other day, one of my clients asked me, “Isn’t it unfair to know that they [people around me] still can’t figure out that I am going through something and that I have to spell it out every single time, even after all these years?”

Unmet Expectations

I sat there in quiet surprise as I remembered asking the same question to myself a few days before. I thought, this is going to be interesting!

Lately, many of my clients have been dealing with the feeling of disappointment in their close relationships when they’ve come to realize that these bonds may not be as they once believed them to be, even after years together. It can be a parent, spouse, or close friends—it doesn’t matter. As their therapist, I have found myself sailing in the same boat, and I am at a crossroad when I am with them in that room trying to hold space for their disappointment—while allowing for my own. I am realizing there is another person who creeps into that space; my own outside-of-therapy-self who is learning to deal with the weight of similar disappointment with those in my life. It’s uncanny how these clients came into my life at the same time. I don’t think this is just a coincidence.

Sometimes, I treat the people in my life in ways similar to how I secretly want them to treat me. I extend my heart in kindness, my eyes to truly witness them, my ears to listen, and my words to comfort them—hoping silently that they will do the same for me.

A client might be sitting in front of me, saying all this as the realization suddenly hits them that their disappointment and anger may be coming from an unmet personal need to be cared for or about. Eventually, the other person falls short of these unspoken expectations, and they sit there enraged, but mostly feeling hopeless and disappointed with the inevitable reality of unmet expectations.

They, like I, build a certain image of a person and our relationship with them in our minds which keeps us from seeing them as they are—humans with flaws. And this can come with a sense of grief of having to let go of a version of a relationship they—and I—hoped for, but that simply was never there or that doesn’t exist outside of the mind’s eye.

From Disappointment to Acceptance

The period of transition from disappointment with and acceptance of people as they are knows no age bounds. The realization can come at any stage of life. And when the realization does come, it is important for the person to accept that the origin of the disappointment is not in the other person, but the result of their own unmet, and likely longstanding inner need for validation. These versions of relationships aren’t lies; they were (and are still) survival tools. In difficult times, they were needed to support the idea that the bond existed. That belief, even if idealized, was sufficient.

As both a therapist and citizen of the world, I believe the mask also comes off only at the time when my clients are ready to see reality as it is. The reality in itself is not bleak; it’s just different. The challenge lies in the decision to take the next step—to fully embrace the reality of a changed relationship with the imagined person who disappoints, rather than continued anger and disappointment. It’s about considering the new, altered relationship rather than expecting it to change. That decision can be made well when it comes from a clear mind and not while in the throes of grief.

Inside the therapy sessions, I see my clients face this disappointment and ask the important questions. Initially, it used to make me feel as helpless as my clients felt. Once we are able to talk about the helplessness, and acknowledge the disappointment that comes with it, we reach a point where I can address their unmet needs that led them to hold on to those versions of relationships that never existed. This, then, opens space for addressing how together, we can fulfill these needs outside of the existing relationships. Only then is there hope that my clients can open their hearts to reconnect and renew older connections with a new perspective.

The message I try to communicate is to be open to the grief and to sit with the disappointment. I ask my clients to open a space for grief related not to the relationship per se, but to expectations that the relationship will or might change. As a therapist, I invite clients to make space for that hopelessness, while as a person, I feel privileged to have clients whose lived experiences I get to learn from and seek support. I thank them for giving me that space, too, unknowingly. This is what happens when a therapist and a client walk through the same storm together. I have not known a greater community support than this!

The fluidity of relationships is beautiful. They shift, stretch, and evolve. They permit me and my client(s) to come out of fantasies in our own time. It allows for a new light and a fresh definition of connection with them. Disappointment is not the end of a relationship but the beginning of a truer one. When my clients—or I—make a space for grief, there is the possibility of re-connection.

Case in Point

I once worked with a client who came to me with the complaint of feeling angry most of the time. “Kunal” was a well settled person in his 30s who had been married for a long time. At the time he was coming in, he had been feeling frustrated in every conversation he was having with people close to him. In our sessions, he would ask questions like, ‘They understand when I am happy, why do the bad moods need to be spelled out?’ Every time, I could see the disappointment and sadness spread across his face.

It took us some time to reach the point where he could acknowledge that relationships often come with disappointment and to digest the ever-changing nature of relationships. As he described these situations, he attempted to soothe himself as he processed the years of disappointment that came with this realization. My goal was to be fully present, mirroring his feelings. This understanding paved our way for communication with a fresh base and a new outlook to look at his existing relationships. An important lesson learned!

Emigration: Hidden Suffering, Complex Grief, and Identity Transformation

The war in Ukraine has persisted for more than three and a half years. In that time, I have supported many Ukrainians navigating the psychological effects of displacement, both internal and external. Much of what is publicly visible focuses on logistics: relocation, safety, and survival. But behind these surface realities lie long-term emotional wounds—complicated grief, loss of identity, and fractured belonging—that are less discussed but deeply consequential

As a psychotherapist with extensive experience supporting clients affected by war through Soul Space, I have seen firsthand how displacement reshapes people from the inside out. The process is never linear. This article shares what I’ve observed, heard, and worked through with clients, offering insights into emigration as a deeply human psychological journey.

Displacement and Identity: A Shifting Foundation

When the war began, many clients were uprooted from their stable lives. In sessions, I hear stories of teachers who no longer teach, parents unsure how to guide their children in a new culture, and professionals who feel invisible. Their roles disappeared almost overnight.

This loss of social function creates emotional detachment and disorientation. People speak of feeling like they are “watching someone else live their life.” This state often resembles a suspended existence, not due to passivity, but because the ground under their feet has shifted too fast to keep pace.

What’s more, it’s not just individual identity that suffers. Whole communities lose their frameworks. The culture, rituals, and structures that support meaning and selfhood are interrupted. Even internal displacement within Ukraine has a similar psychological impact. The place may differ, but the rupture is felt all the same.

Grief That Doesn’t End—Complication, Confusion, and Collective Loss

Clients grieving in displacement are not grieving in the usual sense. There are no funerals for lost routines or roles, and no formal goodbyes to old homes. Instead, grief emerges in the form of disorientation, guilt, exhaustion, and self-doubt.

Many of my clients meet criteria for what is clinically called complicated grief: the kind that stays unresolved, not because people are unwilling to heal, but because they never had the chance to mourn properly in the first place.

As therapist and scholar Thomas Attig has emphasized, people grieve differently. In my work, I’ve seen how displaced clients carry layered grief for:

  • their homes and what they represented.
  • their community and place in it.
  • the future they had imagined.

It’s also common to encounter survivor’s guilt, especially among those who left their families behind. These emotions can complicate both healing and the capacity to feel joy again.

Therapy Themes—What I See in the Room

Functioning Outside, Fractured Inside
Clients may appear well-adjusted. They hold jobs, attend language courses, and care for their families. But inside, many describe emptiness or persistent numbness. Therapy offers space to pause and feel what has been hidden under duty and resilience.

Children and Parents Swapping Roles
Teenagers translating legal documents for their parents, children mediating with landlords—this kind of role shift is emotionally confusing and exhausting. Therapy helps clarify expectations, validate struggles, and restore balance.

The Strain of Chronic Uncertainty
People live in limbo, waiting for visa extensions, worrying about family, or feeling unable to settle or return. This uncertainty is not just logistical but deeply psychological. It erodes agency.

Disrupted Belonging
Even in communities that are welcoming, many clients say they feel “othered.” And often, they feel disconnected from who they were before the war. Helping them reconnect with lost parts of the self becomes a critical focus in therapy.

Host Communities Also Struggle
It’s important to acknowledge that migration affects those receiving displaced people as well. Many local residents have never been exposed to war trauma or large-scale migration.

They may experience:

  • fatigue from trying to help and not knowing how.
  • fear of change in cultural identity.
  • guilt over their own comfort in comparison.

If these reactions go unsupported, they can lead to distance or judgment, making displaced people feel even more alienated. Integration is not only about paperwork; it’s about mutual adaptation, patience, and shared emotional learning.

One Family’s Story

I worked with a Ukrainian family of four who relocated to Western Europe. The parents were in their late 30s. The mother experienced frequent panic attacks. The father became silent and irritable. Their daughter became withdrawn at school. Their son, only 6, began wetting the bed and refused to sleep alone.

We began with structure. We worked together to restore family rituals like shared meals and bedtime routines. The parents practiced grounding exercises such as short breathing pauses and body scans between sessions.

We gave space to grief. Each family member created a “memory journal,” not just for losses but for moments they still carried with them––songs, smells, images. Over time, the children began to sleep better, the father became more involved, and the mother’s panic attacks reduced significantly.

How to Truly Support

Many people want to help but don’t know how. Here’s what displaced people have told me helps:

  • show up consistently. Small gestures matter.
  • ask how someone is – but be ready to listen to the real answer.
  • don’t minimize loss. Being safe doesn’t erase grief.
  • stay open to discomfort. Growth happens in dialogue, not in perfection.

Communities must learn to adapt, just as the displaced do. Without this dual process, there is no true integration. More than three years into the war, the psychological work is still only beginning. For many of my clients, healing does not mean going back to who they were, but learning how to live meaningfully as who they are now. Therapy plays a crucial role, but so does community, policy, and the spaces in between where people rebuild themselves. Emigration is not just a change in geography. It’s a transformation of the self. If we’re willing to witness this transformation fully with honesty, patience, and humility it becomes not just a story of loss, but one of resilience and renewal.

Redefining Strength: A Black Woman’s Journey to Healing

Redefining Strength: A Black Woman’s Journey to Healing

Kayla sat in my office with her arms crossed against her chest—a familiar shield against the world. At 23, she had grown accustomed to protecting herself, whether necessary or not. She avoided eye contact with me like the plague, guarding herself as hard as possible. “I don’t even know what I’m doing here,” she said, her eyes fixed on the floor. “This is so awkward.”

“That’s normal,” I said.

As a therapist, I have heard many clients share that they are unsure of what has led them to therapy. What was always different for me was tonality. I have heard people voice uncertainty about therapy with anger and even sadness. Kayla’s voice was filled with exhaustion.

“I feel so out of control as of late. I feel like I’m in a loop of the worst days of my life. I go to sleep thinking about my mistakes. I always wake up feeling worse than I did the day before. I’m eating and spending like crazy. I’m so tired.”

Kayla’s specific wording and my clinical judgment led me to believe there was more behind what she shared. So, I asked her, “What is weighing on you?”

Kayla burst into tears, and for the first time, she looked into my eyes, hers filled with anger and sorrow. “My mom died! I finally tell her how much I hate her, and she dies!” Kayla sobbed as her words lingered in the air. It had been a year since her mother passed, but as we know, there is no time limit on grief. Grief moves at its own pace and intensity. For Kayla, grief was feeding off her deep-rooted trauma.

“I keep replaying that argument with her over and over. Maybe what I said caused her too much heartbreak. Maybe she’d still be here if I had kept things unspoken.”

I leaned forward slightly.

“Kayla, your mother’s passing is not your fault.”

Kayla shook her head as tears continued to roll.

“Then why does it feel like it is?”

A Childhood Built on Survival

Kayla’s childhood was a lesson in what love wasn’t. She realized early on that her mother was not like the mothers she saw on television who supported their children and told them they loved them at the very least.

“My mom wasn’t like Clair Huxtable or anything. I didn’t get hugs or life lessons. She just wasn’t that kind of woman,” Kayla said. “I can’t recall her ever saying she was proud of me. When I would make good grades or clean my room, she would say,‘That’s what you supposed to do.’”

For Kayla, affection was nonexistent, validation was rare, and she never felt safe displaying anything other than strength. Kayla felt sympathy for her mother as she knew her mother faced hardships as a child herself. Kayla’s grandmother shaped her mother into the woman who raised her—distant and emotionally unavailable.

Over time, Kayla began to convince herself that she was the one who needed to change.

“I just stopped asking for things that she couldn’t give me. I consoled myself. I taught myself. I protected myself. I didn’t want to rock the boat with her because she was always extremely irritable. It annoyed her whenever I was in need, so I stopped needing her.”

By age ten, Kayla had perfected the art of being invisible. She didn’t ask her mom for love. She didn’t ask for affection. She didn’t ask for help. In turn, she saved herself from disappointment.

The “Strong Black Woman”

Kayla’s experience growing up was a complex one due to the emotional neglect and also the unwritten rules of what it takes to be a Black woman (1). She grew up being told to be strong and keep going no matter what. There was not enough room for anything else. Kayla comes from a family of Black women who embodied these qualities as armor against the world. Growing up in a space that offered little empathy to Black women, Kayla’s mother taught her how to survive, and that was her act of love.

“She used to tell me that if I think anyone cares about me crying, then I have a lot to learn,” Kayla stated angrily. “Like crying made you weak or something. In a way, she was right. I had to make sure people knew I was nothing to mess with!”Even after Kayla’s mother died, she felt like she had no space to grieve. “My aunt told me everything happens for a reason, and we can’t spend time crying. So, you mean to tell me I can’t have time to be sad about my mom’s passing? Even in death, do I have to push on? That’s a lot for anyone. If my family knew I was here, they would wonder why. After everything I have endured, they would still wonder why. Because we don’t do this.”

In addition to her trauma and grief, Kayla was struggling with knowing that she needed help but feeling uncomfortable while seeking it. There has been an undeniable stigma in the Black community when it comes to mental health. As a Black woman myself, I resonated deeply with her.

“My aunt would probably be like girl, you need to talk to God, and not no therapist! Talk to God, and you will be all right. Like I haven’t been talking to God. Talking to you is my last hope at this point.”

Kayla was plagued by wondering if she should even be here as a Black woman and also hoping that therapy would “work” for her.

“You know you can do both, right?” I asked. “You can talk to God and spend time in therapy.” Kayla arched her eyebrows as if she were in deep thought. I continued, “James 2:14 says, ‘Faith without works is dead.’ Kayla, you are doing the work right now.”

“Wow, I’ve never thought about it like that,” she smirked. “I like that!”

Naming the Wounds and Breaking the Cycle

Kayala learned to survive from an early age, and her defensive tactics served her well. Now, it was time for her to thrive. I discussed clinical diagnoses with her, and her mood instantly changed. I could tell she was not fond of labels.

“What is Post Traumatic Stress Disorder and Borderline Personality Disorder? Are you saying I’m crazy?” she asked, irritated.

“Absolutely not!” I said sternly. I swiftly disputed Kayla’s thoughts so she didn’t disengage with me. “A diagnosis is not about calling you crazy; it’s about creating a roadmap. Knowing your diagnosis helps us understand what’s wrong and how we can fix it.” I continued while I still had her attention, “Right now, your mind still seems to think that you are in danger, and it is responding accordingly. Kayla, you are safe now, but your experiences in life have wired your brain into a constant state of fear. When this happens to us, it is hard to regulate our emotions or trust new people because that is not a priority; safety is. That is why we are looking at Post Traumatic Stress Disorder or PTSD. We need to look at the research for what has been proven to work with your symptoms.” (2)

Kayla’s jaw tightened, but I saw a flicker of understanding.

I continued. “Now, some traits of Borderline Personality Disorder or BPD concern me. Again, this does not mean that there is something wrong with you. It simply means that something happened to you that is causing patterns similar to BPD to arise in your personality.”

Kayla previously reported mood swings, fear of abandonment, and impulsive choices that she wished to cease. I wanted her to understand that these symptoms made sense when one has endured the trauma that she has. Giving it a name only serves as a guide to addressing her symptoms.

“But here is the most important thing,” I said. “None of these things mean you’re crazy. They mean your brain did what it had to do to survive. And now, we’ll teach it a new way of looking at life.”

She nodded slowly. This time, she was really hearing me.

The Work: Using DBT to Rebuild Control

Kayla discussed feeling out of control when she first sat on my couch. She said she was tired and had exhausted all options. She wanted to feel different. Therefore, we had to try something different. Kayla was stuck in a cycle of emotional dysregulation, intrusive thoughts, and impulsive behaviors—trying to numb a pain that never seemed to dull. As a result of her trauma and grief, she had become avoidant. She had cut off her family in an attempt to forget her past and her unfavorable memories of her mother. She had also distanced herself from friends, convincing herself that being alone was the safest way to be. However, the isolation only compounded her sadness.

“I like to be alone. I don’t have to worry about anything…or anyone,” she said.

It was clear that avoidance had become a comforting survival mechanism for her, blocking her pathway to healing by dismissing the very things she needed to address. That is why Dialectical Behavior Therapy (DBT) was the chosen approach for Kayla—she didn’t just need to talk about her pain; she required structure. She was new to managing her emotions and grasping concepts of healthy communication. As someone who always “just dealt with it,” Kayla needed practical tools to help her regulate her emotions, tolerate distress, and rebuild her broken relationships with family and friends (3). DBT would allow Kayla to accept her past and present circumstances while learning tangible ways to help her approach her overwhelming emotions less detrimentally.

Kayla’s case and the use of DBT demonstrate its flexibility beyond its original purpose for borderline personality disorder for managing trauma and grief as well. Unlike traditional talk therapy, DBT provides tangible solutions to change. It was designed for people like Kayla—individuals who felt emotions so intensely that they often became destructive. With some culturally adapted tweaks, I knew DBT would be life-changing for her.

DBT Treatment Sessions: A Step-by-Step Process

Reframing Emotional Regulation Through Radical Acceptance

“So, what? I just breathe through my feelings? That’s not gonna do anything,” she snapped when I introduced emotional regulation techniques. Kayla came to therapy with the belief that any emotions outside of anger made her weak. She had been taught to be a strong Black woman. For her, that, unfortunately, meant suppressing pain and keeping her composure no matter what she faced—crying, asking for help, or expressing vulnerability felt like weakness. Regulating emotions meant giving in and giving up. We needed to reframe that thinking. I knew I had to introduce something concrete that would challenge this belief in a way that made sense to her lived experience.

That’s when I introduced Radical Acceptance.

“To radically accept something means acknowledging our reality no matter how much it hurts. It doesn’t mean you like it. It doesn’t mean it was fair. It simply means it happened and is out of our control.”

She narrowed her eyes.

“So, I just roll over and accept what happened to me? That sounds like letting people run over me.”

“It’s the opposite,” I assured her. “It means you stop wasting energy on what has happened and can’t be changed, then you can focus on healing and moving forward.”

We practiced this with a powerful exercise. I asked Kayla to create two different lists. On the first, I asked her to list everything she wished had been different. On the second, I asked her to write down the reality of what happened. Kayla hesitated, as if putting the truth into words would finally make things real for her. But eventually, she did it.

When she finished, I asked, “Which one is true?” She looked at them for a long time before responding.

“The second one.”

“And which one are you living in?”

She tearfully stated, “the first one.”

“That’s why it hurts so much.”

There was silence. I saw Kayla arch her brows again, as she always does when thinking.

“I guess I can’t change the past, huh? Being angry about it isn’t going to change it for me, either. I need to focus on what I want to be different now and make a plan to change my now.”

Managing Impulsivity Through Distress Tolerance

In our next session. I wanted to focus on Kayla’s binge eating and spending. These weren’t random actions. They were her mind’s way of coping with her trauma and grief. These behaviors were a quick way for Kayla to feel something other than discomfort, if only for a brief time.

“I don’t think—I just do it,” she admitted when we explored her excessive spending and binge eating.

I introduced distress tolerance skills to teach Kayla to sit with her uncomfortable feelings. One of the most valuable techniques for this was the STOP Method:

  • Stop – Pause before you react.
  • Take a step back – Create space to think before deciding.
  • Observe – Notice your emotions without judgment.
  • Proceed mindfully – Act with awareness.

At first, she was skeptical about being able to control her urges. But then, one evening, I received a text from her: “I almost spent $500 online on something silly, but I stepped away from my phone and did that STOP thing instead. So… yay, I guess.”

It was a small victory for Kayla but a critically important one. Over time, she began to master interrupting her impulsive urges. We were replacing her self-destructive behaviors with healthy coping skills.

Processing Trauma Through Mindfulness & Exposure Our next session was challenging as we addressed Kayla’s most potent and longest-held form of self-protection; we addressed her avoidance. I felt that Kayla had enough coping skills at this point to start to touch on some of her trauma that impacts her today. She shut down and cut off anyone who was a reminder of her trauma, further isolating herself and feeding her negative behaviors.

“I just don’t have time to think about any of that stuff. It feels bad,” she told me once.

But avoidance doesn’t erase trauma—it only buries it deeper.

I introduced mindfulness-based exposure therapy, where she slowly confronted the memories she had been running from. We spent half of one session just looking at a picture of her mother and addressing the emotions that rose from that. Eventually, we reached a point where Kayla was listening to an old voicemail her mother had left her shortly before her passing. Her mother called to check on her as she had not seen her since their argument. Kayla’s hands began to tremble; her breathing became shallow.

“This hurts me so much,” she whispered.

I nodded.

“I know. Just go with it.”

As she let the tears roll, she didn’t dissociate. She sat in how she felt. That was a breakthrough!

Breakthrough Session: Onward to Healing

Months into therapy, Kayla no longer felt like she was spinning out of control.

“I still have my bad days,” she sighed. “But I don’t feel like I can’t do anything about it anymore.”

Her progress was never about curing her pain. It was about living with it more healthily. She was still grieving, still processing, only this time around, she had the tools to cope. As she stood up to leave our session today, she paused. “You know,” she said, “I think my mom would’ve liked you.”

I smiled, and said, “I think she would’ve liked you too.”

Kayla walked out of my office that day, not healed, but healing. For now, that was enough.

Reflections from the Therapist’s Perspective

My experience with Kayla has grown me in ways no training or manual could. After some time sitting across from her, I realized that I was doing much more than simply applying interventions to an issue. What I was providing Kayla was a safe space. As big as the world is, many people do not have the space to be truly vulnerable and seen in their pain. In that space, it was not about how much I knew academically, but how deeply I could listen, be present, and make it safe for her to unravel.

Therapy is often misunderstood as something people do to “fix” an issue. However, healing does not come from quick fixes. Healing comes from connection when I can help carry the weight someone shouldered alone for far too long. Kayla reminded me that everything I do matters. My patience, validation, and commitment to her healing mattered so much. These small and consistent actions are the most powerful tools a therapist can implement during therapy. Most importantly, I learned I cannot validate what I do not acknowledge.

Kayla’s life experiences, beliefs, and values all stemmed from her upbringing. They stemmed from her identity as a Black woman in her home and the world. As a Black woman myself, I resonated deeply with the themes around mental health that Kayla had come to know as truth. As a Black therapist, I am even more grounded in my belief that therapy must make space for cultural humility and the intersectionality of the people we sit across from. Their identity, history, and experiences make them unique. That said, we must see our clients for all that they are.

References

(1) Carter, L., & Rossi, A. (2021). Embodying strength: The origin, representations, and socialization of the strong Black woman ideal and its effect on Black women’s mental health. In WE matter! (pp. 43–54). Routledge.

(2) Bremner, J. D., & Wittbrodt, M. T. (2020). Stress, the brain, and trauma spectrum disorders. International review of neurobiology, 152, 1-22.

(3) Prillinger, K., Goreis, A., Macura, S., Hajek Gross, C., Lozar, A., Fanninger, S., … Kothgassner, O. D. (2024). A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder. European Journal of Psychotraumatology, 15(1), 2406662.

Josh Coleman on the Roadmap to Healing Family Estrangement

Lawrence Rubin: I’m here today with Joshua Coleman, a psychologist in private practice in the San Francisco Bay area, and a senior fellow with the Council on Contemporary Families. He’s the author of numerous articles and book chapters, and has written four books, the most recent of which is The Rules of Estrangement. Welcome, Josh.
Joshua Coleman: Thank you for having me. Pleasure to be here.

The Face of Family Estrangement

LR: I’ll just jump out of the gate by asking you, why do you describe estrangement within families as an epidemic?
JC: Well, there’s a variety of reasons for that. One is, and I don’t know about you in your practice, but in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangement. Another reason comes from a recent survey by Rin Reszek at Ohio State, who found that 27% of fathers are currently estranged from a child. That’s a new statistic. While we haven’t really been tracking these statistics, non-marital childbirth is also a big cause of estrangement, which is 40% currently compared to 5% in 1960.Divorce is also a very big pathway to estrangement, especially in the wake of more liberalized divorce laws. When you look at the effect of divorce on families once there’s been a divorce, the likelihood of a later estrangement goes way up. This is especially so when you add social media as an amplifier, our cultural emphasis on individualism, influencers talking about the value of going ‘no contact’ after the divorce, and family conflict around politics, especially in the recent election. All these point to a rise in family estrangement, particularly parental.
LR: in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangementI know the there is a historical rise in divorce. Is there a parallel rise in estrangement with the rising divorce rate?
JC: I don’t think it’s a 1 to 1 relationship, but I think both occur in the culture of individualism, which prioritizes personal happiness, personal growth, protection and mental health. Prior to the 1960s, people would get married to be happy, but more often for financial security, particularly for women as a place to have children. But today, people get married or divorced based on whether that relationship is in line with their ideals for happiness and mental health and the like.The relationships between parents and adult children are constituted in a very similar way, people don’t stay in touch or close to their parents unless it’s in line with their ideals for happiness and mental health. It’s what the British sociologist Anthony Giddens calls pure relationships. Those are relationships that became purely constituted on the basis of whether or not they were inline with that person’s ambitions for happiness and identity. So, it’s a parallel process. I don’t think it’s completely dependent on divorce because there’s many pathways to estrangement.
LR: if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still marriedWhy is estrangement so different from other problematic family dynamics?
JC: Because of how disruptive it is to the adult parent and because of the cataclysmic nature of event and its consequences for the rest of the family. Once there’s an estrangement, it isn’t just between that adult child and that parent. It also can cause one set of siblings, or one sibling, to ally with the parent, another with the adult child. Typically, if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still married. So, it’s really a cataclysmic event in the whole family system.
LR: In your clinical experience, are there identifiable risk patterns for the eventuality of estrangement?
JC: Divorce is a huge risk, especially when it is accompanied by parental alienation, where one parent poisons a child against the other parent. Untrained or poorly trained therapists sort of assume that every problem in adulthood that can be traced back to a traumatic childhood experience. There seems to be no shortage of those therapists who think everything that is problematic in adulthood is due to some kind of family dysfunction or trauma.Another pathway to estrangement is when the adult child married somebody who’s troubled and says, “choose them or me.” Mental illness in the adult child is also potentially destructive. And last, when parents have been doing something much more psychologically destructive over the years, certain adult children just don’t know any other way to feel separate from the parent beyond cutting them off.
LR: Before we move forward, can you give us a clear definition of estrangement?
JC:  It’s when there is little to no contact. If we’re just thinking of the parent-adult child relationship where there’s little to no contact, and underlying is some kind of, complaint or disruption in the relationship, the adult child is typically the one initiating the estrangement. They determine that it’s better for them not to be in contact with the parent or to grossly limit the contact. Maybe they send a holiday card or something, otherwise they have no contact with their parent.
LR: t’s a complete cut off.
JC: Complete cut off, or a nearly complete cut off. Exactly.
LR: the adult child may not be as motivated to solve the problem as the parent isAnd is the focus of your clinical work mostly on estrangement between adult children and their parents?
JC: Typically, because they’re the ones who are reaching out to me. Occasionally, I’ll have siblings reach out to me, but more typically it’s the parents who are estranged. From their perspective, they’re the ones who are in much more pain. The adult child may have cut off the parent because of their pain, but by the time the parent reaches me, the adult child has concluded that it is in their best interest to estrange their parent. So, the adult child may not be as motivated to solve the problem as the parent is.
LR: Do you have estranged grandparents reaching out to you?
JC: Yeah, and a lot of grandparents say, ‘look, I could probably tolerate estrangement from my child, but not from my grandchildren.’ This feels intolerable, particularly for those who have been actively involved with their grandchildren, as many of these grandparents have been.
LR: This “grandparent alienation syndrome” must be particularly tormenting for them. Have you experienced different cultural manifestations of estrangement?
JC: The data from the largest study, which was by Rin Reczek at Ohio State, found that, for example, Black mothers were the least likely to be estranged. White fathers are the most likely to be estranged. Latino mothers are also less likely to be estranged than White mothers. Fathers in general are very much at risk for estrangement regardless of race.There’s relatively low estrangement in Latin American families as well as Asian American families. And similarly, within Asia, we assume that there’s not a lot of estrangement because the culture of filial obligation is still quite active. So, estrangement tends to predominate in those countries and cultures, like ours, that have high rates of individualism and preoccupation with one’s own happiness and mental health.

Detachment Brokers

LR: That’s interesting. So, there’s a parallel between estrangement and the value particular cultures place on either individualism or commutarianism.
JC: Exactly. Some are much more communitarian, emphasizing the well-being of the family and the group, while others are much more individualistic, like we are here. The sociologist Amy Charlotte calls American individualism ‘adversarial individualism,’ which is the idea that you become an individual through an adversarial relationship with your parent, or you rebel against that. But not all cultures have that kind of adversarial positioning as the way that you become an adult.
LR: You had mentioned earlier that some therapists can actually make things worse.
JC: I think that all therapists want to do good, but some simply don’t think through all of the factors. We have to not only think about the person in the room, but also the related people, because estrangement is a cataclysmic event that affects many beyond the person sitting in front of you. Grandchildren are involved and get cut out from their grandparents’ lives. Siblings typically get divided into those who support the estrangements and those who don’t. It’s also very hard on marriages. It’s easy to get sidetracked into focusing on the mental health of the adult child who is cutting off their parent(s) in the name of self-care and self-protection. We have a rich language in our culture around individualism, but a poverty of language that’s oriented around interconnectedness, interdependence, and care.It’s easy to pathologize someone’s feelings of guilt or responsibility for a parent that may just be a part of their own humanity. By giving them the language and moral permission to cut off a parent without doing due diligence on whether or not that parent really is as hopeless as their client is making them to be, contributes to this kind of atomization.Therapists can contribute to the tearing apart of the fabric of the American family, acting as accelerants to that process. We become what the sociologist Allison Pugh calls detachment brokers in her book, Tumbleweed Society. When we support clients’ absolute need or desire to estrange their parents due to their need for happiness and personal growth, we help them detach from the feelings of obligation, duty, responsibility that prior generations just assumed one should have.

LR: Do you ever encourage or facilitate estrangement as a solution?
JC: The same way that I would never lead the charge into divorce with a couple with minor children because of the long-term consequences, I wouldn’t charge ahead with estrangement either. But I do try to help the person to do their due diligence on the parent. Let’s say the parent who is completely unrepentant and constantly shames the adult child about their sexuality, their identity, who they’ve married, or what their career is every time that adult child is around the parent. It’s sort of hard for me to ethically say, “give them a chance!”But I do think it’s our responsibility to ask them: what other relationships will be impacted if you decide to go no contact, is there some way to sort of have some kind of a relationship where you are protected from their influence, or why don’t we think about why is it so hard on you? A newly reconciled adult child recently suggested to me that, ‘if the adult child is insisting that your parents are the ones that need to change to have a relationship, maybe you’re the one that needs to change.’ I liked that because I don’t think everybody has to stay involved with their parents.I do think parents have a moral obligation to address their children’s complaints and empathize with them and take responsibility. Just like the adult children have a moral obligation to give their parents a chance. I work with parents every day who are suicidal or sobbing in my office, and that really gives you a different view of this.
LR: I imagine the most deeply wounded adult children are the most difficult ones to work with around reconciliation. Can countertransference enter the clinical frame at that juncture?
JC: There have been a few occasions where the adult child was so self-righteous and contemptuous of the parent, despite the parent’s willingness to make amends for their so-called crimes––which were more on the misdemeanor side than the felony side––they remained unforgiving. Even when the parent showed empathy and took responsibility in the ways that I insist that parents do, the adult child remained in this very censorious, self-righteous, lecturing place.There haven’t been very many times when I felt provoked on the parent’s behalf, but there have been a couple times where the adult child was earnest, open and vulnerable, and the parent was not willing to do some basic things at the request of the adult child, like accepting basic limits. The parent was insistent. I just felt like you can’t have it both ways. I remember thinking, ‘You can want to have your child to be in contact with you, but you’re going to have to accept the limits that your child is setting, otherwise, I can’t really encourage your child to stay in contact with you in the way that you want me to.’ The transference is worked on both sides of the equation.

A Roadmap for Change

LR: Is there a roadmap for healing estrangement as you suggest in your book?
JC: Typically, if the parent has reached out to me for the reasons I was just saying, the roadmap begins with taking responsibility and the willingness to make amends. I ask that they try to find the kernel, if not the bushel of truth in their child’s complaints. They can’t use guilt or influence or pressure in the way that maybe their own parents might have used with them, and they can’t explain away their behavior. They have to show some dedication to reconciling. It must come with some sincerity. The challenging part for parents is often that they can’t really identify with what they’re being accused of, particularly since emotional abuse is the most common reason for these estrangements.A lot of parents say, ‘wow, emotional abuse, I would have killed for your childhood.’ The threshold for what gets labeled as emotional abuse is much lower for the adult child than it is for the parents. So, a lot of the roadmap for the parent is just accepting that difference and learning how to understand why the adult child is labeling it as such and not really debating it with them or complaining about it. Instead, that roadmap includes a way to empathize with that and understand that those are the most key aspects.
LR: What about when the road to reconciliation has been damaged by physical/sexual abuse?
JC: You have to go there if you have any chance of healing the relationship. If a parent is lucky enough to get an adult child in the room after that child being a victim of more serious traumas on the parents part, the parent has to be willing to sit there and face all the ways that they have failed their child and how much they hurt and wounded them.And it’s not an easy thing to do, typically, because hurt people hurt people. There is high likelihood that the parent who did the traumatizing was traumatized themselves, but if anything is going to happen, it’s going to be because the parent can take responsibility and do a deeper dive and not sweep it under the rug. And that’s very hard work, especially for the adult child who must expose themselves.
LR: Would you work with the adult child separately from the parent and then together by collaborating with all the players in the same room?
JC: Typically, I will meet with each side separately because I want to see what the obstacles are, what each person’s narrative is, assuming that I think everybody’s ready to go forward, I’ll bring everyone together. I usually don’t keep them separate for more than one session, but not everybody is ready to go forward at the same time. If I think that people are sort of ready to engage, then I’ll do a session separately and then everybody together. I tell parents that this is not marriage therapy. The therapy is around helping the adult child feel like their parent is willing to respect their boundaries and accept versions of their narrative sufficiently that they feel more cared about and understood. It’s not going to be as much about the parent getting to explain their reasons or decisions, at least not early into the therapy. If therapy goes on long enough, and people are healthy enough to have that conversation, then it can happen. But it doesn’t always.
LR: What do you consider to be a successful outcome, and at what point do you say that’s enough for now?
JC: I think when they’ve all had enough time outside of therapy, and they were able, to debrief if there was conflict, and if I feel confident that they have the tools to walk them themselves through the conflict and resolve it. I try to help each person set realistic goals and let them know that they are going to make mistakes going forward. The goal isn’t to be perfect, but instead to communicate around feelings and taking each other’s perspectives so all members feel safe and skilled enough to overcome whatever conflict arises. I don’t want anyone feeling discouraged and helpless.
LR: What protective factors do you look for when working with estrangement? The glimmers of hope that you search for with your therapeutic flashlight?
JC: The biggest one is a capacity for self-reflection on the part of both the parents and the adult children. In the parent, I look for a willingness to take responsibility, the capacity for non-defensiveness, vulnerability, and tolerance for hearing their child(ren)’s complaints without being completely undone. For the adult child, I look for acknowledgment that what they’ve done is difficult for the parent, and that their own issues might have contributed to their decision to estrange them.I look for an adult child to say things like, ‘I acknowledge that I was a really tough kid to raise,’ ‘I’ve been a tough as an adult,’ ‘I can give as well as I get,’ or ‘I know that I have an anger issue.’ Those help me, as the therapist, to feel like, ‘okay, you’re not just here to blame and shame the others.’ It’s about a willingness and ability to come to a shared reality, which is important for these dynamics.
LR: At what point might you suggest stopping with a client?
JC: I’ll keep working with people as long as they want to get somewhere. I don’t usually fire clients. But, for example, if I have an adult child who is just insisting that their parent has to change, and it’s clear to me that the parent has changed as much as they’re going to, my goal would be helping them shift towards radical acceptance, rather than to keep beating their head against the wall. And similarly with a parent, if their adult child is just not willing to reconcile, then it isn’t useful for the parent just to keep trying and banging their head against the reconciliation wall either.
LR: Recognizing not only your own limitations, but those that the family system brings to you.
JC: Exactly! I think an important part of our work is to help people to radically accept what they can’t change and influence. As painful as that is to reckon with.
LR: What does radical acceptance mean in this context?
JC: The term came from Marsha Linehan who developed Dialectical Behavior Therapy. It’s not sort of a soft acceptance, but instead a deep dive that you have to do. She has a great quote that says, ‘the pathway out of hell is your misery.’ It’s a great quote because you must first acknowledge that you’re miserable and accept it and maybe not even hope for change. But it does mean you have to acknowledge that you’re currently in hell. And unless you can really accept that reality, nothing good is going to come of it. The other saying that I like that comes from mindfulness or Buddhism is that pain plus struggle equals suffering. That the more you fight against the pain, the more you’re going to suffer. So, I think those are useful concepts.
LR: In this context, at what point does grief and loss work enter the clinical frame?
JC: Grief work is really part of it. Even if I can’t facilitate a reconciliation, it is important helping parents to feel like, ‘yeah, I think you’ve turned over every stone here.’ At that point, it is important to help them accept it and focus more on their own happiness and well-being, and on other relationships. This would include working on self-compassion while mourning the loss of the relationship that may never be.
LR: In closing, Josh, can someone who’s trained in individual therapy do this kind of work?
JC: If you are an individual therapist, you can’t just sort of suddenly start doing couples therapy. You have to have some facility at keeping two subjectivities in your mind at the same time. You know, being able to, to speak to both people in a way that shows that you’re neutral, even when you’re temporarily siding with one person over the other. I think it’s important to have a sociological framework for this part. You also need to set your own limits and boundaries. Doing family work is a very different sort of orientation and requires a unique skill set.
LR: On that note, I’ll say thanks. Josh, I appreciate the time.
JC: It was my pleasure, Lawrence.
*******
Joshua Coleman, PhD, is a psychologist in private practice in the San Francisco Bay Area and a Senior Fellow with the Council on Contemporary Families, a non-partisan organization of leading sociologists, historians, psychologists and demographers dedicated to providing the press and public with the latest research and best practice findings about American families. He is the author of numerous articles and chapters and has written four books: The Rules of Estrangement (Random House); The Marriage Makeover: Finding Happiness in Imperfect Harmony (St. Martin’s Press); The Lazy Husband: How to Get Men to Do More Parenting and Housework (St. Martin’s Press); When Parents Hurt: Compassionate Strategies When You and Your Grown Child Don’t Get Along (HarperCollins). His website is www.drjoshuacoleman.com/.

Nothing Left to Give: A Psychologist’s Path Back from Burnout

Journal 1: Warning Signs-15 January 2021

I have nothing left to give anymore. I thought the break over Christmas may have helped, but it hasn’t. I am still exhausted, more than ever, and I can’t believe I am saying this, but I feel like I am just going through the motions of caring, that I am “pretending to care,” which is so horrific to say. I do care for my clients; I’m just finding it hard to do this work.

It gets worse. I had a session today with a client. A client with multiple current crises and past traumas still left unprocessed, a presentation making up most of my caseload. This session has floored me.

I am ashamed to admit that my mind was almost completely disconnected from the client throughout the session. My mind was all over the place:

I don’t know if I can help this client anymore.

I wish this client would do what will help instead of just talking about it all the time.

I feel so out of my depth.

I don’t know if I can keep doing this kind of work.

I can’t leave; so many people depend on me.

I feel so trapped.

I need to focus on my client right now. It’s not okay that I’m caught up in my shit.

It is one crisis to the next for this client.

It will never end.

I don’t have anything more to give to this person.

I feel like I’m on autopilot. I’m here, but I’m not here.

It’s hard to know that this client will be safe.

This client deserves a psychologist that can help.

I want this session to end.

I have never been that detached before, and I know I have let her down. A thought popped into my head soon after her session with me ended – you are this client!

I was immediately taken aback as, on paper; we are nothing alike, and we don’t share similar pasts, current life situations, personalities, traumas, or even approaches to life. Despite my immediate disagreement with this thought, it repeated itself. . . you are this client!  

Right here, right now, while reflecting on this session, I still find myself rejecting this thought, this knowing. I’m not this client. My mind is saying:

This client’s experiences, past and present, are a lot more complex than mine.

This client has experienced multiple traumas, depression, and work-life stressors.

I don’t even have half of that…but maybe the similarities lie in how the suffering presents, not the causal events.

Now, this has made me stand up and listen. Despite our notable differences, our suffering does have similarities. We are both going around in circles, staying stuck in situations that are not healthy for us. We both have lost pleasure in our lives in what we do. We withdraw, keep busy or turn to substances (food for me) to cope. We both continue to push ourselves to do better and be better both professionally and personally. We both find it hard to talk about our problems to others. We keep it hidden. We are constantly irritable and exhausted. We both have very high standards and expectations of ourselves. Our worth is caught up in what we do for a living or who we are for other people. We are profoundly insecure and, at the same time, desire safe and supportive connections. We both feel disconnected from who we are. We both suffer from bouts of depression and anxiety. We both dream of escaping, breaking free from our suffering. And we are both beyond burnt out and have no more fucks to give. We are both feeling trapped in our lives.

Shit! We are alike.

Well, what do I do with that now?

I know what I have advised the client to do, and if our sufferings are similar, I need to either step back from my career as a clinical psychologist or make some significant changes to how I’m doing things right now. I need to prioritise care for myself.

But am I that bad?

Maybe this is all just in my head.

It’s just too much even to fathom right now.

Too many people need my help; I need to keep pushing through.

I need to focus on doing what is best for the clients.

Wellness Practice

Don’t shove down any insights you may be experiencing. Don’t question it. Sit with it. Pay attention. You can do so with a daily check-in.

Daily Check-in

Answer the following questions to help you check in with yourself: What is happening for me right now? What am I feeling? What is on my mind? How is my body feeling? Do this regularly to help you gain self-awareness and be in a better position to respond to any difficulties. You can even start a journal to capture these daily check-in insights.

Journal

Start a journal to record your wellness practices throughout this book. The writing process in and of itself can offer therapeutic qualities, and it helps us slow down, pay attention, look in, engage with ourselves, and process our experiences.

Journal 3: Severely Burnt Out-3 March 2021

Since my last journal entry, I have left my job and career behind. I feel deeply ashamed and guilty for leaving my job as I did. It happened so suddenly, so quickly; no one saw it coming. In some ways, even I didn’t, although I had thought about it quite a bit. A week ago, on February 25, 2021, my mind and body spoke for me—“I can’t do it anymore.”

You are not well enough to take care of others right now. Leave this for those who can. Your job is to take care of yourself, and leaving your work is caring for yourself and others.

On that day, I showed up to work at the psychology practice where I had been working for almost five years, Zest Infusion. Like many preceding days, I felt completely and utterly exhausted, emotionally, mentally, and physically. Along with this feeling, I felt a sense of dread, hopelessness, fear, anxiety, self-doubt, and a lack of care to give to anyone.

I had set up a meeting to talk to the practice director, Dr Ilze Grobler regarding the need to change my schedule to support my well-being. I was still struggling with what I wanted to do. Reducing my client load or leaving meant that clients would suffer, but if I kept working the way I was, I would suffer. Both decisions involved suffering; no one would win. I remember feeling very anxious to talk with Ilze about it all, not because of what she’d say (she’d always been compassionate) but my fears of what this meant for everyone—for clients, me, and Ilze’s business.

My heart was heavy, and my mind was too. I knew I wasn’t okay, and something needed to change, but I was battling my need to care for others and myself. I didn’t realise how bad my health was until I was in front of Ilze, letting her know what was going on. Ilze’s compassion made me feel safe enough to connect with the depths of my suffering and listen to what I needed. She mentioned that she knew of a psychologist in a similar position who needed to take time away from the profession to care for herself. At that moment, I admitted I couldn’t do it anymore. I couldn’t push. I couldn’t be present for my clients. I couldn’t adequately put my pain aside and be present; worse, doing so would create more suffering for everyone. I had to stop, and I had to stop then. Ilze’s compassion helped me to find what I needed at that moment and to express it.

I recognise that my awakening to the depths of the pain and suffering I am experiencing has happened because of two compassionate women in my life, Dr Ilze Grobler and Dr Hayley D. Quinn. Without these women, I wouldn’t have been able to take the steps I have made so far. It was Hayley and Ilze who told me…

You are not well enough to take care of others right now. Leave this for those who can. Your job is to take care of yourself, and leaving your work is caring for yourself and others. 

Maybe I can believe, in time, that it is okay to take care of me.

Wellness Practice

Surround yourself with empathic, non-judgmental, warm, kind and empowering people. If you haven’t got them, find them. You will know you’ve found one when you can be yourself around them. If there is not someone in your immediate environment (friends or family), seek out a professional. A mental health professional (e.g., psychologist, counsellor) is trained to provide a safe, secure and supportive environment, so you can be free to be yourself, to share your pain and suffering.

It will depend where you are in the world with how you go about this and what professional to see. In Australia, it can be helpful to see your doctor first, a doctor who specialises in mental health, who can do an assessment and assist with referrals to appropriately trained professionals. You can also visit the following link https://www.healthdirect.gov.au/mental-health-where-to-get-help. This page will help guide Australian readers on the next steps to link with a professional.

If you find this whole process daunting, that’s okay, it is. Bring a friend, someone you trust, so they can support you through the process. They don’t need to know what to do; you can find out together. This way, you don’t have to be alone.

Journal 4: Letting People Down-10 March 2021

I see my burning out and inability to work as being pushed off the side of a cliff, free-falling into the space below with microscopic moments of being lifted, flying to somewhere unknown, feeling scared and free simultaneously.

The past couple of weeks have been extremely challenging. I have spiraled in and out of feeling relief, quickly followed by crippling fear, guilt, and shame. I constantly think that I have let others down (Ryan, colleagues, and former clients) and that I’m selfish for prioritising my care over others. The fear, guilt, and shame are currently overtaking any feelings of relief.

The feelings of fear, guilt, and shame were most substantial when people I care about started to find out I was sick and no longer working. The day the email to my clients and colleagues went out to let them know I had left was particularly gut-wrenching. At first, I couldn’t look at the emails from clients and colleagues. The shame and fear I felt then wouldn’t allow me to read them. I feared they would hate me. I feared harm would come to them; I believed I failed them.

Further, I felt guilty for the position I put them in—not having regular, familiar, and reliable psychological care. I feared they would be angry with me, hurt, and that they’d believe I abandoned them. Or I felt like I had abandoned them. I can’t shake these feelings and thoughts; they are constant companions.

Despite how I feel or think, I must confront this fallout in a way that supports both myself and those affected. I don’t want to hide. I’ve done that before. In my late teens and early 20s, I was experiencing what I later came to recognise as clinical depression. During this time, I worked at a local restaurant fulfilling both waitressing and administrative roles. One day, I upped and left and never returned. I didn’t speak to anyone from work, friends, or family. Those close to me at the time knew something was up, but I didn’t talk; I didn’t know how back then. I felt deeply ashamed for being sick; I believed I had no reason to be. The shame kept me silent. I’ve learnt a lot since then. I’ve learnt to speak up, front up, and recognise that anyone can become mentally unwell and that there is no shame in being mentally ill. I’m thankful for the experience of clinical depression for this learning experience.

This time I want to be the person who fronts up to the fallout, speaks up, and honours the responses from colleagues and clients for my abrupt departure, doing what I couldn’t do all those years before. With this intent, I told Ryan and my family that I was sick and started reading emails from clients and colleagues.

Reading my former clients’ email responses has been particularly tough. I have felt many emotions—grief, loss, gratitude, support, compassion, kindness, and despair. Most of the responses were compassionate, demonstrating concern for me, sadness for not receiving psychological care from me anymore, and non-judgmental support; very few clients responded with what I feared (i.e., feeling abandoned, angry, and let down by me). I wasn’t mad at those who felt this way; I was glad they could express their feelings. It was a difficult time for all.

Despite the overwhelmingly compassionate responses from everyone, right at this moment, I still feel weighed down by it all. I still believe I have let my former clients down; I should be capable enough to support them and hold up my end of the relationship. I want it all to be over. I want to crawl into bed and not deal with it. I still worry about the potential harm that may come to my former clients due to not having a psychologist until they secure a new one. I worry about the workload now on the Zest Infusion team, and I feel bad for no longer financially providing for my family. I feel overwhelmingly responsible for everyone’s pain and suffering at the hands of my actions. I feel like I’m drowning. It’s like it will never end.

What keeps my head above water is the continual support from those who genuinely love and care for me—Ryan, Jayd, Hayley, and Ilze. I love when a message pops up from Hayley or Ilze to check in to see how I am going and knowing I can speak with Ryan and Jayd when I am having a bad moment. I am fortunate to have their support. It gives me the strength to continue putting my needs first, back away from being the carer for others, and allow others to care for me. It helps me to acknowledge that I’m sick and not in a position to care for anyone right now, and it would be wrong for me to do so. They are helping me focus on my choice to care for myself while also doing what is needed to finalise work. For example, setting and sticking to a workable schedule for doing the background work necessary to assist clients in being seen by another psychologist (i.e., writing reports to their doctors, handovers to new psychologists, and answering client emails) and scheduling an appointment for myself as soon as possible with a psychologist. I’m focusing on what is necessary to finalise the care for others whilst also taking care of myself.

I’m in awe of the overwhelming support from former clients for my health and well-being. Many of them have said in their messages to me something to the effect of “if there is anything you have taught me, Shannon, it is the need to prioritise care for self.” I’m so happy they have learned this from me; it helps me to know that they have learned a valuable healthcare strategy, care for themselves. More than this, everyone’s responses (including the clients) showed me that even when what you have to do affects them, it doesn’t mean they will hate you. They may express their hurt but also offer care and kindness. I’m grateful to have been surrounded by such wonderful human beings. The free-falling stopped in these moments, and I felt lifted and supported in this place of the great unknown.

Wellness Practice

You can’t change what has happened. Your illness will impact others. This doesn’t mean you are a “bad” person; it means you are human.

Acknowledge and show compassion for any undue impact on others. For example, “I’m sorry for the impact leaving work has had on you.” Don’t sacrifice your needs to take care of others right now. You will only do further harm to yourself and to the very people you don’t want to hurt.

Turn your attention to your recovery. Do the work so that this doesn’t happen again. What is one small step you can take today in service of your recovery? For example, make an appointment with your doctor to discuss a referral to see a mental health professional, prioritise rest, make time to catch up with a trusted friend, or spend time in nature.

Journal 5: Uncertainty-16 March 2021

At some point recently, I lost that lift and started to free fall again, and this time I was aware I had no place to land. I was fucking freaked out. I was staring into the abyss, and there was nothing. I have never jumped off a cliff; I always have a destination. I’m a planner; I always have a plan.

The free-falling recommenced when I was wrapping up the last bit of administrative work I had to do for my former job. This work has taken a few weeks, working full-time hours to complete, and it has filled my days and kept me from seeing the naked abyss of my life, a protector in some ways.

So, of course, I started to look for work frantically. Honestly, I have been looking for work on and off before then. If you were a fly on the wall for the past few weeks, you would have seen me sitting at my desk, editing my resume, signing up to major job sites, and applying for jobs after finishing a full day of client report writing. You would have heard a few thoughts about what I should do inside my mind. One of them was to do something within my expertise. Another was to do something entirely different with little to no responsibilities. I even thought about not working. My favourite idea was to take off in a van around Australia. At some point, I recognised that my mind and body were busy finding a place to land (i.e., a plan).

I talked about this with Ryan just the other day. I promised to talk more with him, especially when I get caught up in my head about something and take actions that are not helpful to me. Talking with him helps. I know he cares for me and has no qualms about being honest with me if what I do is not in service of that. I wouldn’t share with him or anyone in the past, and I would end up with a messy yarn of irrational thoughts, beliefs, and behaviours that only made me sicker. Talking it out with him helps untangle some of that yarn and keeps me from losing my shit. This time was no different.

On one of our daily walks with our puppy Hana, I shared with him what was happening in my mind and that I had been frantically looking for work, feeling the pressure to earn a living and pull my weight. Just voicing what was going on in my head helped. His words of encouragement, love, and support to do whatever helps me be healthy and happy have helped untangle some of this story and guided me to the firm decision to take 12 months off from working in the mental health field, stepping away from a caring role. I’m very thankful I decided to talk with him about my current messy thoughts; it has led to a critical decision.

This decision felt so good. A weight was lifted from my shoulders. My gap year began. A gap year with a stark difference; one focused on getting better and doing what is necessary to heal.

Gap Year Rule

To engage in activities that meet my needs. Care for self without engaging in work involving providing mental health care to others for at least 12 months.

While this decision and Ryan’s support have helped significantly, I realised I still didn’t have any place to land; I didn’t have a plan. I was still free falling into the unknown, uncertain where I might land. The view was cloudy, messy, unclear, scary, and foreign.

At some point (not sure when), the clouds cleared. I don’t know why; maybe a combination of journaling, talking with Ryan, and time. Whatever the reason, it became clear that I was pushing myself to find land (i.e., a work plan) because I believed doing so would help me feel safe, secure, and in control. I was looking for certainty. However, pushing myself to find a work plan only created more suffering. I needed to stop pushing myself to have a plan and instead let go, be present in the sky, this place of uncertainty, the great unknown. If I remain still, present in this place, I believe the answers will come at some point, and the plan will unfold. A plan that will likely be healthier and much wiser than the one made from pushing.

So, the plan is to be still and ignore the urge to push; to focus on caring for myself— meditating, spending time in nature, hanging with loved ones, stand-up paddle boarding, hiking, and stretching, whatever supports me at that moment.

Wellness Practice

When everything stops, it can be unnerving. Sending you into a tailspin of complicated feelings, thoughts and body sensations, often unexpectedly, especially if you are a high achiever.

Uncertainty is a tough place to be in, and reaching certainty in a moment isn’t always possible.

Instead of dealing with this all alone, talk about it with trusted friends, family or a professional. Speak it out loud. When we voice what is going on, it supports processing our experiences.

Have you ever talked something out with someone, and they haven’t said anything particular back to you, just sat there and listened, and afterwards, you have felt better, maybe even knew what to do next?

Talk with someone. If you don’t have someone, talk it out with a therapist, or write it in your journal.

***

As the sole rights holder and author of Nothing Left to Give: A Psychologist’s Path Back from Burnout, I Shannon Swales hereby grant permission to Psychotherapy.net to reprint the journal entries dated 1/15/21, 3/3/21, 3/10/21, and 3/16/21.   

Can You See Me? Arab Immigrants’ Quests for Identity and Belonging

The multifaceted and emotional aspects of working with Arab immigrants—a community to which I belong—is something I have learned to navigate more effectively through writing. This medium allows me to articulate the ineffable and share my thoughts more sincerely and deeply.

In the coming few paragraphs, I will describe my work with American adolescents of Arab origin, some of which can be found here; my own experience of immigration and mourning; and my experience with an analyst, where the consulting room became a microcosm of world affairs. We both were lost in our own traumas, and our work could not progress. Finally, I will share my present experience in my psychoanalytic treatment in the hopes that these stories can help you better understand Arab clients.  

Between Homelands: Arab Identity and Resilience in the Face of Stereotyping and Discrimination

Although American families of Arab origin come from 22 countries with diverse cultures and backgrounds, it’s important to note that not every Arab is Muslim, and not every Muslim is Arab. Despite these differences, many face common challenges such as acculturation stress, stereotyping, and discrimination. These difficulties have been magnified by the aftermath of September 11, ongoing wars on terror, Islamophobia, pervasive anti-Arab and anti-Palestinian rhetoric, and of the war on Gaza, which has been described by the International Court of Justice as a plausible case of genocide.

The insights I share here are based on anecdotal evidence and are not everyone’s experience. While not every Arab immigrant might relate to my narrative, immigrants from other ethnicities might find similarities.

For first-generation Arab immigrants, acknowledging the profound loss of their homeland and the deep mourning that follows is essential. Furthermore, when we come as refugees, our grief is intensified by the pain, and injustice of being forcibly displaced. Additionally, issues of racism and othering often become more pronounced in their new country.

In addition to mourning and grief, Arab immigrants must balance their love for their adopted land with the awareness that they are often rejected, misjudged, and even disdained. Employing Frantz Fanon’s concept, among the White majority, we become the “phobogenic subject”—a target of racial hatred and anxiety. Imagine, as you hold your children, looking into their eyes filled with dreams and innocence, knowing that in some places, they are not seen for who they truly are but are feared and misunderstood because of these labels. In your heart, they are cherished beyond measure, yet to others, they might only represent fear and prejudice.

In our adopted societies, and even on global and international stages, we Arabs often represent Carol Adams’ “absent referent.” This term, coined by Adams—a vegetarian feminist—illustrates how subjects of oppression are discussed as if they are not present. For animals, it means the pig becomes pork, the cow becomes beef, and the chicken becomes poultry, making our meat consumption more palatable. Similarly, the identity of the Arab is reduced to labels like Muslim, backward, and potential terrorist, as a result the killing of men, women and children, and the leveling of cities becomes acceptable. Arabs are frequently this absent referent, discussed and debated without their actual representation, their narrative or voice, rendering their perspectives and humanity invisible.

It would be wholly insufficient to explore the Arab immigrant experience without delving into Palestine and the relentless war on Gaza. I realize this is a topic that often creates anger and polarization, but it cannot be avoided in this context. Since 1948, Gaza and Palestine have been etched deeply into the Arab psyche, the significance of this tragedy has intensified since October 2023. In my practice, the impact of the war on Gaza is palpable and is a replicated experience of many, if not all, clients who are against the slaughter in Gaza.

For many, if not most of us Arabs, Palestinians and racialized people of color, Gaza looms persistently in our thoughts. The plight of the children, women, and men of the Gaza strip has shattered any remaining veneers of hope, belief, and promises for Arabs and non-Arabs alike: we have come to recognize that racialized colonization is the norm. The so-called universal values of justice and human rights have conspicuously failed us.

For many of us Arabs and other people of color, the situation in Gaza, which has been described by the Israeli historian, Raz Segal, as a textbook case of genocide, has deepened our intolerance for mediocrity and double standards. One cannot advocate for the conservation of sea turtles while remaining silent about genocide, nor can one campaign against global warming without addressing the killing of tens of thousands of civilians. In my practice I increasingly see how Gaza is compelling many of us to reevaluate our actions, career choices, and investments critically: Are they promoting justice and equality for oppressed nations worldwide or merely bolstering oppressors and enriching the affluent?

I vividly recall the dismay when the U.S. persistently ignored calls for a ceasefire and blocked international attempts at halting the carnage. We were not asking for statehood or the start of negotiations—it was a desperate call for the cessation of the killing of children who could be our children, mothers, fathers, brothers, and sisters, who could be us. It was about the basic human plea to halt the slaughter. That such calls did not spur those in power to take decisive action against the atrocities—children maimed, orphaned, and slain in the most brutal manners—was beyond comprehension.

This epiphany has deepened my insight, revealing a painful truth: despite being a mother, a psychoanalyst, a well-established middle-class member of society, and a devoted New Yorker who has served this country for decades, I am perceived differently. Standing beside my White and non-Arab friends and colleagues, a stark realization dawns: “I am not like you.” It is profoundly disconcerting to suddenly see oneself through this lens, to grasp that in the eyes of others, you are not entirely human.

Against this backdrop, immigrant Arab children and families try to adapt. Children and adolescents from American families of Arab descent, especially newly arrived immigrants, tend to excel academically. However, because of this success, they often remain overlooked by research and policy. These young individuals face the challenge of defining their identity in a society that may not fully recognize or understand their history, religion, or customs.

Moreover, adolescence is typically a period marked by separation-individuation—a second phase where the youth begin to distance themselves from their parents, as described by the psychoanalyst Peter Blos. This process can be particularly tumultuous for immigrants, as it may be compounded by their cultural displacement. Such disruptions can cause difficulties in managing emotions and lead to identity confusion, issues that could be alleviated through peer support and opportunities for identity exploration.

Studies have shown that adolescent immigrants often undergo what is termed in the literature as “double mourning,” defined as grieving not only their passage from childhood but also the loss of their homeland and cultural values. This dual loss raises complex questions about loyalty in their new cultural contexts. Additionally, the literature points to significant emotional stress among immigrant adolescents stemming from discrimination, microaggressions, and acculturative stress. These factors adversely affect their social and psychological well-being. Studies focusing on Latino adolescents in North America have highlighted family conflicts and perceived discrimination as major sources of depression and acculturative stress. The role of school environments, including their ethnic makeup and the sense of belonging they foster, is crucial for the mental health of adolescents.   

Literature suggests that immigrant adolescents are prone to emotional stress, exacerbated by discrimination, microaggressions, and stereotyping. Studies highlight that these experiences can lead to a decline in social functioning and an increase psychological distress. Further studies in the United States identify parent-adolescent conflict and perceived discrimination as key cultural risk factors for stress and depression among Latino adolescents. The educational environment, particularly the racial and ethnic composition of schools and students’ perceptions of belonging, also significantly impacts emotional and behavioral issues, indicating potential areas for targeted interventions.

In addition to these challenges, Arab American adolescents face unique pressures such as Islamophobia and negative media portrayals, which can intensify feelings of alienation and cultural dissonance. A study of Arab high school students demonstrated a strong link between perceived discrimination and mental health issues, suggesting a heightened vulnerability among this group.

The Shadow of the Phobogenic Self: Interpellation of An Arab Immigrant

In my work with middle-school-aged boys and girls who, like me, are Arab immigrants, I encountered a reflection of my own “phobogenic” self—an aspect of my identity that, due to its roots in history and heritage, attracts phobic hatred and anxiety. This was not just my experience but also that of my young clients. This recognition brought to light the process of interpellation, a term revived by French Marxist philosopher, Louis Althusser, through which I became identified as the “Arab Immigrant.”

In this role of Arab Immigrant, my subjectivity was shaped not just by personal experience but also significantly by the state and security apparatuses in the United States. These external forces crafted a version of myself that diverged sharply from the person I had been before immigrating to New York. This realization highlighted the profound impact of socio-political contexts on personal identity, particularly for immigrants like myself and my clients, whose selves are constructed at the intersection of past heritage and present circumstances. To understand what I am trying to convey here, consider the image that will come up for you right after I say, “an Arab Immigrant woman.” Other than her image, how do see her life and how she conducts herself in the world?

A Vignette with the Boys: I Am You
For a three-year period, I worked with a group of middle-school-aged Arab immigrant boys. The goal of the group was to help the students adjust to life in the United States. It was the first time I had worked with my own people in a clinical setting and the first time I had worked in my mother tongue. I thought that having lived for so long in the West, I could help the boys in their transition. Instead, they helped me see a part of me I wasn’t aware of.

Early in the treatment, I dreaded the advent of each session. God forbid one of the boys should want to enter the room before the beginning of our meeting, I would eat him with my eyes. I brushed my feelings off as a reaction to the anxiety in the room. I thought the sessions were so difficult that it was understandable that I wouldn’t look forward to meeting the boys. 

The boys, although they came to the sessions willingly, could barely sit still. They fought with each other and with whoever poked his head into the room. It felt impossible to contain them and alleviate their anxiety and mine. For me, they were interpellated Arab immigrant boys in the post-September 11 era. I could only see them through a political lens. My goals for the treatment felt superficial and inauthentic. The anxiety was palpable.

Even to this day, I vividly remember how much it weighed on my chest. I was at a loss. I wished for a manual with clear steps for conducting the treatment. Or perhaps a curriculum of sorts to contain me and the group. Have you ever had a dream where you went to the exam unprepared or perhaps to class in your pajamas? Well, this is how I felt during each session: vulnerable, unprepared, and exposed. For them, I was the White teacher: Although I ran the sessions in Arabic, a language they used among themselves, they spoke to me only in English. In addition, they took liberties that I am certain they wouldn’t have taken with an Arab woman. I conducted the treatment through artwork. If they were not drawing the flag of their country of origin, they would build clay structures that resembled erect penises with testicles or would throw food at each other and make sexually tinged jokes.

My feelings towards the boys and the treatment didn’t change until I presented my work at a case conference, where I was the only Arab and the only immigrant and where I began to experience what W.E.B. De Bois called a “double consciousness” feeling: this sense of always looking at myself through the eyes of others. The audience had only positive statements to offer. Nonetheless, I couldn’t escape my feeling of being an Other.

I couldn’t overlook the fact that we spoke a different language, literally and figuratively. I realized that I did not fool my audience with my Western-looking appearance. I am different. This early feeling of disconnection and alienation came back in full force. I felt as if I had just gotten off the boat. I appreciated that it would be hard for my audience to see through the social, cultural, and political layers between us. But I felt as if the boys and I were specimens for study. We couldn’t be understood intuitively. We needed to be dissected and examined. Something felt so sterile, disconnected, and uncomfortably clean.   

Following the case conference, my feelings for and experience of the boys shifted. I could no longer hide behind the fact that I could pass for a non-Arab. I could no longer project on the boys’ disavowed aspects of my identity. I realized that I had dreaded the sessions because they were making my interpellated self intelligible to me. I had to concede that escaping this self was as impossible as escaping my own skin. The alien feeling I had at the case conference reminded me of how things were when I first landed in New York: scared, alone, and vulnerable. This memory helped me hold the boys in mind (1). I could feel their sense of alienation, experience the lack of warmth they might have felt; taste the dread of living in a land as alien as Mars, and feel heartbroken by seemingly endless losses.

My work with the group was no longer only about the participants’ transition and integration but also about my second chance to connect with my origins. It allowed me to create something of value. From then on, I felt a connection to the boys that could only bring warmth, understanding, and patience to the room. I wish I could tell you that with a magic spell I was able to contain their anxiety and work with them. But no such luck. Our work together had to take its course. I accepted my interpellated self and accepted their stigma and mine.  

A Vignette with Girls: Colonization of the Unconscious Mind
A few years ago, I worked with a group of Arab girls. Most of them wore the hijab, which is a headscarf that covers the hair and exposes the face. Some women who wear the hijab also wear a neutrally colored, loosely fitting long coat, while others only cover their hair and neck and wear Western modest attire.

I showed videos of pertinent issues to engage the students in a dialogue. One such video was a documentary of interviews with five teenagers who immigrated to the United States from various parts of the world. Two of the five interviewees were girls, one wearing the hijab. One of the girls in the group I was working with, whom I will call Houda, shared her reaction to the video. Houda, who wore the hijab, had immigrated to the United States just a year earlier. She was helpful, engaged, and engaging. A group leader’s gift. Houda was clearly upset and deeply touched by the experience of the girl in the video with the head scarf. She told us how the kids in her class often teased her. She said that once, and without warning someone pulled her scarf off. The other girls in the group gasped and looked frozen.  

When she gathered herself again, Houda continued. One day a fellow student asked why she dressed the way she did. Houda explained that she was Muslim, and that Muslims believed that God wanted them to dress like that. The student who had asked her retorted dismissively: “What kind of God is this God that would force you to dress like this?!” Houda related the story with gut-wrenching distress. She was choking, half crying and half laughing, swaying side to side, as if not knowing what to do with the pain. In Arabic, she said, “I wished I could have told her that our God is better than yours. You are idol worshipers.”

I realized then how blinded I had been by the prevailing culture’s values. I thought all along that the hijab was a liability. Following the session, I decided to do an experiment. I wanted to wear the hijab to know how I would feel to carry something so dear, something that sets me apart from most around me. By the way, I want to stress that I come from a secular Christian family. I never wore the hijab growing up, nor was I expected to do so.

That summer was the first time I tried the hijab on. I was taken aback to see myself looking like a conservative Muslim woman. I had a dream after I saw myself in the hijab. To present the dream in context, I need to share a feature of Jordanian society where I grew up: pockets of culture and tradition made of the same substance that, paradoxically, do not seem to link. Although Christians and conservative Muslims live, work together, and have warm a respectful relationship, in Jordan, they don’t always cross paths socially. In fact, it is quite unlikely for my Jordanian family to have close or intimate relations with a conservative Muslim family: in a sense, they just do not speak the same language.  

I was taken aback, therefore, when I had the following dream. I dreamt that I was back in Jordan. It was winter and the weather was rainy and dreary. Streets flooded, mud everywhere. The kind of day that makes you not want to leave the house except in emergency.

The apartment was boisterous and alive with the sounds of children, blasting radio and the cling-clang of some culinary project in the kitchen. Freshly washed laundry was spread out on every open piece of furniture. The humidity and the aroma of home-cooked food sapped every bit of fresh air. The place felt uncomfortable and tedious. Nothing was going on except chores. No playdates to relieve you from the screeches of your quarreling children, or the hope of a lighthearted adult conversation.  

The bell rang. A middle-aged woman was at the door. She was wearing a conservative Muslim dress, head scarf, and long neutral-colored coat. She was softly walking towards me. She brought with her the hope of a pleasant chat and her three children, who would entertain mine and give me peace and quiet. My sister and brother were there. They greeted her as if they knew her. I felt I should have known who she was. I felt I was expected to greet her warmly. After all, she made the extra effort on a bad day and dragged her children along to greet me and welcome me back to Jordan.

When I woke up, I realized that this woman was no one else but me. She is my interpellated Arab immigrant self. I might believe that I am an Arab Christian or think that this made any difference in my social encounters. Christian, Muslim, white, brown, or green, my internalized sense of myself is that of a Muslim woman with a headscarf, and long neutral-colored coat. I am that woman in the mirror, shackled with tradition, fighting for recognition, gasping to rise above the stigma of her heritage. I felt sad and ashamed. Ashamed that I had dismissed and rebuffed her. I denied her existence. On which peg in my New York life does she fit? Among my American welcoming friends, she could be terribly misunderstood. I thought that no matter how hard I might have tried to explain her, tried to bring her into focus, her image will always be blurred and unclear.  

From that moment onward, I began to see how my thinking was colonized. In my article Through the Trump Looking Glass into Alice’s Wander Land: on meeting the House Palestinian I use Malcolm X’s analogy of the House vs. Field Negro to describe how I was the House Palestinian I noticed how often in my work with my people, my thinking and ways of functioning come from a colonized mind. I delivered a keynote address at the National Institute for Psychotherapies annual conference. In a 16-page essay, I repeat the word Christian seven times. I repeat it as if it were an important part of my life when I rarely, if ever, visit a church, and my connection to Christianity is mostly through Christmas gifts and Easter eggs. But on some unconscious level, I felt I needed to claim this religion, perhaps to identify with my aggressor, to tell them that “I am like you,” or, tragically, to disidentify from my own people: to the hijab, a liability is in itself colonial thinking.  

At this point in my life, I refuse to refer to myself other than a Palestinian or an Arab. I believe religion began to be used to fragment our societies because bonding together and our collective power can be formidable.

Immigrant’s Mourning: Peter Pan’s Neverland

I have wanted for a long time to claim that Arab immigrants and refugees have a unique position in terms of our struggle to adapt to life in the United States, especially regarding the history of Arab-West relations and the political issues I outlined above. I yearned to claim that the Arabs had it worse than anyone else, that our pain was more chronic, our longing more tender, our losses irretrievable, and our weeping inconsolable. But I couldn’t. Alas, the DSM-5-TR does not come with a diagnosis a la carte; there is no such thing as Arab Generalized Anxiety Disorder, Russian Paranoid Schizophrenia, or Character Disorder Français. The symptoms are the same, but the causes are different. To paraphrase Tolstoy, every happy immigrant is the same, but every unhappy immigrant is unhappy in their own way. Nonetheless, we are a particularly racialized and demonized minority. We are indeed the phobogenic subject.

Arabs might arrive in the United States as refugees escaping a war-torn homeland or an oppressive regime oppression, such as Palestine, Syria, Yemen, Sudan, and Iraq. Usually, their trip to the US is difficult: in addition to having to uproot themselves and abruptly and without permission, leave family and loved ones behind, they have to find a safe passage to their adopted homeland. When they arrive, they have to adjust to a strange land, language, smells, and faces. In addition, often they have to contend with below-the-poverty-line lives: someone who might have been a well-established office manager in his home country, because of language restrictions, would end up washing dishes for three dollars an hour, barely making ends meet.

In addition to the anguish, sadness, and hardship, they must be in a society that judges them, sees them in one light, and often disrespects them and their heritage. Considering that most of us Arabs are of the Muslim faith, Islamophobia and misrepresentation of the Islamic teachings tarnish a treasure Muslim immigrants hold dearly. A faith built on surrender and respect is misperceived and manipulated and misrepresented by politicians and mainstream media. Consequently, something you hold dearly, a book that is your blueprint for good and patient living, wrongly becomes deformed and ugly. The Arab Muslim immigrant is left heartbroken and dissociated from a logic that does not make sense.

The experience of immigrants, in general, tends to include periods of mourning. I once felt that immigration was like a never-ending funeral—an infinite procession of losses—relationships interrupted, events not attended, words left unsaid, memories that cannot be recaptured… A world and life are gone forever, but they are undying in my mind. I likened this experience to Peter Pan and his Neverland (2). Peter was an immigrant; he left his home in Kensington Gardens in search of a better life.

He told Wendy that one night, when he was still in the crib, “father and mother [were] talking about what [he] was to be when [he] became a man. …” He rejected their plans and left the crib and ran to Kensington Gardens, where he lived for a “long, long time among the fairies.” But, one day, Peter Pan dreamt that his mother was crying, and he knew exactly what she was missing—a hug from her “splendid Peter would quickly make her smile.” He felt sure of it, and so eager was he to be “nestling in her arms that this time he flew straight to the window, which was always open for him.” But the window was closed, and “there were iron bars.” He had to fly back, sobbing, to the Gardens, and “he never saw his dear mother again” (3).

Peter lives on the Island of Neverland, which is make-believe, and everything that happens there is also make-believe—time moves in circles, no one ages, and most of the events are pretend. He comes across as a superhero, an invincible boy who does not want to grow up. Peter likes to portray himself as independent and self-sufficient. He claims he “had not the slightest desire” to have a mother, because he thought mothers “over-rated.” The lost boys were only allowed to talk about mothers in his absence, because the subject had been forbidden by Peter as silly. When he is away, the boys express their love—and longing—for their mothers: “[All] I remember about my mother,” Nibs, one of the lost boys, said, “is that she often said to father, ‘Oh, how I wish I had a chequebook of my own!’ I don’t know what a ‘chequebook’ is, but I should just love to give my mother one.”

Despite his claims of self-sufficiency, however, Peter longed for a mother. Every night, he snuck into Wendy’s house to listen to her mother’s bedtime stories, which he would relay to the lost boys in Neverland.

Part of the immigrant’s psyche, like Peter Pan, lives in a “Neverland,” a make-believe imaginary space. There, relatives do not age, his mother still expects him for Sunday lunch, the dog waits for him at the door, and his friends look for him on the weekends. It is where he is understood without explanations, where he does not need to spell out his name or pronounce it, where his actions and reactions are just the way they should be, where everyone looks familiar, and where he safely blends into the background. Like Peter, the immigrant does not want to grow out of his Neverland, nor accept that his country, as he knew it, is no longer there. He does not want to mourn, for doing so means losing home forever.   

The immigrant is unaware that the interpersonal scene back in his home country is not the same. Time did not stand still: his friends aged, and their roles changed; parents, siblings, and cousins moved on, and the space that he once occupied is now filled with someone or something else (there is already “another little boy sleeping in [the] bed,” to use Peter’s metaphor). The immigrant is left suspended, never landing—a spectator to the events behind barred windows and painfully aware that even if he wanted to go back, he could not.

For the immigrant, visits to his home of origin become a harsh reminder of his mortality and insignificance in the schema of life. The memories he has of himself back then, of the person he developed into—the one who “came from nothing, progressed from a primitive and physical state of being to a symbolic one” (4)—do not exist and there is no proof that he ever existed. He left no traces behind. The memories and emotional experiences he holds are nowhere to be found.

In my experience, the immigrant’s trajectory entails an effort to assuage the pain of leaving “no traces … behind” by creating something that can be productive in the new land and applauded in the old one. It has to be successful enough to make an impact back home, so he won’t be forgotten, valuable enough to mend the rupture (real or perceived) created by his departure, and desired by others enough to give him a sense of still being needed.

Just as Nibs wanted to get his mother a “chequebook,” the immigrant wants to bring back proof that the losses were worthwhile and his love for his homeland is unrelenting. Thus, to view the pain and longing as pathological and to attempt to heal it before the immigrant is ready feels to him like murder—as if separation will kill the person he once was. It is to deny that he ever belonged to a group. To move quickly past the wound robs the immigrant of the energy that propels him to harvest the fruits of severing his ties.

Just as Peter and the lost boys left their mothers behind, the immigrant leaves his mother figure—their motherland and all its symbols—behind. In the New World, they struggle with the loss of psychological existence as a member of the larger group with whom they share a permanent sense of continuity in terms of the past, the present, and the future. Accepted ways of self-expression and old adaptation mechanisms must be shed: they are, at worst, dangerous and threatening; at best, they are unique or exotic.

Freud wrote that one mourns his lost object by separating from it, “bit by bit.” At times, the immigrant’s “bit by bit” mourning of his homeland is seemingly perpetual. For all intents and purposes, his love object is not dead: the country is still there, his parents call regularly, his friends stay in touch, and he can reach his siblings anytime. But he mourns the loss of his country on every significant occasion that takes place there. He might rejoice in a sibling’s wedding, but he will not know the little stories and many encounters that kindled the couple’s love; he might be sad that an uncle died, but he cannot and will not miss the uncle the same way others will. His presence at the funeral or his letter of condolence is that of an outsider; he is the undesignated mourner, unable to soothe or be soothed.

When the immigrant arrives in the new world, he spends much of his psychic energy adjusting and adapting. Unconsciously, he survives on the mistaken belief that his “secure base” is stable, and he can “refuel” anytime.

Speaking of my personal experience, my emotional connection to my country was like Peter Pan’s Neverland—a make-believe space where people never age, and time goes round in circles. My house is just as I left it the day, I moved out more than 40 years ago—as if my teenage siblings are still waving goodbye, as if my friends look for me every weekend, my mother waits for me for Sunday coffee, and my father is no older than I am now. But my sister and brother are parents now, my father passed away, and my friends are busy with new commitments. I am only a spectator behind the barred windows to events that move me, but I can’t touch. To use Peter’s metaphor, there is another baby in my bed.

For many, especially Palestinians, returning home can be a jarring experience, a stark revelation in black and white of all that has been lost, how life has irrevocably changed through no fault of their own. Your home is occupied by someone else, the streets you walked on as a child are barred for you, your neighborhood and your streets have been renamed, and the shop down the corner is now a supermarket that has been built on top of the ruins of most of your neighborhood. “I’m trying to understand why the sight of my son standing near the gate of the house, on a bench stretching to catch a closer glimpse of the garden, shattered my heart”

Recently, my son and I visited Palestine. One winter morning, we went to see my mother’s home in West Jerusalem—the home she lost in 1948. I arrived to find everything as she had described: the big stone construction, the arched balcony, the two staircases, and the lemon tree. It was all there. I longed to nestle under the tree, climb the stairs, or perhaps stand on the balcony. Of course, I could not; this was no longer my home. To this day, I’m trying to understand why the sight of my son standing near the gate of the house, on a bench stretching to catch a closer glimpse of the garden, shattered my heart. Perhaps it felt like he, too, was mourning, dreaming, and wondering what could have been. Or perhaps it was the sense of powerlessness to protect my son’s rights, his dreams, and his wishes.

Radioactive Identifications and the Psychoanalytic Frame

The psychoanalyst Wilfred Bion recommended that we approach treatment without “memory, understanding, desire, or expectation” (5). Is that possible when the intersubjective space is flooded with trauma, hurt, grief, and rage—when it is drenched with sociopolitical forces beyond the control of the clinical couple? Can we hold the psychoanalytic situation when the power differential is not only between expert and client, but also between colonizer and colonized, terrorist and terrorized?

In such circumstances, any communication between the clinical dyad, even silence, Bion argued, is liable to create “an emotional storm.” To sail safely through this storm, the analyst needs to maintain clear thinking. But if the situation becomes too unpleasant, the clinician might opt for other forms of escape, such as sleeping or becoming unconscious. I would argue, based on the personal experience I describe in an article I wrote a few years ago, entitled “Where the Holocaust and Al-Nakba Met: Radioactive Identifications and the Psychoanalytic Frame,” that under circumstances such as those above, it is nearly impossible to do anything more than make “the best of a bad job,” as Bion noted.

In my article mentioned above, I delved into the intersection of historical trauma, psychoanalytic treatment, and sociopolitical influences through my personal experience. As someone of Palestinian heritage, I engaged in therapy with a Jewish analyst, the descendant of Holocaust survivors. Our interactions became deeply influenced by the respective historical traumas associated with our backgrounds—mine with the Palestinian displacement known as Al-Nakba and his with the Holocaust.

The concept of “radioactive identifications,” first introduced by Yolanda Gampel, is central to understanding the dynamics within our therapeutic sessions. These identifications refer to psychic remnants from memories of extreme social violence that remain potent and disruptive. In our therapy, these identifications manifested through various interactions, complicating the therapeutic process.

I worked for a little over two years with an analyst whom, in a paper published, I call Dr. Shamone. I chose Dr. Shamone, a queer Jewish analyst opposed to the American Psychological Association’s complicity in torture, hoping he would understand the experience of being an Other. I was unaware of his anti-Palestinian beliefs at the time. Our early sessions were promising; I felt comforted and believed he was genuinely interested in my well-being.

However, a few months into our sessions, Dr. Shamone accused me of vandalizing his air-conditioner with graffiti. He believed the scribble, which looked like a combination of our names, was my doing, likening it to the act of “teenage lovers.” I could not believe what I was hearing. I sat in utter shock and dismay. I felt my heart shatter into a million pieces. I could not speak. My eyes were welling up. I felt overwhelmed with sadness, disbelief, and powerlessness. Who am I to this man? I wondered. How does he see me? Which part of me comes across as an irresponsible, immature woman who acts like an adolescent? Which part of me seems like a potential vandal and someone who would break the law so nonchalantly?

I spent the time between this session and the next researching the graffiti. Could it be an artist who scribbled on people’s air-conditioners? What could this word be? At the next session, I told him I thought the word on the air-conditioner could have been “Lakshmana,” which is part of the name of an organization called LifeChange. Dr. Shamone acknowledged that a week before the session, someone researching this organization visited him while writing a critical piece on the organization, accusing it of harming those who join it. It didn’t occur to me to ask him why it was that he accused me instead of wondering whether the researcher or someone belonging to that organization was responsible.

I am a Palestinian, but not a Terrorist

I entered psychoanalytic treatment with Dr. Shamone about 13 years after the September 11 tragedy. At the time, I thought the difficulties I faced had more to do with being an Arab from the Muslim world in an environment that demonized and feared people like me. On a conscious level, I was, of course, aware of my heritage but did not realize the extent to which radioactive identifications with intergenerational trauma and global events could affect the treatment. In the consulting room of Dr. Shamone, such identifications seeped between us — formless, odorless, and deadly.

Dr. Shamone began to struggle to keep himself awake during the sessions. Halfway into our meetings, he would become drowsy, his eyes would close, and his head would hang over his chest. At first, I felt as if I needed to protect him. I did not want to embarrass him. When I saw him dozing off, I would look away, pretending I had not noticed. One day, I came in with a bunch of chocolate bars. He wondered if I had a crush on him; perhaps chocolate was a sign of love. I said, ‘‘No, it is just that chocolate contains caffeine.’’ He responded, “You know, you are right, I gave up coffee a while ago.” I smiled and thanked him for accepting my gift. I thought then that his sleepiness was perhaps nothing personal, but caffeine withdrawal symptoms.

During this period, persisting to the end of our treatment, our relationship seemed to oscillate between a waltz, a judo fight, and an extended Amy Goodman interview. Dr. Shamone was only able to remain engaged and present when the discussion centered around Middle East politics. But when issues of everyday life took the place of politics, and topics such as my boyfriend, children, or work took center stage, he would feel drowsy and doze off. It was as if this monster between us was too much to bear if it wasn’t being continuously addressed. The monster had to be front and center; when it was hidden, the atmosphere became heavy and pregnant with unuttered statements. This dynamic continued for over a year.

Finally, I began to take his sleepiness personally. I felt this way because it was then that I began sharing my childhood trauma. I told him that I would feel hurt when he fell asleep and did not know what to do with that. Other times I would tease him; as soon as I entered his office, I would ask, “Are you going to doze off today?” This question usually worked, and he would stay awake.

Dr. Shamone felt certain that I was bringing something to the room that was making it hard for him to stay awake. He said at times what I was saying felt confusing, which made him lose concentration. But his conclusion shed no light on anything useful. Now I wonder if his sleepiness was a way to evade the reality of our dynamic, a flight from his feelings about me, or a way to escape from a traumatic memory that was being triggered by me.

Perhaps it was I who held unbearable trauma that he sensed and could not handle. Maybe he could not bear feeling responsible, at least in some way, for the trauma that led to my damaged mother. Or, perhaps, this was a parallel process to what Palestinians experience their predicament unrecognizable, their lives ungrievable, and seemingly on the road to annihilation. At the same time, the world dozes off on the sidelines.

During that period, I began to censor myself with Dr. Shamone. The analysis stopped being about my internal process and growth, but about how to keep Dr. Shamone engaged, about what material to bring in so he would remain present.

As I considered ending our work together, Dr. Shamone suggested, “Make sure your next analyst is not Jewish.” When I expressed my hurt, he added that I might harbor murderous intentions and come to the session with a weapon. This statement was a final blow, making me feel utterly alienated and unsafe.

In one of our last sessions, I told him about the fictitious traits I endowed him with when I approached him for treatment. I said, “I thought you would not be supportive of the Israeli government. I imagined that you were pro-Palestine.”

“Of course, I would be supportive of Israel! If things get tough for me here, I could always move there and be accepted.” I responded with a heavy heart. “Will you be living in my grandmother’s house?”

With a confused look on his face, he was quiet for a moment. Then he said in a thoughtful tone, “Sometimes we hurt each other.”

Back to the Present: My Journey with My Current Jewish Analyst

About two years ago, I began working with a supervisor to enhance my skills as a couple’s counselor. The supervisor was incredibly thoughtful, kind, and down-to-earth, with no pretenses, just analytic love and acceptance. Our connection transcended a mere supervisory relationship, embodying profound care and hope for my well-being on this life’s journey. Consequently, I decided to engage in personal analysis instead. While we sometimes focus on supervision, our interactions are primarily a therapeutic dyad.

Having previously worked with Dr. Shamone and had this painful experience, with my present analyst, I immediately brought up Palestine after expressing my desire to become his analysand. He reflected, “If you had asked me 20 years ago, my response would have been different. Now, I understand the situation on a much deeper level.” I have been with my current analyst for over two years now, experiencing significant personal growth and feeling deeply grateful for his attentiveness and presence. When the war on Gaza began, he would check in on me regularly, even outside our sessions, to ensure nothing was overlooked and to express his concern during those difficult times.

Contrary to Dr. Shamone’s advice, my current Jewish analyst has become one of the most important and healing people in my life. I continue to work with him because he is an honest and caring witness to my life and genuinely cares about me. Each session enriches my understanding of how to live authentically and trust myself as a therapist. Like my analyst, I strive to be authentic, helpful, and deeply caring with my clients.

Reflecting on my experience now, several years following the termination of treatment with Dr. Shamone and having this analytic experience with my present analyst, I find it insufficient and too generous to attribute my ex-analyst’s action solely to radioactive identifications. I have come to believe that my ex-analyst’s behavior was not just professionally unethical but overtly racist. His demeanor and actions towards me perpetuated a narrative that cast me in the role of a terrorist, devoid of an unconscious—my words came with subtitles I did not write.

Can You See Me?

Remember the experiment I mentioned earlier about wearing the hijab myself? On several occasions, I would wear the hijab and go about New York streets, watching for reactions. On my first trip, I discovered that there was a social network hidden in plain sight. Women wearing the hijab and men who seemed to be Middle Eastern or South Asian acknowledged my existence. They greeted me with a look, a gentle nod or some gesture, as if to say: I am here for you. I see you. I am like you. I realized how much I had been missing. That I have brothers, sisters, and a family I never tapped into. On other occasions, and for no apparent reason, my projections left me anxious and feeling in danger. I was worried someone would intentionally push me or pretend to be tripping and bump into me, or that I might be lynched in plain sight.

One summer, I had foot surgery and had to use crutches. During those times, when I traveled around New York in Western dress, I felt taken care of by many. For example, I never lacked a seat on the subway. Riders would rush to give me theirs. Dressed like a Muslim woman, I felt as if they looked right through me. As if I didn’t exist. Crutches or no crutches, they didn’t know what to do with me. I did not feel discriminated against per se, I just felt invisible.

A feeling of sadness and loneliness took me over. My Palestinian or Arab self is a charged topic. I, therefore, often enter my social encounters edging to be seen, but opting to hide.

I realized that there is a point that my dear psychoanalyst cannot enter;

I wish I could let him in. Perhaps I can hum a tune of a song he’d remember.

I wish he could smell the air of my land, see the beauty in desert roads, rundown houses, and joyfully running barefoot children with smudged clothes.

I wish he could taste the food I miss and know my teenage friends who are grandparents.

I wish I could mention the name of a neighborhood and he’d tell me about the streetlamp that stood there.

I wish he could laugh at my Arabic jokes, know a poem or two, or remember a public holiday.
But I don’t want to share my misunderstood traditions—I don’t want to find out how peculiar they seem to him.

I don’t want to introduce him to my beloved Palestine, I am afraid I might find out that he can’t understand the endless heartbreak I experience daily.

I don’t want to share my wish to remain in Neverland, where time goes round in circles, where no one ages, and where my siblings are still waving goodbye. I don’t want him to tell me that no such land exists.

I don’t want to uncover my inner world and end up being a specimen—dissected by his skilled psychoanalytic blade and disjointedly reassembled.

I really don’t want him to see me, all of me. I just want him to sit with me, hold my pain, blow on my wounds, and just answer “yes” when I ask him:

Can you see me!?

References

(1) Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. American Psychiatric Publishing, Inc.

(2) Barrie, J. (1911). Peter Pan. Barnes & Noble Classics.

(3) Kelley-Laine, K. (2004). The metaphors we live by. In J. Szekacs-Weisz & I. Ward (Eds.), Lost Childhood and the Language of Exile (pp. 89-103). Karnac Books.

(4) Becker, E. (1973). The Denial of Death. Free Press.

(5) Bion, W. (1970) Attention and Interpretation. Tavistock.

 

©2024, Psychotherapy.net

Reflections on Clinical Techniques for Working with Loss

In the “helping profession,” it is easy to talk about how we handled our successes, but seldom do we openly speak about the failures, the ones who got away. The people who leave treatment and don’t come back, or the ones who take their own life. How do you reconcile this?

Losing Clients in Therapy

I remember sitting in a training group run by one of my mentors — the topic was treatment failures. He said clients come and go, and that few therapists get through their career without experiencing the death of a client.
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The Ones Who Come and Go or Don’t Come Back

Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.

On the Death of a Coworker

At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.

Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.

Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.

On the Death of Clients

True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.

The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.

In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.

The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.

I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.   

The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.

I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!

Questions for Reflection and Discussion

How have you dealt personally and professionally with losing clients?

How might you have avoided a particular client’s unexpected departure from therapy?  

What are your thoughts about attending a client’s or their family member’s funeral? 

Existential-Spiritual Techniques for Fostering a Healthy Perspective on Aging

Introduction: The Existential-Spiritual Model

The case vignette that I will share presents the application of an Existential-Spiritual model of coping when working with patients experiencing the natural inevitability of aging and the “normal” responses associated with it. The integrated model includes six intervention practices: self-compassion and mindfulness, discovering meaning in life, prayer, creativity, expressing gratitude, and being open to a sense of awe. Existentialism poses universal questions and concerns, while spirituality provides space to process grief and loss and create meaning in life (1). The aims of spirituality include having compassion for others’ pain and suffering, advocating for social justice, and gaining awareness of and learning from the tragic dimensions of existence, thereby enhancing an appreciation for and valuing of life. This case of Jonathan highlights how dreams can be a valuable resource in gaining a deeper understanding of an individual’s attempts to deal with their existential and spiritual challenges, as well as finding passion and purpose in life (2).

Initial Phase: Processing Unprocessed Grief and Loss

Jonathan is a 68-year-old male who entered individual psychotherapy for the first time. He reported that he has been married for 40 years and has a married adult daughter and two grandchildren, ages 8 and 12, who live nearby. He had retired just one year prior to the pandemic. Jonathan, who majored in English literature, pursued a law degree for financial stability and a personal value of and commitment to social justice. After law school, he worked in his father’s medical supply business to support his father’s declining health due to numerous medical problems and an early death from diabetes at age 56.

Jonathan expressed concerns of feeling “empty inside” and experienced lack of direction, meaning, and purpose in life since his mother died approximately five years ago, just six months after his retirement. He reported feeling numb and indifferent over the wars in Ukraine and Gaza/Israel, and the intensified polarization of political discourse he observed during his extensive time watching cable news. Given his commitment to social justice, these feelings were different for him. In addition, a close friend had died early on in the pandemic, but he was unable to visit him in the hospital or attend his funeral due to COVID-19 safety restrictions.

Jonathan wanted to work with a psychotherapist experienced in Existential-Humanistic approaches based on his longstanding interest in the existential writings of Tolstoy, Sartre, and Camus. During his initial psychotherapy session, Jonathan reported a disturbing dream from the night before. He was in a building with a male colleague and his own daughter trying to find a pool. His colleague pointed to some skin lesions on Jonathan’s body; one had rows of 20 elevated dots that looked like shingles. There was another area that had been festering for some time. He was preoccupied by his skin condition in the dream and when he looked up, his colleague and daughter were no longer there.

Jonathan frantically searched the building asking for help in finding his colleague, daughter, and the pool. He recalled walking into an office with an elderly woman who was volunteering in the building. She was unable to provide any guidance as to his colleague’s or daughter’s whereabouts. Jonathan felt anxious about missing out on seeing them and the opportunity to swim. He woke up feeling worried and not knowing what to do.

I used several existential approaches, including Jonathan telling the dream in the present tense to develop a sense of presence and agency. I asked him what he thought the dream meant and inquired about his main feelings in the dream. Jonathan responded that he felt that something was missing in his life and “life was passing me by.” Jonathan associated the dream skin lesions with his mother’s fatal skin melanoma. He also described the colleague in the dream as confident and adventuresome, much like his recently deceased friend. I wondered if the dream reflected Jonathan’s hope that his therapy would help reduce his anxiety, but also his fear of what his treatment would uncover.

When asked to elaborate on the circumstances of his mother’s death, Jonathan expressed that she had been living in an assistive living facility in Florida for three years with a full-time aide. He then expressed guilt that he only visited her a few times a year due to his busy work schedule. He said he felt emotionally overwhelmed being with her as she did not recognize him during his last few visits, and she needed everything repeated numerous times. Jonathan said he was actually relieved when she passed away but felt ashamed for having these feelings and did not share them with anyone.

To further his sense of agency, I asked Jonathan, “What is the existential message that can be taken from the dream?” He responded, “I need to stop avoiding making a medical appointment with my dermatologist because I am scared of what it could be” and that he might be paying a price for not processing his numerous losses. I then asked Jonathan, “If you could continue the dream, how would you want it to end?” After struggling with an answer, he said he missed seeing his colleague at work, swimming, and spending time with his daughter and grandchildren.

The initial phase of psychotherapy focused on his unprocessed grief and loss over his mother’s and close friend’s deaths, reflecting on the impact of the COVID-19 pandemic, and clarifying his values. He expressed resentment that he and his wife, who were eagerly looking forward to his retirement, were unable to fulfill longstanding travel plans to Asia, South America, and Alaska during the pandemic. Jonathan felt it unfair that he had sacrificed being a lawyer to help run his father’s medical supply business, and that he historically had placed others’ needs above his own.

He felt that it was unfair that these losses happened to him now, just as he was on the verge of finally pursuing his own dreams. He also felt that his mother’s and friend’s deaths, as well as the social isolation during COVID-19, were disruptions of the life “he was supposed to have,” rather than inevitable parts of anyone’s life. He wondered if he was being punished for not being compassionate and supportive of his mother at the end of her life. I suggested using self-compassion statements to soften some of the self-critical attitudes, such as how he should have grieved his mother’s passing.

Jonathan and I explored how his sense of guilt, regret, and shame over his mother’s death had drained his coping skills and flexibility to deal with his mourning process. We discussed how some of his basic assumptions of the world — such as “The world is fair,” “bad things should not happen to good people,” and “there is a reason for everything that happens,” — were shattered and left him “drifting at sea without a paddle,” not knowing what to do. We explored how these feelings were similar to how he felt at the end of his initial dream and how these factors may have impacted — and could continue to impact — his ability to mourn and grieve. Jonathan gradually was able to acknowledge, but not accept, that the world is unfair and unpredictable, and that random events can happen to good people.

I asked Jonathan to describe in more detail his last visit with his mother. He recalled her sitting up in bed requiring her full-time aide to feed her pureed food. She was staring out the window as if she was already in a different place. Jonathan said she was there physically, but in some ways she had died psychologically. I suggested that he was experiencing an ambiguous loss, making it challenging to start grieving her passing because she was still there physically. He tried to imagine what she might have been experiencing looking out of the window, and he wondered if she was scared of dying and being forgotten by others.

The next session included recalling positive memories of his mother — what kind of person she was before her Alzheimer disease diagnosis, and what values she lived by. He brought in photographs including her wedding picture and one where she was holding his daughter when she was an infant. His mother’s eyes in the second picture conveyed a warm, loving glow, which was comforting to Jonathan. He also recalled how she went back to school to become an elementary school teacher when Jonathan and his younger sister were in high school, and how much he enjoyed hearing stories about her work. He realized that his mother was more than his memory of what she was like at the end of her life.

Jonathan also discussed how his best friend, Michael, passed away three months into the pandemic. They had become best friends in 8th grade, and even though his friend moved out West after college, they maintained regular contact, including yearly visits. Michael was adventurous, loved hiking and fishing in the Pacific Northwest, and enjoyed talking to strangers. I suggested to Jonathan that the colleague from his initial dream might symbolize this friend, perhaps indicating a desire to emulate his confidence and adventurous spirit.  

Jonathan fondly recalled that the conversations he had with his friend always had the quality of picking up right where they left off. His beloved friend Michael, a social worker, always provided a listening ear and would ask challenging, but supportive questions. He was non-judgmental and helped Jonathan with various struggles. When asked what he missed most about his friend, he replied, “I could talk about anything without feeling judged, and he treated everyone with respect, always seeing the best in others.” When asked what Michael would say to him now in terms of how he should handle all his losses, he replied, “Just savor the preciousness of each moment, don’t take anything for granted, and take some risks.”

On top of these two significant losses, Jonathan felt that the pandemic was a very isolating and frustrating experience. His retirement dreams were put on hold, leading him into several unhealthy patterns, such as excessively, or perhaps obsessively watching cable news, growing more irritable with others, and being intolerant of conversations with friends and family members with opposing political viewpoints. His main pleasures during the pandemic were his weekly Zoom meeting with his daughter’s family, reading, and taking daily walks.  

I asked open-ended questions at this time, including: “What sustained you during the pandemic?” “What did you learn about yourself?” and, “Where did you find the strength?” Jonathan felt that his longstanding interest in Buddhism and the Jewish value of healing the world (tikkun olam) provided a sense of stability. Specifically, Buddhism stressed the importance of not getting too attached to things, the importance of just “being” and accepting things as they are. Although these beliefs provided some degree of intellectual comfort, they did not have a major impact on his actions or his self-confidence.

In order to provide Jonathan with a deeper foundation and sense of direction, I asked Jonathan to describe his core values, which he identified as supporting his family, treating others equally and with respect, and pursuing excellence in whatever he did. Since his retirement, he felt that part of his identity had been lost even though his career was never in line with his values of social justice and being a lawyer, leaving him lacking passion and direction. He was encouraged to explore if these values were still effective and whether he needed to reconsider refining them in some way. Jonathan was gradually able to realize that although he did not need to financially support his daughter and grandchildren, he could model for them how to handle adversity and aging in a graceful way, as well as find other ways to channel his need to treat others equally and with respect. I stressed that values are not fixed in nature but can be created. At this point in therapy, he was also encouraged to practice mindfulness exercises and self-compassion to increase his level of self-reflectiveness, to be less judgmental of his struggles, and to recognize that his feelings are transient.

Middle Phase: Establishing a New Sense of Self Through Existential Approaches

Four months into treatment, Jonathan reported a vivid dream where he was walking in New York City trying to get to a meeting in his office on the East Side. He was waiting with a group of people in a building near Central Park. Some of the people were taking too long so he decided to leave to make it to the 3:00 meeting. He was trying to find a cab, but they were all full. He walked down an area in midtown that was sectioned off with small houses that one would typically see in the suburbs. One of the buildings had a large window where he saw a group of people relaxing and socializing.

Jonathan realized he had to get to the office, so he finally got into a cab and saw he only had a $10 bill to pay for the short trip to the office. The traffic was slow, so he decided to get out of the cab to walk the remaining distance. There were long, winding, hilly sidewalks that are not typical of the city, and he realized that he was on the opposite side of Manhattan from his office. He sensed he would miss his meeting as he saw trains passing by near the Hudson River. He then found himself walking down a long, beautifully constructed road with tall, shady trees leaving the city through a tunnel. He woke up feeling that he wanted to stay in the city and that going through the tunnel was potentially dangerous.

Jonathan felt the dream meant that he was struggling to find a new path in life, that he had lost a core part of his identity in his retirement, and that he lacked a sense of community. Like in the Robert Frost poem, The Road Not Taken, he feared making the wrong choice, reminiscent of his decision not to pursue his dream of becoming a lawyer. He was asked to visualize what it would be like going through the tunnel. Jonathan imagined it would be dark, claustrophobic, and scary to walk on the narrow sidewalk with a guardrail with all the cars driving by fast. He felt that he would eventually be able to get to the other side, but it would take a great deal of effort and time. He was asked to imagine what it would be like if he went further into the tunnel to the other side.   

Jonathan struggled but was eventually able to say that he wished his parents and best friend were on the other side to greet him, saying how proud they were of him and the sacrifices he made for his family. He cried and realized that he had taken them for granted when they were alive. I acknowledged Jonathan’s determination, courage, and perseverance despite his anxiety and that the dream reflected his progress in therapy. At the end of the session, I asked him to think about if he was currently taking anything else for granted in his life. The following session, he mentioned that he felt gratitude that his family was healthy, that he had a few close friends, and that he could still give to others and pass on his knowledge and insights to his grandchildren. I then suggested that at the end of each day he write down what he was grateful for.

Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values

In the subsequent sessions, I asked a number of open-ended questions to further work through Jonathan’s grief and mourning including, “Are there any ways you can honor your parents and friend by living out the values and causes they believed in?” Jonathan felt that his parents were generous in giving to those less fortunate, and that his mother had volunteered in a pediatric clinic at a local hospital after her retirement. Jonathan was also determined to honor his friend’s life for the years he did not get to experience by being more adventurous and taking more chances, including planning a trip with his entire family out west to a national park. He felt that identifying these values and living them out would be a way of honoring their memory and remaining close to them even after they passed.

Jonathan returned to the next session visibly shaken by an encounter at a supermarket the day before. He noticed a homeless man desperately wanting some food. The people in line were rude and impatient with him, avoiding eye contact as if they felt disgust at his condition and shame for looking away. Jonathan quickly went to the cashier and offered to pay. Jonathan’s and the man’s eyes met, and Jonathan felt that this was something his parents would have done without any recognition for it. He felt that this small moment of compassion was a way of honoring his parents’ values. He eventually decided that he wanted to volunteer in a nearby soup kitchen one day a week and to tutor local elementary school children in reading and writing.

The final stage of psychotherapy included a number of significant events and choices. Jonathan took a trip with his entire family to Yosemite National Park. While looking at the Sequoia trees with his family, he felt a deep sense of connection to his friend, Michael, and a feeling of awe in being in a place so vast and mysterious. He subsequently began to pray more consistently, to be more courageous and adventurous like his friend, gradually releasing his fears of the unknown and uncontrollable. Jonathan appreciated that although someone dies, the relationship does not end and can continue to evolve (3).

Upon return from his trip, Jonathan reported a dream where he was walking a tall winding staircase at a water amusement park. He recalled looking down and realized that he could seriously hurt himself if he fell. Despite his anxiety, he kept on walking up and was securely placed in a luge headfirst while lying on his back. He felt scared and excited about what it would feel like going fast down the waterslide. Jonathan woke up feeling energized and proud of his courage like he did on his recent trip with his family.

Jonathan began to read and write poetry, which he shared with his grandchildren. The poems reflected themes of savoring the moment, particularly in nature and while listening to music, avoiding getting lost in trivial complaints, and expressing gratitude for what one has. Jonathan felt that his creative writing was the beginning seeds of his own legacy.

As the psychotherapy concluded, Jonathan acknowledged how his parents’ and friend’s values and personal qualities had a significant impact on his life and that he shared these values of promoting the growth and well-being of the next generation. Generativity became a new core value that provided a sense of purpose and meaning in his life (Buechler, 2019).

Concluding Thoughts: What is Psychological Health When Working with Older Adults?

The case vignette highlights the benefits of integrating existential and spiritual interventions when working with older patients. Jonathan needed to gradually process his unresolved guilt, regret, and shame regarding his mother’s and friend’s deaths before he could fully experience joy, vitality, and meaning in life once again. His mourning process was further consolidated by honoring his parents’ and friend’s values, the causes they believed in and how their good qualities had changed him for the better (4). He recognized that he shared these same values, which was fulfilling for him in maintaining a deep connection to them even when they were no longer physically present. Jonathan was able to acknowledge the legacy he received from his parents and began to integrate the value of generativity in his life.

The theme of giving to others less fortunate become a unifying thread in his life narrative. While he could not prevent or slow down the inevitable tragedies in life and the regrets over past choices, the thread provided a meaningful foundation and compass in navigating new, turbulent challenges in life. When reflecting on his treatment, Jonathan recalled that his brief interaction with the stranger in the supermarket may have impacted the person’s life, and Jonathan experienced a sense of their shared humanity.

From a meaning-centered psychotherapy lens, Jonathan not only acknowledged the historical meaning of continuing his parents’ values and legacy, but also started creating and experiencing other sources of meaning in life (e.g., experiencing connection and awe in Yosemite (experiential) and deciding to embark on more adventures and being courageous in creating new experience himself (creative source of meaning)). Jonathan’s experience of awe enabled him to deepen his awareness of life’s fragility, resiliency, and sense of wonder (5). His involvement in reading and writing poetry facilitated a change in his attitude and perspective on life. His daily practice of mindfulness provided a safe space to observe his thoughts and feelings in a nonjudgmental and self-compassionate manner, while practicing gratitude increased his appreciation for the gifts of life and the legacy of those who passed before him. Prayer facilitated his ability to let go of his need to control life and provided a sense of safety in letting go of his fear of the unknown (6).

Jonathan’s journey highlights that psychotherapy with an older adult can bring “a heightened existential awareness…a new appreciation of the preciousness of life… (and the ability) to trivialize the trivialities” (7). At this development stage, there is a degree of comfort, meaning, and purpose that one’s actions, deeds, and values can have a known or unknown rippling effect on one’s family and others (8).

Questions for Thought and Discussion

What are your impressions about an existential-spiritual approach to therapy?

In what ways was this author effective in working with Jonathan?

Might you have worked differently with this particular client?

References
(1,6) Gordon, R. M., Groth, T., Choi, E., Galley, J., Marcantuono, J., & Kulzer, R (2023b). An Existential-Spiritual model for coping during and after COVID-19. Spirituality and Clinical Practice. Published online: December 11, 2023.

(2) Gordon, R. M. & Groth, T. D. (2023a). Relational and existential supervision and therapy for adolescents with life-threatening illness. Journal of Infant, Child, and Adolescent Psychotherapy, 22(4), 311-322.

(3) Buechler, S. (2019). Psychoanalytic approaches to problems in living. Routledge.

(4) Kessler, D. (2019). Finding meaning: The sixth stage of grief. Scribner.

(5) Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. Paragon House.

(7) Yalom, I. D. (1996). Lying on the couch. Basic Books.

(8) Yalom, I. D. (2008). Staring at the Sun: Overcoming the terror of death. Jossey-Bass.