Category: Therapeutic Issue

Ethics or Protocol: Children Must Take Priority

Posted on by Psychotherapy.net Team

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

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

An Ethical Dilemma Arises

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

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

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

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

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

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

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

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

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

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

Challenging a Beloved Therapist: A Catalyst to Growth

Posted on by Psychotherapy.net Team

A Break in Need of Repair

“I’ll wear a mask, unless you take a COVID test!” This was the message that I emailed Jeffery, my therapist of 29 years. It was a few days after he returned from a vacation that entailed a long airplane flight. My appointment was the following day.

“Wear a mask,” came Jeffery’s reply. He said he didn’t want to “stick something up my nose,” and was sure he didn’t have COVID because he was masked the entire flight. 

I was startled. His annoyed tone was out of character. I was also surprised to find I wasn’t devastated. In the early years of our work together, I’d been 100% emotionally dependent on him, a child beneath my grownup facade, and the thought that he might be annoyed would have been the end of my world. Now, I knew this was a temporary disconnect, one that could be repaired if we discussed it.

“Let’s do a phone session,” I emailed back. I was at risk for lung infections because of a health condition. Also, I would feel more secure on my own turf if the discussion proved difficult.

When we Facetimed, I saw that Jeffery was home, not in his office. Though dressed in his usual button-down shirt, he was stuffy and hoarse and looked as if he should have been in bed. But he was back to his usual cordial stance.

“Do you have COVID?” I asked.

“Just a cold. I don’t have any fever.”

By then it was common knowledge that fever wasn’t the gold standard for making a COVID diagnosis. I didn’t pursue the repair. He obviously wasn’t ready. I was glad to see him — he’d been away six weeks — but the session was superficial, not emotionally satisfying.

Before our next appointment, Jeffery texted that we should do another phone session, because he had COVID. Again, I was surprised at myself, this time for not wanting to say, “I told you so.” I understood that he could be wonderful 98% of the time and not wonderful 2% of the time.

When we spoke, I tried again for the repair, explaining that I was afraid of getting sick. He said he thought I was telling him what to do, but once he understood why, he was OK with it.

I saw that Jeffery was trying to be conciliatory, but it didn’t make sense. He’d known for a long time that I was afraid of getting sick, in part because I dreaded needing someone to care for me. We had been working on that in sessions. Also, he had never before gotten annoyed when I told him what would make me feel safe, even if he chose not to comply. Most likely, my COVID test request had triggered something in him that had nothing to do with me.   

I grew up in a home that didn’t model the best way to resolve conflict. If my father was displeased at something my brother or I did, he flew into a rage that involved prolonged and intense yelling, often accompanied by physical punishment. If he was displeased with something my mother did or opinions she had, he just yelled. She would answer softly, almost meekly, then later do as she pleased. If he found out, there would be more yelling. Early on, I learned not to rock the boat, a skill that traveled with me to adulthood. I was afraid that people would stop liking me if they became annoyed or angry, so I did everything I could to keep the peace. Now I was stymied.

It was rare that Jeffery let his own issues interfere with our work. In 29 years, that had happened only four other times, the last more than a decade earlier. This was by far the least consequential, but it was the first since I felt like a grownup through and through. I knew that before a meaningful discussion could begin, I would have to wait until he was ready to acknowledge what happened. If this was anything like the other times, that could take months. In the past, I would have discarded the 98% while I waited, just because I wasn’t happy with the 2%. It was a testament to our work together that I didn’t do that now. But gray was a lot harder to navigate than all black or all white.

Healing through Empathic Attunement

At 51, when I began seeing Jeffery, I had already spent 35 years in the mental health system. I’d been hospitalized three times with a misdiagnosis of schizophrenia, lived in a halfway house for a year, and had seen six therapists, each for several years. Though high-functioning at two jobs — weekdays as an I.T. systems analyst, weekends as a librarian — inside I was in emotional pain so great it felt like organ failure.

Relief came only through escape to an imaginary world I called the Atmosphere, where kindly invisible people, more emotionally reliable than real people, understood all my feelings and thoughts. That, and the knowledge that I always had an out: I could kill myself. The one place in the non-Atmosphere world where I was relatively comfortable was at work. I worked seven days a week — to stay alive and to pay for therapy.

Five years earlier, at 46, I learned I had what was then called multiple personality disorder (MPD) and has since been renamed dissociative identity disorder (DID). I was shocked that such a sensational-sounding diagnosis could apply to me. At the same time, I was relieved to finally have a plausible explanation for so much of my past: feeling not real, watching myself from outside myself, talking to faces in the mirror who were not me, functioning on a high level at work yet feeling psychotic outside of work. The diagnosis let me know I was not an alien species. I had a condition documented in clinical literature, said to have been caused by ongoing childhood trauma. That part fit, too.

It was one thing to have a diagnosis, another to find a clinician skilled in treating multiplicity. It would be another five years before I found Jeffery, recommended by a member of the dissociative disorders support group I had begun attending.

Jeffery soon realized that the Atmosphere, which was more real to me than the real world, had developed in response to early attachment trauma. The Atmosphere had been helpful when I was a child, providing the emotional connection I wasn’t getting from my parents, but when I became an adult, it got in the way of my having meaningful relationships with real people. Jeffery believed the Atmosphere had to be dismantled before healing of the multiplicity could take place. His theory, unbeknownst to me until years later, was that I needed to have an Atmosphere-like experience — perfect and unbroken attunement — with a real person: himself. I would then transfer my attachment from the Atmosphere to him, and eventually to other real people.

Over many years, with infinite patience and kindness, Jeffery saw me through the stages babies and toddlers go through when attaching to their caregivers. I may have been in an adult body, but parts of me who were very young still had to learn things as basic as object constancy — that people and things exist even when you can’t see them. Jeffery understood that to my magical way of thinking, I had two versions of him. In-person Jeffery waved goodbye to me at the end of each session, then froze, hand in the air, and stayed that way until I returned. The moment I walked out of his office, Atmosphere Jeffery materialized and remained with me 24/7, knowing everything I thought and felt and did until the start of my next session when in-person Jeffery would be right where I had left him.

In that way, he was with me continuously. Whenever something happened to let me know this was not so (his socks were another color, or he’d gotten a haircut, or worse, I saw the patient before me leave), I would berate him for his betrayal and call him a “deceiter.” He would explain that he hadn’t abandoned me, that I was always in his heart, even if he wasn’t physically with me. His words would soothe me — until the next time.

What went on in any given session depended on which of my parts was “out” (present). There was a sliver of me who was grownup, in particular an administrative part I called AlmostVivian. She kept me functioning in the world but had no depth. The more three-dimensional, feeling parts of me were largely children. These “littles,” who were causing most of the chaos and pain inside me, saw that Jeffery was a safe person, and they gradually began revealing themselves to him. Sometimes the only way I could communicate was by talking in nonsense syllables or writing backward on a piece of paper he had to hold up to the light to read. Other times, a feeling was too big to fit inside me, and I screamed, or hid behind a chair, or wordlessly locked eyes with him in an attempt to connect. And sometimes, ashamed to be visible, I could talk only in the dark, so he turned out the light.

At the start of a session, Jeffery would wait to see where I chose to sit. If it was a chair, he sat in a chair, too. If it was the floor, he would sit on the floor with me. If I was unable to talk, he and I might draw a picture together, taking turns adding a squiggle or something representational, like an eye or a bird. Sometimes we passed a computer back and forth, typing to each other in conversation. I likened our sessions to emotional surgery, where Jeffery dug deep but never more than I let him know I could tolerate. We would both make sure to leave enough time at the end to sew me up, so I could go out into the world and live my life until our next session. The sewing-up routine came to include having toast together, my ultimate comfort food. As we ate, chatting about seemingly mundane things, I would slip in something about my itinerary. “Before I go to work tomorrow, I have to take my mother to the dentist.” Atmosphere-Jeffery always knew where I was. I needed in-person Jeffery to know, too.

There were many bumps along the way, but the more I got from Jeffery what I had previously gotten only from the Atmosphere — feeling seen, acknowledged, understood, and cared about — the more I began connecting on a deeper level with outside people. My cubicle-mate at my I.T. job said, “You seem different lately. More sparkly.” My sister-in-law said, “It’s much easier to talk to you now. You’re more connected.” In my writing workshop, instead of hurrying out as soon as class was over, I began lingering to chat.

It took years, but I finally did “lose” the Atmosphere, and with it, the Atmosphere version of Jeffery. Concurrently, my internal parts were becoming more conscious of one another. While these developments were ultimately positive, adjusting to a new mental map of who I was and how I related to other people was not easy. For a few years, I felt lost from Jeffery, even when he was sitting across from me. A children’s book, Farfallina and Marcel, helped. I kept a copy in Jeffery’s office, and we often closed the session by reading it together. It’s the story of the friendship between a caterpillar and a gosling. One day, the caterpillar says she doesn’t feel well and climbs a tree. The gosling waits below, but the caterpillar doesn’t come down. A long time later, when the gosling has become a goose, he meets a butterfly. As they talk, they find out they each feel bad because they each lost a friend. A while after that, they realize they are the friends they thought they had lost. They look different, but they’re still the same inside.

Confrontation Revelation, and Repair

Jeffery had been my sherpa through decades of monumental changes that literally gave me back my life. Now we were having a tiff about something as trivial as a COVID test. At least I thought we were. From his point of view, the air had been cleared as soon as he understood I was simply telling him what would make me feel safe. I loved this man and wanted everything to be OK between us, so I did my best to ignore the elephant and go on as we had before. But six months later, when he was scheduled to take another trip — brief, but it involved a long flight — the elephant was still there.

“I don’t suppose you want to take a test when you get back, so let’s plan on a phone session,” I said, hoping to start a discussion.

“It’s not going to happen,” he said, smiling as if at a shared joke.

I smiled back, but inside I felt a great loss. The one person who had completely seen and understood me no longer did.

When Jeffery returned, I decided to confront him. I told him again that saying he didn’t want to stick something up his nose had been hostile. He could have just said he wasn’t comfortable taking a test. I repeated that this issue had more to do with him than me. He said he saw it differently. He had always shielded me from things that annoyed him. Now he was allowing himself to be more spontaneous. Then he clarified. During a session, he always saw my point of view, but outside of a session, he felt freer to let his annoyance show.

This initiated a new worry. How many other things had I done over the years that annoyed him? I asked for a list. All he could think of was something from two decades earlier, during the period when I could talk only in the dark. If my session was in the daytime, he had to hang blackout curtains, then take them down when I left.  

In our next meeting, I realized it was up to me to get the discussion back on track. I told Jeffery I had been caught in his forcefield, so I’d gone along with his explanations, but they didn’t make sense. His response: “Just because I disagree with you, that’s a forcefield?” This, too, was out of character. I said I didn’t want to know exactly what sticking something up his nose meant to him. I just wanted him to know that whatever it was had more to do with him than me.

There was silence for several long minutes, during which Jeffery’s eyes went up diagonally, the way they did when he was thinking through a complicated issue. At last, he looked at me and said humbly, “You’re right. There is something. I didn’t know it until now. Thank you.”

This was huge, but I didn’t stop. I brought up what he said about being annoyed outside of a session but not during a session. I told him that was hard to deal with. I needed to know he was a consistent person. Jeffery agreed he shouldn’t have said that. “It was mean and not true. I was just rationalizing my behavior.” That might be, I said, but it still hurt. He nodded his acknowledgment, holding my eyes.

We talked about it for a few weeks. I told Jeffery he was so near perfect that it was hard to know when it was legitimate to call him on something, especially when he kept insisting on his point of view. He admitted he didn’t like to think he had faults as a therapist, so he didn’t see when his own issues got in the way. Then he told me a little about his childhood, no details, but enough to let me know that what occurred between us most assuredly had nothing to do with me. I felt a surge of gratitude to him for his honesty. This couldn’t have been easy. But the elephant was gone.  

Incremental Progress, Monumental Change

At first, I was just glad to have my therapist back. But within months I found myself acting differently outside the therapy room. I had always been surface-friendly with everyone, easy to be around. I rarely became involved in deep discussions because I rarely had strong opinions. Whenever I did have one, if it was contrary to someone else’s point of view, I soon came to feel the other person was right. Now I was finding myself less inclined to remain safely on the sidelines, more willing to take cautious risks and become involved.

Shortly after the air cleared between Jeffery and me, I was asked to become co-chair of an organization I belonged to. While I liked the group and its mission, the thought of having to run meetings where there were sometimes opposing viewpoints — and hurt feelings — was daunting. I declined, explaining my reluctance to the person trying to recruit me. “But you’re so good at handling that kind of thing,” she said. I knew I was, but it was a skill that came with a toll. I was constantly vigilant in my interactions, never fully relaxed. Still, when she continued trying to convince me, I was flattered. She was someone I respected. After a month, during which I thought long and hard, I accepted, having decided it would be good for me to step out of my comfort zone. 

Of all the changes I went through since the start of my therapy with Jeffery, none had announced itself with an ah-ha! moment worthy of documenting in a progress note. Change was so incremental, like the slow movement of tectonic plates, that I never noticed it until a seemingly minor incident, like the COVID-test brouhaha, let me see how far I had come.

It has been said that in psychotherapy, in addition to whatever expertise the therapist has or what their approach is, it’s the relationship that heals. Jeffery was a safe person for me to challenge, and I had become strong enough to trust my instinct that something about his protestations didn’t ring true. While he didn’t agree with me at first, he didn’t try to crush me but allowed a discussion. I saw that we both wanted to reconcile and were negotiating in good faith. Ultimately, the fact that he was big enough to step back and take an honest look at himself, despite his discomfiture, was healing for me.

In my new role as co-chair, I have already been challenged by several disagreements. Each time, I’m initially sorry I accepted the post, but after the issue is resolved, I feel good. When I was on the sidelines, I never took a stand or tried to shape an outcome for fear of upsetting someone. Being involved is more difficult, but also more gratifying. It’s as if I had been snacking before and have only now sat down to a satisfying meal.

At 81, I am still becoming. 

Politics on the Couch

Posted on by Psychotherapy.net Team

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

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

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

Inviting Politics into the Therapy Space

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

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

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

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

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

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

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

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

Donald Meichenbaum on Coping with Loss and Traumatic Bereavement

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi, Don. Thanks so much for joining me today. You are most widely known for your foundational work in developing CBT but it is equally important that our readers know that for these last 35 years, you have been the director of research at the Melissa Institute for Violence Prevention and Treatment in Miami, Florida.
Donald Meichenbaum: (DM) Thank you for the invitation.
LR: You had previously requested that my first question be about the tragic and unexpected death of your wife, Marianne?

The Irony of a Trauma Specialist’s Tragic Loss

DM: We were married 58 years. My wife and I were vacationing in Clearwater, Florida, escaping the snows of Buffalo, where our permanent home is. My wife was tragically hit by a car at a pedestrian crossing. You know they have flashing lights, and this is sort of a warning sign. She was hypervigilant about not trusting people to stop, so obviously she would not have stepped off the curb if the vehicle had not stopped. But for whatever reason, the vehicle continued on and hit her. And in fact, she was lifted by a helicopter from Clearwater down to the trauma center in Saint Pete.I had called her on her cell phone thinking that she was late because she had a Zoom yoga meeting that she usually attended. I got a male voice, and he indicated that she had been hit and taken by helicopter down to the trauma center, but they would provide me with a police car to drive to the trauma center. I got there and the trauma physician indicated that she had already died. I asked to see her, went in and she was covered by a sheet. I pulled down the sheet, and she was pretty messed up from the accident.

I’ve worked with head injured, so I’ve been involved in seeing such incidents. Remarkably, her hand was still warm when I caressed it. There was a chaplain sitting next to us and I asked her to take a picture of me holding her hand. I actually sent that picture to my daughter-in-law who made it into a pillow. So, it was a traumatic bereavement kind of situation.

The irony is that morning I was giving a Zoom lecture for therapists in China on how to cope with traumatic bereavement and prolonged and complicated grief. And by four o’clock that afternoon, I was living my lecture. So, one of the interesting aspects of all this, and I’d be happy to discuss it with you, is what is the immediate and more long-term impact on an individual such as myself, who is in some sense is an expert on the area of interventions — having developed cognitive behavioral techniques.

Interestingly, there are hundreds of these kinds of accidents, many in Florida, of people — for whatever reason, where the driver is not complying with the pedestrian crossing. And there are multiple accidents and deaths in this particular way. So, the issue of traumatic bereavement as compared to a kind of prolonged complicated grief is an issue that I have been preoccupied with. And moreover, I’ll just add this final note before we open it up for your further questions. There are two aspects that are really quite fascinating in the aftermath of such traumatic bereavement.

One has to do with dealing with the grief. And the other aspect that is not readily discussed by clinicians is the sequelae that follow the sudden death of a loved one. And I will give both you and the readers to this presentation, a keyword that will change your life forever. This is the most important thing you should take away from our discussion. And the one word that you need, Larry, that will change your life if you do not already have it in your repertoire, is “passwords.” If you do not have the password of your significant other who died in a traumatic fashion, you are screwed.

LR: You’ll lose access to everything.
DM: Yeah, right. So, at a moment of intimate repose for your listener, they should lean over to their loved one and say, “I love you, but do you know our passwords and how to retrieve them?” So, you know I can fill you in and turn this into a kind of therapy session? And tell you the kind of trauma events, both dealing with the aftermath of the loss of my wife, but also the police reports, the autopsy reports, the life insurance, the banking, all of the credit cards — everything that goes with it.And the interesting thing is, if you are a clinician, one of the things you do in helping me is assessing, what is the lingering impact of this, what was the aftermath like? But it’s unlikely that you would have done that and asked does your social life change, and then a whole bunch of other questions that I’ve put together. In fact, the lecture that I was giving that morning to Chinese therapists, that entire 80-page handout that I provided them with is available to your listeners.

So, if they go to Google – Meichenbaum, Donald, Melissa, Institute – they will be able to download my 80-page tool plus other items on how to treat individuals who have traumatic bereavement and prolonged and complicated grief. So, if there’s anything I say that might be of help, I’m glad for that. And moreover, if there are people who want to contact me, they could do so through the Institute.

LR: I’m fascinated by the one word that you said clinicians, spouses, partners, family members should know, which is “password.” What’s the significance of imparting that piece of wisdom of knowing your partner’s password? And how did it play out in your journey?

DM: To access a number of accounts, my life was such that my wife Marianne was a wonderful wife, a very competent person. She was an actress, and she was a June Taylor dancer. She looked after all of our finances. I’m not a very competent person other than psychology. I’m a really good psychologist. I know a lot.

But when it comes to life, she was what I would characterize as my surrogate frontal lobe. And therefore, I never knew how to run appliances or bank machines or any of these kinds of things, and she looked after it. So, to gain access to that information, you really need the passwords. Fortunately, I have four wonderful children who are competent and loving and supportive, and that helped a great deal. So, we were able to, over a lengthy period of time — trust me, it took more than an entire year — to settle accounts related to adaptive functioning and financial issues and the like.

I won’t trouble you and your audience, but to highlight how unfriendly, how totally unfriendly the system is, to the 1,000,000 people who lost loved ones due to COVID. You know, the 20,000 individuals who died by interpersonal violence. You know, the incidence of mass shootings and all the other kinds of episodes, you know, the 48,000 who have to survive the suicidal death of a loved one. So, this discussion is absolutely remarkably timely, let alone the loss of natural disasters. I mean, just think of all the people at Maui whose lives are just upturned, and the many wars and the like. So, dealing with loss, grieving, traumatic bereavement, and mourning has to be on the top agenda of every clinician.

Difficult Therapeutic Conversations

LR: Working with adult children of elderly parents, clinicians have to enter conversations about what their plans are with and for them. And it seems to really behoove clinicians to engage these clients about the possibility of traumatic loss and unanticipated loss without pre-traumatizing them. How can we do that?

DM: We have to remind ourselves that what makes us effective therapists is the quality and nature of the therapeutic alliance that we establish, maintain, and monitor with our clients. So, to answer your question, I would advise clinicians to not enter that discussion without the permission of their clients. If I were in that situation, I would say something like, “I recently had a personal loss and I had a lot of lessons that I learned. And I was wondering if you would be interested or willing for me to share those.” So, my notion of being a good therapist is always to solicit permission from my clients, no matter what it is I want to ask. The third thing I would do is to say that, “you should feel free if this is not a good time or this is what we want to do, to put you in charge.” Remember that we, as therapists, need to be person-centered rather than protocol driven.

So, it sounds like, Larry, you had a whole bunch of to-do tasks that you think this elderly client or loved one should go through, right? You said you don’t want to traumatize them. Well, I agree totally. You know, so treat them with the same respect that you would want.

LR: How do we have conversations with our clients who may not even have elderly parents, but who are aware that they live in a world where there are dangers around every corner. How do you help clients prepare for the unpredictable without pre-traumatizing them?
DM: I have a kind of style of therapy, and I’ve actually highlighted this. I just put together a legacy course on what makes people expert therapists. As it turns out, 25 percent of therapists get 50 percent better results and have 50 percent fewer dropouts. So, my legacy course is, what characterizes those 25 percent of people and how can I elevate clinicians to that level? I have a kind of interpersonal style of respectful curiosity. And I really want to convey that to the client and wonder if they’re curious as well.I might say things like, we live in — how should I describe it — precarious times. With the COVID epidemic, with unpredictable violence, with multiple disasters and I must confess that I personally wondered to myself, and I wondered if you wondered to yourself about, given the unpredictability of life ever occurring, are we and our loved ones prepared for that? I mean, that’s my style of interacting. So, what I’m doing in that is actually sharing the rationale, and I’m extending an invitation.

My client might choose to take that invitation or not. And moreover, if I am going to see that person again in the future, all I want to do is plant the seed, then I will be able to follow up. I would say maybe this isn’t the right time or I’m not the right person. But as I look around, I think it might be advisable. And even something as simple as knowing the password of your loved one might be a good starting point. So that’s my way of engaging people.

LR: As simple as that. Simple, but complete.
DM: The key, or perhaps the challenge, is to deal with difficult issues in a non-traumatic engendering fashion.

Lessons on Grieving through Personal Loss

LR: In what ways, looking back, has your own clinical work and research helped you in your journey of grieving?
DM: Now that I’ve talked about the sequalae, let me take a moment and talk about the grieving thing. One of the things that’s really important for your audience to know — and there’s good research by George Bonanno and others that in the aftermath of loss — is that whether it’s due to traumatic, violent episodes like this, or whether it’s due to more prolonged, complicated grief as a result of having someone who’s been ill for a long period of time; there’s an expectation and different kinds of deaths have different kinds of impact.The bottom line is you need to recognize that most people are highly resilient. If you look at the data, most people don’t develop prolonged and complicated grief. So, the key aspect is, what distinguishes those who do versus those who don’t? And I even wrote a book called Roadmap to Resilience, that examines this and deals with it. In fact, your audience is welcome, in honor of my wife’s death, to view this and also my legacy course in her memory. So that’s one way of transforming pain into something good that will come of it.

And in fact, the Roadmap to Resilience has been downloaded for free on the Internet by 45,000 people in 138 countries. So now, let’s get to the heart of your question. In fact, George Bonanno wrote a really nice book called The Other Side of Sadness, which I recommend. It’s a nice little extrapolation on the kind of resilience engendering behavior. Therese Rando has also developed a concept that I’d like to comment on, that she calls “STUGs,” Sudden Temporary Upsurges in Grief.”

And in monitoring my own behavior, since I’m a psychologist and good observer, I’ve tracked my own STUGs. These kind of substantial or sudden kinds of upsurges of grief. And there are two kinds of STUGs in my life that I’ve discovered that have important clinical implications. The first STUGs are sort of sudden and unexpected. A song comes up, an invitation comes up to go to dinner with someone who doesn’t know about my wife’s loss. A couple walks by holding hands and lovingly convey their intimate connection.

And that hits me in an unexpected way. I’m moved to tears, and I have a sense of loss and the like. And there’s nothing wrong with that. In fact, I’ve come to believe that each tear that I experience in loss is not only a reflection of the loss and the grief and how much I miss her and the like, but it’s also a tear of appreciation. Of how lucky I was and grateful to have her in my life all these years. And then, I would have never had this career and all that without her. I’m a cognitive behavior therapist, so the whole thing is not that you cry, not that you feel losses.

It’s what is the story you tell yourself and others about that emotion? Each of us, each of your readers of this interview are not only Homo Sapiens, but they’re Homo Narrans. That we’re actually all storytellers. And the nature of the story we tell will determine — I’m going to suggest — whether you fall into the 20 percent who develop prolonged and complicated grief, or you’re part of the 70 to 80 percent who, in spite of the loss, everlasting loss, your STUG is this kind of sudden reminder.

LR: Unexpected!
DM: I sort of expect them, but they come out of the blue, right? The other kind of STUG which is interesting is something that’s a reflection of a prolonged type of routine or activity that we would have engaged in. So, I’m in Cape Cod, one of the things we would do is go down and have our sunset drink on the beach. A saxophone player would often be playing in the background from their beach house, you know, some Cape Cod song that we would have toasted to, kind of thing.Or we have our favorite restaurant, or our favorite hike or something like that. And I’m now doing those activities on my own. There’s another really interesting aspect to this, and that is, is the person who’s surviving the death, male or female? Okay, so most of my social contacts here in Cape Cod, and in other places, are a derivative of my being a partner of Marianne. So, she had a remarkable social network. She was just lovable and likable. There wasn’t anyone who didn’t fall in love with my wife.

And when she died, those social contacts sort of evaporated. People sort of give you occasional email and a “how are you doing?” But you don’t get invited to the same social occasions or dinners or other kinds of activities, so your network is really an important issue. And the important predictor here, especially among men, is loneliness. Okay, and there’s a higher incidence of husbands dying soon after the death of their wife, about 30 percent and so forth, and having other kinds of physical ailments than the other way around.

And then you need to distinguish between loneliness and isolation. Some people choose to isolate — they like being alone and so forth. Loneliness is yearning for this. And so first of all, in the aftermath of both traumatic bereavement and in terms of the mourning process, that becomes important. The other thing that your readers should take away is that there are no stages of grieving. So Kubler-Ross and Ron Kessler’s stuff about going through stages has no scientific basis for it.

And not only do you not have the five stages, but the expectation on the part of the clinician that people need to go through stages, and the failure to do so is a sign of pathology, is indeed problematic and possibly stress-engendering. So, when people don’t get angry, okay, then it’s deniable or they can’t handle their emotions. And I had a pretty good cause to be angry. This happened in Florida, okay? So, the guy who killed my wife got fined 160 dollars and lost his license for three months.

That was the total consequence. Not only that, in Florida — this is a wonderful state to live in if you’re going to retire — you don’t have to have liability insurance on your car. Okay? All you need to do is pay insurance up to 10,000 dollars. The helicopter cost of taking my wife from Clearwater to the trauma center was 68,000 dollars. So not only do I have, look, how much time do we have? You want me to go on and on? So, what am I going to do? And anger we know, gets in the way of processing trauma memories. Of all the emotions, that’s the one you don’t want to give up to. And that’s the one that clinicians should ask about in the aftermath.

So, if you go to the handout that I have, I have put together the most important diagnostic questions that clinicians should ask. Yeah, I give workshops on grief, and I actually bring my pillow and tell people. And I ask, if I’m your client, Larry, what questions do you think you should ask me? You’re a gifted clinician. What do you think are the most important questions you should ask me to see whether I’m going to develop prolonged grief disorders? Because there are now effective treatments. Shearer and others have created really good cognitive behavioral interventions, when I go on and on and review all the literature. So, I can make this a two-way street. I could ask you, what question do you think you should ask me first?

LR: What comes to mind is, how has your life changed?
DM: Wrong question!
LR: Okay, I could probably guess 20 times wrong.
DM: No, no. The first thing you should ask is, “how long ago has this occurred.” Okay, if this happened like last week or last month, that’s different than if it occurred a year ago. Okay? You know, and then there’s a whole set of questions you could ask about the circumstances, like you did at the outset. Okay, so getting to the notion of how you handle this has a kind of implied judgment on your part that I should be handling it.So, am I going to tell you how bad off I am or am I going to say oh, it’s not that bad, right? So, you have to establish a good therapeutic alliance with me, where I’m going to be open and honest. You know, I have trust engendering things, so I don’t know what your agenda is. Anyway, go to my handout.

LR: I will. I will.
DM: Please, I didn’t mean to put you on the spot.

LR: It’s refreshing and intimidating at the same time. What other guidance are you offering to clinicians who maybe are sheepish about asking the questions, or will not openly receive or seek out clients who have experienced loss? 

DM: The first thing — over and above the comment on stages — is that the field of psychotherapy is absolutely filled with bullshit. I wrote an article with Scott Lilienfeld called, How to Spot Hype in the Field of Psychotherapy. The next thing for therapists to understand is that the various therapeutic procedures are equivalent in outcome, and that there are no winners in the race. So that’s the next thing, just don’t believe the hype in these workshops where these people are saying that, “X, Y, and Z works better.”That traumatic bereavement is a common response, will lead to grief and mourning that leads to deteriorating performance is just not the case. So, the second thing that’s really important is that you need to ascertain from the client how to do therapy in a culturally and religiously, and gender-related kind of fashion. You need to ask the person — in my case, whether I’ve had other losses besides Marianne. You need to make me a consultant to you. Okay. And then you need to probe. How did I handle those? And is there anything I learned from them? So, you need to see me as a client as a resource person rather than someone you’re going to treat because you went to some workshop. Okay!

And apropos of the loss and transition website by Neimeyer and colleagues, they have a lot of techniques. Some of them are expressive. Some of these are customary activities that people engage in. So, you, the clinician, need to honor the way in which I want to cope with grief. Okay? And I recently went to a workshop by Mary Francis O’Connor who wrote a book on the grieving brain. And you need to recognize that some of the losses that people experience are natural and a reflection of love.

So don’t pathologize people’s grief or their coping techniques. If I want to avoid certain activities, I don’t go and get rid of the clothing and so forth. And there was a movie that Tom Hanks made that his wife produced called, A Man Called Otto. It’s a bit of a Hollywood version, but they did a really good job on talking at the gravesite. And doing the thing on the clothes. Here’s a wonderful thing that happens. When I cleaned out my wife’s closet, I found out that for the five years that we courted each other, we had written letters. And mind you, that was 1961. She saved all those letters. In 1961, a stamp was four cents. I read those letters as if she was present, each night I take out a couple. I’m now up to 1963, you know that stamps now cost $0.08 in 1963? Her presence, my storytelling, my doing this interview, my reading the letters, are all my own personal ways to honor her memory. The fact that I put the Roadmap to Resilience online for free in her memory.

If you go to the Melissa Institute website, if you’re interested, if you like this interview, go there and make a donation in my wife’s name. We’ve already raised 25,000 dollars for the Institute against violence prevention for her. I’m now in the midst of having done this legacy course of ten one-hour lectures on what makes someone an expert therapist, and then how to take those core principles and the transtheoretical behavior change principles and apply them to a whole host of diverse problems like grief and PTSD and anger and the like.

Each of those courses is only going to cost 150 dollars. Okay, that’s 15 dollars per CEU. All that money is going to go to the Institute in memory of Marianne. So, if you want more of what we’re talking about, track down this legacy course. If you do, there’s the likelihood you’ll be in the 25 percent group and you’ll be able to honor my wife’s memory. You get CEU’s for cheap.

The Role of Resilience in Healing through Grief

LR: You mentioned something earlier on, Don, about resilience as one of the really powerful predictors of how someone will move through their grief journey. Can you say a little bit about what a resilient griever looks like?
DM: In the aftermath of trauma or victimization, and with regard to whatever form it takes, resilience has been equivalated with notions of the ability to bounce back and with dealing with ongoing adversities. And it deals with the notion of personal growth. Margaret Stroebe and her colleagues have an interesting distinction within which people oscillate. That is, they have a variety of coping responses that are loss-oriented or restorative, and future-oriented. One of the things that’s interesting is that people can deal with it as a kind of Viktor Frankl type of observation.That people could deal with any kind of how in their life, as long as they have a kind of why in their life. Some sense of meaning, making purpose. This fits into my constructive narrative perspective that everyone is a Homo Narrans, or a storyteller. So, one of the things that becomes really interesting is how people transform their loss into some kind of effort to help others. So how did the Melissa Institute come about and my involvement therein? So, in the tragic killing of their daughter, Melissa, when she was at college in Saint Louis at Washington University, they have transformed the last 28 years – her loss — into a meaning-making activity.

You can go to the Trevor Project on suicide. You can go to Mothers Against Drunk Driving. There are numerable examples, I give multiple websites of how people have transformed their pain into something good. That doesn’t mean that you don’t continue to have an everlasting sense of grief. There’s nothing wrong with grief. It’s like any other emotion. The key is, what do people do with that emotion? Do they withdraw? Do they isolate? Do they become lonely? Do they use addictions? Do they self-medicate?

So, the key question is not, apropos of the resilience, or that people grieve. The fact that people are in touch with their grief is, in fact, a sign of resilience, right? It’s coming to, how do they honor? How do they memorialize? I deal a lot with returning soldiers. And the other kind of thing is that there are different kinds of losses. There’s loss of people, but there’s a thing called missing loss also. Like imagine people who have individuals who go missing in action. You don’t know if they’re dead right, or in Maui — you know, they haven’t found certain bodies. I mean, does that mean, is there more?

How do I, do I sort of get preoccupied and ruminate about the loss of my loved one, and how I wasn’t there? If I have guilt, shame, humiliation, if I have anger, if these kinds of negative emotions are that which drives me, then that’s the person, those are the folks who are going to be more likely to get stuck, who have hot cognitions and the like. So, you can talk about resilience being the absence of negative stuff, or resilience could be the restorative process on the other end. I don’t know if I’m getting close to your concerns, but…

LR: That resilience, and there are certain personality attributes and certain experiences that predispose people to resilient ways of being, and those people are probably in a better place to move forward in their lives after a loss.

DM: Here’s one of the things I failed to mention. The research indicates that people who have had a prior major depressive disorder are significantly more likely to develop prolonged and complicated grief. So, when I was asking the question, I ask, “Have you had similar losses in the past” and so forth? What we could do is look for vulnerability factors, okay, that are red flags as another tip. To see who would warrant evidence-based interventions, we’re pretty good.

If you look at my core task, there’s a whole way of how we, as therapists, do psychoeducation to educate people about grief. Or how do we help them develop various kinds of coping strategies? And how do we get them to follow through? The big thing is how do you get people who need help to want to come for help? And help them stay there? That’s the artistry of therapists.

LR: Is it more likely that those who have historically reached out to others for help, who have built lives that are rich in community, are just naturally predisposed?

DM: Well, a lot. There’s a fair amount of research by Camille Wortman and Roxanne Silver. Obviously, one of the building blocks for resilience is relationships. I mentioned I have four loving kids who really came to support, I have other people — professionally and others — who’ve come to support. But Wortman then really found a whole bunch of things that people do that are unproductive, that actually make people worse.

They have identified a variety of things that people provide support for, and actually make people worse. Like moving on statements. Things like, “You’re still a young, attractive, bright guy. You’ll find someone. How much longer before you die, You’ll be able to join him. This was God’s mission, He knew something.” So, there are lots of things that social support people offered, so that’s one of the questions you need to ask.

What, if anything, have people done or failed to do that you found helpful or unhelpful, right? Because you want to make sure that you, the therapist, aren’t doing something that I perceive as being unhelpful. So, if you’re a really good therapist, let your patients teach you how to do therapy. Don’t think just because you went to graduate school or took some workshop that you know how. Ask your patient, “What do you think is causing you to still have this lingering grief? And what do you think it will take to help you to move on? And what is it that I, the therapist can do to help you in that process?”

LR: You know, Bob Niemeyer suggests that therapists working in the arena of grief need to be what he calls the guide on the side, rather than the sage on the stage.

DM: Yeah. I like that. That’s a good metaphor. I like him a lot. I’ve read all his stuff. And, you know, my thing is, don’t be a surrogate frontal lobe for your patients. Don’t let the person’s emotions hijack their frontal lobe.

LR: And don’t, as the therapist, let your emotions hijack your presence in therapy. What about those therapists who themselves have had complicated losses, or unfinished business with their own children, parents, and spouses who have died?

DM: Well, I guess those therapists need to be honest with themselves and wonder how it impacts their therapeutic process. Those therapists need to be honest with themselves and decide whether, in fact, they need some therapy. That could help them deal with the issue. And the third kind of issue is, can they strategically use that self-disclosure in a way that facilitates or benefits the patient’s recovery? Rather than saying, you think you’ve got problems with your wife? You want to know what living with cancer has been like? And not only that, my father has Alzheimer’s, and now all of a sudden I have to listen to your shit, right?

So, you can judiciously, strategically say words are inadequate to describe what grief is like. I’ve been there myself. It’s not the occasion for me to share the details, but I want you to know I’ve felt the pain. Okay, I don’t know what the right words are, and you have to say it in an effective way. You can’t say, you think you got problems?

LR: In what way are you — are there any ways that you’re still practicing as a therapist now?

DM: I do a lot of consulting. I work with the head injured thing when people have cases, I train therapists who are doing supervision. I’m not seeing patients now like I did in the past, because I’m not in one place. I’m kind of a peripatetic clinician, so it’s hard to make a commitment to someone being there. I do some consultation with patients by telephone, since COVID.

LR: We could talk for hours Don and I do I hope we talk again. I appreciate your kindness and generosity.

DM: Thank you for the compliment and for inviting me on this journey.

©2024, Psychotherapy.net

Mapping the Heart Of OCD: Going Beyond the Conditions We Know

Posted on by Psychotherapy.net Team

“The heart has its reasons of which reason knows nothing.” —Blaise Pascal

Capitalizing on Empathy in OCD Treatment

Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them what’s the best intervention for OCD, and you’ll get the same answer: Exposure Response Prevention (ERP).

ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their biggest fears and learn not to blink. Intending to conjure up their personal worst-case scenarios — the terror of harming a newborn child, the yuck factor of hands submerged in an overflowing trash can in Times Square, or entertaining the possibility that they just might be a psychopath — ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.

Although highly effective at providing relief for symptoms, ERP is a mind and behavior-oriented approach that misses the most astounding feature of the OCD tribe: their enormous hearts. People with OCD are amongst the kindest and loveliest clients with whom I’ve worked.

And it’s not just my own bias, research confirms this big heart. Recent studies found that individuals with OCD show higher empathy levels compared to healthy controls. They shared the suffering of others in both self-reports and in a naturalistic task designed to test empathy in real time. They also reported more distress over their heightened empathy and are more emotionally responsive and attuned to others compared to healthy controls.

Such responsiveness is at the core of what makes therapists so effective, and yet for those with OCD, it misses two crucial pieces: the self-compassion and self-advocacy to counterbalance a weighted-down heart. Therapist burnout shows it’s possible to be too empathic, but have we ever looked at OCD from this perspective? Maybe we should!

A behavioral approach gives little room to map this expansive OCD heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39-and-a-half-foot pole. Between one quarter and one half of people with OCD decline ERP, in some cases even before it begins.

I regularly take on the challenge of asking myself as a therapist: what more can I learn about this condition by entertaining something completely different? In the spirit of punk rock, what can I glean if I rebelliously take on the mainstream? With its one gold standard treatment, OCD begs the question: isn’t there more we can do to help OCD sufferers find their voice? Perhaps ERP is so popular that few have the audacity to question it. Maybe, as Pascal instructs, the heart has its own reasons. Such was what I learned with and through Kate.

Kate’s Therapeutic Journey

“I almost cried when I read your blog post,” Kate confessed during our first zoom meeting. A cinematographer based in LA, Kate was fast losing hope that she’d ever get past severe OCD that only relented, ironically, when she was on set. “I always thought that I was failing at OCD treatment, not doing it right. Like, why aren’t I strong enough to just sit through the anxiety? But when I read your work, I felt like treatment was failing me.”

Kate read my unconventional theory that OCD arises from an empathic and existential sensitivity that goes unnoticed and unsupported, and turns in on itself. That enlarged heart capable of so much love is also keenly aware of the chasm of loss set before us all. Is it any wonder that the majority of OCD sufferers worry that death might befall themselves or someone they love? Or that the ritual du jour might somehow stave off what we all wish to control? At its root, OCD is a keen awareness of the fragility of life and the myriad spells and incantations we use to hold on to it at all costs, even if we must lose ourselves first.

“My parents and siblings used to poke fun when I was little when I wasn’t ready to let go of my teddy bear like they all did when younger. I carried her everywhere; she was the sensitive heart nowhere to be found in my house. I hated that I couldn’t let her go, and even until recently, I felt that way about my OCD treatment. Why couldn’t I be fiercer and face my fears and just grow up? Why can’t I even do this ERP thing right?”

Kate felt guilty in therapy, too. She admired the OCD specialist who first gave her a diagnosis and regaled her with the promise of ERP. Finally, there was hope that OCD didn’t have to rule her world. If he had saved her — as she so often felt — why wasn’t she more appreciative?

As we talked together, it became clearer: feeling wasn’t on his radar. Her therapist didn’t listen or seem to care about all that sensitivity, and she felt rejected yet again alongside her teddy bear. “What does it matter what your obsessions mean?” he’d shoot back, as if to say, “get with the program, this approach isn’t going to get you anywhere.”

In conventional OCD treatment, obsessions are just noise in the system trying to distract from the most significant mission: full acceptance of uncertainty and ambiguity. While Kate always wanted to make meaning and find ever more intricate forms for her feelings, her therapist just wished she’d keep working hard and be satisfied with her progress. There was little room for her own authoritative and unique voice, all that good fire in her heart.

Kate could also detect something unspoken in her therapist’s heart: how much his identity seemed tied to one singular truth and how it rattled him to entertain otherwise. She vaguely knew something about herself — how she existed in the world — hurt him. But she never put those feelings into words. Instead, they metastasized into self-doubt, self-recrimination, and shame.

It clocked Kate in the face when she recognized her therapist’s philosophy in a meme widely circulating and praised on Instagram in the OCD recovery world: “OCD is just sound and fury, signifying nothing.” Borrowed from Macbeth’s famous line when the walls are closing in on his murderous exploits and he learns of his wife’s death (ironically, Lady Macbeth with her “out-damned spot!” is one of the most famous contamination OCD cases in literature), Macbeth’s phrase is one of horror, lamentation, and hopelessness. The world is a meaningless, obsessional march of tomorrow and tomorrow and tomorrow, a tale told by an idiot.

“What is wrong with me?” Kate wondered. “I’ve always been a failure in treatment just as in life.”

The middle daughter of a highly educated and successful family of Chinese immigrants to California, Kate constantly found herself on the outside. Family members pegged her as unable to let things go, and though they’d never outright say it, weak for not being able to be more driven and hardworking like the rest of the clan. “Even your work is all just fantasy,” her mother complained.

Kate’s sister had already long moved out of the parents’ house at 25 and was now in medical school, setting sights on buying her first home. Her brother, an IT specialist, always seemed to be able to fix just about anything. Kate was the anomaly, still living at home with her parents and never quite fitting into the alpha-driven landscape of her family’s California dreams.

“Why couldn’t she just enjoy the promise of all that beautiful California sunshine?” her father protested. Kate was always adrift in the riptides of her obsessions, what if she forgot the stove was on, burned the house down, and killed everybody’s nascent dreams along with it?

“It’s like I can never do what the mainstream wishes for me. Maybe that’s why I’ve gravitated to indie films so much. It’s my only refuge.”

“I’d reverse that. The mainstream has never really witnessed your profound heart. You have always tried to accommodate the mainstream — your family, your therapist, the world — but it has come at the price of who you really are. Your sensitivity has always been a part of what has made your vision so clear and full. It’s no accident that your OCD largely vanishes when your sensitivity is prized, as it is when you are working on films and the director gives you the go ahead to command what you need to get the right shot.”

Kate always had a whimsical and keenly observant view of the world, and it showed in her cinematography. She always knew which way to angle the camera not just to get the right light or best composition, but somehow, she evoked things out of objects and people that were somehow right there, but beyond them as well. Her prodigious talent landed her on projects that she most dreamed of; it was also one of the few places where she felt free from obsessional doubt.

“Because your parents didn’t see your sensitivity as a gift, it got housed in your own mind, and you had to protect yourself and them from its power. You sensed so much of what was happening in your environment but there wasn’t a place to communicate that. It becomes wild in our own minds, but we need relationships — and art — to tame it.”

Kate is in Good Company

Together, we joked about how many artists and innovators shared OCD and this unique sensitivity, if you were lucky, found a place to give it creative form. How Greta Thunberg, herself an OCD sufferer, marshals her profound sensitivity to the neglect of an entire planet into fierce advocacy to save us all from extinction. How young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis in The Fault in Our Stars and writes of Aza Holmes, the greatest young adult character with OCD in American literature, in his novel Turtles All the Way Down.

Like Kate, Aza seeks her own center. Is she just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself than she is lost again, spiraling about the possible infection she now has unleashed. Compelled to drain the pus and blood, Aza is a hostage of her own self-enclosed system of fear, love, and unboundedness.

The heart figures prominently in Aza’s story too. Her father, also a sensitive soul and unrepentant worrywart, mysteriously drops dead of heart attack while mowing the front yard lawn. Just as Kate is so aware of killing everybody’s dreams and truths in her life, Aza shares a moment of clarity with her boyfriend about the root of her OCD: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.”

“OCD is a sensibility of sensitivity, one that has an exquisite flame for creative possibility but when traumatically misunderstood and misdirected, it burns the house to the ground. If Gabor Mate specialized in OCD (Kate was a huge fan of this rock-star sage) he’d appreciate it with us too. OCD is more than just a biological glitch; nature and nurture are always in conversation, whether we choose to listen. OCD is trying to tell us more than even therapists are ready to hear. There’s interesting music in all that noise.”

Kate was accustomed to having her true interests and concerns fall on deaf ears. Her relationship with this therapist and with cognitive-behavioral therapy itself echoed her ambivalent relationship to her parents: while she was grateful for having been raised and financially supported by them, they minimized her interests as foolish and viewed her obsessions as just more evidence of her immaturity and self-absorption. Without a clear and secure sense of support from these relationships — her parents or her therapist — Kate relied on her own thoughts and rituals to hold her up.

And yet here was the rub! Untempered by any human relationship, these thoughts quickly became savage and cruel, expecting her to be able to live up to what her perfectionistic imagination could dream up: a world of all-or-nothing purity.

Kate suffered from paralyzing obsessions when out in public places, fearful that the looks of others somehow might cause her to implode. Triggered on subways, Kate left the NY film scene for California where she had more freedom to drive solo. But Kate never quite understood why her obsessions centered around this particular theme and not something else.

“It doesn’t really matter,” her old therapist used to say. That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep on going down the rabbit hole. It’s not to be trusted as your friend.”

But Kate, ever-so-fascinated by the motivations of the characters she tracked in the movies she made, knew there must be more. Obsessions had a funny way of both distracting and focusing us on the things we most feared and desired for a reason. Kafka’s Gregor Samsa didn’t turn into a bug just because he had some tic of the mind, but rather because he felt the alienation, oppression, and depersonalization of his family life and modern society combined.

Successfully Addressing the Heart of Kate’s OCD

We worked on a new kind of exposure response prevention, one that dialed down into all of her feelings and associations with her obsessional fear. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others around her. With her big heart, she was so tuned into the unexpressed fears and desires of everyone that there wasn’t enough room for herself. She sensed the fatigue in her parents, their loneliness for their home country, and their overcompensated worries about surviving. They had no idea that internally she was feeling for them, unconsciously trying to imagine every way she could help them control their fate.

She was compelled to avoid any places which might afford too much scrutiny — subways, planes, trains, long car rides— and wisely found the safest place to exist with complete freedom: behind the camera. There, she no longer was the stage for all the unexpressed feelings of others; she could now orchestrate them for her own artistic purposes.

I knew Kate was making progress in our treatment one day when she started our session rather abruptly, “I know you might want to talk more about what we only half-completed last week, but I don’t want to do that. This is what I need today.”

My heart swelled. I loved the grit, fire, and healthy aggression that I knew she needed to have to own herself, even if she risked temporarily losing me. When I expressed this, she was a bit dumbfounded, “You mean, it’s okay for me to ask this? I’m not screwing up your plan?”

“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger; it was Aza’s middle finger. She needed to say a healthy ‘fuck you!’ to the people she loved — her mother, her best friend, even her own OCD — and trust that she was entitled to it. That’s what you’re doing now, and I love it.”

For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.

Together, we found the heart of it, the mystery that constantly hovers somewhere between life and death, love and hate, and disaster and possibility. Like Aza Holmes, who had lost her father, her boyfriend, and her beloved Toyota Corolla Harold, Kate recognized the biggest truth of all: “To be alive is to be missing.” And yet, it’s in that unexpected place where Kate was found again.

Supporting Recently Traumatized Youth in a Crisis of Dissociation and Self-Harm

Posted on by Psychotherapy.net Team

Case Background

Samantha, a 15-year-old African American young woman, was referred for psychotherapy by the hospital where she was taken after she was gang-raped while passed out at a party after drinking more than she ever had. This is Samantha’s first ever outpatient psychotherapy session, and she finds herself experiencing disorienting and, at times, overwhelming waves of depression and hopelessness as well as dissociative fugue states. Trying to calm herself, Samantha also finds herself involuntarily scratching at her arm and sucking her thumb, both of which give her a comforting sense of emotional and physical numbness.

Samantha’s friends describe her as a beautiful, kind, and honest person with a great sense of humor, an A student, and a star athlete. Samantha attends an exclusive private high school on scholarship; there, she is one of very few students of color. Her dream is to get a scholarship to an Ivy League university. When not studying or on the lacrosse field, she volunteers to help children and families in need in the community and for human rights causes. Older boys have frequently asked Samantha out, but she has never agreed because her parents are strict about dating and don’t want her to get entangled in a romantic relationship and lose her focus on college.  

Samantha’s family lives in urban public housing, where drug abuse and community violence are common occurrences. When she was 10 years old, Samantha witnessed her older brother, Andre, get shot and killed. He was walking her home from school, and they were caught in the crossfire of a gang fight. At the time, she didn’t understand what had happened when he suddenly fell down and blood was all over the sidewalk around him. She tried to get him to wake up and get up, but he wouldn’t open his eyes, move, or speak. She remembers neighbors taking her home and her mother screaming and sobbing when told that Andre had been shot. Samantha recalls that her mother “never was the same” after that; She wouldn’t go out except to go to work and return home.

Samantha frequently found her mother seemingly in another world, sobbing and saying, “My boy, my boy!” After the shooting, Samantha’s father also started drinking alcohol to the point of intoxication several times a week. Samantha has learned to stay away from him when he is drinking because he changes from being a loving and kind man to an angry and violent person she doesn’t recognize.

Samantha’s parents kept their jobs; They worked long hours and encouraged her to get scholarships and do well in school and sports. Samantha feels very grateful but also guilty that her parents are stressed and working hard while she seems to be enjoying school and sports in a sheltered school setting. Girls in her neighborhood, though, call her an “Oreo” (because she is Black, but they see her as trying to act like a White girl) and have stopped being friends with Samantha.

At school, girls pick on the way she speaks, saying she sounds like a “ghetto girl,” and that she only got into the school because of charity or government handouts. She has a solid group of male friends but sometimes feels like she doesn’t really fit in with the other girls at school. Girls are also jealous of her because of the attention she gets from boys, which has made making girlfriends even more difficult. She has one close female friend, Lily, who is also on the lacrosse team.

At the end of Samantha’s junior year, after she had aced a very difficult AP (Advanced Placement) chemistry exam, Lily convinced her to go to a senior summer kickoff party. A graduating senior, Jack, who had been asking Samantha out since she was a freshman, was hosting the party and wanted both girls to come. After prodding from Lily, Samantha decided to “let loose” for one night and attend the party. Samantha told her parents that she was sleeping over at Lily’s. Jack made a big deal of Samantha’s being at the party and offered to “grab drinks.” Although he was enthusiastic, Jack had always been friendly and had never been aggressive in his pursuit of Samantha. Samantha had only experimented with alcohol, but she wanted the full party experience, so she decided to “go for it.”

Samantha began by slowly sipping on a drink, but then got pulled into a drinking game with Jack and his guy friends. She quickly became intoxicated. Jack asked her if she wanted to go somewhere quiet to talk, and Samantha agreed. Jack helped her walk precariously to his bedroom, and the moment she sat on his bed, Samantha passed out. Realizing that she needed to be taken care of, Jack went to find Lily. This took quite a while with the raucous party spilling over into all parts of the house.

When Jack and Lily returned, they saw four very intoxicated guys nervously coming up the hallway from the direction of Jack’s room. When Jack and Lily entered the room and turned on the lights, they saw Samantha sprawled out and mostly undressed on Jack’s bed, still unconscious. Lily called an ambulance and Samantha’s parents.

Samantha woke up in a hospital room with Lily, Jack, her parents, and a nurse. “What happened?” she mumbled. “The last thing I remember was being with you, Jack. Something’s wrong. I feel all numb but like my body’s been run over by a truck. Did we get into an accident?” The next several weeks were a nightmare for Samantha, and for her parents and friends. She felt depressed and scared because she could tell she had been assaulted, but she had no memory of it.

When she met with a sexual assault counselor working with the police and learned that one of the boys had confessed and that she might have to go to court if criminal charges were pressed, she felt terrified and like the whole world would know she was “dirty.” The sexual assault counselor got her an appointment with a female therapist who worked with girls and women who have been sexually assaulted. Samantha delayed starting psychotherapy for several weeks by canceling several sessions. Her parents finally insisted that she talk with the therapist and drove her to this, her first, psycho-therapy session.

Session Transcript, Annotations, and Commentary

After the annotated session transcript, I present a summary of Samantha’s observations and reflections on her experience in the session. Following this summary is commentary highlighting key themes and take-home points for handling this or similar crises, and questions for reader self-reflection.

THERAPIST: So, Samantha, tell me a little bit about you.

SAMANTHA: (Stares at her lap) I’m in school.

THERAPIST: Mm-hmm.

SAMANTHA: (Still looks down but glances furtively at the therapist) And I’m into my senior year. I like to play volleyball.

Therapist’s Inner Reflections: Samantha seems very withdrawn and in a lot of pain and emotional turmoil. She looks haunted; there’s definite fear in her eyes, and she’s glazing over and just barely holding it together. Looks like she’s heading for an emergency and a breakdown. I want to help her reorient to the present, so I’ll engage her in focusing on who she was before the rape with an emphasis on her physical self so that she can become more aware of her body and slow down the flood of ruminations that she appears to be experiencing.

By orienting to the strengths and abilities she had—and still has—this can help her do an SOS [as discussed in Chapter 5, SOS refers to slowing down and sweeping her mind clear, orienting to a thought that helps her feel safe, and self-checking stress level and level of personal control] and begin to feel more personal control despite the intense distress she’s feeling. I’m not going to introduce the SOS formally to her because that would seem too didactic and intrusive, but I can help her do an SOS and begin to focus herself by showing an interest in her interests and strengths.  

THERAPIST: Excellent. I know that you know this—I met with your parents a little bit before you, so they told me that you have been a great athlete for a while. So, volleyball is now your favorite sport?

SAMANTHA: (Hunches over, looks at her feet, no longer glances at the therapist) Uh-huh.

THERAPIST: Excellent. Wonderful. Okay. And, um, I also know that things have been rough the past 3½ weeks . . . and that’s why you’re here today. So, I want you to know that—that we can work on this, that this is actually gonna be, um, a little bit hard at the beginning, but I know that you will—we will figure out ways that you can really overcome this terrible thing that had just happened to you. I’m sorry. So, because you’re a good athlete, I know that you work hard . . .

SAMANTHA: (Relaxes slightly) Mm-hmm.

Therapist’s Inner Reflections: I’m not going to ask her to tell me what’s triggering the distress for her because that probably seems obvious to her (even though it’s more complicated than she fully recognizes). By acknowledging the trauma in general terms, I’ve signaled to her that I do recognize what’s triggering her but that I’m not going to dredge up what’s happened or how she’s feeling because she’s probably trying very hard to not be aware of the shame and betrayal that I expect she’s feeling—and to not think about the rape, even though she probably can’t stop having intrusive memories, especially because she was not conscious while the rape happened. For the sake of Samantha’s sense of security in talking with me, which is very new and fragile — with this being our first session, the betrayal she’s experienced, and her damaged sense of self and efficacy—I’m going to emphasize her ability to accomplish difficult goals at this point.

THERAPIST: . . . and also your parents told me that you are a very good student, too.

SAMANTHA: (Looks up tentatively) Uh-huh.

THERAPIST: You have worked for—for everything that you have now. Right? And you really just have to finish your senior year the same way that you have, you know, have worked so hard your whole life to be where you are. So, your parents are telling me that they are concerned because you’re not going to school. Hmm. That has been really hard on you.

SAMANTHA: (Looks at the therapist, then down) I just don’t feel like going to school anymore.

THERAPIST: Mm-hmm. Yeah. So, tell me some of the reasons why you don’t want to go to school.

Therapist’s Inner Reflections: I’m sure there are many reasons that may seem obvious to Samantha, but I’m asking her to support this shift she’s just made from being passive and numb emotionally to being able to actively express her point of view. She’s engaging, even though the first signs are anger. Let’s see what more specific triggers she recognizes.

SAMANTHA: (Looks directly at the therapist, eyes blazing) I don’t wanna see certain people. (She sits back, strokes her ear reflexively with one hand, and sucks on the thumb of her other hand.)

Therapist’s Inner Reflections: The distress she’s feeling is intense. I see her doing several forms of reflexive physical self-soothing to tolerate the distress. As she does that automatically, she could put herself into a dissociative trance. I’ll support her intention of self-soothing and see if I can gently help her to do it consciously and to access other forms of self-regulation as well so that the self-soothing doesn’t lead to a dissociative shutdown.

Dissociation could lead to the healthy self-protective and self-assertive anger she’s understandably feeling to leak into her self-soothing in the form of unconscious or barely conscious self-harm. I’ll start by returning to the first part of the SOS: helping her focus on her breathing and being aware of her body.  

THERAPIST: Mm-hmm. Mm-hmm. Okay. It’s hard to, to see some of your friends or your acquaintances? And now I can see that it is really hard, Sam, to just talk about this. And I can also see that your body is telling you that probably right now you need to be soothed. So, one way of doing it, and I bet it’s helping you, is by touching your ear—yeah? And sucking your thumb. We can explore other ways that can also be helpful. Can I show you some other ways? (Samantha nods.)

THERAPIST: So, let’s try to focus on your breathing, Sam. Can you breathe for me deeply? Can you feel the air coming in from your nostrils? Can you do it maybe one time? Can we try another one? (Samantha looks down and begins rubbing and then scratching her arm.) This is too hard. This is painful. Is the scratching helping you? Hmm. Can we explore other ways, too? (Samantha stops scratching her arm and instead rubs it more slowly and gently. She begins to tap her feet vigorously.)

So, I can see that you’re moving your feet. Can you feel your feet on the floor, Sam? Yeah? Can you tell me if your feet are warm or cold? Yeah. Let’s try to keep on moving your feet. Keep on moving them. Yeah. Can you move your other foot? Yeah. Alright. Can we breathe a little bit more? Let’s do three times this time. Okay? One . . . two . . . three.

SAMANTHA: (Shifts from rubbing her arm to scratching with increasing intensity; begins to hyperventilate.)

Therapist’s Inner Reflections: Samantha’s escalating into emotional dysregulation and what looks like a dissociative state. Helping her to relax may be unintentionally leading her to lose track of her ability to self-regulate, I need to stay with the focus on body awareness but step up and gently but firmly guide her with very specific small steps to doing so without hurting herself.

I think she needs to see what I’m talking about, both to be able to cognitively process what I’m saying and to reorient herself to being present and not alone but supported by me. I’ll keep the focus on her being in control of herself so that she doesn’t experience me as taking control away from her in the way that those boys did by sexually assaulting her when she was unconscious.

THERAPIST: And, instead of scratching, can you touch your other hand and your arm like this? How does that feel? Can you feel your arm? Can you feel your wrist? Yeah? Keep breathing. You’re in a safe place, Sam. Nobody’s trying to hurt you here. Okay. I like this. Do you feel that your body likes it? When you try to soothe yourself like that, how does it feel?

THERAPIST: (Samantha gradually breathes more slowly and deeply with a more relaxed torso and legs.) Nice.

Therapist’s Inner Reflections: As Samantha calms down and comes back into the room, I can feel the tension draining out of my body as well. I’m primarily focused on Samantha, but I’m noticing that it helps me personally to self-regulate by doing these simple self-awareness actions along with Samantha. Now I can help Samantha not only feel calmer but also safer and protected. I’d like to give her a hug myself to comfort and reassure her, but I know I’m not her mother (even though I’m thinking about my daughters and wanting to hold them when they’re upset or hurt), and she needs to know that no one will intrude on her in this therapy. So even through it seems kind of silly, it makes sense to help Samantha to hug herself, and she’ll know that I am contributing to that hug without intruding on her personal space in a physical way that could feel like a replication of the rape (and her brother’s murder). 

THERAPIST: Nice? Alright. Have you ever given yourself hugs? No? Sometimes I give myself some hugs. Sometimes that helps me. Try it—maybe not here but later on. Okay? I’m wondering, you know, how we’re gonna find ways that soothing yourself is going to be part of your daily routine, and, at the same time, you can soothe yourself and only you will know that you’re soothing yourself. Alright? So, we did that sort of breathing a, a little bit of deep breathing, so you know that you’re breathing deeply because you want to focus on the here and now, putting your feet on the floor and making sure that you know that you’re feeling it, feeling your hands. Right? Feeling different parts of your body and focusing on, you know, where you are.

Therapist’s Inner Reflections: If I help Samantha connect these simple breathing and body awareness actions with her athletic skills, that can make this something she can do intentionally both to reduce the intensity of her hyperarousal and to tap into her self-confidence. And I will emphasize the core goal of keeping herself safe, which is what she feels she and her friend (as well as the boys who perpetrated the rape) failed to do. Then I can link the goal of being safe to her withdrawal, which is a problem and a symptom of depression because it keeps her trapped in survival mode but also is an adaptive attempt to protect herself.

THERAPIST: Okay? It’s almost like playing volleyball, you know? I bet that you’re so good at volleyball because you are actually practicing, and when you practice more and more, you get better and better, right? So, it’s the same thing here with our emotions. The more that we try to stay in the here and now, the more that you’re gonna feel a little bit safer. Okay? And, so, the more that you feel, you know, that you are in safe environments like—I bet that you’re spending a lot of time in your house right now. Is it—is your house a safe place for you? Does it feel safe? (Samantha nods.) Okay.

SAMANTHA: (Continues to visibly relax; makes tentative eye contact with the therapist) Yeah, it does.

THERAPIST: Okay. Are there any other places that are—make you feel safe? No? Only your house? Okay. Alright. So, tell me a little bit about what would going back to school look like. What do you think that you need in order to feel calm, in order to feel that you can soothe yourself utilizing healthy ways so you can go back?   

Therapist’s Inner Reflections: Samantha now is associating the main goal of safety with calmer body feelings that represent a main emotion (feeling “nice,” which seems to mean that she feels a sense of peacefulness emotionally) and a main thought (that she is not trapped in horrible distress but has active ways to enable herself to feel better). With safety as a main goal that can organize her complicated emotions and thoughts, we can begin to explore her options for achieving the goal of protecting herself (and the related goal of returning to school and resuming her life and progress toward future goals, such as success in school and sports).

SAMANTHA: I have my best friend.

THERAPIST: Mm-hmm. Your best friend. So, tell me, what is your best friend’s name?

SAMANTHA: Lily.

THERAPIST: How long have you known Lily?

SAMANTHA: Since high school started.

THERAPIST: Okay. Since freshman? Wonderful. So, you’ve known her for 3 years now?

SAMANTHA: Yeah.

THERAPIST: Okay. And you can trust Lily? Has she been contacting you? Yeah? So, has she been supporting you these past 3½ weeks? Yeah? How does she support you? What is she doing to help you?

SAMANTHA: (Smiles shyly) She’ll check up on me like every day or so.  

Therapist’s Inner Reflections: Samantha is such a resilient young woman! Without my bringing it up, she went right to what’s probably the single best way to begin restoring her sense of relational security, which had been shattered by her friend Jack’s neglect and the other boys’ betrayal and exploitation.

Samantha is a little fearful of trusting that her best friend Lily won’t also let her down or even reject her, but she can see that her friend is standing by her. The sense of being cared about and valued, and watched over in a helpful and nonintrusive way are clearly crucial for Samantha’s recovery. I’ll explore that as a potential path forward for her.

THERAPIST: Mm-hmm. Mm-hmm. Wow. So, is she actually contacting you quite often? Yeah. Alright. Have you been able to keep up with some of the work at school? No?

SAMANTHA: (Shifts back to a tense fetal-like position; withdraws eye contact) No.

THERAPIST: Alright. Okay. Is that something that you would like to do? Yeah. Okay. So, you’re a very brave young woman who has gone through a lot, and your body is very wise and knows how to calm and soothe you. So, I’m wondering if, for next week, maybe you can visit your friend Lily at her house before next week and see how that goes? Would that be something that you are willing to try? Is that something that you think that you can do?   

Therapist’s Inner Reflections: That was a mistake and a close call. I jumped ahead by implying that I was urging Samantha to go back to school. I got caught up in the relief that Samantha (and I as well) was feeling when focusing on the security that her friendship provides. I’m glad I caught that by noticing Samantha’s nonverbal signaling and stepped back to suggest a much more manageable first step of just going to the friend but not facing the much larger set of stressors and triggers that she’ll encounter when she returns to school. One step at a time. I’ll help Samantha build a behavioral chain of small steps that can help her reengage with her relationships and her particular areas of strength and success: schoolwork and athletics.

SAMANTHA: (Looks thoughtful, determined, and then makes eye contact) Yeah.

THERAPIST: Okay. Alright. And I’m also wondering if you can start talking with Lily about some of the things that you can start doing at home or maybe with her, some of the schoolwork, especially about the good subjects that you really like and enjoy? Is that something that you think that you might want to focus on this week?

SAMANTHA: (Continues uninterrupted eye contact) Yeah.

THERAPIST: Alright. And the last thing, Sam. I’m also wondering, since you are an athlete and you got this—right—I’m wondering if there is anything that you can do this week that can help you to maybe jog a little bit or walk fast or—or do something like that around outside—around your house, where you can . . .

SAMANTHA: (Nods and continues to make eye contact) Yeah.

THERAPIST: . . . do some exercise?

SAMANTHA: Mm-hmm.

THERAPIST: Is that something that you think that you can do? Yes?

SAMANTHA: Yeah. I can do that. Yeah.

THERAPIST: Alright. Well, I’m really looking forward to seeing you next week. Okay? Thank you.  

Samantha's Observation

In a post session interview, Samantha said that she had been feeling that she didn’t recognize herself anymore and that her parents didn’t look at her in the same way as before. She was ruminating constantly about the party, berating herself for being so stupid and wishing she had never trusted Jack and his “so-called friends.” She had secretly started cutting herself to make the pain and shaking stop and sucking her thumb to comfort herself. In the session, she initially felt physically tense because she didn’t want to have to answer more questions from another adult about the assault and about how she was feeling and coping now.

She was surprised and reassured when the therapist was very gentle and accepting, but then she felt that she let down her guard and started to space out: “I kind of went somewhere else.” She felt extremely embarrassed when she realized that she had begun to suck her thumb in the therapist’s presence, but she didn’t know how to make herself stop. She felt a strong urge to hurt herself when the therapist brought up the earlier experience of witnessing her brother being killed. Samantha described having felt a sense of confusion and shock related to witnessing her brother’s murder that she realized was very similar to how she had been feeling about being assaulted. That realization helped her to understand why she felt unable to stop thinking about the assault: “It was another time when I was powerless to stop something terrible from happening to someone I cared about, and no one else protected them or me, either.”

Samantha emphasized that she found the therapist’s guidance to be helpful in enabling her to be “more in my body” and more aware of the present moment and surroundings. She found being able to be more aware gave her a feeling that she wasn’t powerless, that she could “take back some control.” She also felt calmer and safer, which was very different than the brief feelings of relief that she’d gotten from sucking her thumb or cutting herself—and she also didn’t have to deal with feeling ashamed of herself and embarrassed, which had been making things much worse for her emotionally.

By the end of the session, Samantha was feeling a small amount of hope that, with the therapist’s help, she could talk about the assault and her brother’s murder and figure out how to not feel so terrible that she couldn’t stop thinking about those horrifying memories. She also had hopes of figuring out manageable steps she could take to work toward returning to school and “getting back to having a normal life.”  

Commentary

As the session unfolded, the therapist clearly was focused on three primary goals:

  • building an alliance and instilling hope by interacting with Samantha in a way that was nonjudgmental, accepting, nonintrusive, and responsive, and that facilitated a sense of relational security, resilience, active problem solving, and hope for solutions
  • assisting Samantha in regulating her emotions and becoming nonjudgmentally aware of the understandable emotional turmoil she was experiencing by identifying and adapting her intuitive ways of coping with memories and emotions, and supporting her by affirming, highlighting, and drawing on Samantha’s many personal strengths
  • assisting Samantha in setting and emotionally committing to an over-arching goal that reflected her current concerns and that enabled her to organize her complicated emotions and thoughts in a manner that provided her with a path forward to restore the parts of her life and the aspects of herself—as an outstanding student and athlete, and as a valued friend—that she had relied on as a source of inner security, pride, and hope for the future  
The therapist navigated a number of crucial and challenging choice points in working toward these three goals. As the therapist’s inner reflections indicated, a first challenge was to help Samantha to remain sufficiently oriented to be able to self-regulate and benefit from the support and guidance the therapist could provide. Without explicitly teaching the first FREEDOM (focusing, recognizing triggers, emotion awareness, evaluating thoughts, defining goals and options, making a contribution; see the Introduction) step, the SOS for focusing, the therapist helped Samantha begin to be aware of her body and present circumstances for the very beginning of the session (the first “S” in SOS).

She also helped Samantha to orient (the “O” in SOS) by highlighting her ability and interest in sports. And she helped Samantha track not only the intensity of distress she was feeling (using body feelings rather than verbalized emotions as the guide) but also her sense of personal control (again using breathing and tactile self-awareness as a practical way to feel in control).

A common challenge faced when working with clients in or on the verge of crisis is establishing rapport and trust while determining how— and when—to best help the client disclose the memories and emotions that are causing severe distress. In the post session interview, the therapist confirmed that she was aware of recent traumatic events that had occurred for Samantha but did not ask Samantha to talk about those events. This signaled to Samantha that she could trust the therapist not to be intrusive, which was crucial in light of the traumatic violation Samantha had experienced and the many questions that she and others were asking her about what happened.

By alluding to the events, the therapist also was communicating indirectly to Samantha that it is important to consciously recognize the triggers that remind her of the traumatic events. In addition to simply being in therapy (which almost inevitably brings up memories), the therapist identified other key triggers, including going to school and Samantha’s experiencing distress in her body. Rather than inquiring about the specific triggering stimuli and circumstances, the therapist immediately focused on helping Samantha to respond to triggered distress with body awareness and breathing.

Doing so communicated to Samantha that conscious recognition of triggers does not mean that there is any pressure to dwell on or even talk about the traumas, the triggers, or both that elicit trauma-related memories. In this way, the therapist helped Samantha to recognize—rather than simply react to—current triggers for distress as well as the trauma-related memories. Samantha’s reaction of increased d

Psychotherapy with Dissociative Identity Disorder

Posted on by Psychotherapy.net Team

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

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The Long-term Consequences of Trauma

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

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

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

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

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

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

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

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

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

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

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

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

Suicidal Debates with Clients in Psychotherapy

Posted on by Psychotherapy.net Team

When I started working as a therapist, the prospect of a client dying from suicide terrified me. I worried I would miss the warning signs, and that my negligence would have deadly consequences. There was a dangerous side of therapy, and I worried that eventually, there would be no avoiding it.

I still remain cautious, but I’m no longer terrified. I’m cautious because tragic events in my own practice have confirmed that the dangers in therapy are quite real. Yet I’m no longer terrified because I’ve learned how to think about suicide and depression more carefully. I’ve learned there are deaths that I won’t have the ability to prevent, but there’s still much I can do to help. I still believe that in most cases, therapy can interrupt clients as they shuffle down the path of despair, and it can turn them back towards the community of the living.  

Separating Depression from Sadness

My early concern around suicide came from the difficulty of thinking clearly about depression. The word “depressed” means different things across different contexts. It’s like the word “drugs.” Am I using drugs each time I go through a Starbucks drive-thru? Caffeine is a drug, so by one definition, I’m a daily drug user. A real bad boy. Leather jacket. Fingerless gloves. However, there’s an obvious difference between hot bean water and heroine, even though the word “drugs” can be used to accurately describe them both. When I think of paraphernalia, 20-oz cups and green stirring sticks don’t usually come to mind.

I think the word “depression” is also overly broad in a similar way. Before I was a therapist, I would use the word “depressing” to describe a sad mood, events in the news, or microwaving hotdogs for dinner. I no longer use the word depression in this way. Instead, I try to limit myself to when I’m describing a major depressive disorder. The reason I work to limit my use of the word is because depression, in its clinical form, increases the risk of suicide dramatically, and so I think it’s important to avoid the blurring of language. In matters of life and death, clarity is vital. Forcing myself into this distinction also helped me learn about five significant differences between depression and sadness in my therapy. My clients taught me their five depressing truths about depression.

Five Depressing Truths

When I first met clients who had traveled to the outer frontier of depressed states, I noticed that while despair could be their primary mood state, this wasn’t always the case. For some, it was an absence of feeling that they experienced. The client didn’t always tell me “I’m extremely sad,” but instead they sometimes they said, “I feel nothing — and I don’t know where I went.” Depression could present with a numbness, or more precisely, my clients were experiencing the first of their five truths; self-missingness. Their inner selves had left them behind, and what remained was an empty waiting room. This was one of the first differences that I noticed between depression and sadness.  

I also noticed that depression could create sleeping problems, difficulty with focusing, low energy, and a guilt that bent towards exaggeration. This guilt condemned my clients to wrongdoings they hadn’t committed. They felt guilty about being depressed, and when they had moments of reprieve, they felt guilty about that, too. My client’s minds would become kangaroo courts, and they would find themselves guilty on every trumped-up charge they could conjure. But in its most exaggerated form, this guilt could convince my clients they were harming others by committing the crime of simply being alive. More on this a little later. But this guilt, along with the collection of other symptoms, taught me another distinction between depression and sadness. While sadness is the description of a single mood state, depression includes a constellation of interconnected symptoms. In other words — and here is the second truth for my depressed clients — sadness is singular, but depression is plural.  

The absence of identifiable causes was a third truth, or dynamic, that my clients taught me. While stressors could certainly inaugurate depressive episodes, depressive episodes didn’t need external events to bring them about. Depression simply didn’t care about how well my clients were doing. Depression would invite itself into their life without notice, track mud into their house, and climb into their bed with its shoes on. In fact, many of my clients would tell me that they were on vacation when they first noticed that something wasn’t right. From their wicker chair, they watched the sun flicker on the water, listened to the waves — and felt absolutely devastated. It was the very contrast of the internal and external landscapes that brought them to realize that something was significantly wrong. These clients showed me this third truth about depression: it can darken the internal world, without identifiable darkness in the external one.

A fourth difference between sadness and depression that I learned from my clients was that sadness is an expression of the authentic personality, but depression is a departure from it. When depression eventually loosened its grip, my clients often expressed how unrecognizable their former self appeared to them. Depression seemed to operate like a spell. It would capture their emotional state and pull them into a shadowed place, and when this spell would loosen its hold, a return to their authentic personality would occur.

The final difference my clients taught me, and I think it’s the most important, is that depression can be quite dangerous, but sadness is not necessarily so. Far from being dangerous, I think sadness is a vital feeling. Sadness is how my clients felt when something important had been lost. Whether they lost a relationship, a home, or a career — sadness was the pain of absence. And as much as it hurt for my clients to feel it, this pain of absence was deeply important. It was important because when saddened, what mattered most to my clients was revealed. The pain of absence taught them what needed to be present in their lives. It was in the same moments they learned which losses they couldn’t bear, that they also learned what must be restored. To return wholeness to their lives, sadness told my clients which way to walk.   

But depression didn’t work this way. When my depressed clients looked inward, their inner state offered them no wisdom, but only suffering’s dead eyes stared back. This amount of suffering was unsafe. It was unsafe because this type of pain is simultaneously extreme and pointless. Clients can endure extreme psychological pain if they have a good reason, but depression provides no such reason. It seems that depression is a pain without purpose.

So, these five differences between depression and sadness left me with a more limited definition of depression: it’s a state of despair or self-missingness that requires no identifiable cause. It includes a plurality of symptoms, it’s a departure from the authentic personality, and it’s also dangerous. It’s not about microwaving hotdogs or the news. Or it’s barely about microwaving hotdogs and the news. But as I started to understand depression in this way, two things happened. The first is it made it possible to reconsider how I thought about suicide. The second was that my work with my clients significantly changed.  

Disagreeing with the Depressed

It’s hard for me to overstate how difficult it is for me when my clients try to convince me that they cannot be helped. While they might concede that people shouldn’t wish to die, they often tell me there is one exception, and it’s them. They tell me that the details of their pain are unique, and that they’re a rare and untreatable case. Their suffering stands apart from the rest, and in this way, it’s superior. Sometimes depression can cleverly recruit a pinch of narcissistic grandiosity to increase a client’s despair. Bon appetite!

This creates a challenge because my training taught me to honor, and not to disagree with, the feelings of my clients. In my education, disagreement was to therapy what deodorant was to teenagers. They simply don’t go together. But when my depressed clients try to convince me that they can’t be helped, I’ve found careful disagreement to be important. While it’s true that disagreement can elicit defensiveness and early termination with clients, disagreement has been a a useful skill in the presence of a client’s hopelessness. I think this skill of careful disagreement can be especially useful when it’s implemented in two steps. When I don’t mess it up, these disagreements can sound like this:

Client: I’m going to give therapy my best, but honestly, nothing has ever worked. It’s hard to imagine that after trying therapy for 10 years, this will be different somehow.

Therapist: 10 years. I can’t even imagine that.

Client: Yeah, it’s pretty hard to get that across to people. I’m just one of those rare cases where you can’t make any real improvement. I mean, those cases exist, right? I just happen to be one of those cases.  

Before getting into the heart of the disagreement, I want to mention how helpful the phrase “I can’t even imagine that,” can be. When I was learning to become a therapist, I worried that unless I shared similar experiences with my clients, they would view me with suspicion. I was concerned they would think of me as someone who “doesn’t get it,” and I’d be exposed as the imposter I was convinced I was. I didn’t handle these insecurities well. Instead, I exaggerated the breadth of my own life experiences. The good ol’ therapeutic skill of misleading clients. A classic. I would find ways to connect my client’s experiences with my own, even when there weren’t real comparisons to be made. I hoped that this would reassure my clients that I was qualified to help them, but mostly, it allowed me to hide my imposter syndrome behind my flexible autobiography. In therapy, this was my hiding spot.

I eventually learned that it was better to handle my insecurities by acknowledging when I couldn’t relate. Not lying, I call it. A cutting-edge intervention, I know. But it wasn’t realistic to expect myself to contain the totality of human experience within my past, and when my clients thought our histories were more similar than they were, I was taking too many steps away from sincerus. For me, this style for building rapport was too far from “whole, pure, and clean.” Not only was stretching the truth of my personal history unethical, but I also risked that my clients could be left with the sense that their pain was unexceptional. “I’ve been there before,” didn’t necessarily carry a reassuring ring to it.

But once I accepted that my clients would experience many problems I would never experience, it became easier for me to tame my imposter syndrome. The truth is that personal experience isn’t a prerequisite for clinical competence. Instead, I think it’s better to share with my clients when the depths of their difficulties are hard for me to imagine experiencing. In the case of depression, most clients already know that most people haven’t felt the depth of depression’s deep waters, but when they hear that I know this too, something paradoxical happens — they know they’ve been heard.

Okay, enough about my poor character. I want to move back into the transcript. Here’s how the beginning of how cautious disagreement can occur:  

Therapist: Hm. That hit me a little different than I expected. Let me get some feedback from you, is that alright?

Client: Yeah, go for it.

Therapist: Well, I’m feeling two different things. The first is that I’m hurting for you. You’ve been through so much. But the other is when I hear you talk, I also feel this sense of protectiveness within myself. It’s like an urge to protect you, against you. I’m not sure you’re very fair with yourself. What do you make of that?

Client: Look, I don’t think I need your protection. I’m just saying I don’t think things will get better.

Therapist: Right, after trying therapy for 10 years, improvement sounds unrealistic.

Client: Bingo.  

Two things are going on here. The first is that I’m expressing disagreement by sharing my own feelings about their hopelessness. This is Step 1. There’s nothing to be gained by debating with my clients about whether they’re truly beyond help. This can leave them feeling less understood. But when I express how I feel about their hopelessness, this allows me to disagree without being disagreeable. For me, there’s usually a feeling of protectiveness that emerges, but sometimes there’s a feeling of sadness inside me, too.

There’s another part that I try to keep in mind when disagreeing with clients in their depressed state, and I think it’s the most important: I express my own hope about their situation. This is Step 2, and sometimes it sounds something like this:

Therapist: I gotcha. You know, if I’m honest, I wouldn’t ask you to feel hopeful at this point. My fear is it might feel too risky — like a setup for another letdown, and things have already been hard enough.

Client: Yeah, I’ve been through that. Having hope, and then things not working out. Done that several times.

Therapist: With all you’ve been through, not reaching for hope makes sense to me. I guess I’d like to share that in the meantime, I’ll be hopeful for the two of us. Maybe if you start seeing small improvement later, then you can join me, but for now I don’t want you to have hope. I can carry that part for us both.

My hope is that showing my clients that I understand why they’ve rejected hope can be an unexpected act of kindness. This might seem like a strange way to be supportive, but for many clients, I think hope can feel too vulnerable. Allowing themselves to become excited about the possibility of feeling better can seem risky, and so I encourage them to continue protecting themselves. But I also tell them that in the meantime, I’ll be hoping for the two of us. This lets them know that while I disagree with them about their prognosis, I won’t debate the matter — in our disagreement, I’m still on their side.    

Preventing Depressive Takeovers

That is how I practice expressing disagreement with my clients in their depressed states, but I think managing my private disagreements is just as important. Here is what I mean. I think disagreeing with my clients about the hopelessness of their improvement within myself is a precondition for honest therapy. How could I work with a client if we both agree that they’re beyond help? But in some cases, this private disagreement is a fluid process. There might be sessions when I find myself more optimistic about the client’s progress, and other sessions, less so.  

I think it’s important that when I find myself feeling less optimistic, that I treat this feeling with extreme caution. Hopelessness operates the way that yawning does – when one person yawns, others in the room will involuntarily follow. Hopelessness can also move across the room, and when spending hours in the presence of client hopelessness, it can spread across the therapeutic relationship and into myself. If I’m not careful, I can become worn down, and then I can become pessimistic about the client’s prognosis. When I join in the client’s hopelessness, I haven’t influenced the depression, but instead the depression has influenced me. The therapy itself has undergone a depressive takeover.

A depressive takeover is a phenomenon where a client’s distress spreads to the therapist over the course of therapy. The problem with these takeovers is that if I allow them to occur, my clients can sense that I share their pessimistic outlook, and this can reinforce their preexisting despair. Fortunately, I think there’s something that can be done to prevent this from occurring.

To prevent depressive takeovers, it has helped me to notice the connection between my being emotionally absorbent and the contagiousness of hopelessness. In my view, the more I’m sensitive to experiencing the feelings of others more generally, the more susceptible I am to the contagion of hopelessness. This means that there are rare moments in therapy when, for the sake of my clients, I attempt to become less emotionally porous. I try to shut my inner doors, and to absorb less of their experience.

To do this, I inwardly recite a phrase when I notice that I’ve started to feel pessimistic about their prognosis. I tell myself: that’s your mental health, not my mental health. Reciting this mantra in the privacy of my mind allows me to distance myself from my client’s experience. Creating this internal limit creates a pushing-away feeling, and it helps me close my emotional doors. It’s an empathy reduction exercise. When I create this distance from my clients, it helps me stand apart from the pull of hopelessness, prevent a depressive takeover, and remain hopeful for the two of us.   

The Arrow and Shield

Frank was 75 years old, and he’d never seen a therapist before, but he started saying things that made his adult children nervous and so they convinced him to speak with me. When he walked into my office, he got straight to the point. He told me he was ready to die, and shortly afterwards, he told me his name. Frank spoke with energy, “I’ve lived a full life. I’ve had children, grandchildren, and a lovely wife who died 10 years ago. The truth is that I’ve had everything I’ve ever wanted.” He continued, “I don’t want to get much older than this. I don’t want to become less recognizable to myself. I don’t want my kids to have to deal with that either.”

I was perplexed. It seemed like Frank’s desire to die was coming from a place of focused reflection. He wasn’t tearful, nor was he numb — he was grateful. I wasn’t sure if he was making a rational calculation about ending his life, or if he was under the influence of a depression that was undetectable to me. I took a breath and responded, “Frank. I’ll be honest with you. I’m not sure what to make of what you’re telling me, and I’m not completely sure how I should proceed. I’ve never been 75 years old, and I imagine it’s quite difficult, but I’m not sure if your wish to die is related to an underlying depression or not. If I take your word for it, I run the risk of overlooking this possibility, and that worries me. I hope this doesn’t sound too dismissive.”   

Frank nodded and I continued, “You mentioned you don’t want to put your kids in the position of helping you age. Can you teach me about that?”

“That’s big for me. I’m no use to anyone anymore. My kids are raising their kids, and they shouldn’t have to care for me, too. I can’t really give to them anymore; I can only take. I’m burdening the people I love the most.”

The word burden flashed in my mind. I felt a hunch and I wanted to test it. “Frank, this simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering that if you were depressed, if you might hide it from your family. Maybe you’d worry that, in addition to your age, this would burden them, too. I’m only saying this because if you’re trying to protect your family by keeping things private, I’d hope you’d relax your protective nature with me. But tell me what I missed.”

We sat in silence as Frank looked out the window behind me. He clamped his palms together, cleared his throat, and we restarted the conversation.

Over the course of my therapy, I think it’s been useful to pay attention to the word “burden.” I’ve come to believe that this word, and the emotional experience to which it points, is the first part of suicide’s moral calculus. When my clients begin to think their existence is hurting others, being alive can start to feel like an ethical dilemma. “Should I stay alive if it harms those I love?” they might wonder.

This guilty feeling can become more dangerous when it’s coupled with a strong desire to protect their loved ones. I think this is the second part of suicide’s moral math. While suicide might look selfish from the outside, from the inside, clients often perceive suicide as the way to protect their loved ones from themselves.

With many of my clients who have survived their suicide attempts, they often express that while they were afraid of dying, it was their protective instinct that pushed them beyond this fear. From their vantage point, suicide was the right thing to do. They believed they were hurting their loved ones, and it was their responsibility to protect them. From within their suicidal mindset, many of my clients considered themselves both the arrow and the shield. It was the pulse of a self-sacrificing ethic that motivated them.    

***

As I look back at the therapist I was “back then,” and the clinician I have become, I realize that once I better understood depression and the moral dimension of suicide, this gave me something to work with in therapy. I learned that when my clients expressed the five depressing truths or when they believed they were a burden, there were things I could do to help. I could start by gently disagreeing with their hopelessness, disagreeing within myself to prevent depressive takeovers, and disagreeing with my clients when they’re convinced their loved ones should be protected from themselves. I am no longer terrified when the specter of suicide enters the therapeutic relationship.

Editor’s Note: In the next installment of this five-part series, the author will address strategies to address despair in therapy.    

Psychologists Struggle Too: How Shame Keeps Us Silent

Posted on by Psychotherapy.net Team

Nothing breeds shame more than silence. If something is not spoken about or represented in our systems (e.g., family, workplace, industry), it can be considered wrong. This is why I have devoted my life to speaking out about mental health and, more recently, done so on a public stage as a psychologist who has experienced mental illness. I want to demystify the experience of mental illness in mental health professionals so they don’t suffer in silence, because we are, like the rest of the population, only human. However, it hasn’t always been that way for me.

Back in the 80s and 90s, when I was growing up, there were no representations or discussions of mental health or mental illness within the systems I was exposed to. The only thing you did hear was people being locked up because they were “crazy” or hearing the message that “you are weak if you have a mental illness.” And no one was talking about looking after their mental health, only physical health.

Struggling with Depression

So, when I struggled with my own mental health and eventually experienced clinical depression in my early 20s, I had no idea what was going on, and I didn’t dare speak up for fear of being seen as “less than.” I only received help when my partner contacted my parents for help, as he didn’t know what to do. While I did recover, I did so mostly on my own. I didn’t talk about it to others. I held a lot of shame for being depressed for many years.

Fast forward to my early 40s, early 2021. The world has changed drastically with how mental health and illness are represented and discussed, and I have about 20 years of study and working in the mental health arena under my belt. I now know differently that mental health is essential to care for, and mental illness is not a sign of weakness.

But despite all this, I once again suffered mentally, that time with a combination of burnout, vicarious trauma, and compassion fatigue. You would think that I would have reached out and spoken about my struggles this time with all that I knew and had learnt from my previous experience, but I kept quiet. I didn’t dare say anything because, once again, I felt deeply ashamed.

I felt ashamed and suffered silently for a couple of reasons. First, I believed that psychologists shouldn’t get mentally ill. I thought that, as a psychologist, I should have known better. I should have been able to prevent it. I thought that it somehow meant that I was not a capable psychologist. The other reason that compounded the first was that there was no representation or discussion of psychologists becoming mentally ill or working while managing their mental health or mental illness.

None of my peers, mentors, or senior psychologists ever discussed it. It was all under the radar and not out there for all to see. Outside of encouraging us to care for ourselves and seek professional help when needed, no psychologist or mental health professional I came across in training spoke of their own experiences of mental health struggles. Most likely, they didn’t feel safe to do so because nobody did for them. It wasn’t normalised or validated enough to feel safe to talk about it.

Speaking Out and Sharing Humanness

I only started speaking out about my mental health struggles as a psychologist when I began seeing a supervisor who could provide an environment where I felt safe to disclose my struggles. She was different from other supervisors I had. She was interested in my experiences and what was going on for me in the context of my work. She helped me to recognise my mental illness and take the necessary steps to recovery. She never made me feel like I was “less than,” nor did the psychologist I eventually saw for therapy.

More importantly, they both shared their humanness with me, their struggles, enough to help me debunk my belief that psychologists should be able to prevent their own mental illnesses. These experiences gave me the courage to share mine more with others, and as I did, I discovered that many psychologists and other professionals were also struggling with their mental health and changing how they worked to care for their mental health. It helped me drop the shame I had held for being a psychologist with mental illness.

Having had such a powerful experience of having my mental illness normalised by other people in my field, it became a passion of mine to pay it forward; to continue to change the culture of mental health professionals to one where we can talk freely about our mental health and what we need to take care of it; to recognise mental illness and support each other through it. I now share my mental illness story wide and far through various mediums, writing blog articles, appearing on podcasts, producing a lived-experience podcast, publishing my memoir, and providing therapy to fellow clinicians and others from different professions suffering from burnout.

I still fear sharing my story with fellow psychologists. I know this comes from being someone out on the fringe of my profession speaking out about this, but more robust than my fear is my compassion to help fellow mental health professionals drop any shame with struggling mentally. I can do that by sharing my mental illness experiences and mental health struggles. I don’t want another fellow psychologist or anyone to suffer in silence. We are only human.

Virtual Treatment of Eating Disorders and the Importance of Human Connection

Posted on by Psychotherapy.net Team

Be the person you needed when you were younger

-Ayesha Siddiqi

The Virtual World

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

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

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

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

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

The Young Anorexic Client

The sound machine is roaring.

Two boxes appear on my screen.

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

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

Finding Connection

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

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

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

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

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

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

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

The Young Adolescent Client

The session starts the same.

Two screens.

Sound machine whirring.

I will call this client Abby.

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

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

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

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

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

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

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

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

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

Soccer!

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

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

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

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

References

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

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

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