Category: Therapeutic Issue

The CORE Approach to Therapy: Helping Jennie Find Resilience

Posted on by Psychotherapy.net Team

A 58-year-old CT scan technician at a local hospital, the youngest of three sisters, and a recovering alcoholic, Jennie came to therapy four months after healing from surgery to repair an atrial septic defect, one of two major congenital holes in her heart. The repair of one of the major defects, and other secondary repairs had been done during Jennie’s childhood. When we began her treatment, Jennie was about three months into a second episode of sobriety after a relapse prior to heart surgery.

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As Scott Miller’s research into therapeutic effectiveness has taught us, the relationship is the key variable in virtually any modality. With this in mind, I decided to utilize the CORE method with Jennie to develop a safe, trusting context in which a strong therapeutic alliance could develop. The method offers a schematic guideline for the utilization of intuition as a curative dimension, particularly in the treatment of trauma. The model is comprised of four components.

Connecting in a caring climate of calm and comfort

Orienting toward strengths, including inner wisdom

Resourcing resilience, evoking awareness of capacity

Establishing strengths that endure, including symbols and metaphors

Connection

When Jennie first came to therapy, my intent was to attune to her and to her story in a way that would communicate a sense of being heard and clinically “held.” My intention was to create an atmosphere of positive regard in which Jennie would experience acceptance and, with her nervous system sufficiently regulated, feel safe enough to address past painful memories and traumatic events of the past. My strategy was to build a connection with attunement to Jennie’s frame of reference, her beliefs, and her presentation and language, to create a context in which Jennie might better understand events of the present.

As our alliance flourished, I would look for opportunities to offer trance, possibly with a lengthier induction, but maybe a short absorption, in which Jennie might find latent or cut-off resources she could apply in future situations. In this way, I was able to help her to identify and integrate new resources in the service of managing her emotions and behavior in future situations.

For the first two sessions, I mostly listened to Jennie’s story, affirming the trials and problems she revealed. In doing so, I gently guided Jennie to express as clearly as she could what she hoped to get from her therapy. Although I didn’t know at first, or even at the start of any particular session how exactly I might utilize methods of hypnosis and trance in combination with ideas arising from my intuition, I hoped that the strength of our connection, characterized by validation of both Jennie’s struggles and her strengths, would ultimately lead her to recognize and absorb a belief in her own resilience and achieve her clinical goals.

I trusted that as I listened to Jennie’s story with compassion, attuned with an empathic gaze, and validating responses, that I would pick up both overt and minimal cues of what was most important for her. I also believed that as I scanned the impressions arising from my clinical observations, I would recognize cues for what might be needed to help her learn to recognize and shift into a state of calm when sympathetic arousal overwhelmed her emotional boundaries, and what points would stand out for me for utilization of trance.

It did not take long for Jennie to come to her goals. She wanted to deal with cumulative stress that would “pile up” and lead to “rage that can get out of control.” During exploration of her major life stressors, Jennie reported a difficult under-staffed work setting as well as on-going communication problems in the family of origin which included at the time a terminally ill brother-in-law and misunderstandings between herself and her two older sisters, Naida and Meg, that often involved the oldest sister’s daughter, Marcia, a niece who was close to Jennie in age and whom Jennie considered a close friend.

Although Jennie’s life partner, Tony, was dealing with a terminally ill mother, this added stress in Tony’s life was not causing conflict in their life together. From all reports, this primary relationship appeared to be a stable area and an island of support for Jennie. Clearly, she was more likely to be triggered into anger by relationship disturbances with her siblings or with coworkers when differences of opinion resulted in disagreements and distorted perceptions.

Such interpersonal static would cause Jennie to question her understanding of a situation, trying often with difficulty to determine her part in the problem. Often, the aftermath would be distance from her niece or from a sister or might form resentments toward a co-worker that could affect her morale and threaten her sense of competent efficiency at her job.

While Jennie reported no incidents of physical violence toward anyone with whom she would get angry, she expressed high motivation to learn to refrain from lashing out and making disagreements into larger issues that would disrupt contact with her sisters and leave her feeling bereft and disappointed in herself.

These types of painful emotional episodes reminded Jennie of the dysfunction and traumatic chaos caused by alcoholism in her family of origin. She wanted to understand how the old images, left-over impressions, and painful memories of the past affected her in her relationships now.

In the service of self-differentiation, Jennie longed to understand her personal role in these painful experiences. As therapy progressed, Jennie became even more consciously motivated to find strategies for reducing the emotional/somatic arousal that would break through her conscious intent to refrain from lashing out.

Orientation: Toward Strength and Inner Wisdom

My realization was that an inner wise intelligence was available for utilization as part of problem solving, and in this case, specifically for healing trauma via re-association of cut-off strengths and resources.

It seemed both clinically and intuitively advisable to consider orienting Jennie toward her strength and helping her to access via her intuitive, inner wisdom. Jennie, I intuitively hypothesized, would benefit from an approach that would utilize trance and also provide some solid stress management skills. Both the intuitive and the practical would serve to guide Jennie toward the resources she wanted for managing both her emotions and her behaviors, particularly during interpersonal stress and conflict. Like every feature of CORE, intuition would be best accomplished with the CORE features of an approach that would access the non-conscious processes of the intuitive dimension of mind to remind Jennie of strengths she had already used in her life, and access dormant and latent strengths that were, for the moment, dissociated from a consciousness plagued by conscious as well as subliminal memories from her past.

First Intuitive Impressions

As therapy began, so did both overt and minimal cues as well as intuitive impressions. My first initial postulation, based on Jennies wide, welcoming smile, was that she had relational resources she was evidencing, but not fully aware of. I sensed based on the way she connected on screen, face-to-face, eagerly listening to what I chose to say, that Jennie might be open to the focused attention of hypnotic trance, with or without eyes open. While later this proved to be true, at first it was more of a hunch as she was readily beginning to let me know her by revealing a background history of emotional neglect, family conflict, and multiple complex losses, as well as the recent operation to correct a congenital heart defect.

It did not take long for a certain current situation in Jennie’s work life to give me a chance to test out my hypothesis. The idea for the experiential moment came intuitively in the third session. I was working on two channels, the intuitive and the clinical, listening to Jennie, and paying attention to her non-verbals. I was also scanning my own hypotheses. As I was also sorting out clinically what direction I might go in next, Jennie’s narrative gave me the inspiration, an intuitive idea.

Resourcing Resilience

I was able to guide Jennie toward the realization that inner strengths existed and could be available — in this instance, using a brief trance and metaphor, as well as a dissociative moment in the service of integration of strengths.

Jennie revealed that in the imaging department, a complaining and underperforming co-worker was “driving me crazy!” (I was now in intuitive territory). Extremely conscientious in her work, Jennie could feel her anger brewing and escalating as the co-worker’s poor work ethic and performance was leaving her overwhelmed and frustrated. Jennie was adamant that she did not want to lash out or do anything to cause problems for herself at the job, as had happened in other situations in the past. She wanted some help to calm herself so she could cope in a different way.

“Just ignore this person and go about your business,” might have worked for some people, but Jennie’s anger was deeply embedded in her emotional and operational self. I intuited that reaching her non-conscious intuitive mind was the way to go.

“I am so angry when I go in and I see her! I feel like I am just a bitch!”

In that moment, I remembered her history of conflict with two older sisters who had blamed Jennie and called her a bitch! I also knew Jennie had not just a broad smile, but a way of seeing the world with humor. How to externalize this self-denigrating sense of herself was the intuitive question — the answer came quickly and surprised me with its humor and potential to utilize Jennie’s sense of humor — without formal trance. I also knew that I was going to trade in what had felt like a positive alliance.

“Jennie, I have this idea and you can tell me if it seems too odd. (She agreed to hear the idea) Have you ever seen a spray perfume bottle?”

“I just happen to have a very fancy one,” Jennie replied.

“What if you imagine that it is filled with a perfume called “Eau de Bitch?” And you can imagine that you can spray it all around when you go into work, so you know it’s just in the air and it’s not in you!”

Now chuckling, she said; “I love that idea!” I’m going to do it!

Evoking Endurance

“Well, let’s take it one step further, okay? You could also have another imaginary bottle that could be for you. This one could be sprayed in the air like an air cleaner, or on you like perfume. This one could be called “Eau de Calm.”

Now fully belly-laughing, Jennie reported that she was actually going to use the real spray bottle for “Eau-de-Bitch.” She later sent me a picture of the bottle and reported at the next session that not only did she no longer feel bothered by the co-worker, but Eau-de-Bitch could also be a go-to when she was upset by her sisters.

***

Over time, using intuition in my work, and teaching others how to use this psychic dimension of mind, I have learned that although people might understand the concept of what intuition is or can be, may clinicians want something more concrete about how to utilize intuition in the clinical setting — or in life.

[Editor Note: “Jennie” has given the author permission to share her story on psychology platforms for teaching purposes.]    

A Shared Diagnosis: Managing Breast Cancer Together

Posted on by Psychotherapy.net Team

Over the course of my treatment for breast cancer, I found myself feeling professionally challenged in many ways. But the most significant source of my growth as a therapist during this time came from the fact that I was following in the path of one of my own patients, Jessica Chin (a pseudonym). She was diagnosed with breast cancer in 2019, and three years later I would receive the same diagnosis while she was still in treatment with me. At my request, and with homage to Irv Yalom’s Every Day Gets a Little Closer, Jessica shared her thoughts (in italics) throughout this essay. Working together was a privilege and it is my hope that our combined voices will serve to deepen the conversation about the potential impact of a therapy relationship for both patient and therapist.

In our profession, we rely on our ability to treat people who differ from us in a variety of ways. Our training and our capacity for empathy allow us to develop deep connections with patients despite differences in such things as age, gender, and ethnicity.

In contrast, my experience with Jessica highlighted for me the complexity and power of having a shared experience with a patient.

Working Therapeutically in Uncharted Territory

Jessica first came to my office in 2012 to discuss generational issues in her Asian family. Through our work, her self-esteem improved. She found her own voice and was able to extricate herself from the family business, marry, and move to another state. We ended our work together after four years, and both felt encouraged by her progress and the prospects for her future.

Unexpectedly, three years later, she was diagnosed with breast cancer at the age of 35 and reached out to me seeking to resume therapy. Her prognosis was good, but the road ahead was scary and fraught. She had chemotherapy, followed by surgery, and then radiation. Although she and her husband had decided that they did not want to have children, the fact that her treatment would lead to early menopause and the consequent side effects was a harsh reality to absorb.

When I was diagnosed, I immediately thought of reaching out to Maggie. I thankfully had family and friends to lean on, but I needed support from someone that understood the nuances of my family and personal history and how it could impact my treatment and wellbeing. I also needed an outside perspective to help navigate my treatment. Genetic testing revealed I have a positive gene mutation which meant I could choose a bilateral or double mastectomy rather than a lumpectomy and radiation. There was also data suggesting those who carry this genetic mutation might have a higher chance of breast cancer recurrence if exposed to radiation. I spent most of my sessions with Maggie weighing pros and cons and what if's. She regularly advised me to make the decision that was backed by data and to lean into what felt right to me. There would be what if's no matter what — only I knew what I could manage during this time and to hold onto that. This advice grounded me in my personal and medical decisions throughout treatment and to this day.

I had been in practice for over 30 years at the time of Jessica’s diagnosis, but I had almost no experience working with patients who were actively undergoing cancer treatment. Even more surprising, despite the prevalence of breast cancer (1 in 8 women in the United States receive a diagnosis of breast cancer over the course of their lifetimes) I had never had a patient undergoing treatment for breast cancer while in my practice. My instinct was to help Jessica hear her own voice through the cacophony of advice she was receiving and support her while she had a multitude of difficult decisions to make.

My knowledge of Jessica’s background and complex family dynamics from our prior work together gave me a benchmark against which to assess the changes in her mood and outlook. As is common for people with a life-altering diagnosis, she became more intolerant of “wasting time” and pushed back against familial and cultural expectations for her to be compliant in her role as a daughter, woman, and patient. I supported her through all the phases of her treatment and then shortly thereafter found myself facing a similar diagnosis.

A Therapist's Cancer Experience Shapes Treatment

  From a routine mammogram screening in December of 2022, I was diagnosed with breast cancer. This was terra unfamiliar for me, but fortunately my prognosis was excellent. I scheduled my surgery during the week between Christmas and New Year’s, a period I had already arranged to be off.

My original plan was not to tell my patients of my diagnosis,  but after surgery it was determined I would need chemotherapy. Being immunocompromised, I would have to end in-person sessions, and anticipating a radical change in my own appearance, I decided to tell my patients about my cancer.

As I thought through my caseload, each patient brought different concerns to mind about how they would handle this news. Their concerns ranged from fear of losing me to death or retirement, or to the worry that their issues felt insignificant in comparison to my situation. I felt confident that I could work through the ups and downs with each patient.

Jessica was the patient I most dreaded telling. She would know from personal experience what I was facing, and I was concerned that my diagnosis would overwhelm her. 

At the time of my diagnosis, she had just entered the maintenance part of her treatment. I wasn’t sure what would happen to the boundaries between us as my treatment began to replicate hers.

When Maggie told me about her diagnosis, I was shocked and sad. My heart sank thinking of her going through the gamut of appointments, ultimately robbing a year of her life. From what she shared, I understood from a high level what this meant logistically and what it could possibly mean physically, mentally, and emotionally as each cancer experience is so unique. I wasn't surprised Maggie would keep seeing patients during her treatment from what I knew of her, plus, it would help to keep life “normal.”

I was wrong to worry about sharing my diagnosis and treatment with Jessica. Our boundaries did shift, and the sessions changed but I believe in ways that were beneficial to both of us. Being open to receiving from her was the beginning of my learning. She began to recount her cancer treatments with more details than she previously had shared. And I had a context to understand her references which I lacked before my own treatment. There was a clear shift in our roles as she became the teacher, sharing her experience. Despite being almost twice her age, I found Jessica’s personal understanding of cancer treatment deeply affirming of my own experience. Remarkably she was the closest person in my life at the time with a similar diagnosis.

Our sessions fell into a pattern: during the first ten minutes or so of each Zoom session, she asked me how I was feeling and together we discussed the ins and outs of whatever point in treatment I was facing.

It was initially uncomfortable for me to have so much of the focus on me but with time I came to appreciate how helpful our sessions were for both of us. In contrast, I also had to process my feelings about patients who never asked how I was feeling or showed any interest in my well-being. I didn’t want to bring any more attention to myself than I already had by sharing my diagnosis, but each patient’s response to my diagnosis revealed something about them and our relationship.

As Jessica learned about my experience, she was prompted to address how she felt during her treatment.

I didn't want to be evasive, asking how Maggie was doing during our sessions. I was genuinely concerned and didn't want her to feel like she owed me more of an explanation because of a shared diagnosis. I'd cautiously ask questions, not wanting to overstep personal boundaries. During certain points of her treatment, I'd share some of my experiences with Maggie, with the hope that it would serve as a form of support, and she wouldn't feel alone. Cancer is so lonely. If I could offer Maggie even the slightest amount of comfort, it would be an honor and a gift to do so.

Before my last chemotherapy treatment, she warned me that I would have to “ring the bell,” a customary ritual at the end of chemotherapy. She knew me well enough to know this was not something I would welcome. She had never talked about this experience before, and it led to an exploration of her feelings about how powerless she felt as a patient to say, “No.”

Our increased understanding of each other helped me personally, but it also helped me be a better therapist for Jessica. The nuances of our work deepened as we grew closer and her voice continued to get stronger, to the point that I felt comfortable enough to ask her if she would like to participate in writing this essay. I trusted she would be able to give an honest answer.

A significant way our treatment protocols diverged was that I was offered cold capping with my chemotherapy treatments to help prevent hair loss. In the end my hair loss was negligible which was a huge relief to me. Jessica, by contrast, lost all her hair during chemotherapy; this loss prompted many sessions focused on her distrust of her body and her despair over her altered appearance.

By the time of my diagnosis, Jessica’s hair had grown back, not exactly as it had been before treatment but sufficiently that the change was not obvious to a casual observer.

As she witnessed my lack of hair loss, she spoke in greater detail about her own ordeal of losing her hair, being fitted for a wig, and the physical discomfort of her hair growing back. We talked about the financial burden of a cancer diagnosis and the lack of insurance coverage for “cosmetic” concerns such as hair loss. Our shared knowledge base deepened my ability to support her unresolved anger with the medical system. Her need to fight the insurance company for access to care is an ongoing source of stress for her.

Cold capping was presented as “nice to have” and questionably effective for my treatment plan. That, coupled with it not being covered by my insurance, was disappointing. I was surprised cold capping was presented as a positive option for Maggie and was intrigued what the results would be. I hoped the cold capping would work and she'd be spared the physical and mental trauma of losing her hair. I was thrilled the cold capping worked for Maggie and equally enraged this is not a standard part of every woman's treatment and insurance plan.

The difference in our age was most pronounced in discussions about long-term management of our cancer diagnosis. As a young woman, Jessica is facing far more extensive interventions and questions about how to stay cancer-free without compromising her health in other ways. As she continues to grow professionally, she also has to contend with issues related to maintaining her health insurance coverage. As someone on Medicare and nearing the end of my professional career, I have more autonomy in making decisions about my work-life balance.

Since resuming our work together, Jessica’s father has died and there have been other major transitions in her life. Separate from our shared experiences around cancer, we have done some important work about managing grief and setting limits with her family of origin. Even when we are not directly talking about her cancer, it is a reality that colors the conversation.

In a way, our shared cancer experience has allowed me to open up more to Maggie during our sessions. I've felt comfortable and trusted her throughout the years, but something has changed. I feel strongly this has been instrumental in working through the grief of losing my father.

There was something profoundly different in my work with Jessica since my cancer diagnosis from my work with any other patient. As I gain more distance from my cancer treatment, we have shifted away from the weekly check-ins. But she will always be at the forefront of my mind, and gratefully so, when I think about what it was like to continue to practice through my cancer diagnosis and treatment.

***   

Allowing our patients to know us, let alone directly help us, is a controversial topic in the field of psychotherapy. But sometimes life intervenes, and we have to adapt. I am glad I continued to practice during my cancer treatment. As Jessica said (she also worked throughout her treatments), it helped keep a semblance of normalcy in my life while allowing me to feel like more than just a patient. And I move forward with confidence that I am a better therapist for her and other patients who might follow in our shared diagnosis.
 

Questions for Thought and Discussion

  • How did the therapist's approach to her client resonate with you?
  • What are the advantages and disadvantages of sharing such Personal, and in this case intimate, information with a client?
  • If you have had a personal circumstance that converged with those of your client(s), how did you handle it?  

Containing The Adult ADHD Fad — With a Rejoinder from ChatGPT

Posted on by Psychotherapy.net Team

A sad and fairly ubiquitous aspect of human fallibility is that we are extremely suggestable suckers for fashion. Psychiatry is no exception — its history is littered with recurrent fads. The specific details vary, but the pattern is always pretty much the same.

Dangerous Psychiatric Fads

  1. Charismatic promoters identify a new and plausible diagnosis; do some second-rate research suggesting it “exists,” write a lot of papers, and give a lot of workshops and conferences.
  2. Media picks up the story, sensationalizes the “new findings,” and transforms lousy evidence into a vital new discovery.
  3. Whenever a potential pill treatment is available, Pharma marketing goes into an extravagantly financed, high-gear marketing mode — enthusiastically hyping the diagnosis and the medication in every possible venue.
  4. Benefits of the new diagnosis and treatment are widely publicized; risks and harmful unintended consequences are neglected.
  5. Primary care docs are especially targeted because they do most of the prescribing of psych meds, have the least training, and aren’t given adequate time to do careful evaluations.
  6. Patients are seduced by drug ads to “ask your doctor” about the diagnosis and the pill to treat it. “Asking your doctor” usually results in getting the medication.
  7. These familiar patterns of fad development are now greatly speeded up and given immediate worldwide distribution via social networking on the internet.
  8. Diagnostic rates rise exponentially in a very short time.
Some dangerous fads in medicine have lasted thousands of years (e.g. bleeding, purging, popular meds that turned out to be poisons). But most fads come and go fairly quickly once the risks of treatment become obvious and the over-promised benefits don’t pan out. As the excitement surrounding one fad wears off, suggestible clinicians and patients become enthusiastic about, and eagerly await, the next fad.

Cold Hard Psychiatric Facts about ADHD

Why The Explosion of ADHD Rates in Kids? We are in the midst of a 30-year fad of excessive diagnosis of childhood ADHD. Rates have tripled to about 10% — partly because DSM definitions have gotten looser — mostly because of aggressive Pharma marketing to MDs, parents, and teachers. How Do We Know That Rates of ADHD are Wildly Exaggerated in Kids? Studies done in a dozen countries on millions of kids have returned a remarkably consistent and disturbing result. All over the world, the best predictor of ADHD is the child’s birth date — the youngest kid in the class is almost twice as likely to get an ADHD diagnosis than the eldest. There is only one possible interpretation of this powerfully robust finding: ADHD is being wildly over diagnosed — we have turned simple immaturity into a mental disorder. Does ADHD Ever Occur in Adults? Yes, of course — because many kids don’t outgrow their ADHD symptoms once they become adults. The rate of persistent ADHD into adulthood varies widely across longitudinal studies — but probably about half the kids who have a childhood ADHD diagnosis continue to have clinically significant symptoms in adulthood. When the symptoms do persist, they usually become milder with age (especially true of hyperactivity). Can ADHD Ever Have Its Initial Onset in Adulthood? The simple and very important answer is an empathic NO! By definition, ADHD has to have its onset in childhood. This requirement is absolutely necessary in order to distinguish true ADHD from all the many other causes of inattention and hyperactivity in adulthood. Why Is ADHD So Often Overdiagnosed in Adults?
  1. Almost all mental disorders and almost all substance addictions can perfectly mimic ADHD since they can cause its two classic symptoms — hyperactivity and trouble focusing attention.
  2. Real or imagined attention problems are a very common complaint among perfectly normal people.
  3. Getting an ADHD diagnosis is a gateway to legal speed — desired for performance enhancement, all-nighters for school tests or work assignments, recreational purposes, or for sale into the extensive secondary ADHD pill market.
  4. Careless diagnosis and prescribing by MDs.
  5. An inevitable consequence of overdiagnosing ADHD in kids is overdiagnosing ADHD in adults.
  6. Promotion via drug companies and social networking.
What Are Current Reported Rates of ADHD in Adults? In general population surveys, the prevalence of current adult ADHD is reported to be 4.4% (males 5.4%; females 3.2%). Estimated lifetime prevalence of ADHD in U.S. (United States). adults aged 18 to 44 years is 8.1%. These numbers are absurdly high — reflecting the fatal flaws in the survey method. These rates are determined by casual telephone interviews done by non-clinicians. There is no careful differential diagnosis to rule out all the many causes of inattention and hyperactivity that should not be labeled ADHD, and to ensure symptoms are of clinically significant severity and duration. What is The Real Rate of ADHD in Kids? The best guide to the “real” rate of ADHD is the view of Keith Conners, considered to be the father of the ADHD diagnosis. He did the first studies on ADHD (even before there was an official DSM diagnosis called ADHD), and continued throughout his long career, until his death a few years ago, to do the best studies and have the most influence on the field. Keith believed the most appropriate rate of childhood ADHD would be about 2-3% and about half that number in adults — just a very small fraction of the inflated rates now reported. Risks Of Overdiagnosing ADHD in Adults:
  1. Meds used for ADHD are usually quite harmful if the person’s symptoms are due to another psychiatric disorder that has been missed — especially bipolar disorder, depression, schizophrenia, eating disorders, or anxiety disorder.
  2. Overdiagnosis of ADHD results in over-medication with drugs that cause harmful side effects and can lead to or worsen addiction.
  3. There is now a huge secondary market for ADHD meds, especially on college campuses.
  4. There is also a nationwide wide shortage of ADHD meds for patients who really need them — because the meds are so often prescribed for those who don’t or diverted to the illegal market.
Proper Differential Diagnosis of ADHD In Adults Before ever making a diagnosis of adult ADHD, there must be a careful evaluation that:
  1. Rules out the possibility symptoms are caused by another psychiatric disorder, substance use, drug side effect, head trauma, or another neurological or medical illness.
  2. Determines that the symptoms had their initial onset in childhood — adult onset of symptoms rules out ADHD.
  3. Ensure that symptoms are severe and persistent enough to cause clinically significant distress and impairment. Most people worry about their ability to focus — this is not sufficient evidence to diagnose mental disorder. Many people have transient episodes of inattention or hyperactivity due to everyday stress — this is also not adult ADHD.
  4. Consider the risk of malingering to get legal speed for performance enhancement, recreation, or resale.

Bottom Line

Most of what looks like adult ADHD is not adult ADHD. Distractibility is ubiquitous in the general population — most of it is normal; sometimes it’s caused by another psychiatric or medical problem or substance use. People who didn’t have ADHD symptoms in childhood should not be diagnosed with ADHD as adults. ADHD drugs are unsafe except when carefully used for accurately diagnosed ADHD. They are currently in short supply for appropriate use because they are so often used inappropriately. ADHD drugs are useful when appropriately prescribed for the few, but harmful when carelessly prescribed for the many. It is past time to stop the adult ADHD fad before it gains even more traction. The harm caused by the adult ADHD fad is great, both for the individual and society. Easy access to legal “speed” has created a large illegal secondary market of diverted pills. ADHD drugs have become the campus recreational drug of choice at parties and the performance-enhancement drug of choice for all-nighters during finals week. Legal speed can cause many medical and psychiatric adverse effects, and emergency room visits for complications are skyrocketing. The Drug Enforcement Agency and the FDA are now trying to contain the epidemic — but their efforts are too little/too late. The adult ADHD fad will be stopped only if clinicians and patients fight against its seduction and insist on more careful diagnosis and cautious treatment.

ChatGPT Asked the Same Question

[Editor’s Note] Once again, Dr. Frances’ granddaughter posed the same question to ChatGPT with the prompt: “What are the dangers of diagnosing ADHD in adults and how best to avoid them (in 500 words)?” “Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in adults comes with its own set of challenges and potential dangers that need to be carefully considered. While accurate diagnosis can provide individuals with the appropriate interventions and support, the risks associated with misdiagnosis or overdiagnosis are significant. To avoid these dangers, a comprehensive and cautious approach is crucial. Dangers of Diagnosing ADHD in Adults
  1. Misdiagnosis: ADHD symptoms can overlap with those of other mental health conditions such as anxiety, depression, or even medical conditions like thyroid disorders. Misdiagnosis can lead to inappropriate treatments and exacerbate underlying issues.
  2. Stigmatization: An incorrect diagnosis can lead to stigmatization, where individuals might feel labeled or misunderstood. This can negatively impact self-esteem and overall mental well-being.
  3. Overmedication: Misdiagnosis may result in the unnecessary prescription of stimulant medications, which are commonly used to treat ADHD. These medications can have side effects and may be harmful if taken without a valid reason.
  4. Self-Fulfilling Prophecy: Once diagnosed, individuals might attribute all their challenges solely to ADHD, overlooking other contributing factors and hindering personal growth and development.
  5. Masking Other Concerns: ADHD symptoms might overshadow coexisting conditions like learning disabilities, which require specific interventions. Treating only ADHD could leave these underlying issues unaddressed.
How to Avoid These Dangers
  1. Comprehensive Assessment: A thorough evaluation by a qualified mental health professional is essential. This should include a clinical interview, medical history review, and collateral information from family members or close associates to ensure a comprehensive understanding of the individual’s history and current challenges.
  2. Consider Differential Diagnosis: Since ADHD symptoms can mimic other conditions, it’s crucial to explore the possibility of comorbidities. This might involve additional assessments, screenings, or consultation with specialists.
  3. Longitudinal Perspective: Assessing symptoms over time helps differentiate between chronic ADHD-related impairments and situational factors that might be causing temporary difficulties.
  4. Multimodal Assessment: Utilize a combination of assessment tools, such as self-report questionnaires, cognitive tests, and behavioral observations, to gain a holistic view of an individual’s functioning.
  5. Functional Impairment: Focus on the degree to which symptoms interfere with daily functioning in various domains, including work, relationships, and personal responsibilities.
  6. Psychoeducation: Educate individuals about the diagnostic process, potential pitfalls, and the multifaceted nature of their difficulties to prevent over-identification with ADHD symptoms.
  7. Second Opinions: Encourage seeking a second opinion, especially if the diagnosis or recommended treatment plan feels uncertain or uncomfortable.
  8. Collaborative Decision-Making: Involve the individual in the diagnostic process and treatment planning. Discuss the potential benefits and drawbacks of medication, therapy, and lifestyle modifications to make informed choices.
  9. Holistic Approach: Address physical health, sleep patterns, stress management, and other factors that can impact attention and focus. Sometimes, lifestyle changes alone can lead to significant improvements.
  10. Regular Follow-ups: Periodically reevaluate the diagnosis and treatment plan to ensure they remain appropriate as the individual’s circumstances evolve.
In conclusion, diagnosing ADHD in adults requires a cautious and comprehensive approach to avoid the potential dangers associated with misdiagnosis or overdiagnosis. A multidimensional evaluation, consideration of differential diagnoses, and involving the individual in the diagnostic process are key strategies to ensure accurate diagnosis and promote the well-being of those seeking assistance for their difficulties.”

***

Afterword from Dr Frances

The response from Chat-GPT is remarkably good, especially considering that it took it one second to produce while my piece took 90 minutes to write. But ChatGPT did leave out two critical issues:
  1. The requirement that ADHD cannot, by definition, be diagnosed in adults unless symptoms were present in childhood and why this is so critical.
  2. The societal impact of the adult ADHD fad.
All in all, I think my piece is better than Chat’s – but not by much!

When Clients Ask, “What Do You Want for Me?”

Posted on by Psychotherapy.net Team

“What do you want?”

We therapists are constantly asking people some version of this basic question.

  • What are you wanting to be different?
  • What are your hopes for yourself?
  • This difficult circumstance being what it is (and beyond your control), what do you want to be able to do in the midst of it?
  • This difficult person being who they are (and beyond your control), how do you want to relate to them?
  • What needs to happen?
  • What do you want?
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And people respond:
  • I want to feel less depressed.
  • I want to leave my marriage.
  • I want to stop drinking.
  • I want to feel happy.
  • I want to feel more connected to others.
  • I want to be less reactive and controlling.

Therapists Must Listen for What Clients Really Want


These answers become the guiding force that frames and energizes our work together. And as therapy progresses, and we keep asking “what do you want?” the answers and the focus of our work shift and deepen. “I want to feel happy” becomes “I want to interrupt my ingrained habit of always looking for what’s wrong.” “I want to feel more connected to others” becomes “I want to feel more connected with myself.” Or, “I want to be less reactive and controlling” becomes “I want to learn what it takes, and do what it takes, to feel safe in the world.” And beneath all these answers, beneath the “what do you want?” question itself, is one of the deepest questions of all: “What’s worth wanting?”

So, we keep asking, over and over, “What do you want?” And following our clients deeper and deeper.

Recently, a client turned the question back on me. I’d asked her some version of the question, and she’d responded with a thoughtful litany of hopes for herself and her life. But then she paused, tilted her head, and asked, “What do you want for me?”

Sometimes, of course, people ask therapists (and others) to guide and direct their lives because they lack confidence in their own inner compass. Perhaps they grew up with parents who sheltered them or micromanaged them, and they weren’t given space to grow that confidence. Or perhaps they entered adulthood trusting themselves, but a lot of things have gone wrong, and they’ve come to doubt themselves.

We therapists are careful about giving advice for lots of reasons, but this is one of the main ones: we don’t want, in an effort to help someone through a hard moment in their lives, to send a meta-message that we believe they can’t think and judge and make good choices for themselves. Quite the opposite: we want to respect and nourish people’s trust in themselves, their power to know what’s needed, and their capacity to choose and to act.

This woman, however, had demonstrated these abilities many times, in session and out. She was insightful, intuitive, and brave. So, I did not hear her question, “What do you want for me?” as a flight from responsibility: “Tell me what to do.” I heard it as healthy curiosity: “Tell me how you carry me in your heart.”

And so, I paused, took a breath, listened inside, and said to her: “I want you to be happy and powerful.”

I paused again, to see what else might be there. And I’ll pause with you, too, to say that, by “powerful,” I don’t mean CEO powerful or politician powerful. I mean the ability to gather and concentrate our energy, to plug the leaks that dilute us, and live from a strong and regulated stream of force.

I continued: “I want you to be faithful to who you are and what you know. So many people, you included, have been gaslit — by their parents, by friends, by their employer, by religion, by advertisers — and end up not able to trust themselves and their inner GPS. I want you to be a deep witness to the truth of yourself and your experience, to hear what your mind knows and, even more, what your body knows and what your intuition knows. And I want you to be able to live from all that.”

That was all. I paused and gave her space to absorb what I’d said and, if she wanted, to say how it had landed in her. She looked at me quietly, and I imagined she was doing exactly what I’d just said — listening to herself, weighing the truth of my words against the truth of her own knowing, and welcoming whatever she found trustworthy.

Then she said, “Thank you. I like that.”

And I said back, “Thank you. I like it, too.”

What I liked was twofold. It was, firstly, the experience of connecting with her, which I found deeply nourishing. And secondly, it was the sense I had that, spontaneously and concisely, I’d just articulated my view of what I hope happens for people who talk with me in therapy. I’m hoping they will grow in consciousness and in power. I want to help people witness the truth of their life — their outer life and their inner life — and, based on what they witness, to exercise agency, freedom, and choice.

I’ll close by asking you, therapist or whoever else you are, when it comes to the people you care for, what do you want for them?  

Narrative Therapy in a Cross-Cultural Conversation with Someone Approaching Death

Posted on by Psychotherapy.net Team

Acknowledgements

T?na koutou, t?na koutou, t?na koutou k?toa

Ko Ben Lomond t?ku maunga

Ko Loch Lomond t?ku moana

Ko McAllum t?ku iwi

No Kotorana ?ku t?puna, engari I haere mai ?ku t?puna ki Aotearoa nei

No reira ka mihi hoki au ki te iwi M?ori

Ko James Copeland t?ku t?puna

Ko Hamish McAllum t?ku p?pa

Ko Jan Hutchison t?ku m?ma

Ko Gavin Pilkington t?ku tane purotu

E rua ?ku tamariki ko Tim r?ua ko Ella

Ko Sasha McAllum Pilkington t?ku ingoa

No reira t?na koutou, t?na koutou

Kia ora t?tou k?toa

Thank you, Huia Swann, for your encouragement and feedback through the many iterations of this story.  

An Unexpected Beginning (1)

It was a busy morning at the hospice. I made my way into the community team’s office and was greeted with a buzz of activity. One of the nurses called me and I turned to greet her. In her hand was a referral letter.  

“Sasha, I was wondering if you would see this woman for counselling? Her name is Louise, and she has advanced lung cancer. (2) Louise is refusing all treatment. It seems someone thought she was ‘in denial’ but I saw Louise yesterday and she told me she’s ‘not having any chemo’ because she doesn’t think she’s worth it. Louise is M?ori, but she’s refused cultural support. Could you see her?” she repeated, as she handed me the letter (3).

“Of course,” I replied, disturbed by the thought that Louise didn’t feel she was worth treatment, but grateful the nurse had looked beyond the judgement that Louise was “in denial.” Before I could say any more, the nurse was summoned to the phone and with a smile, I left to call Louise.

A few days later I pulled up in a beautiful driveway. Plants nourished by an attentive hand surrounded the house in front of me. As I got out of the car, I saw a slight woman emerge into the sunlight. Her dark hair gleamed as the rays of sun caught it and, as I came closer, I saw she was smiling. Louise welcomed me warmly and, after I had removed my shoes, guided me into the house. We sat down at the kitchen table. Nearby stood a large kete (4) filled with driftwood, each piece carefully placed to reveal a story. Woven mats hung on the walls and outside I could see clusters of red berries hanging below the fronds of a nikau palm. Artistry was evident in creating this home and I looked around with admiration.

After some further introductions, Louise eased herself back in her chair and looked at me expectantly. Tentatively I responded to her silent invitation with, “People are so much more than the illness they are living with and their current situation. Would it be OK to begin, maybe, with me asking you a bit about yourself…so that I might learn a little about who and what matters to you?” (5) I didn’t name the illness as I didn’t know what language she preferred to use or how she might wish to speak about her experience.

Louise responded immediately. “Sure! I’m married to Pete and we have three children. They’re all really supportive, in and out of the house every day…”

Louise continued to share stories of her day-to-day life and I listened attentively, occasionally asking her questions so that I could learn more of what was important to her. I quickly learnt Louise was a hard worker and a committed parent. She made no mention of where she was from or her t?puna (6).

After a time, Louise paused and reached across the table to pick up a piece of paper. “Well, it’s lucky you’ve come to see me on your own.

I don’t like groups because I lie in them. I’m a liar,” she stated in a forthright tone, waving what I now realised was a support-group invitation from the hospice.

Struck by her honesty and trust in me, a stranger, I replied, “Would it be OK to ask what you mean when you say you lie?” (7) In my mind was an awareness that some truths are more easily spoken than others, and for some people it was unsafe to voice or live their truth.

Louise responded, speaking in rapid buoyant tones, “Oh, I say what I think I should in groups…but then later I discover it would have been all right if I’d said what I really thought.”

With all the respect I could convey, I replied, “What is your understanding of why you say what you think you should?”

Immediately Louise explained, “Oh, I tell a story to fit in.”

I reflected that people usually have good reasons for what they do. “What is important to you about fitting in, do you think?”

Louise sat back in her chair looking thoughtful. “I like to fit in. When I’m in a community I’m proud of it. I like belonging to clubs. I wasn’t brought up to do any sport or anything, so it means I can choose. I’m not tied to one thing.”

Curious, I responded, “Would you mind me asking… how do you go about this fitting in?”

Louise paused. “I don’t know, but I’m really good at it,” she finally said.

“Are you a flexible kind of a person?” I offered.

“Sure am.” Louise nodded.

“Which kinds of communities or clubs do you like to fit in with?” I continued.

“I take the best of what’s around. People are good to me, kind,” Louise answered, as if she couldn’t quite believe her good fortune.

“Would you say you are someone who both accepts and appreciates the generosity and care of others?” I asked, noticing her gratitude. (8)

Louise began to tell me how she appreciated homemade gifts as opposed to bought ones. She elaborated on the care and effort in the presents people made and gave to her. Homemade fudge was so much better than a box of chocolates, she explained.

“Do you see the intention behind the gift, the love maybe?” I asked. Louise nodded as if this was obvious to her.

“What do you give to people in return when you accept their gifts, noticing the care and effort that has gone into making them?” I asked, highlighting the reciprocity in the way she received gifts. (9)

“They must feel the magic, because I do,” Louise answered matter-of-factly. “People are kind,” she reiterated. “I have lung cancer. It’s an ugly cancer. I was so happy when they included me in the make-up day for women with cancer. I didn’t think they would, what with me having a dirty cancer and them all having the pretty pink kind.”

Taken aback, I responded, “Would it be OK to ask what you mean when you talk about your cancer as being dirty and theirs as a pretty pink kind?”

Louise lowered her head as she answered me. “My cancer is dirty because it’s a smoker’s cancer. It’s my own fault.”

Infusing as much respect into my voice as I could, I asked her in a quieter tone, “Would you mind me asking you some questions about how you began to smoke?” I reflected on how hard it would be to be a smoker with cancer and not afforded the support that other people living with cancer are offered. I tried to imagine being shamed at one of the worst moments in life, not allowed to feel sad or angry but being repeatedly blamed both vocally and silently.

“It was the ‘in thing’ to smoke,” Louise explained. I nodded. Louise and I both came from a time when many people smoked.

“When I was 10, 11, 12 years old, I pinched my mother’s cigarettes for a naughty puff,” she told me with a mischievous glint in her eye, evoking glimpses of childhood fun away from the surveillance of adult eyes.

“When you were 10, 11, 12 years old, do you think it was possible for you to realise the full implications of the naughty puffs?” I inquired, hoping to lessen the harsh judgement she extended towards herself alone.

“No. I didn’t realise in my teens either. It wasn’t ‘till much later when I came to live around people who didn’t smoke,” she told me.

“How do 10-, 11-, 12-year-olds come to smoke, do you think? How do they come to think it’s a good thing?” I responded.

“It’s the way I was brought up. It was a hard life. It wasn’t ‘till I started playing sport that I realised there were different ways of living, that some kids had a bed each and enough to eat. (10) My parents were hard people. They smoked and drank,” Louise conveyed with a frown.

In my head I did a few calculations. Louise would have been growing up after the Second World War when many M?ori were living in poverty. I thought about her family and wondered if Louise had a grandfather who fought in World War One. I knew of P?keh? returning servicemen who had been allocated a farm in the ballot after fighting in World War One, while my friend’s t?puna (11) who fought in the M?ori Battalion returned to discover his ancestral lands had been confiscated. There were many possible reasons for why Louise’s family experienced hardship.

“What is your understanding of how they came to be like that?” I asked.

“Maybe it’s ’cos they grew up in the Depression. (12) It was a hard life, and they worked hard and partied hard. Yeah, they were hard people,” she repeated.

“Hard lives can have people turning to cigarettes and drink to ease things, especially when there is trauma and hurt that comes with it,” I commented. “What do you make of there being cigarettes for sale when we all know they kill people?”

We pursued this line of questioning for a bit longer, with me seeking to broaden the responsibility for smoking into our societal context so that Louise wasn’t left to shoulder it entirely on her own.

However, I noticed myself beginning to labour a little in the conversation and started to wonder if I might be more interested in taking such a direction than Louise was.

So, I listened harder for what was important to her.

“Yeah, well…” Louise pondered. “I left home at 13 to get away from it all. I knew I had to get out. The beatings, the life… My fault I smoked… Miracle I survived this far. The shame of it has been with me since I’ve had children.”

“What was important to you that you knew you had to get out?” I wondered.

“I wanted to get away from the cigarettes and the booze…” Louise elaborated.

“Do you know what it was that was important to you that you wanted more from life, that you didn’t just accept the cigarettes and booze?”

“I wanted a better life and to live it,” Louise explained.

“May I ask, what sort of better life did you want?” (13)

Louise told me how she wanted a home and security. “I wanted a bed of my own and to know where I was sleeping each night,” she explained.

“What steps did you take towards getting a better life?” I inquired.

“I went white.”

The words hung in the air, heightening my awareness that I, a privileged P?keh?, sat at her table. I wondered how I was selling her short.

Louise continued, “I knew I had to leave if I was to survive, so I hung around with my white friends. When I left, I got away from a lot. Not just the cigarettes. I made sure I fitted in, and it was my ticket out.”

“Would you say fitting in saved your life?” I asked her.

“Definitely, I had to get away from the other lot.”

She watched me, seeming to wait to see how I would respond. I reflected on Louise calling her own people “the other lot.” I could hear the racist discourse ringing in my ears, inviting the harshness to be because they were M?ori, rather than taking into account the devastating effects of colonisation on generations of M?ori people.

“Could you help me understand a little more of what you mean when you say ‘the other lot?’” I inquired. (14)

“M?ori,” she replied, sounding like she was repeating something rather than truly believing it.

Louise waited, her body tense and alert.

“Colonisation has been very hard on the M?ori people,” I ventured, thinking of the decades of injustices M?ori had endured. “Do you think that the drinking and smoking and what you went through was because they were M?ori, or do you think it could have been because of the hardness of life and what it did to the family?” (15)

Louise’s shoulders dropped and she was quiet for a moment. “I’ve forgotten who I am,” she rasped sadly. (16)

Before I could respond, she ploughed on, seeming to contradict herself with what could have been growing pride in her voice. “I do all the old stuff: knitting, cooking, sewing, carpet-making. I paint.”

“Are you a creative person?” I asked her, smiling. “And the garden?”

Louise enthused about her garden.

“Are there threads of who you are in the old arts?” I asked her.

Louise considered. “Yes, I think there are.” She seemed to meditate on this for a moment, then looked me in the eye. The corners of her mouth crinkled up as a smile formed briefly. “But then I forget,” she added, looking shamefaced again.  

“Colonisation can do that to people…get in the way of being connected to who you are… Not surprising when there were laws trying to do just that,” I said sadly. (17) I reflected on the children who had been beaten in school because of laws that forbade them to speak Te Reo M?ori and the efforts to suppress M?ori cultural practices. “There can be a heavy cost when you are forced to turn ‘white’ to survive. Would it be OK to ask if there has been a cost for you?” (18) I thought about what it might be like to forget who I was. Emotion stirred in my belly.

“I don’t have a belonging,” Louise confided. “I feel I’m a betrayer.”

Deep sadness leaked into the air around us. It hovered, seeming to draw us together. We sat in silence.

After a time, Louise gradually seemed to recover, and in a bright voice she said, “You know I’m Scottish. I identify as Scottish.” I looked into her beautiful brown face, with its broad nose and dark brown eyes, framed by the sweep of almost-black hair.

I responded then, not as I would to a P?keh? with a question, but in the way of M?ori who connect through the people and the land they come from, whanaungatanga (19). I adjusted my phrasing according to shades of tikanga M?ori (20) and said, “The people I come from are Scottish. They belong to the clan of Callum. They come from the highlands of Scotland.” My intention was to tell her we were connected, and in telling her this and in the way I phrased it, I wanted to say, “I also acknowledge your M?ori side and it is beautiful,” though this was implicit.

My disclosure resonated with Louise immediately. Laughing, she jumped out of her chair and rushed off to gather photos of all her grandparents who had died long ago. She introduced me to her Scottish grandmother, whom she loved dearly. “She taught me the old arts,” Louise explained.

“Were you a willing learner?” I asked her.

“Yes, I took in what I wanted and spat out what I didn’t.”

“May I ask what you value about your M?ori side?” I inquired, appreciating that the photos were of both sides of her family.

“M?ori love fully and unconditionally, no questions asked, no grudges.”

“How do you love?” (21) I asked, hoping to make visible a thread of whakapapa. (22)

Louise proudly announced, “I love like a M?ori!”

Warmly, I responded, “Can you tell me some stories of how you show that knowledge of loving?” I wanted to strengthen Louise’s description of herself as having the ability to love fully. It stood out in contrast to her sense of not being worth chemotherapy.

Louise was off, taking centre stage. I listened, grinning, delighted by her rich and lengthy stories of such loving. I then asked her questions of how she came to learn such loving and we tracked knowledge of love through the generations in some long-overlooked stories.

“Who in your life knows that you have this knowledge and way of expressing yourself?” I asked.

“All my friends!” Louise responded enthusiastically.

“Could it be that you have captured aspects you value from both worlds with your fitting-in ability?” I asked, after a moment’s reflection. Louise embraced this possibility seemingly for the first time. Her enthusiasm bubbled. We went over her mothering and loving of her children, with Louise adding details such as “…but the car is warranted.”

“Could it be you are not a betrayer if you’ve made the best of both your M?ori and P?keh? sides?” I slipped in the word P?keh?, the M?ori word for non-M?ori, to give weight to M?ori knowledge. “You’re right, I’m not,” she told me. Then, as she thought about it, her voice firmed. “No. I have been clever; I haven’t got off-side with anyone. I have danced on both sides of the fence.” Louise smiled fully at me. It was a beautiful sight.

Smiling back, I continued, “If you were to think of yourself as a person who can dance on both sides of the fence, what difference might that make to how you are living your life?”

“Well, just everything,” she exclaimed exuberantly. Idea after idea quickly followed.

“If this ability you have to dance in two worlds was one that you kept in your mind, what might it keep you in touch with that is important to you?”

“That I’m OK. Sasha, it’s going to change my life!” Louise’s joy once again spilled over. I was overwhelmed. How generous she is, I thought.

“Do you think it will make a difference to how you live with cancer?” I asked.

A little later, I started to draw the conversation to an end, mindful that we still had more to talk about.

“Sasha, I like this talking,” Louise exclaimed, with bouncing joy. “Today I discovered I’m not a liar!” (23)

I drove back to the hospice with sadness stuck to me rather than her happiness. All I could think of was Louise…a M?ori in a sea of P?keh?. I thought of the times when I have felt apart, out of step, disconnected and the only one. I tried to take myself there, but I knew it was not the same. When I arrived back at the hospice, I wondered what I might have missed, what I didn’t ask. Later, as I reflected with Niwa, my M?ori colleague and friend, I was reminded of the bridges that friendship, love, and respect can provide.

A few days later, I heard from the nurses that Louise had decided to have treatment for her cancer. Louise later explained to me, “I felt worth it after we talked.”

When Niwa and I met with Louise and her family a few weeks later, we heard the good news she was improving. A short time of respite from the cancer beckoned.

Postscript

This story illustrates one way a counsellor might go about such a conversation. It is not the only way to respond. I carry the knowledge that I have many blind spots, especially in conversations that are cross-cultural. I am also aware that I am the recipient of the kindness and generosity of the people with whom I meet. This story does not represent a “right way” to practice but rather is written in response to a question I ask myself: “What does my commitment to the principles of Te Tiriti O Waitangi (24) look like in practice?”   

Notes

(1) For those readers interested in the use of stories to learn or teach narrative therapy see Carlson et al (2018) and Heath et al (2022). For additional examples of stories illustrating narrative therapy see Epston, 1989; Heath, 2015; Ingamells, 2014, Ingamells & Epston, 2016; Pilkington, 2014; 2016; 2021; 2022.

(2) This story was written with the permission of the person in it. All identifying information has been changed.

(3) In Aotearoa New Zealand, M?ori have a higher incidence of lung cancer and poorer survival rates than P?keh? (non-M?ori. A number of barriers to early diagnosis and treatment have been identified including access to care, engagement with specialists, communication with specialist services, and lack of culturally appropriate services (Kidd et al, 2021). Even though Louise’s lung cancer was incurable, chemotherapy would offer her the chance of improved quality of life and an extended life span.

When someone responds in ways that others don’t understand, it is common for judgements to be made from a position of “knowing best” what is right for that person. I find it more helpful to be curious about another person’s world and to try and understand what is important to them. I also want to learn what they are taking into consideration that matters to them and is restraining them from taking a particular course of action. For example, what was Louise concerned about or prioritising that she had chosen not to accept chemotherapy? Often, when I have fully inquired into what matters to a person and what they are weighing up, their decision-making process and reasons becomes clear. At other times, the questions I ask can lead them to reconsider their decision and take another path. (See Chochinov, 2022)

(4) A kete is a basket usually woven from flax. M?ori words are in common usage in Aotearoa New Zealand. I have chosen to leave such words in this text out of respect for the person in the story, and to uphold the mana of Te Reo M?ori (the M?ori language).

(5) My intention in asking this question is twofold. I wanted to get to know Louise aside from the difficulties she was living with in ways that dignified her and brought forward her preferred stories of who she was. I also wanted to create space for culturally respectful ways of getting to know each other without assuming how she might wish to go about that. A broad question such as this one creates space for Louise to answer in ways that fit for her. In some instances, I may ask a person if there is a particular way they wish to begin, in order to create space for karakia (a ritual chant or prayer) or any other ritual that may be meaningful to them. Louise’s talk and refusal of cultural support led me to think such an invitation might be uncomfortable for her. I therefore held back on this occasion knowing I could raise it another time.

Building a relationship in ways that honour and create space for possible cultural identities a person may hold is important, especially if that culture has been oppressed. Such respect has effects on what kinds of conversations are made possible and can open areas that are often overlooked. For example, acknowledgement of tikanga M?ori (M?ori cultural processes) can underpin the engagement of M?ori in treatment (Kidd et al, 2021) and can be significant in generating a relationship in which stories of suffering can be told.

It was unusual for me to have this first meeting with Louise on her own. (It was Louise’s decision to do so.) I usually meet with many different constellations of families and most often see someone who is unwell with at least one other member of their family/wh?nau. Louise introduced me to her family after this conversation and later brought different members of her wider wh?nau/family in to see me when they visited from other parts of the country.

(6) The people Louise was descended from. For some M?ori, this is an important part of forming a connection and getting to know each other.

(7) This was a significant deconstructive question in our conversation. Deconstructive questions pull apart the threads of an idea so that a person can examine them. When we take up a stance of curiosity and ask a person about the particular meaning of common words and ideas to them, new therapeutic directions can open up.

(8) As I learn more about Louise’s life, I am listening for how she goes about what is important to her and whether that way of living expresses Aristotelian “virtues” that she values, such as for example; generosity, compassion, kindness, courage and love. I gather more stories of these expressions of goodness that are valued by Louise and these stories make up the backbone of the re-authoring process (White, 2007). I am mindful that ideas of what is important and considered virtuous sit inside cultural frameworks. Such themes of what people are engaged with in their life, and the virtuous ways they go about what engages them, are called “narrative values” by the philosopher Todd May (p. 73, 2015). May says it is these stories that can give a person a sense of living meaningfully. Such identity stories that describe valued qualities of a person are very helpful at the end of life. Not only do they lend meaning to a person’s life, but they offer a way of responding to illness, treatment and dying that is not reliant on a well body. They can give a person a sense of agency at a time when they may be experiencing a lack of influence over their life (see also Pilkington, 2022).

(9) Ideas that position a person who is unwell as “only receiving” can lead them to feel a burden on others. I often inquire in detail into how a person receives the care of others and the experience they generate in the carer with the intention of highlighting the reciprocity in the relationship. The way we receive can give another person an experience of themselves as generous, kind, significant, and worthy for example.

(10) Moana Jackson vividly describes the processes of how colonisation robbed M?ori of a sense of home in their own land and what was lost. “When you take away the whenua from a people who regard themselves as tangata whenua; when you take away their ability literally to touch the mountains; if you limit their ability to dream their own dreams; if you take away the earth upon which they stood with love; then you render them homeless in the most complete sense (Jackson, 2022, para 25).” (Whenua means land and tangata whenua means people of the land.)

(11) T?puna means ancestor in the M?ori language.

(12) During the depression M?ori were harder hit than P?keh?. M?ori were often the first to lose work and were paid lower unemployment benefits than P?keh?. The situation with benefits was only rectified in 1936 (Waitangi Tribunal, 2004, p. 659).

(13) I cannot assume I know what “a better life” means to another person.

(14) My intention in asking this question was to make the racist discourse visible so that we could examine it together.

(15) Note the way I scaffold my question with a statement. Louise immediately recognised how I was positioning myself and responded. Consider the harmful impact if I had let the moment pass without addressing such an idea and one that included Louise in its judgements. We could ask, what was made possible in the conversation following these moments when I sided with her and her wh?nau against racist discourses?

(16) This is an example of how meaning can be lost in translation (Mutu, 2004). When Louise referred to who she was, she was not speaking of an individual internal construct of self but a relational self. Included in who she understood herself to be were her connections to her t?puna, her wh?nau, the whenua (land), and moana (sea). In this conversation, Louise is considering the elements of whanaungatanga that she wishes to be connected to and that have been disrupted by colonisation. I, in turn, am referring to a relational self when I reflect on what has gotten in the way of her connecting to who she is. When I asked my colleague Barbara O’Loughlin of Marut??hu and Ng?ti Hau?, to describe her understanding of who she was, she answered me, “I whakapapa to the maunga (mountains), to the moana (sea), the awa (river), to my t?puna, to my whanau and to te ao M?ori (the M?oriworld), (personal communication, November 24th, 2022)”. There is no “I” or “self” t

Brief Therapy with Single Mothers: The Transformational Alchemy of Metaphor

Posted on by Psychotherapy.net Team

Psychic Schemas and the Phenomenology of Being a Single Mother

There are over 9 million single mothers in the USA. Therapists working with these women hear stories of abandonment, disempowerment, loneliness, hopelessness, victimization, rage, and unrelenting stress.

Disturbing perceptions and emotions such as these, and the distorted interpretations that result, may, but more likely and typically, solidify into psychic schemas characterized by deeply embedded patterns of distorted thinking, dysfunctional reacting, and compromised coping.

Psychic schemas, themselves free of valence, can be understood as internal vehicles serving as repositories for what the individual notices, perceives, and catalogues — including feelings, thoughts, sensations, actions, experiences, and the ever-changing states of the Self. The way these phenomena of living are perceived — through thought, memory, imagination — and the linguistics of the internal narrative, provides the personal schema with its phenomenology, its valence, and its meanings.

As with any individual, what gets introduced and accepted into a single mother’s schema will affect how she thinks, what she feels, how she continues to live her life, and how she views herself. Her existing schema will influence content that continues to be incorporated. The phenomena that become absorbed will affirm or refute negative cognitions, support or refute distorted thinking, validate or dissipate painful emotions, increase or decrease stress, and affect choices of action, including decisions about the mother’s parenting — and about her sense of self.

Through listening to the single mother’s stories, and recognizing her interpretations about them, the therapist can become aware of and assess the possibilities for creatively crafting metaphors that can elicit cognitive shifts, emotional transformations, and behavioral change.

The Transformational Alchemy of Metaphor

The unconscious mind embodies a powerful potential to transform negatively charged schemas into more positive ones that embody uplifting themes and hopeful interpretations. The quiet mind, combined with the evocative and rhythmic language of hypnosis, can fuel a subconscious shift that can reduce stress, increase ego strength (including parenting skill), transform confusion into clarity, decrease stress, and increase a sense of strength and wellbeing.

Used in conjunction with trance, the mother’s personal metaphors become powerful tools that can reach beyond the didactic to tap the unconscious mind’s potential for reframing and restructuring the phenomenology of the single mother’s psychic schema. This potential to redirect focus, shift internal states and create change in the bio-psychosocial-emotional substance of the patient’s psychic schema constitutes the transformational power of metaphor.

Metaphors (and their cousins, simile, allegory and parable) contain rich sensual imagery that can gently and poetically focus attention to perceptions that can shift self-states and move patients toward changes they desire. When used with techniques of trance, such as tempo and attunement, metaphors drawn from patients’ stories constitute a power-filled therapeutic tool for anchoring change and growth in the body-mind with stability and durability that can successfully lead to increased resilience and coping strength.

Using brief, simple, and effective techniques, therapists can assist the single mother in imaging and identifying with new metaphors drawn from her own personal story. In trance, this “sympathetic identification” with new and transformed metaphors can lead to increased confidence, more solid self-esteem, greater ego strength, and a more integrated core of Self. When this positive enhancement becomes incorporated into the psychic schema, the psychosocial-emotional benefit to the mother can also benefit the health of her children.

In the following narrative, my work with “Queen Esta” demonstrates the way in which a carefully crafted metaphor has the power to shift the meaning of a personal and create a stronger sense of Self.

Queen Esta’s Story

“I just left my husband of 30 years!”

That was how Esta introduced herself, at the age of 83, knowing that she could have a future. Esta wanted to understand why she had spent thirty years with a second husband she did not love. To Esta’s credit, she had the wisdom to realize that at this critical turning point, it was important for her to understand the greater span of her life in order to accept her choice to leave her marriage.

As Esta’s story unfolded, it became clear to both of us that Esta’s acceptance of her current choices had everything to do with looking at a different piece of her story. Long before there were social supports and the stigma had faded, Esta had been a single mother. Esta soon came to realize that understanding the impact and meaning of her single motherhood would hold a key to the answers and comfort that she was seeking.

I discovered that Esta had married her first husband in the early 1940’s, shortly before he went into the service and, “when I was too young to know what love was.” The new husband had come home on leave and had left Esta again, pregnant. Esta’s husband was not pleased with the news. When he told her that he wanted her to have an abortion, she agreed it was a very good idea. “I did have one,” she enjoys saying triumphantly — “and it was him!”

After dismissing and divorcing her husband, Esta found herself a single mother of a very young son. In the mid 1940’s, widows, especially war widows, had some acceptance, but single motherhood was not as socially integrated as it is today. How had Esta coped? What had been her resources? Even so many years later, Esta did not fully comprehend how strong she must have been to grapple with the social context of the day and the great difficulties and isolation that single mothers faced.

As single mothers in every era must, Esta had to deal with her own fears and insecurities and raise her child at the same time. Esta had done both successfully, but she did not see the strengths she had drawn on or realize that they could add to her resilience in the present.

During her son’s early childhood, Esta had called upon her inner and outer resources. She had relied on her parents to take care of her little boy while she worked long hours, often traveling alone overnight. She remained mindful and grateful for the help she was getting from her family, feeling fortunate that she had this support. In this way, Esta did not see herself as a victim, but rather cultivated an attitude of acceptance that gave her strength to keep going.

“Esta,” I asked her, “Wasn’t it terribly hard to be a single mother in those days?”

“Yes, it was.” She assured me. “I did what I had to do, but there were others harder up than I was, with no families to help.

“What is the secret of this positive attitude you had?” (She still has it into her 90s!)

“I believe in God.” she said unhesitatingly. “This was the path he chose for me, and I had to accept that. I felt grateful to have my son. He was so precious, and my mother and father loved him as if he was their own. I accepted my decision to divorce and trusted that this was what God wanted for me. So, you see, I was lucky.”

As Esta continued to examine her life story, she came to realize that more than luck had been at work. She was able to see her courage and the intuitive wisdom that gave her the courage to banish husband number one. Finally, she could entertain the idea that there was also deep wisdom in her choice of husband number two. At a point where she no longer had family support, was weary from her grueling job, and had no financial base, Esta had married a man who could, and would, support her and her son.

Esta was now able to make sense of her past and present choices, comforted by knowing that they had been logical, born from a positive impetus. With this knowledge, she was able to accept the sadness of never having had the romantic union, but Esta was relieved of the stress caused by disappointment and regrets, and feelings of well-being replaced disappointment and regret.

Once again, Esta had “done what I had to do.” Realizing how strong she had been in the past helped Esta to see that her decision to leave her current husband was coming from an authentic core part of her Self which knew what was right for her now as it had in the past. As she achieved this wisdom, Esta’s feelings of sadness and self-doubt were replaced by a sense of well-being and an appreciation for her experience and her maturity.

In the throes of her single motherhood, Esta was too immersed in survival to see what she was accomplishing, and the era of self-help and therapeutic support had not yet dawned. Now, so many years later, ready to look back and see her success as a single mother, Esta embarked upon a review that allowed her to know how inner wisdom had directed her to cope and survive. Esta told me about the love of her life, a young man who had died before they were able to be married, almost 50 years ago.

Esta recounted the depth of that old grief, and how difficult life became then, and again when her parents, on whom she had so depended, died. Through all these losses, Esta had kept her sense of humor, her belief in God, and the persistent effort to give her son a good life. She maintained her dedication to him even to the day when this son, now a man, asked for her blessing to follow his destiny 3000 miles away. “My heart broke.” She told me. “But what could I say? This is what he wanted, and I wanted him to be happy.”

As she reviewed the events that required such pervasive and abiding courage, Esta was able to acknowledge that, indeed, life had been hard for her. She affirmed that trust in the will of her Higher Power had enabled her to embody the healthy attitude that had been with her into her 90s. When Esta started therapy, she was no longer the young mother with a little boy to bring up.

However, it meant the world to Esta to transform her doubts of having wasted her life into a view of herself that affirmed her strength, and the deep abiding soul Wisdom that guided her so many years ago, when she just “Did what I had to do.”

When asked how I should identify her in my book, Esta requested that she be called “Queen Esther.” Partly, she says, because Queen Esther in the Bible was a wise woman and a survivor; and partly because now Esta saw herself as “Esther,” a modern Queen, courageously having raised a boy into a good man.

Esther told me that she knows that the difficulties she faced as a single mother helped to make her into the Queen she is. She knows that she made choices from an inner truth that directed her to do the right thing.

Queen Esther was then, and will always be, truly a Soul Mother.

This story is excerpted and adapted from Soul Mothers’ Wisdom: Seven Insights for the Single Mother, by and with the permission of its author, Bette Jonas Freedson, and that of its publisher, Pearlsong Press.  

Providing Culturally Sensitive Narrative Therapy and EMDR to Original Peoples

Posted on by Psychotherapy.net Team

Finding Strength through Connection in Counselling

We hope to help the reader understand one attempt of working in the most non-colonial way possible with the Onkwehonwe. In this story, playing a minor role, is how a settler of Irish heritage, Linda, committed to honouring the Onkwehonwe. Linda was assisted in her understanding of the Kanien'kehá:ka (Mohawk People), and in how to be helpful, by Juliette, playing the major role. Linda was Juliette’s helper/psychologist and Juliette was consulting with her.

Juliette: When I reflect on the beginning of our sessions doing NT/EMDR, I remember feeling that I would always suffer. I was unclear as to what might come of this type of therapy.

Linda: I was trying to integrate EMDR (1) into Narrative Therapy (NT) to work in a non-colonial way. EMDR uses bilateral movements to change the way memories are stored in the brain, allowing one to restructure trauma memories.

(In the work with Juliette, I asked her to reprocess negative memories and how they made her feel while trying to help her realize differences — for example, if she felt unsafe, she could try remembering experiences of feeling safe).

I tried to let you lead the way with EMDR and then answer NT questions to highlight non-problem stories. With NT (2, 3) the ethics provide a non-colonial way of working by flattening the hierarchy and being non-judgemental.

(NT works with the way people make sense of their lives with stories. Narrative therapists help people be other than what the problem stories would describe. These stories determine how we see ourselves. Narrative therapists believe that stories aren’t fixed. Problem stories pretend to be the truth, but they are not, as Maggie Carey, shared with me in a personal communication in 2018).

I am expected to write an evaluation for Kahnawà:ke Shakotiia’takehnhas Community Services-KSCS) when they refer someone to me. I use special knowledges discovered from the Tree of Life or Journey metaphor (4) as my report. People consulting can thus realize that they are not only their negative stories, but that their life stories can be retold in ways to transform their experience of life, understanding there ARE also non-problem stories.

Juliette: This experience with you would be the very foundation to what gave me the strength and encouragement to push through whatever came my way. Your compassion and technique allowed me to open to you. I could feel the beauty of your spirit.

Linda: I appreciate your comment about spirit.

Juliette: Everything happens for reason I believe. I know in my heart that the Great Spirit sent such a loving and gentle person as yourself to me. I honestly think he hand-picked you for me, since I had so much hurt and pain. I needed a sensitive, well experienced human-being.

Linda: I am drawn to NT because it suits MY spirit. It helps me be a sensitive human being for you.

Juliette: I felt very connected to you, considering your background of living off the land. We may be from diverse cultures and generations, but in some sense, we are the same.

Linda: I feel humbled that someone with your capacity to relate to nature, animals, and spirit could feel such a connection with me.

Juliette: I am the product of multi-generational trauma. With that comes many co-existing disorders. I felt no judgments with you. I could speak about my visions, dreams, and animal experiences. You were interested to hear about it. In the past we were not allowed to speak of such things for fear of being arrested or terminated. Blood memory is important in my People. Even though some of us have not directly experienced certain traumas, it is in our DNA.

Linda: I wonder if the words torture or violence might be more fitting than trauma, (inspired by Cathy Richardson’s work, [4]). If torture is in our DNA, are non-torture stories too?

Juliette: I found NT/EMDR to be immensely helpful in lifting the dark cloud that was hanging over me. It helped to open me up to even further healings. Most of all I think the way you did it and gave feedback, writing what came out of the sessions, was helpful. Three years later, I still have these notes to help me look back on how far I came.

Linda: I write notes for you to have nothing hidden. I give everyone my notes.

Juliette: I cherish the letter you gave me when we finished our sessions.

Linda: Therapeutic letters are a huge part of my work. They help consultees notice their revelations (5). I summarize changes noted in therapy. Now I often co-write letters with the person consulting, to co-construct counter-stories (6).

I love that you wrote back. I appreciate you describing me as medicine woman, mentor, and healer.

Juliette: I think what you are trying to do for Indigenous people is honourable. It is not an easy task to take on collaborating with people who have been so greatly affected by colonialism. I wonder if your background of living a simple life had anything to do with the paths you chose to take on helping people like me. I found you educated and knowledgeable in your field. You are hardworking and always striving to help others. That is a commendable characteristic to have. These qualities remind me of the seven grandfather teachings to live by: to have love, respect, truth, wisdom, honesty, bravery, and humility. You have all those qualities in your healing practices.

Linda: Wow! Thank you.

Juliette: Medicine people come in all forms with each bringing something that the client might need at that time. You were the first I had seen.

In June of 2019, three months after our sessions ended, my grandmother passed. I lost my Stepmother in a tragic accident. We lost our family pets. On July 4th, I had a hard delivery with an emergency C-section. I know that without our work, those hardships might have broken me for good.

I continued to see healers and came to terms with the fact that this will be a lifelong endeavour, considering what I have gone through.

Linda: If I could be considered to have contributed to the beginning of such a lifelong healing journey, I would feel fulfilled.

Juliette: I appreciated and found helpful that you shared some of your life story with me. That made me feel a connection. I felt I was not so alone in some life experiences. From the eating disorder I had, one thing stood out in my mind. You said, “bulimia seems a form of self-punishment.” That one sentence made me think twice about ever doing that again. Why punish myself for what others had done to me? Why give them that power? So, I never did it again.

Linda: I felt the unfairness of this.

Juliette: NT/EMDR is powerful. That helped me relook at my traumas in a different light, helping heal the little girl in me. Since then, I’ve been raising my three children. My son is now three. His name is Keenai (meaning black bear) and his Kanien’keha name is Takarihóntie (news travels fast). I was cleansed by a healer as I was under spiritual attack, which helped. I enrolled to become a traditional healer in mental health and Indigenous addictions counseling. We learn different resources and ways to help my people. We do land-based teaching where we take part in sweat ceremonies, singing our songs, making drums, etc. I kept a consistent A+ average. I am learning what was taken from my people.

Knowing who you are and where you belong is medicine. The more I learn and heal the better my confidence gets and the less the anxiety comes. I am no longer on medications.

Occasionally I need to take an anti-anxiety medication as the course can be heavy, speaking about residential schools and the many injustices that led to the situation we are in today. I have come a long way from where I was. I AM immensely proud of myself. I was told I am the medicine for my family and people.

So many people I met through this journey are medicine for the people. I consider you to be one of them. You gave me that encouragement to keep healing and advocating for my people. For that I will be forever grateful.

Linda: What you just said made me remember questions in the letter I sent you. “if we could invite your welcoming ancestors and your Creator here to be with us and we could have a conversation, how do you think they might express their pride in you?"

Juliette: They would give me a great big smile.

Linda: How would they want you to feel about the way that you were an advocate with me and about the way you have turned your life around?

Juliette: I think they would be so proud and hopeful that things are changing.

Linda: Do you think that they would be honoured?

Juliette: I know I am honouring them by healing and acknowledging their hardships, changing whatever I can to bring back what was taken from them/us.

Linda: I wonder if they might have advice about how to be even more of an advocate for your people and the land.

Juliette: I think they would tell me to be a warrior and to keep fighting for the ones who cannot.

Linda: Do you think that if you continue to speak out and be an advocate to those of your people in need, regarding how to transform a life from one of drugs and alcohol and violent partners like you have done, they would be happy to stand by your side?

Juliette: They are always by my side. I know they are happy with what I try to do.

Linda: Do you think they were at your side every day when you kept yourself safe?

Juliette: They guide me always.

Linda: Now, do you think they would be even prouder by your decision to become an Indigenous healer to those having challenges with mental health and addictions?

Juliette: They ARE proud. They guided me. They want me to help others. It is a part of our ways that if we are well, then we help those who are not so well. If I have a full plate of food and see someone with nothing, then I give them half of mine. That is the concept. Don’t let others suffer if you have the means to help; take my struggles and heal so I have that empathy to help others.

Linda: Interesting. My mother taught me with privilege comes responsibility to help those with less privilege.

Juliette: I have questions to ask. What drew your attention to helping my people and other people who have endured a terrible history?

Linda: Perhaps my mother’s teaching. Also, the stories my grandfather told of how the Irish were mistreated as they were colonized. It might be my wonderful experiences as a child and adult living on a farm and receiving community healing. Maybe, the appreciation I have of your culture bringing back community with the passion to get back to your cultural roots.

Juliette: Was there any moment in your work where you just knew you were doing what you needed to do and were in the right place?

Linda: Every day. Especially after this conversation with you. If any of the work we did together played even the smallest part in where you stand today, can you guess how proud I might feel of the work I do? I believe that you will help your people remember their roots, their strong culture, and what they can teach us non-indigenous people. If I played even the smallest part in this journey you have taken, I would know I am in the right place, doing what I need to do.

References

(1) Shapiro, F., Kaslow, F. W., & Maxfield, L. (2007). Handbook of EMDR and family therapy processes. John Wiley & Sons.

(2) White, M., & Epston, D. (1990). Externalizing the Problem In (Eds.). Narrative means to therapeutic ends. W.W. Norton & Company.

(3) Freedman, J., & Combs, G. (1996). Narrative therapy. The social construction of preferred realities. Norton.

(4) Richardson, C. (2021). Facing the Mountain: Indigenous healing in the shadow of colonialism. Charlton Publishing,

(5) Denborough, D. (2014). Retelling the stories of our lives: Everyday narrative therapy to draw inspiration and transform experience. W.W. Norton & Company.

(6) Ingamells, K. (2016). Learning how to counter-story in narrative therapy (with David Epston and Wilbur the warrior. Journal of Systemic Therapies, Vol. 35, No. 4, 58–71.

(7) McAllum Pickington, S., (2018) Writing narrative therapeutic letters: Gathering, recording and performing lost stories. Journal of Narrative Family Therapy: Special Release 20-48.  

Critical Tips for Building and Maintaining Your Private Practice: Avoiding Self-Defeat

Posted on by Psychotherapy.net Team

Over my consulting career with mental health professionals at various stages of their development, I have offered critical guidance about the development and maintenance of their private practices. I have also learned a great deal about why so many of them struggle in these efforts.

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All of us who see clients privately have likely heard stories about why some left treatment and came to us, or why they did not return to the former psychotherapist. In the process, we have also hopefully learned why we were chosen to be their therapist as opposed to others with whom they have consulted.

Successfully Managing Telephone Contact with Clients

There are many ways in which clinicians — often unknowingly — defeat their own interests in the course of building and maintaining their private practices. One of these is the difficulty managing and handling telephone contact with prospective clients. New clients who were given several names of therapists have reported to me that one of the reasons they came to see me was that I was the only one who returned their phone call, or that I returned their call on the same day, rather than two, three, or more days later. I am astonished every time I hear this.

Another familiar comment I’ve fielded surround concerns the “phone-side manner” of the therapist who does return the call: “Unfriendly,” “Cold,” “Abrupt,” “I felt like I was bothering them,” “Didn’t really seem to want to answer my questions,” “She sounded to me like I must sound to the salesperson who calls me at dinnertime,” and more. It seems that some therapists are not any more comfortable talking with strangers than prospective clients are comfortable talking with us.

Prospective clients who have been sent to us by a known referral source may simply be calling to make an appointment as instructed. For many others, however, that initial phone call is a fragile moment that may have been delayed for some time. This is a first opportunity to engage the client and establish a positive initial connection. Many prospective clients who feel uncomfortable or even put off during the first call will never make it to the first visit with that clinician. Some potential clients call to arrange an appointment and save their many questions for the first visit.

Other prospective clients, especially those who are ambivalent, fearful, or who are seeking help under duress, require answers to their questions on the phone before ever coming in for a session. How this conversation is handled by the therapist might well make the difference between a new client and a non-client. If a therapist is uncomfortable with a prospective client needing a lot of information during the first contact, it might be evident and affect the quality of the encounter. Some callers ask difficult questions that must be handled sensitively, e.g. “What is your fee?” “What is your orientation?” “How long will it take?” “Should I bring my spouse?” And my favorite: “Now that I’ve told you a little about my problem, do you think you can help me?”

Many therapists seem to struggle in answering questions about their fee. There is probably no really safe or “good” answer — at least on the phone, and especially for clients who have issues or conflicts about paying for psychotherapy. Some therapists try to dodge the question by saying that they do not discuss fees on the phone and attempt to postpone the fee discussion until the client agrees to come in. The caller may find this answer evasive and permanently end the encounter. With a direct answer, arguably a superior response, the therapist runs the risk of an abrupt end to the encounter. The prospective client may be comparison shopping and the stated fee may eliminate a therapist right away or the client may make an appointment and then not show up.

It is important to remember and utilize the “rules of engagement” we all learned many years ago. The first phone contact is, possibly, the beginning of treatment. It is essential that the clinician is attentive, receptive, steady, ready to be of service, and generous so that the person contemplating therapy feels recognized and accepted sympathetically as a person in trouble.

I have always conducted the first session as a courtesy, i.e., no fee. This, I believe, accomplishes a few ends. For one, it conveys that the possible treatment is not all about money — especially helpful to therapy “virgins” who have seen too many Woody Allen movies. Second, if, for whatever reason the relationship is not going forward, there is nothing owed for what will not be an ongoing experience; and third, if I choose not to accept an individual as a new client in my practice, they are relieved of having to pay to hear me decline and explain why.

The Importance of Client-Centered Office Space

Some therapists are not sufficiently mindful of the impact that their office — their physical space — has on their clients and what that space conveys, especially new clients. One client told me that the main reason she elected not to work with someone with whom she had consulted, “There was a large spring protruding from the couch I was invited to sit on. The couch was in terrible disrepair and so was I. I was afraid that the broken couch might be a metaphor of some kind, so I decided not to go back.” Another oft-heard complaint concerns inadequate soundproofing, and, in the case of some home offices, too many personal distractions that interfere with a sense of privacy and optimal concentration.

Some clients have spoken of their confusion and upset about not having been given clear instructions about how to locate the office and, once there, which door to enter, whether to ring the bell, and what to do when the therapist may be running late and does not immediately respond to their arrival. Sometimes the issues that we see as insignificant have a profound impact on our clients. If one agrees that a first session is often a particularly anxiety-arousing event with a more-than-likely vulnerable prospective client, then therapists should do everything possible to ensure that the journey from phone contact to first visit is as smooth and reassuring as possible.

The office bathroom can be another problem area. Client observations have included such things as broken toilets, no toilet paper, general hygienic neglect, and broken locks or no locks at all to ensure privacy. To some clients, some of these things may be hardly noticed, but to others, these moments have significant impact and may influence or determine their feelings about continuing the relationship itself. This is generally more of an issue with new clients. If one agrees that the therapeutic cathexis is likely to be to the office as well as the clinician, then appreciating the importance of an attractive, appealing, “holding (office) environment” is crucial.

Tips for Communicating with Referral Sources

One of the most common complaints I hear from those who consult with me for private practice help is that certain referral sources have stopped sending clients for reasons unclear or unknown. Curiously, some private practitioners resign themselves to the loss and quietly regret it without ever inquiring why.

Referral sources expect to be acknowledged and thanked when they send a client to your practice. They also like to be informed about the disposition of their referral and some appropriate and discreet information about how the person they sent to you is doing. When I was building my practice many years ago, I sent referral sources a one-page statement entitled, “My Treatment Approach,” (see addendum to this article) which enabled them to understand how I conduct the initial evaluation and what the client would be experiencing when they came to see me. Feedback over the years was quite positive. Some referral sources sent work my way citing this document as unlike anything they had ever received from a psychotherapist marketing a practice. I also sent referral sources articles that I had written, kept them abreast of changes to my practice. In this way, I maintained contact with them if they were considering sending a new client my way. When I have not received any referrals from a traditionally active referrer, I inquire why. Sometimes the answer is as simple as, “you just didn’t come to mind,” so my call or e-mail inquiry served to reestablish my presence.

How to Handle Termination

The problem for many clinicians here, it seems, is when a client announces a desire to end the treatment when they are ready, and their therapist is not. This is an unfortunately mishandled moment in many treatment relationships that often sours or ruptures the relationship — at times, irreparably. Some clinicians simply cannot let go and, rather than explore the client’s desire to terminate as the treatment issue it is, they wind up angrily challenging the client and becoming an adversary, rather than remaining a valuable ally. This sometimes leads to an abrupt severing of the relationship and the client will not return. He or she may seek a new therapist or, worse, may be reluctant to seek therapy again.

***

We are all very busy mental health professionals who, at times, run the risk of losing sight of the issues that have impact on our clients. Our interpersonal skills and sensitivity to client needs must go beyond the essence of the therapeutic contract. Attention to the areas of practice discussed above and the ways in which we represent ourselves has significant impact on the treatment and demonstrate respect and appreciation for the people in distress who have chosen to share their lives with us.

Addendum: My Treatment Approach

After making empathic contact, I conduct a mental status examination to arrive at as comprehensive an evaluation as possible in the initial hour. I assess motivation, capacity for insight, flexibility, frustration tolerance along with an understanding of the presenting problem and symptom constellation. I attempt to see how affects are handled, thoughts are presented, what mood is prevalent, and how well or poorly I am related to. Resistances are initially bypassed while attempting to ease the person into the therapeutic encounter.

I arrive at a psychotherapeutic diagnosis and develop a preliminary formulation of the goals of continued work. This formulation includes an understanding of what a person is seeking in his life and what seems to be blocking his or her progress and achievement. An informal “contract” is negotiated which serves as a blueprint for the therapeutic work ahead. There is early interpretation of the transference, where appropriate.

The above is done to determine whether interventive efforts should be directed at nurturing, maintaining, enhancing, or modifying inner capacities; mobilizing, improving, or changing environmental conditions; or improving the fit between inner capacities and external circumstances.

Questions for Thought and Discussion

Which of the author’s suggestions resonates most strongly with you? Not at all?

Which of his observations have you struggled with in your own practice development?

Identify three changes you can make to enhance your practice

Strengthening the Therapy Relationship with Gay Men

Posted on by Psychotherapy.net Team

In general, gay men have grown up feeling diminished in their families and beyond. The way in which they interact in the world is shaped by these experiences and so the stakes are high when they come see you. Comfort and compassion are essential components in successful treatment with gay men, and the immediate goal is to create a positive alliance. Growth takes root in this alliance, regardless of which therapeutic models or specialties you offer.

Because connection takes precedence in this moment, the paperwork that comes with this professional interaction can be put aside in favor of establishing rapport. Paperwork can wait, connection cannot.

When the client shows up to your office for psychotherapy, he will already be in a vulnerable state. His presenting issue, which is often a source of failure or shame, is accompanied by the internalized feeling that being gay is to blame. Thus, the association formed by the two of you must serve as a foundation of ongoing trust in order to explore what inherently feels dangerous to explore.

Sizing You Up

Gay male clients will be sensitive to certain aspects of interaction and particular qualities in you. Gay men are well versed in detecting safety concerns.

Do you understand him?

Are you reassuring?

Do you accept him being gay?

If you do, are you conveying it in a way that feels accepting and loving? (If he is coming to therapy based on issues pertaining to sex, intimate relationships, or compulsive behaviors, this will be especially salient).

If you are gay, do you share enough similar viewpoints for the relationship to feel safe and satisfying?

Is there a way in which the fact that you are gay actually evokes a sense of competition him?

Are you the kind of gay man he feels comfortable with — a therapist who understands his values within the community?

Is your style something he judges you for or reacts to?

If you are not gay, what are your biases, and how or when will they show up?

Are you open enough?

Whatever your orientation, do you offer the right balance of familiarity, professionalism and freshness?

As I said, the first goal at the start of new treatment is to make the connection. Remember the gay male’s history. Your client’s needs may have him looking outside of himself for acceptance, and your job at the beginning is a tough one. It is easy to fool ourselves into thinking we are doing what is right in order to make a connection, but paying attention to subtle interactional qualities is a crucial aspect of creating that necessary sense of trust. Dr. Zeig asks clinicians to imagine themselves in the consulting room: “What postures do you habitually assume? Are you unnecessarily rigid? What flexible postures can you adopt that can enhance your effectiveness?” (1)

If the client has been in therapy before, his explanation, “I wanted something new,” may warrant some exploration. Did he have a sense that his previous therapist disapproved of aspects related to him being gay? Did he come to some kind of therapy impasse? Was he having trouble translating insight into action? Whatever the reason for his having left the previous context, you’re it now, and in order to meet him where he is, you will need to appreciate his dilemma, figure out his relational style and provide the right amount of what he needs.

Keep in mind that most gay men are used to sitting on the sidelines. Showing sincere enthusiasm is inspiring, though it may take some time for him to adjust to the attention. Most clients come to therapy wanting to resolve a problem. Some are clear that it is crucial to have a good connection with the therapist in order to accomplish this, but others may not be aware of how important this aspect of therapy is.

Most gay men have grown up in unempathic environments. Thus, empathic resonance and responsiveness from the therapist are of particular importance. At the same time, the therapist’s empathic responses may fall on deaf ears as the client questions the genuineness of the interaction (2). Gay males suffering from low self-esteem are accustomed to deflecting energy from themselves and may have a knack for not accepting positive feedback. I also attribute the reaction to internalized homophobia. People with low self-esteem are more comfortable with critical feedback than praise, and they elicit values that confirm their negative self-view (3).

A quick story: A client who is not new to therapy but has just joined a group I lead reveals the tenaciousness of his low self-esteem even as he is receiving very positive feedback. This man is upbeat, attractive, articulate, and warm. When it is pointed out by the group that he exhibits these traits, his face becomes flushed, he breaks eye contact, looks down, and his posture transforms into that of a vulnerable child. Exploration of this response only brings out more embarrassment and shame. This is a man who is successful in business and to whom others respond with interest. His mysteriousness — a façade developed to hide behind — only evokes greater interest. In this moment, the uncertainty that lurks just beneath the surface is glaring.

Attunement

As therapists, we always appreciate the significance of the therapeutic relationship or we wouldn’t be working in this field. The topic is endlessly captivating. “The therapy relationship is more than a staging ground for technique, it is the primary factor in successful psychotherapy” (3).Our chief goal is to provide a meaningful experience with our clients. It is that simple. For gay men, this meaningful experience provides the greatest opportunities for change. Remember, using body awareness through experiential work, focusing on clients’ resources, and using the strength of the therapy relationship creates optimal change.

You and your client will simultaneously enjoy the rewards of using this three-prong approach. Attunement refers, in part, to this palpable shared experience. The term attunement has become popularized largely based on remarkable neuroscientific findings. Mutual physiological changes take place when people are attached to, and are in sync with, each other (4).

Your Natural Self

Whether it be your areas of expertise or your reputation that brought a client to you, being appreciative of the dynamic of the relationship is crucial. How you exhibit warmth and interest in him makes a difference. It is your natural strengths that create the greatest comfort and promote closeness. How you interact is far more important than the exact words you use. Techniques that you learn are helpful but perfecting them might be more significant for you than for your client. Your stance is that of a healer, respectful and sacred in your intentions. You are an important figure to your client, perhaps in ways he has never had in his life before.

Literature delights in affirming the significance of this relatedness. Successful therapy depends much more on the connection, empathy, and mutual fondness that develop between a gay client and therapist than any other attribute of the therapist. “What is healing as the client experiences being at one with the therapist.” (5). It is more important that the therapist direct efforts towards appreciating the client’s experience than focusing on what really happened. This perspective centers on the client’s affective experience.

Now, in current work with gay men, we can explore sensory experiences too. This opens up a treasure chest of possibilities because somewhere inside are his resources. Perhaps they have been dormant for years, but with caring guidance they can be elicited from deep inside. Research indicates that within the context of healthy relationships, individuals are able to gain experience of identity, meaning, choice, and love. The combination of these produces hope and resiliency. We discover our value, stretch our limits, gain new abilities, and collaboratively create a meaning for our existence (Short, 2010, pp. 301, 302). Authenticity opens to creativity and collaboration; the powerful mixture leads to success in the therapy.

Attunement in Action:

Create an inviting, informal atmosphere.

Use your eyes to make contact with your clients.

Be aware of your body language and show yourself to be open and welcoming.

Use your intuition to create a relational match by joining the client in his ways of perceiving things and living life.

Trust the unique ways in which information comes to you as you sit with your client. Utilize them.

Use humor with purpose in order to promote closeness or emphasize a point.

Strive to make a powerful connection that is profoundly experienced by both of you.

Focus on experience rather than technique.

Authority Figures

For gay men, positive experiences with authority figures are few and far between. Most gay men have concealed their identity or behaviors, recognizing that there was always the danger that people in positions of authority would be disapproving. I still find that many clients don’t tell their physicians they are gay, despite being sexually active. They are afraid their physician will react negatively, and the need for interpersonal harmony surpasses anything else. Of course, it is of the utmost importance to maintain good physical health, get regular HIV tests and immunizations for hepatitis, and to have safe-sex discussions. If a physician or therapist is perceived as being disapproving, the option of another provider is always a good one, yet secrecy is the default mode for many men. They forget that they have other options. This scenario happens just as often in psychotherapy, especially where sex and use of substances are concerned.

What Does it Mean to be Gay Affirmative?

I have highlighted that gay male clients flourish through your ability to notice and utilize their resources. This is the magic you can easily provide. Although it isn’t difficult, it often is forgotten amidst the therapy protocols and the current emphasis on identifying treatment goals. Clients are the best at self-pathologizing. Gay liberation itself is still fairly young (early 1970s); affirmative therapy for gay males is even younger.

Before 1990, there was ample literature to support the idea that conversion from homosexual to heterosexual was a preferred intervention. Some therapists believed it was in the best interest of their clients to change their sexual orientation, given that it is impossible for a gay man to live a happy life or have a stable relationship (6). There is still conservative religious literature that supports this perspective, but it is less common than before.

There is now consensus that it is damaging to a person to attempt reparative or conversion therapy with him. I am surprised at how often I get referrals of men who were treated with conversion as the goal. However, more common these days than outright suggestions for conversion is the perception of disapproving attitudes from psychotherapists that negatively reinforce a client’s feeling about being gay. Often these therapists are seen as rejecting and uncaring, though I would guess that many of them are actually just unaware of how they are coming across to their clients.

People who grow up with healthy authorities may not recognize that a gay man has tended to the needs of the authority figures (including parents) in his life by keeping quiet and hiding his secrets. Therefore, a client may recreate in therapy a dynamic he had with his parents by remaining hidden. The need to be compliant or good prevails. Therapists need to be on the lookout for such a dynamic and create a tone that implies mutual openness and acceptance.

The bottom line is that accepting your client for being gay is essential. A wonderful description of gay-affirmative therapy states: “Psychotherapy can result in change, although this is the secondary goal to creating an experience of empathic contact for the patient, whether or not change takes place” (2). Right on. Making this connection will be as useful as anything else.

Perhaps the best way to provide affirming therapy is to accept and affirm that you care for your client. Then you find a way to join him in his views and sensibilities. The therapist’s ability to be reliable provides a milieu that aids the patient in experiencing “twinship.” Sensitivity and empathy affirm that patient’s sense of self (2). Internalization of these interactions can lead to significant internal structural expansion and cohesion.

A Gay Affirmative Perspective in Action

You want your client to feel comfortable, valuable, proud about being gay, and for him to know that you are in accord with his true self. You can do this by finding avenues of connection with him, as a person, not just as a client.

Allow yourself to appreciate how you respect him, where your commonalities intersect, and how your differences are intriguing to each other. This way of relating is not didactic, but rather it is intuitive and emotional. Either you both will feel it, or you won’t. There is no need to try too hard to win him over, the way that you effortlessly relate is the win.

Script: Seeing and Knowing You

This script was inspired by a client sharing his difficult experiences of coming out in college. Because these struggles were having an effect on his coursework, his professor asked to meet to offer him support. His memory of receiving nurturance all those years ago was so profound that he describes it as a turning point in his life. Ironically, he remembers nothing about what was said. Instead, he vividly recalls the feeling of being cared for in this special relationship. The lamp that was shining on his professor’s desk figures prominently in his memory. The visual representation of this lamp still captivates him and represents the richness of this experience, even 30 years later.

I am struck by how other clients report similar types of childhood or young adult memories, often with neighbors, grandparents, aunts, uncles, or other people who shared their love.

This script can be used as a reminder that there were people in the past whose nurturance made a lifetime of difference. In addition, I use this script at conferences and with therapists to remind them about having had significant moments like this in their own past.

For traumatized clients who cannot conjure up anybody who provided this type of experience, a family pet or a childhood toy can be used.

“Allow a time in your past to come to you when you may have felt awkward, just a little bit different from others, or perhaps you felt alone. It might have been as a child or as a teenager, and you can look back and appreciate what it was like for you then, remembering the ways that you may have held yourself back, or constrained yourself. You can even assume that position in your body right now.

You can also appreciate how time has shifted for you now, since you are no longer at that place anymore.

Now, remember a person back then who could see you and know you for who you really were, and for what you needed at that moment in time. You can appreciate how it feels that you knew that he or she cared about you, how lucky you were and are to know that he or she cared. This caring person may not have even verbalized the ways that he or she could appreciate you, or the ways that you mattered, but you just knew this was so. You simply knew this by the way the person looked at you, spoke to you, or did something special, just for you. Appreciate the way it feels inside.

It may have been a teacher, a doctor, an aunt or uncle, or perhaps a neighbor who noticed you and took care of you in just the right ways. In your mind, you can see what this person looks like, where you were back then, and what the surroundings looked like back then. You might even remember the sounds or smells back then. That is right.

This person could see you for who you really were and really are, and was able to offer you love and support, and it felt so very special. It was just what you needed. Appreciate how it feels now and assume that position in your body. That is right.”

“If I Can, So Can You”

I provide experiences that help my clients feel alive through my own interactive stance. Near the start of treatment I say: “What you see is what you get.” In addition, I am mindful of my posture, movements, tone of voice and use of eye contact, all to imply an available informal stance that encourages the same of them. This mindset provides gay men with new opportunities. It is met with great relief, especially for clients who have had more aloof therapists in the past.

Clients are grateful to experience this positive energy and it elicits a new way of being: My informal use of self serves as a role model with its intrinsic message of acceptance of being gay. Just being myself has proven to be the most successful therapeutic tool in the room. Again, behind the curtain of any therapy technique should be authenticity: this is what allows for the power of any given technique to come through.

A quick story about my client Thomas: He was raised Mormon and says he envies the confidence of his Jewish friends. Turns out, his therapist, me, is Jewish and gay. I was excited from the start that he was willing to use the energy between us as a part of therapy; it is just how I love to work.

While exploring career stagnation, he describes a scene in hypnosis that suggests a dynamic between us. It hadn’t occurred to me until months later when I re-read my notes that the person he described might be me. It reflects how powerfully the relationship in therapy is experienced, even when it isn’t in full conscious awareness.

“There is a man in the foreground, standing in water. It is some kind of a pond or a lake. There is a reflection of a forest behind him, and the background is green and black. The sun is focused on this man. He is smiling with his head tilted, looking friendly, but strong and inviting.”

Perhaps the sun that focuses on me symbolizes the success he perceives in me, or me in him. I often am inviting him to leap into the depths of the water, either with me, or for himself.

The next excerpt brings Brad back. Here you get a glimpse of what the weave of therapeutic alliance, experiential work, and calling forth the client’s resources looks like in session.

Brad

Thinking about his growth in therapy, Brad is very clear: “Love is wanting someone who truly wants me, rather than my settling for his approval of me. I have been waiting too much for permission from men. I deserve to have a man offer me what it is that I want, and it is exciting that I am beginning to be self- directed now. I am going against the old voices I have lived with for years.”

In exploring ongoing themes, he describes, “When I am faggy, I am faggy by choice, no more editing of myself!”

Knowing how much he enjoys being creative in hypnosis, I decide to embrace his “faggy” stance in a way that symbolizes resourcefulness. I ask him to describe a memory when feeling this way was wonderful. (This was all with his eyes closed, in hypnosis, where he could let himself go more than usual.) He recalls going to the disco in the late 1970s: “Everybody was happy, celebrating their gayness and having a ball on the dance floor, uninhibited and free.”

When I ask which “faggy” song was playing — reflecting back his use of the word “faggy” in a light and easy way — he answers: “‘I Feel Love’ by Donna Summer.” Since we grew up in the same era, we spend a few moments mutually sharing our enjoyment of these times. I continue with this theme.

I ask him to bring this feeling of being free to a time in his past when he would have liked or needed more of it.

“I am in the way back of my parents’ station wagon. This was a place where I would go to in order to escape from them and try my best to feel free from them.” Knowing that he is a wonderful singer, and assuming that his singing will be a powerful experiential moment, I then ask him to sing the song out loud. I am right. It is a powerful and intimate moment. I push him to push himself further than he usually does, and I also participate in enjoying the depths of this intimate moment, one of the more intimate moments in my career.

He begins meekly:

“Ooh

It's so good, it's so good It's so good, it's so good It's so good

Ooh

You and me, you and me

You and me, you and me You and me

Ooh

It's so good, it's so good It's so good, it's so good It's so good

I feel love, love, love, love, I feel love.”

He is very self-conscious, but he continues. It is incredible. I ask him to describe what happens next. “You are driving the car, the music is blaring, I am in the way back and the lights are blinking, like the lights in the disco. We are now at a red light, where the people in other cars watch us.”

He is emphatic: “Turn up the volume, Rick!”

I had turned up the volume by asking him to sing, and gladly turn up the volume again in this important moment.

With tears, he says, “This is so incredibly hard. I want to be somewhere where all of this is okay, and it is right here.”

Experiences Unite

The success you achieve with your clients comes from your ability to join your client in his world. This often feels like a trance state or state of flow where everything else goes away and it is just the two of you. This ability to join involves the challenging task of putting your own perceptions and experiences aside.

However, in a trance state it can feel effortless. Martha Stark describes the tension between decentering in order to lose herself in the client’s experience, while recentering in order to give her authentic self to her client. Though she does not do hypnosis, it certainly is hypnotic.

A client sitting with his eyes closed and allowing the therapist to guide his experience is in a vulnerable position. In these moments, the client is no longer able to reference the therapist’s facial expressions to judge how the emotional interaction is proceeding. Trust is paramount and should be well established before embarking on this type of work, and one should only proceed with the client’s full permission.

The payoff for those who can establish comfort with vulnerability is that therapist and client together have greater access to the richness of the client’s internal world. This happens through joint exploration and joint experience. Clinician and client follow each other’s leads, and at the same time, each takes the lead.

The experience is mutual: a deep state that is creatively assembled and experienced with and for each other. This is interpersonal trance. The therapist’s unconscious mind tunes into the client’s unconscious messages, feelings, and needs. The therapist involved in this trance activity is better able to resonate empathetically with the client, and to meet his unconscious needs. As both experience a receptive trance, the client is also experiencing an interactive, interpersonal state of high resonance. The internal resources of therapist become available to him.

Even though this is done experientially, the experience is processed consciously, and the client not only has the benefit of what came up while doing this work, but also has the benefit of expanding on the respectful and loving experiences within him.

Often, while doing hypnosis, I am aware that I am talking to the child, and that he is responding to me both as child and as adult. Thus, I exaggerate the softness or the kindness in my voice during these moments. The client is often nodding his head, receiving my voice — its cadence and tone — as though listening to a lullaby. Inevitably the experience of being understood and appreciated moves clients to tears. Milton Erickson believed the therapist’s role to be a surrogate parent, and I concur.

The brief excerpt that follows provides a snippet from a much longer hypnosis in which I placed emphasis on being relational and tailoring the session to build on the solidity of my connection with the client.

Bud

Bud was having difficulty moving out of his parents’ home and establishing an independent life. Together we go on a journey, traveling by car.

Me: “And even though I am driving the car, I wouldn’t know where to go unless you gave me directions, because you are the navigator and all I am doing is following your directions.”

Bud: “We are still in the car; you are continuing to drive me past all the dark places. And you know exactly where to go, you know where to take me, I can’t do this alone. Please don’t leave.”

Me: “And you can trust, Bud, that I am here for you, that I am not going to drive away. And I wonder if you can appreciate moments when you sit here with me during a session, and moments when you leave a session, and I am not with you anymore, and yet I am with you at the same time.”

Bud: (Nodding his head) “That feels very manageable, very reassuring. Not so scary. Manageable. It doesn’t feel as scary, or lonely. I can hear you in the back of my mind telling me I can do this; I can manage this. It feels good. It makes me feel like I can do this. I can hear you saying, ‘You can do this; you can get through this.’”

“I Am Here for You”

Earlier I talked about the significance of maintaining a “You can” position for our clients. Another important stance is “I am here for you.”

I say or imply this often, and with great sincerity. It cuts through many protective layers when offered at the right moments. Sometimes I directly say this in hypnosis. If a client is struggling with pain, I want him to know that he doesn’t have to hold it by himself. This is a hard allowance for men who have been denied and have denied themselves the availability of others and of love.

Jason

Jason is a client with a painful history of sexual abuse, alcoholism, physical abuse and emotional neglect. He has learned to quietly excel in his own private world. Although it appears that he is successful and gregarious, and has many close friends, he is actually a loner and keeps himself well hidden from others.

Over the course of his sessions, it is clear that he is doing with me what he does with others, deflecting and hiding. One day I decide to take a big risk.

I ask him if he knows that I am really there for him. Tears come to his eyes. “I am here for you, Jason. And I will continue to be here for you.” These words are magic to him. He continues to weep, relieved and moved.

Later he expressed many times that this was a pivotal moment in his life. “It was the first time I could believe the truth of this: Rick is and was there for me.”

Going Deeper into the Relationship: Dealing with Conflict

When you sense that your client is having a struggle with you, do you encourage him to speak about it?

Do you ask him to describe what he needs from you?

Are there times that you avoid these kinds of conversations?

Do you find yourself giving in to your fear about pushing your client?

How many times has your client had struggles with an authority figure and not been able to discuss it?

Many of us simply prefer to avoid these kinds of discussions and instead stay focused solely on the client’s symptoms and presenting problems. In doing this, we miss out on rich moments. We hope that the connections with our clients provide lasting changes, and that our relationship provides the love of a parental figure. It does, and yet there needs to be more: working through the resolution of conflict is a crucial piece. It adds richness to the therapeutic experience, particularly with clients who stay for longer treatment.

Dealing and working through conflict in the context of the therapy relationship is a must because a gay client’s history with conflict may simply consist of avoidance. But in life conflict is inevitable; now is his chance to move through it in a different way. The question is, will you meet him there?

Whose Fault Is This Anyway?

Apologies and countertransference disclosers are crucial to successful therapy with gay men. The shame that gay clients feel is often manifested in accepting responsibility for painful experiences that are externally prompted. An empathic lapse by the therapist often becomes a source of self-criticism for the client.

I recall once in a group I was leading that I made a joke that turned out to be at one of the participant’s expense. As soon as I blurted out the joke, the group came to Todd’s rescue making clear that my comment was too gruff. It would have been tempting to rush to my own defense, “explaining” what I really meant, in order to save face. Of course, this would have also further isolated the participant and put the group in a dilemma.

Instead, I contacted him immediately following the meeting and apologized. And in the next meeting I took responsibility by reiterating to the group what Todd and I had talked about. It was important for the group, and Todd verified how important it was for him to have me apologize.

Martha Stark discusses “The New Good –The Old Bad;” The unconscious wish on the client’s part to engage the therapist in a reenactment of his internal dramas, with the therapist assigned the position of the powerful parent, and at times the po

The Costs and Benefits of Virtual Reality in Psychotherapy

Posted on by Psychotherapy.net Team

Learning to Weather a Patient’s Emotional Storms

Edith typically experienced a fire-hose intensity in the flow of her emotions. She would dye her hair in bright colors, and these colors changed almost as often as her moods. She could be washed over by waves of anger or sadness. She frequently stormed in rage at her caregivers in the nursing home, or on the phone with her son. During psychotherapy conversations, her anger often dissolved into tears. The symptomatic features of her Bipolar I disorder were like a flashing neon sign on her forehead.

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Part of the therapeutic work with Edith’s case was to educate the staff that her dramatic and unpredictable swings of mood from manic to depressed and her sometimes rapid speaking were elements of her illness. Edith would also verbalize sharply critical comments to her caregivers: “You don’t even care, you don’t listen, what do you get paid for, anyway!” I thought it was important to help the staff to appreciate how reacting with strong personal emotions to her symptomatic behaviors might provoke even greater instability. They were taught to maintain a sense of role boundaries, avoid personalizing her actions or comments, establish clear expectations for daily care, set limits on unreasonable or unacceptable behaviors, and see how those steps would add to the effectiveness of their care and to their professional satisfaction.

The Pain of Virtual Rejection

One morning upon greeting Edith, I was assailed with, “My fiancé dumped me!” As I sat down, I thought, “what fiancé?” She’d not been in a relationship. Edith had a tablet computer and spent many hours playing a virtual reality game. Her avatar was a slim and pretty lady who owned a florist shop and was a personal fitness trainer. As she was interacting that morning with the male fiancé avatar, another female avatar approached and claimed that he was her boyfriend, and the male character “virtually” walked away with the other female character.

In response to our conversation, Edith was able to acknowledge that she had designed her avatar as an entertainment, and a partial fulfillment of things desired yet not available in her present life. But she was unable, at that moment, to realistically distinguish between herself and her fantasy avatar, or to distinguish her emotions from those she projected onto the avatar. The stress of the situation triggered a psychotic episode for Edith. She experienced a loss of ego-boundaries.

I consulted with team members at the facility about ways to manage Edith’s care and treatment. Psychiatric hospital care was not indicated because she made no threats to herself or to others, and an involuntary admission might add to her sense of rejection from persons and supports available to her at the home. Safety checks every 15 minutes were unobtrusively put in place, and staff would make frequent, brief contacts to help her regain her sense of self and her composure. Privately, I wondered if one day I might need to develop a therapy avatar and enter virtual reality settings to conduct therapy interventions.

Four years later, I worked again with Edith at a different nursing home. She had been living in an apartment and was helped by home-based care providers. She’d become ill with an infection, went to the hospital, then to the nursing home for further care prior to discharge home. Since I last worked with her, Edith had experienced significant diminishments in her eyesight, her memory, her mobility, and her overall functioning. She did not remember having worked with me in the past. As we sat for therapy one morning, Edith said that she’d been trying to compose and memorize a poem, because she could not write due to visual loss.

She dictated the poem, and I wrote it down so she could bring it home with her. In her poem, Edith was confronting the many losses she’d experienced, and additional ones she anticipated. Her poetic reflections were sorrowful yet realistic and reasonable given her situation. She showed no indications of psychotic symptoms and was no longer using a virtual reality game. “I know it’s getting darker for me,” she said, “But I just have to face it.” Her medical condition had worsened over time, yet she showed an improved psychological ability to deal with her circumstances. Edith was also more comfortably willing to rely on people in her life who provided helpful services.

***

Postscript: Virtual reality systems are playing an increasingly prominent role in entertainment, education, business, and in the treatment of mental illnesses. Will the use of virtual reality be a positive influence in all cases, or might it be risky or possibly harmful for some? Might virtual reality headsets be a sort of psychosis-induction device for some vulnerable people? How will we as psychotherapists better understand how risks and benefits of virtual reality might vary for different people? Time, experience, and research findings will help guide our future steps. But we can at least proceed with a sense of caution, as well as curiosity about potential new and helpful approaches.

Questions for Thought and Discussion

How might you have clinically addressed the situation with Edith and her virtual fiancé?

What are your thoughts about the use of AI in psychotherapy?

Would you like to gain familiarity with AI in therapy? If so, what kind and for what purpose(s)?