Category: Therapeutic Issue

Stealing a Passage Home: Narrative Therapy to Re-claim Honesty

Posted on by Psychotherapy.net Team

First Meeting: Dignity and Grace

What I most remember about my first meeting with 12-year-old Dilip were his deep brown eyes which spoke to me of a tenderness and sadness that I am not used to witnessing in boys of his age. He was accompanied by his mother, Sangita, who entered my room with the grace and dignity that came to characterize her in every one of our meetings. I didn’t know then how much suffering that dignity and grace had survived.

Sangita had explained to me on the phone that she was desperately worried about her son who had been stealing for some years from family members and shopkeepers. More recently the stealing and lying had spread to friends’ houses and to school, sites that had previously been exempt. Dilip’s intelligence was clear in everything he did. He had recently helped draw up plans for his mother’s projects on her architectural design course, including 3D movies and elevations. Sangita proudly told me how he had set up his own business repairing electrical items he had found on the roadside in “inorganic rubbish collections” and then successfully selling them online to help raise money for his family when times had been hard.

She told me how she and her husband, Kulwinder, would lie awake at night contemplating how Dilip’s entrepreneurial abilities might take him in the “wrong” direction in life and how his prodigious intelligence might be put to ill use. Sangita confided in me that they were worried that one day they might “see him behind bars.” I marvelled as I looked into this young man’s eyes. He seemed like a vulnerable innocent — not an enterprising entrepreneur with a dubious life ahead of him.

Sangita’s voice quietened, and her face became strained as she began to relate to me how Dilip’s brother, Harman, had been diagnosed with leukaemia five years previously and was now in remission. She spoke carefully and softly with the matter-of-fact-ness of someone for whom devastating events have become routine. She told me how they had only been told of the diagnosis shortly after they had left India and arrived to start a new life in New Zealand.

Kulwinder and Sangita had taken Harman with them, ahead of the other children who were to remain in India until their parents had found a home and work and had applied to become New Zealand residents. Dilip was to remain with Sangita’s in-laws and, because they had room for only one child, Dilip’s younger sister Ravi went to live with family friends nearby. Kulwinder and Sangita had adopted Ravi after the Indian earthquake of 2001 when she was four months old. She required special and tender care as she had not only been orphaned by the earthquake but also suffered from Autism and Dyspraxia.

Sangita leaned forward as if her shoulders were struggling to hold the weight of her story. She told me how she had returned to India to visit Dilip and Ravi. No sooner had her feet touched Indian soil when Kulwinder phoned her from New Zealand and broke the desperate news that Harman had a severe form of Leukaemia which had already spread to 98% of his body. He had immediately been admitted to hospital where he had begun radical treatment.

She told me how the doctors broke the news that he would be starting intensive chemotherapy and would “need his mother.” Faced with the knowledge that Harman was unable to receive the treatment that he desperately required in India, Sangita and Kulwinder made the difficult choice that they should remain in New Zealand with him. Torn between her children, Sangita was given a visa to return whilst their residency application, already delayed for a year, was being processed. She returned to New Zealand, little knowing that it would be more than two painful years before the family would be reunited.

As they had yet to become New Zealand residents, they were not covered by New Zealand medical care and had to meet the expenses themselves. To do this, they had to draw upon their savings and that of many of their family back home, running up bills of half a million dollars for their son’s radical treatment.

Somewhat shaken by Sangita’s story, I silently held her eyes to acknowledge the pain which she had conveyed with such dignity. Together, we then turned to look at Dilip. Dilip’s eyes had remained downcast throughout his mother’s tale. Collecting myself, I realised that I must turn my attention to him and the impact of his mother’s account. In his eyes, if not in my own, the stealing problem would have centre stage. Only too aware of Dilip’s nervousness and the likely embarrassment that a stealing problem might have brought upon him, I was quick to externalise the apparent problem and to add lightness to the tone of my voice. I said, “Dilip, your mum tells me that she has been worried because she thinks that there is a stealing problem that has been trying to take over your life and that is why she has asked us to meet. Is that what you thought too?”

Dilip uttered a barely audible “yes.”

I gently enquired when the stealing problem had first come along and how it had made its presence felt in his life. He informed me that it had begun when he was five, during the time he had been left behind with family in India, anticipating his reunion with his family in New Zealand.

Speaking through her tears, Sangita, told me, “He was not sure we would call him back. He was so angry that twice we had to cancel his return because of Harman’s illness and problems with the visa. He told us that he would only believe that he was coming to us when he was sitting on the plane. Many times, Kulwinder called him because our relatives said that he was bullying other kids. Even the bus driver was not willing to take him on his school bus. When Kulwinder called him, Dilip was not saying anything. He was just silent. His father was angry that every day we were counting each dollar because Harman’s treatment was so expensive, and Dilip didn’t speak when we called. Kulwinder said that it was not worth phoning him anymore. We had been telling Dilip that he would be coming soon, but in the last few months, he lost patience and said ‘every time I pack my bags nothing happens. I will only believe I am coming to New Zealand when I am on the plane.’ Our family in India had a servant who had known Dilip from birth. One day he called me and ordered me to ‘come here and take this child or pack up and come back to India.’ It was a very bad time for all of us.”

“Did he have some idea of what was going on in Dilip’s heart?” I asked.

“Yes,” she replied.

“Would he have said that his heart was breaking?” Sangita nodded, tears on her cheeks. “Dilip, was your five-, six- or seven-year-old heart breaking?” I asked.

“Yes,” he replied. “Was it heart-breaking for your mum and dad that your heart was breaking?” Sangita began to sob. “Have you talked about these matters like this before?” I enquired.

“Never,” she choked out through her tears.

“Had your family’s heart been breaking in that time? Not just your heart and Dilip’s heart but your husband’s heart and perhaps your daughter’s heart?”

“Yes,” Sangita replied.

I noticed that Dilip was sitting uncomfortably on the edge of his seat. I thought to ask him whether he would prefer it if we were to speak alone. Before I did so, Sangita swiftly looked at her son and said, “He wants me to sit outside.” Dilip nodded and she discreetly left the room.

To lighten the sadness that had fallen upon the room, I wondered aloud, “Is this stealing problem an international stealing problem that has followed you across continents?” The corners of Dilip’s mouth rose slightly.

“Did you know,” I enquired, “that, in all the time that I have talked with young people about the problems that have bothered them, I have discovered that sometimes problems start out trying to be helpful and only later become troublesome? Might that possibly be true of the stealing? Did the stealing try to help in any way with the sadness of being left behind in India and the sadness for your brother in his illness?”

Dilip replied, “Yes, maybe it took the sadness away a bit. It did help to start with!” Dilip’s body seemed to relax, and his eyes focussed intently upon me. Alarm crossed his face and tears filled his eyes as he said, “I wasn’t sure they would call me back.”

I said, “Call you back? Do you mean that you didn’t know whether or not you would ever be called back to live with your family again in New Zealand?” Dilip nodded. “Dilip, does anybody know just how sad you have been?” Dilip shook his head slowly and thoughtfully.

“No one knows. I don’t want my mum and my family to be sad.”

Realising that this sadness was at the heart of the problem but also knowing that I must tread carefully, I gently asked, “Dilip, would you mind if I try to understand a little more about this sadness?” He hesitated but then nodded his approval. “Could I start by asking you how big the sadness has been?” He looked a little confused. “If we could measure the sadness [a concept of David Epston’s creation], and let’s say the most sadness there could ever be is the width of this room which is, oh, about three metres, how much sadness was there in India when you feared they wouldn’t call you to live with them in New Zealand?”

“Two and a half metres,” Dilip replied with considerable certainty.

“And how much sadness is there now here in New Zealand?” It turned out that now there was between one and one and a half metres of sadness remaining. When I enquired, Dilip told me that the remaining sadness came from missing the family he had left behind in India.

“They keep coming to visit but they can’t stay because of their visas. I don’t want them to be sad either.”

I asked, “Are you worried that they will be sad if they know of your sadness in the same way that you are worried that your mother and your family might be saddened by your sadness?” Dilip held my gaze intently as he nodded in agreement. I gently asked if he thought that talking about their shared sadness would bring about more sadness for everyone.

Timidly he said, “Talking will make them more sad. I don’t want them to know.”

Sensing that our conversation might be on the verge of being overwhelming for him, I asked him if he thought it was time to welcome his mother back into the room. He nodded, adding, “But I don’t want to talk about what happened.”

Aware that the sadness was key if Dilip and his family were to be rescued from the effects of his stealing reputation, but also mindful of the need to honour Dilip’s tenderness, I asked him if I could briefly mention that we had talked about his life in India and how the stealing had come about. He nodded.

“Could I also mention the sadness and how it had become less since he had been reunited with his family?”

Dilip nodded hesitantly but went himself to invite his mother to return.

Sangita came into the room hesitantly. I pondered how much hope she had pinned on the time I had spent alone with Dilip.

“Sangita, Dilip and I have been talking about his time away from you all in India and how the stealing began. He felt very sad whilst he was without you but, since returning to be with you, the sadness is very much less.”

I saw Sangita’s tears begin. Mother and son glanced at each other. The sadness was palpable.

“Sangita,” I ventured, “have you talked together as a family about all that has happened to Harman and to each of you?” Dilip’s eyes widened in what suggested to me renewed alarm. “No, not even Kulwinder and I have talked.”

I asked, “Has the strength that this ordeal required of you left little room or time for really feeling or really talking?”

“Yes,” she replied. “Every year something big is happening. When I was saying goodbye to my brother-in-law at the airport last week, he said, ‘In your life it is always headlines, not small news.’ There are always big things happening. When Harman got sick there was no one. We were here alone. There has been no time to talk.”

I realised that for the previous few years, the family had been just surviving all that had happened and had not had the opportunity to reflect. I was also aware of the need to honour the tenderness of this family who had lived through so much with grace and dignity. Contemplating the way forwards, I felt unable to venture further into the territory of their sadness. To do so would have been to trespass unnecessarily into their pain when surely there were other routes available. With this in mind, I asked, “If we were to find a way to try to put the sadness to rest without talking about it directly, would that seem helpful?” Sangita and Dilip, without reference to each other, nodded in unison.

“How are you hoping that our conversations together might help Dilip and your family?” I enquired.

Sangita gazed at me for a moment and then said, as if uttering a prayer, “we want to know him better again. I would like to try to help the sadness not to come into his life again. I would like him to be happy.”

Second Meeting: Honesty as a Way through Sadness

A week later, Kulwinder was the first to put his head around my door. I had hoped that he might join us. Dilip and Sangita followed. With Dilip’s and Sangita’s permission, I summarized for Kulwinder our conversation of the week before. Kulwinder quietly took in my words. I proposed that whilst talking might be one way, there are other ways to tend to wounds. Turning to Dilip, I asked, “Am I right in thinking that your family’s suffering make you suffer?” He nodded without hesitation. “May I speak a little about your suffering as I understand it?” The family nodded their consent.

“This family has endured much. Many people have told me that when there is too much suffering, they come to believe it is better not to talk about it. Instead, they decide to get on as best they can with their lives. And they say that has worked for them for a while. But then they tell me that the suffering and sadness catch up with them; it can reach them in the strangest ways. I am not sure about this, but could the stealing have been a way to draw others to the suffering that you have all gone through? It is a measure of this family’s wonderful dignity, endurance, and perseverance that you have not cracked under the pressure of so much suffering and sadness.

“Dilip, you are a very young man and I think you can help your family out of their sadness. I know it is odd to turn for help to one of the very youngest as usually we turn to the eldest. But you are different. You have talents which show that you are a very quick learner. What you can do — and we all will help you with it — is to prove once and for all, beyond a shadow of doubt, that you are an honest boy, son, and man to be. When you do, I will ask your family to show you their happiness and, when you think people are happy enough, then, and only then, we will talk about the sadness from the past. Then we will see how everyone can be together in sickness and in health as a wonderful family who suffers and has suffered. And, Dilip, you will always know when you grow up that it was you who led the way from sadness to happiness for a family who has had more sorrow than almost any other I have known. But yours is also one of the strongest families I have met, and I am proud to know you all.”

Turning to Dilip, I addressed him alone.

“Dilip, I am going to suggest a way of restoring your reputation as an honest person. You won’t need to talk about your feelings right now. Would you be interested in such a way, even if I were to tell you that for it to work I cannot reveal to you exactly what it involves, and you will only discover this over time?”

Surprised, Dilip looked towards me, a shy enthusiasm for the project I had outlined beginning to light up his face. He nodded and then looked to his parents who nodded their assent. I said, “This is an idea that has worked many, many times before. Do you trust me that I have a way to prove beyond a shadow of a doubt that you are either a stealer or an honest boy?” Dilip’s eyes grew wider, this time with intrigue. He mouthed a silent “Yes.” I added, “I cannot give you all the details now, but next week I can meet with you all and we can begin. Today, could you help me understand more about the stealing and the reputation it has left you with?” Dilip, Sangita, and Kulwinder nodded in agreement.

I said, “Now, to begin, I need to know who in your life cares whether you are an honest boy or a stealer [Family members and friends are recruited as members of the young person’s community for the restoration of honesty].”

Dilip looked for assistance from his mother, who replied, “Well, his grandmother. She cares for him very much.” Then directing herself to Dilip added, “And your uncle, my sister, your brother, and your teacher. She is very much worried about you.”

I asked, “Is there anyone else in India who particularly cares about Dilip’s reputation as a stealer?”

“His grandparents and my father in particular” ventured Kulwinder. “Not everyone in our family knows but my parents are worried about his future and about what will happen if the stealing and lying grow with him.”

“And Arthur and Julie and Daniel,” added Sangita.

“Who are Arthur and Julie and Daniel?” I enquired.

“Arthur,” Sangita replied, “is an elderly man who is a friend of the family. He is very fond of Dilip and Dilip is very fond of him. Arthur lets Dilip spend time with him in his workshop, he shows him how to use tools and make all sorts of things. Daniel is Dilip’s school friend and Julie is his mother. Julie was the first person who talked to us about the stealing in New Zealand. She carries a loving heart. She didn’t want to punish him. She just talked kindly to Dilip. After that I told Dilip not to go to anyone’s house anymore.”

I ask, “Dilip, how has the stealing affected these people who care about you? [The effects of relationships of the stealing reputation are established] Let’s take your grandfather for example.” Dilip remained silent until Kulwinder rushed to his rescue.

“His Granddad — Sangita’s father — is worried about what will happen to his life. My parents love him very much and you know what it is like when a loved one is not on the right path. It is very hurtful. It breaks your heart.”

I ask, “And Dilip, what do you think the effects will be upon these people who care about you when they find out that, beyond a shadow of a doubt, you are now an honest boy and honest son? Can we start with your Granddad?”

Dilip looked surprised by my question but seemed to be sticking with it. I offered a question to scaffold his response.

“When he finds out, will he call on the phone or send you an email? What will he say?”

“He will be happy,” Dilip said shyly. I asked him a question closer to home.

“Do you have any idea what a reputation for honesty would mean to your parents?”

Dilip replied, “It would bring peace and happiness to their hearts.” Sangita, tears in her eyes, looked to her son and replied to my question.

“We love him very much. Knowing that Dilip is an honest boy would be the biggest gift to us. The stealing has weighed on our hearts. We have come to feel that we cannot believe in what he says. It will take time for us to know if he becomes honest again. We have to be sure his honesty is real.”

Third Meeting: The Idea is Revealed

“Dilip, as I said, this is a tried and tested way for you to prove that you have regained your honesty. Are you sure you want to go ahead?” Dilip nodded hard. “Okay, I am going to propose that you are honesty tested.” The family looked at me quizzically. “Dilip, as these are tests, I cannot tell you the details because if I did it would mean you were not being tested. The honesty tests will take place over a period of time. Your parents will decide how long the tests will take — it could be weeks or months — to satisfy them that you are honest. When the time comes, when you have proven beyond a shadow of a doubt that you have redeemed your reputation as an honest young man, we will hold an honesty party to celebrate. Now, if you are sure you wish to go ahead with the honesty testing, let us shake hands to confirm our trust in one another.”

Dilip dutifully placed his hand in mine and the deal was sealed with a firm handshake [Consent is given for honesty testing to restore an honest reputation].

“Dilip, now I am going to meet privately with your parents to let them know what this challenge to restore your honesty involves. Then you and I have a letter to write.”

After Dilip had left the room, I outlined for his parents how we might set the honesty tests [Setting up the process of honesty testing].

“Over the next few weeks or months, you will set Dilip tests which will confirm him as either an honest boy or a stealer. These must be carefully planned so that he has no idea they are tests. Just to give you some idea of what other families have done in the past, I can tell you that some parents have left change where it is visible when they have left their child briefly alone in the car. Others have left money on the hall table, etc. The tests should vary in location and be as unpredictable as possible. It would be a good idea to involve Dilip’s supporters. For example, you may want to ask Arthur or Julie to set some of the tests in their homes. It is up to you to decide how long you continue to set more honesty tests. It is all a matter of how much time and how many successful tests you think you need to be convinced that your son is truly honest. After that you might like to consider a further period of probation without tests until you are both sure that he has restored his honesty.”

Kulwinder and Sangita decided on a period of three to four months during which Dilip would have to face the challenge of six tests followed by a probation period of three to four weeks. After they had asked a few questions, I explained that it is vital to the success of the tests that others who care for their son are enrolled as witnesses. To that end, I would assist Dilip to write a letter in which he would formally disavow his stealing habit and declare in writing how he wished to renew his honesty. Dilip would be expected to post or email this letter to the concerned parties or read it to them over the phone. Immediately after each test had been completed Dilip would be required to call or contact each person on his “honesty team” to declare the result revealed to him by his parents.

Dilip returned, and we slowly and carefully crafted the following letter to send to his honesty supporters. In collaboration, we composed the letter by way of an extended enquiry which was continually interrupted so I could write down his answers [Co-crafting of letters].

Dear Granddad, Grandma, Uncle Sanu, Uncle Achyuta, Auntie Amrita, Auntie Pavani, Arthur, Julie, Daniel,

I would like to ask you for your help in changing my reputation. As you may well know, I have developed a reputation as a stealer. This reputation has grown over the last five years or so even although it has come and gone several times.

This stealing reputation has caused me and the people who care about me a lot of worry. It has been hard for me to change this reputation on my own because a reputation like this is very powerful. It is so powerful that it has followed me all the way from India to New Zealand.

I know that the people who care about me are worried about my future because they fear that this reputation could grow even bigger.

The stealing reputation has meant that lately I haven’t been able to stay at friends’ houses. This makes me sad.

I want to be able to prove to you all that I am now on the right path. I want to bring peace and happiness to your hearts and to reassure you that I will have an honest future.

I don’t expect you to believe me if I say there will be no more stealing. Kay, a counsellor, has told me that it is possible for me to prove that I can be. To prove to you that I am honest I am willing to go through some honesty tests that my parents will set for me with Kay’s help. I and my parents will call you after each honesty test to tell you the result. When I have passed all my tests and enough ‘honesty time’ has passed to prove to you that I now deserve a reputation as an honest boy, I will invite you to my ‘honesty party’. If you cannot come, then I will invite you to write me a letter or send me an email that can be read aloud at the party.

Love,

Dilip

I read the letter to Dilip, waiting for him to signal his approval after each paragraph. He looked at me thoughtfully before commenting, “I think they will trust me to get the better of the stealing.” Together we agreed that all the letters would all be delivered the following week. A last-minute amnesty was offered to Dilip so that he could admit to any stealing that might have been worrying him because it was undiscovered or not proven [The opportunity for eleventh-hour admissions].

Fourth Meeting: Eleventh Hour Confessions

We met again in a week. Kulwinder was eager to tell me of a very recent development: between meetings, perhaps because of the amnesty, Dilip had confessed to having stolen and eaten a box of chocolates bought as a present for a family friend. Although upset that the chocolates had been stolen, they were relieved that he had confessed, especially as this was his inaugural confession. He had never admitted to a theft before despite at times very lengthy interrogations to establish his wrongdoing.

Both parents had taken heart at his confession, as did I. This event seemed like a timely departure from the path that Dilip had been travelling. I hoped that it would spur their confidence in Dilip’s commitment to honesty and decided to make the most of it.

“Does this confession speak of anything that you are proud of in your son?” I enquired. Sangita eagerly responded.

“It shows he wants to be truthful; it shows the purity of his heart.”

I asked, “Have there been any other ways that Dilip has shown you the purity of his heart lately?” Kulwinder spoke of how Dilip had been listening to his mother more and contributing to the care of his sister.

“I believe he has more strengths than he can see!”

“And how did you get on with the letters, Sangita?” I asked.

“There was only one problem. He didn’t want to give the letter to Arthur. He actually cried the night before Arthur was due to come with a pet rabbit for him. I said, ‘You have to tell him, or you won’t be going to his house.’ The next morning, he said that he would give him the letter. He gave it as Arthur was leaving; it was hard for him, but he did it.”

I asked, “And how did the other people whose support Dilip called upon respond?”

Sangita was quick to reply that, when Dilip had bravely read his letter to them on the phone, her father and mother had said they would be very happy if the stealing went away, and they would show their happiness in the form of a large gift for him when he passed all the honesty tests. She said that they had already begun the honesty tests and so far, Dilip had passed two tests with flying colours. Their confidence in him was palpable.

I flung out my hand to meet Dilip’s in a “high five.”

“Great. Great, fantastic!” Seizing the moment, I asked, “Are you feeling the effects of having a more honest reputation?” The restoration of an honest reputation is proposed in place of the refutation of stealing.

“Yes,” he replied confidently.

“And tell me, how would you say having a more honest reputation has affected you?” Dilip’s reply surprised me.

“Well, I am allowed in the garage now. I haven’t been allowed in there for a while which was really hard because that’s where I make things. My parents said I couldn’t go in there because of the stealing. Now I am making a steamboat out of oil cans. Arthur has lent me a soldering iron.”

I said, “Okay, would it be fair to say that your honest reputation is winning back your parents’ trust in you?” Dilip’s expression said it all as he shot a shy smile at his parents whose faces were already alight with pleasure.

I asked, “What’s it like for you to know that your parents’ trust in you is growing as your reputation for honesty is growing?”

Dilip replied that it was good. Eager to capitalise on the growing trust by naming the pride on all their faces, I asked “Are you feeling a little bit more proud of yourself?”

“YEAH.”

Comparing the present pride with the sadness of our first meeting, I

The Symbolic Healing Power of Traditional Coping Strategies

Posted on by Psychotherapy.net Team

Why do coping strategies help to resolve psychological symptoms? I once assumed that this question had a simple answer, but I have found over the years that the answer is much more complicated. There is a hidden depth to this question that is both mysterious and life-altering.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

As a therapist, I regularly offer an assortment of coping strategies to help my clients cultivate symptom reduction. The empirically grounded strategies that I most commonly provide include breathing exercises, grounding techniques, mindfulness practices, and/or distress tolerance skills. My clients typically report these techniques to be effective physically and psychologically. Despite their positive impact, I often wonder how exactly these coping strategies work — beyond the obvious, that is!

How Coping Strategies Work

The apparent reason for the success or failure of any coping strategy is its potential to effect visible or discernable change in behavior, thought, and/or feeling. However, I have often found both in my personal life and clinical work, that there is a deeper symbolic process contributing to these outcomes.

For example, I love to run simply because it makes me feel better. While the science suggests that running promotes neural growth, creates a reduction in inflammation, stimulates new activity patterns in the brain, and releases endorphins which help to regulate mood, sleep and energy levels, these are not the reason why I run.

I run because it “carries me to a new place,” beyond the literal, that is. Symbolically, this seemingly simple, mechanical activity “opens me” to new paths and possibilities within my own internal experience. It reorients and centers those parts of myself that have gone astray. I return to who I truly am when I’m running, and I am never the same once finished. If, once I begin running, I’m angry, my feet can stomp out my frustration. If I’m anxious, my body can unwind, working through its tension. Beyond the positive, physical outcome, these symbolic gains are what keep me going, so to speak.

Along similar symbolic lines, I often de-clutter my home when my thoughts feel cluttered or chaotic. Sometimes, however, I forget to attend to this symbolic process, getting lost in the physicality of de-cluttering. In those moments when I should be focused on the symbolic, I feel too distracted by the misguided pressure of the physical act. In instances like this, and in retrospect, I often wonder how much more benefit I would gain if I were to better recognize and then enter more intentionally into these symbolic processes.

Transforming Act into Symbol

In a similar way, I often wonder if my clients are missing out on the full benefits of their coping strategies by not paying attention to their symbolic healing potential. For example, one of my client’s daily practice of journaling became much more effective when he began to intentionally symbolize the words he wrote as thoughts that were finally “leaving his mind.”

This particular client initially presented with “stress” related primarily to his inability to let go of the future-oriented worries that regularly “pulled at” his attention. These thoughts typically intensified in the quiet of the night as he obsessed over the demands and possibilities of the next day. These thoughts made it impossible for him to fall asleep, which left him fatigued and even more worried the next day. Over time, this cycle solidified into a holding pattern that dominated his life, making it impossible to freely move forward.

I asked him to write down his worrisome thoughts before bedtime to externalize them. Initially, he found it difficult to banish these thoughts to paper, so he stopped trying. The action didn’t seem powerful enough to help. The full benefits of writing down his worries made sense only when he intentionally embraced the symbolic process by truly experiencing his worries leaving him through the embodied process of writing.

He also expressed the need to add a symbolic ending to the process by crumbling and tossing away the worry-laden paper into a small trash can that he set up in his nearby hallway. While he considered other symbolic acts including storing the paper in a designated box, shredding it, or setting it on fire, the act of tossing it away made the most sense to him. Over time, the journaling practice extended beyond the original act and into his everyday activities so he could experience a more complete sense of separation from the worries that had previously dominated his life.

Bridging the Gap Between the Physical and Symbolic

My clients and I find that the physical and symbolic need to be explicitly paired in order for the coping strategy to work most effectively. For example, I had another client who was struggling to experience the full advantages of diaphragmatic breathing. Despite the research suggesting the many neurophysiological benefits of this activity, she wasn’t experiencing them.

As it turns out, this client had struggled with anxiety for most of her life, incessantly shopping for and trying on coping strategies in search of “the one” that would finally “fit” and bring her relief — hobbies, relationships, etc. Over time, we realized together that the “real” cause of her unrelenting distress was the fear that she would not be able to endure “standing still” and being in the moment. Searching for, trying on, and then discarding technique after technique was an illusory quest, denying her peace in the moment.

Together, we discussed this disconnect, and I suggested that she take a small step towards stillness by intentionally pairing a pleasant feeling (one she wanted to bring into herself) with every inbreath, and an unpleasant feeling (one she wanted to release from herself) with every outbreath. She chose to breathe in peace and breathe out anxiety. She came to the following appointment excitedly celebrating the positive effects of this modification to her breathing practice. The simplicity of the assignment, and her willingness to literally and symbolically “breath into it,” helped to override her deeper fears of being fully present, reduced her anxiety, and freed her to more fully and deeply engage with life.

Both clients provide striking examples of the transformative power of symbolic acts for enhancing the efficacy of otherwise traditional and mechanical coping strategies. One of the major benefits of the symbolic process is how easily accessible it can be for clients. The benefits await clients willing to engage with the limitless possibilities that symbolism provides.

For example, taking a shower may help me to wash away the shame that is held in the body. Pulling weeds can help to eradicate negative thoughts that keep “popping up.” Simply locking the front door to one’s house is a symbolic gesture that offers a sense of safety. Every moment, every act, every thought contains the possibility of actualization. The quest for symbolism, whether in or outside of clinical space, is an endless call to adventure.

This call is also a call to more fully enter into the mystery of this human experience, and to participate in the world with a fuller sense of awareness and being. Personally, these symbolic processes enrich and transform me on my own personal journey to feeling fully human. They help me to not only cope with my own day-to-day challenges, but more importantly, they pull me into a much deeper participation of healing that continually restores my own love and appreciation for life.

Professionally, I remain eager to deepen my engagement with the symbolic so that I can help guide my clients toward transformative experiences, regardless of the troubles they present. Whether they “write out” their distressing thoughts or “breath away” their anxiety, I admire their willingness to entertain and benefit from venturing into the symbolic with me. I am also amazed by and find beauty in their commitment to do so. I am fully committed to offering all my clients these symbolic pathways they can use in and outside of my office and consider this a fundamental aspect of the therapeutic process.

Questions for Thought and Discussion

What are your reactions to the author’s premise of the importance of symbolism in healing?

How have you used this process with your own clients?

Which clients with whom you currently work might benefit from this strategy?

How have, or might you use this symbolic process in your own personal life?  

Katja-Writing: Being Author and Audience to Fictionalized Stories of Trauma- Part II

Posted on by Psychotherapy.net Team

Irene wrote this story in August 2017, based on a recurring nightmare. Parenthesized comments are Christoffer’s responses.

Freedom — A Dream Story by Irene

Kate got up early that morning. She could not sleep. This night had been particularly ugly, and Kate had not dared to fall asleep after dad had gone.

(I am at a loss for words to connect to this. Even though it calls for something to be said. Somehow these words are powerful, even though it is short and describes so little.)

Kate lay there for a long time, observing her sister’s alarm clock that she had forgotten to set yesterday evening. It did not matter that much, for Kate would make sure that sister got up on time. Although the sound of sister snoring was calming, Kate also had a particular unrest and tension in her body. She lay scolding herself in her head: “Kate, get up now! Sister is safe now. You can go back to your own bed!”

(Dearest Kate. You protected your sister in this ugly night. That is what you were doing. Your love is so great that I have difficulty imagining it. And the injustice is so great.)

Although she could hardly stand to leave her sister, Kate forced herself out of the bed. She knew the danger was past and that they should be getting to school soon.

(It seems to have two meanings, this word [In Danish, the words “the danger” and “the father” are spelled exactly the same.])

Kate picked sister up from the floor and tucked her in bed.

(This is beautiful. It glows in the darkness.)

Then she set the alarm clock to ring in half an hour.

(No sleep for Kate. She must be exhausted.)

Kate walked through the dark attic and down the big staircase. She took out oatmeal and two plates. Just as she had just about set the table for sister and herself, dad came in the door.

(Stay away!)

Dad smiled with a look in his eye and said, “Good morning. Did you sleep well?”

(Are you insane?! What the **** kind of question is that?! Are you absolutely insane?)

Although Kate had not slept, she said that she had indeed. It was a good morning, for Kate knew that sister had slept all through the night.

(Your heart always belongs to your sister. I wish someone’s heart was yours in the same way. You too should be safe so that you could sleep all through the night in safety)

That was good. Dad asked if she wanted a “super-sandwich” or “sloppy-sandwich.”

(Does he not get anything? It is like he does not have any awareness that he has given his daughter “a particularly ugly night,” which I am sure is the world’s biggest understatement!)

Kate wanted a super-sandwich. She knew that the sandwich only consisted of a slice of rye bread and a slice of white bread put together with liver pâté between them. Dad believed that if the rye bread was on top when you ate it, it was a super-sandwich, while white bread on top was a sloppy-sandwich, while in the eyes of the children it was reversed. Dad and Kate used to laugh about it in the morning, but on this morning, she did not think it was very funny. The sandwich had no superpowers, no matter how she turned it. She did not feel very strong.

(Kate, you must be absolutely exhausted. And violated and degraded.)

Sister came bumping down the stairs. Kate had taught her to sit on her bum and take one step at a time.

(I bet you have taught her a thousand good things, Kate.)

Sister smiled and had slept well.

(Because Kate protects her and makes her safe. Is there a better gift to give to a child than that?)

Dad teased her by putting half a “super-sandwich” (rye bread on top) on her plate. Sister made a sound of joy and seemed as surprised about it as she did every single morning.

(This tells me that Kate succeeds in protecting her sister. Because sister seems like she feels safe.)

Sister’s happy laugh always got Kate in a better mood. They ate their bread with some oatmeal that they knew was not mouldy like the bread often was.

(I never feed my children mouldy food. Why do they have to eat mouldy food? Does Kate’s mom and dad not care? Do they eat mouldy food themselves too?)

Kate took sister along to the school bus. It was Wednesday so Kate did not have to look after her sister so much during the ride. The big kids were not riding along on Wednesdays. While sister was being silly with the boy from next door, who got on just down the road, Kate sat looking out the window. She liked to look at how the road, the trees, houses, and people disappeared.

(Is that because it feels like escaping?)

That made her calm. The further away from home that they got, the worse Kate felt. She knew it was not because she would rather stay at home, but it was like her body began to wake up.

(Does this say something about what Kate does to survive? Does it reveal how she prevents her body from being awake so that she does not feel what it is subjected to? Is that necessary to survive? Her body ought to be honoured as the way in which she is present here in the world. That body is sacred and should be protected and caressed. True caressing that stems from caring and loving from people you love and with whom you feel safe and are safe.)

It began to hum and hurt, and she felt nauseous. Sister and the boy were playing energetically with their bags, and one bag hit Kate on the face by accident. Kate scolded and told them to sit and be nice. When Kate turned to the window again, she felt how the pain increased on her cheek. It was nice. Her cheek went all warm, and everything else disappeared.

(Is this also a way to escape? A way to slip away? A way in which Kate protects and upholds herself?)

It was as if Kate’s brain no longer focussed on the nausea, but only on Kate’s cheek. It was a nice feeling, because strangely it somehow made her clean. It was as if it sucked up (like a vacuum cleaner) all the bad so that it only existed on the cheek.

(I think I understand what it says here, but I am not sure I properly understand what this is and why it works this way.)

Kate knew what she had to do!

The bus arrived, and Kate hurried sister along. Sister did not understand why they were in such a rush this morning.

(It is because you have something you need to do, is it not, Kate?)

The bus always arrived 10 minutes before the call to attend class. Sister was being difficult and did not want to come along, and so Kate spoke to her in an excited tone of voice:

“Look!” Kate pointed into the empty air in the direction of sister’s classroom and said, “Do you see the giant ice palace?! It’s made of ice cream!!” Sister looked around with big eyes but did not see anything.

(You are amazing at this, Kate. I think you really understand a lot about how your sister thinks and what is fun for her. And I think it is a significant accomplishment to be so imaginative and convincing while there is at the same time a seriousness in this situation. I bet there is a history of how Kate and her sister found this imaginativeness together. Kate, I know this is something you do to lure your sister along and get her to do what you need her to do. One might say that you manipulate her a bit. I know that. But I do not think it is evil. I am impressed at your skill in making life a little easier for your little sister, and that is loving.)

That did not matter, though, because Kate’s voice assured her that if you imagined something strongly enough, there was a real possibility that it could become real. And who would want to miss an ice cream palace?!

“I’ll get there first!” Kate yelled, picking up sister’s backpack and started running.

“Wait for me!” sister yelled and dashed after her. When they arrived, Kate took out some paper from her backpack, folded it and gave it to sister.

“You mustn’t eat it all at once. It’ll give you tummy ache.” Sister skipped over to the boy from next door in excitement and showed him the “ice cream”. They immediately started playing with it, while Kate put sister’s backpack in its place.

(Sister is having fun. You are giving something good to your sister’s life, Kate. That is true, even though I know that it also has a different purpose. But that does not make what you give to your sister any less real.)

After Kate had said goodbye to sister, she ran to the restrooms in the building for the middle age group. It was right next to Kate’s classroom, so she had time if she was quick. Kate locked herself in the toilet and put down her backpack and pulled out a small razor. She had stolen it from dad’s toiletries once. Kate knew stealing was wrong, but she was going to give it back – someday.

(He he. I bet that when Kate grows up you will still be able to recognize her by things like this here. This particular way of phrasing it. I like it. There is life and self-determination in it.)

Kate got everything ready like she had done so many times before — rolled up her sleeves, unrolled most of a roll of toilet paper to form a little blanket that she placed in her lap and got ready with the razor. It was important that no blood got on her clothes, because then the grownups would get angry at her — or the other children would see confirmation that she was weird. Kate stretched out her arm, pressed the razor into the skin and pulled. What a relief. She was liberated!

(Does that not hurt? In biology class we once had to cut ourselves in the finger to measure our own blood sugar. I couldn’t do it. The thought of it made me nauseous and I refused. Not because I can’t stand the sight of blood. I am fine with that. But cutting myself deliberately. I can’t. Here is something that is different from what I am familiar with. What is this? Kate, you call it liberation? When you cut yourself, is it like cutting a rope that had you tied? Or is it because it is like something being able to come out of the body?)

The first cut opened her and let out her ugly thoughts and feelings.

(So it lets something out. Something that was trapped inside?)

The next cut wiped away her personality.

(Is it a particular version of you that is wiped away, Kate? Something you precisely do not want to be?)

The third cut gave her a feeling of strength and courage.

(Does something else step in when ugly thoughts are let out and personality wiped away? I wonder where that strength and courage comes from?)

And the last many cuts made her invincible.

(Wow! This is powerful stuff. Is this a big contrast for you, Kate? Compared to what you are otherwise made into by humiliation and violation?)

She always tried to cut around the bruises on her skin, but that was not possible this time. Kate had been very bad all summer, so dad had had to punish her.

(Did your father himself teach you that this is something he has to do, Kate? He does not have to do anything. It is a choice. And what must a little girl do, I wonder, to deserve so much “punishment” that she is covered in bruises? I cannot think of anything to justify it. And by the way, it is illegal. And Kate’s dad, will you stop making your daughter believe that you have to beat her up because she has been bad? Would you like to know who I think is bad? Kate’s dad: Keep your hands off your daughter. She is a most beautiful human being and you do not even grasp it. You treat her as if she were a thing that exists only for you.)

The bruises covered almost all her body. But it didn’t really matter. She could not feel the bruises at all when she cut in herself. Kate always did it quick, so it did not hurt. The pain began to make itself felt after a little while. It warmed, removed the nausea, cleansed the filthy body and made her alive.

(It cleanses? And makes alive? How does this transformation work? And perhaps more importantly: Where does it take you, Kate? I am fascinated with this Kate that appears when the body has been cleansed and a personality has been wiped away. This strong, courageous, invincible, alive person. Do you know where that comes from? What are you capable of when you have become that person? Would you like to always be that person?)

For a moment, she rested her head against the wall. Her arm fell into her lap. She went all limp. It was as if all bad that had ever happened to her disappeared. Like a wet sponge erasing all traces of chalk on a dirty blackboard. Kate had become clean. She made a new cut every time the blood coagulated. It was beautiful to behold how the blood first streamed down over her arm and coagulated in big lumps. Observing how the blood coagulated, she knew that she was normal. Her blood coagulated as it should. No one could prevent it from coagulating. She knew that in this, she did not differ from other people.

(Does the blood make you part of humanity? I am sorry that your skin must be cut and that you must bleed to know that. But I am also glad that it is possible for you to know that, even as I wish you had a different road to that knowledge.)

It told her that she was more than a kind of object only to be taken out for the pleasure of others.

(I think we see the same in how your parents treat you, Kate: They treat you as a thing that exists for their sake. You are truly more than that. You are a living human being. I believe that when you treat a human being as a thing, then you are practicing a form of evil.)

She was a human whose blood coagulated as it should. Kate also knew that NO ONE had touched her blood and thereby spoiled it. It was all clean and now it covered her filthy body.

(Kate, does this tell you that some of you is out of reach of others? That there is something in you that is clean regardless of all the filth they throw on you? I am sorry that it takes blood to know that, but I am so happy that it is possible for you to know. I imagine that the knowledge that there is something that nobody has touched and that is clean and proof that you are a real human being – I imagine that that knowledge is quite significant for you! Has that knowledge contributed to Kate’s survival?)

While Kate sat there on the floor, her eyes closed and enjoying being in a sort of parallel reality that protected her from the evil world she otherwise inhabited, it suddenly called in for class. Kate returned to reality. Now she was busy.

She panicked while she wrapped her arm with the remaining toilet paper. Kate only now realized she had cut herself much deeper than she usually did. The blood under her arm had not yet coagulated, as it should! Kate wrapped more paper around it, but it kept seeping through. If she put more paper around the arm, the thickness of it would give her away. That must not happen! Kate had to think fast while she pulled her sleeves in place. She concluded that luckily it was only the lower arm and therefore easier to hide it, as long as she took care to turn it away from others. She flushed the bloody paper in the toilet and made sure there was no blood on the floor or anywhere else.

When Kate tried to get on her legs, it was as if she should faint. She had not felt that way before.

(Has she bled too much? Is it so serious that she has suffered significant blood loss?)

Kate thought it was probably because she had been running with her sister and hoped that sister was okay.

(It is always your sister that you have in mind, Kate. I wish someone had you in mind as much as that.)

Kate struggled to her legs and supported herself into class. The others were running around and were too engaged in their own activities to notice that Kate was not feeling well. She sat down on the chair, even though she knew the teacher had not given permission for that yet. Kate probably got on her feet as she ought to when the teacher came in, but she was too unwell to remember if she had.

(Kate is usually quite sharp, even in extreme conditions. And it is not usually like this? So, it is not because she is still in a rapture or in another world?)

It was not until she saw the teacher explaining a lot of things to the class up by the blackboard that Kate registered that class had begun. Kate could feel the vessels in her arm pumping blood into her body. It was almost as if she could see the arm rising every time her heart made a beat. Kate could not focus on what the teacher was saying at all. It was as if the teacher’s mouth was just moving without any words coming out. The teacher moved from side to side; and Kate felt almost car sick from watching her.

(This sounds bad, Kate, are you alright? You don’t sound at all alright!)

Kate saw how the other children opened their math books and started solving problems. She tried to do the same but got so dizzy when she bowed her head that she was close to falling off her chair.

(!)

Kate tried to focus on the math problems, but her eyes kept wanting to close, and the fingers could not manage to lift the heavy pencil. The teacher came over to her table, while she supported her head with her arm. Astrid, that was her name, sat down and asked her in a friendly voice:

“Do you need help?” When Kate did not answer, Astrid asked, “Let me see. Which problem are you at?” Kate would usually turn the numbers the wrong way, hoping to be sent over to the special education teacher. It was nice to get away from class and get help from the special education teacher.

(Does that feel more like caring than most other things that happen to you, Kate?)

Kate liked Astrid, but Astrid always paid so much attention to her.

(This is a form of caring from Astrid.)

She did not like that. It was hard to hide anything from Astrid.

(A dangerous care? Is it because this attention could unravel the masks and the acting? And then what? Would the consequences be overwhelming for Kate, even though she would like someone to be nice to her? It must be a terrible dilemma; Having to participate in maintaining one’s own prison and cover for one’s own executioner while a kind person is standing right there and wants something good for you. How do you survive that? Because you know nothing else?)

Kate always succeeded to do so, but it was difficult. Perhaps because secretly, Kate wanted to tell Astrid everything, but she could not do that. The special education teacher was very pedagogical and would end up doing the problems for you if you pretended to be really bad at it. That was nice, because then you did not have to think. It was not like that on this day, though. Kate had not written anything wrong, so she could not be sent to the special education teacher. She had not written anything right either.

(She has not written anything because she can barely stay conscious. There is something really wrong, Kate!)

Astrid moved closer to Kate and put her hand on Kate’s arm. Kate was startled and pulled in her arm in a sudden movement. She did not really intend to respond like that. It was not like it hurt or anything, but Kate was just startled that someone was suddenly nice to her.

(I suspect your body is used to responding to violence. That is its first response. Is that right?)

People around Kate usually never touched her. Perhaps they thought that it was best for Kate when you did not show her kindness or attention.

(Oh no. What may that give Kate reason to conclude? Does that not fit in all too well with the idea of being filthy and wrong and not a real human being?)

At least then she would not tell any crazy stories. Maybe they were right?! Kate sort of woke up a little when she caught sight of Astrid’s hand. Astrid had gotten blood on her fingers but did not seem to have noticed it yet.

“You look pale. Are you alright, Kate?” asked Astrid, now in a worried voice. Kate replied that she was just a little tired, but then it happened! Astrid discovered that there was a fresh drop of blood on Kate’s sleeve. It was just a little blood off of Astrid’s finger. Fortunately, she had not seen how much Kate had bled through her jumper.

(!!)

Astrid again put her hand on Kate’s arm and asked if she was okay? While Astrid repeated the question in different versions, the shame grew within Kate; “Why are you so STUPID to bleed through?! You do not deserve Astrid being this nice to you at all!”

(Dear Kate. I want to tell you that you are never stupid. And you are not at all in control of what your body is doing here. Your body has suffered injury and it cannot close the injury. Someone being nice to you is exactly what you deserve. That is precisely what you deserve, for you are a beautiful and good human being, doing all that you can to solve all problems under completely awful, hellish conditions.)

Astrid pulled up a chair next to Kate. This time she must have noticed the blood because she twisted Kate’s arm around forcefully so that she could see the lower arm. Kate knew that the forbidden thing happened and that she should resist, but she just did not have the energy.

(!!! She does not have the energy. This is bad.)

Astrid lifted Kate’s sleeve a bit and looked positively shocked when she saw the blood soaked paper that had tried to hold back the blood in vain. Kate came quickly to her own defence:

“I won’t do it again! It was just one time!” Kate knew that was not true, but she was willing to say anything to get rid of Astrid.

(Is this the dilemma again? Being forced to cover over your own imprisonment just when a kind person wants to help and has seen something right. Is it not terribly destructive for a person’s perception of oneself to be put in that situation?)

In a firm and serious tone of voice, she asked Kate to accompany her out of the room. Kate, ashamed and fearing that her classmates would see how weak she was, tried to get up, but her legs would not carry her. Kate sent Astrid a look that told Astrid that the legs refused to lift Kate off the chair. Astrid told Kate to wait there and bolted out of the classroom. Kate was ashamed and knew that it was all wrong with her.

(No, you do need help, Kate. You are allowed to. It is right.)

It was not nice of her to make Astrid so worried.

(Astrid’s worry is not your creation, Kate. It is not a pain that you have inflicted on her. Astrid’s worry (and I think that word is an understatement) is a result of Astrid’s moral character and her responsibilities and duties to other people in general and to children and pupils in particular. In fact, she must feel that way as a moral being and a responsible schoolteacher. That is not something you have created, Kate. You are entitled to Astrid’s worry, Kate. You are entitled in being the occasion for the activation of Astrid’s moral character and duties to other people)

Kate found it more difficult to stay awake and again supported her head on her arm.

Kate suddenly awoke at someone pulling at her. It was Astrid and some other teachers. Kate could not quite figure out what had happened — or where she was.

(It makes me silent inside to read this, Kate. Because I think you lost consciousness just now. I think you are in very serious danger, Kate. Will you please let the adults do what it takes to help you? These people wish you no harm. I know that is probably difficult for you to believe, but will you try please?)

She was not in the classroom any longer but was lying on the floor in another room. A bunch of teachers stood around her. They looked uneasy and talked amongst each other in serious voices. Astrid had put Kate’s head in her lap, while someone else was in the process of cutting open Kate’s sleeve.

(I value the care that Astrid shows by doing like this. That is caring in a fundamental human way with no professional distance. I am drawn to the fact that the dream allows Astrid to do this.)

“You mustn’t!” Kate burst out. Kate panicked and tried to free herself. One of the teachers yelled, “She’s trying to grab the scissors!”

(Do they think Kate can be a danger to herself?)

But that was all wrong. Kate just wanted to get free and look after her jumper.

(Dear Kate. You always look after everything so well, and also other people. But right now, you are more important than the jumper. You yourself are precious. The jumper is just a thing. You are a human being.)

Astrid stroked Kate on the forehead and assured her that nothing would happen to her, that she was in safe hands and that they just wanted to put a band-aid on it.

(Thank you, Astrid. I think that is the right thing to do. And thank you to the dream for letting Astrid do this.)

Thinking a band-aid would be nice enough, Kate calmed down.

(Good!)

When they lifted up her sleeve entirely, they could clearly see the many bruises and the blood seeping from the toilet paper. They exchanged serious looks along with some sign that Kate did not understand.

(I think they realize something of what Kate is subjected to. I think that they think it is horrible that a child has been treated in such a way. And I think they may understand something about why Kate has done as she has. That she suffers and tries desperately to do something about the pain and the fear and the humiliations she is subject to.)

The school nurse removed the paper. When the paper was all gone, the blood flowed onto the floor. Panic shone in their eyes and they got busy.

(It is really serious. I hope Kate makes it.)

Kate felt that she was all wrong because the blood had not coagulated by itself.

(That is for the blood to decide. You cannot decide that, Kate. It is not about whether you are wrong. If I were to point out who was wrong in all this, you would not even make the list. You would make the top of the opposite list.)

A teacher passed some more towels to the school nurse and they put them on her arm and pressed hard. The school nurse looked at one of the teachers and asked, “Will you make the call?” The teacher confirmed the order and ran. She tied the towel tightly and pointed further up.

“Look!” They began to evaluate Kate’s bruises, but Kate was too tired to fight against it and could not keep her eyes open. While they shook her, she only managed to feel how the blood in her veins pounded against the tight bandage. Everything was hazy and confusing, but it was quite nice to be unable to think.

(This sounds so desperate. So utterly desperate. That the reality in which you live is so horrible that you just want to not think, and that to be able to escape thinking, you have to not be able to.)

When Kate woke up again, they were taking off her jumper. Kate resisted and Astrid asked them to stop. They did.

(I think they understand something here. I think they become aware of Kate’s dignity and the inviolability of her body — especially in light of how others have transgressed against that inviolability.)

As Astrid lifted her arm, Kate noticed that Astrid had goose bumps. “Oh, I have hurt her!”

(Dear Kate, you have not hurt Astrid. It is true that what is happening here is painful for Astrid. But it is not an evil you have inflicted on her. Astrid’s pain is a consequence of her morality and humanity and her care for others – including you, Kate. Astrid’s pain is testament to her moral character and human qualities. It is not your fault, Kate. You deserve Astrid’s worry. You desperately need people who are intensely worried for you, or else I think you may die. And it would not be best to die. That would be a loss for the world and for those who care about you, and a loss of what your life might turn into. Your fate is not sealed. Your life is so young. You are still all new. Life is not only this.)

Kate felt bad and felt tears coming. “1-2-3-4-5-6-7…..” That helped Kate regain control.

When Kate woke up again, more footsteps could be heard, and a panicky voice shouting, “It’s in here!” More people came in. Four of them were paramedics. “I don’t like men,” Kate thought and was reminded of her dad.

(That is understandable.)

“He will get SO angry when he finds out I have caused so much attention… and they haven’t even seen the bruises.”

(HE will be angry about what YOU have done? That pathetic excuse for a man who with such vile and cowardice blames his daughter for the consequences of his own actions. He should be ashamed! What kind of thing is this to do against another human being, and even a child this loyal?! May you choke on it, Kate’s “dad.”)

One of the paramedics pushed hard on Kate’s collarbone, so she opened her eyes again.

(Then they are worried. This is done to see if a person has cardiac arrest)

“Am I sleeping?” asked Kate. “Why am I sleeping?” she mumbled. Said Astrid calmingly:

“You must be tired.” Kate smiled inside — they knew nothing!

(Oh, Kate. You are far away. But I am glad that you don’t feel fear. That way you suffer less right now.)

One of the ambulance people said something to Kate about staying awake and staying with them. Kate did not understand, because she was right there?! Another asked where she got the bruises? Kate knew they wanted her to say something bad about mom and dad, and that would give them an excuse to send her to the orphanage,

(Have your parents made threats about this to you, Kate? Have they frightened you with such tales to silence you and not reveal the horrors that they inflict on you? Remorseless cowards! To think to scare a child into being one’s own prison keeper.)

but Kate didn’t want to leave her sister.

(Yes. Y

Will Computers Replace Psychotherapists?

Posted on by Psychotherapy.net Team

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

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

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

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

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

The Rise of the Machine

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

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

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

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

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

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

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

The Pros and Cons of Computerized Therapy

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

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

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

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

A Look into the Future of AI Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

Postscript: ChatGPT Responds to the Same Question

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

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

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

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

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

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

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

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

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

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

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

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

Makungu Akinyela on Testimony and the Mattering of Black Therapy

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hello, Makungu. I first became aware of your work through conversations with Drs. David Epston and Travis Heath, both of whom have worked clinically and written within the Narrative Therapy sphere. However, they've also made me aware of different approaches to narrative storytelling, including the oral tradition of West Africa, and your work. And that led me to an interest in Testimony Therapy. With that said, what is testimony therapy and what is testifying? 

Testifying and Testimony Therapy

Makungu Akinyela: Testimony Therapy is a discursive therapy, related to Solution-Focused Narrative Therapy, and any of those therapies that we think about that focus on privileging people's stories about their lives. I tell people that testimony is a narrative therapy with a small “n” because testimony and testifying come from my tradition — the Black cultural tradition, to testify. The way Black folk use it is to tell your story but also to tell the story that you want told about you, to give your testimony. It has some roots in the Black church experience. Folks who are from the South or have been to the South and maybe to a Black church, might have witnessed a testimony service or folks testifying in church where they get up and tell a story. There are parts to testifying it. Usually, a testimony starts out with what I call a doom-and-gloom story. For folks who are into Narrative Therapy, Michael White and David Epston used to call it a thin telling of the story.
testimony therapy is a discursive therapy, related to Solution-Focused Narrative Therapy, and any of those therapies that we think about that focus on privileging people's stories about their lives
So, it starts off with this real doom-and-gloom narrative that goes something like, “Well, I woke up, and the doctors told me that I had cancer and I was going to die. And I've been sick ever since and in bed and I couldn’t get up. And that’s what my life is about.” That's the doom-and-gloom telling. But then usually a testimony begins to sound like, “But if it had not been for my friend or my neighbor, who came to give me support and help…” The important thing about that testifying process — the dialogue — is in Black orality, which is that orality that we are grounded in, the oral telling of stories.
And that call and response becomes a community telling of the story. It's not just the storyteller telling the story
There's also call-and-response. As the “testifier” begins to tell that doom-and-gloom story, there is a response to the call. The “witnesses” let them know that they're listening. “Wow! Really? Well, okay. Amen. I get you.” And that call and response becomes a community telling of the story. It's not just the storyteller telling the story. The witness to the story, by engaging with the story, also helps to shape where the story goes. The testifying usually goes from doom-and-gloom to the call-and-response, and then all in the “community” begin to identify what I call the “victorious moments” in the story.

Narrative Therapy might say those victorious moments contradict the thin telling of the story. And as you get to those victorious moments — if it were in a church ceremony, as people begin to give that feedback, that response to the call — they begin to say things like, “Yeah, it wasn't so bad. It was good.” And then people might start seeing the blessings in their lives in the middle of the doom-and-gloom.

The story begins to become a little stronger and a little more positive. By the time the story finishes and all have experienced victorious moments, transformation has happened, and the testimony becomes, “This is the story that I want people to have of me. This is the story that I want.” It uses narrative ideas, and for folks who are familiar with Narrative Therapy, the preferred outcomes have replaced the doom-and-gloom, thin story.

the critique that testimony gives to narrative therapy is that all storytelling and all ways of telling stories are not grounded in the metaphor of literacy
The important thing about testimony therapy is that it is a discursive therapy. I consider it a narrative therapy in the sense that it's a storytelling therapy. I agree with the narrative therapist, that people use stories to constitute their lives, to describe and explain the meaning of their lives. The critique that testimony gives to narrative therapy is that all storytelling and all ways of telling stories are not grounded in the metaphor of literacy. Narrative therapy, the therapy that was developed by Michael White, David Epston, and that is contributed to so strongly by all those other great people — you know, Steve Madigan, Jill Combs, and Gene Freedman – all those ways of doing narrative therapy are particularly grounded in the metaphor of literacy.   
LR: Storytelling in a linear kind of way. 

Oral Culture: A Different Kind of Listening

MA: Exactly, in very linear ways, even the metaphors that are used such as “Turning over a new page, re-authoring our lives.” So, the metaphors reflect the culture that it comes out of, which is primarily a culture whose consciousness is developed through literacy. What testimony therapy says is, “What about those people who come from cultures that are predominantly oral cultures, grounded in orality?” Like the culture of Africans from West Africa, where my folk come from, the culture of so-called African Americans who, basically, trace our lineage and heritage back to West Africa?

Our cultures are primarily oral. So, the thing that shapes our thinking, the way we talk about and think about relationships is grounded in that orality. Storytelling will look different, and the meaning that's given to the story is different. And so, within testimony therapy, rather than being grounded in the metaphor of literacy, I ground it in the metaphor of orality and musicality. Does that make sense? 

LR: As a narrative therapist but also as a client-centered therapist, I would be validating. I would be using nonverbal gestures. I'd be highlighting unique outcomes. I would be listening to elements of the client’s story, which are doom-and-gloom-centered, and asking for counter-stories. What would I be doing differently if you were my therapist in this interaction and coming from that oral tradition? Now, what would we be adding as therapists in this moment? 
MA:
I'm paying attention to the rhythm and the beat of a conversation
I'm paying attention to the rhythm and the beat of a conversation. So, it's not just the words of a conversation that are important, right? It's not just listening to the words that are coming out of your mouth. It's how the words are coming out of your mouth. I'm paying particular attention to things like the relationship between bodily space and the words, the rhythm that's created through bodily space. I'm paying attention to things like the expression on your face because those are all things that also begin to define orality.

In other words, people from oral cultures don't just use the words out of their mouth. It's the tone of the word. You know, where there might be three or four ways that I can use the same word, depending on the tone, it means something different. Also, it might be even the way I might use my body. You know, sometimes people make jokes about Black women. You know, if a Black woman is talking to you and she starts snaking her neck…what's the meaning of that? So, no matter what the words are that she's using, that body motion, the way she takes up space, begins to define the rhythm of the conversation –   

LR: So, what feedback would you be giving me in the moment?  
MA: I would be getting in rhythm with you, right?  
LR: You would be mirroring? 
MA: I might be mirroring, or I might be thinking, “Wow, he's really agitated here. And I might even slow down my rhythm, and I might begin to speak more slowly. And I might even become a little more reserved, again, because I'm believing that the rhythm and the beat of our conversation is just as important as what you're saying. I might be taking note of and become curious about what the emotional content of your speech might be at that moment, and I’d bring that out.

I'm a testimony therapist whoever I'm working with, just like narrative therapists
I was talking to a couple just the other day. Now, this couple happened to be White, but I'm a testimony therapist whoever I'm working with, just like narrative therapists. A narrative therapist, whoever they work with, they're simply using their cultural understanding to engage the work. And that's what I talk about with this. I don't believe that “techniques” in themselves fix things or do things.

But with that couple, there was a conversation going on. In this case, it's a heterosexual couple. The husband listened to the wife say something, and it felt as if she was saying he was the problem. But he was his usual calm demeanor, almost a flat effect. But he began to describe how he was resentful that she was making him into the problem. Sometimes, not always but sometimes therapists are really afraid to engage emotion, particularly “negative” emotion, right?   

LR: I'm on the edge of my seat. So, how did you manage yourself with that White couple?
MA:
one of the things I point out is that oftentimes, particularly for Black people, we're encouraged to suppress our emotions
First of all, I validated what he had to say. And then I said, “You know — ” Let's call him George. Not his name. “George, I get the feeling that you are real pissed off about right now. And I'm really appreciating that. I'm really glad that you got pissed off enough to say that.” In other words, rather than running away from the emotion, to name the emotion — because I also believe that all our emotions are important. You may have read one of my articles, and one of the things I point out is that oftentimes, particularly for Black people, we're encouraged to suppress our emotions.
LR: Especially anger. Especially anger. 
MA: Right, especially anger! You're not supposed to do that. I believe that my work as a therapist is creating a space where all emotions are safe, and all emotions can be validated and understood and experienced. Because one of the things that I'm trying to do when I'm working with my clients is — and again, these are my philosophical understanding of this work — that, under conditions of oppression or suppression, people are alienated from their emotions.

A lot of the ideas that I work with come from the psychiatrist, Frantz Fanon. And Fanon talks about alienation, which comes with colonization. And when people are alienated from their emotions, they don't feel their emotions. They don't experience their emotions. So, the emotions control them rather than them being in control of their lives. And so, a lot of the work that I do is about helping people to feel their feelings, to experience their feelings, and to dis-alienate themselves from that.   

LR: So, going back to George and his wife, you highlighted what you surmised to be George's emotional reaction, his alienation from his emotions. And you helped encourage a conversation around that. How is that different from what a good Rogerian therapist or a linear narrative therapist might do? 
MA:
one of the big complaints that I often get if I am referred a Black client, who maybe has previously had a White therapist, is the cultural uncomfortability that they felt in those relationships
That's a good question. And one of the emphases that I make is that this is not about trying to find something that on the front looks like a radically different practice. It's about worldview and understanding. One of the big complaints that I often get if I am referred a Black client, who maybe has previously had a White therapist, is the cultural uncomfortability that they felt in those relationships. It's like that person just didn't seem to get them. They say, “Well, they just sat there and listened. They didn't say anything.” You know, they didn't say anything.” Sometimes they'll even say, “They didn't tell me what to do.” And I'll say, “Well, you know, I'm not going to tell you what to do either.”

But again, it's just that interaction, that responding in those conversations in oral ways as opposed to this kind of a linear conversation. I ask you a question, and then I quietly wait for a response. And then I assess that response. “Okay.” And then I ask another question. And then I wait for a response. That's that linear conversation. Even when I'm doing supervision, I don't want therapists to try to be like me. In this field, that's what a lot of people do, particularly from our generation. You know, we used to go to those demonstrations, and we would be mesmerized by the experts.

LR: Nobody could be Albert Ellis, regardless of how hard they tried.  
MA: Yeah. But, again, when I talk about Testimony Therapy, I'm talking about a conceptualization of the work that we're doing, which is grounded in a philosophy. In a very similar way, when Michael and David began to develop Narrative Therapy, for the most part, they were grounding their therapeutic work in the philosophies of Michel Foucault, in other words, a conceptualization of the meaning of the word. Does that make sense, what I'm saying?

So, you know, human interaction is human interaction whatever the culture, but there are conceptualizations that define the meaning of the interaction. There's a difference between people who come from oral cultures and, again, how stories get told and the meaning of those stories, and people who come from literary cultures.   

LR: What about when you're working with a Black client, a Black couple, a Black family who don't identify with their ancestral roots, who have no connection to the oral tradition of West Africa? Does that make a difference? 
MA:
I believe that when Black people say, “Hey, I know I'm Black. I'm Black,” that's not about having some deep sense of West African culture, because culture doesn't work like that. You see, the culture of African American people is African, I believe
I think you're asking a philosophical question. Just off the top, I say, okay, probably that couple that you're describing in that way wouldn't even be coming to see me, right? But also, I think this is about a perception of what culture is and what culture means. I believe that when Black people say, “Hey, I know I'm Black. I'm Black,” that's not about having some deep sense of West African culture, because culture doesn't work like that. You see, the culture of African American people is African, I believe.

It's African in the context of 300 years of colonization, but it's still African. And that doesn't mean that people go around every day thinking, “I'm African. I'm African.” They just are. They're being what they're being. Using Frantz Fanon once again, he once said, “A tiger doesn't have to proclaim its tiger-tude. It just is what it is.”

I described the whole idea of a Black church testimony service, right? That's African. Those are African ways of engaging. People don't name it that, but that's what it is. You know, the way that we talk, right? When we talk about Black ways of speech that we call Ebonics. I guess the more professional way is AAVE, African American Vernacular English. I'm speaking to you right now in pretty standard English. But if it wasn't you and it was somewhere else, I would be talking in Ebonics. But the thing about the way that I speak — I call it my grandmother's language — is that it’s grounded in a mixture of African and English vocabulary, but primarily West African syntax and grammar. It comes from there. 

And this gets far beyond therapy, but we've got tons of research that shows the continuities, the continuations, the relationships between the cultures of African people in the western hemisphere, who are here because of enslavement and other things, and Africans on the west coast of Africa. So, when I'm talking about culture, I'm not talking about something that's this kind of mechanical thing that is easily identifiable. I'm talking about what we understand about the nature of culture, which is constantly moving, changing, and growing. Does that make sense?  

Double Consciousness

LR: It does. Is there an implicit assumption or a presumption that an African American client, a Black client, has experienced or has internalized colonization and is living a story that really is one of adapting to those colonializing practices, whether or not they acknowledge it or feel it or resent White people?
MA:
every Black person has two souls in one dark body, an American soul, meaning White, and a Negro soul. And they're constantly fighting and struggling against each other
Absolutely. And, again, I ground my ideas in, like I said, Frantz Fanon and W. E. B. Du Bois, who was probably one of the greatest minds of the 20th Century — from the whole 20th Century because he wrote his first book in 1903, and he died in 1964. But he wrote a book called The Souls of Black Folk. In there, he defines this idea that's called double consciousness. Basically, he calls us Negros, but he says every Black person has two souls in one dark body, an American soul, meaning White, and a Negro soul. And they're constantly fighting and struggling against each other.

That's something that I could never explain probably to you because you've never been through that. But to be a Black person who is constantly doubting their Blackness but also affirming their Blackness at the same time, right? If I told you, as a little boy — we're about the same age — one of my favorite shows used to be Dennis the Menace. Remember Dennis the Menace?   

LR: I remember Dennis the Menace.  
MA: And wanting to be Dennis the Menace but also saying, “Wow. I wish I had hair like Dennis,” or, you know, “Wow. How come my mom doesn't stay home and bake cookies all the time? My mom is up working,” right? You know, “My dad doesn't wear a tie except on Sundays,” right? But it's also giving meaning to that. Or growing up — again, we're in the same age group – remember Tarzan on Sunday afternoon, the Tarzan movies?
LR: I do. Johnny Weissmuller, yep. 
MA: – and identifying with Tarzan more than the so-called natives? And, as a matter of fact, not wanting to be the native. That's the double consciousness that Du Bois talks about. Fanon calls it the zone of nonbeing.
LR: The zone of nonbeing? 
MA: And Fanon, going from Hegel's master-slave hypothesis. I don't know if you're familiar with that.
LR: Familiar only by name. 
MA: Fanon says that's about the idea of recognition and consciousness, that we become conscious of ourselves by being recognized by others. Now, that's fine, but Fanon says, in a colonial situation, the colonizer never recognizes the colonized as human, right?
LR: And the colonized don't recognize necessarily that they have been colonized. 
MA:
In the colonized relationship, the third person is always in the middle of the relationship
Sometimes. Exactly. But also, what he says, in the zone of nonbeing, the colonized is never able to have a “normal” relationship.” Because a normal relationship is this, Larry: I and thou. I see you. You see me. We recognize each other. We are conscious of each other. In the colonized relationship, the third person is always in the middle of the relationship. 

So, in describing another person, and this is using me hypothetically, I might say, “You know that guy over there? He's dark-skinned, but he's handsome.” So, in other words, there's another measuring stick to that person to help me describe that person. “You know that guy? He is really dumb for light-skinned dude.” So, there's always these relationships that are in the middle of our relationships. These are the things that affect relationships.

I'm a family therapist, right? These are the things that begin to affect relationships even when they're unspoken. And if you're not aware of the nature of those things, that's what testimony therapy brings to the forefront, that these are also things that are important to think about in these situations. When I've got a husband and wife come in, it's not just the problems they have. It's the problems they have that have been exasperated (sic) in the everyday lived experience of just being a Black person growing up in America.   

LR: Is there a presumption that all Blacks, all African Americans have this double consciousness whether they're aware of it or not? 
MA: Absolutely. Can you be Black in America and not always have this small voice in the back of your head? For Black women, the decisions about how they fix their hair is a political decision and not just a daily decision. The choice. How they do that. Decisions about how we speak and how we are heard, right? If we speak and our speech sounds too Black, or if we speak and our speech sounds too White, right?
LR: Or not white enough. 
MA: The clothes that we might choose to wear. All of those are decisions which are grounded in, “How will I be perceived?” And it's not just how I will be perceived. Also, I'm concerned about how other Black people are perceived because I'm afraid that how they're perceived also may have some effect on how I'm perceived.
LR: So, the Black person is always being evaluated. And if they're not receiving overt criticism, there is this other consciousness in which they're either comparing themselves unfavorably to other Blacks or unfavorably to Whites. So, your clients, to the one, your Black clients experience oppression whether they are conscious of it? 
MA: Even if it is not named that. There's always this question of… For instance, I was at a conference last week. And my wife and I were about to open our hotel door. I was kind of casually dressed, had a nice little jacket on. You know, my wife is super colorful and flamboyant. So, she had some colorful clothes on. There was a White family about three doors down, and I think they were locked out of their space. And we went to our door, and we opened it up, and one of the women said, “Oh, it's down here." She's telling us, “It's down here.” And we kind of looked confused. And she says, “Oh, never mind.” [laughs]
LR: They thought you were the help opening – 
MA: They thought we were the help. [laughs] You know, I wasn't dressed in any kind of uniform or anything like that. And so, now, the part of that is, you know, my wife kind of got a little… She's like, "Argh.” I said, “Look.” As I thought about it, I was like, “Wow. Why?” What was that about? Why would they assume that I was the help? What is there about me that looked like the help? I wasn't dressed like the help or anything else. But there was that quick assumption. That's what the young people call everyday microaggressions. It's like those things that make you wonder. Now, you're not quite sure, but it's, again, to always have those thoughts. It is not an unusual thing for me to have conversations with my clients, and in some way experiences like that come up in the conversation. Or ideas like that come up. And, again, this is not about people being hyper-politicized or understanding. This is the everydayness of life.
LR: Black life. 
MA: What testimony therapy is about is about having a framework to understand that and to understand the meanings of that and a framework that allows us to engage those conversations in ways that feel safe and also are not committed to having you just basically fit in. You know, our traditional training as therapists is to help people fit in. Do we really want people to fit in to that experience of life, or do we want to give them ways of challenging that and seeing themselves in more powerful ways? 

Therapy Embraces Culture

LR: Is psychotherapy with Blacks/African Americans diminished if the therapist does not take a testimony-oriented approach or that does not focus on that double consciousness?
MA:
I don't get into the wars about what approach to therapy is best
No. The reason I'm not going to say that is because I don't think just taking a testimony approach, even though I think that the things that I talk about are valid and should be dealt with, is critical because I don't get into the wars about what approach to therapy is best. But I do think that the dominant Eurocentric approaches to therapy are oppressive in that they try to force people to fit into a cultural context that is not their home. That is the subject of the book that I'm working on which is about decolonizing therapy, and that idea of decolonizing and dis-alienating the work that we do away from that kind of therapy which basically assumes Western ideas and cultural values. Eurocentric ideas are the norm and, in that context, the best way to help people's mental health is to help them better be able to fit into those norms. And so, we use those Eurocentric approaches to fit people in.
LR: I appreciate this and am very excited by this conversation, and I see how animated you’ve become — your gestures, your tone, your body movements. And I guess, if I was doing a testimony-type therapy, we would be talking about this experience between the two of us. 
MA: This is what I do in my therapy room.
LR: So, if you believe that all Black America has double consciousness, is therapy with Black folks less than good enough therapy if we don't touch on the issues of double consciousness and colonialization? Is it incomplete therapy by definition? 
MA: If we are not aware of that reality, yes! I believe that the reality of double consciousness, the zone of nonbeing, as Fanon calls it. But there has to be a consciousness of the lived experience of Blackness in the West.
LR: Living in a Black body. 
MA: – and how, as a family therapist and systemic therapist, that impacts relationships. That's always the undercurrent of relationships. Even when it's not spoken, even when it's not something that people are consciously aware of in sophisticated ways, it's impacting the way they think. 

There's always this comparison. When we talk about Black male and female gender relationships, there's always that under thing. You know, it's always racialized. When you have Black men who don't like Black women, they say specifically, “Black women ain't shit.” Black women may be thinking, “You know what? I can't stand Black men. I'm thinking about dating out of my race because these men…”

It's all of them, right? And the thing that defines them is their Blackness. That's what makes them Black. So, it defines those relationships. When people are afraid of how their kids look. “I don't want you braiding your hair like that. People are going to think you're a gangbanger or something.” 

LR: Or have “the talk” with them. 
MA: So, this lived experience shapes relationships. And, again, so th

Therapy as a Means of Balancing Loss with Acceptance

Posted on by Psychotherapy.net Team

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

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

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

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

Therapy as a Road to Acceptance

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

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

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

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

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

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

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

A Requiem for All That Was Lost

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

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

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

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

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

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

Questions for Thought and Discussion

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

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

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

Katja-Writing: Being Author and Audience to Fictionalized Stories of Trauma- Part I

Posted on by Psychotherapy.net Team

“Love of the Written Word”

Poem by Irene

I feel like singing, dancing, — yes, even weeping,

I feel like playing music, loudly rejoicing, — yes, even singing psalms,

I feel like exploring, re-experiencing, — yes, even dreaming,

Each time I look to the written word.

I feel special, chosen, — yes, even honored,

I feel pure, poetic, — yes, even pretty,

I feel happy, joyful, — yes, even worthy,

Each time I look to the written word.

I enjoy paper, pencils, — yes, even glue,

I enjoy stanzas, verses, — and rhyming too,

I enjoy letters, notation, — yes, even grammar,

Each time I look to the written word.

I fill with harmony, trust, — yes, even wisdom,

I fill with loss, sorrow, — yes, even wrath

I fill with zeal, loyalty, — yes, even love,

Each time I look to the written word.

This paper describes a writing-based, storytelling approach to engaging with the consequences of extreme violence and sexual assault in childhood. This approach emerged spontaneously during a therapeutic collaboration between myself, psychologist Christoffer Haugaard (Aalborg Psychiatric Hospital, North Jutland Region, Denmark), and Irene. We wish to provide an insight into how this approach arose, how we practice it, and what effects it appears to have. In doing so, we hope that others may derive some benefit from these experiences towards finding ways to live a life beyond trauma that maintains and empowers one’s dignity and humanity.

Irene is in her early thirties. Throughout her childhood, her parents had subjected her to a multitude of forms of violence, including rape and physical as well as psychological violence. Shortly after reaching adulthood, she started seeking help in order to deal with the traumatization caused by her parents. This eventually led her to contact psychiatric services. Prior to this, Irene had some experience with self-harm practices, but this was inconsequential. This changed dramatically upon becoming a psychiatric patient, after which extreme and even life-threatening self-harm was a persistent hazard (Irene has not performed self-harmed since 2015). She was diagnosed with a personality disorder.

The Early Therapeutic Relationship

I met Irene after she was referred to psychotherapy for the second time within the hospital. This was in early 2012 when Irene was in her twenties. By then, she had frequently been hospitalized on account of dramatic self-harm and suicide attempts over the previous seven years. We have had weekly meetings since then and up until the present. Finding a way to engage with Irene’s story proved to be a significant challenge in itself. The fact that I am a man made it no easier for Irene. Therefore, our collaboration has also very much consisted of a search for, and a testing of, ways of talking about matters of concern. We would like to begin by describing some of the history of how the approach to therapeutic conversations that we discovered emerged:

Christoffer: We were attempting to talk about your life, Irene. I was focused on understanding how the things you were subjected to through so much of your life had been a shaping force on your way of being, and how you had resisted that power and the violence. I think that sometimes led to rather divergent characterizations of your person, whether your past self should be regarded as wrong, selfish, dirty, and guilty, or alternatively be regarded as caring, intelligent, and strong-willed.

At that time, I began to write abbreviated stories about you to convey what it was that I saw in you. I remember you telling me that when you read those stories, you were seized by a strong urge to refute the veracity of my claims, as if the text was subjected to an intense criticism because I dared to propose a different perspective on your character to the dominant version. At some point, you named this urge to criticism The Shadow Side. It readily reacted against attempts to challenge the heavy and dark interpretation of your story and your moral character. I recall you forcefully bringing The Shadow Side’s refutation to my attention at one point regarding the significance of me referring to you by the pronoun “you.”

Irene: I could hardly read the texts when you referred to me as “you.” The Shadow Side, the judging side of me, got angry and became automatically defensive. It wanted to tear the paper apart and shout at you, but it knew nothing was to be gained that way. Instead, it scolded me for being so stupid as to talk to you or read anything from you. We talked about how it was nearly impossible for me to read anything that portrayed me in first- or second-person grammar, so you changed your text into the third person. It was still a tough read, but it was acceptable because The Shadow Side perceived a small victory in this.

Christoffer: The first time I wrote to you addressing you in the third person was in 2013. You made me aware of The Shadow Side, and we described it and tried to deal with it through 2014. Would you mind describing The Shadow Side as it was at that time to provide an impression for our readers?

Irene: The Shadow Side destroyed my possibilities by repeatedly telling me that I was too ugly for anyone to like me, too fat to have friends, too dirty to receive a hug, too stupid to give my opinion, too wrong to breathe, and more insults like these. It constantly brought my attention to similarities with my parents whenever I said or thought anything that could remind me of their cruelties. If I got angry, The Shadow Side immediately made me think that I was evil and therefore capable of becoming violent or otherwise mean-spirited. Even though I never became violent, it had me believe that I was. The Shadow Side convinced me that I had anger like my parents and therefore I was identical to them and their atrocities.

The Shadow Side was a merciless judge or a desperate prosecutor. It devised well-thought-out and devious methods of making me portray myself as stupid and unworthy. Every time the cautious Defence managed to argue well, the desperate Prosecutor convinced everyone in the court with 10 strong arguments to the contrary. Some were a little far-fetched and had no truth to them, but when you listen to something long enough it is likely that you will come to believe it.

The Shadow Side was always hard, indifferent to anything anyone else said and always awake and alert. It never took a break. The Shadow Side made me become hard and live my life in a self-destructive bubble. It made me harm myself so that I could cope with everyday life, keep others out so that I would not be let down, live a façade so that I did not fully realize the horrors, ignore possibilities for getting help so that I could be strong, and so on. The Shadow Side made me believe that I was insignificant, as if I wasn’t even alive. It always told me how wrong and useless I was. The Shadow Side was my thoughts, beliefs and actions. It took over everything and swallowed my identity.

Christoffer: We arrived at me attempting to write about a fictional person instead. Someone not you, but similar to you and having endured similar trauma. In 2013, I started writing such stories about a fictional version of you in the third person that I called Kate. These stories were surprisingly not attacked by The Shadow Side. They were allowed, and you were able to read them, and we could talk about them without The Shadow Side attacking the veracity of the facts in the story or Kate’s moral character. It also made it easier for me to write stories, because now that it was fiction, I had creative license and consequently didn’t have to worry so much about getting all the facts right. Instead, I could focus more on the moral of the story. You have told me that when you read these stories about Kate, you were able to have an opinion and feelings concerning the subject matter. It became possible for you to feel compassion for Kate in the story.

Irene: That is correct. Kate came alive through third-person stories.

Christoffer: In 2015, we were focusing on circumstances, events, and actions that have contributed to your survival and to the moral character that you have today [Christoffer and Irene looked through examples from her childhood with a focus on her ways of taking care of herself and her dignity, as well as her survival strategies]. There were many things, but two things are of particular relevance in this context:

Having an Audience

As a child, Irene was the one amongst her siblings who took care of most of the practical tasks on a daily basis, while her parents did nothing. At a young age, her parents charged her with the responsibility for cleaning the house, tidying up, cooking, doing the dishes, looking after her younger siblings, including comforting them, protecting them from violence and rape, helping with their schoolwork, washing clothes, tucking in her siblings at night, getting them up in the morning, getting them to school and so on. She was also held responsible for unjust chores, such as chores given to other siblings that they had neglected or avoided, in addition of course to the basic unfairness of being forced to do all the work parents normally do.

Irene was often given additional tasks on top of this, or their demands were increased with the intent of punishing or humiliating her. She was forced to live such a slave-like existence by means of threats of violence, humiliation as well as acts of brutal violence leading to physical injuries.

How does a 10-year-old child survive such circumstances? Irene did so by imagining she was the main character in a fairytale like Cinderella. She would make believe that all these exhausting, humiliating, and unfair chores were like Cinderella’s, and that she herself was a kind of Cinderella in a movie and had an audience that witnessed everything.

This audience understood Irene to be the main character of the story and felt sympathy for her. They could see all the injustice that was otherwise hidden from everyone’s view and never spoken of as anything unjust within the family. The audience saw what happened, understood the injustice and reacted to it. This type of fantasy contributed to Irene maintaining a sense of dignity and justice throughout her childhood.

Writing Stories

Irene only revealed to me that she had previously invented a similar writing practice for herself after we had already developed our method of writing fictionalized versions of her life in the third person. She had begun writing stories about a fictional alter ego when she was around 10 or 11 years old and had even made an illustrated story prior to having the skills to author a written narrative. Irene’s fictional alter ego was called Katja, and Irene continued to update Katja as the years passed. The latest additions were written when Irene was in her early twenties. I was quite amazed when Irene told me this. Had we reinvented a new version of a practice that Irene had in fact invented for herself many years before? Unlike Irene, Katja of the story fled her home and had adventures and faced dangers in the wide world, finally becoming a physician and married with children. However, this alter ego was more to Irene than a character of this unfolding narrative. She was also a sort of invisible friend and companion to her. Here is Irene’s poem about her, written in July 2018:

Who Is Katja?
Katja was once a little girl who fled from her home.
She is the girl who held my hand when mom yelled at me.

She played with me when no one else was around.
Katja was moved to a foreign land.
She is the girl who held me when I fell.

She helped me when life was hard.
Katja was subjected to horrible things by her own parents.
She is the girl that hid with me when dad beat me.

She whispered words of comfort into my ear when dad left my bed.
Katja hurt herself.

She is the girl who carried the pain when I cut my body.

She managed fear so that I could breathe.
Katja experienced many betrayals.
She is the girl who suffered with me when dad kicked me.

She gave me sustenance when mom starved me.
Katja was assaulted many times.
She is the girl who never complained when we were tortured.

She sang for me so that I could fall asleep.
Katja never grew up.
She is the girl who shielded me from evil.

She followed me my whole life as a side of myself.
Katja’s life is my life.

Looking back and wondering what may have inspired the character of Katja, Irene points to fictional characters that were significant to her in her childhood: Astrid Lindgren’s “Pippi Longstocking” and Katarina Taikon’s tales about the Roma girl Katitzi that she had seen on television (Use of the name Astrid in the stories about Kate is in tribute to Astrid Lindgren).

We did not consciously create a therapeutic method out of these elements, but we discovered in hindsight that these survival strategies seem to foreshadow the approach that we arrived at. For that reason, we have chosen to name our approach after, and in honor of, Katja. The step from me sometimes writing to Irene about a fictitious version of her that I called Kate (Both names — Kate and Katja — are short for Katarina, a name that means “The Pure.” What a fitting name!) and to the approach containing precisely those two elements described above didn’t happen until 2017.

The World of Katja-Writing

Irene had been haunted by several nightmares her entire life. They were connected to her childhood but were not simply horrifying memories on repeat. Some of them did indeed take place in her childhood, but they contained twists and events that belonged in other periods of her life and even contained events that had never happened in waking life. An example was a nightmare about her school years in which she self-harmed in a way that was not part of her life until later. It also happened that she discovered her parents’ violence in a dream, and that someone tried to help her, even though that did not happen in waking life.

Anticipating such nightmares prevented her from getting any proper sleep. She would wake up in shock every morning due to the extreme content, feeling as if the events of the dream had really just taken place. It took half a day to get out of this state of shock and it was difficult for her to relate to other people due to the nightmares. She would have this surreal sense of something catastrophic having just happened; by contrast, all the while the whole world acted as if nothing had happened.

This chronic lack of sleep resulted in periodically occurring depressive states that involved an increase in risk of self-harm and suicide attempts. This pattern had led to frequent hospitalizations for years, often involving physical restraint. Irene and I had been working since 2012 on escaping the emotional numbness she had experienced for many years, so that she could feel and react to these bouts of depression at an early point and reduce the intensity of these cycles. We hoped that this would lead to less dramatic hospitalizations and a reduction of the risk to Irene’s health and life. This part of our collaboration was quite successful.

In June of 2017, we were focused on finding ways of alleviating these nightmares. I had the idea that perhaps Irene could influence her dreams by bringing moods with her from the waking to the dreaming state and thus create a less devastating course of dreaming. Irene had said that she was sometimes able to become lucid towards the end of her dreams and then be able to influence the events to some extent. Could this be expanded so that Irene could act within the dreams or shape them? I suggested writing a kind of good night story to investigate if elements of such stories could be brought into the dream if Irene read it just before retiring. The nightmares felt indescribably horrible to Irene, and therefore she had not described them to me in great detail. Based on what impressions I had, I wrote a short fiction about the girl Kate, and let the story take a turn in which Kate fled her parents and sought refuge at the house of a kind woman living next door. This woman realized that Kate was a victim of violence and called the police. Irene took this story home to read before bedtime.

It did not work!

Irene had become annoyed and frustrated with my story. It did not succeed at all in describing the reality of an 11-year-old girl who is a victim of rape and violence from her own parents. Irene was shocked at how ignorant I was and realized that she had assumed that I understood a lot more than I actually did. I could do nothing but admit to this and say that my own life experiences had not equipped me to know what it is like to grow up amidst such violence. It became very apparent to us both that we were on opposite sides of a deep gulf in understanding and experience.

We came from very different life experiences that amounted to inhabiting different realities, each lacking insight into that of the other. She felt compelled to write a story of her own and wrote an account of the fictional Kate, based on one of her many recollections of being brutally beaten by her parents. Like me, she allowed the story to end with Kate running away with her younger sister. She then gave me this story to help me gain some insight into the reality that she knew only too well.

I admit that her story was horrible to read. It confronted me even more directly with what I already knew I did not comprehend: How can parents do that to their own child — or any child for that matter? It was painful to read and to know that it was based directly on Irene’s reality as a child. The story also taught me something of what it is like to be a child under such circumstances that I obviously had great difficulty imagining dependent on my own imagination and disparate life experiences.

For example, the sympathy she felt for her father as he kicked her again and again. Or how guilty she felt for every blow she received, as if she deserved it. And how most of her attention was directed at her little sister who was hiding nearby, and how Kate was preoccupied with keeping her parents’ attention fixed on her, so that her sister was not discovered. It was so painful and heartrending to read that I felt I could not refrain from some kind of response. But how? This was a fictional version of something that happened many years ago. I had the spontaneous inspiration to write a reaction to the events, much like a witness that sees all these things unfolding, but who cannot be seen or heard by any of the people involved until many years later. I read the story again, but this time I marked every place in the text that made me think, evoked an emotion — whether it was anger, despair, compassion, hope, or that provoked my sense of justice and morality — and made comments that were sincere, immediate, and spontaneous responses to everything I had marked out. I gave this, unedited, to Irene to read and then we talked it through at our next meeting.

Without knowing it, we thereby created a method that we would continue to use with a number of Irene’s nightmares and memories from several periods of her life, a method that uncannily seemed to contain those two prominent survival strategies from Irene’s childhood: Writing fictional versions of her life about an alter ego in the third person, and having a sympathetic and responsive audience, advocating for the protagonist of the story.

In August 2017, Irene decided to convert one of her recurring nightmares into such a story about the alter ego Kate, who had now become our shared version of Katja. We agreed to follow the same procedure as before: I would write down my immediate, unfiltered responses while reading the story and send this back to Irene.

An Example of Katja-Writing

Irene and I would like to share with you an example of this work as we believe demonstration is the best possible explanation for it. We also hope that the contents of the example may contain knowledge about the effects and the responses of a survivor of severe childhood trauma, sexual assault, parental violence, and horrification. We hope such knowledge may be of some assistance to others seeking to address such problems. This specific example is the second story of this kind that Irene wrote to me in August 2017, based on a recurrent nightmare. It makes reference to sexual assault and parental violence but does not contain explicit descriptions of such actions. It does, however, contain an explicit description of self-harm which might affect some readers and therefore reader discretion is advised. To read this material, we refer you to Part Two of this paper, which will be published separately.

How We Do It

Irene writes a fictional story about an alter ego going through something very much like real events from her life or an actual dream. I receive this story and respond to it in writing as I read it. The concept of responding that guides me is this: I read the story as if I were a fly on the wall, an invisible presence in the story as if it were reality, or like an audience watching a live documentary in the cinema. I take Kate to be real, but someone I can only reach with considerable delay. I respond as a human being and not a therapist delivering psychological interventions to some determined effect. I am a representative of humanity and a moral universe that is against violence and oppression and holds the person to be of fundamental worth, and life to be sacred.

When I have received such a story, I find the time to privately commit myself to it without having to hurry or be interrupted. I return the text to Irene with my comments and when she has read it on her own, we have a conversation where we go through it comment by comment and discuss the significance and meaning of it. Conversations emerge that are by no means limited by the story but go beyond it. Sometimes Irene writes a response to my responses. And sometimes I also write a response to her responses to my responses, creating a written record of effects and reflections emanating from the story. Such material has been an invaluable source of learning for me.

Effects of Katja-Writing.

The following is Irene’s account of the effects of working in this way for about a year:

Irene: Having this heap of accounts is evidence. Evidence for reality and existence. It is hard evidence of a history and a life. It is there — no matter what anyone else thinks. It makes it possible for me to be a person, and not to just have to fit in, in the eyes of others. These accounts give me a place to stand. It makes it possible for me to live and exist and find peace with myself and not have to “pretend” so much to other people, in place of the feeling that I always have to please others by approaching them, being polite and similar things. The heap of tales make up my life and give me the right to be — in my own way. This is a great change. Being able to feel that way just some of the time is unbelievable!

Living with these stories about Kate and the responses to them is a whole other way of living your life. It makes a very big difference. Everyday life itself becomes different. For example, it matters in daily life that I can say to myself that, “I am allowed and have the right to go and buy groceries.” This gives me a place to stand in life that makes it possible to be. My history still takes up space and haunts me, of course, but suddenly without being heavy and depressing. I can breathe.

All those things I have been called so many times, I have always just had to take it. These words tear one’s personality apart – one’s whole identity that you try to build up — and divide body and soul. It is ripped to pieces so that it is in rags and tatters, but the stories about Kate make it possible to sometimes accept myself.

Working with Katja-writing means that I don’t have to be the main character and carry all the burdens. Instead, it is “someone else,” even if it is about me. It is not remote, but there is more distance. It is almost like becoming part of the audience, and there it doesn’t hurt the same way. There is space to have an opinion about the story. When it is not “yourself,” then maybe you don’t need to keep your guard up to defend and explain yourself so much.

Reading the stories about an alter ego makes it possible to think about the content. It makes it possible to feel something, to see clearly, and to have compassion for the person in the stories. It sort of takes all the “noise” away so that you are able to look at something ugly, but at the same time relate to it. When it is written about someone else, then you can feel something without it being “wrong.” If it is written about me, then it is dangerous and forbidden.

The stories and the responses are enticing. They give me a desire to read them again and again, both inside my head as well as reading it aloud to myself. It is fascinating that it is your own story that you suddenly gain access to.

Katja-Writing and The Shadow Side

In October 2017, Irene explained to me something of the conduct of The Shadow Side when she read my responses to her stories. It had basically given us permission to do this writing practice and seemed to have an interest in it. Irene told me that she got the impression that The Shadow Side is like a frightened child acting in a violent and repellent way to keep everyone away. It doesn’t trust anyone. It had helped and protected Irene and she feels she has an obligation to it. Hearing Irene’s impressions of it, I began to feel sorry for The Shadow Side and desired to recruit it “on our team” rather than seeing it as something “evil.” Irene explained to me that it can take on many guises and speak with different voices, but she could tell that at its core, it is basically a frightened, rejected child.

Irene has kept a continuous diary of every conversation she has ever had with me. In May 2021, she decided to share an entry with me as part of a letter from her, concerning our work on the story Freedom:

“Around the summer of 2017 I suddenly felt a stomachache — in a good way. I started to look forward to reading Christoffer’s responses to my Katja-stories about Kate. I think it was when I read the responses to the story Freedom that I quietly smiled to myself. It was responses like: “Dear Kate. You protected your sister in this ugly night. That is what you did. Your love is so great that I struggle to fathom it. And the injustice is so great.” Did he just praise Kate? And if it was praise for Kate, then was it not also praise for me who survived that ugly night?

In the same text, Christoffer responded: “You are giving something good to your sister’s life, Kate…” Did Christoffer think that Kate did a good thing when she looked after Little Sister? In that case, would that also be what he would think of me, if he had been around at the time?

I smiled and got all warm inside — someone thinks I am doing well. That I did well when everything was at its most chaotic and I didn’t know what to do.

For some reason, I was not attacked by The Shadow Side when I read these responses to Kate. That was probably why — because they were for Kate. But I was Kate! The responses had to apply to me too! Apparently, that was all right with The Shadow Side, who began to empathize with me instead of acting like a harsh judge.

In a diary dated August 18th 2017, I wrote about a conversation with Christoffer:

“We started talking about those responses he has written for the first part of the dream. I asked him if he wrote these responses for ME or Kate?! He replied that it was probably for Kate, but that he was also aware that there was a certain connection between me and Kate. He told me that he didn’t try to analyze what was me and what was Kate but responded very directly to what the story said. I was happy with this. I made a point that I was not Kate and at the same time not not-Kate [This is similar to the ‘Insider Witnessing Practices’ of Epston and Carlson (1)]. So, he chose to respond in the same way. I felt gratitude that he could be so liberated and honest, without hidden motives about achieving something definite. That he was willing to share his immediate thoughts with me without reservation. I explained to him that by doing this, I actually felt that Kate was finally getting a response! Yes, and maybe I am getting it too through Kate, but that is really good, because when I reflect on all that has happened, then it feels so real and at the same time so unreal. Almost like Kate — or Katja.

I said that this in a way made the past easier to deal with. And that someone could react to it. I added that at home, I had imagined that I had to remove everything that didn’t fit into the story. Make it chronological and detailed — and as such write a completely truthful account of that time. I would not have been able to do that. It would not have been nearly as free — and it would have been way too hard. But th

Cognitive Reframing is the Key to Counselling High-Conflict Couples

Posted on by Psychotherapy.net Team

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

Being a Clinical First Responder in Couples Therapy

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

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

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

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

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

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

When Couples Clients Dodge Conflicts

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

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

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

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

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

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

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

Effective Need Management in Couples Counseling

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

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

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

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

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

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

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

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

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

Psychotherapy With Non-Verbal Clients: Blending Empathy and Flexibility

Posted on by Psychotherapy.net Team

Psychotherapy with Non-Verbal Clients

Hello, Jane.

My name is Tom.

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

One blink.

Is your name Jane?

One blink.

Is my name Tom?

One blink.

Is my name George?

Two blinks.

Is your name George?

Two blinks.

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

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

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

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

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

Combining Empathy, Creativity, and Flexibility in Psychotherapy

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

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

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

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

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

***

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

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

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

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

Using Common Sense Problem-Solving and Worry Containment to Subdue Ruminations

Posted on by Psychotherapy.net Team

The Devil of Rumination and Obsessional Thinking

I often wonder how I as a therapist can best help clients who torture themselves by overthinking and over-analysing in a cyclical manner that essentially gets them nowhere. If it is not possible to help them purge themselves of such burdensome thoughts, is it at least possible to help them make peace with the “unwelcomed devil” of rumination?

I’ll start by reframing rumination as the devil we know, which may still remain a devil, but maybe less scary than the devil we don’t know.

Rumination is a form of obsessional thinking characterized by excessive, usually unwanted, and repetitive thoughts or themes that hijack other mental activity and it is a common feature of obsessive-compulsive disorder and generalized anxiety disorder. It is also dwelling on negative feelings and distress, and their possible causes and consequences. Furthermore, the repetitive, negative aspect of rumination can contribute to the development of depression or anxiety and can worsen pre-existing conditions.

Ruminative states, even for non-depressed people, are directly associated with negative affect. In fact, the more clients ruminate, the more they are likely to throw fuel on the cognitive fire, so to speak, and become entrapped in a vicious cycle, making them feel even worse. My experience with these clients has been that they ruminate in all three time zones of their lives — past, present, and future — on events of both real significance and seeming significance.

A method for tackling rumination that I have found to be particularly useful with these clients is to use problem solving, pondering, and positive reflection. If rumination is overthinking a problem and worries related to that problem, it makes sense to take a positive stance and use problem-solving skills to find the optimal solution that rumination seems to seek, and that could put it to rest. Furthermore, problem-solving strategies can be even more effective when they actually aim to resolve the problem the rumination seeks to magically dispel.

Classic problem-solving models in organizational psychology suggest a series of stages in problem solving culminating in the implementation of action, which can help individuals to either confirm that they are moving in the right direction or think about what changes they need to make in their plans — the verification stage. I also believe that linking problem solving and positive reflection with the specific actions can help to enhance clients’ confidence and sense of efficacy and help them to break the repetitive cycle of rumination.

Applying a Solution Focus

Integrating the above perspective into Cognitive-Behavioral Therapy and Solution-Focused Therapy, I may ask my client to identify and engage in a (small and feasible) first task related to the content of their rumination and plan to complete it as soon as they realistically can. For example, if an individual ruminates about their upcoming “job performance,” they could identify one or two minor work-performance-related tasks and aim to complete them initially.

This first step would not necessarily mean that they have found all the answers to their worries, but it would help them feel that they have at least done something, even quite small, which brought them closer to the achievement of their goal (a positive job performance review in this example). Moreover, from a positive reinforcement perspective, they could also plan to reward themselves with something enjoyable that they “deserve to do” (since they will have managed to take some action, instead of overthinking or freezing).

For certain types of rumination (such as work-related stress or perfectionism), I have found this approach particularly useful as my clients find it easy to find a series of actions or tasks that help them develop a sense of moving forward — and slowly moving away from the gravitational pull of rumination. However, there are other frequent types of rumination that, by their nature and content, do not lend themselves directly to interlinked specific actions, such as “is this the right job for me or not?” or for those clients who don’t have the practical or mental resources at a given time to explore how their rumination could be translated to any specific plan.

In such cases, I invite them to “take a break” from their laborious, constant effort to find a “solution,” which would cease the seemingly incessant pressure to ruminate. This suggestion, of course, is often challenging for them as it directly opposes the very nature of rumination — the underlying implicit, irrational belief that “I need to keep analysing a specific concern, until I find an answer or a solution that I am completely happy with.”

The client’s resistance to pause their overthinking may be underpinned by another implicit belief that “there is no way I will be able to relax and find mental peace until I get everything outstanding done and dusted.” This notion is sometimes effective to help clients increase their motivation to fight procrastination and eventually solve problems and achieve their goals. Nevertheless, at other times, it will just not be possible to solve something as soon as possible, nor to even envision the solution — leaving the client feeling even more frustrated, anxious, and predisposed to continued rumination.

In these situations, the biggest trap is not that they will still have “unfinished, disturbing (pragmatic or emotional) business,” but that they will have trained their brain to believe that it is possible not to have any unfinished business, not to have any more intrusive worries and that “when there is a will, there is always a way.”

However, this otherwise helpful and motivating attitude can often just fuel further excessive worry and rumination. The curious question then becomes, “how can the normally reasonable aim to solve problems as quickly as possible become a problem on its own?”

A Pragmatic Approach to Rumination

In my experience, western culture values a proactive, problem-solving approach that rewards and encourages taking responsibility, a sense of agency, and ownership of our lives, as opposed to being passive and reactive. My aim here is not to explore this cultural notion as such (which would entail a much broader philosophical discussion), but rather to highlight its limitations and to reflect on the ways that we can contain our excessively proactive stance, and the worries and perpetuated rumination that often accompany it.

I have come to believe that as important as it is to be proactive and to take responsibility, it is equally important to fundamentally acknowledge that we only have certain emotional and pragmatic capacity at any given time to deal with our goals and our relevant worries. Thus, we may need to decide that we can only deal with just one of our concerns at a time, while we may also endeavour to teach ourselves to tolerate and bracket all other ones.

Rumination by nature “demands” immediate answers and solutions. In contrast, I encourage my clients to allow their intrusive thoughts to emerge and claim their space, while at the same time, challenge them to fight their urge to engage thoroughly with them in-the-moment (which only fuels further and futile rumination). I encourage them to slow down and allow some time to observe their worries as they emerge naturally and unfold in their mind. At the same time, I ask them to make an “appointment” with that urge a few days later, at which time they can, if they choose, respond to their demand for their attention. During that appointment, they can calmly reflect on which of their worries really matter, which ones require more time to ferment, and whether there is any proportionate course of action they can take (or not?) in response to them. When they manage to gain some distance from the urge to ruminate, or from the rumination itself, they may find out that — not surprisingly — several of their worries no longer claim much of their attention.

Of course, this is much easier said than done. Worries are unrelenting. They have their backhanded way of persevering and drawing clients into their dark, seemingly bottomless pit without offering even a glimmer of light or hope that might otherwise offer a solution that feels “good enough,” and without offering the slightest means of escaping their gravitational pull.

An additional strategy I have found useful to help my clients with rumination has been to invite them to implement an easy, positive distraction at the time when their urge to ruminate emerges. This is indeed one of the common techniques, along with other ones such as mindfulness. However, positive distractions seem to be most useful when they are combined with a “reassurance” to our worries that we will indeed come back to them at a more appropriate time, when we will be better prepared and have the mental space to deal with them.

In this context, I have had clients set an appointment with their worries and I actually encouraged them to take this appointment quite seriously. Thus, when clients actually engage in these appointments, they often find that some of these worries have been impatiently awaiting their arrival and are still adamantly demanding their attention, while others have not. At that point, and only at that allotted time, the client is better prepared to address those worries, having built the patience and mental space to do so. As therapy itself is an ongoing process as is problem resolution, clients come to appreciate that it is not necessary to respond to the siren call of worries when they first arise. Pandora’s box will always be there waiting for them in the therapy room, and they will choose when to open it or not.

Most of the above points were at play in the work I have done with one of my favorite and long-term clients. Stuart, as I will call him, was ruminating equally about “small things,” like the slight slope on the floor of his Victorian-age house; and big things, like the dilemma of whether he would ever find a more meaningful job and career. I knew that saying to Stuart something like, “don’t think about this,” would just make him think about these concerns even more.

Instead, I said to Stuart, “you can think about this as much as you want, but could you possibly give up on finding an answer to your worry in-the-moment? And maybe, as you will still be thinking about it, could you also try to do surface research online about any jobs that are out there, that could potentially be meaningful for you in the future?’’ This intervention was a combination of a positive distraction, patience, and looking forward. When Stuart came back for his next session, he told me that even though his ruminations were still there, he was much more able to contain them. Was he then able to “become friends” with them? Well, not necessarily, but by practising to sit with them, slow down, and possibly add a positive distraction in the mix, his ruminations certainly became a more familiar, less scary, and more tolerable devil.

Stuart was a willing worker, as are many of my clients. But it was as important to build a relationship of trust and hope with him as it was to help him build a sense of hope and confidence that he could eventually subdue his ruminations and live freely.