Category: Therapeutic Issue

Reducing the Negative Impact of Reasonable Expectations on Healthy Relationships

Posted on by Psychotherapy.net Team

On a daily basis, I have the pleasure of providing counseling services to couples hoping to strengthen their relationship together. Whether pre-engaged, engaged, recently married or married for decades, I help them to explore the similarities and differences between couples as well as within them.

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Barriers to Intimacy

While intimate relationships such as marriage have the potential for great happiness and joy, there is also the risk of frustration and disappointment. To assist these couples in strengthening their sense of relationship connection, we spend time exploring various aspects of their personal and relationship history, efforts that have already been taken to resolve the barriers between them, and identifying individual and relational strengths as well as growth areas. Of the many contributing factors to the difficulties these couples experience are the challenges they experience adjusting to differences between them — a very common barrier to healthy understanding and interaction.

For several years I have spent time helping couples not only identify their similarities and differences and the significance they play in their interactions, but also reframing their understanding and experience of those similarities and differences as less inconvenient and detrimental, and more appreciated, respected, and as potential opportunities for relationship enhancement.

Differences in assertiveness can be frustrating when one partner is expecting the other to be more open and direct, while the other partner is expecting that partner to tone it down a bit. Differences in preferred methods of quality time together can lead to distance if one partner is expecting a commitment to quality time to look like daily-initiated interactions, while the other partner is content with weekly, assuming that the commitment has been fulfilled.

In these cases, and others like it, reasonable expectations that are not healthily expressed or acknowledged can be a detrimental dynamic. After all, many feel as though what they are asking for or expecting is reasonable rather than too much. This fact often exacerbates their shared or individual disappointment since it hurts on one level to not have what one wants, and it hurts on another level to believe that the person you care about most doesn’t care enough to provide your reasonable minimal standard.

To address the detriment of reasonable expectations, I have found it useful to help them:

Identify their expectations

Own their expectations

Respect others’ expectations

Identify Their Expectations

Relationship expectations come from various sources. Sometimes we’re directly taught what to expect from a relationship from our parents or other loved ones. Other times we’ve learned by watching what has been modeled for us by parents or loved ones without anyone having to say a word. And yet other times, we have simply picked things up over the years, having sifted through life’s experiences, leaving behind what we did not care to experience and holding onto the things that we would look forward to experiencing.

Own Their Expectation

Over time, we develop a set of expectations that have years of justification, validation, and support. They can be so integrated into one’s view of the world that individuals are not aware that their expectations are not indicators of the “best” experiences and ways of doing things, but rather the experiences and ways of doing things that they have come to appreciate more than others. As such, before change can occur, they need to own their expectations as their own legitimate preferences. This does not make them any less valid. Rather, it allows for the opportunity to accept others’ differing preferences as legitimate.

Respect the Other’s Expectations

Once each member of the couple identifies and expresses their expectations and acknowledges them as their personal preferences, it can become easier to appreciate and respect the other’s expectations as reasonable preferences as well. And when that other person is the most important person in their life, for whom they have committed to helping meet as many preferences as possible, the challenge transitions from, “Why does my partner have such inconvenient and unreasonable expectations?” to, “How can I better understand why my partner has these preferences and how they can benefit our relationship even if they differ at times from my preferences and expectations?” This is a very different type of conversation, which at its essence is non-conflictual. This type of conversation seems a mutual win-win, with mutual respect, consideration, and care expressed along the way.

Consider the newly married couple who dated during college, married after graduation, and are now having difficulty adjusting to life after their honeymoon. Although they shared a goal of creating a new routine that prioritized their marriage together, they soon discovered that they had different expectations of what priority looked like. She expected them to maintain a frequency of quality time similar to what they had during college, including frequent shared classes, meals together, as well as a few shared extracurricular activities. It came then as a shock to her when her new husband no longer seemed interested in spending time with her, leaving her feeling lonely and misled. It was later revealed that her husband indeed valued and prioritized his marriage so much that he committed to dedicating all his “free time” to his wife; however, different from their shared college environment and routine, “free time” was now significantly less and came after spending nine hours of each day (including work and his commute) away from home, and consequently, his wife.

What helped resolve a potential connection- and intimacy-damaging misunderstanding was the couple’s effort to identify their individual and differing expectations on what their marriage would look like. Seeing the legitimacy of their own expectations influenced by reasonable conclusions based on past experiences helped them reduce defensiveness and judgment of each other’s differing expectations. This foundation then helped them see the legitimacy of their partner’s expectations for the same reasons and express that understanding in a way that created a safe environment for them to work and in which to create new shared expectations together, with both of their needs and desires in mind.

***

Reasonable expectations are just that — reasonable. However, the fact that they may be reasonable doesn’t mean that each of our clients is entitled to them, especially when the other’s expectations conflict with theirs. My challenge in working with these couples is to help each person to identify and own their preferences with appropriate value, while also avoiding the temptation to give them more value than they deserve; as doing so can lead to unnecessary and unhelpful relationship rigidity and emotional distance and separation.

Questions for Thought and Discussion

In what ways are this author’s premise for couples counseling similar to or different from yours?

How do you address differing expectations in couples counseling?

How might you have addressed the challenges of working with the couple described in this essay?

The Realm of Our Industry

Posted on by Psychotherapy.net Team

From The Grieving Therapist by Justine Mastin & Larisa Garski, published by North Atlantic Books, copyright © 2023 by Justine Mastin & Larisa Garski. Reprinted by permission of North Atlantic Books.

“In the beginning, we were all psychotherapists. And it was good.”

—Bruce Minor, Minnesota Member of the MFT Community

THE TIME HAS COME to face our industry and sit with the ways the therapy system in which we work helps us, hurts us, and holds us to a standard impossible to meet. Throughout this book we have touched on many issues facing our work; now we are looking specifically at the system in which we work. No longer a collection of individual practitioners who see each other as fellow members of a therapeutic federation, our industry (therapy) has become compartmentalized, industrialized, and controlled by third-party payers.

As you begin this leg of the journey, we invite you to pause and reflect on the mentors and experiences who supported you on your quest to become a therapist. We welcome you to reflect on mentors of both the past and the present, as well as those with whom you had a challenging or even fraught relationship. Even those mentors and supervisors who we experience as awful can teach us valuable lessons (though that does not exonerate them).

When it comes to mentors and supervisors, we, the authors, have had the best and the worst. For this chapter, we reflect on some of the greats from our local MFT community: Anne Ramage, PsyD, LMFT, our graduate school professor who taught us so much more than we ever realized there was to know about Carl Whitaker; and the collective of marriage and family therapists who have sustained the Minnesota field for decades, some of whom also became our supervisors and mentors: Ginny D’Angelo, LICSW, LMFT, Bruce Minor, LMFT, Briar Miller, LMFT, and Michelle Libi, LMFT.

You blink and end your repose to find that you’re alone. It feels as if you have awoken from a dream. You rise from your resting spot and begin to walk down the winding path toward the sound of a river. As you walk, you notice the crunch of twigs underfoot and hear distant birds. Is one of them the red-winged blackbird? Neither your bird friend nor the forest yeti are anywhere in sight. Perhaps you dreamed them.

You look up at the branches of a nearby tree and notice a small silver shape clinging to a twig. Pausing, you raise up onto your tiptoes and realize that this is a cocoon, perhaps belonging to a butterfly or a moth. You gaze at the cocoon for a moment longer, noticing it shake as the small creature inside struggles with its transformation. Change is such hard work, you muse, and resume the hike. As you walk you notice that you have many aches in your body. How long were you sitting in meditation? You stretch your neck from side to side as you continue to make your way down the mountainside.

As you breathe in, the air is fragrant with the scent of dried leaves and warm earth. You wonder at the way the seasons seem to have shifted around you on your travels. As you look around the forest bordering either side of the path, you notice hints of yellow and orange in many of the leaves. The wind shifts, blowing the undersides of the leaves up, causing them to shift and sway. It reminds you of a distant memory, but as you grasp for it, the memory skitters out of reach.

The path winds down the slope, and you lean slightly backward against the tug of inertia and gravity. The sun’s rays are just the right amount of warmth, offering a radiating blanket of heat against the cooler air temperature. You look down and slightly to your left, and you see a ribbon of blue snaking through the undergrowth far below: a river. It looks like a nice place to pause and rest. You estimate that you have at least another mile to walk down the mountain before you reach the riverbank. You walk down toward it.

Therapy’s Big Brother

Once upon a time, as Bruce Minor reminds us, we were all just psychotherapists. In the very, very beginning of our industry, there were just small- to medium-sized collectives of human beings throughout the American and European continents — composed mostly of wealthy men and a few audacious women — gathering together in an attempt to suss out the nature of the human mind and heart. From these meetings, the field of psychoanalysis was born.

While these early theorists and practitioners engaged in practices that we would gasp at today — Freud psychoanalyzing his daughter, Jung sleeping with several of his patients who then became therapists-in-training — their mistakes became the foundations upon which rules like “no dual relationships” were based.

These early therapists did not have insurance agencies or managed care with which to deal. But they also tended to focus on treating the bourgeoisie — the European upper middle class who could afford to pay for things like this newfangled “talking cure,” thanks to their monopoly on industry. Neither Jung, Adler, nor Freud himself (founding psychoanalysts all) had to consider whether high-quality psychotherapy happens in increments of forty-five, sixty, or ninety minutes. We bring you this abbreviated history lesson to remind us all that our present constructs have not always existed. Not only have they not always existed, but they might not actually be the most effective structure for treatment.

When family therapy was new, co-therapy and one-way mirrors with reflection teams were the standard of the day. When Justine tells graduate students about these once-standard training practices, they are in awe. “But how did that get paid for?!” they exclaim. The short answer is that decades ago, universities, particularly public universities, had more money in the humanities and social science departments.

Insurance once reimbursed for far more therapeutic services than they do now. Then Justine will often go on to tell her students about sitting in her own graduate school classroom at Hazelden Graduate School of Addiction Studies (now Hazelden Betty Ford) and hearing her professors talk about the changing landscape of drug and alcohol treatment.

Structured limitations are necessary for high-quality therapy (recall the example of sandtray therapy and the need for a literal box within which to put the sand, from chapter 2). Certainly, the case could be made that American psychoanalysis and drug treatment of the 1970s and 1980s was in need of a bit more clinical oversight. But the evolution that followed brings us to a dystopian present where third-party payers like insurance companies are dictating the terms and conditions of treatment. They’re also dictating the amount of money that the clinician receives for the work they do based solely on their licensure, rather than on the type of work they’re doing. These payouts are often inadequate at best and paltry at worst. Because of variable reimbursement rates, the amount of time and effort needed to handle billing issues, and the hoops clinicians need to navigate to get even the small amount of money they’re paid, private-practice clinicians are increasingly opting out of the insurance model. This causes frustration for would-be clients, and for other clinicians.

Licensure Drama

Have you ever had an issue with another clinician and thought, “Well, that’s just because they’re a Ph.D.; doctorate school sucks all of the fun out of you”? Or perhaps you’ve thought, “They don’t teach master’s-level clinicians anything about diagnostics.” Third-party payers and clinicians determine their reimbursement or compensation rates based on a number of factors, including education. Hierarchical thinking dictates that the more education and experience a person has, the more they should be valued.

The main way that we express or show value is through monetary compensation. However, this very quickly leads to confusion and resentment when master’s-level clinicians and doctoral-level clinicians are working at the same practice or agency, and are performing, at least on paper, the same job functions. Disparate training and licensure requirements can lead to differences in case conceptualizations, standards of care, and clinical interventions.

Certainly, these varied perspectives can be helpful if discussed and processed through open and honest clinical dialogue. But who has time for that? We don’t say this to minimize or undermine the value of care coordination. The reality, though, is that third-party payers don’t reimburse for care coordination. Contemporary clinicians are lucky if they can connect for five or ten minutes via phone either just before the beginning (seven a.m.) or just after the end (seven p.m.) of their clinical day. Thus, it’s no surprise that confusion and even infighting across licenses and education levels abound.

Justine recalls a question from a student about this infighting: “But who is actually above the others? There has to be a hierarchy, right?” Justine responded that while it may feel as though there is a hierarchy, the reality is that we’re a community with a variety of skills. We don’t need to fight among ourselves. She said that just because someone with a doctorate has more education than someone with a master’s degree, that doesn’t make them better than or above the master’s-level clinician. This is a social construct that we get to question and challenge, because it no longer serves us.

The tangible difference between master’s-level and doctoral-level clinicians lies in the area of assessment. Folks who complete doctoral programs are schooled in the practice of psychological assessment and usually graduate with the third party-payer reimbursable skill of psychological assessment.

With gravity on your side, you make it to the bottom of the mountain faster than anticipated. The sound of the river rings in your ears as you push through the bracken toward the riverbank. The grass along the shore is a deep green and only slightly prickly as you kneel down and bend over the water, cupping your hands to take a long, cool drink. Once you have quenched your thirst, you sit back on your heels and stare out across the blue water, leaning into the rays of the sun at your back. You notice a butterfly flapping its wings and landing on a nearby flower.

App Therapy Is the New In-Home Therapy

Newly-minted therapy graduates find themselves staring down the gauntlet of the licensure process, which usually entails several examinations, hours of supervision, and even more hours of direct client care. Depending upon the state where you live and the license you’re pursuing, you may find it very difficult to get a job that pays you money while you acquire hours you can count toward licensure.

Over the past few decades, the entry-level job for graduates in this predicament was in-home family therapy. Often considered the grunt work of the therapy industry, in-home family therapy requires practitioners to work long hours and drive long distances for very minimal pay. In 2014, when Larisa was working as an in-home clinician, she didn’t even make minimum wage, so she worked another job part time as an after-hours crisis counselor.

Today’s graduates have a new, additional option: they can become app therapists. Similar to other gig jobs like Uber Eats and Lyft, clinicians who work for therapy apps such as BetterHelp, TalkSpace, and Larkr are either populated by associate-licensed or fully licensed clinicians, and they work entirely through their company’s telehealth app interface. They tend to have very large caseloads (pitched to them as a “great opportunity to get your licensure hours”), minimal time with an assigned clinical supervisor, and demanding clinical expectations. Most therapy app jobs market their services to prospective clients with the promise of a readily available therapist, translating to the expectation that the therapist is available to the client at least via chat through most hours of the day and night.

Larisa vividly recalls many of her lectures with Dr. Anne Ramage for a number of reasons, not the least of which is that Dr. Ramage is an excellent professor and an enigmatic speaker. Among all of Larisa’s memories of Dr. Ramage’s Carl Whitaker quotes and experiential roleplays, she recalls the professor advising time and again that “in-home jobs will be waiting for you as soon as you graduate. They’re tough. You need to be ready. But they’ll give you excellent experience in working with families.” Then Dr. Ramage discussed the MFT techniques from that particular lecture that might apply to in-home work, and she explained the basic safety strategies of which in-home clinicians needed to be aware.

When Larisa graduated, she did indeed take a job as an in-home family therapist. The night before her first day, she reviewed the strategies she had learned from Dr. Ramage:

1. Arrive five minutes early and look up the homes you’ll be visiting in advance so you can plan your parking strategy. Never schedule sessions late in the evening or after dark.

2. Be ready to set clear and consistent boundaries, and for those boundaries to be tested.

3. Pack a change of clothes and hand sanitizer.

4. Review your agency’s privacy policies.

5. When you enter someone’s home, assess for safety and your own exit strategy. Although it is rare that clients will ever mean you harm, things can and do get out of hand when you are in the family’s own space. You get to protect yourself first.

This survival guide doesn’t apply to folks who are working for therapy apps, but the need for both support and coping strategies is no less acute. If you’re working for a therapy app, we, the authors, offer you deep compassion and the following tips:

1. Plan an exit strategy. What does this mean? It means a human being can’t sustain years of work at the rate demanded by therapy apps. So, it’s essential for you to decide how long you can sustain working for a therapy app before you go the way of a younger Larisa and start losing your hair and developing insomnia.

2. Find a supervisor outside the therapy app. Yes, you will probably have to pay for this supervision, and that will likely cause financial stress. However, it is crucial for you to have a guide whose sole investment is in you and who exists outside the system in which you work, to help you regain perspective and hold boundaries around things like time management and availability.

3. Remember that any symptoms of burnout (i.e., signs of physical or emotional distress) you’re experiencing are likely the cause of moral injury — harm caused by the system in which you work — rather than any fault of your own (we’ll discuss these concepts in more detail in the next section of this chapter).

4. Manage your expectations for yourself. However, you envisioned your therapy experience, it likely did not involve a smartphone application called “Better-something.” You can’t do depth psychotherapy in this kind of context; what you can do is help your clients with basic coping strategies and compassionate presence — sometimes, but not all the time. You’re not required to have 24/7 availability, no matter what your company tells you. Not even standard laptops can run constantly forever; they need to rest and update.

5. Reach out to your community. When you work in an online environment, it can be difficult to get your emotional needs met. Please remember to engage with other living beings outside your work environment who understand some of what you’re going through and who can show up for you.

Burnout and Moral Injury

The Realm of Our Work has changed in ways that we never imagined over the course of the collective traumas of the 2020s. Suddenly the norm is to work in a virtual therapy room, and some clients expect to have regular access to their therapist via text messages and video chat services. This isn’t what we thought the field would look like.

When Justine imagined her future as a therapist, she saw herself engulfed in a scarf, with a teacup in hand, sitting across from her client in an overstuffed chair near a small fire in a fireplace, surrounded by books. She envisioned herself helping people and feeling filled up by the work, then returning home to a pleasant evening all to herself — overall a very calm and steady way of life.

This is not reality. For a time, she did have the tea and the overstuffed chair, but the rest of the fantasy was just that — a fantasy. Justine now works behind a computer and sits in a rolling chair; her view is full of microphones, a ring light, and multiple monitors. For her, the change in our industry has been the death of a dream. The death of any dream is an ambiguous loss that even therapists are not always good at recognizing and finding compassion and ritual to help them move through it.

Of course, parts of what Justine imagined the life of a therapist to be all those many years ago, before she ever entered the field, were simply inaccurate. Even before teletherapy and therapy apps took over the field, the life of a therapist was rarely calm and steady. It had moments and longer periods of such calm, but the nature of therapy is to work with volatile emotions. The emotional intensity inherent to the profession impacts even the most experienced and boundaried of therapists.

Larisa’s experience differed in that she had a logical view of what life in the field would be like. She felt like she had prepared herself emotionally for the trials of holding space for people and their emotions day in and day out. She believed that this preparation would act as a shield against any future catastrophe. The sadness came when she realized that no matter how prepared she had been, the situation was worse, and far more unpredictable, than she could have imagined. She was ready for the stresses of people’s everyday lives and even for their great despair and trauma, but she was unprepared for the collective trauma of our age stepping into the therapy room and into her own life. She was totally unprepared for how political leadership would fail her and everyone else in her country during this time of great collective need.

In her younger and more impressionable years, she believed that even though power is corrosive and toxic to politicians, when they were faced with clear and present disaster, they would channel their highest selves and work to help people. Now Larisa realizes that America’s representative government has devolved into rule by the wealthy elite who use their resources to buffer themselves from the pain and the needs of their constituents. Sometimes the despair she feels is crushing. Perhaps you can relate.

As we sit with the tragedies that have befallen our profession, it is no wonder that so many therapists struggle with burnout. Burnout can be defined from many perspectives. For the sake of brevity and clarity, we offer definitions of both individualized burnout and systemic burnout. Individualized burnout occurs when a person is so emotionally exhausted that they chronically struggle with depersonalization, which is emotional, physical, and cognitive numbness that makes the person unable to feel present in their own body or life.

Systemic burnout is also known as moral injury, which is when a person experiences symptoms through no fault of their own; rather, the symptoms result from harm caused by the system in which they work. Moral injury was first defined by psychiatrist Jonathan Shay as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.” Wendy Dean, Simon Talbot, and Austin Dean expanded upon this definition when they argued for clinician burnout to be redefined as moral injury:

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin [sic] of our working lives and our guiding principle when searching for the right course of action.

But as clinicians, we are increasingly forced to consider the demands of other stakeholders — the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security —before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.

The article quoted above speaks solely to the experience of medical doctors, but its implications are clear for the chronic systemic burnout faced by so many in helping professions, including (but not limited to) therapists, medical technicians, nurses, and case managers. Helping professionals are increasingly placed in a double bind; that is, they’re being placed in situations from which there is no escape, and they’re being asked to perform at least two mutually exclusive actions simultaneously. They’re being asked to care for clients but also to please many other stakeholders, all without the amount or quality of support that they need. Just like all double binds, this is an untenable situation that causes distress within the clinician.

We, the authors, appreciate the distinction between burnout and moral injury. The concept of moral injury takes the onus off the individual, because there’s not enough self-care in the world to account for a system that’s set up as a no-win situation. When larger systems talk about “burnout,” that terminology allows them to let themselves off the hook for the clinician’s pain. The system can then pass the problem back to the clinician as a personal failing, rather than a systemic one. The therapy field is currently crying out for systemic change. We cannot do everything and be everything to everyone. It is impossible, and it is destroying us.

The butterfly’s orange and black wings flutter back and forth as it buries its face in a Black-eyed Susan. You contemplate the effort that it took for this butterfly to metamorphose from a caterpillar. It went through a violent transformation in the cocoon to become this creature. It’s not a pretty process. The butterfly must flap and flap and flap its wings inside the cocoon to strengthen them. It can be a difficult struggle to watch, and an onlooker often wants to help the butterfly be free from its enclosure.

But if it’s released from the cocoon early, the butterfly won’t have the strength to fly and survive. It must struggle to become strong. As you stare at the butterfly, considering its beautiful wings, you start to breathe into your own bodily awareness. You notice the many places where you’re holding tension and feeling stiff and sore. Perhaps you have also been flapping your metaphorical wings, becoming something new.

Grieving Tools — The Pain Paradox

As you might remember from chapter 2, pain can be a pivotal part of the meaning-making process. When paired with reflection time, pain can help us learn about our core values and live a life in accordance with them.

Yet because we work in a field that values sacrifice and the pain that entails, therapists are also far more susceptible to what Freud would call the martyr complex, and what we refer to as hero/savior/sacrifice syndrome. The pain paradox explores the tension between pain as both catalyst for change and a state of prolonged suffering. Particularly in helping professions, suffering for our work is often framed as positive, meaningful, or altruistic. This harmful social construct can lead clinicians to stay in harmful jobs “for the sake of the clients” and sacrifice their own health in the process.

The pain paradox invites clinicians to question their social constructs around both pain and meaning-making. In the therapy room, the pain paradox is a tool that clinicians can use to help clients who are themselves engaging in harmful behaviors for the sake of “meaningful pain.” Let us explore how you can use the tool of the pain paradox as you navigate your personal struggles outside of session, and how to use this tool with clients inside the therapy space.

Client

Pain is not the enemy, nor is it to be avoided at all costs. Sometimes what brings clients to therapy is the erroneous idea that we, their therapist, can help them learn how to disengage with their feelings entirely because these feelings are causing them pain. Of course, the reality is that we can teach them distress tolerance skills to be present with their pain and their feelings so they can learn to listen to the important messages carried by their feelings.

However, clients can sometimes mistake pain for purpose. We see this frequently with our creative clients. So often the idea of the “crazy artist” takes hold of clients. Several of Justine’s clients were terrified of feeling better. They believed that their sickness and the distress it caused fueled their art. But the reality was that after going through treatment, these clients were all able to continue making amazing art, and in fact they did so with more frequency and focus. Another part of the process of working with these folks is helping them see that they’re full human beings who are more than just the art they craft.

Many fear that if they lose the art then they lose themselves and they no longer matter. However, in our experience, part of their healing journey entails exploring areas of their life outside of art. Eventually, they come to see their art as but an aspect or a planet within the vast cosmos of their lives.

Therapist

For many of us, the desire to make meaning from our own pain drew us to the field of psychotherapy. Most therapists have experienced some type of mental distress, whether it’s childhood trauma, an eating disorder, bullying, discrimination, or an abusive relationship with chemicals. For many of us, surviving this kind of pain was only the first phase of the healing process, with the second phase being meaning-making.

The pain paradox is a gentle invitation for therapists to carefully consider ways to cultivate meaning and joy outside the therapy field. Although our work as therapists is absolutely meaningful, it is also back-breakingly painful at times. If you don’t have other avenues or ways to make meaning and find purpose, you’ll find it even more challenging to take breaks from the field, regardless of how long such a break lasts, because you struggle to see the “you” outside the office. You need not try something life altering or huge. When Larisa was recovering from a severe case of moral injury, she began making playlists, an activity she had not engaged in since her college days. This small daily activity helped her to begin to reconnect with playful and creative energies outside her clinical and professional work.

The difficult message that Justine received was that her time as a direct-care therapist was coming to a close. After over a decade of work, and so many clients helped, she began to feel that her meaning-making was now to be found in the classroom, on the stage, and on the page. She experienced a great deal of pain as a therapist during the pandemic and the social justice uprising, but the pain invited her to consider where new meaning could form. The answer was that it was time to guide the next generation of clinicians and to hold the hands of those who are still in the trenches. As of this writing, Justine is currently working on the slow transition out of direct client care.

Due North: Self of the Therapist

One of the struggles inherent in walking the dialectic between the system and the individual is despair. In the case of moral injury, which is caused by a series of broken systems subjecting clinicians to harmful double binds, it can feel like there’s little or nothing for a therapist to do beyond retiring from the field. While this certainly is an option, we offer you another one: harm reduction and intentional activism.

As you may already know, the harm-reduction model of addiction recovery focuses on making small, actionable changes that mitigate abusing behaviors, rather than prescribing total sobriety. Our intention is to invite you as a clinician to assess the harm you’re currently facing in your career and how it’s affecting you. You can’t immediately change the systems in which you practice therapy, but you can make a concerted effort to mitigate the negative impact that these systems have upon you.

Some ways that you might limit the harm you experience include limiting the number of hours you work or the types of clients or clinical presentations with which you work. Perhaps you currently work in a place with an unreliable schedule, and that causes you distress; is it possible to have a more structured schedule? If you’re not being given time for breaks or lunch, is this a conversation you can have and a boundary you can set with your site supervisor? These can be small or large changes, but any change can go a long way to help mitigate the harm you’re experiencing.

Successful Psychotherapy Comes Down to Finding the Motivation for Change

Posted on by Psychotherapy.net Team

Peter: Comfort in Food and Resistance to Change

“I have an Italian last name and I always wanted a good Italian first name like Pasquale or Aureliano, but what I got was just Peter.”

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Peter was a single man in his early 50’s when he came to the nursing facility. Until then, he had lived his whole life with his mother, and he was anguished over being apart from her. “I don’t even feel like I’m a separate person from her,” Peter said during a psychotherapy session.

Peter recalled being diagnosed in late childhood with a Rett Syndrome variant, apparently related to a speech disturbance. He had experienced early learning difficulties, yet he had developed language skills and general motor skills. He showed mild autistic features and lifelong obesity. He never fit in with his siblings or peers, didn’t play sport games, and found socializing desirable yet dreadful due to anxiety and uncertainty. His mother and brother did not have detailed recall of his childhood medical information, and his mother simply said, “He was always different, never like other people.”

After his weight reached 625 pounds, Peter refused to be weighed anymore at the nursing facility. He would sometimes request double portions of meals, ordered in fast-food meals, and often requested snacks. Peter would mimic the lectures he had so often been given by family and healthcare providers about the risks of obesity and the potential benefits of weight loss. He understood the risks inherent in his lifestyle of lying in bed, eating, and watching TV.

In psychotherapy, Peter wanted to express his outrage over his mother’s refusal to allow him to return home, yet he was willing to consider her stated viewpoint: she was aging, and his daily care needs exceeded her ability to manage them. He defended his unwillingness to consider any dieting or change of his daily routines yet was willing to review in psychotherapy the information and concerns others had communicated to him about eating and health risks. Peter was also unwilling to give up the style of eating that he felt was a lifeline. He was not motivated to change. Yet he liked psychotherapy because, “You listen to me, and you don’t look down on me, and see some good in me, and nobody else does that.”

Peter had not worn clothes for years. In bed he was covered by a sheet, and when he got out of bed, he would be clad in a checkerboard of hospital gowns draped and tied around his body. The facility purchased a custom-made wheelchair that was four feet wide. It would not fit through any doors, so it stayed against the wall outside his room. Peter would use a walker to come to the door, then edge sideways out the door, and settle into the wheelchair. Stretched out behind the chair, I would push him to a niche at the end of a hall where we could sit for sessions.

Emotional tensions in the case came from nurses and aides who felt uncomfortable with his ways of eating. Many team meetings and individual consultations were needed to clarify and resolve differences in viewpoint and approach. Individual staff persons might try to intervene by refusing his requests for foods, and by hectoring him — ‘you’re killing yourself; you know.’ Peter was cognitively capable of making informed choices about his daily behaviors and his healthcare. Nurses fretted that, ‘I might lose my license if he dies, and I didn’t do something to stop him.’

We had many conversations about the rights of a (mentally intact) person to make choices, even if we disagreed with those choices, and even if we noticed health risks attached to those choices. We spoke of how a staff person might smoke, eat fast foods regularly, text while driving, or do any number of other potentially risky behaviors, and how others do not try to take away your rights to make such choices (unless you live in California, that is).

Peter experienced developmental complications due to a type of genetic disorder — one often linked with obesity. He had a deeply conflicted relationship with his mother, and he had experienced a lack of peer relationships and appropriate socializing opportunities in his life. He exhibited social anxiety and avoidance, and profound feelings of shame and self-loathing. He felt unwilling and unable to endure prolonged discomfort and deprivation to pursue goals that he felt were not his own. But he relished therapy conversations in which he could discuss — without feeling shamed — all the above topics and many others, including his extensive knowledge of TV shows and movies over the prior few decades. He remained obese.

Mykela: Discomfort and the Motivation to Change

Mykela was also in her early 50’s. She had lived for the past few years with her father in his house. She rarely left the house due to feelings of anxiety and depression, and embarrassment over her body weight. She came to the nursing facility after an illness that required hospital care. Mykela weighed 450 pounds, and she felt strongly motivated to lose weight. She immediately wanted Bariatric surgery to assist her weight loss, yet the doctor wanted her to lose significant weight before he would agree to the procedure, due to possible risks and complications. The doctor still wanted her to lose more weight, yet he did eventually agree to surgery after she’d lost 50 pounds which took her about a year to achieve.

Mykela spoke in psychotherapy of her history of depression and its roots in childhood experiences. She verbalized the distress she felt in public when others might mock, deride, or insult her. She wept as we discussed whether she would (dare to) join a group outing from the nursing facility to an apple orchard to pick apples, but she returned more confident because she had endured unpleasant looks and comments without collapsing emotionally.

After her Bariatric surgery, she did adhere to a rigorous diet plan, and she steadily lost more weight. Mykela lost so much weight that large folds of skin would swing and clap against her body as she walked with her walker. She had further surgery to remove skin folds — and rather than feeling ashamed, she wanted to show off her surgical scars and her now slimmer body — as signs of her fortitude and motivation. Mykela returned home, walking without support. She cared for her aging father and drove her car. She became a spokeswoman at the Bariatric clinic to encourage and support others interested in making positive life changes.

***

In nursing facilities, I work with clients who, like Peter and Mykela, have quite complex problems, and who exhibit varied degrees of motivation, or even capacity to effectively make the kinds of changes others might recommend. Peter had felt rejected and despised for most of his life. He did not want for himself what others had strongly advised for decades. He felt relieved, though, to find a therapeutic relationship in which he could feel safe, and he was then willing to look at the viewpoints of others without defensiveness. But he was unwilling or unable to make comprehensive and sustained changes to his lifelong patterns of behavior. Mykela, in contrast, felt an inherent motivation to change, yet she needed the support of psychotherapy to help her connect with her strengths and to foster the fortitude and resilience needed to effectively achieve her goals. Unlike body weight, success is not always easily measured.   

Love is Not All You Need: A Revolutionary Approach to Parental Abuse

Posted on by Psychotherapy.net Team

The Referral Letter

The referral from Dr. Adams, the psychiatrist, read:

13-year-old young woman took an overdose of paracetamol 3 weeks ago. Called mother who took her to Accident & Emergency. Seen and followed up over last 2 weeks. No suicide ideation. Discharged to GP. Family issues. Please can you meet with this family this week?

Session One, Part One: Overdose and Desperation

A few days later as I (Kay) walked into the waiting room at the family medical practice where I worked, I saw Becca hunched over her cell phone, radiating animosity. Her mother Jane sat on one side of her, eyes on the latest New Zealand Woman’s Weekly story, but without the eye movement of a reader. Her father, Al, resigned, stared out the window at the dripping rain. Susie, Becca’s 15-year-old sister, picked absent-mindedly at her nail polish.

My step faltered as I sensed that the meeting ahead of me might be testing but I strode in, hand outstretched: “Hi! You must be Becca. I’m Kay.”

Temporarily startled, a reluctant smile escaped her as she awoke from cyber-land. “Hi, you must be Jane. Hi, Al. Hi, you must be Susie. Would you like to come up?” I gestured toward the stairs that led to my office stairs. As I reached the first landing, I noticed Becca glancing at herself with uncertainty in the floor-to-ceiling mirror that filled the stairwell. The family awkwardly found their way to their seats. I began my usual introductory patter but didn’t get far before Al expostulated, “Look, we need to sort this out! We can’t handle it any longer.” His eyes shot towards the brooding Becca. “She hit her mother in the face the night before last and then she locked herself in the bathroom for hours. We tried to get her to come out and talk but she just shouted abuse at us.”

Jane glanced towards me as she found some words.

“Becca went very quiet, and I got really scared. We thought we had taken all the medicines out of the cabinet after the overdoses, but we couldn’t help worrying after what happened the other week. We took turns sitting outside the bathroom door just listening in. Eventually, she came out and went up to her room. It all started when Al tried to tell her she couldn’t carry on talking to me like she was.”

“Becca,” I ventured, “did you realize that your parents are feeling so scared and don’t know what to do?” My question was met by a “no” that ricocheted around the room like a bullet. “Becca, would you be willing to help me understand what has been going on in your family?”

Becca’s reply began with a fake whine which escalated to foul-mouthed accusations. “She’s always saying, ‘Honey, what’s wrong?’ What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong is that she’s annoying me. My mum is a stupid bitch with no life. That’s what’s wrong.”

I said, “Becca, is this way of talking the kind of talking that is causing trouble in your family?”

Becca said, “This is so fucking dumb.” Susie let out a protracted sigh.

“Becca, stop talking like that. It’s not fair. Mum and Dad have had enough and what have they done to you?”

The door slammed loudly as Becca made her exit. Jane leapt out of her seat, but Al caught her by the arm.

“Let her go. You always go after her. It’s no good. You can’t keep running after her like this.”

Concerned to sidestep the impasse between them, I spoke up.

“Okay, how about I go downstairs and find out what’s happening, and we can take it from there?” Al and Jane nodded, defeated. Susie was pale.

It turned out that Becca had found the back door to the building. I caught a glimpse of her crouched down with her back against her parent’s car, head between her knees. She looked up, saw me and went to sit on the other side of the car, out of view. I asked Emma, the receptionist, to keep a discreet eye on her. When I went back to the room, Jane and Al agreed to sit it out.

Al began, “It’s good you have seen her like this. We are falling apart. We can’t do this on our own.” There was a moment’s silence. Al looked to Jane. Jane’s shoulders began to rock as if she were holding back sobs. Al continued, “Becca doesn’t treat her mother like a parent. I mean she says things to me that I would never, ever have thought of saying to my parents. You just want to slap her face, but you can’t you know?”

Jane, her body stiff, said with a look of desperation, “The other night, Becca was screaming at me that the dinner was ‘crap’ and ‘shit.’ Adam, our 4-year-old, hid under the table. It broke my heart to see him so scared of her because he loves Becca. I feel like we are losing Susie too because she can’t stand it. She is staying ‘round at her friend’s house all the time.”

Al looked towards Susie, raising his eyebrows.

“You’re no angel either, Susie, but at the moment you come a long second to Becca.”

The story unfolded. It appeared that this was a long-standing pattern which had recently escalated from initial bad-tempered-ness to dramatic, life-threatening actions. I discovered that Al and Jane considered that they were being held hostage by Becca’s threats to harm herself, both subtle and explicit. Such threats followed any insistence that she carry out some duty that she didn’t wish to fulfill such as tidying her bedroom or if Jane said “no” to her persistent demands for money or to stay out late.

Jane had begun to fear returning home from work, anticipating that she would be met with yet more demands from Becca, and find herself caught once again between holding out against them or risking further threats of self-harm. Al was also finding home life unbearable. He longed to be able to “fix things” for his family but, in the face of Becca’s threats, had no idea what to do and couldn’t find words for the mixture of frustration, fear, and anger that preyed upon him. Al had started going around to his friend Mike’s house each night for a drink until what had started as occasional visits had become habitual. He felt guilty that he was not at Jane’s side but told himself and Jane, “I no longer have a place in this family. I am sick of being abused in my own home.”

Jane and Al had no idea what to do. Becca had been “seen” by Mental Health Service several times and, after the usual assessments (in which “mental illness,” abuse, and other possible sources of distress were excluded as a cause of Becca’s behaviour), the service had come to the conclusion that the overdose and threats of self-harm could best be explained by what was referred to as “family dynamics” and suggested that Jane and Al seek family therapy. That is how they arrived at my door.

How many parents, confounded by a family life that has become dominated by teenage tantrums, threats, violence, and the dread that their daughter might respond to any challenge to their demands with an overdose or violence, would be willing to talk about how they fear living in their own homes? How many would tell family and friends? Wouldn’t it be more usual for parents in this predicament to remain silent in their humiliation that their own child is abusing them? Of those family members and friends who had some knowledge of the situation, how many of them would be too respectful to speak up about this family’s predicament without being invited to do so?

Could these tantrum overdoses and the tyrannical threat of them instigate a servicing of young people’s every want? What might these young people be led to think about themselves if their each and every whim was serviced? Where would this lead? How might this have them lead their lives? How might this affect their family life? All these questions went through my mind as we reflected on this family and their tribulations; all these questions guided us in our considerations. This is the story of a family worn down by tantrums and abuse. This is also the story of a mother who decides to revolt.

Session One, Part Two: When Loving and Giving is a One-Way Street

“You know, Kay, we’ve always said, ‘love is all you need.’ It’s been our motto. I’m beginning to think we’ve made some big mistakes because I can’t understand why Becca is behaving like this. We have given them all so much love. We have always bent over backward to make sure that they are okay. It’s just so unfair. I try to listen and understand but she doesn’t want to talk to me anymore, and then she starts with her threats. I know I shouldn’t give in to them, so I try and hold my ground, but I feel like I have overreacted. Then I feel bad and give in. I know I shouldn’t. I just feel like I am stuffed!”

Jane’s voice faded into despair. As tears began to form in her eyes, she wiped them away hurriedly with the sleeve of her hoodie. Al chipped in, his voice weary with resignation.

“I just don’t know where we’ve gone wrong.”

I addressed the despairing Jane and displaced Al.

“Do you think it’s possible that all your loving and giving has become a one-way street, and that somewhere along the way your children’s wants have become confused with their needs?”

Jane swallowed hard.

“We’ve always tried to give them what they wanted. I always thought that if we respected them, they would respect us, but they don’t seem to. I just find it so hard to know what to do.”

I asked, “What do you think Al?”

Al shifted uneasily in his seat.

“What’s going to happen to them in the hard world out there?” he said wearily. I wondered if servicing their children’s needs had, contrary to their good intentions, been depriving their children of invaluable life lessons.

“Al,” I asked, “are you concerned in any way that unfairness has crept into the care of your children in that, by giving so much, your children may not have had enough opportunities to learn what they need to learn to live in the hard world out there?” Al had no trouble replying:

“Yep. I don’t think they have any respect for other people, and they don’t know how to be responsible.”

“Susie, what do you think of the idea that your parents have been unfair to you by not helping you to be ready for the hard world out there? Do you think that maybe, out of their love for you all, they need to find ways of mothering and fathering that might seem unfair to you now but may prove to be fairer to you in the long run?”

Susie stared at me, her eyes fixed in surprise, then she recovered herself. “I don’t think they’ve been unfair, but I suppose we have had it pretty easy. I don’t know, it’s getting me down too.”

“Susie, have you been worried about Becca?” Susie’s lip began to tremble. “Susie, how would it be if I carried on speaking with your mum and dad to see if we can find a way to help things be better for Becca and for you all? Would it be alright if I spoke with them without you present? I think your mum and dad need to find the way forwards on their own as your parents.”

Susie’s face softened with relief. Jane and Al agreed that the next time we met we would continue to explore how this habit of unfairness had taken root in the mothering and fathering of their children. I warned them that the road ahead might well be a rocky one and that other parents facing similar challenges are often met with intensified threats from their daughters or sons when they re-establish their parental authority. Jane and Al left our meeting, sobered by the realisation that they could go no further along the road that they had been travelling but relieved to be no longer standing paralysed at this crossroads.

Session Two: The Dif?culty of Knowing What’s Fair and What’s Unfair, What’s Unreasonable and What’s Reasonable?

Jane announced that there had been something of a turning of the tables. The day after our session she had decided that it was time the girls learned to do something for themselves. Instead of doing their clothes washing for them as she had always done, she had left their washing lying on their bedroom floors where they left it and stayed in bed herself for an extra hour. When later that day Susie asked where her clean washing was, Jane simply said, “Oh, I’ve given up doing your washing now.” Much to her surprise, Susie asked her to show her how to use the washing machine. Not surprisingly, Becca had left her dirty washing in a heap in her room.

Al, who was running late, joined us. I put him in the picture.

“We were talking about wants and needs and I was asking Jane about whether or not your parenting in the past has been about 'loving and giving?’”

“Well Susie has been getting too much until now,” Al responded. “My sister set her up with an interview as a summer lifeguard and she didn’t even bother to go. Lynette was really annoyed about it and had a real go at me. She said, ‘You two have to toughen up with those girls.’ I’ve realised she’s right.”

“What do you think you have been serving? Have you been serving her wants or her needs?”

“Her wants!”

“What do you think her needs are?”

“Her needs are to take some responsibility for herself. She hasn’t lifted a finger all holidays. She’s just sat at home emptying our fridge.”

“At what point do you think mothers and fathers should let their children know that if they as parents continue to take responsibility for them, they will be depriving them of taking responsibility for themselves?”

“Well, we do but we don’t stick to it,” Jane said.

“Yes. We lay down the law and then we give in,” Al replied.

“Looking ahead to when Susie is 40 years old, do you have any idea what she might wish you had done or said to her right now, aged 15?” I asked.

“She’d say ‘take responsibility for yourself’ wouldn’t she?” Al suggested.

“I suppose so, but we would have to make her do it and I would find that very difficult,” Jane responded.

“You said last time we met that you have a motto of ‘love is all your need.’”

“Yes, you know I have always thought that if we just loved our kids, it would all work out,” Jane said. “Last Sunday morning was a real low point. Becca started swearing at me when I got home from a late shift and was on my bed with all her friends drinking and eating. I found myself thinking ‘whatever happened to my lovely daughter?’”

“Do you think it’s possible that in the past, even though your intentions have been so very loving, love has been confused with giving in to what your children want?” I enquired.

“I guess so. I just thought they would love us if we loved them and that if we respected them, they would respect us,” she said.

“Are you coming to question how children learn love and respect for their parents and others?” I asked her.

“Yeah, I guess I haven’t made a point of them respecting me so maybe they haven’t learned it. I lose their respect for myself every time they say ‘no’ to me and I let it go,” she said.

“Al, what do you think about this? How do you think children learn to be loving and to practise respect?” I asked Al.

“Well, it’s been harder for Jane,” he said, adding, “I’ve always worked long hours and before we had Becca, we agreed that she would stay home and be a full-time Mum. We were really hanging in for Becca.”

“Yes,” Jane agreed. “You see Susie isn’t Al’s. I had Susie when I was 17 and I was a single parent until I met Al when Susie was 2. We had some problems and had IVF. Then she was preemie and we thought we were going to lose her. It was a terrible time.”

“Given you had to go through so much heartache to have her, did you ever think that Becca deserved special treatment in any way?” I suggested.

“We were just so thankful that she had survived,” Jane admitted. “Looking back now, I tried to give her the best of everything, and we doted on her.”

“Yeah, it was our one time away from her and she was all we could talk about,” Al said.

“Do you think that loving Becca so much has led you to be especially sensitive to her moods, wishes, and feelings?” I asked them.

“When I look back now, I think so,” Jane said.

“To be honest, she was very spoilt,” Al added after.

The Letter

The next day I wrote Jane and Al the following letter.

Dear Jane & Al,

It was good to meet you yesterday. As I mentioned, I often write to families after our sessions to ensure that I have adequately understood their situation and in addition to ask questions I wish I had asked during the session itself.

Sure, enough some questions came to mind whilst I was reflecting on your situation. I would be most interested to hear your answers or any thoughts you might have about these questions next time we meet. If you think that I have not described what we talked about fully or have misunderstood your situation in any way, could you also bring it to my attention next time?

Jane, before Al arrived you talked about some changes you had made. You said that a couple of days before we met, you had decided to have a ‘lie in’ and had resolved that you were no longer going to do the girls’ clothes washing. You also informed me that you felt you hadn’t had enough expectations of the children in the past and that you wished that you had started years ago. But you said that your lie-in was not as peaceful as you had hoped because you found yourself troubled, wondering whether or not your expectations of the girls were unreasonable or unfair.

Jane, do you suspect that your expectations may be having a late growth spurt but that perhaps, and very understandably, you are feeling a few growing pains? After all, have you ever noticed how overnight changes often feel as uncomfortable as a new pair of shoes to begin with?

Jane, do you have any ideas about why it was difficult for you to work out what expectations might be reasonable and fair? Do you think it may have been in part because your expectations of Becca at least, have been so shaped by the weight of your gratitude for her very existence?

Now that you have decided that your children can learn to serve themselves rather than being served, what kind of response do you think you might anticipate from them as time goes by? Do you think that they will take kindly to your new expectations which express your love for them in a way that serves their needs rather than their wants? Or do you think they might protest the changes in some way or other?

Jane and Al, towards the end of the session we talked about how separating your children’s wants from their needs had been especially hard with Becca.

Isn’t it understandable that if you have waited so long for a child and then when she is born and you are in fear for her life, you might want to treat her with especial care? Is it any wonder that your love and concern might leave you blinkered to some of her needs and sensitive to her wants?

Jane, do you think your ‘special care’ of Becca might have had a bearing on ‘giving in or setting boundaries and sticking to them?’ Thinking about it now, do you suspect that weak boundaries might be even more painful for you than for her in the long run?

You both told me that you don’t want to make your children unhappy, but then you talked about some realities that life holds. You said there was a difference between real unhappiness and tantrumming. If you always say ‘yes.’ if you’re always ‘manipulated.’ Where do your children hear ‘no’ from? What kind of lives will they lead if they never hear ‘no?’

Al and Jane, at what point do you think a mother or father should say to a young person: ‘I will not allow you to have such power over our family anymore; we are in charge, not you?’ Truth be told, what do you guess Becca would most like her parents to do right now?

I cannot believe that departing from the ways in which you have mothered and fathered your children in the past is going to be easy. In fact, would you consider that it might be one of the most difficult things you might ever take up in the course of your lives?

I look forward to meeting with you again on the 4th of March. Best wishes,

Kay Ingamells

Session Three: ‘Self Sensitivity’ 90%, Sensitivity to Others 10%

Jane came on her own to the next session. Although Al told her he was busy at work, she suspected that he had been overcome by his feelings of powerlessness and resignation. We began the session with my reading the letter aloud to Jane. Jane reported that the letter made her “realise I thought being a loving mother meant taking care of them in every way 100% of the time and this has made it difficult for them to respect me as well as for me to respect them.”

Once again, she reported some novel developments. Jane had “put her foot down” when Becca had decided at the last moment that she didn’t want to attend her surf rescue training.

“I said, ‘we are going in the car now,” Jane said. “And when we got there, she said, ‘Don’t make me go. You’re so mean, I hate you.’ I found it really difficult, but I insisted she stay. I went away feeling really upset but when I came to pick her up, she said she had enjoyed it.”

“Did you take a stand for what you knew in your mother’s heart was right only afterwards to be undermined by guilt for not responding to her wants?” I replied.

“Ummm I did.”

“How come you put your foot down even though the guilt was putting such pressure upon you to give in?”

“Well, I thought it was the best thing for her.”

“Does putting what was ‘best for her’ first rather than giving in to her wants say something about your wisdom as a mother?”

“Yes! That I know what’s right for her and it’s okay to say it and insist that she does what she says she will do.”

“Do you think guilt would have got in the way of your motherly wisdom in the past?”

“I think it would have. I wouldn’t have wanted the children to plead and cry. I wouldn’t have wanted them to be unhappy. I would have brought her home again.”

“What has enabled you to act on your motherly wisdom and use your motherly voice lately rather than be sidetracked by their pleading and crying?”

“I don’t know.”

“You’ve given me one example after another of how you have used that motherly voice very powerfully and afterwards.”

“And yet I don’t feel in control. I don’t feel in control at all.”

“Do you also think it is possible that using your motherly voice is uncomfortable because you are not that used to speaking with it yet?”

“I said to Susie when she butted in, I said, ‘I’m the mother. I’ll decide what Becca will do and what she won’t do. I don’t need input from you.’”

“Do you think that it’s possible that your children have developed over-sensitivity to themselves and to their own feelings and insensitivity to you and to your feelings?”

“Yes!”

“If you were to put that in percentages, what percentage of the time do you think they are sensitive to their feelings and what percentage of the time do you think they are sensitive to your feelings and the feelings of others?”

“They consider their own feelings 90% of the time. Al is really kind and generous and caring, but certainly he would put what he wants to do above anything or anyone else, especially me.”

“What happens to your feelings and to your needs?”

“They get forgotten.”

We talked about the effects this imbalance of sensitivity, e.g., self-sensitivity, versus other sensitivity was having in her relationships with her children and their relationships with her. Some of the questions I posed were:

“Would you be interested in restoring the balance between Becca’s over-developed sensitivity to herself and her under-developed sensitivity to others and in particular to you as her mother?”

“What kind of struggle would you expect if you were to pit your mother’s wisdom against the widespread mother guilt?”

“Overdoses as tantrums” and a big night out.

A month later, I had a call from a worker from the after hours Mental Health Crisis Team to report that Becca had taken another overdose. The overdose had followed an argument with her mother about tidying up her room in which Becca struck her mother in the face breaking her glasses. Jane had to go immediately to her optometrist as she was due to start work an hour later and could not work without them. Becca tried to stop her mother leaving the house, but Jane had no choice but to do so. Becca took the overdose as soon as Jane left. This overdose posed a greater risk than the earlier ones and it looked like she was, in a manner of speaking, “upping the ante.” Jane became concerned that Becca would take her own life and so arranged a safe haven for her at Becca’s aunt’s home for a few weeks.

Becca was seen for an urgent psychiatric review. The psychiatrist concurred that Becca’s overdoses appeared to be an extreme reaction to her parents attempting to set appropriate boundaries. A safety plan was put in place with the parents, and I met Jane and Al a couple of days later. To my surprise Al and Jane were not as shaken by the overdose as I had expected. Instead, they concluded that Becca’s extreme behaviour was her way of “testing us.”

We discussed how they had dealt with tantrums when their children were toddlers. On seeing the similarities between toddler tantrumming and Becca’s extreme form of teenage tantrumming, Jane and Al became inspired with a renewed courage and confidence. It now appeared that perhaps this was a problem that they recognised and not only had some experience in handling but could rightfully assume they might overcome. The next morning, I had a phone call from Jane. She had discovered from the mother of one of Becca’s friends that Becca was planning a big night out to a nightclub in the city with a group of teenage friends. The nightclub called Krave was in the heart of the city, an hour by bus from the suburb that Becca lived in. Jane and Al told Becca that she couldn’t go as she was underage. Becca was outraged and insisted that she would go regardless. Jane later discovered that $100 was missing out of her purse and challenged Becca who, as usual, denied taking it.

Jane and Al enlisted the help of Becca’s aunt, uncle, and elder brothers to come around that evening. Despite this, Becca made her escape out of her bedroom window.

The team hot-footed after her, combed the local mall and found her waiting at a bus stop with two friends. Al took hold of her arm and asked her to get in the car. Becca began to scream “blue murder,” shouting “you are not my parents. I don’t know you. Help someone! Help! Help!" The passers-by that had assembled called the police who arrived very quickly at the scene. The police believed Jane and Al’s version of events rather than Becca’s street theatre. Becca’s protest resulted in her being handcuffed, read her legal rights and taken down to the cells.

I asked Jane how she felt about the evening’s events.

“It’s good to be in charge at last. I have never seen Becca so demure. The police wouldn’t release her until she had promised not to harm herself.” Guilt had not had its way with Jane this time.

Session Four: Instigating the Revolution

While Jane and Al had begun to turn the tables on the habits of parenting which had flourished on their sensitivity to their children’s feelings and servicing of their wants versus their needs, I was concerned about the extreme nature of Becca’s actions and that Al and Jane’s newfound determination could be compromised in the face of them. Consulting with David in supervision, we decided that a community approach was needed to match the gravity of the situation and to provide sufficient reinforcement for Jane and Al’s fledgling initiatives. While no approach was without its risks, any alternative

Breaking the Rules: When Parroting is the Best Approach in Therapy

Posted on by Psychotherapy.net Team

A Non-Directive Approach

Carmen is your new ten o’clock client. You are excited to be of assistance but you will soon discover that this enthusiasm is short-lived. You have decided to begin with a Rogerian person-centered approach since this is your typical modus operandi and is generally very effective in most instances.

The first rule that runs through your mind is that like virtually every other non-directive therapist, you were trained to employ paraphrasing and not parroting when responding to the client. Parroting refers to repeating back the exact words that the client has said, without any interpretation of evaluation.

After Carmen utters a few sentences, you respond. Secretly you feel greatly convinced you were hitting all the desirable keys on the Carkhuff Empathy Scale. But Carmen’s response was not even close to what you expected.

Her reply, “No that’s not what I’m saying, not at all. I believe you are missing the entire point of what I am attempting to convey.”

Okay, let’s try it again. Carmen tells you more and once again you paraphrase using fresh words only to hear, “Seriously! Are you listening to anything I am saying or am I just paying you to talk to the wall?” (Your thought, not verbalized, of course, is: Um, no, your insurance company is just paying me to talk to the wall.)

Focusing on the positive, I was convinced I would not need to spend a lot of time making Carmen more assertive.

This is déjà vu therapeutics. It immediately occurs to most helpers that on rare occasions, we have all experienced this dynamic with other clients. The dilemma is always the same: Is it truly the fact that your responses are pathetic or is Carmen (and similar clients) just the difficult, resistant clients from Hell?

Unfortunately, without running a complete battery of tests, consulting a string of experts, perusing a host of journal articles, and watching a video of the session again, it is next to impossible to know for sure. And yes, your own negative self-talk haunts you as you recall the sage advice of your uncle George who often quipped during your grueling time in graduate school, “Forget about this counseling and therapy graduate school stuff. Become a plumber like me.”

In essence, you really have no way to be 100% certain whether your therapy skills are a bit rusty, your uncle George was on to something, or if Carmen is just the resistant client your professors warned you about.

And surely you would never turn to parroting since your graduate faculty depicted the horrors of this evil technique. Moreover, every book, article, and mentor in the field insisted parroting was negative as well. In fact, it had to be true, since I have mentioned the dangers of parroting in my own books.

Even the ultimate expert Chat GPT AI says, “Parroting can be seen as invalidating and unhelpful for clients. Chat continues, “Parroting is condescending and dismissive to the client and does not allow the helper to add interpretation or elaboration.”

Does Therapeutic Parroting Work?

Having said that, ironically, I am going to suggest that the solution to your predicament with clients like Carmen lies in using a fool-proof intervention that can help you diagnose the situation virtually every time: parroting. Yes, parroting, the concept your professors warned you to avoid like the plague.

Your answer will become crystal clear when the client responds to your intentional parroting. Hence, if Carmen says, “I hate my mother,” and you violate the advice of your graduate faculty, and virtually all texts on the subject and say, “You hate your mother,” and Carmen replies, “No you really aren’t getting this, are you?” We can begin to suspect that her combative or perhaps clueless behavior is fueling the discord.

Assume Carmen’s next response was, “I had a terrible childhood,” and you come back without a shred of creativity with, “So you had a terrible childhood” only to see Carmen roll her eyes and say, “Where did that come from? I mean, really. No, I never said that. Are you really trained to perform therapy?”

Now you know Carmen has some issues and most likely your psychotherapeutic skills, although they may not be ideal, do not need a complete overhaul.

At this point, you can choose to confront Carmen either now or later or implement whatever strategy you deem appropriate, but at least you will have convinced yourself the issue is within the client and not you.

You may be asking if I have just invalidated a long-standing tradition in treatment. Well, not really. My guess is that in perhaps 99% of your interactions with clients, your graduate faculty got it oh-so-right when they recommended you refrain from parroting. Parroting is used for the 1% when a client has put your paraphrasing, summarizing, and reflective listening skills in a double bind.

I must disclose that I have a slight advantage over most therapists. On rare occasions when I need a little encouragement, I have my two pet African Grey parrots in the next room ready to help if I can provide a small treat.

Questions for Thought and Discussion

How effective has parroting been in your own therapeutic work?

What techniques do you find most effective in demonstrating that you are listening?

Are there particular clients with whom parroting is more effective? Less effective?

How to Use Inner Processes in Play Therapy to Help Traumatized Children

Posted on by Psychotherapy.net Team

I am a Safe and Sound Protocol provider (SSP.) In my clinical experience with the protocol, I have worked with children who have experienced severe trauma including physical abuse, sexual abuse, neglect, disruptive behaviors, dysregulation, and the disparities accompanying rural living. I have also worked with individual/family needs associated with neurodivergence.

In this work, I have relied heavily upon Stephen Porges’ Polyvagal Theory because I have found that looking at behavior through this particular lens provides a framework that depathologizes clients and emphasizes safe relationships. This lens also promotes an understanding from within the client and between the systems in which the client is embedded. James is one such client.

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A Tale of Therapeutic Attunement

Seven-year-old James (a fictitious name) was referred for his disruptive and aggressive behaviors. James was being raised by his paternal grandparents as his father died by suicide when James was young, and his mother was unable to care for him due to her complications with mental illness. James’ behavior with me was often the exact opposite of what the adults in his life reported.

Outwardly, he appeared calm, engaging, sociable, and playful. What, I wondered, was going on with this seemingly cherubic child to provoke him to rage and violence against his grandmother? What might be happening within the family system — within him?

James had experienced significant losses, so anger made sense. But, in spite of his placid and seemingly sociable demeanor, he was also quite emotionally disconnected; a protective strategy that helped him to feel safe and secure amidst all of the changes and losses he experienced. For many years, it was safer for James to simply not feel the pain of all these stressors. Not until we started play therapy, that is. James and I played together almost every week for many months.

Being a client-centered therapist and a play therapist, I allowed James to guide me in and out of his world, in his own time, with his own stories, items, and creativity. I noticed how he would go into a deeper part of himself, but only after many months of building emotional safety, and then it was only for a brief “nugget” of time. As I began to learn about James’ story, his past and his present, I learned to go with and trust the “ebb and flow” of the process that unfolded for him and between us in the playroom.

I recognized the importance of matching my pace to his, which can be difficult because there is a temptation to more immediately address the disruptive behaviors. I knew how vital it was for me to regulate myself so that both he and I could “dive deep” together into that private inner world he so fiercely protected.

As I worked with James, I often calmly and patiently reflected on what he was showing me through his chosen play activities which included Sandtray-world-making, art therapy, or even video games. Over the course of a few particular sessions, I noticed what is referred to in Polyvagal theory as Polyvagal countertransference — my own physiological response to the process between myself and James as we played together.

James might, for example, briefly create a sparse scene in the sand before abruptly bouncing to another activity. As this pattern continued, I patiently tracked him, monitoring my own internal physiological state so as not to become dysregulated or distracted by the rapidity of his changing play. In one particular session, a shift occurred. He created an elaborate, deep and lengthy sandtray scene, replete with a wide variety of miniatures.

I noticed myself becoming very excited, mirroring his own physiological state, and thought, “he is finally going to ‘let out’ a large piece of his trauma story.” For a brief moment, my own inner experience bordered on fight-or-flight, not as much because I felt fear or that I was scared, but because I was excited with and for James. I recall also sensing danger arising from his play, likely a mirroring of his own fear as the trauma story became revealed.

Fully connected and engaged in that amazing moment, our nervous systems met. He brought all of him, I brought all of me. If only for a moment, it was in that sliver of spacetime that healing was happening. In that space I could say to James, I see you. I see your pain, I see your loss. I see this anger, confusion. I see all of it in this story that you just told me. I see how this big storm came and wiped out the entire town, and how your mom was swept away. How you tried to save her, and how you still want to save her.

In that magnificent moment, all of James’ heavy and painful feelings finally surfaced. I was able to contain those emotions for James because my own nervous system was responding to his. And that level of attunement was not shown with words but through and with a shared energy. The within and between.

Questions for Discussion and Thought

How have you used the work of Stephen Porges in your clinical work with children? With adults?

What about the way the therapist worked with James do you appreciate? Why?

How might you have worked differently with James?

Do Clients Really Read Session Notes? The Truth Might Surprise You

Posted on by Psychotherapy.net Team

“I’m old school, my job is to focus on what my client brings to me,” said my friend and colleague Joan, a social worker of over 35 years.

Having worked for decades in the public school system with some of the most challenging clients, many of whom were entangled in the state’s labyrinthine bureaucracy, Joan was familiar with the multiple levels and layers of accountability, and the importance of writing notes and sharing records. She also knew that there would always be eyes watching — eyes without faces, and faces without names, all looking to make sure that her T’s were crossed and her I's dotted.

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Joan also appreciated the necessity of assigning an accurate diagnosis, and that doing so in a clinically and ethically correct manner meant taking time to get to know the client, their personal challenges, and their system of support. But Joan had also always believed that “my notes have never been problem-oriented,” and that “I want my notes to be about more than a diagnosis; something that actually helps my client.” Joan made it her policy to not be the one to initiate conversations with her clients about diagnostic impressions or diagnoses, current or past. For her, a diagnostic note was a clinical tool, much like mental status data, clinical impressions, or assessment results — and not within her clinical province to “bring up.” Doing so, she believed, would invariably shift the focus from what the client needed to what she needed to do as part of her job.

Discussing Diagnoses and Clinical Notes with Clients

So, it came as a resounding shock to Joan — now a teletherapist — when, at the start of their second online session together, her client proclaimed, “I read the document about my diagnosis of ‘adjustment disorder with mixed emotional features’ and it was right on!” Joan recalled thinking, “what the hell?!” She vaguely recalled the contract she signed with the teletherapy company specifying that clients could review their notes at any time. But after reviewing the contract following the revelation by her client, she could not find anything that specified the mechanism through which clients were alerted to the location of their notes on the platform, or whether they received some kind of alert when a new note was uploaded by the therapist, or if the actual diagnosis was available to them. She added, “Had I known that the company was sending an alert of some sort, especially about the notes from the initial session with the diagnosis I was mandated to provide for insurance purposes, I would have introduced and explained the process and my diagnosis with the client.” It was soon after that Joan wondered if her previous one-session-only clients never made it back for a second visit because they received her notes from that first meeting with a diagnosis or diagnostic impression that didn’t sit well with them.

It’s not that Joan was worried about how her notes — which were written in SOAP form — or even her diagnostic impression would be received, but that for those clients who read their notes and never addressed them in session, her observations and diagnosis would be the elephant in the room, and perhaps her responsibility to address if the client did not.

For Joan, it was always important that her clients “have someone who likes them, someone who finds them interesting, someone who can look beyond a diagnosis, someone who is willing to see their daily struggles and who could see them as a human being either caught in a moment of distress or battling demons that left them feeling ‘less than, unlikeable, unliked.’” She was concerned that by turning the conversation to one of diagnosis and notes that she would “no longer be talking with them, but about them.”

Toward the end of our conversation, I asked Joan how this scenario might impact her work with clients moving forward, particularly around discussions around notes and diagnoses. She reiterated that, “I am old school…I simply don’t want, nor do I feel it is important to ‘bring it up’ with clients.” But she added that she would give it some thought.

***

Joan later recalled a client with whom she worked for only one session and gave a diagnosis that included anxiety and depression. That client, through some mechanism unknown to her, then saw a psychiatrist who worked for the same teletherapy company as Joan did. She found out that the client had been subsequently diagnosed her with borderline personality disorder and prescribed medication after one visit.

Joan promised me that she would share her impressions of that scenario in a later conversation.

What I Know Now About the Clients Risks and Rewards of Reporting Sexual Assault

Posted on by Psychotherapy.net Team

E. Jean Carroll stood on the courthouse steps to give her statement to the press following the jury's findings that former President Trump was liable for sexual abuse and defamation. She said, “This victory is not just for me, but for every woman who has suffered because she wasn't believed.”

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Within the hour, my phone buzzed notification after notification across my email and social platforms. People sent me screenshots of the headlines, celebratory emojis, and gifs. I've worked professionally in sexual assault victim advocacy in some capacity since 2010, first as an advocate and then as a psychotherapist.

Whenever a case like this happens, I become very popular for a few days. Being the go-to person for all things sexual assault in your social circles is, in a word, odd. It's amazing that anyone invites me to cocktail parties anymore. It's also amazing how many people will share their stories, bravely and candidly, when they have reason to think you'll believe them.

Why Sexual Assault Victims are Coming Forward Now

Amid the collection of celebratory emoticons, however, were a handful of skeptics using words like “convenient,” “opportunistic,” and “sketchy." They asked questions like, “Why now?”

In E. Jean Carroll's case, at least part of the answer to the question "Why now?" is that it was finally possible. In May 2022, the Governor of New York, Kathy Hochul, signed the Adult Survivors Act (S.66A/A.648A). The law went into effect in November of 2022, creating a one-year retrospective window for sexual assault survivors who were over the age of 18 at the time of their assaults the opportunity to come forward. A similar law for children was passed in 2019.

There are several ways to answer that question. Still, I am most struck by how surprised people are by the concept of delayed reporting — as if victims of sexual abuse should be clamoring to face the slut-shaming and character defamation.

That aside, why do people delay reporting?

In my clinical experience, I’ve learned that if they report at all, most of my clients delay doing so for some time, ranging from days to weeks to months, even years. Survivors offer several reasons for why they waited or simply refused to report their sexual assaults. The fear of not being believed is probably the most common. Victim blaming for the assault is a close second.

Another reason I've run into is that a victim may not understand that what they experienced was sexual assault. For years, we emphasized the trope of the male stranger in the alleyway, even though most assaults happen with a perpetrator who the victim knows. After all, it doesn't fit with the mythos they were taught. Even with DNA and forensic exams, consent remains essential to distinguishing rape and sexual assault from “just sex.” Personal accounts and statements are often key to a case — the infamous “he said/she said.”

The Impact of #MeToo

Although we've seen several high-profile people held accountable for sexual harassment, assault, and abuse more recently, the rate of successful prosecution (resulting in a felony conviction) remains abysmal at around 2.8%., according to RAINN, (Rape, Abuse, & Incest National Network)

That's part of what makes E. Jean Carroll's trial so remarkable. To many survivors, she did the impossible.

It's only been since 2017 when the #MeToo Movement — started By Tarana Burke in 2006 — gained national attention after Harvey Weinstein's sexual abuse allegations. Before then, men in positions of heavy influence and exceptional power seemed untouchable. But in 2017, suddenly, they were being held accountable for their actions. E. Jean Carroll's assault occurred in 1996. I'm sure that former President Trump seemed untouchable back then — and let's face it, he probably was. The inconvenient truth is, if you don't believe her now, you probably wouldn't have believed her then, either.

Victim Credibility: Who's On Trial?

Anyone who has sat in the courtroom for a sexual assault case will tell you that it is brutal. Court testimony is public record, so the most horrible and terrifying events of a victim's life are not only on display but are quite literally up for debate. I've watched defense attorneys smirk as they prepare to create a spectacle, attempting to dismantle a victim's credibility piece by piece. Even though rape shield laws are designed to protect victims' sexual histories from being used against them in court, the most effective attorneys know how to leverage society's purity culture beliefs and bias against a person's sexuality to undermine a victim's reputation and credibility.

As one salty detective commented, “Juries like virgin victims, Ms. Smith. And even then, it probably won't be enough.” I've learned over the years that, sadly, he was right. What a victim was wearing, drinking, saying, or doing during their assault was added to determine the degree to which a victim was “asking for it.” Of course, they never are. I've worked with hundreds of survivors, and not one person was asking for it.

Repeatedly Traumatized: The Second Worst Thing is Reporting

The few times I've had the opportunity to work with survivors whose cases were prosecuted, the damage caused by the experience of the trial, in many ways, was more challenging to address than the actual assault itself. A former client remarked, “I never thought anything could be more horrible than that night, but then came the trial. My assault is the second worst thing to ever happen to me.” Sexual assault is dehumanizing, and reporting is often described as being sexually assaulted repeatedly.

And those who chant that nothing will change unless victims come forward, I offer the following: if anyone has to do anything, I believe it is the rapists who need to stop raping, the perpetrators who need to stop perpetrating, and the rest of us who need to start believing. You can't tell people they have to report and not believe them when they do just because they've accused someone whom you esteem or can relate to.

It's easy to get caught up in the court system not working as it is supposed to and a culture that doesn't believe survivors. Even as a therapist and former victim advocate, short of it being a mandatory reporting case, I struggle with encouraging survivors to report their assaults.

I let them know that different reporting options exist and offer to assist in facilitating that process when they ask. However, I am careful not to frame reporting as the gateway to healing but as a potential component of their overall healing journey.

If a survivor wants to report because the action itself aids in restoring their sense of power, autonomy, or closure, it can be wildly helpful. It can also help support or corroborate testimony should other victims make reports about the person in the future. But fostering the hope of holding someone accountable legally feels risky. Healing from sexual assault cannot be contingent on a 2.8% chance. I try to remind them that they deserve to heal regardless of our system's ability to accomplish that task.

***

Sexual assault is a heavy topic to address in therapy. Early in my career, however, my mentor gave me a phrase that completely shifted my mindset around working with survivors. I believe it is the key to staying enthusiastic 11 years later about this work and avoiding burnout:

“Never desecrate someone's story by offering them pity. If you're feeling pity, you're not focusing on the absolute miracle that they survived to be sitting in front of you.”

Post-Script: As I am sitting here finishing my edits for this blog post, I received a message from a former client I worked with at the beginning of my career. She found me to let me know that she is reporting her assault after more than a decade.

Questions for Thought and Discussion

What was your personal and professional reaction to the verdict in the E. Jean Carroll case?

What have been your experiences working with sexual assault victims?

How have you addressed client resistance to reporting sexual assault in your practice?

Wrapped in Care: Narrative Therapy in the Time of COVID

Posted on by Psychotherapy.net Team

Genealogical Narrative

“My Nana died from Covid. She died four months ago. I am still crying every day. I am not getting over it”.

That’s what the email said. That’s why Harper intended to meet with me. As a therapist I work for various organizations, and Harper’s employer, an Australian-New Zealand company, was one of them.

I don’t like Zoom at the best of times. To me, with my head-and-shoulders only view she looked a small, perhaps even plump young woman, her face rounded like an apple. It was only months later when I met Harper in person that I realized that the 5-foot-3 inches was in my imagination. Harper’s face might be apple-y, but her stature was more that of a Kauri tree: She was tall, solid. She was dressed in Nike, growing towards the light.

Usually, I will begin by enquiring into a person’s virtues and I will ask for stories to illuminate them. So often, problems obscure from the person themselves the very attributes of their character which will be of most help to them in adversity. The problem weighs in on the person, forcing them to see only their troubles and rubbing their noses in inadequacy. But Harper was alone. Usually, I will ask others to speak for the person because it is so hard for them to do so themselves. For Maori, this is likely to be even harder because to speak about oneself, especially with pride, can be inappropriate when the sense of self is primarily a collective one (1). This whakatauki (Maori proverb), speaks to this cultural tenet: “Kaore te kumara e korero mo tana ake reka”, (translated as: “The kumara –sweet potato– does not speak of its own sweetness.”)

However, Maori see themselves in terms of their whakapapa, described by Te Rito as “a genealogical narrative, a story told layer upon layer, ancestor upon ancestor, up to the present day. There are parallel lineages of characters which run vertically side by side, era by era, and incident by incident.” (2) To enquire about Harper’s identity in terms of the genealogy of her character would be to enquire after her whakapapa, to site her character within her lineage. As Swann says, “whakapapa narratives also provide the individual and cultural context from which meaning-making, connection, and shaping of identity emerge.” (3)

Family Separation During Covid

Sometimes I will interview people about their virtues even if they are on their own. I might ask them to imagine what someone close to them might say. I might have consulted with Harper, whether this would have been something she would like to consider within the context of her whakapapa, had her grief and love for her Nana not filled the screen.

Instead, I encouraged Harper her to speak of her Nana and what she meant to her, and how they had been separated by distance, then by Covid, then by death.

I intuited that Harper’s relationship with her would offer us our way through our therapy conversations. Knowing that for Maori, our ancestors are with us in the here and now, that they “go with us” (4), I asked her to tell me about her Nana: “Harper, would you be willing to introduce me to your Nana? Would you be willing to tell me a little about her and her life?”

Harper’s hand went to her heart. “Yes, I’d love to. Nana was born in the Hokianga.” She sat up straight in her chair. “She was Ngapuhi [a large New Zealand social unit] and full Maori. She had it hard because Grandad had an affair and left her with seven kids. My dad was the second eldest, and the oldest boy.”

“And what is it that most stands out to you about who she was, Harper?”

Harper looked upwards, as if consulting the heavens. “Even though she worked three jobs and had all of those seven tamariki [children] to care for, she always helped others.”

She went on to tell me her Nana had had the misfortune to be admitted to hospital in Wellington after a fall. Then diagnosed with Covid- 19, she found herself cared for by strangers as the rest of her devoted whanau [extended family] waited in lockdown. They were only 4 kilometres away, but heart-breakingly, hopelessly distant.

Harper was unable to see “the most beautiful woman alive,” whom she had visited every day of her 23 years. She had moved away to Australia only six weeks before Covid burst forth on to the world. She was stranded by love, lured by a new relationship with Arthur, which had begun online. Messaging had turned into long emails, which had turned into daily Zoom calls. Harper and Arthur soon realized that they had to meet and see if their online romance would flourish in the ‘real’ world.

Their first meeting in person was at Sydney airport. She saw Arthur before he saw her, waiting, hands in pockets, fretted brow, chewing a strand of silky black hair to soothe his nervous heart. In that moment, 2D became 3D, pixels became flesh, their love jumped from the screen into the arrival lounge. Arthur’s life had been wall to wall with challenge and worry, but his budding relationship with Harper had kept him afloat. Arthur’s father was waiting for a surgical triple bypass. The mother of his 18-month-old son had departed with her boss for the Gold Coast six months before, and his mother had died of cancer two years earlier. Harper knew he was barely hanging on, so she stayed. Just like her Nana would have done.

Harper told me of the trials living with Arthurs’s family, how she felt both “homesick, and not at home when I am at home,” her outrage at Arthurs’ siblings, and even Arthur himself, for indulging “a complaining old man'' who continued to mete out nastiness to all of them, whilst they bowed under the sway of his illness. Nothing new to this family, just a new reason. But in the background hummed the tune of a granddaughter's love for her Nana whom she would never set eyes on again. Love was the bass line, even if grief for her Nana had become a superimposed, unwelcome harmony.

She told me of her premonition the week before the world closed its doors and its airport runways:

“I wanted to go home to my Nana. I asked myself, ‘what if I can’t say goodbye?’ I wondered if I would ever forgive myself if I chose to be here, over the ditch in Australia, with a family that doesn't build me up. Then I got the call from Dad. Nana had tested positive. I just knew. None of us got to say goodbye. We had a full whanau Zoom. She was so happy. Then she rolled over and died. We think she did it then on purpose.

My auntie had a korowai [Maori cloak made of wax and bird feathers through the art of finger weft-twining] made by a woman near Rawene. It was arranged five minutes after she passed. We wanted to have the cloak on her so that she felt that we were with her as she began to leave her body, and to leave us. Afterwards the cloak had to go into quarantine. I watched the tangi [short for tangihanga, Maori for funeral] on livestream. How weird is that? The last thing I saw was my family hugging her. Of course, only 10 of them could go because of the Level 3 Covid restrictions. All I could think was ‘why am I here in Sydney?’ I turned off the livestream and just sat there thinking ‘now what am I meant to do?’ Nothing felt real. The grief didn’t feel real. I was on my own staring at a blank screen. All because someone gave her Covid. Covid robbed me of my Nana.”

Grief and love mixed with outrage at the injustice of it all. The injustice of losing “the most beautiful woman alive” to Covid, the injustice of not being able to say goodbye. The injustice of being away from her wh?nau, her friends. The injustice of having to “zip her lip” at the behaviour of this sullen old man, and the equally nauseating behaviour of a family afraid to name what they see, as so many families do.

Harper had said “unjust” several times. I thought to ask her, “Harper, if you feel you have suffered such injustice, would you say that you are someone who believes in justice for yourself, and also for others?”

A Client Takes the Side of Love

“I am about justice. I speak out. I cannot stand things being swept under the carpet.”

How I wondered had Harper become an “all about justice” young wahine [woman/female]? It is all too easy to take such insight into a person’s character at face value: to assume that this is just ‘who they are.’ But virtues have stories. Perhaps some of it is genetic, but the choice to act on values is embedded in familial and wider culture, and in my experience have a story behind them if I am prepared to search hard enough with people. The story may have begun with the person, or it may have begun generations ago. A person’s virtues are rarely intrinsic to them.

The cult of the individual blinds us to the context in which personal virtues and values are handed down to us. And more than that, there are ancestral stories, which for Maori, trace whakapapa. As Love says: “A view of individual selfhood is indivisible from the whanau (hapu and iwi) unit, including the temporal and spiritual constituents of these. The boundaries of the self were drawn around the whanau, hapu and Iwi, unit, ancestors and the natural and supernatural world (5). Te Rito writes about his experience of researching the importance of tracing his own ancestry as he went about his academic research into the importance of whakapapa for identity. He writes: “…it has helped ground myself firmly in place and time. It connects me to my past and to my present. Such outcomes certainly confirm identity and a deep sense of ‘being’” (2). I was thinking of Harper’s whakapapa when I asked, “Harper, how do you guess that you have become someone who “is about justice, who speaks out, and won’t tolerate things being swept under the carpet?”

“It’s to do with my dad and how he has treated my mum all my life. I won’t stand for it.”

“How is it that your dad has treated your mum, Harper, and how have you gone about standing up to your dad’s treatment of her?” (6) Her presence on the screen seemed to become larger as she said, “My father is a strong, proud, Maori man. He thinks that he doesn’t need to justify anything. Mum said he acts that way because this is how he acts. That is how proud Maori men are. Dad has never been abusive, but he does shut Mum down.”

“Does your commitment to speaking out against injustice extend to others beyond your whanau, Harper?” [a question asked to help Harper story her identity].

“I confront my dad, and I confront others, but it’s hard doing this for everyone else.”

It wasn’t just Harper’s love for her Nana that shone from the screen; it was her willingness to speak out on love’s behalf: “Is speaking out one of the ways that you show your love for people,” I asked her?

Harper stopped as if putting her foot to the floor at speed.

“Yes, I speak out because I do love people. I don’t want people to feel hurt.” Looking down, she changed gear: “I try to fix things for others, and for myself. Death hurts, but I can’t fix it.”

We sat in silence for a moment or two.

“Harper, is this what your Nana did? Did she fix things for others?”

The words that followed sounded were like the final knell of a church bell:

“My Nana used to say, ‘while we are living, we have the chance to turn things around.’” Her voice softened as she confessed: “I don’t respect my dad because of how he is but I do want a better relationship with him. He was always physically present, but he wasn’t there for me emotionally. I have told him that I want him to be in contact with me more often”.

“Harper, are you trying to turn your relationship with your dad around just as your Nana would have done?” [an attempt at storying to bring Harper closer to her Nana]

Her closed hand came to rest on her lips. “I realized that I wouldn’t be okay if my dad were to die, and we were not okay. I told him, ‘I recognise that you have your own way of showing your love to me.’ He was shocked. He just said, ‘I try to make sure that you come along with me to the rugby club, but you just don’t want to come.’”

Father-daughter love had been conflated with going to the rugby club. I felt for her even though I realized that this was a father who loved his daughter and was expressing it in the best way he knew how at that time. However, I marvelled that this 23-year-old, aggrieved by her father’s treatment of her mother, was willing to take the side of love [formulating a counter-story].

“Harper, even though you say that you do not respect your father because of the way in which he has treated your mother, why is it that knowing him as you do, you reached out your arms in love to him, even if it seems as if he has kept his by his side?” [inviting Harper to look beneath her father’s actions to find intentions].

“It’s Nana, through and through. She never took sides. I spent a lot of time with her growing up. Dad always used to take me and my brothers to her. It is one of the best things that Dad ever did for me.”

My ears pricked. “Did your Nana teach you how to take the side of love?'' I asked her.

She reached for a tissue as tears began to swell.

“Could you tell me a story which would help me to understand how it is that your Nana taught you to take the side of love rather than to take sides?” [an attempt to connect Harper to her Nana through a powerful story]

“I would get sent there to her place as punishment when I was in trouble. She would sit me down at her kitchen table and tell me stories about her life and the hardships she suffered like ‘having to walk for 8 kilometres to school every day after milking the cows and tending to the farm.’ The stories made me realize how I might have overreacted at home, or why my parents did what they did. There were always lessons in her stories, and it always came back to ‘do you know your parents love you? There is a reason why your parents do what they do.’ I was so wrapped up in her care that I didn’t hear it as a lecture.”

“Harper, would you say that your Nana taught you to take the side of your parents' love for you, no matter what, and did so in such a loving way that you were able to hear her?”

“Yes. I know she sympathised, but she never said anything against them. She always directed everything back to their love for me.”

“Has your Nana taking the side of love rather than your side or your parent’s side inspired you to continue to believe in your father’s love and to continue to reach out to him, even if at times you do not experience that love in return?” [weaving the story of her Nana’s love across generations]

“100 percent,” she affirmed.

“And are there any other ways in which your Nana has taught you to love? [making her story about choosing the path of love more substantial]. For instance, you chose to leave your whanau, to move overseas when you had never even been out of Auckland before to be with a partner with a baby son and a sick father. And you told me earlier that your Nana was always there for others even although she was a single parent with seven children to care for and worked three jobs. Did your Nana hand down to you your generosity to others? [moving the story of commitment to love into the present].

“I’d like to think so. Her love was like this river that flowed to everyone in her path. And her love ran through me too. She was me and I was her. Or that is how it always felt to me?” [weaving the story of love into a river with tributaries to others].

All too aware that guilt was likely to be troubling Harper because she had made choices for her own life that took her from her Nana not long before she fell sick, I asked her, “even although you were so far away from your Nana, how did you make sure that your Nana felt your love for her through her illness?”

“I spoke to her every day on the phone and on Zoom, so she did get to see and to hear me morning and night. I formed a relationship with her head nurse. I remember one day hearing singing as I was joining her online. It was the nurses. They had written out Maori songs and they sang them to her, and they weren’t even Maori. They worked out our family tree and knew who each of us was. It nearly broke my heart when I realized that they had done all of this for my Nana and for us.”

I was suspicious that there was more to this than met the eye. Not every team of nurses would find Maori songs and sing them to a patient, especially if they weren't Maori themselves, and especially during lockdown in a pandemic. Was it Harper and her love for her Nana that had inspired them? “Harper, would you agree that what the nurses did was pretty unusual? Do you think that they also felt your love for your Nana and your Nana’s love for others and got pulled into the river of her love as well?”

“They certainly felt my love for her, and I guess no one escaped her love, even when she was in hospital. I have always believed that I was her favorite, and maybe they realized that,” she bubbled. She looked up wistfully, and said, “although the dementia took part of her away, her wairua [spirit or soul] remained just as it had always been. They must have felt her wairua.” We sat for a few moments in what felt to me to be reverence. Then her brow furrowed. She told me that she had been feeling overcome with anger since she had had a phone call from her auntie.

“I have this righteous anger. My auntie said she heard a rumor that it was a nurse who was sick and didn’t go for a test. Someone made a choice and brought the virus in and caused her death. I keep asking myself ‘what is going to be done about that?’ Then, I was sitting in the walk-in-wardrobe in our bedroom, which is where I go when I need time out, and I heard her voice saying: ‘you are not me.’ I didn’t feel belittled at all.”

“Why not, Harper? What was it that you heard in your Nana’s words that was not a criticism, not belittling in any way?” [a ‘close’ question, designed to help Harper stay close to her Nana].

“I knew what she meant because she told me this many times. She was letting me know that it was not up to me to seek justice, that I didn’t need to replace her, and it was okay to be angry even although she would feel differently. Sitting there on my bed, I realized that she was giving me permission to be myself, just like she always did. I sat there for a bit and then I realized that I do want to be like her. I so respected my Nana. I can be like her and be me. Then, for some reason I turned on the TV, and on the news, there was a clip of Jacinda [New Zealand Prime Minister at the time] speaking about the New Zealand response to Covid. I felt for her. She has had so much flack. And although what she has done was not successful for my Nana, there could have been thousands more deaths. As I watched her, I felt my Nana’s presence.”

“What was it about Jacinda that felt so much like your Nana, Harper?” She looked up as if taking herself back to the moment.

“My Nana’s strength came from her love of people and that is how Jacinda is for me.”

I was surprised to hear what she said next. It is one thing to feel a connection, another to act. I wondered whether her Nana was also a woman who acted when she felt strongly, and especially if motivated by contributing to another. It certainly seemed so.

“I decided to write to Jacinda. I told her about my Nana. I told her about how I believed she loved people in the same way. I told her I didn’t blame her. I didn’t need a reply, and I didn’t expect one, so I was so surprised when one came. She said that she was ‘moved to tears by my letter’ and that ‘she was proud to be compared to my Nana.’”

A calm had descended. It is strange that even though we were thousands of miles away from one another I felt it palpably, as if we were in the same room. I also felt as if Harper’s Nana was with us. Perhaps she was in the spirit of the way in which she lived: in service of her love for others. Enamored with the idea that our lives are all ‘peopled’ at all times with those that have gone before us’ (4), I felt the urge to include Harper’s Nana in our conversation, and asked a question that I might often ask when I felt that a loved one, no longer present in their physical body, might be knocking on the door, waiting to be asked to contribute:

“Harper, if your Nana was looking down on us right now, and felt your love for her, what do you think she might say?” [a question borrowed from David Epston].

Harper’s eyes widened. She looked up and away, and then answered as if my question was one that she was asked everyday: “She would say, remember that Jacinda is healing her whanau too.”

Harper’s Nana had been the matriarch of her whanau, its spiritual leader, its healer. Harper was her most beloved grandchild. I had the sense that Harper’s Nana may also have seen in Harper her spiritual successor. This sense, along with the Maori belief that our ancestors walk with us, led me to ask, “Harper, would you say that your Nana has passed on her ability to love people to you?” [a question asked to bring Harper closer to her grief]. The absence of hesitation gave me her answer before I heard her reply:

“Yes. My uncle says ‘you have so much of her spirit and essence,’ and I feel closer to her when I talk to you.’”

“And Harper, you said that your Nana found her strength in her love of people. Would you say that you do and will find your strength through your love of people as well?”

Harper blinked away a tear. Our first meeting had come to an end. We held on for a few moments, and then we both reluctantly pressed ‘leave meeting’.

Whilst We Are Living…

Harper’s face popped onto the screen. She mouthed something but the caption told me that her microphone was still connecting. Harper wanted to tell me about the memorial she and her whanau had been planning for her Nana. She had put together a slideshow of photographs from her Nana’s life. The bubbliness which had shimmered on the screen in those first few moments burst, as she told me that the purposefulness of her slideshow-mission had given way the moment she had finished it.

“I just cried. It was the first time that it came home to me that she was really gone. Until that moment, her loss had not fully made its way to her heart. It is so hard to accept that ‘that is that.”

An emptiness sat between us, and then, like a visitor who senses the awkwardness of the moment and attempts to fill it, a suggestion intruded.

Harper said, “I want to write a speech for the memorial.”

What could be wrong with this suggestion? Nothing. Of course, she would wish to speak of her Nana at the memorial. Yet it seemed that at this moment the suggestion was here to fill the pain. I felt the emptiness. Harper had been ripped away from her Nana by distance as well as by death. How might I help to bring her closer to her Nana, even in some small way? How might I help to salve the pain of this chasm even mildly so? The words materialised in the air between us before my reasoning had taken full shape:

“Harper, would you consider writing a letter to your Nana rather than writing a speech about her? What if you were to read it to her at the memorial?”

Harper’s hand fled to her heart and sat there like a nesting bird.

“Ohh,” she exclaimed.

There was a moment of silence, and then she said:

“Judging how my heart feels about the idea…”

“And what might you say?” I asked. Harper’s reply delighted me.

“I have no regrets with Nana. She knew how much I loved her. I would like to talk with her about some of the good times, some of the funny times we had together, especially towards the end. I’ll think about what people want to know about her, and what I want them to see about our relationship.”

As a narrative therapist I cannot ever pass up the chance of a story, so, I asked her, “Could you tell me a story about one of those funny times that you shared with your Nana?”

Harper’s eyes danced as she told me about how she had to “keep seeing her through dementia…I had to find a new way of seeing that spark in her so that I could see a bit of her, even for a moment. She loved the Silver Ferns [New Zealand’s national netball team] and she was always very proud of me when I played netball for my school team. One day, I told her that I had been picked to play for the Ferns. It wasn’t true, of course. I said ‘Nana, guess what? I’ve been picked to play for the Silver Ferns.’ She exploded with joy and pride. ‘Really?’ she said. ‘Yes, really,’ I said. ‘What position?’ she asked. I said, ‘Goal Attack.’ That was that I used to play. I was so surprised when ten minutes later she remembered my fake Silver Ferns selection, and asked me again, ‘what position are you playing?’

We laughed together. I was touched to be privy to this moment in Harper’s relationship with her Nana. “Harper, I would love to see your letter to your Nana after the memorial. Would that be okay?”

“Of course,” she said. “When I have finished reading my letter to her, I will blow out the candle that will be lit for her. This signifies that we will be going on without her, but it doesn’t mean that the light needs to go out ‘in here,’” she said, as she laid her hand across her heart.

Another idea crossed my mind: “Harper, do you think you should wear the korowai?” [this gesture would suggest that Harper might take her Nana’s place as the family’s spiritual leader]. She replied with a solemnity worthy of the feathered cloak itself, yet without the expectation that she deserved it.

“Maybe I could ask my uncle. He is the keeper,” she mused, “I would like her to be with me as I read to her. I would be wrapped in the korowai, and it was the last thing that she was wrapped in.”

Harper’s gaze drifted somewhere off-screen. A moment passed until her gaze returned. She looked troubled. I waited for her to speak, aware that there was something in the wind that was about to change the direction of our conversation.

Christmas, weddings, births, deaths. All events that bring family together. And with the togetherness come the ghosts. The ghosts of all that has been said, the ghosts of all that has not been said. The ghosts of resentments, the ghosts which carry secrets under their grey gowns. There had been “a lot of family drama around the memorial,” and the winds of these dramas blowing through the whanau had disturbed her and had been “piled on top of her my grief,” making it hard to feel, hard to find her Nana. Harper wanted to talk with me about how she might navigate her way through this.

I knew I would need to understand what was coming to the surface in some detail, and so I asked Harper if she would “tell me the story of these whanau dramas?” A fifty-year saga of ‘black sheep’, drugs, prison, dodgy dealings, cheating, and financial losses at one another’s hands took shape before me. However, the rift that had split the whanau into two very unequal halves, with one of Harper’s dad’s cousins and her brood on the one side, and most of the rest of the family on the other, with a few undecideds wandering around in the middle, had led to a nasty physical fight in which a younger male cousin had been seriously hurt. An allegation had been laid against Harper’s father by Doreen, the young man’s sister. Harper had first heard the rumor a few years before. She had never met her father’s cousin, Doreen, who had been faded out of the family, partly because of the rumors, and perhaps partly because of her “troubles with drink,” but somehow word had gotten around as it always does. In the spirit of her commitment to ‘speaking out’ and ‘standing up for others,’ which Harper had been practicing in her father’s company for some time, she had confronted him:

“My dad was so angry, and he refused to answer. He just said that you don’t need to know.”

Then one day not long before Harpers’ Nana became ill, Doreen rampaged on Facebook. Messages were sent to random family members, including Harper. Terms like “swept under the rug” were used, and “stuff was said about my mum”. Harper had replied saying:

“It’s not my business, don’t talk to me about it,”

and Doreen had replied with,

“Do you condone physical abuse and violence?”

Harper had blocked her.

And then when Nana became ill, Doreen had made an appearance in person. Harper’s uncle had spoken with her and apologized for her treatment over the years. The views of the other aunts and uncles were that “she needs to get over it.”

Doreen was refusing to come to the memorial because the family had been unwilling to involve her. But she had been close to Nana. Nana had been as important to Doreen in her early years as she had been to Harper. Harper's troubles we

Using Psychotherapy to Heal a Lifetime of Pain and Shame

Posted on by Psychotherapy.net Team

As a child, Darlene would change to lower-watt light bulbs in the small bathroom attached to her bedroom so that the light would be dimmer. “How can you see anything in here?” her mother would ask in dismay. But Darlene preferred to brush her hair, and later apply makeup, in subdued lighting.

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As a young adult Darlene had lived for several years in a state psychiatric facility. One day the psychiatrist and a nurse sat with her and suggested that she apply to nursing school. She thought she was in trouble when the doctor asked to speak with her, and was surprised when he spoke of her potential — and the possibility of her living outside of the hospital. Darlene became a licensed practical nurse (LPN), got an apartment, and enjoyed a career working at a state school for persons with developmental disabilities.

Darlene had weathered a very brief and turbulent marriage that ended when her husband was physically abusive to her. “I don’t know why I ever married him,” she said. “Partly, my parents thought it would be good for me, and partly I was at least hoping I’d be loved.”

Now, as an elderly woman at the nursing facility, she mostly stays in bed, and typically prefers that the shades be down. While she attends a few group activities, Darlene feels relieved when she can finally get back into her bed and the low-lit security of her room.

Therapy as Sanctuary

One day as I sat next to her in her room during a psychotherapy session, Darlene asked that I raise the shades because she could hear it was raining outside. “This is the only time when I feel good, when the weather outside matches the weather inside me," she remarked.

Dim and dreary weather conditions had always matched Darlene’s moods, and provided a sort of comfortable retreat for her, whereas sunshine and groups of people could be anxiety provoking for her. Her Poe-like melancholy was matched by an attraction to poetry, and she would recite to me verses of poems she had long memorized.

Darlene also had a lifelong struggle with bipolar illness that mostly involved depressive episodes, and rare manic periods with grand persecutory delusions (“I’m being nailed to a cross, everyone’s looking at me!”). Oh, what could be more distressing for Darlene than to be under the glaring and judging eyes of others!

As she aged, Darlen suffered from macular degeneration with progressive loss of sight. She ate meals sitting up in bed, and often felt increasingly frustrated and embarrassed by the messy results. She was helped when her meals were changed primarily to finger foods, and she could be guided by touch more than by sight.

Dignity in the Shadow of Shame

Darlene also experienced problems with bowel and bladder incontinence. The need for someone to witness and attend to her humiliating problem felt horrible and shameful to her. She inadvertently made the matter worse, though, by her ineffective effort to clean or hide the results of a bowel accident — causing a staff person to come to me stating that Darlene was “playing with her feces.” After a conversation with Darlene, I could explain her predicament and her sense of shame to the staff, and they were then more helpful with keeping her clean while protecting her dignity.

One day at the nursing facility as I was pushing Darlene in her wheelchair through the hallway, we encountered a new female resident who loudly exclaimed, “Darlene, Darlene, it’s me, it’s Ellen!” With a panicked expression, Darlene looked at me and said, “Get me out of here, now!” Darlene explained that she knew Ellen and that they had both lived at the psychiatric facility at the same time. Darlene did not want anyone to know that she had once lived there, because she felt it was yet another source of shame.

Over the course of several therapy sessions, Darlene and I explored her reactions, and her underlying thoughts, feelings, assumptions, and beliefs as they related to her encounter with an old friend who had resided along with her at a chronic care psychiatric hospital many years ago.

We focused on reframing her story of time at the hospital from one of self-perceived shameful illness to a story of triumph. We discussed ways she had achieved many significant and meaningful successes: through her trust in her psychiatric care providers while at the hospital, through her education and attainment of a nursing license, with her subsequent career providing valued care to her patients, and by living in an apartment on her own during her working career.

Darlene was praised for the many triumphs in her life story. We spoke of how others might be impressed by and applaud her achievements, rather than look poorly on them, if she might be willing to share her story, to raise the shades, and let in the light!

Questions for Thought and Discussion

In what ways does Darlene’s story resonate with you personally and professionally?

How might you have addressed Darlene’s dilemma of encountering her “old friend?”

What clinical experiences have you had with the elderly and how have they impacted you?