Category: Therapeutic Issue

Therapy as a Means of Balancing Loss with Acceptance

Posted on by Psychotherapy.net Team

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

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

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

Therapy as a Road to Acceptance

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

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

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

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

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

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

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

A Requiem for All That Was Lost

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

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

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

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

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

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

Questions for Thought and Discussion

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

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

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

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

Posted on by Psychotherapy.net Team

“Love of the Written Word”

Poem by Irene

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

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

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

Each time I look to the written word.

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

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

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

Each time I look to the written word.

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

I enjoy stanzas, verses, — and rhyming too,

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

Each time I look to the written word.

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

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

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

Each time I look to the written word.

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

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

The Early Therapeutic Relationship

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

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

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

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

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

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

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

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

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

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

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

Having an Audience

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

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

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

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

Writing Stories

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

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

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

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

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

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

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

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

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

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

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

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

The World of Katja-Writing

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

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

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

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

It did not work!

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

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

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

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

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

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

An Example of Katja-Writing

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

How We Do It

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

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

Effects of Katja-Writing.

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

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

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

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

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

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

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

Katja-Writing and The Shadow Side

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

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

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

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

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

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

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

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

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

Cognitive Reframing is the Key to Counselling High-Conflict Couples

Posted on by Psychotherapy.net Team

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

Being a Clinical First Responder in Couples Therapy

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

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

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

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

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

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

When Couples Clients Dodge Conflicts

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

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

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

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

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

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

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

Effective Need Management in Couples Counseling

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

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

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

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

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

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

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

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

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

Psychotherapy With Non-Verbal Clients: Blending Empathy and Flexibility

Posted on by Psychotherapy.net Team

Psychotherapy with Non-Verbal Clients

Hello, Jane.

My name is Tom.

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

One blink.

Is your name Jane?

One blink.

Is my name Tom?

One blink.

Is my name George?

Two blinks.

Is your name George?

Two blinks.

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

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

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

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

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

Combining Empathy, Creativity, and Flexibility in Psychotherapy

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

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

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

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

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

***

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

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

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

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

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

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The Devil of Rumination and Obsessional Thinking

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

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

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

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

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

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

Applying a Solution Focus

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

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

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

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

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

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

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

A Pragmatic Approach to Rumination

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

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

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

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

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

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

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

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

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

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?