Category: Therapeutic Issue

A Powerful Therapeutic Tool for Defeating Negative Self-Talk

Posted on by Psychotherapy.net Team

A client of mine, let’s call her “Jill,” got nervous for business meetings no matter what they were about. She often worried, daydreamed, and lost sleep the night before meetings. Afterward, she typically acknowledged something to the extent of, “It wasn’t as bad as I thought.”

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This was an exhausting strategy. Jill was convinced that her stream of hyperactive self-talk was preparing her for what was to come, but the amount of bandwidth chewed up by worry undercut her ability to plan well, if at all. On the day of the meeting, Jill presented as anxious, at least at first, until she realized that all was well. Fear of the moment was worse than the moment itself.

Sound familiar? Many of our clients experience similar struggles with anxiety and negative self-talk.

Eventually, Jill enlisted a strategy called WBL. Instead of steering her away from negative thinking (which would have felt precipitously close to telling her ‘How to feel’), we tapped into her brain’s natural predisposition to predict and created some parameters around it. It proved to be a powerful tool in our work.

A Cognitive Behavioral Intervention: The WBL Strategy

I adapted the WBL model from core CBT principles and have found it useful while working with clients like Jill. At the beginning of our work together, Jill and I defined the specifics of situations that aroused her anxiety. Often when anxious a set of varied concerns coalesced and appeared as one item. We combatted this generalized anxiety through a process called “unbraiding,” wherein we specified one particular concern from among the many. When her concerns appeared tangled, we pulled at only one thread.

Despite her competence and high level of achievement, Jill had grappled with imposter syndrome in the past, and at each new meeting, was inclined to “prove” her professional value.

After identifying the concern, we began the WBL process. The W stands for Worst. Jill was asked to imagine the worst possible scenario, with two limits: 1) take notes; and 2) keep time. We did this with pen and paper handy. The task was to write the ideas down and, importantly, to be honest. This was an important phase for multiple reasons.

First, we honored the inclination of her mind at that moment. In a recent incident, Jill was afraid of being shouted at. She said she did not want to feel powerless. She recounted her journey to achieve her position in the company and was terrified of losing that status. Once this worst-case scenario had been named, we were able to create space for it and distance from it. By talking through the W, we determined that it was not the business meeting that was bothering her, but the fear of feeling inadequate.

Together we agreed not to focus on the W for too long. We set a timer for five minutes and stuck to it. Importantly, Jill was the one who physically set the timer on her phone. She owned the duration; she set a barrier around the time we were allowed to spend considering the W. Before we started this process, Jill spent too much time contemplating the worst possible outcome.

The longer she sat in that hypothetical, negative situation, the more she colored her mind with negativity. Prior to beginning the WBL process, she would enter business meetings in that hyper-negative state, and as soon as she sensed that the meeting felt “off,” she would interpret it as a confirmation.

Therefore, the immediate next step, B, asked her to consider the Best possible outcome of the situation. Entertain the idea that the meeting will be full of praise, ending in a big promotion. What would that look like? Would it come with more free time? More money? More travel? It took considerable effort for Jill to allow herself to consider such a positive outcome. This phase of our work was not about considering what was “pretty good,” but instead, what the best could look like.

Jill had trouble getting to this place. She was hesitant to think big. She had no trouble going to the W but believed that the wonderful reaches of the B were not likely, so she talked herself out of them. Over time, we worked together to understand that the best was, by definition, just as likely as the worst — they were two ends of a hypothetical spectrum that she created.

Once we identified those two poles, we found a spot in between (it can be helpful to draw out the continuum on a piece of paper). In the L phase, which stands for Likeliest, we took a moment to be truly sensible. The outcome of Jill’s upcoming meeting was not likely to be at the worst pole, and, unfortunately, not likely to be at the best pole.

So where was it most likely to be? At this point, she tended to lean back toward the W side of the spectrum. It was important that she catch herself leaning into that negative default and do the work to stay centered. I encouraged her to, if anything, lean toward the B and let her mind be colored by positive thoughts, as they would have an impact on her interactions.

Once we did the work of naming the concern, then working through the WBL model, we put it all together. She had the power to influence the direction of the meeting through the energy she would bring to it.

Cognitive Strategies Lead to Successful Outcomes

Cognitive strategies like CBT did not rid Jill’s professional life of challenge but improved her approach to challenges. Jill was successful and driven. She was accomplished and continued to move in a positive direction. She credited taking control of her self-talk as an important step in the future she imagined for herself.

Deliberately cultivating Jill’s mindset was not a soft, feel-good skill (though it did feel good). It positively impacted outcomes. We call those positive outcomes feedback. The more positive feedback she received, the more confidence was built, and the less likely she would default the next time around toward a worst-case scenario. The more we repeated this process, the more we shifted the default positions away from the worst and toward the best.

The brain is, first and foremost, a prediction machine. The WBL tool helped us get behind the wheel of that machine and steer it. The difficult journey for Jill turned out to be well worth the effort.

In the Shadow of COVID, It’s Play Therapy to the Rescue

Posted on by Psychotherapy.net Team

Kevin’s Worried Parents

In March of 2021, families were emerging from almost a year of isolation due to the COVID pandemic. As a Licensed Professional Counselor Supervisor and Registered Play Therapist Supervisor in private practice specializing in children, I was flooded with requests for services.

During one particular intake interview, the parents of a four-year-old boy I’ll call Kevin asked me a fair question. “How will our son’s development and mental health be impacted by this year of isolation?” I immediately reflected their feelings with, “You are really worried about the long-term impact on your son.”

Their worry was understandable given the emerging research showing increases in children’s anxiety and depression since COVID began. Yet, multiple factors of genetics, parents’ behavior, peer interaction, and available resources contribute to children’s developmental and mental health trajectory after a crisis. To respond to their fair question, I needed more information from them.

I asked, “What is concerning you the most?” Both parents had college degrees and were well read so they had valid concerns in mind. “Our son has not seen, much less interacted with, another child for over a year. He is our only child. Even though we took him to the public playground, as soon as another child got within 20 feet of us, we would leave quickly.” I thought to myself, risk factor one — no peer interaction during a critical developmental period.

Preschool is when children learn to tune into peer facial cues, scaffold their own physical and cognitive learning by watching other children, negotiate sharing, and so on. I needed to provide some hope to the worried parents, so I tried to normalize the fact that most of his peers had a similar experience. I replied, “Some children’s social, physical, and cognitive development may be a bit delayed during COVID. Fortunately, children are resilient and can learn together, starting from where they left off.” They nodded with seeming understanding.

Then Kevin’s parents said, “Our son could tell we were stressed when we were working from home and paying bills with less money. We tried to play with him, but we had many conference calls. He didn’t understand and thought that we were ignoring him. He became clingy and we became irritated, occasionally speaking to him more harshly than we desired.”

I thought to myself, risk factor two — parent behavior that was interpreted by the son as anger, resulting in increased anxiety. Being a parent myself of an only child who also has ADHD, I empathized and normalized with a compassionate groan. “I get it. I experienced something similar with my child.

We can feel so disheartened, trying our best to juggle it all, and losing our temper more than we want. We are human, not superheroes. We need self-compassion. That’s why I go by the 80-80 rule of parenting. About 80 percent of the time, I try to do about 80% of what I know to be helpful. But during COVID, I lowered my standard to 70-70 because that is passing.” They laughed!

The parents added with a heavier tone, “We are also concerned about his anxiety because we both suffered with anxiety during our childhoods.” I thought to myself, risk factor three — genetics. Research shows a strong genetic influence on the development of childhood anxiety disorders. Again, the parents needed some hope. I reflected, “You both know the pain and struggle as a child with anxiety. You love your son so much that you want to intervene as early as possible. You are wise to do so. I can help with that. Research shows that play therapy can decrease children’s anxiety. Together, we can work to build those limbic system neural networks toward calmness rather than fight or flight.”

Yes, the risk factors for this child were compounded during COVID. He had no peer interaction for a year, stressed and distracted parents, and a genetic predisposition toward anxiety. Yet, he also had the biggest protective factor we could hope for — caring and proactive parents. This plus mental health treatment, interventions of parent guidance, twelve sessions of Child-Centered Play Therapy (CCPT), and psychoeducation could shift this boy’s development and mental health toward a more positive path.

Prior to beginning my work with Kevin and his parents, and to gauge the level of his behavioral and emotional difficulties, I sent his parents a link for the web-based child version of Achenbach’s System of Empirically Based Assessment (ASEBA) Child Behavior Checklist for ages one and a half to five. The results revealed a pattern of emotional reactivity, anxious and depressive symptoms, and sleep problems. While Kevin’s scores on the DSM-related scales for Autism and ADHD were in the normal ranges, his other scores were consistent with DSM anxiety and depressive symptomatology. These results corroborated his parents’ concerns.

The parents’ main goal was to decrease Kevin’s anxiety so that he could calmly engage with others without clinging to his parents. Their prior attempts to reassure him through reason were ineffective. Using Daniel Siegal’s Hand Model of the Brain, I explained strategies to calm the lower regions of the brain through deep breathing, rocking, and soft voice rather than trying to reason with his prefrontal cortex, which was “offline” during his anxious times.

To reinforce these concepts, I asked Kevin’s parents to watch a parenting video by Tina Payne Bryson called 10 Brain-Based Strategies: Help Children Handle Their Emotions, and to read Siegal and Payne Bryson’s No Drama Discipline. These two resources helped them improve their ability to calm their own anxieties so their son would co-regulate with their calmness. To deal specifically with anxiety, I also recommended Calming Your Anxious Child: Words to Say and Things to Do by Kathleen Trainor to guide them in the step-by-step process of systematically desensitizing his fears.

A World Opens

In the waiting room prior to his first play therapy session, I greeted Kevin, commented on his red tennis shoes and matching shirt, and said, “It is time to go to the playroom. Your mom will be waiting right here.”

I smiled with friendly confidence, moving toward the door, and gestured for him to follow me. “We have lots of toys there.” His curiosity was stronger than his anxiety, so, he followed me. Kevin’s eyes opened wide seeing my play therapy room filled with carefully selected toys for nurturing (dolls, doctor’s kit), creativity (puppets, paints and easel, dress-up clothes), real-life mastery (kitchen, tool bench), and aggressive release (swords, bop bag, army men). As we entered, I said, “In here you can play with all the toys in most of the ways you like.”

Kevin was hesitant and stood near me, asking questions. “What do I do first?” Given his anxiety, this was not surprising. “In here you can decide.” He moved his eyes but not his body. I view this as a “freeze” state, a survival response for people perceiving threat and feeling overwhelmed. The threat was not necessarily coming from the playroom but from being separated from his parents or close family members for the first time in over a year. I reflected his feeling with reassurance, “You are a little scared being in a new place,” and role modeled taking a deep breath. I waited patiently so he could sense my calmness and confidence, thereby communicating this was a safe place.

Kevin moved toward some small cars on the shelf and pushed them along the floor. This action with familiar toys gave him a sense of security and mastery. I reflected his feelings by saying, “You enjoy seeing how far you can push those cars.” My statement reassured him that he really was welcome to play and built his confidence. He said, “Yes, I have a blue and red one at home that I like to race.” I gave him credit for his skills, “You are an experienced car racer!” He smiled and pushed the cars toward the four-foot red bop bag, named “Bobo.” Kevin lightly pushed on it to see how quickly it moved. “What’s this for?”, he asked. I returned responsibility to him with “You are curious what you can do with that. In here, you can play with it in most of the ways you like.”

Little by little, he courageously experimented with different actions from punching it, sitting on it, hitting it with a sword, and shooting at it with a dart gun. With each step, his sense of power grew. Toward the end of the session, he expressed creativity by painting a picture of the bobo. I ended the session with 10 minutes of psychoeducation on managing stress. I demonstrated and guided him through deep breathing, progressive muscle relaxation, and a self-soothing butterfly hug. After walking Kevin back to the waiting room, I prompted him to demonstrate his new skills for his parents and asked them to practice at home each day.

Bugs All Over You

In the fourth session, Kevin began with rolling cars again followed by punching Bobo, providing him with a familiar rhythm and routine. Once he established his sense of mastery and power, he collected toy spiders, snakes, and bugs and put them on my legs, hands, and shoulders. “You have bugs all over you. You can’t move.” I stated, “You are showing me it is scary to have bugs on me and not be able to move around.”

He exclaimed, “Yes, you are going to be stuck there forever.” I responded, “It seems like it will never end!” Eventually, Kevin decided to rescue me by knocking off the bugs with a sword. His symbolic play reflected his experience during the pandemic of feeling scared and trapped. Yet now he was in charge, rather than being the one trapped. He was gaining an emotional understanding to master his traumatic experience of COVID isolation.

At the end of the session, I engaged him in a children’s book that illustrated listening to his body to notice when he may need to take deep breaths and seek soothing sensations such as rubbing his hands and legs. This combination of child-led restorative play reenactment plus the intentionality of anxiety management skills strengthened his ability to emotionally self-regulate.

Mommy Dies

By the sixth play session, Kevin had gained enough comfort in the playroom that he was ready to play out a hidden fear — mommy dying. He approached the playhouse and put the “daddy doll” upstairs in the office to do his work. The “boy doll” was downstairs by himself watching TV. The mommy doll ran out of the house to go to a work meeting on a nearby table. Kevin drably said, “Mommy went out of the house, got COVID and died.” I reflected, “Super scary and so sad she died.” Kevin quipped, “Yup. Now who’s going to make dinner? Daddy is busy working.The boy will have to go out and hunt for food.”

I responded, “The boy feels all alone AND he knows how to get some of what he needs.” Eventually, Kevin brought in the army to help him hunt for food. I facilitated understanding: “There were strong people out there who could help the boy when he needed it. They kept him safe.”

Underlying Kevin’s fear of his mother dying was the basic existential question of “Will I survive?” Through play, Kevin created his answer — letting strong people help him. During the last 10 minutes of the session, I facilitated psychoeducation by playing a detective game with Kevin. “Let’s list lots of things many kids are worried about these days.” Kevin said, “Losing their favorite toy and their dog running away.” I added, “Family members getting sick, going to the hospital, and dying.”

Then I challenged his all-or-nothing thinking. “There are 100 kids. One kid loses their toy. Does that mean every kid loses their toy?” “No.” “There are 100 dogs. One dog runs away, does that mean everyone’s dog will run away?” “No.” “There are thousands of people. One person may get sick from COVID and die. Does that mean everyone will?” “No. If someone gets sick, they go to the doctor and the doctors do their best to help them.” “Let’s think about all the kids who are playing with their toys, dogs, and family members. What would they be doing?” “Playing fetch.” “Yes! I love to play fetch with my dog.” Since Kevin was calm, he could engage in basic reasoning that most people will be OK and the importance of focusing on the positives in the here and now.

Doctor Superhero

In the tenth session, Kevin walked in with confidence. He rolled the cars, punched the Bobo, and took the baby to the doctor. “Your baby is sick. I am the doctor.” He used the stethoscope, took the temperature and blood pressure, and gave the baby a shot. I reflected, “You knew how to doctor the sick baby and get the baby better.” He got the cash register and declared, “That will be $10,000.” I paid up — a small price for his victory.

Then Kevin put on the Superman costume and flew around the room “saving everyone.” I enlarged the meaning: “You are an important, powerful person who can help so many — even yourself.” With his chin tilted up, he said, “Yup, I’m not scared anymore!” Indeed, his parents had confirmed that he was no longer sleeping with them, and he was willing to stay with a babysitter for them to have a date night.

Reflections

From a Child-Centered Play Therapy perspective, Kevin was experiencing incongruence between his ideal self as a confident, engaging boy, his current self as an anxious boy, and his experiences of isolation and fear during the COVID pandemic. He was not accurately symbolizing the behavior of his parents and other adults in that he interpreted their cautions as a lack of confidence in him. Over months of physical and emotional isolation, his self-concept was of a timid, weak child who was unable to move forward in his world.

Kevin’s time in the playroom with me along with his parents’ support provided him with a developmentally appropriate intervention in a safe playroom with an empathic play therapist, representing a microcosm through which he could master his world. He was able to come to an emotional understanding that his past anxious experiences were about an illness doctors were trying to heal and not about him. His self-concept strengthened to see himself as a strong, powerful boy who knew how to get help, help others, and help himself. Parent consultation, Child-Centered Play Therapy, and psychoeducation were the healing components of treatments that showed such love to this family. Kevin emerged from his isolation and anxiety. He flies like Superman toward a more positive developmental trajectory.

Parents and children experienced suffering during COVID. Many experienced existential anxiety from recognizing mortality, confronting pain and suffering, and struggling to survive. Mental health professionals were trained to support people in crises such as COVID. Yalom and Josselson remind us, “No relationship can eliminate existential isolation, but aloneness can be shared in such a way that love compensates for its pain.”

Reference

1. Yalom, I. D., & Josselson, R. (2011). Existential Psychotherapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 310–341). Brooks/Cole, Cengage Learning.  

The Gift of Presence in Grief Counseling: A Path Forward

Posted on by Psychotherapy.net Team

Grief is an inevitable part of life, one that I personally believe to be among the greatest sufferings of humankind. Yet, while often a source of deep pain, grief can also be a source of great love. That reluctance to let go of someone we cherished is the last act of affection we give to those who have passed.

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Grief is a process of many intertwining emotions. Shock, anger, depression, and confusion may surface, to name just a few. While Elisabeth Kübler-Ross created a helpful formula addressing the stages of grief, it is important to remember there is no right or wrong way to grieve. Contrary to what people may say, each person grieves differently.

Grief is Like an Ocean

Grief is like the ocean; enormous, ever-changing. It comes in waves, ebbing and flowing. Sometimes it is calm, gentle, almost peaceful. Other times it is overwhelming, strong and aggressive. These are the times it can knock us off our feet, taking the wind from our sails. The enormity of loss often weighs heavily. When that heavy feeling right in the pit of the stomach forms, we can feel like we are sinking into it.

On other days, it is almost manageable. Life continues. We get caught up in everyday routines, our pain almost fleeting. A gentle wave comes to the surface when we are hit with a memory or a reminder of our loved ones. We slowly learn to tread water, working to keep our heads above the tide. It can be challenging at first, but we get through. The day passes. Much like the waves in the ocean, our pain is fluctuating.

Can we ever really learn to live well in our grief and move on from the pain of our loss? I feel we never truly part from those we love, and many people don’t wish to. We can, however, move forward and learn to live with our loss, gradually easing the pain. We can adapt, move around our grief, and eventually rebuild a life without our loved ones. Counselling can help reach this goal.

Working with grief in a therapeutic setting has been one of the most beautiful yet difficult presentations for me and the clients I have had the privilege to work with. I have found it important to honour the strength it takes for a client in their suffering to show up each week to face their pain.

Grief counselling is intended to help the client process their thoughts and feelings around the loss. Of course, talking through grief does not take it away, nor minimise the impact the loss has on the client’s life. It can, however, soften the experience, allowing the client to healthily process their thoughts and feelings, holding space entirely for the client’s experience, anguish, and grief, enabling a level of gentle healing to occur.

When beginning to work with grief in the therapeutic setting, I value the importance of firstly holding space for the clients. I emphasize the value of the client’s emotional experience, allowing the raw feelings to surface in a gentle, safe environment. It is important to sit with these feelings, holding the client fully in the presence of their pain.

When Anger Gives Way to Pain

Recently whilst working with a new client in session, they seemed reluctant to visit their grief, presenting each week with anger and deflecting on the initial reason they had begun therapy. Each week they presented irritated and angry, often projecting these emotions at small minor inconveniences that happened within the week, sometimes exploding and intensely reacting as they told their stories. Sessions became governed by anger, with the client unwilling to take it anywhere else. For a few weeks, I allowed space for this anger, and we worked in the moment to afford the client full autonomy in the sessions.

A few weeks on, the client presented another angry story, like the previous week and the week before that, and again over a small inconvenience. As usual, I held space for the high emotions, and once the client had finished their story, silence filled the room. They looked at me for empathy and understanding, but I did not respond to the story on this occasion.

“Would you not be angry at this?” they asked. After some silent pondering, I shared that in my experience of working as a therapeutic counsellor, at times anger can be a secondary emotion, explaining that sometimes if you are hurt in some way you might express this negative emotion instead of emotional pain — that for some, it might be easier to express anger rather than hurt. A pause.

I felt now was the opportunity to move into the next phase of our work, compassionately inquiring about the feeling of anger further. “Tell me, what is underneath your anger?” I noticed the shock at being challenged on their aggression as the client processed this question.

Softly encouraging the client, I invited them to “Stay with the thoughts and feelings that are surfacing,” and in response, they had a deeply emotional reaction to the question. Answering quietly, they said, “grief, my anger is grief.”

Relief washed over them as they identified and acknowledged the emotion. “Ok,” I said as I let out a breath, “let us together hold space for your grief. I know this is hard, I know this is painful, but let us together sit with this pain until it passes, soothes, or settles. I promise you are safe. If we sit with it right here, right now, exactly as we are, it will soften for the time being.”

On Reflection

On reflection, I realise the importance of sitting with these feelings, fully leaning into the experience, holding the client present in their pain and softly working through the emotions. Reassurance and gentle guidance are paramount when working with grief.

Within my therapeutic work, compassion and empathy are a salve to emotional injury. Sitting with a client in their pain is a powerful thing to do. It does not come naturally to a lot of people, as often they will want to repress, suppress, or avoid that pain and those experiences, much like my client did. However, the healing is in feeling them.

Now that my client had accepted their feelings, we began to do the work. Sometimes we would sit in total silence, acknowledging the energy in the room while my client worked through the feelings they experienced, and once the energy shifted, we began to regulate each emotion.

To move into this level of awareness and regulation I often encourage clients to acknowledge where in the body they feel sensations, softly inviting them to explore the feeling with me. “How does that feel? Does it feel hard or soft? Describe the sensation your body is experiencing right now?” This keeps the client grounded, and usually I find the feelings soften.

It may feel beneficial to lead the client into some gentle breathwork, staying present and engaged, co-regulating alongside the client. I may invite them to put their hand on their heart, to keep eye contact with me as we inhale through our noses and exhale through our mouths. This encourages the body to regulate and settle. Once I feel regulation has occurred, we may move into sharing memories of their loved ones, often discussing loving moments or times of laughter.

My clients’ laughs and their glistening smiles as they recount their memories are beautiful moments to witness, and moments I will always be very humbled to be part of.

Questions for Thought and Discussion

What is your reaction to the author’s approach to addressing grief therapeutically?

Is her approach similar to or different from your own way of addressing grief?

Are there particular grief-related issues that you struggle with in counseling?

What personal life experiences have influenced your approach to grief counseling?   

Spitting Truth from My Soul: A Case Story of Rapping, Probation, and the Narrative Practices- Part II

Posted on by Psychotherapy.net Team

Recapitulation

This is the second part of a two-part case story that focuses on a 24-year-old African American client named Ray who was referred to me (TH) by probation services. In this brief introduction I will try to summarize what transpired in Part I. Whenever possible, I will attempt to provide phrases or “pieces” of Ray’s language so the reader can begin to get a “feel” for him and our work.

Rap music was introduced as an entry point to our work. After our first session Ray could probably best be described as equal parts skeptical and intrigued. He enjoyed sharing rap songs that were meaningful to him as well as having the opportunity to create rhymes of his own.

We rather quickly discussed ways in which rap music was misunderstood (“Adults throughout my whole life telling me it’s violent and the music of the devil . . .”) and how others could not or were not willing to hear the important messages that can be contained within certain songs. We proposed a pair of magic headphones (“Magic Beats”) as a way to help those who would not listen begin to hear rap’s message. This idea will prove particularly important as our conversation progresses in Part II.

As our first conversation continued, we started exploring the sociopolitical implications of rap music and hip-hop culture. We framed rap as a kind of philosophy (“But without all the white cats . . .”) that served as a voice for the voiceless. We also stumbled across a connection between Ray’s grandmother and rap music (“I’m rapping about the same s**t she’s saying but in my own way . . .”). This struck him as perplexing (“That’s crazy bro . . .”) and also enlightening (“I never thought of it like that . . .”) given the disdain she had expressed for rap music throughout his youth. Our first meeting came to a close by having a conversation about our conversation.

We explored the difference between just talking and rapping, to which Ray responded, “It’s like when I rhyme . . . I spit truth from my soul.” We both agreed that inviting rap to our future meetings would be of benefit. More specifically, we discovered that rapping might serve as a pathway to liberation (“Remove the shackles from my soul . . .”). I invited Ray to consider composing a rhyme that paints the part of the picture that probation services doesn’t see. He responded enthusiastically but seemingly nervous that probation services would discover the way we were working and somehow veto it (“You’re the weirdest shrink they have ever sent me to. Not weird like bad, not bad at all, but does probation know you do this?”). We then decided that calling our work together a “studio session” was a better fit than therapy.

Ray picked up in our second meeting directly where he left off in the first. He came prepared with a rhyme that would be the foundation of a counter-story. He noted in that rhyme the importance of challenging rules (“Just because these are the rules you play the game by doesn’t mean these are the only rules . . .”). The conversation evolved into looking at whether or not Ray had found some ways of challenging rules more effectively than others. He then traced the relationship between rap and anger (“It’s like my anger would leave my mouth through my rhymes . . .”). Part I concluded with a pensive Ray searching for a rhyme that captured this most important function of rap music as an antidote to anger and aggression. The following rhyme picks up where our original story concluded.

An Antidote to Anger

Judicial system mad puzzling

DA presents two options
Jail cell or rat on my cousin
Death sentence if I’m released
Seen on the streets
All free
They’ll be like “who you dropped a dime on g’”
Obscene language make them ends
So I’m squeezing my pen
That’s mightier than the blade
Not trying to see death
Strategize and not be so impulsive
Quiet cats survive
Bullets for the ones boasting
Friday night drive on Colfax
Enjoying the madness
That was created by fascists
Reagan-nomics took our tools away it’s so savage
Regardless of politics
This my Mile High life
Shout out to my bail bonds-man.

Travis (T): What speaks to you in this verse?

Ray (R): The line, ‘So I’m squeezing my pen, that’s mightier than the blade,’ is the main one. I mean, the rhyme talks about the stress, the penitentiary, but then boom (begins rapping) So I’m squeezing my pen, that’s mightier than the blade.

T: Did you fight with your pen instead of your blade before you ended up on probation?

R: Usually, yes. But there are these times where I just lost it.

T: The pen was knocked out of your hand?

R: Yeah, you could say that.

T: What happens when the pen gets knocked out of your hand?

R: It’s like I’m a different person. I do these things I know are stupid, but I just do them, anyway. It makes no damn sense.

T: But when you have the pen?

R: I can do anything.

T: Would it be accurate to say that when you have the pen you can spit truth like you said in our last meeting and that’s when Ray The Philosopher comes out (I uttered the term Ray The Philosopher without giving it much thought and certainly without an understanding of how it would later be adopted in our work together)?

R: For sure. That’s kind of a dope name right there, brother… Ray The Philosopher (said with gusto)

T: Do many people in your life know Ray The philosopher?

R: My homies do.

T: Is there anyone else you can think of?

R: No, not really.

T: What do you think would happen if we introduced more people in your life to Ray The Philosopher and his rhymes?

R: I think it would be good, but like I said last time, nobody wants to listen. They think rap is corrupt.

T: What if we were to inform them that when you can think ahead and fight with your pen through rap it helps you avoid anger and thus probation? Do you think they know this about you?

R: Nah, they don’t know that. I still don’t know if they would hear me.

T: Even if they knew that it would help you avoid future relationships with probation, they still wouldn’t hear you?

R: (silence for 15-20 seconds) Maybe. I mean, I hope so.

T: What do you think your grandmother would think about rap as a way to fight with your pen instead of your fists? Have you spoken with her about how you and rap have this kind of relationship?

R: No. I’ve never spoken much about my rhymes at all with my grandmother. I’ve just always known how much she hates rap. Like if I bring it up, I know she’s going to roll her eyes at me.

T: Do you think the kind of rap she hates and the kind of rap you’re tight with when you’re fighting with your pen are different?

R: Oh, yeah! She thinks rap music is just about cursing, talking about hoes and drugs and shit like that.

T: If she truly knew how rap music unshackled your soul do you think she might begin to have a change of heart?

R: Yeah, I still just don’t know if she would listen, though.

T: What if we created a space in here where you could perform for her, and we constructed a marquee (points upward) that lights up and says Ray The Philosopher!?!

R: (Laughs)

T: If you rapped for her and she could feel the words instead of just hearing them, what do you think might happen?

R: I really don’t know.

T: Would you say that your grandmother’s wisdom finds its way into your rhymes?

R: Oh yeah, I know it’s in there a lot.

T: Can you think of an example in the rhyme that you shared with me at the beginning of our conversation today?

R: My grandmother has always wanted the best for me. That’s why I started out that first line with her. You know, (begins rapping) Grandma said I should reconsider law school. I was sampling from another rhyme that starts with mama instead of grandma, but it’s because I know she wants the best for me and that’s why she’s always bothering me about school.

The thing is, she also taught me to be street smart, which is why I like to challenge the whole foundation that student loans and shit are built upon. It’s like a scam for poor people. You know what I mean? I would have never thought about shit in these terms if it weren’t for her. I would have never looked deeper. And that’s what that second verse is about, too, with people on TV commercials acting like they can save your life and shit. You ever watched TV at like 2:00am?

T: I have a few times, yes.

R: Then you know what I mean, right? There’s these cats trying to sell hocus-pocus. They are saying shit like, (changes voice to that of a highly embellished television salesperson) “For 20 years now I’ve been helping people change their lives. For only three easy payments of $99.95 you can get the 7 secrets that will make you rich. Order now!”

(Both bellowing with laughter)

T: I didn’t know you were an actor, too, Ray?!

R: (Laughs)

T: In all seriousness, if I’m hearing you right, Ray, your grandmother’s wisdom is everywhere in your rhymes, and she doesn’t even know it?

R: Yeah, I guess you’re right.

T: Do you think we might be able to invite your grandmother to see, hear, and feel that rap can be a philosophy of street smarts and wisdom and not just a form of music that young people like to listen to?

R: I think so.

T: If we are successful do you think this would be sort of like putting the Magic Beats we talked about on your grandmother’s ears?

R: Yeah, but the rhymes will need to be just right.

T: Perhaps we should take some time in here to get them where you want them?

R: For sure.

Turn Up the Sound

Ray and I spent our next two conversations focused on taking the various rhymes rapped during our first two meetings and worked on creating a mega-anthology. It was a scintillating process that saw KRS-ONE, Tupac Shakur, and other artists rapping in unison through Ray’s mouth. I brought in my laptop computer to help with the process, and Ray made it do things I did not know it was capable of.

He turned my computer, and my office along with it, into a fully functioning recording studio. I even created a marquee (clearly the work of a second-rate artist) that read “Ray The Philosopher,” which always led to a hearty chuckle from Ray every time I hung it up at the beginning of our meetings.

“Yo, Travis. Turn up the sound a little bit,” Ray said as I scurried over to the computer. “Yeah, that’s good right there,” he reassured me making an ‘a-ok’ sign with the finger and thumb on his right hand. I watched, often in awe, as Ray meticulously perfected his craft. He was locked in his element, and I was an enthusiastic fellow traveler.

“Nah, we need to change up that baseline a little bit,” he said shaking his head and taking a swig of water. “It doesn’t quite pop. I need more time.”

I have had the great fortune of working on similar projects with people who had sought my counsel in the past, but this was among the most ambitious ventures I had encountered. As we started to make our way toward the end of our fourth session together, I started to wonder if perhaps we had bitten off more than we could chew. Now I knew that Ray had similar feelings. It wasn’t as though we hadn’t been aware of time but more like we had lost ourselves in it.

T: Ray, the last thing I want to do is rush you through this process.

R: But I only get to come here one more time.

T: Well, I know that’s the initial agreement you had with probation, but I can see you as many times as we think would be best.

R: What about you, though? I don’t want to be a leach?

T: What do you mean?

R: You’ve got to get paid, man. This ain’t no charity. This is your livelihood, bro.

T: I really appreciate you thinking of me, Ray. Tell you what, how about I give probation a call and tell them a bit about the situation and see if we can get some more time? In the past this is something they have often been willing to do.

R: What if they’re not?

T: Then we will see the work through to its completion anyway, Ray. As long as it takes. This is just too important. Don’t you agree? Besides, I have been thinking about something. Would it be okay if I shared it with you?

R: Of course.

T: I know your grandmother is going to come in at the conclusion of our work to celebrate with us. I was wondering what you thought about perhaps inviting other people to meet Ray The Philosopher? Is there anyone else you who you think it might be good to invite to wear the Magic Beats?

R: Hmm… I haven’t really though about it too much.

T: I’m just thinking out loud here, Ray, so stop me if this doesn’t make sense, okay?

R: Okay.

T: What do you think would happen if your probation officer were introduced to this idea of you fighting with your pen instead of your fists?

R: I mean, I’m sure he would like it. He just wants me to keep my hands clean for the next year.

T: What do you think would be the consequences of us not bringing him up to speed on this?

R: I don’t know.

T: As it stands now, do you think your PO views you as someone who is going to fight with his fists and get into trouble again or someone who is going to keep his hands clean?

R: (Laughs cynically) I damn sure don’t think he trusts me. I think he believes I’m going to be out gang-banging (a hip-hop term for engaging in violent acts as a member of a street gang), and I don’t even do that shit.

T: How has it come to be that you don’t even do that shit and yet your PO thinks you do? Do you think we should try and set the record straight and let him know how rap allows you to fight with your pen instead of your fists?

R: But he’s going to give me that same old bullshit about how I don’t take responsibility and blah, blah, blah (uses his right hand to imitate a talking mouth).

T: Do you think if you rapped for him and let him know how rap can strangle the advances of anger and aggression, he would look at you as more likely to keep your hands clean or less likely?

R: (Pauses for 10-15 seconds) More likely to keep my hands clean.

T: What do you think the consequences would be if we weren’t to set the record straight?

R: Yeah, I get what you’re saying now.

T: How do you mean?

R: Like, it’s not enough for just me to come up with this plan if he still thinks about me a certain way… like I’m a criminal.

T: Do you believe this is an opportunity for Ray The Philosopher to replace the other names that have been placed on you in the past like criminal?

R: Now that you mention it, yeah, I guess so.

T: Would you say that sometimes your PO is a tough nut to crack?

R: C’mon, now! That dude is like impossible to crack.

T: Do you think then that we might have to prove to him just how effective fighting with your pen can be?

R: Sure, but how the hell are we going to do that?

T: How long have you seen me for now, Ray?

R: (Pauses to think) Like about a month.

T: I know this is a tricky question because I’m asking you to guess what another person might be feeling, but do you have any sense for how your PO would say this last month has been for you.

R: I actually talked to him about this last week. I’ve been squeaky clean. Not one single issue, homie.

T: What do you think he would have told me about how things were going if I had talked to him prior to you coming to see me?

R: Man, he was always in my grill about shit saying I was defiant, I was going to go to jail, and this and that.

T: Fair to say then that he believes things are going better now?

R: No doubt.

T: Has one month been enough to convince him that you are on the right track?

R: Hell no! It’s like he’s just waiting for me to fuck up.

T: How many months do you think it might take to convince him that you are on the right track and ready to end your relationship with probation?

R: I mean, I still have over a year of this.

T: Do you think it will take all of that time to show him just how effective fighting with your pen can be?

R: Probably so.

T: What if we were to invite him in here, bring him up to speed on your philosophy of fighting with your pen and not your fists, and then make a commitment to this going forward?

R: I don’t know if he’ll believe it.

T: You make a good point. Like you’ve told me, he can be a bit stubborn and so can your grandmother! Even as tough as it is going to be, are you willing to fight with your pen and prove to your grandmother, your family, and your PO the true character of Ray The Philosopher? You already have one-month under your belt!

Ray paused after my question. I started to wonder if perhaps my query had pushed him a bit too far. His face remained stoic as the silence continued beyond 30 seconds. Just as I started to ponder my next move fearing I had lost him, he replied, “I’m down (a hip-hop term voicing agreement).”

After the conclusion of our fourth session Ray and I agreed that it would be good to check in with his PO together. We decided that in addition to talking about the need for more sessions, we would also let his PO know (a signed release was already in place) about how Ray had been fighting with his pen instead of his fists. The PO acknowledged that things were going better the past month, but he remained skeptical. He agreed to get payment covered for half of every session for the next month. The way the following month was structured it would afford us five more weekly meetings.

Two Different Stories

Ray seemed somewhat relieved that more sessions had been granted but also a little bit ticked that his PO was still unconvinced. He felt his PO was “playing games” and “testing me.”

Our next three meetings were spent wrestling with these feelings. Ray began discovering that restoring his reputation burned nearly as many calories as he was taking in. Instead of being consumed by anger towards his PO, Ray stayed true to his word to fight with his pen. He remixed a song by the artist Common:

We should name the block poverty
That rock stole our humanity
You hear that glock pop?
For dough we perform beastiality
“Fucking each other over
What you expect they animals”
Then act like they the ones offended
When TMZ release the audio
If life’s a game
They withhold that playbook
But playas make that scratch
We get the itch
Run your shit
This a jook
Or a lick
See that’s a stick-up if you down with my click
We starving in the darkness
Force upon us they man made eclipse
Is it a curse?
Mad poisons in our blood?
My pops tried to disinfect it
Chugging that rum
And I do the same (word?)
Like father like son.

Ray no longer waited for me to inquire about the lyrics. He would deconstruct them now almost as a natural part of our process. “See, this is what he (probation officer) doesn’t understand. I was born behind the god damn eight-ball. No father. Poor. I’ve always had to hustle to survive. He doesn’t know my pain. Does he even care to know it? But that don’t even matter. Is he testing me? I’m going to pass that test.”

Ray began rapping the second verse from this song:

To my reflection I scribed
What I be feeling inside
Can’t leave it buried in the dirt
Gotta breathe it and give it life
My neighborhood taught us no self-control
That boom-bap made us feel like it’s our right to explode
No positive role-model
The hustlers were our fathers
Rappers instructed us to spit rhymes
And don’t bother
With the life of an outlaw
It’s a trick to keep us blind
And deny our title as God
Preventing our rise
They been doing this for centuries
Stolen lands from our North and South American fam
Jews burnt
Japanese thrown in determent camps
Hatred can hide
Right in front of our eyes
But I flipped that same hate
Used it as fuel to survive
I’m of a mind that believes love will conquer hate
They be seeing black and white
While my crew is dazed by all the gray
So gather around the fire
Light it up
Continue the cipher
Cause in the darkness of nights
Our stars still shine brighter
This is my dream!

T: Ray, are there two different stories in the two beats you have shared with me today?

R: Yeah, the first one is the pain and strife. The second is what happens when I look ahead and fight with my pen.

T: Pain and strife and fighting with your pen… both of those are rhymes that you brought into our work earlier, right?

R: Yep.

T: Would it be right to say then that these last two verses are a sort of remix of all of the beats we’ve heard in here so far?

R: Pretty much.

T: Would these verses be good to share with the folks who join us for our final celebration of the work you’ve accomplished in here?

R: Yeah, but I might tweak them throw in a couple of other verses from different rhymes to get it just where I want it.

Our second to last session was a dress rehearsal. Ray came with the beats he wanted to perform and refined them. We also talked about how he wanted our final celebration to commence, what would happen, and who to invite.

He joked that it “would be kind of like a block party, but where a therapist lives in the house on the corner.” We also decided that those in attendance would have an opportunity to voice their support of Ray’s efforts over the past two months as well as hopes and dreams for the future. As this session came to a close I could detect a nervousness that was following Ray.

T: Ray, I could be wrong here, but I am wondering if some nervousness is hanging with us right now.

R: Yeah, I guess so.

T: Do you mind if I ask you what kind of nervousness it is? People I’ve worked with before have taught me that there are different kinds? Do you know what I mean?

R: You know, I’m not like a professional rapper or anything like that, but I’ve performed in my neighborhood before. It feels like that. Like, you think you have a good rhyme, but you never know for sure until you get on stage and the crowd is feelin’ it.

T: What gives you confidence that the rhyme you have created in our work together will deliver just the message you hoped it would?

R: I put my whole heart and soul into it. I didn’t leave one drop.

T: Do you think the people who are here with us next time will feel your heart and soul coming out through your lyrics?

R: (Pauses for 10 seconds or so) I really think so.

T: Do you remember when I first asked you about what would happen if you rapped for your grandmother or your probation officer?

R: Yeah, I said they wouldn’t hear it.

T: Are you saying that you feel differently about that now?

R: Yeah, I guess so.

T: What would you say has shifted?

R: These rhymes are me but just in lyrical form.

T: And you don't believe your grandmother or those who love and care about you would reject this gift that is a lyrical manifestation of you?

R: No, my grandmother always tells me that she’ll never run out of love for me.

T: Hey, something just struck me, Ray. Would it be okay if I share it with you?

R: For sure.

T: I wonder if you just discovered the Magic Beats?

R: What do you mean?

T: Do you believe that when you create a rhyme that fully represents you and comes from the deepest depths of your soul that even those who don’t prefer rap music could still hear it?

R: (A smile overwhelmed the now dwindling doubt on his face as he nodded affirmatively)

T: Ray! This is great! What an incredible discovery you have made!

Ray often tried to minimize any expressions of emotion, but even he smiled loudly at this development. In our excitement we almost instinctively exchanged daps (gesture similar to a handshake) with our right hands before giving one another a quick hug. With this we had established an unspoken agreement that we were ready for Ray’s performance and celebration next week.

A Celebration of Hope

Ray and I agreed to meet about a half an hour before everyone else to prepare the room for the celebration. As we moved tables and chairs and geared up the laptop computer everything was coming together. “Alright, I think we’ve got it,” I said looking in Ray’s direction. He then shook his head ‘no’ and looked upward to indicate to me to direct my gaze towards the ceiling. “What?” I said with a perplexed look.

He nodded upward once more. I stared skyward still trying to decipher what Ray was communicating. Then I realized that in my haste to make sure there were enough chairs for everyone I had forgotten to hang up the marquee. Like a dog with his tail between his legs I went back to my desk in the back room and removed from the top drawer the “Ray The Philosopher” marquee. I dashed back out to the main office and hung it up in its customary location. “Now we got it,” Ray asserted.

Soon, Ray’s grandmother, his sister, and a few other people from his neighborhood began making their way into the office. There was a sort of nervous excitement that filled the room. Lost in conversation, time had escaped me. I

reached into my pocket and pulled out my phone to take a quick look at the time. In doing so I noticed a message was waiting for me from Ray’s probation officer. Oh no, I thought to myself. He had left me a message stating that something had come up and he wasn’t going to be able to make it. Just as I was about to hold the phone to my ear to listen to it, he lumbered through the front door. “Sorry I’m late,” he said. “Did you get my message? I got caught up with a few things at the office.”

Relieved that everyone was now here, I looked at Ray to see if he was ready to go. Ray had asked that I start by saying a few words to give folks a sense of what today’s meeting was all about. After welcoming everyone and thanking them for attending, I began discussing a bit about Ray’s journey.

“During our two months together, Ray has reaffirmed how rap music can be an ally in helping him be the person he wants to be. He has composed a series of beats he would like to perform for you today. Ray suggested that

Therapy in the Shadow of Death and Its Remarkable Privileges

Posted on by Psychotherapy.net Team

Concerns Converging on Loss
 

“So, the doctor told me that it is cancer, and that there's nothing they can do. I just hope I have a little more time; my biggest hope is that my sons will reconcile with each other.”

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“The doctor came to my room to see me. He held my hand and said, 'I'm sorry you have cancer, and I'll do everything I can to keep you comfortable.' And he said, 'From everything you've told me about who you expect to meet when you leave, I think that should be the best comfort for you,' and the doctor was right, my faith is a comfort to me.”

“My daughter, my beautiful daughter killed herself. There's just no answer to explain it.”

“Don't say goodbye, I'll see you in heaven; I've been there before (near-death experience) and it's beautiful.”

“Oh, Tom, can you see this client today, her son just died; they think it was a drug overdose.”

“They're all gone, my parents, my wife, my children, everyone; I'm the last one left. I don't know why, but I'm still here.”

“This is the third time my mother is in hospice. I wish she would die, but then I feel so guilty for wishing that. Then I wish she would get better, but I don't think she will; it's all just so difficult and confusing.”


Walking with My Clients
 

Over four decades, I’ve provided psychotherapy to residents in nursing facilities. I have worked with many thousands of clients, most of whom have died. I have been privileged to accompany so many on the last steps of their journey through this world. All persons die, and virtually all persons have lost someone, or many others dear to them. I have likewise been privileged to provide companionship to so many amid of their grieving. Speaking with someone with a terminal illness or someone grieving is a weekly, if not daily, or even several-times daily part of psychotherapy in a nursing facility.

Sometimes I know in advance, and can have sessions in which to work reflectively with the client as they approach the end. Other times I come to the room of a resident and their belongings are gone, and inquire of the nurse and am told they died. Sometimes, I receive an email telling me the sad news before I arrive, and sometimes a staff person will console me, “I know how close you were to her.”

For many clients who have a terminal illness, it is a comfort and relief to speak frankly in psychotherapy about matters of death and dying. The person's family members, and even some caregivers, might tend to avoid the topic, perhaps due to personal discomfort.

Staff persons might encourage continued socialization, yet the dying individual may be occupied with the internal work of preparation. A nurse asked me to “talk to” a dying resident because she thought her TV show was inappropriate. The resident was sitting up in bed while a television show for toddlers was quietly playing. While the resident sat facing the TV, she was clearly looking inwardly.

As I quietly kept her company between brief bits of conversation, I noticed how the TV show in the background provided a soothing backdrop. This particular resident, like others close to death, needed to pull away from the ordinary things of this world and reflect on their life, their relationships, and their eternal future. My father was lucky to die at home. As I visited him weekly towards the end, he would each time give me a book or another item of his. I thought of how I pack up when I am preparing for a journey. He was unpacking as preparation for his journey.

Sometime around 12 to 15 years into my 40-year career, I started to experience burnout; a result of too much trauma and human suffering. For me, it was a deepening of religious faith that allowed me to once again fall in love with psychotherapy and learn to practice without being harmed by it.


Of Greeting and Bidding Farewell
 

Some dying individuals are comforted by their faith, and some struggle with doubts. Everyone will have some fear of death, yet I notice how each person has their own kind of fear as they near it. For many of my clients, the fear is of God's judgment. Clients often voice worries about their mistakes and misdeeds in life — yet I regularly see how narrowly a person might look at their life experiences and influences, and how harsh and disproportionate is their judgment of themselves.

Many of my clients have been rejected by so many in life, they doubt there is a God, or let alone a God awaiting them with kindness and understanding. I feel a tenderness for each of my clients, yet often in therapy, sometimes as a client most severely chastises themselves, I feel a loving kindness in me that does not seem to begin in me. I notice a gentle feeling of wanting to reach out and touch their cheek, or a reassuring largeness of understanding that surrounds all the good and the bad of that person’s life, and I simply hold those ideas or sensations as aspects of my bringing a therapeutic presence to their suffering.

I have worked for many years in particular facilities; maybe 10 years in one, or 18 years in another. As I walk through the halls, I often think of the individuals who previously stayed in those different rooms, recalling their personalities and the challenges of their life.

Psychotherapy in nursing facilities is often a process of greeting, uplifting, supporting, and of saying goodbye. It can encapsulate and intensify the general experiences of life and death one might encounter in other settings or ordinary living. I am grateful for this work. When the time comes to retire, I will continue to see in my mind's eye the many people I have worked with and to thank them for their trust when they were most vulnerable.

 

Should Transgender Youth Care be Guided by Beliefs or Science?

Posted on by Psychotherapy.net Team

Introduction

The current American approach to transgender-identified youth and adults is strongly affirmative. Many professional organizations in the United States have endorsed the safety and efficacy of social transition, puberty-blocking hormones, cross-sex hormones, and breast, genital, and facial surgeries as the ideal treatment of gender dysphoria.
 

These prestigious decade-old endorsements have led to the development of gender specialists in over 70 US clinics where children, adolescents, and younger and older adults are seen. It also has led to affirmative care being taught in medical schools, residency training programs, and various mental health continuing educational programs. For half a century, WPATH has been the key nongovernmental organization that has gathered specialists, provided courses that promulgate clinical principles, and published standards of care. WPATH represents itself as an advocacy, policy, and scientific organization.

Its membership recognizes a great need for social change as discrimination in housing, employment, health care, intrafamilial and peer relationships, and incarceration are significant cultural sources of stress for the transgendered. WPATH considers its recommendations to be scientific, even though its author-committees recognize a need for improved scrutiny of outcomes of social, medical, and surgical interventions. While it recognizes that the quality of supportive evidence is objectively low, nonetheless, it treats affirmative care as a settled scientific matter. DSM-5-TR and ICD-11 diagnostic criteria exist, elective treatment sequences have been defined, and many clinicians and patients consider affirmative care to be life-enhancing and sometimes lifesaving.  


Affirmative care, however, is not a scientifically settled matter. There is much justifiable ferment. Affirmative care is far more fraught and uncertain than WPATH and professional associations have suggested. (1-3) It is a paradox for WPATH to portray itself as a trustworthy authoritative advocacy, policy, and scientific organization in the face of uncertainties about long-term treatment outcomes, the unexplained dramatic explosive incidence of new gender identities, and the increasing recognition of de-transition.

There is an ongoing culture war within the US about the treatment of transgender youth who are uncomfortable with their bodies. (4) The political aspect of this culture war addresses transgender treatments as a conflict between those who support and those who oppose the civil rights of LGBTQI+ individuals. Those who question the wisdom of affirmative care are described as “anti-trans.” A medical perspective begins with a different question: Is the scientific basis for affirmative care sufficiently established? If the answers are either no or uncertain, three other questions follow.  

  • Can gender specialists separate their beliefs from what is scientifically known about etiology, incidence, psychopathology, and the long-term benefits and harms of affirmative interventions?  
  • Can these specialists provide parents and patients with the legal and ethical requirements for informed consent? (5)    
  • Can high-quality research be designed and funded to answer the current relevant clinical uncertainties?  


Usually when health is the topic the medical profession leads the way, relying first on rigorous science, and second on the values of individual patients and their families. In the arena of trans care, however, values have historically played a more important role than science. This may be summarized as eminence-based or fashion-based medicine dominating over evidence-based medicine. As has been seen with the COVID vaccine, mask mandates, the opioid epidemic, and the FDA approval of a drug for Alzheimer’s disease, trust in the medical profession is far from universal. Consequently, what individual doctors, gender care clinics, professional societies, and mental health professionals may have to say about the ideal care of trans persons may not be the most powerful force governing social policy.    


Forces Shaping Attitudes About Transgender Care

Transgender phenomena elicit intense feelings among laypersons and professionals. Such passion, which is destructive to objective scientific appraisal, derives from many personal sources. While numerous factors influence attitudes toward transgender care, their confluence makes it difficult to judge their relative contributions to how individuals and institutions regard trans healthcare.  

There are five universal potential influences.      

1. Fascination with sex change. The intriguing question, “Can sex be changed?” has long been explored in the arts, where men and women have for centuries been presented as the opposite sex in humor, drama, dance, opera, drag, and popular music. Today, it is better understood that in a basic biological sense, sex cannot be changed, but gender presentation can, with or without medical assistance. 

2. Political sensibilities. The Left may consider transgenderism the courageous pursuit of self-expression, a civil right, a movement to improve diversity in all walks of life, and a praiseworthy social movement to eliminate discrimination. Their political values lead them to view studies and clinical services with trust. The Right, on the other hand, may consider transgenderism morally wrong, threatening to societal health, and dangerous to the health and well-being of individuals and families. These assumptions lead to a skeptical approach to studies and clinical services.

3. Religious sensibilities. These value-laden thought patterns derive from theological assumptions. They may resemble the Right or the Left. In the United States, the most vocal religious institutions on this topic lean to the political Right. 

4. Sexual orientation sensibilities. Membership in the heteronormative or sexual minority communities often generates opposite responses — the former may have initial unease with, and the latter, initial comfort with trans phenomena. One’s sexual orientation, per se, does not guarantee a particular attitude any more than one’s political or religious affiliations do. However, many of the leaders who advocate trans care identify as a sexual minority.

5. Intuitive age-related sensibilities. Intuitive sensibilities are best reflected through age. Younger and older generations have different life experiences with which to be intuitive regarding attitudes toward the transgender experience. The very existence of sexual minority communities and their entitlement to civil rights are far more visible today than was the case when older persons were growing up. These generational differences reach into each group’s system of values. 

There are four influences that are unique to professionals.  

6.Personal clinical experience. The 7th edition of WPATH’s Standards of Care (SOC) downgraded the importance of a comprehensive assessment of psychiatric co-morbidities in determining the next step. 6 The process of evaluation was then pejoratively referred to as gatekeeping. Prior to 2012, adults who immediately wanted hormones or surgery were often impatient, demanding, rude or dishonest about their histories. With the 2012 guidance, adults and older adolescents were assumed to know best what should be done. Respect for Patient Autonomy became the primary ethical principle to follow. The frequency of unpleasant clinical experiences dramatically diminished. When professionals experience unpleasant patients, those with conspicuous emotional impairments, or those who deteriorate with hormonal treatment, they are more likely to be avoidant of future encounters. Positive experiences with appreciative patients and families yield more willingness to engage. 

7. Knowledge of clinical reports from clinical innovators. Positive outcome studies of transgender treatments typically consist of retrospective case series without control groups and without predetermined measurement instruments. Such outcome reports are numerous for each intervention. Positive results tend to be more often published than negative or uncertain outcomes. The most influential studies for minors were published in 2011 and 2014, and while they too lacked a control group, they were interpreted as establishing the concept that selected prepubertal cross-gender identified children could benefit from affirmative social, endocrine, and surgical care. (7),8 

Clinicians cannot be expected to keep up with the burgeoning literature; they trust what they read, heard about, or were taught. Such learning reflects a chain of trust that is basic to all medical education. It has become apparent that the chain of trust is not necessarily trustworthy, as positive studies are published in peer-reviewed journals only to have their conclusions criticized by knowledgeable academics. Once clinicians begin to facilitate patients’ transitions based on the studies they have seen, they believe they are facilitating happy, successful, productive lives even without having the reassuring follow-up information to verify their beliefs.

8. Scientific studies. Groups of studies demonstrate patterns that individual studies do not. Scientific data are widely assumed to dominate institutional policy. This is not necessarily so, however. For example, high desistance rates in trans children have been demonstrated in 11 of 11 studies, (9) but a committee of pediatricians created a policy of supporting the transition of grade school children. (10) As a result of these often-conflicting processes and sources of data, comprehensive evaluation and psychotherapy rather than affirmative care are increasingly being recommended

9. Source of income. With 70+ clinics in the United States, with many individuals in private practice who practice affirmative therapies, and with special units within prisons to support trans inmates, the attitudes of new-to-this-arena clinicians may be quickly determined by their work environment. In these settings, disapproval of affirmative care, which may grow with experience, as it did for many psychologists at the Tavistock Clinic, means resignation or job loss. 


Sources of Controversy about Affirmative Care

1. Morality — Conservative citizens, religious denominations, politicians at local, state, and federal levels, and some gay, lesbian, and feminist groups view affirmative care as dangerous. They ask, “What are we doing to these young people? What will be the outcome for them and their families? Do doctors really know what is best for my son or daughter? Why is it acceptable to sterilize young people? Why is the suicide rate high after completion of medical and surgical interventions?” Such questions burrow down into moral values.

Some religious groups assert that since God made male and female, this provides fundamental guidance to decision-making. However, because these groups have historically been similarly against homosexual lives, the power of this theological assumption is politically diminished for many others.

Some gay and lesbian organizations see affirmative care of feminine boys and tomboys as an attempt to eliminate gay and lesbian people. Almost all groups recognize that cross-gender identification is nothing new. What is new is its dramatically increased incidence and Medicine’s response to it.  
 

2. Questions Emanating from Medical Ethical Concerns

  • Are children and adolescent patients experienced enough, cognitively mature enough, to make life-altering decisions that will predispose them to known challenges such as sterility, sexual dysfunction, decades-long medical care, discrimination, and loneliness (11, 12)  
  • Do their frequent co-existing psychiatric diagnoses further impair their ability to thoughtfully consider the consequences of each of the steps of affirmative care? 
  • Are affirmative professionals knowledgeable about the limitations of their recommendations? 
  • Do they know the inadequacies of the outcome data supporting the policies of socialization of children and endocrine and surgical interventions with adolescents?
  • Do they know the fate of most patients given hormones a few years after they age out of pediatric endocrinology?
  • Are they aware of the rates of complications, physiological consequences, long term unhappiness after the surgical procedures that they recommend?
  • Are parents sufficiently informed about the limitations of outcome data?
  • Are they told of Sweden’s, Finland’s, UK’s, and France’s shifts towards psychotherapeutic-first interventions?
  • Are they informed about the social, economic, vocational, physical, and mental health problems of transgendered adults? 
  • Are they told about detransition following hormonal and surgical treatments? 
  • Are they told about the elevated suicide rates after surgical treatment of adults? 

3. Confirmation bias — When defending a particular position, authors tend to quote studies supporting their position and ignore contrary findings or glibly dismiss them as methodologically unsound. This confirmation bias creates important scientific concerns on both sides of the debate. Science advances by defining controversy and designing a study that may better answer a specific question. Independent reviews have concluded that the evidence is not convincing that puberty blockers and cross-sex hormone administration lastingly improve mental health, decrease suicidal ideation, or eliminate gender dysphoria. (13) 

The Endocrine Society acknowledges a low level or very low level of supportive evidence. Advocates, however, portray certainty that science has already demonstrated these lasting benefits without significant harm. When they list supportive studies there is no mention of the published criticisms of them. A scientific review is characterized by balance; it is not performed only by those who deliver the treatment. (14,15) Trustworthy reviews point out the limitations of studies and ideally suggest a study design to answer the specific question.  

4. Political — Nowhere in Medicine has free speech been as limited as it has been in the trans arena. Skeptics are being institutionally suppressed. Critical letters to the editor in journals that published affirmative data are refused publication, symposia submitted for presentation at national meetings are rejected, scheduled lectures are canceled, and pressure has been exerted to get respected academics fired. A notable exception to this pattern occurred when a paper investigating the long-term mental health outcomes of trans adults (a basic unanswered question) was published in the American Journal of Psychiatry.

It, of course, had undergone a peer review process by experts in gender care. When the authors asserted in their online publication that their data supported increased access to surgeries, the editor received seven critical letters. In response, Dr. Kalin had two independent statisticians review the work. They agreed with the twelve authors of these letters to the editor that the data did not demonstrate improvement in mental health. The editor published the original article, the seven letters, and the authors’ response. The authors retracted their conclusions. (15,16) When critical letters have been sent to other journals, they have been rejected. As a result, they are published in separate journals.

This makes it more difficult for clinician readers of the original journal to know about the critique. Unless published with open access, the original flawed article’s limitations are difficult to access in another journal. A significant paywall is often encountered to obtain articles in journals to which the professional does not subscribe. Given the well-known attacks on those who question the prevailing wisdom of affirmative care, it is not surprising that many mental health professionals avoid working with these individuals and their families for fear of being labeled as anti-trans, transphobic, or conversion therapists.  
 

5. Familial — The parents, siblings, and extended family members, each of whom have different relationships and responsibilities for the trans-declared person, typically have intense feelings about their relative’s gender change. Family members’ affects, attitudes, and behaviors derive from one or more of the five sources discussed above but take on a new poignancy. While parents are the only ones that professionals deal with, the intrafamilial ramifications affect everyone.

Parents have realistic, reasonable concerns. What will gender change mean for my child’s developmental future physical, social, and mental health? Their assumptions that the outcome will be negative often create an acute depression. This intensifies when their expectation of informing the mental health professional (MHP) about the child’s development, personality, and previous challenges.

Many parents are distressed when the MHP seems far more interested in making the diagnosis and declaring their belief in affirmative care. Parents who have not previously seen behavioral evidence or heard expressions of cross-gender identifications prior to puberty want this new identity to be taken away. Other concerns emerge over time. How will the gender change impact siblings and grandparents? How to discuss it with others? How to ensure we don’t lose our relationship? What to do with one’s anger at the child and one’s guilt of not seeing this earlier? How to find an MHP who will not quickly affirm but is willing to spend time understanding the family situation? 

Parents who are not supportive are often described as transphobic by their child. They often learn this accusation on the Internet. A more accurate and kinder description of these parents might be trans-wary or trans-opposed. When transphobic is used, it induces some adolescent patients to behave hatefully toward their parents. While the medical profession focuses on the patient, parents are immersed in a dramatic conflict within the home. Gender specialists only gradually become aware of this when they follow the family. This is one of the reasons for an extended evaluation process. (8, 17)   


Problems Facing Transgendered Persons

There is agreement about the challenges that transgender adults as a group are facing. The medical profession has been repeatedly told that the explanations for the poor state of physical and mental health and the diverse health disparities are minority stress, discrimination, and barriers to health care. (18) There is no mention in such discussions of the possibility that the mental health of a trans person may be intrinsically compromised even though many studies have shown the poor mental health of children before the diagnosis of gender dysphoria is made. (19) 

Rather, discrimination experienced by some in healthcare settings and fear of mistreatment in health facilities by others are emphasized. Higher rates of cardiovascular diseases, obesity, cancer, sexually transmitted diseases including HIV, syphilis, hepatitis C, and papillomavirus, and shorter life spans have been noted. Higher rates of depression, anxiety, substance abuse, suicide attempts, and suicide, (20) as well as seeking psychiatric services have been documented. 21 Gender minorities are more likely to live in poverty, be unemployed, be victimized by domestic partners, be homeless at some time, and be on disability. (20)   


Nowhere in these well-documented patterns is the suggestion that what is known about adult trans populations should create more caution about affirmative care for minors. Rather, many articles urge better medical education to promote affirmative care for young persons, (20, 22) or for medical institutions to fight against the legislative forces that are attempting to limit affirmative care to minors. (23, 24) These authors ignore the more cautious approaches developing in Europe.  
 

Affirmative Care Assumptions

The following concepts, sometimes articulated as principles of care, (6) enable the conviction that more, rather than less, affirmative care is indicated. When these ideas are presented as unproven, those who practice or support affirmative care of youth

Powerful Therapy Strategies for Healing Wounded Couples

Posted on by Psychotherapy.net Team

I remember greeting them for the first time in the lobby of my office. At first glance, they seemed like gentle people, kind to each other and to me. As they entered the corridor leading to my office, he deferred to her, politely allowing her to go before him as they entered the room. I recall thinking to myself, “I wonder why they're here?”

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But apparently this had been performance art, a quick bowing to public expectation. Soon after taking their seats, finding themselves safely sequestered behind closed doors and out of public earshot, those first-impression niceties vanished, and the emotional floodgates burst wide open. With what seemed like the disgorging of years of pent-up acrimony, accusations began to fly like the shrapnel of a bomb blast.

Blame and Accusations in Couples Therapy

She was first to launch her attack with the speed of a knee-jerk reflex. “He never listens to me…We don't communicate at all… I try to talk to him but it's like talking to a brick wall… I get so angry at him! I've tried everything.” Each new rendition of her complaining was an embellished and emphatic iteration of the previous one.

Notably, throughout her hair-pulling allegations, her eyes fixed solicitously upon me, as though she were expecting me to jump into the fray—once she'd fully discharged her accusations—and like a biased, one-sided arbiter, I was to join her in a corrective condemnation of her partner. Instead, probably to her great disappointment, I looked back at her with an empathic expression of heartfelt concern for her gnawing frustrations and deep hurt.

Amid her scalding allegations, her partner sat stoically, appearing inured to the barrage of insults and blaming he'd no doubt endured many times before. Then, with the first lull in her opening assault, when her “guns” appeared emptied and before she could “reload,” his defensive counter-indicting assault began with a fury matching hers, “She is always critical… She's so negative and judgmental… Nothing I do is right… I walk on eggshells all the time… It never used to be this bad… She used to be kind and loving… Now look at her… I don't know what happened.”

I've learned the hard way not to allow raw venting such as this to continue unharnessed for too long. I've found, probably as you have, that if “law and order” aren't soon imposed, the potential for a productive session soon diminishes, and can even irrevocably tip over into non or counterproductivity.

I typically jump in quickly, stop the mudslinging, and administer another dosing of empathy, followed by questions such as “Did you just give me a sample of how you talk to each other at home? If so, how do these conversations usually run their course?” As you might imagine, their answers are predictable: “Not good…We get nowhere…Things just get worse….”

Validating the Legitimate Needs Behind the Arguments

After allowing a moment for their answers to percolate, I typically find it therapeutically helpful to ask, “Do you think your upsets could be this intense were it not for the fact that each of you brings to the other important personal needs, indeed, very valid ones?” Of course, this is a therapeutically-baited question with a largely calculable answer.

But the question also flings open a window onto a wider batch of potentially therapeutic questions, like: “Wouldn't you agree the legitimacy of your needs is clearly evidenced by the strength of the emotions that attend them? And because of the importance of your needs, don't they beg for your best reasoning and problem-solving, in short, your best need management? Wouldn't this be more achievable in an emotional atmosphere of nonjudgementalism, mutual acceptance and respect?” More time for percolating.

In the case above, once we collaboratively agreed on these goals, I turned to her first and asked the seemingly obvious question: “Can you identify the basic needs at the heart of your arguments?” Her answer came swiftly: “I need him to listen to me.” I replied with a quick confirmation and a slight tweaking of her response, “Yes, your need is to be listened to, which seems perfectly reasonable to me.”

Then while my confirmation was still fresh, I turned to him and pointedly asked, “Is your wife's need to be listened to a valid one?” Put in this strategic manner, his affirming response was all but guaranteed because her need had been stripped of its biting and condemning emotional overlay, its legitimacy laid bare with plain and calculated neutrality. So, expectedly, his affirmative response was speedy and unequivocal. Then, without hesitating, I again responded with a deliberate, co-confirming, “I agree, your wife's need is valid.”

Now, in turn, I directed the same questions at him, first by asking him to clearly identify his needs. Foreseeably, he answered, “I want to be treated kindly and with respect.” Following the same protocol, I confirmed the legitimacy of his need which had just been divested of its own attention-gobbling, counterattacking emotion and was now openly “on parade” for its indisputable validity. Now, turning back to her, I asked in the same manner, “Does your husband's need for kindness and respect seem reasonable to you?” Again, you can guess her answer.

The stage was now set to bullhorn what had become increasingly obvious. Formerly vitriolic and contentious partners were questioning their use of blame and accusation and were now instead marching to the tune of mutual respect.

Moving Forward in Couples Therapy

I’ve been fortunate enough to apply this technique with relative effectiveness, so it has been my experience, and I suspect yours as well, that this purposeful trio of empathy, caring, and genuinely curious question-raising can soften these “marital combatants” to a degree that their cognitive flexibilities and problem-solving skills become more accessible.

Once this appears clear, I drive home the same critical point. “Could you be at odds with each other to this extent over needs that possess little, or no personal significance? And given the in-your-face evidence of the strength of your personal needs and the intense emotions that orbit them, what if we were to carefully examine how you manage them now, and maybe better, how you might more effectively manage them moving forward?”

The demanding work of implementing this strategy outside of therapy certainly belonged to the couple and others like them, but in my experience, these partners leave my office with a helpful set of tools, a cause for optimism, and hope for re-connection.

Questions for Thought

What is your reaction to the author’s approach to dealing with “warring” couples?

How do you address anger and blaming in your own couples work?

Can you think of a warring couple that you successfully helped? One with whom you were not successful and why?

Successful Trauma Therapy Does Not Require Forgiveness

Posted on by Psychotherapy.net Team

Research indicates that forgiveness can positively impact physical and mental health. Yet, few studies explore the impact of forgiveness on trauma survivors. Existing studies suggest that forgiveness can be beneficial. However, these few studies have small sample sizes and are often conducted or funded by forgiveness advocates. If we can’t rely on the research, clinicians must ask themselves, “Does forgiveness benefit trauma survivors as a part of their recovery?” Can CBT Truly Benefit Trauma Survivors? To find an answer, consider this question, “Does CBT — frequently used in the treatment of trauma survivors, benefit their recovery?” The answer is yes and no. Some survivors do, while others do not. The same applies for forgiveness. Some survivors benefit from forgiving their offenders, while others do not. There is no universal treatment for trauma. There is not one intervention that works for all survivors. If forgiveness may or may not benefit survivors in their recovery, could incorporating it into treatment harm them? And by “incorporating” it into treatment, I am referring to those instances when the therapist does so, not at the request of the client, but because they believe it will be beneficial. By “harm” I suggest that survivors could potentially: end therapy prematurely and not resume with a new therapist for years (as seen below in the cases of Marcus and DeAndre) continue to sacrifice their safety to forgive (which April, also below, was able to avoid) avoid, postpone, or try to skip vital emotional processing, which is often necessary for trauma recovery (such as with DeAndre) repeat old patterns of self-sacrifice, or pleasing their offenders to support their safety (continuing the flight, freezing, or fawn response) encourage silence, preventing survivors from embracing their narrative and sharing it with others, which can support recovery interfere with reporting dangerous people to the authorities if needed After 15 years as a trauma psychotherapist, I’ve discovered that when forgiveness is pressured, recommended, or even encouraged, it can cause harm in any of the forms noted above. I assume that many well-intended clinicians believe that trauma survivors will progress in therapy if, and perhaps only if, they forgive. These clinicians may unintentionally cause damage when they advocate forgiveness in circumstances where it doesn’t meet the needs of survivors. “Forgiveness Was Never for Me; It Was Always for Them” Marcus experienced emotional abuse as a child from ages 6-12. His father would scream at him, call him derogatory names, or ignore him for weeks. At age 14, he began instigating physical fights at school and was suspended. Therapy was recommended. When Marcus disclosed the abuse, his therapist encouraged him to let go of his anger by forgiving his father. There was no exploration of Marcus’ capability, readiness, or willingness to forgive. Instead, it was determined by the therapist, the school, and the family that Marcus needed to forgive so that he would stop physically assaulting others. A few months after starting individual therapy, Marcus participated in his first and only family therapy session with his father. Under the watchful eye of Marcus’ therapist, his father gave a one-minute apology for six years of emotional abuse, and Marcus sheepishly replied, “I forgive you.” Since that family therapy session, Marcus was not allowed to express anger directed at his father, mother, or anyone else. When he did, people would say to him, “What are you so angry about? Didn’t you forgive him?” and “It’s time to move on.” Five years later, at age eighteen, Marcus ended all communication with his parents. “Please, don’t ask me to forgive them,” 32-year-old Marcus told me during his first therapy session since he was 14. “Forgiveness was never for me; it was always for them.” “Deal,” I said without hesitation. “We are officially taking forgiveness off the table.” “Really?” “Yeah, we don’t have to focus on forgiveness. What would it be like if we focused on what you need instead?” Marcus looked shocked. He glanced around the room with fluttering eyes. Then, he placed his head in his lap and cried. For the next five years, Marcus learned to embrace, express, and process his anger, fear, and grief. Then, gradually, he experienced authentic forgiveness. This was never the focus of our treatment. Instead, it was an organic result. When he ended therapy with me, Marcus decided not to reestablish contact with his parents, whom he hadn’t spoken to in 14 years, a reminder that forgiveness is not the same as reconciliation. Marcus focused his efforts on the people he believed could provide safe and trusting relationships. “Women Are Supposed to Always Forgive, Even If It Kills Them” April began therapy when she abruptly left her physically and financially abusive husband. It was her third attempt at leaving and what she called “My last Hail Mary.” She moved out of the state with her children and ceased communication with her husband. She worked with an attorney and a case worker to pursue a divorce and full custody. Yet, her family members and friends encouraged her to resume communication with her husband, and at times passed messages along to her from him. They had good intentions. They didn’t want her to return to her husband; they wanted her to experience an uncontested divorce to minimize the financial burden and to participate in co-parenting to support the childrens’ relationships with both parents. When April began therapy, her therapist, who was not trained in working with survivors of domestic violence, agreed with them. In therapy April was encouraged to consider reestablishing contact with her husband to experience relationship closure by embracing forgiveness. Her therapist wanted her to “not have long-term trauma symptoms,” as April recalled. Therapy consisted of April learning coping skills to use when she was ready to reestablish contact with her husband and visualization exercises to help her to be open to forgiveness for the sake of her children. A month later, April ended therapy and all communication with her family and friends. Two months later, her case worker recommended that she work with a trauma-trained therapist, and she agreed to participate in a consultation call with me. “If I talk to him, I’ll go back,” April said in a tone that sounded angry, but all I heard was fear. “If I go back, he will kill me, or I’ll kill myself. You need to understand that.” “I get it. You have no plans to reestablish contact. All communication will go through your attorney or case worker. Is that correct?” I asked. “Yes. It’s like, people don’t get it. Women are supposed to always forgive, even if it kills them.” April agreed to try trauma therapy with the understanding that she could end treatment at any time. She didn’t. Instead of reestablishing communication with her husband and seeking forgiveness, April’s therapy focused on establishing safety. With a trauma therapy recipe consisting of EMDR, Somatic Experiencing, Internal Family Systems work, self-defense classes and support groups, April learned to create and maintain safety in her new home and city with new friends. Three years later, she resumed contact with a few family members and friends who were receptive to following firm boundaries regarding their interactions with her and her ex-husband. At that time, her ex-husband had ceased contact with all of April’s family and friends, had given April full custody of the children, ended contact with his children and remarried. “I Thought Forgiving Her Would Save Me” DeAndre’s mother would become rageful without warning. She’d scream, mock and belittle her children and damage property. As a result, he developed a fear of anger, as his childhood experiences taught him that anger was an unsafe emotion that should be avoided. He learned to suppress feelings and expressions of anger and was considered an easygoing guy. Yet, his relationships lacked closeness, and at 27 years old, DeAndre began therapy for the first time. DeAndre and his therapist discovered that his anger and fear prevented him from engaging in healthy conflicts, establishing boundaries, and presenting his authentic self in adult relationships. This avoidance caused a lack of vulnerability and closeness, leaving him feeling isolated. DeAndre’s therapist recommended that he engage in conflicts with others to achieve forgiveness. The therapist suspected that DeAndre would feel safer with his anger if he could do something healthy with it, which would be forgiving. As a result, DeAndre became a prolific forgiver. He forgave his mother, his friends, and everyone who had ever wronged him. He didn’t require acknowledgment, accountability, or apologies from his offenders. He quickly forgave them. After a year, he ended therapy because his relationships did not improve, he continued to feel isolated, and thought that people were taking advantage of his easy-going, forgiving nature. Twelve years later, DeAndre was married with children. He began therapy with me to address his lack of boundaries in his relationships. “I feel angry for a few minutes,” he said in the session. “What happens after those few minutes?” I asked. “I don’t feel anything,” DeAndre described. “That’s when I forgive them and move forward.” After working with DeAndre, it became clear that he was not forgiving; he was dissociating. Experiencing anger was so overwhelming that his mind and body could not tolerate it for more than a few minutes at a time. DeAndre and I focused on increasing his tolerance and feelings of safety related to anger. As therapy progressed, he discovered that he was angry at his mother for her abuse. He resented his extended family members for not protecting him. He was also disappointed in himself for being unable to protect his younger sisters from his mother’s rage. “The truth is, I haven’t forgiven her,” he said. “I thought forgiving her would save me from my anger, but it didn’t. It just helped me avoid it for forty years.” Two years later, DeAndre was able to experience anger for extended periods and safely express this anger to others. Once he discovered his anger did not harm others, he could engage in conflicts and establish boundaries in his relationship with less fear. He was now participating in closer relationships with his sisters, wife, and children. When DeAndre ended treatment, he had not forgiven his mother, but that was never the goal.

***

If forgiveness can harm trauma survivors, what should mental health clinicians do? Clinicians should not force, encourage, or recommend forgiveness. Instead, they should allow trauma survivors to decide or discover their needs regarding forgiveness. Survivors might choose to forgive, or they might embrace organic forgiveness. Survivors might choose to withhold, resist, or forgo forgiveness. Some survivors might not be capable of authentic forgiveness no matter how hard they try, and others may wish to take forgiveness off the table. The giving or withholding of forgiveness is a choice that should always be left to the survivor. Questions for Thought What are your thoughts about the author’s approach to forgiveness with trauma survivors? What is your approach to integrating forgiveness into your own trauma work? Can you think of instances where forgiveness helped the client? Can you think of instances where forgiveness did harm instead?

Dreams, Nightmares, and the Key to Successful Trauma Therapy

Posted on by Psychotherapy.net Team

A client of mine dreamt that she had sat so long in the bath that the water had turned cold. While I have heard thousands of client dreams, this one brought me to a realization about how dreams may be graphic depictions of client’s shifting autonomic states — images from and of the body. Far less filtered by our internal censor than waking thoughts, dreams are more image-based, visceral and fluid. Spending time with my clients’ dream images in a calm and curious way has been inherently soothing for them, and of late, I am beginning to suspect why this is so. While many have offered opinions on the nature and purpose of dreams, this notion that they are images the body projects onto the dreamscape has become clinically compelling to me. Nightmares Can Be Most Useful Dreams The late Ernest Hartmann, a celebrated dreamworker and researcher, famously said, “The nightmare is the most useful dream.” This is not meant to dismiss the real distress and terror that our worst dreams can bring. Nightmares are perhaps the most troubling symptom of post-traumatic stress injury and are prevalent in fully two-thirds of those with a mental health diagnosis. The benefit of nightmares is that they represent extreme emotional and physical states, and as such, ones that we can learn the most from. I’ve spent the last few of years investigating the link between nightmares and the autonomic nervous system (ANS) through the lens of Porges’ polyvagal theory. Although I think the implications of this for nightmare formation and treatment are still largely unexplored, I started the ball rolling with the recent publication of an article with an optimistic title: Solving the Nightmare Mystery. In it, I imply that the role of the nervous system is a missing link in our understanding of how to treat nightmares. I have been working clinically with those who experience deeply disturbing dreams for many years. One of the main things I do to help is facilitate the search for, and embodiment of, cues of safety that help alter the dreamer’s perception and experience of these dreams. Clients tell me that this embodied process of dreaming their dreams forward (called ‘rescripting’ in modern nightmare treatment literature), changes how they hold the dream in their body. Typically, the memory remains, but the emotional and physical “charge” dissipates. For example, during the pandemic I dreamt of a woman falling to her death. She is a dear friend of mine with a highly compromised immune system, and it’s clear that the dream depicted my fear for her safety. I worked with this dream and found some hope in the athletic way she leaped onto the roof (before losing her balance). In dreaming it forward from there, she used that virtuosity to land safely. This dream session helped me feel better about the situation, and later she did indeed survive a nasty bout of COVID. Nightmares as Lived Bodily Sensations Nightmares are often quite dramatic depictions of current fear and/or past traumas. There is clear autonomic activation during sleep state shifts for those who experience them frequently. Nightmares are easily recalled, and their impact is tangibly felt, as is the relief one experiences when they begin to fade or shift into a more benign form. In a clinical setting, we can easily track clinical progress for those with intense dreams because when they shift toward more normal dreams, the change is welcome and obvious. In a recent class I taught on the clinical use of dreams, I realized that all dreams might be expressions of our autonomic state, even the quieter ones. A student brought a dream with the central image of a still, dark woman in a tub. She had sat there for so long the water had gone cold. When I invited the dreamer to allow the dream to continue, her impulse was to turn on the hot water faucet, to bring some warmth to the bath and to the woman’s body. At my invitation to enter the dream further, she took notice of the tub itself. It was older, more ornate and beautiful than the one in her bathroom, where the dream was set. I encouraged her to enjoy the details of this tub, and it began to feel like a precious heirloom. Details in dreams that depart from waking reality (called counterfactuals) warrant particular attention. The dreamer’s demeanor changed in this process of warming the bath; her face coloring and smiling as she described making the bath a sanctuary, adding scent and oils, and dipping into the enjoyment of it. Later, she told me, “I continued to experience ‘mini shifts’ in the following days and was able to access and carry the felt sense of the warmth and beauty of the bath into many areas of my daily life. I noticed I feel more present when I bring a sense of aesthetics, a little beautifying and warming detail, to tackling some of the mundane daily tasks which have been weighing me down lately.” The Critical Role of Polyvagal Theory This entire dream process could be seen as an image of the autonomic nervous system (ANS) as described by the polyvagal theory. Porges’ theory updates the former conceptualization of the nervous system as paired opposites that shift between sympathetic arousal and parasympathetic relaxation/shutdown. Instead, the theory suggests that we automatically shift states in a specific order depending on our sense of threat: we move from safety and social engagement to activation in the face of threat (fight/flight), and lastly, to immobility if the threat is perceived as overwhelming. And the theory suggests we move out of these states in reverse order. The woman in the dream followed these steps as she shifted from a cold, immobilized (dorsal vagal) state, into one of animation. The changes were clearly visible on her face. Her fellow classmates remarked on the change as the color returned to her cheeks, and her physiology demonstrated a clear shift into a state of social engagement and warmth (ventral vagal). This kind of shift is depicted in the imagery that arises in working with dreams. For example, the images from nightmares are clear representations of autonomic states. Activation or fight/flight – being chased or engaged in a battle are among the most prevalent nightmare themes. What I am suggesting is that nightmares are the most obvious expression of what happens in all dreams. They are our bodies expressing, in image and sensation, our fluctuating internal state. They are a doorway into its expression, particularly valuable for those clients who have trouble hearing what’s going inside. This brings me to another of Hartmann’s famous statements: that dreams are ‘picture-metaphors’ for our most salient emotional concerns. Sometimes our most pressing feelings are repressed, historic, or fleeting enough that we don’t think about them during the day. But our dreams have an uncanny way of picturing what matters most, even if we have repressed it. Our bodies carry the charge of feelings and memories that are unmetabolized, and these find expression in our dreams. The True Purpose of Dreaming? My sense, which is shared with many dreamworkers and researchers, is that the purpose of dreaming about emotion is not to upset us, but to help us process and shift such feelings. Sometimes, the dreams do this all on their own, like a nocturnal therapist, and sometimes it helps to have another person process the dreams with us. Sharing our dreams and bringing them into company and the light of day helps them do their job better. And increasingly, I’m beginning to think that a large part of their purpose is expressing and regulating the state of our nervous system. However, I need to give the dreamer the last word here. In the example of the woman in the bathtub, the dreamer accepted that yes, the dream did depict welcome state changes. But there was more — an invitation to sink into the beauty and warmth of an elegant bathtub, and a new way of being with life’s mundane chores. In other words, the shift in physiological state is welcome and accurate, but the invitation to appreciate beauty was compelling. And please forgive the very intended pun — to focus solely on physiology and ignore the depth and nuance of dream expression would be like throwing the baby out with the bathwater. Questions for Thought How does the author’s clinical use of the client’s dream fit with your own approach to dreamwork? What might you have done differently with this client regarding her dream? What is your own theoretical understanding of dreams and their “purpose?”

How Mental Illness Protects Clients Wounded by Trauma

Posted on by Psychotherapy.net Team

All persons, those with and those without a mental disorder, exhibit both conscious and unconscious defense mechanisms. Conscious defense mechanisms are organized by, and act in service of the ego and seek to preserve the integrity of the person’s self-image. Unconscious defense mechanisms are organized by the unconscious mind — the mind’s mind — and serve the integrity of the whole person.

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Rationalizations and Reflections

Rationalizations about the symptoms of a mental illness (for one with a mental illness), or about the vagaries of one’s actions (for one without a mental illness), are a form of conscious defense. Reflect briefly on the excuses you make, and you can see examples of a conscious defense in service of your projected or preferred self-image.

In my clinical experience, some persons with a mental illness devise alternate explanations for their diagnosis in ways that help preserve a sense of personal integrity. “I don’t think I have schizophrenia, I am a psychic,” said one female resident at a nursing facility where I provide counseling. “I don’t use the word schizophrenia, I think I have time-travel and mind-travel,” said a male resident. “It’s not right to say I have schizophrenia,” said another woman. “I have PTSD because of the things I’ve heard and seen being done by the government and the mafia.”

If the person admits to the disorder of their mind as an illness, it could imply that they cannot rely on their mind for coherence or integrity, and so feel like a kaleidoscope of fragments without coherence. That would truly be terrifying.

The defensive rationalization might provide an explanation that bestows a special significance to the person—I am gifted; set apart from others, unique, contending with things others know nothing about. Such rationalizations exist in a borderland between the conscious and unconscious mind; they are partly delusion and partly ego repair. Rationalizations are at least partially conceived by the conscious mind, while delusions are sensed as received, and incontrovertibly true; they have the authority of otherness.

Delusions, like defensive rationalizations, tend to serve a purpose yet they may originate from a deeper element of the psyche. Delusions can sometimes offer a glimpse into the working of a broader intelligence within the psyche. Fortunately, we are more than the contents of our conscious minds. We each are served by a deeper source of intelligence and creativity, the unconscious mind that envelopes the ego and seeks to broaden its understanding and foster its wholeness.

Manifestations of the individual unconscious can be seen in dreams, and the power of the archetypes of the collective unconscious can be seen in large social situations—witness the power of the archetype in the world-wide response to the recent death of Queen Elizabeth, for example (I think it is important, though, to view Queen Elizabeth as a rare living exemplar of the four Cardinal Virtues: Prudence, Justice, Temperance, and Fortitude).

Dream-Digging as Archeology of the Soul

Many years ago, I wrote a master’s thesis entitled “Dream-Digging: Archeology of the Soul,” in which I excavated through a stack of journals in which I had been writing my dreams over a 17-year period, examining the appearance and actions of a particular recurring image, that of a snake.

As part of my preparation for practicing psychotherapy, I had undertaken a two year long Jungian dream analysis. Each week I would type — on a manual typewriter with a sheet of blue carbon paper between two sheets of paper, so that I would have a copy — the dreams I had collected that week in my journal and would explore their meanings with the analyst.

Noticing the sometimes-ingenious incursions of the unconscious mind into daily life is not limited though, to dream analysis or to the study of archetypes. One can even notice the protective functioning of the mind's mind in the tragic consequences of trauma with dissociative features. Consider the following examples from my clinical work in nursing facilities.

Hazel’s Front Line Defense

Hazel was a 94-year-old lady living in a nursing facility. She was alert and quite talkative and actively wheeled through the building daily in her wheelchair—and always wore a red terry cloth bathrobe over her clothes. In childhood, she and her sisters were repeatedly sexually assaulted by their father who eventually went to prison for his crimes.

Hazel had an encapsulated psychosis with delusions involving possible threat from demons. She believed that many years ago demons had entered her childhood bedroom through hidden doors, and she claimed that one time while brushing her hair, she saw in the mirror that Satan was in her bedroom doorway. She felt the need to be perpetually on guard to notice and defend against any re-occurrence of demon activity.

Through the unconscious and protective functioning of dissociation, she split off awareness of her father sneaking into her room or looming ominously and projected it as having a supernatural source from which she might thereafter protect herself, if adequately vigilant. Her omnipresent red bathrobe also pointed symbolically as a sort of alarm, a warning about the earlier scene of the crimes.

Lucy’s Isolation as Protection

Similar in many ways to Hazel, Lucy was serially raped by her father and uncles over several years in her early adolescence. Lucy described leaving her body and floating at the ceiling and watching what was happening to her body below during assaults.

Due to severe trauma, she subsequently suffered from mental illness with dissociative features. She rarely chose to tell others of her thoughts and feelings because, “they’ll think it’s just all schizophrenic stuff.’ She isolated herself in her room at the nursing facility, wearing only hospital gowns, and kept the curtains drawn around her bed. She complained periodically that something had gone wrong with her mattress, and that she needed another one or it would make her ill. Lucy believed that she was supernaturally ordered not to wear clothes, and that they would make her ill if she did.

Lucy told me that the men who assaulted her were not actually to blame, because they were under the control of an evil spirit who made them do what they did. Again, we see how the symptoms of wearing only nightclothes and the sometimes-sickening mattress point to the earlier scene of the crimes. Her unconscious dissociative and psychiatric symptoms allowed her to imagine that her persecutors were not responsible for her abuse, and that she might be safe now if she lived within restrictive parameters.

Her goal in psychotherapy was simply to sustain her daily stability with as little change as possible in her daily routines. Lucy described living in her own world, which was more satisfying for her because the outer world had been so painful for her. She viewed psychotherapy conversations as a kind of visiting at the doors of our different worlds, where she could greet me and offer a report about how she was doing in her world.

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The symptoms of mental illness can sometimes seem chaotic, yet while irrational, they may still be filled with meanings, and can point to their origins and to the unconscious strategies that help sustain a broken psyche. As a psychotherapist, I have come to notice and work with the often-clever manifestations of the “mind’s mind” as I have tried to decipher the hieroglyphic language of disordered thinking and acting that has been brought about by trauma, and by the creative efforts of the unconscious to try and manage the destruction.  

Questions for Clinical Thought

Can you think of clients with whom you’ve worked where this perspective might have helped, or may help?

How useful or not are the unconscious mind and ego defenses as therapeutic concepts?