Category: Therapeutic Issue

Dr. Shelley F. Diamond: A Psychotherapist Facing Death

Posted on by Psychotherapy.net Team

How to Tell My Patients

My doctor at first thought my month-long pain was probably heartburn, and I said “No, I’ve had heartburn before, and this does not feel like that.” And she said, “Well, take some Prilosec for a week.” I did that, but the pain was getting worse. That’s when she said, “Well, let’s do some tests.”

They tested my urine and blood, which determined that I needed an ultrasound, and that determined that I needed a CT scan, and that showed I needed a biopsy, which diagnosed pancreatic cancer.

All that was very disturbing, of course—medically and existentially. Once I got that clear information, my first thought was, “Oh my god, I have all my patients!” and my first decision was, “I can’t deal with my personal issues until after I figure out what am I going to do about all my patients first.”

I’ve been a psychologist in private practice since July 1, 2006. It’s been over 15 years. I have a full seven day-a-week practice. I had to deal with all the patients that were currently scheduled and those calling for an appointment.

So I realized I had to come up with something to tell my patients. Each person is different, so how would each of these people need to hear this news? Certain patients do everything over email, including arranging appointments, and I realized—okay, certain people I can tell over email. But some people don’t do email.

I knew I would have to tell some people over the phone, and I was concerned this might cause them harm. One older woman only communicated through phone calls, and I knew I would have to tell her on the phone; I knew that would be the most difficult person to tell. In my own life I’ve been told that way that loved ones of mine were dying, and it felt like a horrible way to hear this news. And I didn’t want to tell anyone via text, so I just sent them a text saying “I sent you an important email. Please read it.” It required juggling several different communication methods.

Some of my patients were going through a bad time in their lives, and I knew I needed to wait a few weeks to see if there was a better time to tell them this bad news.

What I realized was that for most of my people, it would be best to compose an email message that I sent them the day before our scheduled session. I had a template with the first paragraph, and then I customized the rest of it for each person.

Most of the people received the subject line: “Bad News.” They needed to have a heads up so that before they opened it, at least they knew it was bad. It would be helpful for a lot of my people to prepare them to open the message.

Then I started out with their name and, “I have some bad news to tell you. I’ve been diagnosed with pancreatic cancer, and I only have a short time to live.” Then I said, “Please accept my apologies for this abrupt change in our relationship. It hurts me to have to share this bad news. I wish this wasn’t happening.” It was important to connect with them in a human way, because anyone knows this is a horrible thing to have to write.

The third paragraph was, “The only good thing is that I know you have learned a lot in the time that we’ve been talking together. We can still have our session scheduled for tomorrow, but that will probably have to be our last session. In the last session we will review the progress you’ve made, because I don’t want you to forget what you’ve learned.”

Each in Their Own Way

I had to send this to about 40 patients. There were a couple of people that I thought were going to need more than one final session. So, for a few of them, I wrote, “If you need more time we can have another meeting, but let’s see what we can talk about tomorrow.” But no one wanted more than one session. I think it was too painful for everyone. The one last session was so intense that they couldn’t open up again in another session.

They all expressed a concern about taking up my time, and I had to reassure several that it was important to me that we have that last session. There was one person who couldn’t respond at all, and just didn’t show up for the last session. I sent him a message saying, “I understand this was probably too much to deal with, and I have known you long enough to know how you feel, and it’s okay.” And then there was nothing else from that person. I knew he needed me to acknowledge that, because I DO know how he feels. I have several patients that I’ve been seeing for years. He was the kind of person who expressed very frequently, “Oh, I’m so grateful for our work together.” He didn’t need to repeat that, I knew how he felt.

I had a different relationship with each person, of course. Some of them needed to say things in the last session, and some of them didn’t. One woman was inappropriate, in that she had boundary issues. She said, “I looked up your home address on the Internet, and I want to come over and feed you soup, and I want to take care of you.” She had an “I’m going to smother you with love” kind of response. And so I had to make the boundaries clear and told her, “I appreciate your intentions, but that’s just not appropriate at this time.”

With her and several other people, I had to immediately connect them to another therapist. That was the other challenge I had—getting them referrals. Because I knew someone like her needed to transfer immediately to someone else. Luckily with her, I was able to identify a therapist I knew would be good, and she did connect with that person right away. Then I was able to say, “Talk to your new therapist about how you’re feeling. I know you’re grieving, and this is your way of trying to stay connected to me, and I know this is part of the grieving process. This is reminding you of all the people in your life who have died and you’ve lost connection with. There is a lot to talk about, and this will be a good way to connect to your new therapist.”

With some people, I had to help facilitate their taking their emotions and using them to be with someone else, because that I couldn’t do that with them anymore.

I’m taking this opportunity to say a little bit about what I did because when it happened to me, I had no idea what to do. Graduate schools and continuing education need to show therapists how to deal with such situations as I found myself in. It seemed up to me to reinvent the wheel, or perhaps even to invent it. The only good thing was that I was very aware that I had to figure this out. I had an intense feeling of urgency. I just used what I felt with my patients to guide me in sensing what each person needed from me in each moment.

And for people who I had seen for many, many years, I was able to say things like “I know you’re in a stronger place now than you were when we first connected, and I know you have the resilience now to deal with the ongoing challenges in your life.” I needed to reinforce some of the ways that I really did know that they had grown over time. To one person I said, “I know you have more confidence in dealing with the challenges in your life. It’s made me happy to see you grow and change for the better over time. I’ve seen you so many years, it feels bizarre that I won’t ever see you again;” validating the feelings that I knew they would have. I would add, “I’m glad I was able to be there for you during your long divorce process;” “I’m glad I was a witness to your changes in emotional maturity over time;” “I know you’re capable of commitment, and I hope you can find someone else who is capable of that.”

Email communication was good because it’s a document that they could come back to. I made sure that I wrote things to people who I knew used written materials in their process. In their last session, they said, “Oh, I’m going to keep this by my bedside, so I can read it again when I get discouraged.” That’s why I sent them these things the day before, and then in the last session reinforced this again. I said, “Let’s talk about your progress and how we can make sure that this grief doesn’t trigger a relapse into your old unhealthy ways of coping with things.” I said, “The only good thing is I know you’ve made great progress, and it’s been a pleasure to watch you free yourself from all the old patterns in your life.”

People responded with, “I’ve never talked to anybody about death like this before.” In the last session, I would ask them, “Who have you known that was dying or died. What did happen?” And 99% of the people said, “We never talked about it. It was just something that you didn’t talk about. It was always something to avoid as a terrible thing.”

One thing I do want to mention is that when I put my original notice to the San Francisco Psychological Association, with the subject line, “Telling my patients I’m dying,” I received an outpouring of support and messages from my colleagues who were wonderful. People were very kind.

One of my colleagues who responded shared that she had also faced cancer, and that she had talked to her patients and said, “I know that it’s scary to talk about cancer and death.” She added, “I’ve had some very good conversations, and it was important to talk about it, and it was helpful to them…We’ve had some profound conversations.” Her saying that really helped me become more conscious of what these last sessions could be. I realized, this is a therapeutic issue, and I need to think about how this could help them to talk about death. Because before that I was thinking, “Oh my God, I’m causing them harm by having to tell them this.”

I knew I needed to be thoughtful about not causing them harm. But my colleague’s message awakened me to the possibility that this discussion could be a profound therapeutic gift. And that is exactly what happened; I would say 98% of the people had an amazingly deep therapeutic session where they opened up about how talking about death was something they’d never done before. Even the men were sobbing. I’ve never heard the men cry like that before, even the very macho kind. They said things like, “I could never talk to my mother or grandmother like this when she was dying,” and, “I wish my mother had been able to talk about this”—they grieved not getting that opportunity before with various people in their lives.

They were able to talk about our relationship and what they had gotten out of being in therapy with me. And they were able to expand it to the idea of death in general, how we don’t talk about it, and were glad that we were able to do so. Some said, “I’m going to live a better life because of this. You’re helping me realize I can’t take each day for granted, and I can appreciate everything more.” “Because this has happened, I’ve reached out to my family and told them that I needed their support.” “Now I feel more connected to my support people because you’ve given me the courage to talk about this, so I’m going to talk about it more with them. You’re helping my whole family.” People were very effusive and heartfelt. I mean, many were sobbing. The only people who didn’t really cry were a few people from cultures that taught them not to show deep feelings, but I could tell they were shocked and saddened. Everybody was profoundly touched. Some said, “Thank you for being so honest about what’s happening,” and “I had people who died, but they just disappeared, and I didn’t even know what happened or why they died. There was no way to get any questions answered.”

Grokking the Infinite

There’s another kind of pain. I’ve almost died many times from eating nuts. I’ve always felt that I wasn’t afraid to die simply because I’d come so close to it before. It was always an experience of just letting go and surrendering to the process. Because what I learned from that is, don’t fight it, just relax. The best thing always in that situation for me was when I realized, “Uh-oh, I’m having anaphylaxis, and so I might die right now,” was to be as completely physically relaxed as possible, and sort of go into a trance. That’s really what helped me. I would go into what I would call a hypnagogic state, where I was conscious, but it’s an altered consciousness. Like just before sleep, for some people. I really use that time as I’m falling asleep or as I’m waking up, to hold onto that hypnagogic state. It’s an altered state, but it’s a very peaceful state. I always associate that with a dying experience because it feels like it’s between worlds.

I remember one of my early existential experiences, when I went on a camping trip with my family. We were outside at night under the stars. I remember I was with my father and we were looking up at the sky, and it was one of those places where there were no lights, so you really could see more stars than you could at my suburban home. And I remember looking at the sky, and at that time, they had this TV show called Ben Casey, M.D., and in the beginning of each episode a Dr. Zorba would write symbols on a blackboard, and say, “Man, woman, birth, death, infinity.” And I remember asking my dad, “Dad, what’s infinity?” And he just said, “Look up at the stars, that’s infinity.” He said something very simple like, “It goes on forever.”

I looked up at the stars, and I felt I could suddenly grok the idea of infinity. It was like the movie about Helen Keller learning the sign for water by feeling the water coming out of the pump. I must have been about eight years old, and I remember this intense awareness of the immensity of the universe. For a moment I felt it, and then the next it felt too intense, and I shut it down. But I always remembered that moment I did let it in, I could let it in, and it has stayed with me all these years. I can go to a planetarium and feel it in a way I couldn’t feel it when I was a little girl. Now I love to go to the planetarium and be absorbed into that immensity for an extended period.

To me that’s what death is, you get absorbed into that infinity, that immense infinity that our human brains are too small to comprehend, the totality of the cosmos. Humans are probably too fragile and limited to hold the voltage of that infinity experience, and so we have to kind of shut it down to some degree. Because when you really think about how vast it is, it’s beyond our capacities. We blow fuses.

As my Zen friend says, Death really is the Great Mystery. And I’ve always said it’s a mystery what the true cosmos is; I don’t believe we can comprehend it. Every human finds some way of explaining it for themselves, whether it’s a religion or a faith or a philosophy. I just think of it as all philosophy, of what helps them tolerate this ongoing uncertainty, that we’ll never know. We cannot know. But we need to know. That’s what being a human is. We want to know, we need to know. We need an explanation.

My recent experience has been sort of a building on that foundation, in that my experiential reality since I’ve been given this diagnosis is that I have a felt sense of my molecules preparing to disperse. It’s very hard to put into words, but I feel my—that’s the only way I can say it—my molecules are preparing to disperse into the cosmos. There’s some—it feels almost physiological, but it’s clearly a psychophysiological experience—it feels like my molecules are preparing to expand. There’s a sense that something is expanding and opening. Every single cell in my body is starting a journey.

It’s very subtle. I feel slight changes in every level: my body, my thoughts, and my emotions. I had to go through a process of understanding what’s been happening to me. I’ve been writing in my journals, and that’s been very good. In these hypnagogic states I’ve been trying to process, how do I conceive of this? I’ve always been prepared to die, from having had childhood medical problems; for so many years I was suffering a lot, and spent most of my life thinking that I would be so glad when I die and be done with all this suffering. I was always expecting to have no problem jettisoning everything.

But I’ve been feeling very good physically these last five years, and I’m 65 now, so I’m having a different experience, “I’m feeling good now! Oh no, I see why people don’t want to die. I’m having mixed feelings because I just figured out how to feel good and now, I must go?”

Another level of it is being aware that my sense of time has changed. I now live with a time reference point that other people don’t have. I talk to people and I’m aware they’re living in a time structure that I used to live in, and I’m not in that anymore. I’m in a different group now. Over the last five years, whatever happened, I’d think, “Well, I’ll do that someday. At some point I’ll get around to that. If it doesn’t happen this week, that’s okay, it’ll happen at some point soon.” I can’t use any of those reference points now.

I’m very glad I had those experiences with anaphylaxis from exposure to nuts, because I know I’m so much better prepared for what I’m going through than someone who’s never had that. And I can tell from talking to other people, the way they are imagining what this would be like is so different. It’s been interesting to talk to people. Some people say things like, “So now you know you’re going to live less than six months, do you have a bucket list? Are you going to go have fun and do whatever you never got a chance to do?”

No Bucket List, Just Gratitude

No. Number one, for my whole life I did everything I wanted to do because I knew I might not live very long. I’ve always done everything I wanted to do. I was never waiting for retirement to do fun things. That would never have occurred to me.

Number two, I have so many things I HAVE to do right now, I don’t have time to go have fun. I’m grateful that I am not going through any medical procedures, because the only suffering I have is pain. Other than that, I feel fine. I can do everything I want to do. My mind is sharp. I’m in charge of everything that’s happening. I’m juggling ten different things. I’m juggling attorneys, and accountants, and doctors, and who’s going to help with my patient files. I’m juggling so many different projects that I probably wouldn’t be able to do if I were sedated or going through some sort of medical procedure.

Another thing I am grateful for—and I spend a lot of time writing about what I’m grateful for—is that I am still mentally fine right now. I didn’t add more side effects from medical problems to my suffering. I have had a certain amount of time to get my affairs in order, for which I am truly grateful. Some people get this diagnosis and they’re dead in a week or other very short time. I’m grateful, I’ve had months, because when I first got the diagnosis, I thought I’d better act as if I were dying next week. “You better get into gear, overdrive, because you may be dead in a week. You have no idea how much time you have.” And so I’ve been very, very active, as much as I possibly could, from the day I got this diagnosis.

I’m grateful that I have lived as long as I have, because I thought I was going to be dead before I was 20. My father died when he was 60, and at the time I thought he was an old man. I was 19 when he died. At the time I thought that at 60, a person is old. And I remember people saying, “Oh, your father, it’s such a shame he’s dying at 60.” I thought, “What’s he going to do after he’s 60?” I remember I didn’t understand why people thought that was a short time to live.

For resources I recommend an organization called You’re Going to Die, which does public gatherings where people talk about death. They tell stories, sing songs, read poems, and they share whatever they need to talk about in terms of an awareness of the fact that “you’re going to die.” I think they are a beautiful organization. They’re here in the San Francisco Bay Area. During COVID they are doing it over the Internet, but they did do them in person.

They have a little coin they give out. On one side it says “You’re going to die,” and on the other side it says “You’re not dead yet.” The whole point of it is to raise your consciousness to be aware that yes, you’re going to die, and we need to be able to talk about the pain of knowing that is going to happen, but we want you to be aware that you’re not dead yet. You need to have both so that you can be present in the moment in a more helpful way.

I also recommend the Ernest Becker Organization (ernestbecker.org). He was a cultural anthropologist who wrote the ground-breaking Denial of Death in 1973. Another resource is Death Café (deathcafe.com), which I have attended in the past.

Thank you, dear readers. I will just say goodbye for now. I hope to encounter your spirit again.

Shelley Diamond, PhD
San Francisco, California, USA
 

***
 

Editor’s Note: Dr. Diamond closed this conversation by sharing the 2019 poem “You Will Lose Everything” by Jeff Foster, noting that she had shared it with people who said it was helpful to them. It begins with “You will lose everything” and ends, “Loss has already transfigured your life into an altar.”

This article was excerpted from a conversation between Dr. Shelley Diamond and Dr. David Bullard on January 23, 2022. 
 

In Praise of Termination

Posted on by Psychotherapy.net Team

I don’t think I’m the only one, at least I hope not, who feels an immense pressure to produce a “win” with every client. I feel like I owe clients a positive outcome and if I’m not able to produce, then I’ve let the client down. This pressure leads me to put the blame, if that’s the right word to use, on myself. If the client is struggling in any way; if they aren’t seeing results; if they aren’t motivated; if they aren’t putting in the effort to complete their homework or follow the steps in their treatment plan, I am the one who failed, according to that lingering, irrational neural circuit. All that changed after one fateful conversation with a colleague.

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I remember unburdening my woes on a colleague regarding a couple I was working with. I told her that every week the couple would spend their time complaining about each other. We would discuss their relational problems ad nauseam, inevitably arriving at the same place when they would proclaim some version of “If only we could just do X, then everything would be better.” They would get so excited, and I could hear their thoughts as if broadcasted; this idea was their silver bullet. The excitement was palpable as they left the office with an action plan, only to return the next week to tell me they hadn’t done anything we’d discussed. This pattern repeated week after week. I found this baffling. But, as I told you, the reason had to be that somehow I dropped the ball. So each session I’d go into overdrive and dissect what didn’t work and strain every last neuron in that circuit to come up with yet another dazzling idea, which, as you guessed also wouldn’t work.

I finally finished telling my colleague about the couple and downloading all my feelings when she looked at me and said in a matter-of-fact tone, “You’re way more patient than me. I would have fired them long ago.” “Huh?” I replied. Fire my client?! I had never done this or even considered this as a possibility. As I asked her more questions, she explained that when you have a client like this, the problem may not be you, or even them. Maybe the timing isn’t right. Maybe they aren’t in a place to make change. Maybe it’s easier to dream about change than actually doing it. Maybe the fit isn’t right and they would be better served by another clinician. Or maybe I needed to draw a line somewhere, and tell them that I could no longer work with them if they were not willing to follow through.

My colleague was making this pretty clear, but I honestly needed her to spell it out for me. She told me to make continuation of the therapeutic relationship contingent upon their completing their homework. If they said they would commit to a date night once per week, then I needed to raise the stakes and make doing the date night actually matter. They clearly valued coming to therapy every week since they were willing to pay for something that wasn’t producing the results they allegedly desire. The fact of the matter is, she went on to explain, that there could be a hundred different reasons why they weren’t actually following through, but in the final analysis, I was not doing them any good by smoothing over their failure to complete the homework or follow through with other therapeutic suggestions.

Yeah, I had to sit back in silence and take a few minutes to digest this. My first thought was, “Well, isn’t this kinda mean? Or, at the very least, won’t my client think I’m being kinda mean?” My colleague disabused me of this idea rather quickly. Holding my client accountable does not have to be a mean thing to do, nor does it mean that I am being so. This can be done in a very professional and respectful manner, and even in a way that may at some later time lay the foundation for real therapeutic progress—you know, planting seeds! Besides, I would hold myself to no less of a standard. I would not let myself off the hook if I committed to something and then never followed through. So why the double standard? Why do I look the other way with clients, but not with myself? Further, my clients most likely hold themselves to this standard when outside the office. So, why the double standard? Why do they look the other way when it comes to their relationship?

This question was very challenging, but incredibly helpful. I went back to my couple, nervous but motivated to put these new ideas into practice. I let them know, respectfully, that I noticed a pattern of them not following through on homework. And that if they wanted to continue working with me, we needed to agree that doing so was dependent upon their completing homework. My heart was in my throat when I said this, but to my surprise, they had little to no pushback. Despite their agreeing to the terms, the next week they had not completed their homework. As I said I would, we decided to wrap up therapy.

Fast forward a few weeks.They called me asking if they could come back, but they said this time would be different. They would not only agree to the homework-related conditions for termination, but they committed to actually doing their homework. Suffice it to say, they did, and the change they so badly wanted started materializing.

***

In reflection, I learned a lot from this couple and from my colleague’s insight. This lesson has stayed with me and affected my work with virtually every client since. I no longer place immediate blame on myself for clinical failure (although I do reflect often on how I can do better). Rather, I am more broadminded when things aren’t working. I’m more open to the option of terminating the therapeutic relationship, and, in fact, I see it as a potentially important step in the healing journey of some clients. I share with my clients that termination can be an act of empowerment. If the client feels like they aren’t getting what they need from a therapist, they should not feel beholden to stay for the therapist’s benefit. Instead, I encourage clients to broach the topic of termination, to explore other options, and to find what works for them, as I am now in the habit of doing.
 

Whose Exposure Is It, Anyway?

Posted on by Psychotherapy.net Team

My guess is that most therapists, even if neither trained in or actively practicing CBT, are familiar with the technique of Exposure with Response Prevention (ERP). Simply put, it is one in which the client, typically struggling with OCD, is systematically exposed to thoughts, objects, images, or situations that fuel their anxiety, which in turn triggers their obsessions and compulsions. As they are guided through the exposure scenarios, which can be imaginal, “real,” or more recently through the use of VR technology, they are provided with alternative skills for coping with and reducing the triggering anxiety. Over time, the anxiety diminishes, as do the obsessions and compulsions.

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I had been working for a relatively short time with my newest clinical supervisee, S, who shared a heartrending account of a childhood scarred by parental instability and early sexualization, profound feelings of vulnerability and insecurity, and his subsequent trajectory beginning in adolescence along a painful path of sexual compulsion and risk-taking behavior, including high-risk sexual hookups with strangers.

This was quite distressing to hear, considering that he was working in a treatment facility with highly disturbed clients, half of whom were referred for “mental health” issues and the other half for substance use disorders. Triggers abounded for this emerging clinician, who thankfully and much to his credit was simultaneously receiving counseling, attending Sex Addiction Anonymous (SAA), and supervision with me.

And then came C, an attractive, thirty-something, HIV-positive client with an early family history not very different from S’s, and who like him was a self-described “sex addict,” was involved in a BDSM relationship with someone considerably older, who worked in a sex shop much like the ones S historically frequented, and who also sought sexual hookups with strangers like he had (up until only recently).

While my primary obligation was to my supervisee, I was also technically accountable to his client. And in light of the similarity of their early adversities and subsequent behavior, I was compelled to carefully monitor what I considered to be the inevitable emergence of countertransference.

As a clinician, clinical educator, and supervisor, I am familiar with the many manifestations of countertransference, especially among freshly-minted therapists and those who may not yet have met, let alone confronted, their own demons. And I know that although clinicians sometimes benefit psychologically from their work with clients, there is a powerful edict in our field that says, “thou shall not use your clients for self-healing.” But it happens, and sometimes, as they say, the universe sends us the clients we need, although it remains important that the clinician not use or exploit the therapeutic relationship for their own psychological gain.

At the outset of his work with C, and much to his credit, S immediately recognized similarities between his and his client’s story and problematic behaviors. He knew that a minefield lay ahead, saying to me, “My mind was racing 100 miles per hour when he told me about his life.” C was the kind of person—young, attractive, needy—that he might have hooked up with on the outside, although he very quickly recognized that crossing this particular boundary would be career suicide and would leave everyone devastated in its wake. While he wasn’t concerned that he might cross that particular line, S was deeply concerned that his client would trigger him to act out in his own life, so had to be vigilant for feelings and thoughts that heightened his own anxiety and which were historically triggers for his compulsive use of pornography and search for hookups. I was very relieved that he had broached this difficult topic with his own therapist, was sharing it with me in supervision, and had been attending a local SAA meeting.

Along this path of inquiry, I have conceptualized S’s treatment of C as his own, rather than his client’s exposure with response prevention (ERP). In this case, the ERP is not being used directly, or even consciously, in the service of the client’s sexual obsessions and compulsions as it might otherwise be, but instead as S’s own means of monitoring the triggers that the therapeutic work has evoked, and thus as a way to mitigate the impact of those triggers within himself so he is able to control his own sexual obsessions and compulsions. While I initially thought it might be more effective to keep this insight to myself, I decided that sharing it with S might aid the supervision, and in turn positively impact his therapeutic work with C.

And so, I inquired and learned that in addition to his own therapeutic and supervisory work, S was doing some powerful internal work when in the room with C. Like himself, C had survived, albeit scathed, from a traumatic earlier life and had stopped growing in early adolescence. It helped S to conceptualize him as a vulnerable teenager who needed a deeply supportive and empathetic clinician who could relate, although not project. Only in this way could he simultaneously help C to develop more mature, effective, and developmentally appropriate intrapsychic and behavioral coping skills for addressing his own intra and interpersonal challenges. My supervisee and his client, both wounded and fragile in their own right, are growing together.

***

As of this writing, I have yet to speak with S’s therapist and may or may not, but I am very appreciative to know that together they are discussing, among his other issues, countertransference matters and how they are factoring into his therapy with C. I felt and still do that it is my role to carefully explore the countertransference for the purpose of helping S recognize not only the triggers in the therapeutic work, but to become as aware as possible of the ways they impact not only that work but his own personal life.

The Subtle Art of Therapeutic Rudeness

Posted on by Psychotherapy.net Team

Beginning therapists typically struggle with a particular issue that can be the cause of much consternation given that they tend to be “nice” people. You might already know where I’m going with this—therapists struggle with interrupting, cutting off, butting in, or engaging in any kind of behavior with clients that might be perceived as rude.

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Under what conditions would a therapist ever need to resort to anything that resembles rudeness? I could give you a number of reasons, but I’ll limit myself to just one. A client could consciously or unconsciously avoid a certain topic for fear that it will be overwhelming for them, or because they don’t want to own up to something or acknowledge the impact of X on their life. A “nice” therapist will not want to upset their client; they will indulge the client’s avoidance by following the client-led conversation along a subject-hopping surface-level path. But ultimately, this is not to the client’s benefit.

We are not in the business of being nice, we are in the business of healing. And healing can hurt. If I am truly committed to the healing of my clients, I have to be willing to be rude, or at least act in a manner that may strike the client as such—to interrupt their avoidance and redirect their attention, sometimes kicking and screaming, to the topic they are sidestepping. My motivation is not to be sadistic, for I know that those areas that clients avoid are usually those that contain the greatest potential for growth and healing. But by indulging in their avoidance, I potentially infantilize my client. I reinforce the implicit notion that they are weak and incapable of facing the issue. Therefore, I have to notice the niceness tendency within myself and purposely tell myself that what feels comfortable is not for the ultimate good of the client. I then have to step outside of my comfort zone and act out a behavior that in most circumstances would be considered rude. This might include talking over my client by raising my voice and refusing to stop until they relinquish the reins of the conversation.

Now, this is where the art comes into play. When interrupting, I am trying my best to be artfully rude, but never disrespectful. I never denigrate or judge my client. I never put them down or do anything that undermines their dignity. Rather, my rude interjection comes from a place of empathy and understanding. I get it! I avoid hard stuff, too! It’s painful to look in the metaphorical mirror and face yourself. But avoiding the mirror only elongates my problems; it only gives more time and space for my issues to grow. So, if I truly love myself, I must drag myself over to the mirror and force myself to look. I need to love my clients in the same way.

I remember working with a middle-aged mother who had recently suffered a number of setbacks in her life. I remember looking at her and thinking to myself that she seemed so sad. Despite my best efforts to focus on and build up the positives in her life, no footing could be found in anything resembling hope. I remember one session in particular, where she kept talking about her knitting group and one group member’s relationship problems. I asked why it was important to discuss this person and not what was going on in her life. She said she was worried about her friend and was really trying to help her. I kept pressing my client to get a better sense of what she was thinking and feeling.

Over the course of our conversation, it became clear to me that my client felt as if her life was over—she had no sense of a future, and she was just trying to help someone, anyone, before she took her own life. She didn’t say this outright, but I could read between the lines that my client was considering suicide. I felt an internal panic when I realized this. I really liked this client. She reminded me of my own mother in some ways. I also felt a tremendous urge to keep the conversation away from the topic of suicide, to indulge my client’s wish of focusing on her friend in the knitting group. I also knew I could not let her leave my office without assessing her risk level. I took a deep breath, and as kindly as I could, I interrupted her and asked if she had been or was currently thinking about hurting or killing herself. The tears started rolling down her cheeks. What followed was a very helpful conversation that involved a safety plan, engaging with a support network, providing contact information in case of an emergency, and pulling in additional services. The conversation shed light on her under-the-radar risk for suicide that had developed over the last few weeks and provided a space for planning and support. That conversation needed to happen.

And I thank the art of rudeness for giving me the insight and words to respectfully interrupt my client and ask a tough question.

On the Continuum of Real to Imagined Abandonment

Posted on by Psychotherapy.net Team

Real or Imagined Abandonment

Real or imagined abandonment. I read the words out loud in time with my ex-fiancé Dan’s index finger as it moved along his computer screen. The DSM pages that had been all too familiar to me since graduate school felt like a loved one’s obituary following a car accident. The term borderline personality disorder has fit many of my clients over the years and, at the risk of sounding cliché or contrived with “some of my best friends are,” well, some of my best friends have shown signs of BPD. And I have experienced these signs in myself. While my long-standing self-diagnosis of Complex PTSD has often felt like a badge of honor, attachment issues have always been my true Achilles heel. The dull ache of a relationship’s potential for derailment and deterioration has been etched on my mind and present in the throbbing headaches that often settled between my brows. Headaches and worry became as familiar—and as distressing—as red lights and waiting in line.

A glass of ice-cold water in the face could not rival the moment when the man you love asks you to read the word “abandonment” in conjunction with all the associated components of borderline personality disorder, the condition that is the zenith of the experience of pain-by-abandonment. BPD is a testament of pain. Just the phrase stirs in me that same kind of sadness as whenever I look at old family photos, watch the movie Of What Dreams May Come or listen to the song “As Tears Go By” by Marianne Faithful.

My whole body trembled as I forced myself to remain standing steadily enough to continue reading the rest of the diagnostic criteria out loud. We were technically in his living room, which sometimes felt like our living room, standing in the aftermath of one of our all-too-regular fights.

My tears, the white flag of surrender, bonded us. Again. I fell into the warmth of his familiar, coffeeshop-scented Saturday sweatjacket and strong heartbeat as his arms tightened around me, his hands first locked on the middle of my back, gently patting me until finally finding their way to my face in order for him to gently pull the hair away from my tear-bleached eyes until those tears finally stopped.

After a childhood derailed by my parent’s and stepparent’s drug use, along with the twists and turns of moving in and out of assorted relatives’ homes, I had earned my black belt in therapy patienthood by the time I was twelve. And while my vocational pathway was not a carefully pre-planned collaboration but a mystery left for me to solve on my own, I condensed what I knew of life to that point and studied counseling psychology in order to become a therapist. My torturous family history prepared me well to hone in on the essence of what those around me were feeling and what their state of mind was. My direct familiarity with how invalidation stung empowered me with a stance of caution in my work that, paired with curiosity, became a starting point for my work with clients through which I could offer validation and encouragement. With caution, I could spare clients from the therapeutic experience of being pathologized for circumstances that were beyond their control.

The adages of the shoemaker’s children having holes in their shoes or the hairdresser’s hair never quite looking good always seemed to ring true for me. In my personal life, I could not access my own therapy skill set. The never-ending question “What would you tell one of your clients?” was posed like clockwork by those well-meaning people I confided in during moments when my pursuit of comfort overshadowed practicality.

Understanding another’s life is risky business, even with the best of intentions. As a therapist, I have asked clients struggling with abandonment issues to try to make sense of the very same message Dan was trying to convey to me after our most recent fight as he attempted to quiet my own abandonment fears. Even our own couples therapy sessions, which initially seemed promising, resulted in my pained response to Dan’s distancing, deafening silence; with that, those sessions failed to yield a secure structure for the relationship we had co-created.

Why was Dan immersed in his phone at all times, especially right before and during that very therapy session, why was the therapist not acknowledging this, why did we have a constant rotation of bonded togetherness followed by cold detachment, without any seemingly clear catalyst? Why was this the one relationship on any level that I could never figure out? And, most of all, how could a union hold so much potential and goodness, only for me to then feel fleeting and irrelevant to Dan before cycling back to calm and contentment?

The deeper my intimate feelings for Dan became, the more urgent it seemed for me to safeguard our relationship by vigilantly monitoring its emotional climate—and his commitment to me. Priority one was seeking out potential threats along with warning signs of betrayal, loss of interest in me, or perceived slips in my relational ranking compared with his family, friends and co-workers. While Dan brought me into his family fold and once said he would make me part of whatever he was part of, he also said he wanted to protect me from the meanness of the world. And there was always something about his whiskey bar associations that felt like exactly that—the meanness of the world. I suspected that he interpreted my stance as that of the insecure and controlling female who wanted to dominate her guy’s friend time. I’d argue with him that even a broken clock is correct twice a day, but our relationship security, or at least mine, repeatedly seemed to plummet until my frustration turned to rage, and I was then the screaming woman ranting about a few hours at a bar or a house party planned for the weekend. Validation became too emotionally expensive, no matter how much I wanted to participate in making my point of view clear and appreciated for its well-meaning intent.

My favorite quote in Who’s Afraid of Virginia Woolf, “What we are talking about is not what we are talking about,” always seemed to apply during one of these moments. What I was focused on was not what I was focused on. I had my appointment book, my pen-to-paper lists always at the ready in order to securely defend my position of insecurity. And I had my “tangible and legitimate” complaints. His nephew didn't want us to marry or be in a relationship; Dan treated me differently after his nephew called or they spent time together. His friends wanted to see him often and I wasn’t fitting in, his work was demanding, his mother needed him on Sundays. These were real reasons for stress for me, but they weren’t giving us the real reasons for our seemingly predictable conflicts. Even his fluctuating treatment of me felt impossible to describe, except for my feelings about it. Life was the equivalent of reading accurate directions for finding a building, but still not finding its entrance even after circling the building with a Quonset light overhead.

Focusing on Survival Can be a Liability

“In your childhood, you were forced to live a borderline life,” I once said to a client who responded by saying how true it was. The image of baking a cake with the needed ingredients came to mind. Past events, such as her father not showing up to pick her up from the first grade on his various visitation days and a mother who was always traveling for work, were like toxic ingredients in her upbringing used to bake the cake of her later pain, problems, and pathology.

With similar clients, I have been able to offer understanding and to then use this to set goals, but I could never quite develop the same traction in my own relationship with Dan. With my clients who were trauma survivors, I always felt like there was a clear linear strategy that guided the order of our work—first, build rapport; second, accumulate recent history and present life circumstances; third, explore assets and resources, such as friends, talents, finance, hobbies; fourth, assess liabilities, including symptoms, people, events, debt, health; and last was the hook, the motivation. What was it in their darkest and most painful eleventh hour that motivated them to seek the safety net that kept them from hitting bottom and giving up? Could they share this with me? And could I help them to recognize that I valued this very private and fragile inner faultline they’d given me access to?

For trauma survivors, the asset of being good at surviving and focusing on keeping the safety net secure can also be a liability. I have to carefully keep this in mind with my clients. The risk is that the frame of therapy, along with my validation of their status quo and past pain, can become too much of a lifeline. If this happens, a client who is accustomed to getting by on little comfort and relatedness from others may become too comfortable to take social and emotional risks outside of therapy. Here is where the balance of minimal confrontation over avoiding fun or healthy risks must be met with continued acknowledgment of their survival skills and circumstances.

Cindy, my smart and savvy managing director client, was often reluctant to go to her company's happy hours. She emphasized how different she felt from her coworkers because of her family background. She resented the feelings that came up for her whenever others spoke about their lives but, at the same time, she hated feeling alone. Curiosity about others helped create an emotional bridge strong enough for Cindy to give the happy hour—and others—a chance. While she didn’t find much to feel compassion about, she continued acting curious until doing so took her focus from herself and onto the social world around her. Cindy liked this feeling. We named it “Moment Therapy.” We then established a Moment Therapy Quota, where she scheduled three moments per week where she would attend an event that she could bring curiosity to, and through which she could begin to cross the bridge to a safe connection.

Sacrificing Sanity for Connection

My client David wanted his wife to be on his team. He often returned home well after dinnertime, which was upsetting to his wife and led to conflicts. He felt distanced from her at those times but felt more at peace and secure in their relationship whenever he bought her jewelry. Six months into therapy, he described this cycle as one of conflict, followed by estrangement and then presentation of the jewelry, much like a cat triumphantly bringing home its catch of the day to its owner. Then all of a sudden, presents no longer worked. He would try to help around the house, even when he wouldn’t get home until 8 PM, even though his wife was a self-described stay-at-home pet-parent. He always felt like he was failing her until finally, when he would start to give up, she’d turn around and embrace him.

David’s scenario evoked memories of my relationship with Dan, particularly when he would hang out with his friends in whiskey bars. I believed that Dan's relationship with these particular friends was ripe for trouble and fueled my own insecurities, I could just feel it. Being around them made me feel the way I did many years before when I did my internship at a state-run drug and alcohol facility. While some attendees did hard work and were honest, there were also the court ordered system-savvy patients who offered little more than mock compliance at best. The whiskey bar hangout of his friends was a breeding ground for gambling and other so-called hobbies that pair accordingly with sinister people masquerading as friends. Some of the whiskey bar guys were okay, some very likable and even charming, but the setting was rough and some of them were rough with it. Dan had an ability to access people with a combination of book and street smarts. This did not include the people from this whiskey bar party-based petri dish. I believed that I had a right, an obligation, to share my concerns with urgency. The problem was that I was a one-trick pony. My mind had its doctorate in domestic trauma, but not in the imperfections of regular life. I couldn’t communicate to Dan my concerns with an emotional delivery that didn’t push him away.

With my clients such as David, I easily described their behavior as blocking old punches in real time. They typically appreciated and quickly understood this phrase and worked on compiling a weekly list of such events where the analogy applied. Many eventually learned to recognize their pattern of reacting from past conditioning as if it were happening in the present. We would then work on finding the similarities within each event and then the meaning—the core essence that they were responding to. Once my clients demonstrated security in feeling validated and were comfortable challenging their impressions, we questioned the meanings they assigned to the events and wondered together if they could be exchanged for other, less destructive interpretations. Did the original meanings still feel accurate? Or were past meanings from past events being recycled, like a hand-me-down-sweater from a relative that never quite fit and nevertheless compelled wearing during visits from them?

The Illusory Promise of Diagnosis

While I permitted Dan to highlight my flaws in our review of the DSM, I remember having fantasies in which he underwent psychological testing which would provide us with some insight into his behavior and relational style and move the focus from me to him. Dan and I would sit holding hands as a team, ready to face the results as the psychologist spoke. In the calm of this fantasy office, the psychologist would reveal a truth about Dan that lay hidden from him and me that would explain so much about our quixotic relationship and offer it hope for survival.

Asperger’s Disorder—Marked impairment in the use of multiple behaviors such as eye-to-eye gaze, facial expression, body postures and gestures to regulate social interaction, a lack of social or emotional reciprocity. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest. A psychological diagnosis is an odd thing to wish for anyone, let alone your significant other. But more than anything, I wanted answers for why Dan felt out of reach when we were together, why even our phone calls could deteriorate into mini verbal landmines, and why I couldn't somehow find some way to get us to have a shared emotional experience, a mirrored sentimentality of love and life or home and hearth. Something so seemingly trivial as a kiss outside a restaurant where we had just had dinner could be risky. I would be heading home, and Dan wanted to stop off at the bar. I’d make a silly, playful comment about parting being such a sweet sorrow, and Dan found it irksome. Finally, I’d call him out for not caring. “It's not true, Pamela.” That's what he would say to me whenever I accused him of not loving me or wanting me. I missed him much of the time even when we were together, and somehow, I would blame myself in the process. After all, it was me with the diagnosis, not him! Yet when he would leave to meet his friends, I felt like the warden helplessly watching a prisoner escape. I wanted something—anything—a diagnosis to make our reoccurring disconnect make sense. I wanted a diagnosis to take on wearing the hat of the culprit. I wanted a diagnosis to blame, something instead of Dan and me. And though I had my own challenges to still work through, I wanted the diagnosis to belong to Dan.

In retrospect, and into the present, the clarity a diagnosis promises is illusory because ultimately, we all find a way to do what we want in life, especially within our closest relationships. Actions speak the loudest, by themselves. Under the refracting and distracting prism of diagnosis, explanation, or etiology, as we professionals call it, still falls woefully short of explanation. Emotional matters like attachment and love cannot be solved solely by looking at someone’s actions or solely through the lens of a diagnosis. Even combining a person’s actions and their diagnosis doesn't promise all the answers. Nothing can offer that promise, not even time.

Sometimes a diagnosis is validation, affirmation, confirmation. Sometimes, a diagnosis tells a patient, “You've been heard. And here is tangible evidence.” In working with couples, if we all get on the same page as to agreeing about the specific problems and, if then, each is capable of articulating the other’s point of view as well as their own, then we can effectively talk about symptoms of a disorder and what each is experiencing. The result is a combination of mutual personal responsibility and empathy.

Jane felt anxious every time Ben didn’t call on time. The two had recently married after a year of dating. Both were in their early forties. It was Ben’s second marriage and Jane’s first. On the heels of Ben’s ultimatum that Jane seek therapy, she called me for an individual appointment. Following an initial double session, per Jane’s request, I scheduled a session for both her and Ben.

The two sat together on my couch and eagerly faced me. They looked prepared, Jane wide-eyed and Ben holding a notebook and pen. Jane was clear that she was looking for understanding from Ben about her recent behavior, however, she then said that even she didn’t fully understand why she did the things she did. Her latest self-identified “stunt” was shutting off her cell phone and checking into a hotel room when Ben failed to call as scheduled. Jane had waited an hour for Ben to break from hanging out with his friends. By the time an hour passed with still no phone call, Jane made herself unavailable until the middle of the night when she came home.

Ben was not experienced with therapy, but said he was open to trying anything in order to save his marriage or come to terms with another divorce. The last part of his statement led to a marked change in Jane’s physical appearance. She became almost feral, in what seemed a ready- to-pounce position. I let the therapeutic silence communicate my acknowledgment of what Ben said and how Jane reacted. Each looked uncomfortable but ready to continue, waiting for my lead.

We agreed that the initial goal was for Jane’s experience of Ben and life in general to be understood—not declared right or wrong, sustainable or not, but solely to hone in on uncovering what her life and her interactions with Ben felt like. We agreed that our focus did not mean Ben was less important or was exempt from responsibility for contributing to their problems and that, in time, we could shift the spotlight to him. We also agreed that I could take license to use psychological material to help strengthen the meaning of what we would be uncovering. They accepted my request to be seventy-five percent clients and twenty-five percent psychology students, learning terms and doing assigned research online.

Fantasy (and Reality) Therapy

Many people plan fantasy vacations, ones that they never take but experience internally at the mere sight of a palm tree or the fleeting sound of notes from a favorite song. In my mind's eye, I used to picture a therapy session that never happened. A session where Dan went alone and met with a male therapist about ten to fifteen years older, just enough to earn the status of wise older brother. Instead of the therapist taking a passive position, providing a psychoeducational lecture on boundaries and intimacy or encouraging Dan in an unfettered, free association-driven monologue, Dan would be challenged to explore his own role in our tumultuous relationship and not engage in diagnostic finger-pointing at me.

My fantasy therapy session for Dan would also include his feeling the same pain I experienced whenever that familiar and predictable disconnect occurred, and deeply breathing into and accepting his own role in that painful process. After a moment of therapeutic silence, Dan would be encouraged by the therapist to describe the disappointment he felt when his father was preoccupied with work and his own financial struggles to the point that he was unavailable for his family, and the disappointment when his first wife started working long hours and decided that married life was interfering with her career. Where was the pain, the abandonment that Dan felt from his own father and later his wife? Letting my fantasy tape roll, the therapist would highlight Dan’s experiences of having felt let down by his own parent and, later, his spouse, and how those painful feelings and memories played out in his future relationship with me. Empathy would follow, and we would be freed to have a relationship grounded in mutual understanding and respect, and the relational skills needed to weather whatever storms lay ahead.

***

The most valuable part of the fantasy therapy session with Dan has been the way that I have since then been able to apply it in both my own personal life and in my therapeutic work. I have learned how it is essential to help clients, particularly those in tumultuous relationships, to understand the other’s point of view. How the emotional upset in one must be met not with withdrawal and distancing, but with even greater empathy and attempts to remain connected. I have come to appreciate that raw and deeply pained emotional and angry outbursts can be, and often are, pleadings for acknowledgment, validation, and acceptance. I have also come to appreciate how avoidance and distancing are just as credible forms of emotional expression as anger and sorrow. With these insights, hard-earned through my own subsequent relationships and my own therapeutic growth, I have had more to offer clients who are playing out similar cycles of withdrawal, anger, and re-connection within their relationships. Where I might have previously rushed to diagnose the shut-down client, in the shadow of my own experiences with Dan, I now lean forward with far greater empathy and hope that they can learn to do the same. I have also learned the importance of expressing my own pain whenever the specter of abandonment rears its ugly head in my intimate relationships, and teach my clients the importance of remaining whole, even when feeling fractured.

Taking Care of My Own Mental Health

Posted on by Psychotherapy.net Team

In August 2021, history was made at the rarely visited intersection of the worlds of Olympic sport and mental health. Renowned gymnast Simone Biles intentionally chose to self-select out in an effort to protect her emotional well-being. Wow. Just wow. She respected that she was not strong enough emotionally to be able to perform at her best and decided to support her team from the sidelines.

I often ask myself, “When was the last time that I, as a clinician, ‘sat out’ because it was creating too much of an emotional struggle for me? And what does it mean to ‘sit out’ as a therapist? To not take on a new client? To limit the time I spend in my practice? To block out thoughts of clients when I am not with them? To do less? To be less?” While it may not always seem so, especially when clients are not in crisis, therapeutic stakes are typically high for them most, if not all, of the time. And I don’t want to do less at the cost of the therapeutic relationship, let down my guard or put either my client(s) or myself at risk or in a potentially libelous situation. Yet how this constant pressure to perform at the highest clinical and professional level does impact my physical and mental health.

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Being a caretaker to my patients, my practice, and my own personal and familial obligations requires an ongoing Olympian effort. No breaks, no holidays, no weekends, no sick days. Always on. Always watching. Always watched. I don’t often have the luxury of turning off my mind, letting the next steps or decisions play out on their own. I don’t easily turn off my mind as I am always thinking about the next step or, even worse, what could happen.

I can’t just turn off and not take care of my patients, my child(ren), my family, my job, my house. And I don’t typically ask myself to make big shifts, as they can be too scary and abrupt. Instead, I try to think about changing the way I can more seamlessly (when possible) build in mental and physical breaks. I’m not suggesting that I regularly schedule weekend yoga retreats or hours at the spa. That kind of thing doesn’t work for me, although it sounds lovely. And these activities aren’t realistic for me at this point in my life.

My concern is with burnout, which I have come to recognize in myself in the following ways. It’s not an all-or-none thing, as I may experience variations on these themes at different times:

  • Fatigue
  • Agitation
  • Feeling sad
  • Difficulty formulating thoughts or sentences
  • Struggling to make simple decisions
  • Feeling waves of anxiety without a known trigger
  • Overeating
  • Undereating
  • Waking up in the middle of the night and not being able to return to sleep
  • Not being able to turn thoughts off at night
  • Staying busy and distracted all day
  • Feeling overstimulated—it’s too loud, it’s too bright, feeling over-touched
  • Not being able to start and finish a task
  • Noticing daily routines, like showering, seem complicated and laborious

Shifting My Mindset

As a psychologist who has a strong sense of responsibility, I set unrealistically high standards for what I “should'' be doing on a daily basis. I am often anxious in my attempts to stay on top of it all. I attempt to anticipate and accommodate the needs of my children, family, friends, my employees, and my patients. You could call me an over-functioner. My natural tendency is to give, give, give, and I have a hard time receiving. This mind contributes at times to a feeling of being burned out, depleted, and resentful. These are some of the mental tactics I have tried:

Instead of thinking…“I have to get this done today.”
I try to think…“If I don’t get this done today, I will get it done tomorrow or the next day.”

Instead of thinking…“I didn’t get enough accomplished today.”
I try to think...“I got as many things as I could get done today, and that is good enough.”

Instead of thinking…“I didn’t anticipate that well.”
I try to think…“I’m not a fortune teller, and I will manage whatever situation arises as it arises.”

Instead of thinking…“I can do more.”
I try to think…“I need to stop when my body and mind tell me I’m done.”

Instead of thinking…“Everyone needs me.”
I try to think…“I need to satisfy my own needs first so that I can be there for others. I need to fill my cup first.”

Case Example

I have been working with a particular woman, a mother of two children with special needs whose anxiety mimics mine. Sometimes her anxiety triggers mine. She is often in tears during a session and feels like the demands of her world are many and overwhelming. She is burned out from her daily internal high demands that she believes she simply can’t meet. She feels that she has a “role” and “job” to complete each day, which is to tend to her children, husband, mother, siblings, friends, and her children’s school as a PTA member. Her self-care is forced and difficult for her to implement. During our sessions, I am very aware of how her experiences are very similar to mine, and how difficult it is to help her find good outlets for her anxiety and to help her set boundaries in her life. I often think, “I can dish it, but it’s so hard to take my very own advice.”

Find Boundaries and Set Them

Setting boundaries has always come hard for me when it comes to choosing myself over others. However, I have had some success with practice in saying (and sticking with) practicing some of the following:

  • “Thank you, but I’m going to pass.”
  •  “I appreciate you thinking of me, but not this time.”
  • “Thank you, but that’s not going to work for me.”
  • “That sounds good, but I’m going to take a raincheck.”
I have often learned the hard way that there is no reason for why I can’t do something for myself without apologizing or feeling the need to apologize. I’ve learned that it’s okay to decline joining the PTA committee or whichever school committee I know is going to take big chunks of my time and energy. It’s okay to not agree to host a family event at my home if I know I don’t have the time or energy for it. It’s even okay if I decide not to join the next professional meeting. It’s okay. It’s just okay.

Setting boundaries has also come for me with a ton of guilt. I have come to expect these feelings and so have learned to respect them, honor them, and let them pass. I have resisted the urge to return to the person I said “no” to and change my response. And the more boundaries I set, the more comfortable I have become. It has gotten easier. These have been important lessons that I have been able to impart to some of my clients who are willing to try to be different—for their own sakes. Sidestepping my own burnout has been the payoff. Helping my clients do the same is a bonus.

Data Mining: The Brave New World of Mental Health

Posted on by Psychotherapy.net Team

‘There will come a time when it isn’t ‘They're spying on me through my phone’ anymore. Eventually, it will be ‘My phone is spying on me.’

Philip K. Dick
 

Our smartphones spy on us day and night. They know where we go, who we know, what we buy, what we read, how much we exercise, our vital signs, the meds we take, even our patterns of sleep. So it's no great leap for savvy tech entrepreneurs to hype the idea that our smartphones can be the missing link to better mental health.
 

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Numerous therapy apps are already available. Most were developed for profit, with greatly varying quality, little testing, and no regulation. Commercial apps often push outlandish claims: “Once you download our app, our technology starts to get an idea for how you tap, scroll and type on your smartphone—a new way to measure things like your stress, mental health symptoms, and well-being.” “You can track your measurements in the mobile app, and they’re shared with your clinical team, so they can provide you with more personalized care.” Therapy apps are pretty scary stuff, but it’s the mining of big data sets using machine learning that really terrifies me.

The idea seems so superficially appealing. Machine learning allows computers to analyze huge data sets, revealing patterns too subtle and obscure to be picked up by us mere humans. Promoters promise a brave new world of more rapid, rational, and personalized diagnosis and treatment for mental and substance use disorders. Why depend on error-prone humans when we can substitute the precision of hi-tech data science?

The possible benefits are so obvious.

Tracking how people use the internet might identify who has psychiatric problems even before they become aware of them; might help prevent suicides or violent behavior; might determine risk factors for mental illness; might improve treatment selection; and might be used to evaluate progress and identify relapse.

The hype is so easy to spin. Data mining is an inexpensive way to improve the individual patient’s mental health and the overall mental health of our society. Machine learning can even predict the future—identifying people at risk for later mental disorders, allowing us to intervene to prevent them.

Well, folks, what looks too good to be true is almost never true. In my view, mining big data sets with machine learning to diagnose psychiatric disorder is a disaster waiting to happen.

Why is it so scary and potentially evil? First off, follow the money. Big private equity money is being put into the big data mining startups. This encourages the exuberant “fake it until you make it” hype pumping up future technical potentials and ignoring obvious risks. The main customers for findings of big data analytics will be drug companies, insurance companies, and big healthcare systems—industries that have in common a terrible track record when it comes to choosing greedy profit over patient welfare.

Second, the hype is hype. Screening for psychiatric disorders in the general population has a long and doleful record of inaccuracy, misuse, and misallocation of scarce resources. There is always a huge false positive rate, falsely identifying as mentally ill individuals who have some psychiatric/psychological symptoms, but not at a level of severity or duration to produce clinically significant impairment or to require professional attention.

My nightmare scenario: the worried well will be misidentified as psychiatrically sick and start receiving repetitive pop-ups announcing that their pattern of smart-phone use suggests they may need mental health help. Soon they are flooded with ads promoting therapy apps, treatment centers, and psych medications. An incredible 12% of adults already take psychotropic medication, many without clear indication, often causing more harm than good. Data mining will help dig out an ever-larger pool of people stigmatized by false diagnosis and mistreated by psychotropic over-medication. And meanwhile, services for people with severe mental illness (who desperately do need help) will continue to be shamefully underfunded (because there’s no profit to be gained in treating them).

And finally, data mining digging for psychiatric disorders is an incredible invasion of privacy and a very slippery slope toward a dangerous surveillance state. The idea of an ever-vigilant Big Brother monitoring your every click to determine your state of mind terrifies me and should terrify you.

It is very easy to make diagnostic mistakes, very hard to correct them—and people are often haunted for life by the mislabels they carry. Rather than improving precision, I fear that machine learning will provide a pseudo-precise profusion of mistaken mislabeling. Diagnoses should always be individual, cautious, carefully done, and written in pencil—not based on untried, unregulated, overinclusive, obscenely profitable, computer algorithms.

Thomas Insel on Science, Zip Code, and Future-Proofing Psychotherapy

Posted on by rezendevknowfully.com

Return on Investment

Lawrence Rubin: Hello, Dr. Insel; it’s an honor to be with you, the former director of NIMH, the leading federal agency on research into mental health and illness and author of the recently-published Healing: Our Path from Mental Illness to Mental Health. It’s a rare opportunity for our readers, largely practicing nonmedical therapists, to gain a glimpse into some of the critical issues impacting the assessment and treatment of those with behavioral and mental health challenges. Thank you so much for joining us.
Thomas Insel: It’s a pleasure to be here, and I’m glad that we’ll have a chance to talk about some of the nonmedical aspects of mental health care, which have not received enough attention.
LR: Why do you think that’s the case?
TI:
we have bought into a medical model for how we think about mental disorders broadly
There are two parts to that. I think the first part is that we have bought into a medical model for how we think about mental disorders broadly. And the second part is that the medical model is part of a large healthcare industry, at least in the United States. I don’t know if this is true in other places, but in the United States, healthcare is a massive business, a $3.5 trillion business.

A lot of that business is driven by a particular model which says that illness is due to a singular, often simple cause, whether that’s a bug or a gene or a particular endocrine factor, and that the solution is a relatively simple intervention, often a drug. And that has proven to be really a good business model for the pharmaceutical industry and, to some extent, the medical industry, which has done pretty well over the last four or five decades.

And I must say that for a lot of people with medical problems, this has worked pretty well. I think if you had gotten HIV in the 90s, you certainly were better off than if you got it in the 80s. And if you have cardiovascular disease today, you’re certainly much better off than you would have been 30 years ago. And that’s true now, fortunately, for some forms of cancer as well, where we’re seeing remarkable progress with new diagnostics and new treatments.

the simple bug-simple drug model that has been so effective in the world of infectious disease is really not so effective for the millions of people who have a mental disorder
I just don’t see the same sort of breakthroughs and the same opportunities yet for people who have PTSD, depression, OCD, a range of mental disorders. It feels to me like that medical model has helped some but not enough in the mental health field. Part of why I wrote the book was to try to understand why we haven’t made more progress. And part of that “why” goes right to that issue that the simple bug-simple drug model that has been so effective in the world of infectious disease is really not so effective for the millions of people who have a mental disorder.

A Crisis of Care

LR: You began your time at NIMH shortly after the end of the decade of the brain, when so much research funding was going into genomics and neuroscience. Do you think that we got the bang for our therapeutic buck under your stewardship there?
TI: In some ways! It’s a mixed bag. I think that we learned an enormous amount, but I would say that it’s still very much in process. I don’t think we’ve fully gotten the return on the investment. I think we will, and that science is going to be really critical for us in trying to go deeper into understanding these disorders.

The problem for me was that—and this is just a personal reflection and is not in any way an indictment of the NIMH—but when I look at this state of care and what’s happening for most people, particularly those with severe mental illness, with schizophrenia, bipolar illness, severe depression, severe PTSD, it’s not a scientific problem these people face.

They face incarceration. They face homelessness. They face this massive injustice in a kind of crisis-driven system that actually leads them out of the care system and into these other pathways that are often deadly and certainly unfair, generally punitive, and not compassionate. So, that’s not a NIMH problem.

what we are seeing is this egregious set of policies that lead to people with mental illness going everywhere except into compassionate care because there’s no capacity for that
For me, so much of the sorts of public health problems that we’re facing aren’t really about genes or neuroimaging or the science. It’s more of an almost, and I loath to use the term, but really a social justice issue. And what we are seeing is this egregious set of policies that lead to people with mental illness going everywhere except into compassionate care because there’s no capacity for that.

So it actually had nothing to do with NIMH. I left NIMH and kind of never went back because if you want to address those issues, you’ve got to go someplace else with a very different army. And it’s not the army of neuroscientists and those who are brilliant in the fields of genomics and data sciences. It’s an army that is really willing to take on those big social problems and begin to deal with them.

And I think we know what to do. I think we know how to do that, and that’s beginning to happen. But my goodness, it’s not going to happen through NIMH funding. It’s just not their job. That’s something very different from the world that they’re focused on.
LR: Is that why you said in your book that “there’s a crisis of care for the mentally ill in this country?”
TI: That’s right. A crisis of care. It’s not really a crisis of science. It’s not because we don’t have good research or that we’re not spending the research dollars correctly. I argue, actually, that we probably need more research, more science, more funding for NIMH.

You know, we always need better treatments; we always need new diagnostics. But let’s get real here. We haven’t been implementing the things that we discovered 30 years ago. NIMH spent a huge amount of money in the 80s and 90s on the Nurse Home Visitation Program. I write about this a lot in my book because I think it was just a brilliant investment.

But it’s not a research question anymore. We don’t need to put a lot more NIMH dollars into that. We need to implement this for millions and millions of families who are disadvantaged and who need that kind of support, because we know it works.

At some point, you have to try to solve the problem and not just study it
I don’t want to see us get caught up in this academic cycle of “let’s keep studying this problem.” At some point, you have to try to solve the problem and not just study it, and that was what led me moving from this kind of research career to a career that was much more about advocacy, policy change, about making sure that we were starting to invest in the kinds of services and broad social supports that we need and sadly lack in this country.
LR: Is that related in part to what you also said in the book that for therapists, whether researchers or applied clinicians, that zip code is more important than genetic code?
TI: Yeah, exactly. I think where I ended up, and it’s so interesting when you write a book like this; you think you know what you’re doing, but you have no idea. You usually end up someplace very far away from where you started, and that was exactly the case here.

I started this book when I was working at Google, where I was trying to develop really interesting ways of digital phenotyping. I was convinced that technology was really going to transform mental health care, and I still think that’s probably true. But I ended the book by realizing that the problems that we’re focusing on are really problems of mental health. That’s very different from mental health care. And I have to say, I don’t think I understood that.

When I started the book, every conversation I had about health or mental health was about health care or mental health care. And it wasn’t until I was two-thirds of the way through this, and in this odyssey that I took around the state of California to try to understand why we hadn’t seen more improvements in public health measures like morbidity and mortality, that I began to realize, like, wait a minute, this is not a health care problem.

All this stuff, incarceration, homelessness, poverty, health disparities, is happening way outside of healthcare. It’s actually something very different. We could probably fix healthcare. We could probably do so much better on health care, but barely move the needle for morbidity and mortality.

most of the disparity in race- and gender-based mortality in this instance is really about your zip code
As an example, I was just looking at this over the weekend: the chances of turning 70 years old or living to 70 in terms of life expectancy are at about 82% for White females and about 54% for Black males in the United States. That 82% to 54% disparity is not really a function of what medications they’re on or how many clinic visits they have, or even what health insurance they have. That contributes a little bit, we think it accounts for maybe 10% or 20% of that disparity. But most of the disparity in race- and gender-based mortality in this instance is really about your zip code. It’s about your lifestyle, your exposure, your environment. It’s about a lot of other stuff that’s not really in the healthcare system.

I guess the really hard question to ask, and the one that I’ve been thinking a lot about lately since the book came out is, do we need to rethink what we mean by health care? And specifically, do we need to rethink what we mean by mental health care? Is it really just about medication and psychological treatments and maybe some rehabilitative care? Or is there something more essential that has to do with recovery, has to do with thriving, has to do with wellness? Does that need to come into focus, and does that need to be within the scope of what we mean by healthcare?

Making Psychotherapy Better

LR: Within this context of health care, certain models of psychotherapy have been proven empirically to be effective. So why is there such a disparity between what we know and what we do?
TI: I struggled with that in the book. I start from a perspective that psychotherapy is a really powerful intervention and that we have specific, skill-based therapies that have been demonstrated to work. I also understand that outcomes may depend more on the therapist and the therapy, and that’s always a challenge in any kind of randomized clinical trial that one does on these interventions. But the evidence is pretty compelling for both the safety and ultimately the effectiveness, which is quite different from the efficacy of psychotherapy.

we need to look closely at the training of psychotherapists, how we do it, where we do it, and also when we do it
So the question is, with a treatment that’s so powerful, why have we seen this gap, and why has it become so difficult to actually get it delivered in the way that it should be? I think there are a couple of things. One is, we need to look closely at the training of psychotherapists, how we do it, where we do it, and also when we do it. We’ve had this notion that you train, and then you have supervision for a period after graduate school, and then you’re kind of on your own until your next licensure comes up.

I think we want to look more carefully at how we make sure people get the kinds of skills and the feedback to get better and better. I’ve been fascinated by a company with which I have no connection but am really intrigued by, called IESO. It’s not in the United States, it’s just in the UK, but they’ve really focused on, how do we help our therapists who are online to get better and better?

They’ve built this natural language processing engine so that every interaction between therapist and client is captured. It goes through this engine, and they have a dashboard that shows them levels of therapeutic rapport, levels of effectiveness of their comments, and also the state of play for the client; better, worse, what’s the emotional tone in the interaction? It’s really fascinating to watch.

But what’s amazing about it is that by getting this kind of real-time feedback, therapists have gotten better and better. And when you look at outcomes, they went from 49% recovery to 67% recovery just by providing this real-time feedback, not just to patients and clients, but to therapists themselves. It was actually more useful for the therapist than the client. But ultimately, the clients enjoyed that impact.

So I think part of what we need to do is to think about how we help our therapists to navigate and to improve what they do. The other part is we have to ask, what do we pay for? Are we paying for a number of hours spent, or are we paying for outcomes? Basically, are providers being rewarded for how long somebody stays in treatment, or for getting people out of treatment and getting them well? We need to begin to look at the incentives that are built into the system and ask, are we incentivizing for the right things?
LR: Does this IESO program also include biological markers embedded in the therapist/client interaction, like heart rate, blood pressure, and brain wave activities, to get a complete picture of the reciprocal impact of the interaction? Or is it a glorified electronic satisfaction survey?
TI: No, it’s neither. There’s nothing biological here. It’s really taking language and decoding it. If you think about what we do in psychotherapy, it’s listening, it’s observing, it’s communicating. And through that, we hope that there’s understanding and trust and change ultimately through the relationship.

That process of using language to communicate is a process which has really been revolutionized by artificial intelligence and very good data science through this thing called natural language processing, which was created to try to understand how words got glued together and what coherence looks like in language.

But over time, it’s been used to measure sentiment, like mood, and is now being used to measure how well people are connecting and if they’re communicating effectively. This is a multi-billion dollar industry that’s been taken over largely from the call centers. Call centers are now far better than they were five years ago because of the ability in real-time to decode the communication between two people.

Let’s provide objective evidence about how a therapist and client are communicating and relating and actually literally measure things like trust and measure therapeutic alliance
What IESO has done is to take that same kind of effort and said, “Let’s provide objective evidence about how a therapist and client are communicating and relating and actually literally measure things like trust and measure therapeutic alliance.” And they found ways to define that, which I think are really interesting.

It may not be for everybody, but it is fascinating to me that by capturing that kind of data objectively, they have been able to provide a source of feedback that actually helps people do what they’re trying to do, which is create trust, create the therapeutic alliance, build that rapport. Who would have thought that you would actually do that through technology?

And yet, they’ve demonstrated that this can work without any burden on either the provider or the client. It doesn’t take any extra time. It’s kind of like the speedometer in your car, you know, it’s a part of the dashboard, it tells you as you go how fast you’re going and how you’re driving.
LR: There is extensive research on what we call common factors in therapy, those aspects of the therapeutic relationship that contribute to a positive outcome. This process that you’re talking about sounds like it’s algorithmically mediated. Rather than just asking the client, was trust built or how safe did you feel or how effective do you think your therapist was, you’re interjecting elements of AI into it to give more specific data beyond just the self-report of the client.
TI:  It is. I guess I would just push back with the word “just,” because I think we need both. We need both that subjective experience, like, how was this for you? And then, you know, the objective readout of what does the algorithm say? And it may be in the gap between those two that there’s a lot we can learn.

There’s this really interesting new science that is just beginning to shine a light on our behavior, and particularly on our language in a way that I think will revolutionize psychotherapy
There’s this really interesting new science that is just beginning to shine a light on our behavior, and particularly on our language in a way that I think will revolutionize psychotherapy; it will revolutionize the study of mood, behavior, and cognition. I really think we’re just beginning to see that happen.

One kind of untapped example of this, which I’ve been so intrigued by but haven’t yet seen really developed, is that you can use this natural language processing approach to measure the coherence of speech, because every two words have a vector that attaches them. So if I use the word “dog,” it’s not unlikely that the word “bone,” or the word “cat,” or the word “food” would come up in the same phrase, right?

But the word “algorithm” or the word “church” may not be as easily associated as that. And so by measuring what we call semantic coherence, the likelihood that words could come together or maybe wouldn’t be found together, you get a sense of how people are thinking and how things get put together. In contrast, great poetry often has longer vectors, less coherence.

But as people become psychotic, for example, this is a very sensitive way of picking up thought disorder. And you could say, “Well, yeah, but you could just listen to them and know that’s happening.” Maybe, but how helpful would it be to be able to say, “Well, their coherence moved from 0.6 to 0.74.” Or to be able to provide a tool so that a nurse in an emergency room in a rural community, who really isn’t trained to do a lot of the assessment of thought disorder, would be able to say, “Well, according to this tool, this person’s semantic coherence is about 0.68.”

In understanding thought disorder and psychosis, for example, it provides an objectivity that we’ve come to expect for assessing diabetes or hypertension. It gives us a number which is reproducible and which ties back to something that’s truly actionable because based on that number, you might decide “this person is, in fact, currently psychotic and needs to be treated along this pathway,” versus “this person is a very good poet who tends to put ideas together that are very creative and that are different, but this is not necessarily pathological.” So I think we’re at the beginning of a revolution in our ability to add objective measures to what we are currently and have traditionally done just subjectively.
LR: I can see how that can really be useful in working with people with serious mental illness, like schizophrenia and other disorders with psychotic features. But what about with what we might call more garden variety emotional, mental, or behavioral problems, or even subclinical presentations, where the person is not going to necessarily come to the attention of an emergency room clinician or an algorithm?
TI: Actually, the subjective experience may be what really counts or is far more important. But that’s why I brought up the IESO example, because I think there is an opportunity for technology to improve the quality of what we provide in the psychotherapeutic relationship.

there is an opportunity for technology to improve the quality of what we provide in the psychotherapeutic relationship
It may turn out that we don’t need that. But I think the data would suggest that there’s room for improvement. And, to be fair, there are people who are just naturally gifted as clinicians and who just have the ability to do this without a huge amount of training and without needing many years of experience and probably won’t need that kind of a tool.

But there are a lot of us whom I think would benefit from getting that continual feedback in a way that’s passive and ecological, because it’s done within the hour. It’s not, you know, in a supervisory hour. And it gives you a sense of something that is probably fundamental to the treatment process, which is the development of a therapeutic alliance.

People, Place, & Purpose

LR: This focus on strengthening the therapeutic alliance sounds fascinating and important, but I wonder how, in the shadow of the expanding medicalization of mental disorders, these two pathways can work in parallel. Can they coexist?
TI: I think that’s a really key question, and it’s one that I also struggled with in working on the book. I’ve spent four decades making the argument that these emotional and behavioral problems are medical problems. And I ended up in the book saying, yeah, these are medical problems, these are brain problems, and they deserve the same reimbursement, the same rigor, the same science that we would expect for any other medical problem.

But the solutions are much broader and much different. The solutions are relational, they’re environmental, they’re political. We have to really widen the lens here if we want to begin to have the impact that I think all of us care about, particularly at a population level, and the medical model just isn’t really built for that.

the recovery model, to me, is really defined by these three P’s that I talk a lot about in the book: people, place, and purpose
I talk a lot in the book about—and to be fair, you’re right, this is more about serious mental illness—but I talk a lot about recovery. And I have to say, I was not the person pushing the recovery model. I sort of see there’s a medical model and a more recovery relational model. I think we need them both, but the recovery model, to me, is really defined by these three P’s that I talk a lot about in the book: people, place, and purpose.

If we really want to think beyond just symptom relief and we want to see people thrive, we want to see them recover, we want to see them have a life, then we have to be thinking about more than the medical model. We have to be thinking about, how does someone with a mental illness have a shot at getting the things that all of us want? Social support—that’s the people, a safe environment—that’s the place, and a purpose—a reason to recover, something that they wake up for, something that they see as a mission.

We don’t do that in the medical model. That is not what we mean by mental health care in 2022. And what I’m arguing for in the book and in trying to start this kind of new social movement around mental health is that we just take on a broader perspective that says, actually, we should reframe what we mean by care, and the care should include the three P’s, that providers ought to be able to write a prescription for housing, and we ought to expect Medicaid to pay for a clubhouse which provides the three P’s every day for people with serious mental illness.

We need to think about how we get beyond this simple idea that there’s a magic bullet intervention
We need to think about how we get beyond this simple idea that there’s a magic bullet intervention, that if we get just the right pill to just the right molecular target in just the right patient, we’ll solve this problem, because that’s probably not ultimately the way we solve this problem. It’s going to be actually from multiplexing the problem or thinking about people, place, and purpose and providing a much broader range of care, not a more narrow focus on medication.

Best of Both Worlds

LR: So the medical model doesn’t necessarily, in your thinking, preclude interventions that are social and even moral. You can spend money doing research on biomedical markers and the neuroscientific basis of mental disorders, but you can’t let that steer the car to treatment necessarily. Because if you don’t provide people with these three P’s, then it doesn’t matter what part of their brain or what part of their genome has been somehow disrupted. It won’t matter.
TI: I guess the argument is we need both. I think about psychotherapy as learning to play the violin. You’re learning a skill. It takes time, it takes practice, and it often usually takes a really good teacher. But that’s really hard to do if you have a bad tremor. So, I’d start by treating the tremor so somebody has a decent opportunity to be able to actually learn how to play the violin, but I wouldn’t stop with treating the tremor. I think that is a part of it. You need both, and you need to be able to do both over a long period of time.

our field has been, unfortunately, very fragmented between medical approaches and psychological approaches
And I guess what I feel really strongly about is two things. One is that our field has been, unfortunately, very fragmented between medical approaches and psychological approaches. The science says that the two of them together are better than either one alone. And yet in practice, we rarely see them combined in a way that’s most effective for patients or clients. I think that’s something we need to fix.

But the second part of that is, we often don’t pay for this in a way that it merits. There’s a tendency, I think, by both public and private payers to undervalue the treatments. It often is easier to pay for the medication because, by the way, they’re almost all generic, super cheap, it’s easy to write a prescription, and payers are very comfortable with that. It’s harder to require the combination and to be able to pay for the combination.

It’s so funny, I was just in a conversation about the use of psychedelics. And if there’s one area today where everybody is thinking, “Oh, this is the new…” you know, it’s very hyped. “This is the new magic bullet,” that psychedelics are really going to matter. Again, it’s just one more pill that you can take, and you’ll be able to play the violin.

And yet, what’s so interesting is when you talk to people in that space, they talk about psychedelic-assisted psychotherapy. It’s so refreshing. It’s the first time in 40 years I’ve heard people committed to combining medical and psychological approaches in a way that’s really thoughtful and potentially very impactful. It’s such a paradox, with all the hype around taking the magic pill. That is actually the place where we may find and understand the importance of combining the two therapies.
LR: You said in your book that the term “psychotherapy” is a misnomer.
TI:
the process of change is also a process of neuroplasticity
I don’t remember saying that, but one of the things that I tried to convey in the book is that the process of change is also a process of neuroplasticity. And the idea that there are medical treatments that affect the brain, and then there’s psychotherapy that affects behavior, is really probably grossly simplifying. It’s very likely that the change that occurs with medical treatments partly relates to opening people up to behaving in different ways and exposing them in new ways.
LR: Which changes the brain.
TI: Which changes the brain. And likewise, that going at this from a psychological perspective also changes the way people think, changes the way they behave, which also changes the brain.

behavior and the brain are inextricably linked together in ways that we can’t often see, but we have to accept
To go back to my violin analogy, when you learn to play the violin, you wire your temporal cortex. There’s no way around that. We have to begin to think a little more mechanistically about what actually happens with behavior change and to realize that behavior and the brain are inextricably linked together in ways that we can’t often see, but we have to accept.
LR: So when we consider both the biomedical bases for and psychosocial treatment of mental illness, the brain inevitably changes, hopefully for the better, which then starts the cycle all over again. Complex, yet simple at the same time.
TI: I like that idea, Lawrence. We have to get out of our sort of tribal approach to this. It’s so frustrating, and I kind of understand it, you know, it’s where people come from, it’s their identity, but what if we flip the narrative and say, “What’s most helpful?” What actually helps a 14-year-old with anxiety or a 24-year-old with psychosis? It’s not about our role. It’s not about our skill set, necessarily. I mean, we have to think much more broadly about putting all of the tools in the toolkit together in a way that serves that person in a way they will want and accept it.

Only about 50% of people who should be in care or could be in care and would benefit are actually buying what we sell
We haven’t been very good at that. I mean, even the very fact that we built a care system that’s really built for payers, to some extent, for providers, but not for the consumer. And it’s one of the reasons why I think we get very low engagement. Only about 50% of people who should be in care or could be in care and would benefit are actually buying what we sell.

Bridging the Divide

I think the next decade is an opportunity to say, “Can we meet them where they are?” Particularly for young people. They’re not likely to show up at a brick-and-mortar office. They are likely to be on TikTok or Discord, or now maybe even Twitch. I mean, there are lots of places where you find them. Is there a way to meet them there? Should we rethink the mental health care that we want to deliver so that it’s much more person-centered, more culturally sensitive and adapted, and begin to understand that what we’ve been doing hasn’t really worked for a lot of what we had hoped it would? Yeah, we have great treatments, we have great skills, we have something that really is useful, but it’s not getting the people in the way they want it. Particularly, I would say, for communities of color, LGBTQ communities, I mean, there are just lots of people who feel on the outside and who see mental health care as we built it as not friendly and not matched to what they’re looking for.

This is a place where I think technology can make a big difference. It can help us to democratize care and give people choices that they haven’t had, particularly people who are in rural areas and underserved communities. People who feel that, for whatever reason, they’re part of a small niche in society that’s been underserved. I think now is the time we can say, can we create a different platform, meet people where they are in the ways that they would want to be engaged, and give them something useful?

I guess in some ways, helping people with mental illness is a little bit like what we learned with COVID, where there was this gap between creating vaccines and delivering vaccinations
I guess in some ways, helping people with mental illness is a little bit like what we learned with COVID, where there was this gap between creating vaccines and delivering vaccinations. I think NIMH and others have done a spectacular job of creating the equivalent of vaccines for psychological treatments, for medical treatments, and for people who struggle with emotional and psychological issues. We haven’t been so good at delivering the vaccination part, actually delivering these in a way that people want them and can use them and can benefit. I think that is the challenge for the next decade.
LR: Some psychotherapists work in private practices while others work in community mental health centers. How can psychotherapists, irrespective of where they’re delivering service, be part of this movement you envision over the next decade?
TI:  I think it’s already happening. In my career, I’ve never seen the kinds of transformations we’re now witnessing—and I don’t think that’s too strong of a word, it really is a transformation of this workforce and care system. You have the aggregation of large numbers of private practice psychotherapists into these massive groups, and there are companies that have gotten very wealthy through doing this. Lifestance and Uplift Health are doing a piece of this in several states. It’s very interesting. It’s changing the culture of how people practice. It ultimately will provide them with resources, as they get in group practices that will make their jobs in some ways more effective and hopefully easier.

You also have the advent of teletherapy on a big scale. Last year $5.1 billion was being invested in mental health startups. How amazing is that? You’ve got hundreds of new companies starting off. Eight of them are already unicorns, meaning they’re valued at over $1 billion. You have a company that I find really interesting, Cerebral, that’s a little more than two years old. It started at the beginning of the pandemic. It’s arguably one of the largest mental health care providers in the United States today. They have many, many thousands of providers. They talk about having served 350,000 clients in the last two years.

So, we’re going through this massive change. I don’t know where it’s going to end up, but I would imagine many of the people who are listening, who are in private practice, are thinking about, should I (and maybe they already do) work for Talkspace or Cerebral or Lyra or Ginger or Modern or Better Help. I mean, there’s so many of them that are hiring. In a way, it’s sort of an invitation to a new economy, a gig economy, just like we saw for Uber. People are having opportunities. They have a lot more possibilities of what they can do and how they can spend their time and work.

I don’t know how this is going to end up, but I guess the question I’m asking myself, again, going back to what does this mean for the 14-year-old with anxiety or the 24-year-old—
LR: The kid of color who’s struggling with sexual or gender identity issues, or the suicidal Native American. We have to reach them.
TI: So, are they better off or worse off at the end of this? Or is there no change? I do know that there are now startups that are just for African American male therapists so that African American male clients who are looking for that can find it.

this whole transformation of mental healthcare delivery is probably a play in five acts, and we’re in Act 1
So I think it’s early. I always say this, Lawrence, this whole transformation of mental healthcare delivery is probably a play in five acts, and we’re in Act 1. In Act 1, we’re getting to see who the main characters are; we’re trying to solve the problem of access. And by the way, we’re starting to address some of the conflicts and some of the problems that are coming up.

I think Act 2 is going to be really interesting. I think it’s going to be more about improving quality and starting to find ways of measuring outcomes and all of that. We’re not there yet. It’ll be really interesting to see how that works out.

But what a fascinating time to be in this field! It’s all changing very quickly. In 2027, you know, five years from now, I think we’ll be having a really different conversation. I think the access issue may be largely fixed through the democratization of care and through the fact that it doesn’t matter where you live or what your race or ethnicity or zip code might be, you’ll be able to find someone who can help or someone who has at least signed on to help who looks and talks and maybe even understands you in a way that might be hard to do today. The question will be, can they teach you to play the violin? Do they have the skills and the experience to be able to do this well?
LR: It seems that in order for this revolution, as you describe it, to take hold, to democratize access to care, to reach people technologically, you’d require funding on a massive scale that only seems possible at the federal level. So do you envision that the NIMH 20 years from now will be dedicating itself to this parallel track of implementing what medical science has told us?
TI: Well, the NIMH in 1970 or 1980 would have done that. But in 1990 or 1991, there was a fissure and the federal government created SAMHSA, the Substance Abuse Mental Health Services Agency, and they said to NIMH, “Going forward, you’re like any other NIH Institute. You’re just like NIAID or NINDS. Your job is science. You’re a research agency. We don’t want you to get involved in service delivery. You shouldn’t be thinking about that. That’s SAMHSA’s job.”

The reality is that SAMHSA is still a fairly small agency. The federal government still, it’s changing a little bit, but largely has delegated to states and counties the provision of mental health services. So what you get for mental health care is going to be very different depending on where you live, what state, which county—
LR:  Politics, huh?
TI:
I look at what we’re doing here in California, with $4.4 billion now dedicated to youth mental health
Yeah, but there’s still a large investment. I look at what we’re doing here in California, with $4.4 billion now dedicated to youth mental health, the transformation of the Medicaid system, the development of the Mental Health Services Act—it’s this millionaire’s tax that pays for mental health care. This year that will generate about $3.7 billion for mental health care in the public sector. There’s a lot of stuff you can do and a lot of stuff that’s happening.

I wouldn’t lay this on NIMH. Really none of this is their job. On top of all that government spending, last year we had $5.1 billion coming from the venture capital industry invested in startups. That’s two and a half times the size of the NIMH budget.

So there’s a lot of investment, a lot of money being pushed into the system right now. We just need to make sure it’s going to the right things and that we’re holding funders and beneficiaries accountable for results. So that it’s not just pouring money in and not actually seeing changes in outcomes, which, at the end of the day, that’s what we care about. We want to make sure that, in fact, the rate of suicide is coming down, the rate of employment is going up, kids are finishing their education. It’s not just measuring PHQ-9s [a depression questionnaire]. It’s actually knowing that people are beginning to recover and function in a way that we haven’t been measuring and we certainly haven’t seen over the last 30 years.
LR: As we close, I’d like to know, if such a thing even exists, what do you want your plaque in the NIMH Hall of Directors to say?
TI: Gosh, I have to think about this for a moment. It probably should say something like, “He Served in the Golden Age,” because this was just an extraordinary moment to be leading this research effort and to see where the science could take us in terms of understanding the brain and health and disease.
LR: Thanks so much for sharing your time, experience, and insights with our readers, Dr. Insel.

Reclaiming Our Artistry, One Session at a Time

Posted on by Psychotherapy.net Team

“Who, me, an artist? But I’m not going to drop an album, release a book, or be in a movie anytime soon.”

Yes, you, an artist! Hear me out before you wave this one away, as did Irvin Yalom when I initially posed the question to him at a Psychotherapy Networker conference. I had asked him if he realized how he had taught so many therapists to be artists like himself, when he quickly demurred that he wasn’t really an artist in the way we usually think of it and in the way he admired so many artists himself. In a subsequent communication, he acknowledged the connection I had attempted to make when I posed the question to him at the conference.

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Wait, master clinician Irvin Yalom doesn’t see himself as an artist, either, at least not in the traditional sense or strict definition of the word, or the way in which I am asking you to consider in this essay? That’s right, even the best therapists out there don’t always appreciate the “artistry” in what they do. Sound familiar?

So many of us fail to see ourselves as artists, and yet it’s also crucial so we remain solidly confident and regularly inspired in our day to day work. And don’t even get me started on how it cushions against the rampant burnout happening on both sides of the couch during this pandemic.

We conduct intakes for a reason. We are implicitly asked all the time to figure out the unique music our clients are playing without even having a score or knowing the key, tempo, or composer. Imagine yourself as a jazz player reading the chord changes, making something interesting and musical out of the sadness, anxiety, fear, pride, and desire all trying to express themselves in your client’s unique pain and possibility.

Isn’t this what we do?

Every day, we summon ourselves like actors into the role of deeply imagining and empathizing what our clients are experiencing and playing it back to them, so they can vary it and try on new roles, so they can have more freedom, fulfillment, and hope.

It’s easy for us to see ourselves as authors, helping clients tell their stories more fully, switching back from present drama to flashbacks and, of course, the future dreams they only wish someone could help them see more clearly. What is it that I really wish to happen, and why, like a dream, can’t I grasp it? We write and revise with and alongside our clients, and it’s about time that we see ourselves as the artists we truly are.

Starting to get convinced? Don’t feel bad, even the high-level musicians I work with at the Manhattan School of Music don’t see themselves as artists, either. In their personal lives, that is. As a culture, we lop off our personal creativity from our artistic creativity and only reserve the term “artist” for a small subsegment of the population: painters, actors, musicians, dancers. But this is a disservice, not only to the general public but even more so to we therapists who need to lead the way, showcasing mental health as the art of living life creatively.

Therapists, like artists, make new forms out of old, familiar ones and, better yet, they take liberties and become subversive with them. Think Bansky. His punny painting Show Me the Monet reimagines and refashions Monet’s iconic Waterlilies strewn with toppled grocery carts and a jarring orange construction-site cone. It’s a tour de force commentary of the ways in which humankind pollutes the environment it wishes to glorify and how we overconsume and lose contact with what is most essential. And yet it also echoes and builds on the work of the masters, paying homage to Monet’s capacity to see the beauty in his world and challenge it with his realism. As therapists, we, too, help our clients to both connect and complicate what is both possible and real in their family stories, relationships, and unfolding selves.

We are neurologically built to be artists, as Pablo Picasso once noted when he suggested that all children start out being artists but merely forget as adults. Our right brain’s capacity for imagination, empathy, metaphor, humor, and dreams is the true maestro, to paraphrase writer Iain McGilchrist, and our left brain, the home of our vaunted logic, language, and linear view of ourselves, is the emissary. Albert Einstein once said, “The intuitive mind is a sacred gift, and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift.” Nowhere is this more important and more lacking than in therapists.
We need to reclaim the notion of our work as art and take pride again in the unique music, narrative, and drama that our work produces, and how it changes us, them, and our world, one session at a time.
If not now, when?

Survival Strategies

Posted on by Psychotherapy.net Team

Survival Strategies

Stories have to be told or they die, and when they die,
we can’t remember who we are or why we’re here.
–SUE MONK KIDD
 

A few years ago, I was giving a presentation about mental illness to a group of schizophrenic clients and their families. My hour-long talk included a description of symptoms, medications, and various forms of available treatment. After I was done with my talk, I took some questions, the group had a brief discussion, and we ended for the evening. As I was putting away my notes, one client came up, vigorously shook my hand, and said, “Good job, Doc. You’re just a suppository of information!” He then spun on his heels and left.

At first, I thought this might be a loose association. Then I began to suspect that he was telling me where I could put my “expertise” concerning his illness. Regardless of his true intent, whenever I begin to take myself too seriously, remembering that I am a suppository of information helps me to put things into perspective.

We do serious work. At times it can overwhelm us. Too often we are left to discover the risks and pitfalls of the profession on our own. Therefore, it is helpful to begin training with some strategies to increase our chances of having long and enjoyable careers. Following are a few “survival strategies” that I have found to be particularly helpful.

Don’t Panic in the Face of the Pathology

When I reflect on my past experiences, the clinical situations that have most challenged my ability to remain calm and centered have involved the following:

  • Suicidal threats and behaviors
  • Self-mutilation
  • Child sexual or physical abuse
  • The reporting of traumatic experiences
  • Dealing with a client’s sexual interests and/or advances
  • Bizarre psychotic beliefs

If you are facing any of these, you need to remember survival strategy Number One: Don’t panic! A competent clinician remains competent in the face of these kinds of challenges. Anxiety is the enemy of rational problem solving, and panic leads even experienced clinicians to operate from survival reflexes instead of therapeutic knowledge.

Clients with painful experiences and frightening symptoms are accustomed to living in a world where others avoid and reject them. Our ability to remain empathically connected to them through the expression of their suffering sets the stage for therapy to be a qualitatively different relationship experience—?one where they are accepted, pain and all. Whether they are telling stories of their traumas or acting out their struggles in the therapeutic relationship, remaining centered, attentive, and connected is the foundation of our ability to provide a healing relationship.

Another reason not to panic is more subtle and more profound. Victims of trauma and abuse often find that sharing their experiences is extremely upsetting to listeners, so much so that they end up having to take care of the very people who are supposed to be taking care of them. Many victims report that others can’t tolerate knowing what they have been through and, sadly, this is often true. Victims learn to edit or silence themselves to avoid upsetting others, being rejected, and having to cope with the emotional reaction their victimization engenders. Not telling their story is the most untherapeutic outcome possible. By not panicking, you allow your clients to share their painful experiences, which frees them from slipping into the familiar but untherapeutic caretaker role.

One of my first clients was a young man named Shaun. He had a flair for the dramatic and would stride around the consulting room making grand gesticulations while wrapping his problems in eloquent words. On one occasion, he threw open the window and sat on the sill. He took the cord from the blinds, performed some clever knot making, and came up with a perfect hangman’s noose. He dangled the noose from his hand, swinging it back and forth like an executioner. Every so often he would look over to check out my reaction to his nonverbal communication. Alternately, he would lean out the third-?story window to the point where most of his torso hung outside.

This was my first clinical panic. I thought, “Oh, great, I’m going to be known as the intern with the client who jumped out the window during a session. There will probably be a famous lawsuit with my name on it. How will that look in my evaluations?!” Each time his head disappeared out the window, I turned around to look at the one-?way mirror, behind which my supervisor and other students were observing the session. With the expressiveness of a tragic opera character, I mouthed the word “help!”

In his wisdom, my supervisor chose not to intervene, and Shaun, fortunately, never jumped out the window. I later came to realize that Shaun was testing my ability to cope with his behaviors; he knew he was a handful. He wanted to see if I had the courage and centeredness to remain calm and stick with him in ways that his family and friends could not.

Over the years, I have had to deal with clients showing up at my door with gashes in their wrists, fathers threatening violence because I reported them for abusing their children, and tales of the most depraved human behaviors (the latter while working with victims of political torture and sadistic child abuse). Clients have had seizures, gone into diabetic comas, and experienced long and painful flashbacks during sessions. Although I haven’t always known the best thing to do, I always remember survival strategy Number One – – don’t panic. If I don’t panic, I can think about what is happening and what I can do.

Experience counts. The more you deal with situations like this, the easier it is to stay calm. Part of this is developing a “memory for the future” – – ?meaning that, over time, we become accustomed to facing frightening and dangerous situations, which are followed by conscious problem solving and good outcomes. Repetitive experiences like this form an emotional memory that we have access to in crisis situations and that reminds us that things will work out.

In addition to a growing sense of confidence, it also helps to have crisis – situation action plans prepared in advance. For example:

  • Early in supervision, discuss with your supervisor, in detail, what you should do in case of various emergencies such as when a client is a danger to himself or others.
  • Put emergency phone numbers, including your supervisor’s, on speed dial.
  • Schedule potentially problematic or dangerous clients for times when your supervisor or other backup professionals are present.
  • Alert others around you when you are meeting with a client who makes you uneasy so that they are on alert and can serve as backup if needed.
  • Pay attention to your subtle feelings and instincts about a client and discuss them in supervision

Expect the Unexpected

Never underestimate the value of preparation in being able to successfully deal with crises and problem situations. This leads to survival strategy Number Two: Expect the unexpected. When extreme situations do arise, keep some of the following principles in mind:

  • Don’t catastrophize. A client’s strong emotions such as angry outbursts and uncontrollable sobbing tend to shift in a matter of a minute or two.
  • Maintain boundaries. If a client has a feeling, it does not mean you also have to have it.
  • Stay centered. If you sit calmly, it will provide a sense of safety and calm to your client.
  • Provide structure. When a client is emotionally out of control, it is often helpful to provide gentle but firm instructions, such as “I think it would be helpful if you would sit down and focus on your breathing – – let’s do it together.”
  • Provide hope. While understanding your client’s feelings, also remind him or her that things will get better. Many clients find hope in the fact that you have helped others with problems similar to theirs. Tell them stories of clients similar to them who had positive outcomes.
  • Discuss strengths and resources. It is easy to forget our strengths, resources, and accomplishment when in a crisis. Taking a couple of minutes to discuss these at the end of a difficult session not only provides hope but also yields clues for additional interventions, such as the reestablishment of relationships and activities that have been forgotten during difficult periods.

I received a call on a Sunday morning with a request that I meet a young girl for an emergency consultation that afternoon. When I arrived at my office, I found Sandy slumped down in a chair, looking half asleep and half in shock. She looked so emaciated, her color so bad, that I felt immediate concern for her physical health. Once in my office she told me in an emotionless tone that she thought that she had been raped the night before in a parking lot outside of a nightclub. She was home for a week from her East Coast prep school and had gone out dancing with some friends. As was her habit, she had drunk to the point of unconsciousness, so she couldn’t recall whether the sex she had was consensual or not.

Sandy’s words flowed like water from a cracking dam; she wanted and needed to tell me everything on her mind and in her heart. She described a long history of bulimia, cocaine use, binge drinking, a number of serious automobile accidents, failing grades at school, and her victimization at the hands of numerous boyfriends. Sandy also told me of her loveless childhood and her parents’ sending her off to boarding schools from a very young age. She spoke for almost 90 minutes and I didn’t interrupt because I sensed her need to finally share all of her pain with someone who might be able to help.

Sandy said that she had “half a dozen” problems, many diagnoses, needed to be in several support groups, and felt that there was no hope for her. What had happened to her the night before wasn’t atypical for her; what was different was her feeling of hopelessness and thoughts of suicide. After this, she became silent, glanced over at me, sat back into the couch, and gave me a look that said, “Okay, your turn.” I was so immersed in her story and so impressed with her emptiness and pain that it took me a while to turn my attention to what I would say.

Sandy’s life clearly felt out of control. What I wanted to do was to take all that she had told me and to present it back to her in a way that demonstrated to her that I had heard what she said, understood the depth of her suffering, and could provide a perspective and plan that would give her hope of having a better life. I thought about all she had told me and came up with some ideas. This is what I told her: “Sandy, although it feels like you have many different problems, it seems to me that you have one core struggle – – the need to feel loved and cared for.” I thought that this might be correct because I could see Sandy’s posture change as the first tears poured from her eyes. “My sense is that although your eating disorder, alcohol and drug use, and bad relationships all seem like different problems, they may all be attempts to cope with the loneliness and anxiety you feel every day. Even your car accidents, where you drive your new car into a tree, may be a way to tell your parents something is wrong. With each accident, instead of hearing your pain, they only have another car delivered to your school.”

Having one central problem as opposed to “half a dozen” made Sandy feel a sense of hope. She took off time from school and I began to work with her and her family around issues of attachment, bonding, parenting, caring, and love. Sandy’s family wasn’t ideal for her, but she needed to learn that many of her parents’ emotional inadequacies were not because she was unlovable but because of their own limitations. They needed to learn that their daughter needed more than money from them and Sandy had to learn a healthier way of asking for what she needed.

Having one central problem as opposed to “half a dozen” made Sandy feel a sense of hope. She took off time from school and I began to work with her and her family around issues of attachment, bonding, parenting, caring, and love. Sandy’s family wasn’t ideal for her, but she needed to learn that many of her parents’ emotional inadequacies were not because she was unlovable but because of their own limitations. They needed to learn that their daughter needed more than money from them and Sandy had to learn a healthier way of asking for what she needed.

Crisis as Communication

As with Sandy, crises are often forms of communication–ways of communicating when words can’t be found or aren’t heeded. Many clients struggle with suicide and there are few clinical situations more difficult to deal with. Suicidal acts, gestures, and ideation make us concerned for our clients and ourselves. We are all told that we have a duty to protect our clients, but what is the best way to do this and still preserve the therapeutic relationship and the client’s confidentiality? These are difficult clinical situations that we learn to cope with but never get easy.

Roberta had been depressed for years. She told me that every few years she would try to kill herself in ways that were fairly lethal. Over the years, Roberta had come to understand that her suicidal actions were desperate attempts to gain the love and attention that she never felt she was given by her parents, siblings, or friends. Although it was clear to me that she wanted to live, I was concerned that she would someday miscalculate these calls for help and accidentally kill herself. One afternoon, she came to my office with a clear plan to commit suicide later that evening. As she described her detailed plan of getting a gun, going down into her basement, and setting the stage for her death, I grew more and more frightened. Her description was so detailed, I could vividly picture every stage of the process. I raced through options in my mind: barring her from leaving my office, calling the police, taking her to a hospital, and so on. I tried not to panic, stay calm, and think through the logistics, complications, and risks of these options. All of the interventions that came to mind had been done by Roberta’s previous therapists and had led to her ending each relationship. Was there something else I could do?

Still struggling to remain calm, I asked Roberta what she hoped to accomplish by attempting suicide. As she spoke, it became clear that she wanted her brother to know how alone and hurt she felt. She wanted him to feel guilty for not paying better attention to her. This soon flowed into a discussion of her wanting me to know these things about her inner experience and my empathic shortcomings. Roberta somehow felt that a suicide attempt was the only way she could make me understand the intensity of her pain.

By the end of the session, I had somehow assured her that I understood the depth of her suffering and why she would commit suicide, but that a suicide attempt (as a form of communication) would be redundant to what I already knew. I also assured her that I wanted our relationship to continue and that her past hospitalizations always resulted in so much shame that she discontinued her work with her therapist. Roberta and I made a standard suicide contract and scheduled extra meetings to help her through this difficult time. For me, the most important aspect of this session was my ability to avoid panicking, remember my training, stay in the role of a therapist, and hang in there with Roberta’s experience.

Don’t Try to Reason with an Irrational Person

This is survival strategy Number Three. It will save you hours of wasted energy and keep you from missing the important emotional realities behind much irrational behavior. Although we can generally rely on reason to aid us in finding solutions to complex problems, it doesn’t always work. Some people have such a firm image of what is true that they cannot be swayed by reason. The emotional circuits of the brain are easily capable of inhibiting or overriding rational thought; some clients only see things that fall in line with their prejudices and beliefs. Those fighting with God on their side seldom stop to think about the god leading their enemies into battle.

For a number of years, I worked in a hospital ward with actively psychotic individuals. I saw clients in both individual and group therapy and participated in many ward activities. During a session with a woman named Wanda, I became aware that she believed she was a few months pregnant. In discussion with the nurses, I was assured that this could not possibly be the case and that Wanda was suffering from a delusional belief. It made no difference that the nurses had told this to Wanda; she remained steadfast in her belief that she would soon be a mother.

To complicate things even more, during one of our sessions, Wanda revealed to me that she was pregnant with a cat! I liked cats, but this one caught me by surprise – – I still hadn’t learned to expect the unexpected–and I decided that I definitely needed to do something. I suggested that she bring this belief up in group therapy later that day, assuming that when the other group members heard her story, they would help Wanda to realize the impossibility of her belief.

Based on my suggestion, she waited her turn in group and made her joyous announcement. Although there were some doubters at first, by the end of the hour Wanda had convinced the group that it was possible for a woman to become pregnant by a male cat if the conditions were right. Amazed and impressed by her skills of persuasion, I nevertheless refused to give up my reality campaign. After the group meeting, I asked the nurse to schedule a pregnancy exam so that Wanda could hear from a physician that she was not pregnant. That had to work!

The next week Wanda came back from her pregnancy test just beaming! She told everyone that she had been to the doctor and was happy to announce that her kitten was doing fine. In fact, she had even spotted a few whiskers during the pelvic exam. The group began planning a kitten shower and, under some pressure, I agreed to contribute a litter box. The nurses cried with laughter when I told them about the kitten shower my group was planning for Wanda. They had learned long ago not to argue with Wanda’s delusional beliefs. Apparently, I was not the first intern who had tried to get her to engage in “reality testing.” Wearing a sympathetic smile, one of the nurses suggested that I might have bumped up against the limits of psychotherapy.

We run into irrational beliefs all the time. The chronic alcoholic client will insist he can drink in moderation; the emaciated anorectic client will adamantly claim to be obese. Rather than feeling compelled to impose your reality, sit back and discover what the world looks like through their eyes. Be patient and understanding. As most people go through the process of therapy, they steadily reevaluate their beliefs with gentle, strategic, and well-timed doses of reality. As Wanda demonstrated, “in your face” reality testing doesn’t always work. Even very delusional clients often realize that their reality differs from yours. Your empathic availability may do more to bring them to consensual reality than any rational argument, and it will protect you from feelings of frustration that may be counterproductive.

Instead of trying to impose my reality on Wanda, I needed to learn that, despite her mental illness, she desired to be loving and nurturant. Wanda was coping with other realities – – separation from her family, getting older, and never having children of her own. Her needs to nurture and be fulfilled as a woman were the eventual foci of therapy, as they should have been from the beginning. She needed to take her medication on a regular basis, so she could be home with her family, and her family needed to know how to care for her illness. Perhaps now I would have started therapy by going to the animal shelter and getting Wanda a kitten.

Don’t Forget a Client’s Strengths

After you’ve spent years in classes focusing on abnormal psychology, diagnosis, and treatment, it is easy to see pathology in every action and behavior. But, as Freud suggested, not every cigar is a phallic symbol. Because people are coming to therapy for their problems, it is easy for both client and therapist to get tunnel vision and forget to see the positive aspects of their lives. If your client has struggled with anxiety, depression, or trauma for a long period of time, they may have lost sight of the people, accomplishments, and good things in their life.

In your quest to diagnose and treat pathology, remember that every client possesses at least one strength. Whether that strength is a musical talent, the love of a pet, or a burning passion to ride motorcycles, it may boost self-esteem or motivate change. A desire to see lions in their natural habitat–or to show up a high school counselor who said they would never amount to anything-can be used as leverage to take on new challenges and inspire new behaviors.

Describing resources and strengths may help to put the problems you plan to focus on in perspective. Keep in mind, however, that this needs to be done with great care. You run the risk of having your client think that you are not taking their problems seriously and that you want to avoid their negative feelings. They may actually have a point if, based on your discomfort with their troubles, you try to steer the therapy in a way that communicates to them “just look at the bright side” or “keep a stiff upper lip.” With this caution in mind, try to balance your attention to “problems” with attention to “strengths.”

I have been pleasantly surprised on a number of occasions at the positive results I’ve gained from encouraging (and sometimes even harassing) clients into describing their strengths. I’ve found that encouraging clients to review their past accomplishments, positive relationships, interests, hobbies, and passions will actually lift their spirits. Having them reconnect with activities of interest as soon as possible in the process of therapy can also enhance their receptivity to what is focused on during sessions. When people feel sad and guilty, they often deprive themselves of positive experiences. If you prescribe these as part of the therapy, they may feel less guilty about doing them and rationalize their enjoyment as “doctor’s orders.”