Category: Therapeutic Issue

“Insta” Therapy on Social Media: Caveat Emptor

Posted on by Psychotherapy.net Team

A client whom I had been seeing in couples therapy recently contacted me with an urgent question. She anxiously asked, “Could my husband be cheating?” Catching her breath for the briefest of moments, she explained that she follows various “other” therapists on TikTok and Instagram, so she sent me an email with videos she had viewed from one of their sites. The video was quite concerning to me because the “therapist” did not provide any citations for the material she used and made authoritative, expert-sounding statements about which types of people engage in infidelity. This particular therapist went on, without clear context, to intertwine various concepts from different popular theoretical models. These concepts, which included attachment styles, triangulation, the unconscious, and enmeshment, were drawn from the corresponding theoretical models of Emotionally Focused Therapy, Bowenian Family Systems Theory, Psychoanalytic Theory, and Structural Family Therapy. The resulting statements describing the “typical” unfaithful partner were a discordant patchwork quilt, which from a distance seemed to be an integrated whole, or the blanket prediction a fortune teller might offer—something like “there will be change in your life,” or “you are seeking answers to important questions.” This particular experience, along with other recent similar ones with other clients who have asked follow-up questions about information that they obtained from therapists they follow on social media platforms, has prompted reflection upon some questions related to how social media is the “new self help.” These include:

  • How are our clients to evaluate the credentials of therapists, life coaches, trainees, and even graduate students who post on these social media forums? And, relatedly, what is our ethical/professional obligation (or not) to “educate” our clients in doing so?
  • How can our clients verify whether the content they are reading, and perhaps integrating into their lives, is accurate? And relatedly, what is our role and obligation to help them in doing so, especially if what they are reading is at cross-purposes to the clinical work we are doing with them?
  • What are the clinical implications of having an uninvited co-therapist on our treatment team?
  • When might it be our ethical/legal obligation to report one of these “well-intentioned” clinicians who want to democratize the therapeutic process?
  • How can we explore the influence of these other voices on our clients’ experiences and perceptions? And relatedly, should we? Must we?
  • What is the legal responsibility and ethical obligation of therapists who have followers on these platforms if a person who is not their client follows their “advice” and has an adverse outcome? I have not seen disclaimers on most sites that these sound bites are not a substitute for therapeutic services.
Despite the above concerns, I do believe that there are certain benefits to therapists offering online information and general guidance to their audience, although disclaimers, risks and benefits, and the sources of this information and guidance are important to include. Additionally and once vetted, therapists can offer these sites, their information and videos as they might utilize bibliotherapy or cinematherapy. But in the final analysis, we should both practice and teach our clients the therapeutic version of caveat emptor.

How to Survive Pandemic Pandemonium in Nursing Facilities

Posted on by Psychotherapy.net Team

“We were left too alone at times, in these incubators of COVID at the nursing home, and we experienced true fear, and that fear is still present for me.”
 

“I’ve learned that if you allow yourself to go arm in arm with someone else, you can really accomplish something.”
 

The COVID-19 pandemic has had a tremendously disruptive impact on multiple aspects of personal life and on society across the United States. Yet the impacts in hospitals and in nursing facilities have been especially catastrophic, with shocking numbers of deaths, and severe effects on care providers.

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Nursing facilities continue to experience dramatic changes because of the pandemic. As a psychotherapist providing treatment in these facilities, I lost many therapy clients to coronavirus, as 20 residents died in this facility, 30 in that, and 36 in another facility, for example.

In the spring of 2020, during the early stages of the pandemic and as the level of risk rose, my employer placed us on a temporary furlough. Many workers at the facilities, though, had to persevere in the face of cascading catastrophes. I felt so relieved to be home and to feel safe, yet I felt guilty to not be in the facilities when the need was greatest. I recall the anxiety I felt upon returning to the devastated facilities as I dressed in surgical gown, mask, face shield, and gloves before entering the buildings—something I’d never done before.

Plastic sheeting covered the entrances into some of the units, and at one facility the doors of residents’ rooms were covered with plastic sheeting with a zipper in the middle. A 55-year-old man with schizophrenia unzipped the plastic as I approached and handed out two dollars, asking if I’d get him a soda from the vending machine in the staff lunchroom.

A 51-year-old female resident had recovered from COVID infection and was aware of many fellow residents having died, yet she asked me if I really thought it (COVID) was real—she was strongly influenced by ill-informed and insincere information she’d gathered on TV and on social media, despite her direct experience. Such fearful spellcasting continues unabated, and I, along with my fellow workers have had to rely on critical thinking skills to help dispel, or de-spell, malign messaging wherever it appears.

As a mental health professional, I know that isolation can be kryptonite for persons experiencing mental health issues, and yet, to protect vulnerable persons from imminent danger, we needed to subject them to unprecedented degrees of isolation—weeks at a time closed in their room, months with no dining room, no group activities, and no family visits.

There was an early rise in mental health and behavioral symptoms in these facilities, and then an unexpected phase of collective self-suppression—passivity and apathy—as an apparent mode of coping. I was puzzled as one resident after the next stated that they were “okay” when they were immersed in this unusually unpleasant and lonely and anxious time. Were they okay or collectively experiencing a blunting of affect as an element of PTSD, or a type of useful detachment linked with dissociation?

It is still too soon to measure or appreciate the scale of the impact, as facilities continue to experience occasional positive tests for staff or residents. Many facilities have achieved a semi-normal state of daily activity, yet staffing has been decimated, and the need for new staff persons too often goes unfilled. Many TV and print news reports have described the negative impact of the pandemic on hospital staffing, yet few have examined the erosion of staffing at nursing facilities.

In some nursing facilities in Massachusetts, we have National Guard men and women in uniform performing non-clinical tasks: helping in the kitchen, folding laundry, and mopping floors, among others. It is wonderful that the Governor of the Commonwealth of Massachusetts has provided this support, yet it is shocking to see their presence and to know how much they are needed. Some facilities are leaning heavily on the National Guard’s men and women, and on expensive and budget-busting agency staffers. From where will the much-needed workers be found when the National Guard departs?

I admire the valiant, and exhausted, workers—the nurses, aides, directors of nursing, administrators, social workers, housekeeping, maintenance, laundry, food service, and floor care workers grinding on daily through risk and hardships. Call them heroes and they’d shake their head and roll their eyes—dead tired and just trying to get on with it, they’d say, instead.

It’s a challenge for my employer to hire enough clinicians to cover the needs for behavioral health service at the nursing facilities. Some clinicians seem to shy away from nursing facilities, and too many psychotherapists have migrated to telehealth jobs. We are still awaiting the phoenix phase of the pandemic, the rebirth of a personal and a shared sense of mission, as individuals recover from severe and sustained burnout.

For this article, I asked two questions of several residents and staff persons at different nursing facilities. Their responses vividly illustrate the range of poignant human reactions.

What has it been like to live through this period of pandemic in the nursing facility?

Resident: “It was a life changing situation. I’ve had to learn to survive—through all my mental issues; it’s been difficult.”

Resident: “It’s been frustrating, because of the repeated COVID testing.”

Director of Nursing: “It has been awful, stressful, and heartbreaking. But it was impressive to see, in the early stages, how all the people in the building came together to take care of the residents. I still feel like I haven’t coped with it, like I have post-traumatic stress disorder. I’m getting better, but I’m not yet coping as well as I want to.”

Director of Social Work: “It has been very traumatizing, actually, with so many residents passing away and being urgently sent out to the hospital in those early days of the pandemic. We had residents getting sick so quickly, and ambulance and fire people who wouldn’t go up to their rooms to get them—we had to rush sick residents down to the lobby in the elevator to get them out.”

Social Worker: “There’s been a heaviness about it, with unending changes and a sense of not-knowing every day, and a lot of fear. But also a lot of people who have stepped up with great compassion. We were left too alone at times, in these incubators of COVID at the nursing home, and we experienced true fear, and that fear is still present for me.”

Director of Nursing: “It has been extremely difficult for me, emotionally and professionally.”

Resident: “It has been a mixed experience. On one hand, I received good care from the aides—at least in the early stages, and when I was sick with COVID, and I got good physical therapy, and that got me walking again. I also got a little insensitivity, at times, because the workers needed to take care of their needs rather than mine, or so it seemed.”

Social Worker: “It has been sad, and challenging. We lost so many residents. Two years ago today, I came down with COVID. When everyone was in isolation we used Facetime, and we took photos of residents and posted them online, and the families were very grateful. But many of those pictures turned out to be the last ones of their family members. It is still very traumatic for me [said with a quavering voice and streaming tears].”

Administrator: “It has been extremely challenging and emotional. I’ll never forget family members visiting their loved ones—separated by glass windows, talking on the phone, and crying. It has been life changing, and points out things we often take for granted.”

What lessons have you learned from coping with the pandemic?

Resident: “To be kind, to ask for help, to reach out to other people, to accept my circumstances for what they are, and that every day is a new adventure.”

Resident: “You just try to keep your distance from people who are coughing and sneezing.”

Resident: “Being ill with COVID was rough for me, and I learned a lot by surviving it. I was grateful to be in a nursing facility rather than an assisted living program because of the greater amount of care I got here.”

Resident: “I guess I’ve learned that you’re stronger than you thought you were—or we all are.”

Social Worker: “I’ve learned that if you allow yourself to go arm in arm with someone else, you can really accomplish something. I’ve learned tolerance, especially around faulty systems, and I’ve learned to be more grateful than I ever have been.”

Director of Nursing: “That it is okay to feel vulnerable, and not strong; and how important is the gift of life, and how family is the priority.”

Director of Social Work: “I have learned the importance of teamwork. It taught us to work together, and to lean on each other for support. It is important to surround ourselves with a support system when dealing with such unfortunate circumstances.”

Nurse’s aide: “I learned more about a new disease, and that added to my knowledge. It has encouraged me more in my job. When I recovered from COVID , it made me stronger, and made me want even more to help people through my work.”

The process of asking these questions of staff and residents was emotionally powerful. It prompted me to spend time reflecting on my own reactions to the pandemic, and it pointed to the need for additional support to help staff persons manage the pandemic’s impact. So I developed a plan for “Pandemic Processing: In Search of Healing” support groups. Management staff at each of the facilities where I work were keenly interested to hold such groups. The meetings start with a simple relaxation exercise, then comments to set the context for conversation, and then a list of uncompleted sentences that act as springboards to the sharing of emotions.

The purpose of the support meetings is to step from coping toward healing. Coping is short-term efforts to function amidst an enduring stressor. Healing is a gradual process leading to lasting relief. Even while we continue to battle this enormous dragon of COVID, we need to reach out to one another and exchange support and encouragement so that we may emerge as stronger, more resilient, and more compassionate individuals—persons readier and more willing to devote themselves to the service of others.

What Root Canal Surgery Taught Me About Being a Therapist

Posted on by Psychotherapy.net Team

Although I don’t have a full blown case of dental phobia, suffice it to say that I wasn’t looking forward to my root canal surgery that morning. I maturely prepared for the morning’s activity by queuing up a psychotherapy podcast, thinking that listening to it would distract me from the unpleasant sounds and smells of the offending tooth being drilled. While the endodontist had previously assured me that I would feel no pain, my eternal skepticism left me in doubt.

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As the procedure progressed, I found it increasingly difficult to relax—if relaxation is even possible during a root canal. My garbled responses and feeble hand gestures were futile attempts to communicate with the surgery team, and it quickly became clear that my brilliant distract-by-podcast plan wasn’t quite as practical or effective as I had hoped.

So I removed my AirPods, and without a conscious choice, found myself turning my attention inward, focusing on my bodily sensations, and trying to relax as deeply as I could. Although I consider myself fairly attuned to my somatic being—and I use that attunement in my therapeutic work—the length of the procedure and its intensity motivated me to increase and deepen my level of focus.

I first tuned into my breathing, and then into what I can best describe as “energy flow”—although as I write this I worry it will sound a little too “woo-woo.” But whatever one wants to call it, it is something I regularly experience quite viscerally: the sense of energy flowing through my body, often stopping or disappearing at certain locations, such as my waist or hips when seated, but at other times like a creek which goes underground only to resurface later, reappearing in my calves or ankles.

I attended to this current of energy, noticing its ebbs and flows, and its associated sensations: pleasure, tension, openness or closedness, as well as the degree to which I was fully immersed in the experience. Then I began to have images and associations, most particularly related to table tennis, a sport which I’ve been playing for a few years (switching from tennis after developing tennis elbow) and had just played the previous evening at a local club. I’ve been getting coaching from an elderly Salvadoran man who played on his national team half a century ago, and am struggling to take the nice, relaxed forehand topspin shots that I can occasionally execute during our practice sessions and bring them into the matches at our club, only to find myself tightening up during my stroke and hitting the balls into the net. Yet as much as I tell myself that the stakes couldn’t possibly be any lower—what difference does it make if I win or lose one of these matches?—I find it extremely hard to change these habits. And there I was, in that chair, trying to do pretty much the same thing at the receiving end of the endodontist’s drills, picks, and pokes—focus, relax, let it happen.

And here my mind goes off in a number of directions. First, how hard it is to make any changes, and how the essence of who we are is so embodied. Think of anyone you know, and then how they move, whether it’s walking, dancing, or doing one sport or activity. If you see them again 10 or 20 years later, you can probably recognize them just by these movements alone.

And then I think about how we as therapists receive just about zero training in attending to the body, both our own and those of our clients. Sure, we may have been taught at one point how to lead a client in a relaxation or body-focused mindfulness exercise, but that’s likely about it. That’s barely scratching the surface. I realize that in recent years I’m much more attuned to my own bodily sensations when I am doing therapy. Sometimes it’s in the form of an emotional response in my heart or chest or throat, which I assume to be some form of empathic resonance. Often I share it with my client, not as a definitive statement, but merely as an observation, often with a question such as “I notice I feel some emotion swelling up in my chest; am I picking something up from you?” Other times I don’t share it but make a mental note for later consideration. This may take the form of something like, “Hmm, I find myself feeling ___________ (fill in the blank: softer, more vulnerable, tired or restless) with this client and wonder what might be happening between the two of us.”

There are indeed various somatic-oriented “approaches”—but these are far from mainstream, or from being taught in most of the grad programs which focus on “evidence-based” therapies. But there is no firewall between mind and body, and it’s patently absurd that therapeutic approaches should be Balkanized into separate fiefdoms: cognitive vs. emotionally focused vs. somatic. One hears about integration and flexibility as being hallmarks of mental health; if so, we therapists and our battles between theoretical schools aren’t doing a very good job of modeling this.

As I finish this blog a few days later while waiting in the San Francisco airport for our flight to depart after a four-hour delay due to leaking hydraulic fluid, I am grateful that this glitch was discovered on the runway before takeoff. I check into my body and feel the impending relaxation that comes with vacation, despite the false start on the runway. My shoulders are relaxed, my ankles warm, and I feel the energy flowing despite a slight constriction in my crossed legs. I notice a slight sadness, or perhaps melancholy, but am not sure what that’s about. Maybe I’ll sit with that a bit and see what I discover. Or maybe it will just fade away and remain a mystery.

Clients Deal with Ethics Too

Posted on by Psychotherapy.net Team

If you use the phrase “ethical issues in therapy,” every therapist on the planet will assume you mean the ethics of the therapist—confidentiality, client autonomy, duty to warn. Licensure renewal typically requires ongoing continuing education in ethics. Ethical questions show up in our clinical consultation groups in the form of our obligations to our clients and how we make sure we don’t inadvertently harm them. Ethics and our ethical obligations to both clients and the profession are ubiquitous in the fields of psychotherapy and counseling.

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Here’s a new thought: clients have ethical concerns, too. And a related thought: we therapists have approximately zero training in how to help clients address these ethical concerns. A partial list of ethical dilemmas that clients bring to therapy includes whether to: stay in a difficult marriage or divorce, maintain a secret affair or end it, cut off or stay connected to a difficult parent, tell a non-vaccinated loved one to skip a family gathering or let them come, keep a family secret or reveal it. And then there are ethical issues that the therapist sees but the client may not, such as when a divorced parent is undermining a child’s relationship with a despised and destructive ex-spouse.

As someone trained in the 1970s, I can tell you how I was taught to deal with these ethical dilemmas. Keep the focus on the client’s personal needs and desires (“What do you need to do for you?”) and steer the client away from the other side of their ethical dilemmas—their sense of responsibility to others. In the language of the day, we learned to discourage clients from “shoulding” themselves.

This “do what works for you” paradigm came crashing down for me in the 1990s, when I worked with a distressed, newly-divorced father I’ll call Bruce, who was about to abandon his children by moving away and starting a new life. He had already done the same thing after his first divorce in another part of the country. He came to a session to wrap up our work and say goodbye. I knew I had to try to influence him to do the right thing by his children, but nothing in my training had prepared me for that conversation. What skills could I call on to navigate between the Scylla rock of silent neutrality (“What do you need to do for you now?”) and the Charybdis whirlpool of prescriptive moralizing (“Just do the right thing for your children”)?

That case, along with readings about the cultural impact of “value-free” individualistic psychotherapy, helped me to realize that the therapy field has a blind spot when it comes to ethical issues in the lives of clients. In this context, “ethical issues” refers to client behavior that has consequences for the welfare of others. We either see clients’ ethical struggles in strictly psychological terms, like the punitive superego, or as something we ought to steer clear of lest we impose our values on clients.

A problem with either of these default positions is that they do carry an implicit ethical message: that the only moral stakeholder is the client. An exclusive focus on asking, “What do you need to do for you?” carries the message that complex ethical dilemmas involving tension between self-needs and obligations to others really come down to one dimension: the needs and desires of the self. For years I told clients agonizing over whether to divorce that “your kids will be fine if you do what makes you happy.” My point is that when clients bring us their ethical dilemmas, we are ethical consultants, like it or not. So I decided it was time to get good at it.

In my recent APA-published book, The Ethical Lives of Clients, I articulate five skills in ethical consultation, using the acronym L.E.A.P.-C: Listen, Explore, Affirm, offer Perspective, and (sometimes) Challenge. Therapists use these skills all the time in our work. Now I am applying them to the client’s ethical issues: listening for the client’s sense of how their actions are or potentially are affecting others, exploring their ethical concerns and the roots of those concerns, affirming their willingness to confront an ethical dilemma, offering perspective on the tension between the client’s needs and responsibilities to others, and, in some cases when there is imminent, foreseeable harm, challenging the client to consider the impact of their actions on others.

After decades of doing this work and teaching it to therapists, I am convinced that skillful ethical consultation not only does not drive clients away—a common therapist worry—it empowers them. With Bruce, I listened to and explored his pain and worries, I affirmed him as a father, I offered a perspective on his importance to his children and the likely consequences if he abandoned them, and finally, when he minimized the impact of his exiting their lives, I challenged him by saying that I was worried that he was treating a short term problem (his distress over the divorce and his desire not to have to deal with his ex-wife anymore) by risking long term damage to his children. I offered to be there for him to deal with his current personal crisis, which I was confident he could get through.

Bruce made a decision that had integrity for himself and his children—he stayed with them and later reconnected with his older children from his previous marriage. In the years since that case, I’ve learned that while there is tension in the short run between needs of self and ethical responsibilities to others, in the long run, human flourishing comes from facing the tension and finding authentic ethical integrity. Helping people in this crucible is part of our job as therapists, so let’s get good at it.

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.