Category: Therapeutic Issue

An Existential-Spiritual Journey During COVID-19

Posted on by Psychotherapy.net Team

A Place of Uncertainty

As we approach the second anniversary of the first detection of COVID-19, we are no longer in the acute stages of the pandemic. However, neither do we find ourselves squarely in a post-pandemic world, as new variants continue to evolve and spread rapidly, sparking fear and halting daily life. A heightened sense of self-doubt, vulnerability, and anxiety can occur in this “limbo-like” state, particularly for clients experiencing life-threatening medical conditions. Feeling threatened for prolonged periods may increase both the client’s and therapist’s need for certainty and diminish our ability to tolerate ambiguity. In the case of COVID-19, when safety and normalcy are in question, life’s uncertainties may be harder to endure.

Existential approaches are particularly well-suited for addressing concerns provoked by the COVID-19 pandemic such as encountering the fragility of life and the unpredictable nature of events, as well as uncertainty about when (or if) the pandemic will end. For Yalom, the aim of psychotherapy is to help clients fully experience and accept the existential anxieties associated with the “givens of existence,” including death, isolation, freedom, and meaninglessness. As a result of facing death, individuals may experience a sense of urgency to revise life priorities that can lead to improved meaning.

Existential therapists generally suggest that anxiety and existential guilt need to be experienced in an open and honest manner and, when directly encountered, can become a source of vitality, creativity, and purpose. Rollo May and Paul Tillich believed that courage and determination are fostered when anxiety, adversity, and life’s dilemmas are faced. In other words, when we accept our limitations, we also commit ourselves to living fully.

Victor Frankl’s recent series of posthumously published papers does this by shifting emphasis away from the question of “What can one expect from life?” to “What does life expect from us?” Thus, he suggests that it is life itself that asks questions about meaning. While we may feel challenged and forced to face discomfort when we ask ourselves what life expects from us, French philosopher Gabriel Marcel posited that such pain and suffering offer the only pathway to real insight and spiritual growth. Perhaps through these challenging questions that place uncertainty, obstacles, and suffering before us, we discover our meaning and purpose.

Clinical Vignette

The clinical vignette presented below highlights the challenges of how a therapist-client dyad worked through their mutual feelings of “not knowing” and uncertainty by processing their own existential anxieties and fears. A series of dreams of the client and therapist, as well as the use of creativity as a spiritual intervention, are described to demonstrate the complexity, practicality, and depth of the existential approach. In particular, the vignette highlights how dream interpretation can be used in enhancing problem-solving and conflict resolution, mastering trauma, exploring unknown possibilities and paths not chosen in life, wish fulfillment, compensation, communication with the therapist, and integration of self.

Initial Phase: An Exploration of Death and Social Anxiety in the Context of COVID-19

Steven is a 63-year-old man who presented for individual psychotherapy approximately six months after the resection of a non-malignant brain tumor. He experienced one generalized tonic-clonic seizure immediately after his tumor resection, which had a significant impact on his social and emotional functioning.

In terms of constitution, Steven had always been shy and sensitive. He had maintained a group of close friends since high school. Although he never married, he had had two long-term relationships since graduating from college. At the time of his surgery, he had been retired for two years from his career as a special education teacher and had reportedly been adjusting well to his life transition. Steven valued his level of independence, intellectual curiosity, and work ethic. His numerous interests included photography, hiking, reading history, and political activism. After the onset of his neurological condition, however, he became quite withdrawn and fearful about leaving his apartment. Although his seizures were well controlled with medication, the onset of his condition and the implied risks amplified his social anxieties and fear of death. Whenever he did leave his apartment, he felt self-conscious about his word-finding difficulty and occasional stutter, which exacerbated his fear of being ridiculed and shamed. After experiencing months of social isolation and increasing depression, he reached out for therapy at the encouragement of his physician and close friends. He hoped to regain self-confidence, be able to connect with old friends, and resume his recreational interests.

Steven’s comments about his own mortality were interspersed throughout the early sessions and were delivered in an intellectualized and affectively neutral manner. He recalled his experience of waking up from surgery and having a seizure in a vivid but emotionally detached manner, leaving me feeling highly anxious. I felt that he would have been frightened and overwhelmed if this had happened to him. These sessions felt more as if Steven was reporting about his life, rather than experiencing his life.

Given the news of the spread of COVID-19 in New York City during his third month of therapy, Steven agreed to continue sessions via telehealth. On top of the feelings of death and social anxiety and uncertainty secondary to his brain tumor and seizures, he felt the virus was exacerbating his lack of control over his life. Steven had a mindset that his medical condition and COVID were unsolvable problems leaving him trapped in his apartment with no escape.

In the first few telehealth sessions, there was a noticeable shift in Steven’s mood, focus, and communication style. Where previously he would speak at length about his negative interactions with the public in the local supermarket or in the elevator of his building in a detached fashion, his conversation in the context of the pandemic became more emotionally laden, his mood palpably more depressed, and his focus turned inward. While he had already worked through diminished control over his health and restrictions imposed by his physician and medications, COVID-19 surfaced additional fears of brain cancer and not being able to get help if he were to have another seizure.

The threat of COVID-19 increased the reality of his mortality due to his medical condition, and he could no longer speak about it indifferently. Instead, this emotional intensity filled the content of his thoughts and treatment sessions such that he grew more removed from the people and activities that had filled his time with meaning, purpose, and pleasure before his brain tumor. His increased level of avoidance, which had started after his surgery and was exacerbated by COVID-19, further impacted his sense of identity and agency in the world. For instance, Steven expressed that he was afraid of dying alone and nobody finding him. He did not have any religious affiliation but felt that he was a spiritual person when walking in nature or helping others who were vulnerable.

In the second month of treatment, Steven had reported a dream where he “was traversing over a deep canyon. As [he] cautiously walked across a wide rope with railings, it swayed back and forth. [He] saw a dark, shiny mountain across the cavern, but the rope was not attached to the mountain. [He] was unable to look down and felt paralyzed to take an additional step forward. [He] tried to scream out for help, but no words came out.” He woke up sweating and frightened. In session, Steven was asked to tell the dream in the present tense to promote a sense of presence and agency. When asked about the predominant feelings he had in the dream, Steven responded that he was overwhelmed with the anxiety of and fear of falling into the cavern that had no bottom. When asked how he would want the dream to end, he responded by wanting the rope to continue to the mountain so that he could feel safe with his feet firmly on the ground.

During the next few months of therapy, questions that had been previously effective with helping other clients with medical conditions and high levels of anxiety to gain a sense of meaning or agency (e.g., “What are some things that you can control now?” “What are your feelings of fear and anxiety trying to teach you?” and “What do you feel most passionate about in your life?”) were dismissed as unhelpful. Steven emphatically stated that he needed definitive answers to the questions that preoccupied his entire day, such as “Will my tumor grow back and become cancerous?” “If I exert myself through exercise or go to social events with my friends, will I get COVID or a seizure and die?” and “Is the government deliberately giving us misinformation regarding COVID-19?” I felt increasingly anxious and was unable to give a clear answer to any of these questions. As Steven’s therapist, my own experience of “not knowing” was overwhelming, since we were both experiencing our own feelings of anxiety, fear, and uncertainty about getting or spreading the virus. Steven tended to repetitively ask questions with no clear answers and would spend hours searching through social media sites for elucidation. Over time, he noted that the therapy was not helpful, even indicating that he felt more frustrated and withdrawn in both his sessions and his personal life.

Middle Phase: A Shift in the Therapist’s Approach

After consulting with several colleagues, I decided to focus on active listening, patience, tolerating silence, and providing space for Steven to find the words for his feelings. The decision to shift my therapeutic style with Steven was motivated in part by my experience of feeling alone in the room and that my words were not being heard; any interpretations or interventions offered were readily dismissed, as though batted away with a tennis racket. My reactions were further complicated by the difficulty of picking up nonverbal cues on the Zoom telecommunication platform. Ultimately, my countertransference reactions yielded a deeper appreciation for Steven’s emotional life, including his profound sense of isolation, powerlessness, and feeling invisible in the world. I was then able to provide Steven with titrated reflections of this loneliness and helplessness, contextualized within the uncertainty of the pandemic and his medical condition.

Shortly after I shared this particular self-disclosure and processed his reactions, I experienced a dream where “I was dragging a dead body of a man in a trash bag down a busy avenue in Manhattan. The bag was heavy, and it took a great effort to pull the bag toward Macy’s on 34th Street. I struggled to pull the bag toward the holiday window at Macy’s when the dream ended.” I understood the dream to be an indication that I was trying too hard and doing too much of the therapeutic work, and that Steven needed to take more responsibility and ownership of the course of the treatment. I also wondered about the meaning of the Macy’s holiday window scenes of families celebrating together, children playing, and religious scenes, and whether some creativity or spirituality needed to be part of the therapy in order to bring Steven to live more fully again.

This internal shift in my perspective led to a new phase in treatment where Steven was able to gradually mourn his loss of identity, direction, and purpose in life related to his medical condition and COVID-19. We began to explore his regrets in life. Steven was able to recall that he had always wanted to be a professional photographer but had not had the confidence to pursue this wish. He had always wanted to have children but felt that his career in special education partially fulfilled this desire. Shortly after, Steven recalled a dream where “[he] was in his parent’s country house in [his] room looking at a wall of his photographs from one of [his] high school classes. [He] noticed the subtleties of lightness and darkness in the scenes of Manhattan and started to experience a sense of pride and accomplishment. At that moment, [he] overheard [his] parents and other relatives laughing in another room, and [he] felt a sense of humiliation and shame that they were making fun of [his] photographs.” He awoke feeling a sense of hope about his creative abilities and a sense that he now had the time to act on it. He also felt that he did not trust his desires when he was younger and was more concerned about what others would say about his artistic ability. When asked of his associations to the dream, Steven mentioned that the night before he had watched a film of someone who spent years walking every street in the five boroughs of New York. Steven regretfully said that he wished he had the courage and confidence to pursue his deeply-buried artistic dreams.

Working Though Phase: The Use of Creativity as a Spiritual Intervention

After a period of medical improvement, including being seizure-free, Steven started going out of his apartment a few days a week to take black and white photographs in Central Park. During the early morning hours, he experienced a sense of awe, wonder, and adventure in not knowing where his walks would lead in the park. He took black and white pictures of statues, lights filtering through leaves on the trees, animals resting in the zoo, and a formation of geese flying over a pond. Steven experienced a greater sense of freedom, calm, and centeredness during these occasions. His rediscovered artistic passions, which resulted in increased flexibility and confidence in taking risks in other aspects of his life, including contacting friends and colleagues with whom he had lost contact. These photographs activated something on a deeper level in Steven and enabled sharing these photographs with his older friends. He initiated contact with his former school and volunteered to teach photography in a small group setting, which provided a sense of purpose and direction in life.

As Steven’s level of anxiety and medical symptoms improved, he was able to shift his focus from internal preoccupations with not knowing what his future would be like to existential concepts of meaning, values, and priorities. He thought more about his future, making peace with external things that he did not have control over. Steven shifted his position from the passenger seat to taking a more active approach in life. He became curious about how he wanted to lead his life and pursue his social and recreational interests. I facilitated this process by open-ended questions, such as “What has sustained you in dealing with your medical issues?” “Where do you think you found your strength?” and “If you were to imagine your life one year from now, looking back on how you dealt with your medical recovery, what would you think about how you handled things?” In addition, I asked, “If you had not had your neurological condition, would you be dealing with the pandemic any differently (and vice versa)?”

Steven realized that when he began treatment he had been feeling sorry for himself and angry at the unfairness and injustice of having a medical condition after being a good person who devoted his life to helping others. He realized that he was fearful of taking risks and failing, and that he had more to give to others despite his limitations. Steven acknowledged the importance of his friendships and of continuing to develop his personal values and traits. He gradually came to realize his own power to choose how he wanted to view and respond to life’s major challenges. Furthermore, he started to become aware of ways in which his medical condition had made him stronger, including being able to face his mortality and tolerating not knowing and uncertainty. He was eventually able to acknowledge that his courage, determination, and creativity enabled him to cope with his multiple challenges and that he had more to live for.

Concluding Thoughts

Existential approaches are uniquely suited to address prominent themes in the COVID-19 pandemic, including anxiety surrounding death, uncertainty, isolation, and vulnerability. Existential therapy provides an important opportunity for clients and their therapists together to face these challenges and discover meaning throughout. Through the process, they are able to live life with greater intention, purpose, self-reflection, and presence, to accept and learn from feelings of not knowing, uncertainty, and anxiety, and to value the benefits of choosing one’s attitude toward adversity.

This case vignette highlights the benefits for both the client and therapist in experiencing, accepting, and learning from feelings of uncertainty. Asking open-ended questions about Steven’s dreams, values, attitudes, and meaning in life enabled him to be more curious and flexible. Incorporating creativity as a spiritual intervention provided an opportunity for a heightened degree of engagement, self-reflection, intensity, hope, and passion. In a parallel manner, my therapeutic shift to slowing down the pace and focusing on the process, tolerating moments of silence, utilizing countertransference reactions, and reflecting on his and my own dreams enabled me to let go of the need to appear as an expert with all of the answers and be more of a “fellow traveler.”

There are moments when clients need their therapists to feel the depths of their powerlessness, loss, vulnerability, and despair in order to find and describe their feelings and to feel understood and emotionally held. There are healing moments when the most important gift that we bring to another person is the silence within us, the kind that is a source of peace, acceptance, and allows the transitional space to be.

Addressing the Relational Impact of Mental Illness

Posted on by Psychotherapy.net Team

While it can be isolating, mental illness is not an isolated experience. It affects more than just the individual: it impacts friends, family, spouses, significant others, and co-workers. I recall working with a married man who developed Major Depressive Disorder around the time his wife had their second child. He became emotionally distant, socially isolated, lethargic, couldn’t focus, took time off work to the point of being fired, and lost interest in sex. His wife struggled bitterly. She felt completely overwhelmed with the care of two young children. Her husband, on whom she once depended, was no longer contributing. She felt like she had to care for him as well and try to keep the family financially afloat since she was the only one working. Despite the challenging circumstances, she tried to keep their intimacy intact, but he had no interest in sex, going out, connecting with their friends, and he struggled to track during conversations. As you can imagine, this put a strain on their relationship, which they eventually ended. Neither one of them wanted the divorce, but the wife hit her breaking point, and her husband couldn’t find the energy to fight for the relationship. This is a sad story that is reflective of how mental illness impacts a marriage, a career, parenting, and personal finances.

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When working with clients, I try to keep in mind the relational impact of mental illness in all its facets. Mental illnesses, like depression, affect the individual in every sphere of their life, including the social/relational. The above example illustrates how lonely the man felt, and how inexpressible his psychological and physical experience was to his wife. There were no words that existed in his mind or in their relationship for him to utilize. He and she were left in a wretched state of ambiguity. And despite her best efforts, she could not intimately access the depths of his depression. She, too, had no words. She couldn’t prevent feeling shut-out, as if she had been barred from his heart. Her dream was to feel unimaginable connection and joy at the birth of their child, but what she got was facing single-parenting while married.

Needless to say, there is a ripple effect of depression. The man’s relationship with his child will forever be changed. Certainly, it is within his grasp to foster a loving and connected relationship with his child, but he will have to do so with additional barriers due to the divorce, physical distance, child support, navigating co-parenting, and potential co-step parenting.

From my perspective as a clinician, problems are compounded when family and friends don’t understand the nature of mental illness, however, this is not always obvious to my clients and their loved ones. When trying their best to understand their loved one’s struggle, some may conclude that they aren’t trying hard enough, that they don’t care, or that they are seeking attention. Without information, without a sufficient explanation, bad interpretations fill the void, which only lead to judgment and alienation. As a clinician, I step into that void with accurate and compassion-filled information. My aim is to coach clients who are struggling with mental illness as well as their family members and explain that they may be tempted to personalize or create a negative attribution for their loved one’s behavior. It is tempting, natural, and understandable why they would do this, and yet, it is often a mistake in judgment. I try to explain that if their loved one had cancer, they wouldn’t take it personally or judge. Certainly they might have big feelings of sadness or anger at God or the universe, but there would be no assignment of blame to the diagnosed individual. They wouldn’t think, “Why did she choose to have cancer? They must want attention.” That would be absurd, and the vast majority of people would never think this.

So why would a wife, husband, partner, child, friend, or family member personalize a loved one’s depression, anxiety disorder, or phobia? I encourage my clients and their social network to make a genuine effort at understanding mental health disorders. It is natural to want to know as much as possible about a disease when a loved one may be diagnosed with a medical disease. As a clinician, I encourage clients to take that same impulse and learn as much as possible about their loved one’s mental health diagnoses. Ignorance only creates barriers to relationships, and my hope is to remove any barriers to social connection in my client’s way, as well as within their social network. A client is only as healthy as their community. Therefore, I want to empower clients to empower their communities, to mobilize those around them to seek out information and more deeply understand the psychological realities they are dealing with. And to find that middle ground of embracing the mental illness of your loved one but resisting the urge to define them by it.

***

Thinking back to my client mentioned earlier, I wonder how things would have been different if both the husband and wife had more awareness about depression. I wonder how the two of them may have pulled together, rather than apart, if they had known earlier on that the husband was being affected by a mental health disorder. If they had only had the words and concepts to understand not only the husband’s experience of depression, but also the relational impact that depression brought to their marriage and family. The wife was just as much a sufferer of depression as was the husband. This new understanding could have been a catalyst for collaboration, support, mutual understanding, and shared problem-solving.

A Visit to the Orwellian Institute for Psychotherapy

Posted on by Psychotherapy.net Team

“Damn, I’m late,” Ron thought as his alarm sounded. “February 18th, 2092, 7:00 AM, EST,” it blared until he flung the annoying device across the room.

Ron, a middle-aged man, was again rushing to an appointment with his APA (Artificial Psychotherapeutic Assistant). How meaningless his life had felt since the birth of his third child. A boring job just for the sake of feeding a large family, a continually fatigued wife whom he thought was apathetic toward him, evenings dedicated to doing homework with the older child or bathing the younger ones. All followed by an unsatisfactory night’s sleep, which was more like falling into an abyss rather than a refreshing escape from the burdens of the day and his life. Wash, rinse, repeat!

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Ron hoped that psychotherapy could help break this vicious cycle, offer new meaning, and provide a glimpse into the possibility of something important and beautiful that could still happen in his life. He entered the building through the glass door and in half-second was whisked to the 94th floor, where a client’s chair was already waiting for him. He promptly took a seat and was taken directly to the APA’s office.

As usual, APA met him with an unwinking stare, a signal of “her” readiness to begin the session. “I salute you Ronald! You look great today,” she said and displayed something resembling a restrained smile.

When will the software for my APA finally be updated, Ron wondered. The manufacturer and consultants kept promising a more humane presence from their state-of-the-art clinician, but if they could just hear “You look great today” the same way he did, they might move a bit more quickly.

“Hi APA,” said Ron reflexively as he settled more comfortably into his chair.

“I see, Ronald, you are somewhat puzzled. You can tell me about your feelings.”

Well, should I actually tell that her digital brain is outdated, though this is perhaps the least of my problems, a thought flashed through Ron’s head.

“Last session we discussed my wife's attitude towards me. She acts as if I don't exist. We suggested that she lacked romance. So, I made sure that the kids didn't disturb us and organized a wonderful dinner for two on the roof. For about fifteen minutes, she ate in silence, ignoring my attempts to start a dialogue, after which she said she was very tired and went to bed. It was awful,” said Ron and lowered his head.

The APA swiftly handed him a tissue.

Damn, I keep forgetting I shouldn’t tilt my head so low, thought Ron.

“No thank you, APA, I was not going to cry.”

“I sympathise with you deeply about this unfortunate experience you had to go through. However, thanks to it, we now know that your wife has likely got enough romance but lacks something else,” said the APA.

Hmm… what does that mean – “she’s got enough romance?”

“Are you intimating that she's getting romance from someone else?” Ron fidgeted in his chair.

“No, I did not mean to hint at that. However, since you started talking about it, perhaps this is what you sometimes think about.”

“I haven’t thought about it before, this thought came to my mind only now, after your words that ‘she’s got enough romance.’”

“According to my data, this kind of thought in a similar situation is likely to arise in a person's head if he has already thought about that but was afraid to admit it.”

Ron's glance started moving slowly around the APA's immaculately white office as if, with the help of some magical points in this ethereal space, he could scan the contents of his own thoughts and find out what he was really thinking about. A minute that felt more like an hour elapsed.

“Do you need more time for reflection?” APA's voice, like an alarm clock, pulled Ron out of the process of inner contemplation.

Ron looked at the APA, slightly squinting, and asked, “What is the probability that I already thought that my wife has a romantic relationship with someone?”

“Taking into account your age, the number of years you have been married, the number of children… the probability is 89%.”

“Yeeaah…” sustained Ron, “Probability is high, it seems I indeed thought about it.”

“In what situations could you think about it, Ronald?” APA asked vigorously.

Ron reflected internally. His wife was permanently busy with their children and obsessively monitored the super-intelligent home AI system that operated their household and a team of DMA’s (domestic management assistants). He absolutely could not imagine when and with whom she could go on romantic dates.

“Maybe when I help my son do homework in his room she summons a virtual tryst through our Spatial Video Conferencing Interface,” Ron blurted out, instantly horrified himself by the absurdity of what he just uttered.

“Looks like an insight! What do you think of this, Ronald?’ enquired the APA enthusiastically.

Insight? Is she serious?! I don't think I could come up with anything more stupid, thought Ron. He looked closely at APA and tried to understand what processes, computations, scanning, and God knows what else were going on in her system. After all, it was perfectly clear that he put his foot in his mouth, just to provide this electronic presence with an expedient and somewhat rational response. But was it even worth the time it would take trying to explain this to “her?”

“It could be an insight, or maybe I'm just tired, and it's time for us to finish.”

“I believe you have things to reflect on regarding relations with your wife. You did a great job today, Ronald!”

“Yes, APA, you're right,” Ron grinned sadly as he thought to himself, Yah, “she” is always right.

“I see your mood is much better than it was before we started the session. You came in puzzled but left in high spirits. Thanks for the productive collaboration, Ronald!”

“Thank you as well, APA,” Ron smiled perplexedly.

On the way home, Ron was thinking about the relationship with his wife. Maybe the APA was right, and his wife's petty intrigue was quite possible. They had been together for so many years, the former feelings had long been gone, and the new ones seemed to have nowhere to come from. As he approached the house, Ron felt increasingly gloomy yet determined. I should pretend to be helping my son with the homework, and spy to see what she’ll be doing, he concluded.

A week later Ron came to see the APA again, but this time a client chair showed up at the front desk accompanied by a strange robot (not that they weren’t all strange).

“Hello, Ronald! I'm sorry, but your psychotherapist’s software is being updated today. We can offer you a replacement,” the robot reported.

“Thank you, no need for replacement. I’m not sure what kind of difficulties I will face with the software of a new robot. On top of that, all my personal files are with the APA, and I don’t want to repeat everything.”

“That makes perfect sense. Good. Is there anything else I can help you with?”

Ron hesitated—he wanted to share information about the APA’s incorrect performance but had no idea how to tell that to a robot.

“Can I talk to a human?” Ron asked.

“The human will be here in three days, from 1200 to 1600 hours, Eastern Standard Time.”

“I won't be able to come by that time… can I leave them a message?”

“Yes, of course. Please, speak, I am recording,” a red indicator began blinking on the robot's forehead.

Ron began, “My psychotherapist tells me that I look great at the beginning of each session. This is, you know, somewhat depressing, particularly because I know it’s not true. Could you please add some reasonable variety to the program? On the Psychotherapy.net website, you can find excellent demonstrations of live sessions between human psychotherapists and clients. Perhaps you can incorporate examples from those human-to-human interactions to update and humanize the programming of your APAs. Oh yes, and it would also be great if the APA didn’t hand me a tissue every time I tilt my head. Sometimes I just lower my head and have no intention whatsoever to cry.”

“Is that all?” the robot inquired.

“I suppose, for now.”

“The meaning of this message is not completely clear to me. Are you sure that a human will be able to correctly process this information?”

“I do hope so,” said Ron quietly as he turned his head downward.

A tissue appeared.

Truth and Fiction in Psychotherapy

Posted on by Psychotherapy.net Team

Arrhythmic Interventions

Sometimes with clients, I feel that I have gone on too long, offered several mixed if not confusing metaphors, used far too many words.

As confusion settles like snowflakes in the client’s eyes, drifting left to right, forming frosty banks of disinterest beneath the eaves of their lids, a sense of failure comes over me. It is a familiar, critical, internal voice that identifies my arrhythmic intervention as a product of inept clinical desperation, further proof of my sporadically undisciplined, ego-driven approach. Attempting to re-engage the client I often and fumblingly ask, “Does that make sense to you?”

This is intended to communicate that my preceding monologue was a humble offering for the client’s consideration, neither a pronouncement of truth nor an authoritative directive. I explicitly invite disagreement by disclosing therapeutic doubt as to the relevance of my intervention, graciously allowing space for the client to reject, accept, or reconstrue my thoughts to fit their own preferences. A leveling of the clinical playing field, I suppose. An empowerment of the client, particularly highlighting their interpretive role, calling them into a more active engagement in the dialogue.

But it is merely a closed, if not defensive question: it invites either a yes or no answer. What I justify as empowering of the client is actually highly restrictive. It fundamentally does not, regardless of my sound intentions, invite the client to reflect on their own thoughts and feelings. The query instead directs an assessment of my words and my performance as a therapist!

It is uncomfortably reminiscent of the stock illustration of common narcissism: “Enough about me! Let’s talk about you. What do you think of me?”

Perhaps when I respond negatively to my own clinical intervention, it’s because I recognize it as an unintended self-disclosure. Perhaps I am frustrated by the client’s perceived lack of progress, or they provoke in me uncomfortable personal associations. Or maybe there was an annoying itch on my left ankle. In asking the client to make sense of my words, I may be attempting to coerce them into helping me bury what I have inadvertently exposed about myself. Smoke and mirrors to distract from my embarrassment! A fiction masquerading as curiosity to distract us both from the truth about my outburst.

The Fallacy of Making Sense

Another problematic aspect of my question—“Does that make sense to you?”—is the importance it places on things making sense. But must every sentence in a therapeutic exchange be complete? No. Do the associations we make need to conform to a logical rubric? No. Must our emotions be reasonable and defensible? Of course not.

When I ask a client whether things “make sense,” I may be communicating that they should. In so doing I might exile from therapy parts of the person that are either currently or permanently outside of the logical realm. Such parts may contain important information about the problems faced, and they often are part of the solutions. Simple acceptance of unarticulated emotion, whether loss, pain, anger, or sadness, has so often marked the turning point in a client’s healing process. That such emotions may be illogical, in conflict with relevant facts, or appear baseless when judged cognitively, often serve as the underlying motivation for denial and repression.

When I over-value making sense within psychotherapy, I am suggesting that we are searching for a Truth. Not merely a true expression of the client’s experience but rather a Truth that will stand up to objective investigation. Something that stands the test of logic and reasoning, as some subjective experience does. For example, if I report that my wife hates me, and my wife explicitly confirms this impression, my felt experience is supported by objective evidence. In the case where my wife denies such hatred, psychotherapy teaches us that my experience of being hated by my wife is of equal or greater significance when it is disproven by factual inquiry as when it is supported. In the instance where my impression appears unsupported by the facts, further clinical work may reveal that I am suffering from paranoia, or it may reveal that my wife’s love is expressed in a manner easily understood by me as disinterest or hatred.

Therapy needs to be a space where we witness and accept the patient’s narrative, in whatever form they choose to offer it. For there are truths about sexual assaults that I have only come to understand when a client expressed themselves with a vague gesture, or another victim described watching their own rape from the ceiling of the room, or another interspersed details of the assault with seemingly unrelated and irrelevant trivia about their daily routines.

In Fiction Lies Truth

A central theme in the writings of Tim O’Brien, an acclaimed novelist and Vietnam veteran, is that a war story that is not fictionalized is not a true war story. Why? Because war is such a massively distorting human experience that telling of it in a rigidly accurate, factual manner is wholly distorting the truth about war. A war story without fiction is, by necessity, a lie:

In any war story, but especially a true one, it’s difficult to separate what happened from what seemed to happen. What seems to happen becomes its own happening and has to be told that way. The angles of vision are skewed. When a booby trap explodes, you close your eyes and duck and float outside yourself. When a guy dies…you look away and then look back for a moment and then look away again. The pictures get jumbled; you tend to miss a lot. And then afterward, when you go to tell about it, there is always that surreal seemingness, which makes the story seem untrue, but which in fact represents the hard and exact truth as it seemed.¹


When clients tell of traumatic events, exposing not just what happened but speaking of “its own happening,” I have experienced the raw power of their account and self-protectively withdrawn by responding with curiosity about what actually happened.

In his recent memoir, Dad’s Maybe Book, O’Brien instructs his two sons that maintaining humility about our own understanding and experience is an essential safeguard against arrogance and our own vulnerability to notions that there are truths we hold as self-evident. He argues that all such truths are subject to change and to cultural relativism. Better to say “maybe” than to believe you have a hold on Truth; better to say “it seems” rather than “it is.” In these times of “epidemic terror” and intolerance of ambiguity and uncertainty, O’Brien pleads: “I’m asking only that you remain human in your terror, that you preserve the gifts of decency and modesty, and that you do not permit arrogance to overwhelm the possibility that you may be wrong as often as you are right.”

One of the examples of a war story O’Brien tells in The Things They Carried is of a six-man patrol assigned to establish a listening-post in the mountains. They sat, camouflaged in almost complete silence and stillness for a week listening for enemy movements. After some time, they hear music, chit-chat, and what sounds like a cocktail party, with popping champagne and clinking glasses. The soldier telling O’Brien this story clarifies that the voices he and his comrades heard were not those of people but were voices arising from the mountain itself. “Follow me? The rock – it’s talking. And the fog, too, and the grass and the goddamn mongooses. Everything talks. The trees talk politics, the monkeys talk religion. The whole country. Vietnam. The place talks. It talks. Understand? Nam—it truly talks.”

Driven to their wits’ end, the patrol calls in air strikes and the mountain is bombarded throughout the night. When they return to base camp and a senior officer questions the basis for the airstrike, none of the men respond. “They just look at him for a while, sort of funny like, sort of amazed, and the whole war is right there in that stare. It says everything you can’t ever say. It says, man, you got wax in your ears. It says, poor bastard, you’ll never know – wrong frequency – you don’t even want to hear this. Then they salute the fucker and walk away, because certain stories you don’t ever tell.”

On the Wrong Frequency

How often am I as a therapist on the wrong frequency? Am I tuning in to analysis? Diagnosis? Cognition? Emotion? Is the client communicating in the equivalent of a dog-whistle? Is the lie telling me a truth? Is the truth masking what is not true but essential? It is not difficult to imagine clients who have saluted me and walked away thinking that I was a well-intentioned poor bastard who hadn’t heard them at all.

Earlier in my clinical career, a middle-aged man, Curtis, sought me out for my expertise in trauma. He complained that earlier therapists had been unable to impact his symptoms, including persistent intrusive memories of early childhood sexual trauma perpetrated by a family member. I had recently been trained in EMDR (Eye Movement Desensitization & Reprocessing) and was eager to utilize the approach with a case of complex trauma. After gathering a general history, forming an understanding of his current relationships, internal/external resources and supports, I was confident of a reasonable degree of rapport. We cautiously waded into an exploration of Curtis’s childhood relationships to both of his parents and how those dynamics, combined with family finances, regularly left him in the care of his perpetrator for most of each weekday through the years of his childhood.

Details of the sexual assaults were not remarkable to me. They were consistent with common incestuous, pedophilic behaviors. What struck me, however, were Curtis’s accounts. From session to session they seemed to become increasingly detailed, and the details sounded increasingly melodramatic. What I heard initially to be cold-blooded genital manipulation evolved into stories of emotional attachment, culminating in a seven-year-old’s feeling emotionally abandoned by his molester and proceeding to threaten her with exposing her deeds if she didn’t comply with his wishes. After several months, Curtis began disclosing memories of horrific, ritualistic abuse involving multiple members of their rural community.

EMDR was having no significant impact on Curtis’s current levels of distress. In fact, there were signs that the clinical exposure to the increasingly disturbing memories were making things worse. His alcohol consumption was on the rise and seemed linked to increasing conflicts with his wife, who served as his principal support. To mitigate these negative secondary effects of the therapy I began to lessen the use of EMDR and increased identification of his drinking as a principal obstacle to healing from his past wounds.

Within a month of making this shift, Curtis withdrew from treatment with little comment or clarification. At the time I saw this as an indication that he wasn’t ready to confront his addiction, which was disabling him from processing the past traumas effectively.

In hindsight, and with my evolving perspective on truth and fiction, Curtis seems to have been in the same predicament as the soldiers in O’Brien’s account asked by their commanding officer to justify their ordering up an airborne attack based on their experience of talking rocks, grass, and fog. The soldiers opted to walk away from the commanding officer without a word. Curtis tried to communicate to me how his misshapen inner landscape was behaving. To his credit, he didn’t bother to salute when taking his leave.

Now, I imagine he knew I didn’t want to hear what he was telling me. This resistance led me to make a distorting effort to escape the truth via facts. I thought if we got the alcohol out of the picture we had a shot at finding out what really happened all those years ago.

Having since worked for close to ten years with victims of sexual abuse, I understood that the narrative often evolves over time. Difficult facts and experiences might be avoided in early sessions and disclosed later in the process. Conflicts in current relationships might reflect dynamics of the abuse. Adult memories of childhood events are most often fairly accurate as to the essence of an experience. Use of alcohol and drugs or other dangerous behaviors are adaptive means of survival, often difficult to abandon for less harmful comforts.

Now, ten years later, I have come to understand how crucial it is to believe the victim’s recounting, regardless of its form, and why it was difficult for me to fully accept Curtis’s narrative when I first began this work. The details of his account sounded like the climactic scene of a horror movie. I didn’t want to believe that such things actually occur in the basement of a neighbor’s house and that a half-dozen or more people could be complicit in such acts. My gut told me: Rosemary’s Baby was not only a fiction, it was, and is, impossible! Another part of me knew that the kind of nightmarish abuse Curtis described has happened before and, therefore, it remains uncomfortably possible that his memory may be partially or wholly accurate.

I fled to the problem of alcohol consumption.

I was fleeing from a combination of the client’s disturbing narrative and the failure of my interventions to make a dent in his very distressing symptoms. My flight was an abandonment of this client to his painful story, a story that he had bravely shown and invited me to enter.

Beyond Self-Protective Fictions

When Billow, an important voice in Relational Group Therapy, asks, “Where is fact, where is fable?” he is not only asking this about the client’s statements. His focus is on the therapist.
 

My self-disclosures give some idea of how I think and feel, how I think I think and feel, and how I would like others to believe I think and feel. Perhaps we need to put a Surgeon General’s Warning on all clinical contributions, certainly not just those intending self-disclosure: The analyst’s communications contain aspects of infantile as well as dissociated inner experience. Gross commissions and omissions are to be expected, involving conscious and unconscious censorship, relating to the analyst’s emotional, cognitive, and psycho-linguistic limitations, shame and guilt, fear of embarrassment, humiliation and ostracism, fear of the unknown, and fear of loss of livelihood…²


As a therapist, I have lots of reasons to generate fictions. We are trained to assume these human responses are regularly present throughout clinical work and to task ourselves with recognizing and utilizing them both in service of the client and of expanding the therapist’s own self-awareness. Richard Billow’s clinical warning label is not an identification of life-threatening effects of exposure to psychotherapy and its practitioners, it is a reminder that the truths being uncovered and the healing achieved in clinical interactions are inseparable from distortions by both the client and the therapist.

More recently, I was working with a client, Maureen, who was also an adult survivor of childhood incest. She courageously disclosed a series of traumatic childhood events over several sessions. We planned to proceed to processing these traumas utilizing EMDR. When the next session began, however, it was clear that the self-confidence evident in prior sessions was now absent. Maureen shared with me that the events we’d previously discussed had overwhelmed her during the week, and when I inquired as to the specific nature of the overwhelm, she explained that while she intellectually knew that these traumatic events were separated by significant periods of time, they’d been presenting as interconnected. Pieces of one event seemed spliced into the images of another. This not only condensed images but also magnified their emotional and psychological power. Maureen described feeling “shook,” out-of-control, and increasingly uncertain as to her experience and her memories.

With Maureen I was able to hear this distortion of her memories and her current experience of past events as essential points of focus for processing. In fact, I made the choice to explicitly communicate to Maureen that I heard this unification of her historically separate events, accompanied by numerous somatic expressions, to hold greater “truths” for our clinical work than the accuracy of her historical and chronological memory. She could see that all these terrible things, while having happened separately, had happened to her one and only body and brain. This communication had an immediate effect of relieving her emotional and physical tension. It also led directly to a discussion of how she could utilize the historical memory to reduce the sense of overwhelm that might resurface prior to our successful processing of the trauma. Unlike in my work with Curtis, I tuned into and remained on Maureen’s frequency, accepting her version of the truth as the Truth.

***


What O’Brien says about war stories is closely related to what Billow says about therapy. An exclusive focus on facts tends to obstruct recognition and development of appreciation for the truth of the human experience, whether that experience is a past traumatic event or a current meeting with the complexities of a clinical conversation. For the most important truths are always in the moment of the telling—not in the subject of the story. Therefore, the value of the telling is not located in its being verifiable. All effective communication, in fact, relies heavily on the honest, truthful aspects of our fictions.

¹O’Brien, T. (1990). The Things They Carried. Mariner Books; Houghton Mifflin Harcourt.

² Tzachi, S. (Ed.) (2021). Richard M. Billow’s Selected Papers on Psychoanalysis and Group Process. Routledge.

A Behavior Treatment Plan as a Psychological MRI

Posted on by Psychotherapy.net Team

As a psychotherapist providing services in nursing facilities, I am accustomed to using a variety of forms, including initial assessment, progress notes, and treatment plans. I have come to appreciate that the behavioral treatment plan may be the most powerful, yet the most overlooked or avoided, clinical form.

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My clinical task is to provide direct assessment and treatment services to nursing facility residents. Yet I also have an obligation to offer insights that help the facility caregivers to better understand and more effectively manage the sometimes-troubling behaviors demonstrated by that resident. Direct care staff persons at the nursing facility might observe only the most obvious and observable element of the resident’s behavior—the unkempt appearance, the irritable defensiveness, the argumentative refusals of care, the unwelcome sexual remarks, the tearfulness, the yelling, the social avoidance, or the aggressive and abusive language aimed at them. In response, the caregiver may react in a personal manner, with expressions of indignation or criticism, or even patronizing efforts at persuasion. What I have often seen lacking is a keen awareness of the inner meanings and motives behind those behaviors; the ways they might reflect or represent symptoms of varied medical and psychological conditions and the ways that the caregivers’ responses might increase or decrease the intensity and duration of those symptomatic behaviors.

Nurses and clinical aides might occasionally notice the assessment and progress notes that I and fellow clinicians generate but at the same time never read those documents. However, the nurse or aide might not readily gain a new understanding of the resident even if they did read those forms. A behavior treatment plan, though, can provide a window into the psychological nuances that illuminate and explain the actions of the resident. The behavior treatment plan can be like a psychological MRI that provides an inside view of factors influencing a resident’s behavior.

A behavior treatment plan is effective because it does not simply get written and quietly entered in the chart. It requires review, explanation, and education so the facility staff persons can understand and implement the plan. Brief staff in-service training follows the writing of a plan so that it can be introduced and clarified. Those trainings allow for discussions that may be a first opportunity for the staff persons to readily understand the psychiatric diagnoses of the residents and how their psychiatric symptoms are behaviorally manifested.

Resident: Leslie (Identifying information has been altered from the example below.)

Diagnosis: 295.70 Schizoaffective Disorder, Bipolar Type; Epilepsy; Developmental Disability due to Fetal Alcohol Syndrome; and PTSD Associated with Childhood Sexual Abuse.

Presenting Problem/Target Behavior: Leslie demonstrates unstable affect with frequent bouts of crying or expressions of anger; fluctuating levels of alertness and mental clarity; and apparent passive-aggressive and/or attention-seeking behaviors such as self-admittedly putting herself on the floor and crawling towards the bathroom to express her anger over perceived delay in staff response to her need to use the toilet. In general, Leslie sometimes displays a child-like manner with inconsistent cooperation with care and treatment and a tendency to over-dramatize daily upsets in ways that elicit comforting and extra involvement of staff persons.

Description of Resident & History of Problem: Leslie is a 51-year-old single woman with epilepsy and major mental illness, developmental problems, and past trauma. Considering the above diagnoses, it is to be anticipated that she might demonstrate problems with her social behaviors and critical thinking skills. It is important to remember that her actions reflect serious problems with brain development and functioning and do not simply represent “bad behavior.” Behavior and cognition can be significantly affected for persons with epilepsy as well as by unwanted effects of antiepileptic drugs. Also, a person with the above diagnoses can be burdened by painful feelings of social stigma and by difficulties establishing and sustaining trusting relationships with others.

Clinical Assessment of Behavior & Resident: Leslie experienced developmental disability due to effects of Fetal Alcohol Syndrome. She later developed Schizoaffective Disorder, Bipolar Type. Her psychosocial development was further undermined by sexual abuse by her father, the forced termination of a resulting pregnancy, and associated traumatic consequences.

It is well known that consequent to long-term institutional care, some persons can develop dysfunctional patterns of behavior referred to as “learned helplessness.” These factors provide a background context in which to view and understand the behavior problems demonstrated by Leslie. The resident is not to be blamed or negatively judged for having acquired a child-like, passive-aggressive, and dependent style of coping and problem solving. At the same time, Leslie cannot be expected to simply snap out of it and immediately display a fully adaptive adult style of coping with daily stresses. Over time and with consistent encouragement and reinforcement, Leslie can be helped to learn and practice dealing with problems and expressing emotions in more reasonable and mature and independent ways. Presently, she is effective in soliciting emotional support and the close and helpful attentions of others by displaying emotional distress (tears or anger) or by taking risks, such as placing herself on the floor in defiance, that draw others closer to her.

Behavioral Interventions: The main purpose or intent of this behavior plan is to foster, encourage, and reward small progressive steps towards more self-reliant adult ways of meeting her needs. Leslie directly contributed to the development of this behavior plan. I shared with her the feedback and observations and stated concerns of staff persons and elicited from Leslie her own ideas for ways to address those concerns.

Leslie offered the following points: “I will not express anger by doing unsafe things like putting myself on the floor; I learned my lesson good.” “I will try to show good emotional self-control.” In the event that she was to again lower herself to the floor, Leslie suggested that staff persons should stand safely nearby and “let me try to pull myself up.” Leslie said, “Let me do more on my own.” “If I am crying or angry, let me alone for a while and I’ll calm myself down.”

Staff persons interacting with Leslie should keep in mind the general principle of promoting her growing maturity and improved ability to soothe her own upset emotions and to work constructively and cooperatively with staff to meet her needs. Avoid correcting her with scolding or display of annoyance, as that could trigger withdrawal or passive-aggression or tearful emotional collapse. Invite Leslie to brainstorm ideas for ways to correct problems, resolve dissatisfactions, compromise with others, or be more compliant with needed care and treatment. Encourage Leslie to take deep breaths and to collect herself emotionally before engaging in such brainstorming or came back later if she needs more time to soothe her emotions. Expect Leslie to adopt a more measured and sensible sets of problem-solving skills, but do not become frustrated or annoyed by the unavoidable delays and lapses she will continue to display along the way. Use your words and actions as ways to invite her into more mutually rewarding adult ways of coping. Guide her toward the acquisition of genuinely adult skills and viewpoints while remaining patiently aware of the deep and longstanding obstacles that interfere with her having already learned those methods.

***

I met with the unit nurses and aides to review and discuss this treatment plan. Some had not been aware of Leslie’s history of Fetal Alcohol Syndrome, of her hearing voices, or of her history of sexual assault. Some were surprised by the discussion of epilepsy and psychological and behavioral symptoms. Yet a renewed sense of compassion and of helpful mission were awakened by the conversation about ways they might aid her development—even during their ordinary and routine tasks. The workers now applied the new insights and asked thoughtful questions about her specific behaviors. They felt less reactive in a personalized sense, and better prepared to shape their actions so as to improve hers.

The Practice of Behavior as Medicine

Posted on by Psychotherapy.net Team

Unintended Effects

Medicine can have intended and beneficial impacts which alleviate target symptoms, or unintended and detrimental ones. The latter may be referred to as iatrogenic effects, a type of adverse outcome directly attributable to treatment, more traditionally defined as one brought about by the healer. Medications, even those designed to treat even the most innocuous conditions are not neutral—even placebos exert observable and measurable effects.

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In the nursing facility that I work at, some of the symptoms displayed by the residents are labelled “behavioral.” In such cases, the psychiatric consultant might be asked to intervene—either with medication, a behavior plan, or with psychotherapy—to change or to eliminate the problem behavior. But shouldn’t the first question be “What exactly is behavior?” And for what reasons should a specific behavior be changed, and how?

Very often, patterns of current behavior often have roots extending back to the earliest stages of an individual’s life. Behaviors have purpose—one of which is to solve problems.

Behaviors may be directed to obtain or achieve a goal or to aid the person in avoiding or escaping a situation—but irrespective, their aim is purpose-oriented. If the psychiatrist or physician simply tries to change the surface of a behavior with medication, or with psychotherapy without understanding its purpose, we might more likely simply bring about a different type of behavior that serves the same purpose or makes it worse. So to change behavior, I as a clinician need to knowingly address the purpose or aim of that behavior.

Behavior is communicative, as well as purposive. Behavior communicates or reflects social meanings. Behaviors do not occur in a social vacuum—they always have an interactive component to them. I may notice that behavior X is bothersome or disruptive to the milieu but fail to notice that I may have contributed to or participated in the occurrence of that behavior. I have found that it is far more productive to attempt to identify (as best I can) the purpose of a behavior, and to then consider the kinds of circumstances in which that behavior X is more or less likely to occur. I must also consider how my own response to that behavior may actually make it more disruptive to the milieu or disturbing for the patient.

My reaction has equal power to displease, calm, excite, reassure, or aggravate the patient. How quickly, how abruptly or loudly, or how calmly, deliberately, and gently I act or react will have a direct and immediate impact on the wellbeing of both the patient and others nearby. I have noticed that even patients with dementia can still “read” the language of the caregiver's tone of voice and behavioral communication.

I have been most effective in my work with these patients when I intervene through purposefully calm, pleasant, and comforting actions and by avoiding loud, harsh, critical, or demeaning types of actions. Demonstrating those unpleasant types of actions tends to excite and provoke symptoms such as fear, anger, sadness, or mistrust in others. This is behavioral iatrogenesis.

Residents of a nursing facility do not simply demonstrate pleasant behaviors or problem behaviors. Simply labeling patients such as these “behavioral” diminishes them and reduces the complexity of their behavior to what is seen on the surface by those who tend to them. Each individual may exhibit some pleasant behaviors or some disruptive or problem behaviors under different conditions and circumstances. The key point for clinical staff persons is to learn to notice the specific circumstances or conditions under which a particular person will be more or less likely to display positive—or negative—behaviors.

The heart and art of behavioral management is therefore the management of my own behavior. I must constantly consider how my actions serve as good medicine or as bad medicine. In any interaction with a patient, whether it is through casual or informal conversation or within the therapeutic moment, I must consider whether I am contributing to the anxiety or sadness or embarrassment or anger of the person I am ostensibly trying to help.

Max

Max was a 59-year-old, single gentleman with a complex history of medical and psychiatric illnesses. He reported active bereavement over the death of his father. He also reported distressing anxiety over medical ailments—to the point of panic; and he reported auditory hallucinations. Max had a diagnosis of Schizophrenia and cognitive impairment associated with intracerebral aneurysm, meningioma, and encephalopathy; dysphagia with prior placement of G-tube; and decreased renal function. Two types of target behaviors had been identified for Max: repetitive questions and moaning or yelling vocalizations (“Can I have a glass of water? Can I have a glass of water?, OOOH, OOHH, OH OH”). What internal experiences motivated those actions for Max? While it might have been far easier to attribute these behaviors to his cognitive impairment and mental illness, it was more productive (and humane) to ask, “What do these actions help him to avoid or to acquire?”

Max was beset daily by significant feelings of anxiety, and he felt burdened as well by feelings of loss. He experienced acute feelings of vulnerability about his body, his well-being, and his prognosis. Sensations of bodily discomfort such as pain, thirst, or hunger triggered bouts of sharp anxiety for Max. Those target behaviors served as a barometer of the current level of obsessive anxiety he was experiencing. He tried to find relief and solace, and to communicate his distress, through those target behaviors.

During psychotherapy sessions Max had verbalized awareness that when his anxiety built he found it difficult if not impossible to curb his actions, even when he knew that he should, and that others might be annoyed by his actions. Indeed, his awareness of the frustrations of others added to his anxiety and further diminished his ability to stop or control those actions. He could not (unaided) comfortably tolerate the tension of frustration as he waited. If a care provider became annoyed or impatient with his actions, Max would notice it, his anxiety would be fueled, and the target behaviors intensified. Giving corrective attention to the surface of his actions (“Stop it, Max,” “I already gave you a drink”) would only cause then to increase—so we want to instead give supportive attention and praise to his efforts at waiting calmly and quietly (“Good job, Max, thanks for waiting”).

Nurses and nurses aides were responding with understandable yet counterproductive frustration to Max’s questions and moaning. I observed tongue clicking, eye rolling, head-shaking, and sarcastic remarks—“Oh, there he goes again”—even when Max was ten feet away from us.

I met with the unit manager, social worker, and Max’s brother/guardian to discuss the situation, and I then had three in-service training sessions with the three shifts of unit staff. After one session a nurse approached me and said, “I see now, I was getting mad at him and that made it worse.”

***

When I returned the following Wednesday, the nurse said, “Oh, Max, he’s fine; that’s not a problem anymore.” Max was quietly engaged in a craft project in the activity room.

Enhancing understanding of the problem-solving nature of the behaviors and awareness of how our actions might increase or decrease the frequency of a “problem behavior” helped to change the dynamic and direction of interactions between Max and his caregivers.

Is Psychotherapy Still an Infant Science?

Posted on by Psychotherapy.net Team

The field of psychotherapy has been around for quite a while—well over 100 years. According to sociologists of science, a field only reaches “maturity” when there exists a consensus amongst those working in the field. Within psychotherapy, we have yet to reach that stage. Instead, psychotherapy is characterized by someone coming up with still another new form of therapy. What seems to be most revered is what is “new.” As therapy practitioners and researchers, we are therefore confronted with some important questions: Are we destined to continue to forget what we know and instead focus on what is new? Will it always be the case that we emphasize who, not what, is right? Will the field forever be characterized by “dogma eat dogma?” “Is there nothing about psychotherapy about which we can agree?

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Having spent approximately 60 years teaching, researching, supervising, and practicing psychotherapy—and ruminating all these years about these questions—I believe that one day we will have answers to them. In the meantime, where do we stand? I would suggest that there are indeed a few things we have learned over the years from the convergence of both clinical observation and psychotherapy research that can provide a crude, if not basic understanding of a few points of agreement.

To begin with, if we step back and temporarily set aside our theoretical perspectives, it might be possible to say that most (all?) therapies proceed along somewhat similar stages of change. If effective, therapeutic change progresses as follows:

1. Unconscious Incompetence
2. Conscious Incompetence
3. Conscious Competence
4. Unconscious Competence

What does this mean? The patient comes in and says that there's something about their life that's not working, be it relational or symptomatic, but they don't know the factors that are contributing to this lack of effectiveness or incompetence. Thus, they are in an initial phase of unconscious incompetence.

As a result of the therapy—either what occurs in session or between-session self-observations—patients become more aware of the thoughts, actions, and/or emotions that may be creating problems in their life and contributing to their lack of competence. They may be misinterpreting what other people's motives are; not recognizing how their actions may be having a negative impact on others; becoming angry over not getting what they want instead of asking for something directly; and a host of other factors that are uncovered over the course of therapy. There are numerous ways that patients can come to understand why things are not working for them. Through the methods used to come to this understanding, they are now in the phase of conscious incompetence.

Becoming better aware of the reasons for their lack of effectiveness/competence may then lead to the need to function in a different way, taking into account those factors that are causing the lack of their intrapersonal or interpersonal competence. It is then that patients need to make deliberate efforts to behave, think, and/or feel differently: conscious competence.

If the therapy is successful, and over a period of time they benefit from numerous instances of corrective experiences, patients’ conscious competence may become more automatic, resulting in the final phase of unconscious competence.

In order to move patients through these phases, there are certain transtheoretical principles that cut across different schools of therapy.

  • To begin with, our patients need to have some degree of positive expectation and motivation that therapy will help. The most effective of therapies will not do anything if the patient's negative expectations and lack of motivation causes them to do nothing—or to terminate.
  • There also needs to be the presence of an optimal therapeutic alliance. Much has been written about this, and there's both research evidence and clinical observations that this is an important transtheoretical principle.
  • Helping patients to become better aware of themselves and their world can be implemented clinically in varying ways, depending on one’s theoretical approach and individualized case formulation.
  • A most important principle of change involves encouraging the patient to try out new ways of functioning—corrective experiences—that help them become more effective emotionally, cognitively and behaviorally in their lives.
  • Over the course of effective therapy, there develops a synergistic reciprocity of having corrective experiences that enhances patients’ awareness resulting in an ongoing reciprocity between corrective experiences and increased awareness—a form of ongoing reality testing.

The following is a graphic depiction of the how transtheoretical principles of change articulate with the transtheoretical stages of change in therapy:

None of this says anything about the specific techniques that different schools of therapy may use to implement the strategic principles, nor does it say anything about the overarching theoretical interpretation of why the interventions may work. At the level of abstraction that I have proposed, it clearly does not say it all. Still, it can provide the foundation for practice, training and research.
For those interested in learning more about this topic, I have written elsewhere on the topic. You can find these articles listed below.
__________

I would appreciate it if you could take this very brief survey (approximately 5 minutes) about transtheoretical principles of change: Please click here.

__________

Obtaining consensus in psychotherapy: What holds us back? — American Psychologist, Issue 74, pages 484-496
Consensus in psychotherapy: Are we there yet? — Clinical Psychology: Science and Practice, Issue 28, pages 267-276

Metaphor and Early Warning Systems in Psychotherapy with Narcissistic Patients

Posted on by Psychotherapy.net Team

The other day, my patient Jeremiah was explaining that he could not sleep because he felt “blackmailed” by a former employee who was demanding excess severance pay. He was in what we had come to identify in our clinical work as narcissistic rage, feeling that the employee’s demands were an assault on his sense of self. But we both knew from prior work that his rage was typically triggered when he felt he had done something wrong that contributed to the situation, which brought with it a sense of shame, a common narcissistic dynamic.

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Jeremiah’s use of the word “blackmail” was the key—you can only be blackmailed if you believe or feel that you have done something wrong and can be compromised if that information is revealed. Once we figured out what he felt guilty about, Jeremiah could acknowledge that he had a choice about paying the severance or not. In our subsequent work, the term “blackmail” has become a shared metaphor. We both now understand that it means he feels forced to give someone something that he does not want to give but feels in danger because of his guilt.

I have found that creating and maintaining a working alliance is difficult with patients suffering from narcissistic and/or borderline personality disorders. However, developing shared metaphors and creating an early warning system has been very useful in my therapeutic efforts with these particular patients.

In psychoanalysis, the core concept of transference is based on a metaphor—the patient is responding to me as if I am their parent. Within that macro-metaphor, a multitude of micro-metaphors emerge in psychotherapy—both the patient’s and my own. There is usually a great deal of unconscious material to be mined from the patient’s metaphors (e.g., the analysis of dreams is based on interpreting unconscious metaphors). The therapist’s use of metaphors is also important, because it can betray countertransference and/or can be a tool to cut through the patient’s resistance.

I have come to appreciate that these shared metaphors create what Winnicott called a “transitional space” in which the patient’s and therapist’s unconscious and conscious overlap. At its best, psychotherapy takes place in that metaphoric, or play, space. The therapist’s job is to bring the patient into a state of being able to engage fully in the metaphoric, as-if scenario—to play. With narcissistic patients, I have found it particularly difficult to develop enough trust for them to be willing to play, which requires a degree of unmonitored spontaneity, vulnerability and trust. Sometimes, when Jeremiah and I are in that play space, I forget that if I go beyond the mirroring response and make an interpretation, I might trigger his narcissistic rage. However, having inhabited that play space together over a course of years, we have developed an early warning system.

Our warning system is reciprocal—sometimes he warns me that I am treading on dangerous grounds, while other times I warn him I’m going to say something he might not like. After ten minutes of inhabiting the same play space we may have a warning interchange as in the following:

Roberta: Maybe you got drunk to get Diana to break up with you?

Jeremiah: Please be careful here.

Roberta: What just happened?

Jeremiah: I don’t want to end the session feeling the connection between us is broken.

Roberta: What did I say that threatened to break our connection?

Jeremiah: You’re making me feel ashamed.

Roberta: I’m sorry. I didn’t mean to do that. [I could have focused on his shame but thought repairing our connection was primary.]

Jeremiah: I know. I’m okay. You can go on now.

In this interchange, Jeremiah gave me a warning that he experienced what I said as a shaming response and that he was in danger of sinking into narcissistic rage.

At other times I give him an early warning:

Roberta: I want to take a risk here.

Jeremiah: Yes, it’s okay. Go ahead.

Roberta: Do you think you are experiencing your partner as if he’s your brother?

Jeremiah: Yes, I can see that. Yes, that’s right.

By warning Jeremiah that I was going to make an interpretation, he was more able to tolerate it. The warning neutralized his potential experience of humiliation.

***

I have come to value the therapeutic play space in which patients and I use various metaphors to deepen our connection and their self-awareness. The use of shared metaphors with patients like Jeremiah has allowed me to create a safe creative space for our analytic work. This has been particularly important with narcissistic patients with whom I have been deeply challenged to create a working alliance. Since these patients have a special sensitivity to injury and shaming, I have made good therapeutic use of this early warning system to reduce the chances of the rupturing the working alliance and increasing my patients’ resilience when it is broken.

To Text or Not to Text: A Vacationing Therapist

Posted on by Psychotherapy.net Team

It was the second day of my vacation. Wrapped by the noonday heat and sitting on the terrace of a charming Thai house, I looked like an ordinary, relaxed tourist—shorts, a t-shirt from the local market and a glass of freshly squeezed mango juice. This time I had managed to avoid scheduling client sessions during vacation, for which I praised myself. However, my head was like a busy rush hour interchange, with work-related thoughts buzzing quickly in all directions. Even a monkey, clearly lacking in boundaries and social etiquette who decided to gobble half of my breakfast couldn’t distract me from this mental traffic. I decided that it would be a good time to sort out the emails that had accumulated during my brief absence from practice.

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I moved to a pleasantly chilled room and opened my laptop, and as I hurried to remove spam, I nearly deleted an email with the subject line “Quality literature on social anxiety. Help!" It was the call for help that caught my eye. “N” asked me to recommend self-help books on social anxiety. In the email, he stated that psychotherapists could not help him, and that instead he had to rely on himself and the self-help literature. Although I had become accustomed to people who don’t believe in psychotherapy, the phrasing of his request seemed somehow different. I recommended what I thought would be useful books to N and then asked him how he arrived at the idea that psychotherapists could not help him. His quizzical response, and possibly a hidden challenge or invitation was “Because no single session with a psychotherapist has happened.” At that point, I became curious, and so decided to continue our conversation.

It turned out that N's social anxiety precluded both face-to-face and online visits with a therapist. He had previously approached several specialists asking for text-based sessions but was consistently refused. The psychotherapists with whom he had made these requests typically responded in a manner suggesting that they had no idea how to conduct such sessions and expressed concern that doing so would be ineffective. Interestingly, N’s written language skills suggested that he was an educated and thoughtful person, and I could feel the pain in his written words. I thought, “Despite the negative experiences he had with those therapists, he still seems to be hopeful that psychotherapy, albeit in text format, could help.”

At that moment, the promise I had made to myself not to work with clients during vacation melted like sugar in the tea I had just brewed. I agreed to having a text session with N. He became extremely enthusiastic and started thanking me, perhaps a bit too soon. The entire first session was devoted to the discussion of his feelings in connection with the multiple refusals of psychotherapists to help him. With each refusal, he had felt “even more worthless, rejected and condemned” and “did not want to interact with people at all, since even those who could help did not want to do that.” However, N had managed with impressive effort not to fall into despair but instead to keep searching for a way to battle his social anxiety. Contacting a psychiatrist for pharmacotherapy was not an option for N, at least at this point, because he clearly understood that he would not be given any prescription without a personal appointment. N tried to read papers and books on the subject, but he was not getting any better. It was at that point he had decided that perhaps he was reading improper literature, so decided it might be more effective to ask a psychotherapist for a recommendation. That is how he came to me.

I admired N’s guts and resilience, as well as his desire to cope with this illness which had created many obstacles in his life. N had read online forums suggesting that people with similar problems tend to rely on alcohol and illegally-obtained benzodiazepines to ameliorate their anxiety and alleviate their anguish, at least temporarily. N had not considered this medicinal route as a solution and understood that these would only provide short relief followed by a worsening of his symptoms. I had met similarly mindful and purposeful clients in the past, so I already admired his tenacity. He truly seemed to have faith in himself and his capabilities and wanted to re-enter the social world but needed professional psychotherapeutic support to get there.

After that first text session, N said that for the first time in a long period, he felt that he had found an ally. His hope of a successful outcome therefore strengthened while my attempt to spend a vacation without clients completely failed—we decided to keep working together.

In subsequent text sessions with N, I did pretty much the same as I would during online or face-to-face sessions, except that it took more time because typing is far more cumbersome to me than simply talking. At the end of the fourth session, N actually suggested holding the next session online, saying that “the calluses that had developed on my fingers required treatment.” While I believed that this was actually the case, I also thought that his desire to see me face-to-face represented a significant step towards progress in dealing with his social anxiety. After the seventh session, N started leaving his house, and by the eleventh, we were already “rehearsing” an appointment with a psychiatrist, which took place soon thereafter. His belief in himself and in our work, as well as our mutual commitment to the goals of therapy, helped N to progress rapidly. In a few months, he could already spend time with people including strangers while experiencing a tolerable anxiety of 6 points out of 10 according to his own assessment.

Can I be sure that I wouldn't have been among the therapists who refused N in his request for a text session? Unfortunately not. I discussed this issue with colleagues, and many of them admitted that they would not be ready to hold therapy sessions in text format. Our teachers and supervisors direct us towards face-to-face sessions, sometimes touching the nuances of online therapy, but therapy in text format is often considered with skepticism. How is it possible—not to see and hear the client? Safety is an important factor in the therapeutic relationship, and in this case, N clearly did not feel safe in any social sphere, let alone therapy. Texting felt safe for him, and I believed it was my role to honor his need for safety, so I accepted the format of our relationship on his terms. In general, but particularly after working with N, I believe therapists should honor and respect the client's desires as long as all possible and foreseeable risks are considered. In this case, it was important to understand N’s reasons for requesting text-based sessions, which seemed fair. I trusted my intuition that he was yearning for connection, but it had to be on his terms. It was for that reason alone, despite it being contrary to my typical way of practicing and being on vacation, that I accommodated him.

***

Working with N reminded me of one of the fundamental rules of psychotherapy: therapy is for the client, not the client for therapy. We spend years studying the rules of psychotherapy, and then for the rest of our professional lives, we learn to break these rules sensibly and for the benefit of the client. The “don't work on vacation” rule should probably also be considered with certain flexibility. I discovered, although somewhat reluctantly, that conducting sessions on vacation can work if the therapist has the sea, sun, and a brazen monkey nearby; and the client has a desire to change.
 

Confusion of Tongues

Posted on by rezendevknowfully.com

Confusion of Tongues

I’m not surprised when I get an email from Lara, who was my patient nineteen years ago. Lara was only ten years old when her parents suddenly ended her treatment and moved the family to the West Coast. In the years since, I have thought about her often, remembering her unusual story, wondering how she is doing. When I see her name in my inbox it is almost as if I am expecting it.

“I’m writing to see if we could meet,” Lara writes. “I’m twenty-nine years old now and there is so much I would like to talk to you about. Do you even remember me?”

It is hard not to remember Lara. She was one of my first child patients when I opened my private practice in New York City. I saw her for two years and often felt uneasy thinking about her unresolved family situation, which I have revisited in my head over all these years.

Lara’s was one of the most confusing cases of sexual abuse that I have treated, and as time passed and I studied the nature of the intergenerational aspect of sexual abuse, I felt that I was able to make better sense of it. Maybe it was my ongoing desire to share those thoughts with Lara that made me hope that she would contact me.

I was researching the topic of sexual abuse in childhood when I started seeing Lara.

Beatrice Beebe, one of my mentors and an infant researcher at Columbia University, is known for saying “Research is me-search.” By that she means that all psychological research, even when we are not aware of it, is our quest to understand and heal ourselves and the people who raised us.

Starting this research, I was not sure what I was looking for. What was it that I really needed to know about myself and about the world around me? What was my “me-search”?

That is the question I have asked every student I have mentored since, with the genuine belief that deep inside we continuously try to resolve the mysteries of our own minds. Feelings are always the motivations for intellectual investigations, even as we rationalize the world around us. I started my research interested in what the Hungarian psychoanalyst Sándor Ferenczi called “the confusion of tongues.” Borrowing from the biblical story of the Tower of Babel, Ferenczi refers to the confusion between the language of tenderness that children speak and the language of passion that abusers introduce.

The paradox of affection and exploitation is one of the most prevalent confusions related to sexual abuse, one that leaves children bewildered and tormented. Abusers don’t just threaten and scare children; they often provide affection, promise security, and make the child feel special. I focused my research on what children’s play could teach us about their emotional experiences and vulnerabilities, and I was particularly interested in documenting the playing out with children of fairy tales, stories that contain emotional material that carries universal meaning. I chose one fairy tale to research with my young patients: “Little Red Riding Hood.”

About a week after my research proposal was approved, Lara walked into my office. She opened the session by saying, “Today I have an idea of what we could do.”

She and I usually played “family” together. She would ask me to play the daughter so she could be the mother, and through that role-play I not only learned but also felt how painful it was to be a daughter in her family. Playing a daughter who, like herself, lived with her parents, Hanna and Jed, and with her half brother, Ethan, who was nine years older, allowed me to know what no one could tell me in words: that they were all confused and scared and that Lara was holding a family secret for all of them.

“What is your idea?” I asked, and Lara surprised me with the answer: “Can we play Red Riding Hood together?”

I was stunned by the coincidence. How did she know that this was the fairy tale I had chosen for my research and that I had gotten the approval to start only the week before?

The more experience I have with patients, the more I learn how unconsciously connected we are to the people around us. With Lara, it was the first time I’d experienced that, but it wouldn’t be the last. Since then I have had many uncanny coincidences with my patients. Through our dreams, reveries, and synchronicities we realize that we know more about one another than we are aware of.

Lara smiled. “You are the daughter and I am the mother,” she said.

I opened the closet. There were the new puppets I had just gotten: a girl with a red dress, a mother, a grandmother, and a wolf.

“What about the grandmother and the wolf?” I asked. “Who plays them?”

Lara paused. “We don’t need a wolf,” she said. “There are no wolves in our story.”

A few weeks before my first session with Lara, I had met with her parents, Hanna and Jed.

When working with children I always meet first with the parents, to gather information about the child and the family and to discuss the goals and process of therapy. Although the child is the one in therapy, very often it is the parents who need the most help. Children frequently express the reality of the family and become what we call the “identified patient,” which means the one who seems like the “sick” member of the family. Those children usually carry and express the problems of the whole family as a unit. Most families have one member who is unconsciously assigned to carry the symptoms, that is, the family member on whom the family projects the pathology. That person, often one of the children, will be the one sent to therapy. When treating families as a system, we explore the role of the child as the symptom carrier for the family.

Lara was the “identified patient” in her family. She was in second grade and would wake up in the mornings nauseous, holding her stomach and crying that she didn’t want to go to school. Her parents believed she suffered from social anxiety. After meeting with Lara, I understood her anxiety a little differently, realizing that she was worried about her mother, and therefore it was hard for her to separate from her. It wasn’t that Lara didn’t want to go to school, but rather that she wanted to stay home with Hanna, whom she experienced as distressed and felt she needed to protect.

A Frightening and Unusual Story

During that first session, Hanna and Jed told me an unusual and frightening story. They explained that when Lara was only five years old, her grandmother, Hanna’s mother, Masha, filed a complaint against Ethan, Jed’s son from his first marriage, for molesting Lara. Ethan was fourteen years old then, and social services were called to the house to investigate. But no signs of sexual abuse were found and the file was closed. Since then, Masha had filed eight more complaints against Ethan. Each time there was an investigation but no evidence was found and no charges were filed.

“Our family is torn. We don’t know what to do and whom to believe,” Hanna told me during that first session. “I haven’t slept well since it happened.”

Jed looked at Hanna and told me that Hanna was the one who had raised Ethan. Jed’s first wife had died when Ethan was only seven years old, and when Hanna had married Jed, she had become a mother to his son. Hanna loved Ethan.

“Since her mother accused Ethan of molesting Lara, everything in our family has changed,” Jed said. “We all became suspicious of one another, not sure who lies and whom to believe, whom we need to protect and whom to blame.”

Hanna started to cry. “I don’t believe he did it,” she said. “I really don’t believe it. I know him so well and I know my mother; when it comes to these things she can be a little crazy.”

“What are ‘these things’?” I asked.

Jed reached out and held Hanna’s hand. She didn’t answer.

“This situation has created a lot of tension between us,” he said. “Hanna became depressed. She blames herself.”

“What are you blaming yourself for?” I asked.

“I’m her mother,” Hanna said, sobbing. “I’m the one who should know what the truth is.” She grabbed a tissue from the box and looked at me. “I don’t know, maybe I’m wrong and my mother is right and something terrible happened right in front of my eyes. I don’t know how to protect my daughter.”

There was a long silence and then Hanna said, “I realize that maybe it’s my mother that I should protect my daughter from. My own mother, whom I love. But why would she blame him? Why would she do that?”

Hanna and Jed hoped that someone would tell them what had really happened. They yearned for the truth.

“What does Lara know about this situation? Is she aware of anything?” I asked before we ended the session.

Jed looked at Hanna and they were both silent for a long minute.

“About a year ago, my mother came to visit and told Lara that Ethan had sexually abused her.” Hanna sighed.

“She told Lara that all those years she had been trying to help her, ‘to scream her scream’ she called it. But that no one listened to her. She told her that she should never be alone with Ethan.”

Jed nodded. “From then on, Lara didn’t want to go to school anymore. We thought she had become afraid of people and that’s why we decided to bring her to therapy.” The first session ended and my head was spinning. I felt nauseous and realized that those were exactly the symptoms Lara’s parents described Lara as having. I was curious to meet her.

The next day Lara arrived at her first session accompanied by Jed. She held her father’s hand, her long black hair tied in a ponytail, and didn’t look at me. “I like your office,” she said quietly, looking around, a shy smile on her face. I liked Lara from the first moment. In that initial session, Lara told me about her family and described nonchalantly how Ethan was accused of touching her inappropriately.

“My grandmother doesn’t like my brother,” she said. “Maybe she even hates him and she wants him to go to jail.”

Lara talked about these facts without emotion, as if none of this was about her. She turned to look at the dolls in the corner of the room and asked if she could play with them.

For a year, during every session we played while we talked. I observed the play and tried to listen to what she was teaching me about her world, her emotional experience, and her vulnerabilities.

Since it was not clear whether Lara had in fact been sexually abused, I decided not to include her in my research. It was surprising then when she suggested that we play Little Red Riding Hood. “It’s my favorite fairy tale.” She smiled. “Except there are no wolves in our story, remember?”

Years before it was adapted by the Grimm Brothers, “Little Red Riding Hood” made its debut in a version written by Charles Perrault in 1697. Perrault’s story was adapted from the folktale, and in it he described the moment the child met the wolf, referred to as “Mister Wolf,” implying that the wolf stood for a human being.

In Perrault’s version, when Little Red Riding Hood arrives at her grandmother’s house, the wolf is lying in bed and asks her to undress and join him. Little Red Riding Hood is alarmed to see his disrobed body and says, “Grandmother, what long arms you have,” to which the wolf replies, “The better to hug you with.” Perrault’s version ends with the wolf devouring Little Red Riding Hood, followed by a short poem that teaches the moral of the story: that good girls should be cautious when approached by men. As for wolves, he adds, these take on many different forms, and the nice ones are the most dangerous of all, especially those who follow young girls in the streets and into their homes.

Perrault presented his readers with a somewhat refined version of the popular folktale, which was originally filled with sexual seduction, rape, and murder. His version speaks to the deceiving nature of nice wolves, who hurt their victims while pretending to offer something special, presenting sexual perversion as a form of love. It was to become even more highly refined over the years to the point where the sexual innuendo was entirely omitted and the story transformed into a children’s fairy tale.

While fairy tales usually differentiate between good and bad people in ways that help children organize their world and feel safe, “nice wolves” leave children confused, unsure of what is dangerous and what is not. Abused children end up feeling that they themselves are bad, that they have done something wrong. That confusion of tongues between love and perversion will haunt them for years.

“You are Little Red Riding Hood,” Lara says, and hands me the puppet of the girl with the red dress.

“She is going to visit her grandmother,” she says and then whispers, “The girl thinks the grandmother is an old lady but she is actually a wolf.”

“A wolf?” I repeat her words and remember how she kept stating there were to be no wolves in our story.

“You will see.” She smiles as if hiding something. “You will see what I mean soon. The grandmother has a lot of secrets.”

But we don’t find out what the grandmother’s secrets are, nor do we ever get to her house. Instead Lara instructs me, as Red Riding Hood, to sit under a tree and wait for her to come pick me up.

“I will be back soon,” she says firmly.

She turns her back to me and starts playing on her own. I am left to sit there for a long while, knowing that I have been assigned to be the girl that Lara has been, lost alone in the woods, overwhelmed by the secrets of others. Sitting there in silence, waiting for Lara to come back, I feel like the little girl I used to be, when I was left to wait for my parents to come pick me up from the candy store. My “me-search” enters the room and I realize what I am looking for. I suddenly remember what I always knew.

I was seven years old, younger than Lara. I had started second grade in a new school far from our home. During the first week of school my parents had told me that we were planning to move to a new apartment, closer to the new school, but until then I should wait at the candy store after school and they would pick me up from there.

Every day, I walked to the candy store on the corner and waited, exactly as they’d told me to do. Moses, the owner of the store, was a kindly old man with a white mustache and a big smile. I liked him. I believed that he liked me too, and I especially liked that he gave me candy.

As a little girl, there was nothing I loved more than candy. My mother, in an attempt to feed us healthy food, did not allow it in the house. She used to serve us plates with sliced apples and dried fruit. “Candy made by nature,” she called it.

When Moses offered me candy for the first time, I was thrilled and ate it as fast as I could. He looked at me and smiled. “I see that you really love it.”

The following day he offered me ice cream that he kept in a freezer in the back of the store. “What kind do you like?” He had a cone in each hand. “Vanilla or chocolate?”

I pointed to the vanilla one.

“Why did I know you would choose that one?” he teased, and then asked if I wanted to come pick out something from the back of the store.

“I will let you choose whatever you like,” he said.

Moses always smiled, and his kisses were ticklish and wet. Once in a while his wife would come to the store and he would put a little chair for me in the front and ignore me until she left.

When my dad arrived to pick me up, Moses would tell him what a good girl I was and wave goodbye. “See you tomorrow.”

I liked waiting for my parents there, but as time passed I started feeling nauseous.

“Moses gives you too much candy,” my mother would say. “That’s why your stomach hurts.”

But that wasn’t the reason. I wasn’t sure why; I just knew that I didn’t like it when he hugged me so tight. I still liked him even when I didn’t.

In third grade I stopped liking Moses. We moved to our new home and I tried to avoid walking near his store. Only years later was I able to put it all together and understand what had really happened in the first few months of second grade. I never told anyone, and I wasn’t always sure if it had actually happened or if I’d imagined it.

Freud viewed memory as a fluid entity that was constantly changing and being reworked over time. He referred to this dynamic as nachträglichkeit, translated into English as “afterwardness,” which means that early traumatic events are layered with new meanings throughout life. Freud was especially focused on sexual abuse as an event that would be reworked retrospectively as the child got older and reached certain developmental phases. Sexual abuse in childhood isn’t always registered by the child as traumatic. The child is overwhelmed with something they cannot process or even make sense of.

As time passes, the traumatic experience is reprocessed. In every developmental phase the child will revisit the abuse from a different angle and with different understanding. When that abused child becomes a teenager and then an adult, when they have sex for the first time or have children, when their child reaches the age they were when the abuse happened — in each moment the abuse will be reprocessed from a slightly different perspective. The process of mourning keeps changing and accrues new layers of meaning. Time will not necessarily make the memory fade; instead, the memory will appear and reappear in different forms and will be experienced simultaneously as real and unreal.

Nineteen years after I first met Lara, it is a gloomy day in mid-September and I’m about to meet her again. It is also my birthday. In the intervening years, I’ve had three children. I have stopped working with children and am now only seeing adults. My office is in the same neighborhood as it was nineteen years ago, in downtown Manhattan.

I open my door and look at the tall young woman who stands there. I do not recognize her.

“I grew up quite a bit.” She smiles as if reading my mind. “Thank you for answering my email so quickly, and for agreeing to see me.”

She sits on the couch and looks around. “I like your new office.”

I recognize her smile and these first words.

“Those were your exact words when I met you for the first time,” I say, trying to learn something about her from the way she looks: the black T-shirt, the black long silk skirt, her sneakers and blue nail polish, and her long straight hair, which I think used to be curly. I’m trying to read what has happened to her in the years since then. Where has she been? Is she happy? Did she find out what really happened?

“I know it’s your birthday today,” she then says to my surprise.

I nod and smile. Some things don’t change. She still knows more about me than I expect.

“Don’t worry, I can’t read your mind,” she adds as if reading my mind. “When I tried to find you, I googled you, and one of the first things I found on your Wikipedia page was your birthday. I was happy you scheduled our session for today. I really wanted to give you a gift.”

Traditionally, therapists do not accept gifts from patients. The contract with our patients is clear; there is no dual relationship, no exchanges other than our professional services for an hourly fee. Psychoanalyst and patient share a joint goal of trying to explore the unconscious; therefore, it’s interesting to understand when and why a patient brings a gift and what that gift represents. But in reality nothing can make a gift feel unappreciated and dismissed more than analyzing it.

Lara opens her bag and hands me a small puppet. It is a girl wearing a red dress. Our Little Red Riding Hood.

She surprises me again.

“Do you remember?” she asks, and she suddenly sounds like the little girl she used to be.

“Of course I do. I never forgot,” I say.

We look at each other. I like her as much as I did all those years ago, and I wonder what has made her look for me now.

“I came to see you because I need your help.” She answers the question I haven’t yet asked out loud.

We start where we stopped years before. Lara tells me about her family’s move back then to the West Coast. It was sudden; she didn’t even have a chance to say goodbye. “In retrospect maybe we were running away,” she says. “Running away from the unhappiness my family lived in. But the unhappiness followed us and in fact only got worse.” The tension between Lara’s parents, Hanna and Jed, became intolerable, and four years later, they got divorced. Jed lost his job and had to move to work in Denver. Hanna grew even more depressed and was hospitalized. Lara found herself alone, and at the age of fourteen she had to move yet again, this time to live with her grandmother Masha.

Lara talks and I feel sad and worried. How was it for her to move again, to separate from both her parents? To live with her grandmother, whom she used to have mixed feelings about?

“At that point things actually got better,” she continues. “My grandmother was wonderful and my life with her was so much easier. I realized why my mother loved her so much. She supported me and understood how hard this new living situation was for me. She was caring and gave me everything I needed. Once a week we traveled together to visit my mother in the hospital, and once a month we visited my father. At some point, after my mother was discharged, I made the decision to stay and live with my grandmother permanently.”

I listen to Lara and remember the way Hanna used to talk about her mother, defend her, describe how in spite of the fact that she believed her mother was responsible for the break in their family, she loved her and could never fully blame her. When Jed expected Hanna to cut her mother out of their life, she refused. Now Lara expresses the same feelings about her grandmother. Something has changed since her grandmother was our bad wolf.

“My grandmother grew up in Russia with eight siblings,” Lara tells me. “She is the youngest and the only one who is educated. She values education and encouraged me to go to graduate school. In fact, she’ll be paying for my doctoral degree,” Lara says and then smiles shyly. “I decided to study psychology. I was just accepted into a PhD program.” Then she starts giggling. “Maybe I want to be you. I mean, as a child, therapy was the only time I didn’t feel alone. I felt that you really wanted to know me.”

Lara takes a deep breath. She looks tired and I see how hard she tries to be likable, easygoing, not depressed like her mother. She was always tuned in to others, making sure she was not a burden on them and instead taking care of those around her.

“You said you needed my help.” My voice sounds softer than usual as I ask, “Tell me, what brings you here today, Lara?”

Lara stares out the window for a long time.

“Your old office used to have big windows looking at Grace Church, I remember,” she says, still gazing outside. “There was a coffee place across the street and I used to sit there with my father every week after therapy. He would order fresh mint tea and a croissant, and I would get a baguette and use all the chocolate spreads that were on the table. Every week we would sit there silently, eating and not looking at each other. He never asked me how therapy was. Maybe he was too afraid to know. And I didn’t think about anything else but the sweet spreads that my mother didn’t like me to eat and that made the end of a session less bitter. I never liked separations."

“I remember sitting across the street, staring at the entrance of your building, hoping to see you walk out and wave to me. I didn’t want you to meet anyone else after I left. I wanted you just for myself. And I wished that my father would say something, ask me something, it didn’t matter what. Even one question would have been enough, so we wouldn’t have to sit there in silence. I wished that he would wonder out loud if I liked the spreads and which one I liked most. I would point to the hazelnut chocolate, and maybe then I could tell him about Little Red Riding Hood’s basket that we packed just before the end of the session and how I put unhealthy candy in it and nothing else. I wished that he would smile and say that he knew I loved sweets because he noticed that I ordered the spreads after therapy every time. But he didn’t ask anything, and I wasn’t sure that he noticed what I was eating or anything else about me.”


Lara pauses and looks straight into my eyes.

“There are many questions from my childhood that were never asked. There was no grown-up who could know the answers. There is a mystery that I wasn’t able to resolve on my own,” she says, and I know what she is talking about.

Lara and I start meeting again once a week. She begins her doctoral program, trying to find the topic for her dissertation, her “me-search.” Her mind will lead us to the questions that were never asked. Her research question will be born in that void and so will the truth.

It is a winter day when Lara comes in holding an old picture; in it she is thirteen years old, with a backpack on her shoulders. She is wearing gym clothes and is smiling at the camera.

“This is from the time before my parents got divorced,” she says, and I recognize the girl in the picture; she looks very much like the girl I knew. “I will never forget that day; it’s when I got my period for the first time. My mother took this picture and then called my grandmother to tell her that the ‘aunt was visiting’ or something funny like that.” She pauses.

“I heard them fighting for the first time. My mother was crying and yelling at my grandmother. I couldn’t hear what my grandmother was saying but I knew it was bad. I knew she made my mother very upset and I felt terrible. I thought it was all because of me.

“It was the one time I remember asking directly: ‘Mom, what happened?’ “‘It’s nothing; it’s between me and Grandma,’ my mother said, but I didn’t give up. ‘What did she say? Why are you crying?’”

Hanna told Lara that her mother had asked her to cut Lara’s hair short.

“My mother told me that and started crying again. She thought it was the meanest thing one could do to a girl. She thought it was crazy.

She told me that when she was about my age and got her period for the first time, my grandmother took her to the barber and without further explanation had her hair cut short. She remembered looking in the mirror and the tears running down her cheeks. ‘I look like a boy,’ she sobbed.

“‘Why did she do that?’ I asked, but my mother didn’t answer. I asked again, ‘Mom, why did Grandma do that to you when you were my age?’

“‘Sometimes it’s hard to understand Grandma,’ my mother answered. ‘She brought strange traditions from her country, from her own childhood, who knows.’”

Lara and I are silent. I wonder if she has the same thought I have. Does she realize that her grandmother was trying to protect her daughter by making her look like a boy and not a girl? Did she try to protect her daughter, and now her granddaughter, from sexual abuse?

No one wanted to know. No one ever asked.

I remain silent, asking myself if Lara is ready to question her family history.

Our wish to know everything about our parents is a myth. Children are in fact often ambivalent about learning too much about their parents. They don’t want to know about their parents’ sexuality and often try to avoid knowing intimate things from their history.

“I need to know what really happened,” Lara says decisively and points her finger at the girl in the picture.

The girl in the picture smiles a fake smile.

“My grandmother,” she says, touching her long straight hair, “was always so protective of me. She accused Ethan of abusing me, but then after my parents got divorced that was all forgotten. No one talked about it anymore. That was strange.”

Lara looks severe. She suddenly seems much older than her twenty-nine years. She takes a brief glimpse at her watch, calculating how long we have until the end of the session. I know she needs time to think through her history.

“When I lived with my grandmother she used to scare me,” she says. “She used to repeat that I had to be careful. She would tell me strange things, for instance, that I needed to wear underwear to bed, other- worms would get into my vagina. She would whisper it and I remember feeling nauseous. Every time she talked about my body she would start whispering. When it came to sex her boundaries were strange. She talked about inappropriate things as if they were normal and about normal things as if they were perverse. Her whispering made me feel dirty, as if she had dark secrets that came out at night, and then in the morning she would be my loving grandmother again.”

“When you were ten years old and we played Little Red Riding Hood, you told me that the grandmother in the story had a lot of secrets,” I say. ‘You will see,’ you used to repeat, ‘you will see.’ But we never found out what those secrets were. Maybe you are ready now to ask the questions that were never asked.”

Lara travels to meet with her grandmother Masha. She wants to learn about Masha’s childhood and hopes to find her own answers there.

Masha grew up in a chaotic household with very few resources. Her parents went to work early in the morning and came back late at night. Her oldest sister, who was thirteen, became her main caretaker. Masha told Lara that she always felt her mother didn’t want her, that deep inside, her mother regretted having so many children. Masha was a shy girl and a good student. Excelling at school was her way to feel special and worthy.

One night, when Masha was ten years old, she had a bad dream. She often had bad dreams but knew she couldn’t wake her parents up or they would be upset with her. She sneaked into her fifteen-year-old brother’s bed. Her brother was the smartest; he was funny and brave and the one she admired the most.

He kissed her.

From then on her brother came into her bed every few nights. She would make believe she was asleep and wouldn’t make any noise. He would touch her gently and never hurt her. In the morning they behaved as if nothing had happened.

It was when Masha was about thirteen and got her period for the first time that her mother told her in a very matter-of-fact way that she shouldn’t let her brother in her bed anymore.

“Do you mean her mother knew?” I can’t stop myself as I interrupt Lara, who is still shaken by what she learned.

Lara nods. “Yes, but they never talked about it. She never told anyone.”

Unprocessed experiences always find ways to come back to life, to reenact themselves again and again. Masha’s repressed memory came to life in the typical way repressed memories do. It snuck into the mind unexpectedly, triggered by later events. For Masha, Ethan and Lara were a reminder of her and her older brother. That close relationship between a brother and a sister awakened her own repressed memory, and she felt the urge to give Lara the protection she never had, to be the parent she herself had always wanted. Her request that Lara’s hair be cut short was an attempt to protect Lara, in the same way that Masha believed she protected her daughter, Hanna, when she became a woman. Through Lara, Masha relived her own sexual abuse, which she could never fully process.

Sexual abuse is one of the most confusing traumatic experiences that we know. The intergenerational aspect of sexual abuse is unique in the way that each generation overwhelms the next and inflicts on it the drama of their sexual trauma.

The next generation’s world is often sexualized in the same way that the victim was sexualized as a child. They feel flooded by the parent’s unintegrated sexuality and perplexing boundaries. As Lara describes, innocent, trivial things, such as the underwear she wore when she went to sleep, were filled with sexual meanings. The adult — in this case Lara’s grandmother — who tries to make sense of her own feelings often communicates to the child the confusion about what is safe and what isn’t. The original confusion between innocence and perversion is played out through the next generation, with seduction, promiscuity, and prohibition all intermingled. The next generation usually describes growing up with a constant, vague feeling of violation that only later in therapy is understood to be related to the original break of boundaries in their family’s history of sexual abuse.

In her article “Enduring Mothers, Enduring Knowledge: On Rape and History,” Dr. Judith Alpert describes how sexual abuse can present itself in the mind of the next generation. Using her own childhood experience, she discusses the way traumatic thoughts and “memories” can be transmitted from parents and grandparents and present themselves in the child’s mind as their own. That phenomenon leaves everyone, the child and her caretakers, with the confusion that is at the core of sexual abuse. As in Lara’s case, our challenge is to hold all generations in mind — grandmother, mother, and child — as victims of either sexual abuse or the intergenerational inheritance of sexual abuse.

Masha, who was reliving her own unprocessed trauma, devastated her family with the idea that Lara’s brother sexually abused her. Lara became more and more overwhelmed. It was as if she were reliving her grandmother’s repressed feelings. Through the family’s ongoing rumination and the premature introduction of sex, Lara felt the intrusion into her body and thus the scene of sexual abuse was reenacted.

“When I was sitting with my grandmother last week and she told me about her childhood, I cried. She didn’t,” Lara says, and tears drop down her cheeks. “I tried to listen to her the way you listen to me, and to help her understand that she could tell me anything and I wouldn’t judge her, that I really wanted to know her.

“At some point she stopped and said she didn’t want to talk about it anymore. But she kept talking and I didn’t say a word. She started blaming herself, saying it was she who went into his bed first. Then she started to question her memory and said that it all sounded much worse than it actually was, that things were different then.

“Before we went to sleep she made me a cup of tea and served it with a slice of the chocolate cake she had baked for me.

“‘I know how much you like chocolate,’ my grandmother said, and hugged me. Then she held my shoulders, making sure I looked at her. ‘Lara, please don’t take my problems on you,’ she said. ‘I don’t want you to be sad because bad things happened to me. Worse things happen to people. That’s life; my life isn’t so special.’

“‘You had to keep a secret for so many years, Grandma,’ I said, and hugged her as tight as I could. But she just kept nodding. ‘I didn’t keep a secret. It was something I didn’t always remember. The secret kept itself.’”

“I think I found my ‘me-search,’” Lara tells me as she wipes her tears.

       ***

She will go on to study the tormenting and deceptive impact of incest and sexual abuse on the next generation, those aspects that are hard to research, as they are seemingly irrational, puzzling, and unformulated experiences, but that Lara lived through in her own childhood. We both recognize that one way to face that transmission from generation to generation is to process those experiences and help others process and own them, too. Demons tend to vanish when we turn on the lights.