Category: Therapeutic Issue

Melting Fear with Love

Posted on by Psychotherapy.net Team

Walking up the back stairs, I heard someone yelling and cursing loudly. I pressed the red button releasing the door lock and came onto the third-floor unit. The fire of her fury had burnt out rapidly, and a 32-year-old young woman—I’ll call her Gwen—now sat hunched and sobbing in the nook at the end of the hallway. I thought if I spoke or approached too closely she would dismiss me, so I sat quietly 10 feet away. Her breathing slowed, she sighed and looked questioningly at me. I introduced myself and my role as a therapist, and she began to tell me of her frustrations: with her medical problems, her mood shifts associated with bipolar disorder, and feeling trapped in a nursing home with people ordering her around.

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During her stay, Gwen had many similar fiery outbursts aimed at authority figures, and weekly conversations with me in which she spoke of being trapped and tormented as a child in foster care. She felt furious with her biological mother for abandonment, and with her abusers. As a child, her proficiency with math was a saving grace for Gwen, and her most keen desire was to teach young children about the delights of mathematical thinking. Gwen had been burned by betrayal as a child, and suffered inflammatory medical problems and destabilizing bursts of inflamed emotions that limited her progress in pursuit of her goals of a stable life and a teaching job. She loved being a teacher of young children and wanted to stabilize her physical and mental wellness so she might obtain an apartment and a return to work.

Yet Gwen could easily erupt in dragon’s breath fury when frustrated or challenged or limited by an authority figure. We talked of how her suffering as a child was unjust, and how her feelings of anger were understandable, yet how the heat, hammer, and anvil of her anger needed to be forged into steel-strength skills for successful adult functioning.

Watching the movie Frozen with our grandchildren, I was reminded of Gwen, and reflected further on the emotional themes she and the fictional character Elsa had played out in their lives. Each an orphan with a gift, overwhelmed by circumstances and emotional reactions to them and fleeing into unhelpful and alienating defenses—either with ice or fire—and as yet unable to assume full adult responsibility until brought home by love.

***

In the movie Frozen, the initially playful child, Elsa, has been endowed with special powers over the piercingly beautiful yet dangerous elements of winter.

In Norway, the setting for the movie, the freezing powers of winter exert tremendous influence over the lives of the Norwegians. It seems only natural to mythically imagine reversing the dynamic and exerting unique and personal control over cold, ice, and snow.

Elsa is not only endowed from birth with ice magic, but she is also likewise enlisted from birth to inherit grand royal authority as the Queen. Yet with a lack of parental or adult guidance or guardianship, she is left unprepared to understand or to cope with either form of power. With no guiding principles or instruction, she can only rely on her increasingly troubled and difficult-to- control emotions for direction.

In her journey from fear towards love, Elsa magically conjures two characters: Olaf and the Snow Monster, which represent differing elements of her character and of her reactions to the overwhelming circumstances enveloping her. Olaf represents the playful joy of Elsa’s childhood with her younger sister Anna, and the Snow Monster embodies the ferocious defensiveness Elsa has developed as a coping strategy.

Elsa learned only fear and cover-up as ways of managing her special gift. Added to that were the burdens of unresolved grieving over the deaths of her parents and her misguided estrangement from Anna. Under the additional burden of authority as a newly crowned queen, Elsa fails and flees; from the sister she ostensibly wants to protect—even when Elsa knows that Anna is actively endangered by a conniving scoundrel—and as well from her responsibility for the needs of the people she is destined to rule.

Elsa experiences an initial, albeit illusory, euphoric sense of release—which is anything but genuine freedom—as she isolates herself ever further inside a grand though chilling fantasy of solace through solitude.

Elsa, sadly, is not—at least not yet—a heroic figure. She never risks herself for the sake of another. Elsa is a tragically lonesome figure who withdraws from others into an ever-deepening coldness. Elsa even rejects her sister after Anna has come to call her back to family and community and responsibility.

The real heroine of the movie is Anna, who remains hopeful even while enduring a childhood of rejection and imposed isolation. Anna always believes the best about her older sister Elsa, and Anna departs immediately, and on her own, to find and rescue the sister who has run away.

Anna awakens love and heroism in the character Kristoff. It is their budding love for each other, along with the vestiges of Elsa’s hope and joy in the figure of Olaf, which prepares the way for Anna to give of herself to the end in a successful attempt to save Elsa through an act of true love.

***

Two years after my initial encounters with Gwen, I had the opportunity to work again with her in a different nursing facility after she experienced another medical flare-up. This time, her attitude and outlook were far more mature and optimistic than when we first met, yet she still struggled with unstable medical and emotional distress. She was considering the short-term goal of moving in with a family—a lady and her two young adult daughters—under a foster family care program. One morning she was crying heavily when I came to her room. Gwen said, “I know it’s different, it’s not the same as foster care when I was a kid, but it reminds me of that.”

The host family was patient and kind and invited her six times to their home, so she might gradually consider the option of living with them, without any rush to decide. Gwen reflected with me on each contact she’d had with the potential host family—what they said and did, and how kind they had been and how hard it was for her to trust that it might turn out well. However, she also felt reassured to learn that the host family would hold no authority over her, and that she would be free to move on from their home to her own when it became available. She could live in a house with a friendly family—with ordinary routines and with full opportunities and encouragement to pursue her dreams.

Here finally was a chance for the stability she yearned for without the need of flame-throwing defenses. For me, Frozen was the perfect illustration of the challenges of coping with losses and misfortunes and injustices, while learning to love and care for others and to responsibly develop one’s particular gifts. As a psychotherapist, I was able to draw from the riches of mythology, fairy tales, literature, and cinema to elicit analogies and insights to formulate broader understanding of the trials encountered by my client.

Two weeks after moving in with that family, Gwen returned in triumph to the nursing facility to share her relief and satisfaction. The gentle and loving support of the host family helped to melt her dreadful fear and allowed her to enjoy the ordinary, yet for her rare pleasures of family life.

Anger and Powerlessness in the Era of COVID: Changing the Narrative

Posted on by Psychotherapy.net Team

Anger seems ubiquitous in our society, a pandemic, perhaps, if not an epidemic. Our clients come to us angry about a great many things, and have a right to be angry about many, if not most of them. Furthermore, while anger is usually thought of as a dangerous, uncomfortable, or even “negative” emotion, it can actually be very healthy—an emotion that alerts them to the fact that they might be in danger—that things are not okay. That a boundary has been crossed. That they are not safe or someone else isn’t. Anger can provide our clients with important information—that action needs to be taken to make things right or to create safety.

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That said, just like any emotion, while the initial feeling of anger might be justified, our clients’ understanding of the feeling, and the narrative that accompanies it, might not be. In other words, feelings are never wrong, but interpretations or narratives about them (and what to do about it) often are.

To give a simple and common example, a patient of mine, Jonathan, has struggled mightily with road rage. If he was driving and another driver made a dangerous move in front of him and nearly caused an accident—or even simply made a move he considered to be “inconsiderate” of him—he often felt a surge of adrenaline, experienced initially as fear and then as anger. Here his anger was telling him—in some cases rightfully—that the person made a dangerous choice that was not safe for him.

However, as we slowed down and analyzed his reactions and looked into the narratives he created around these incidents, we learned that there were layers of interpretations. The first was obvious and caused anger from feeling unsafe: that the other driver was being unsafe or not considering other drivers. But Jonathan was also creating a second narrative with that anger: he was interpreting the other driver’s behavior to mean that they didn’t care about him or, worse, that they were recklessly disregarding his safety on purpose. It is this second narrative that would cause him to become even angrier and lash out at the driver in some way that would lead to intimidation or unsafe behavior by him or both parties.

In our work together, Jonathan became able to suspend his second narrative and hold the possibility that it could have simply been that the person wasn’t paying as close attention as they should have at that moment—something that happens to almost all of us. Or that they were rushing to the hospital because of a medical emergency and paying less attention to safety in the interest of speed. Or perhaps something flew into their eye, and they were temporarily blinded. Or maybe even that people’s definition of consideration was different than his, and that was okay. In time, he was able to understand that he didn’t actually have the information that would allow him to attribute motive or intent to the other driver.

Allowing his anger to create that second narrative might have made him feel good or righteous at that moment, but ultimately it wasn’t based on fact and, more importantly, it frequently led to less safety rather than more. Most often, the reason he created that second level of the narrative was because of rage’s closest companion: powerlessness.

When hurt, our clients’ safety has typically been threatened, or a boundary has been crossed. It is not just anger that they feel, it is powerlessness. They feel out of control. Someone, or some group, has made a choice or choices that had an effect on them (or people they cared about, or the planet), and they hadn’t been consulted. The choice was made without them.

This points to an experience that is deeply uncomfortable and yet an undeniable fact of life: our clients don’t always get to choose how things go, even when it is painful for them. They come to recognize that to a degree, powerlessness is part of life.

This fact of the human experience is so difficult to accept. And it’s especially difficult to accept for clients who were traumatized as children—they were taught that powerlessness brings victimization and pain, so they feel terrified of being powerless again. This was certainly true in the case of Jonathan, who was severely abused as a child. Experiences of powerlessness would trigger that childhood trauma, and he would respond with rage and actions that instantly created a feeling—for a moment at least—that he could feel safe through feeling powerful, even if it was at the expense of the comfort of others (or ultimately even his and their safety).

But even among those who were treated well as children, our clients would all so much rather feel in control of their lives. Make no mistake—they should feel empowered to do all that they can and make the best of the life that they have. But the hard truth is that their power is limited. For some more than for others, but no amount of money or status will create immunity from powerlessness. If it rains when we are out for a walk, we will all get wet. Anyone could get cancer. Bullets won’t bounce off any of our flesh. If the global climate catastrophe in front of us continues, none of us will survive.

And so it is with COVID. Our clients feel deeply powerless when faced with the virus that is circulating the globe and wiping out millions of people in its wake. They come to understand, slowly in some cases, that they are all, to a greater or lesser extent, dependent on everyone else in order to create safety for themselves—in essence, as individuals they are powerless to stop it. This profound powerlessness is deeply uncomfortable and, along with the anger that naturally comes from feeling unsafe, many of our clients have coped with that by creating a second level of narrative to try to regain a sense of power.

Helen is an elderly patient in her late seventies whose husband of over fifty years had a kidney transplant several years ago due to a genetic disorder that caused kidney failure. Because of the transplant, he is on daily, lifetime immunosuppressants so his body doesn’t reject the kidney. Unfortunately, these immunosuppressants also make it impossible for his body to effectively fight off illness or respond to a vaccine in a way that would create immunity from COVID-19. Given his age and compromised immune system, he would in all likelihood die from COVID were he to contract it.

Helen and her husband are still full of energy, creative, and sharp of mind. They want to visit their children and grandchildren, travel, volunteer, and spend time with their friends. Instead, they are forced to be extra cautious and conservative in their actions and activities, reducing their world to one that is much smaller and less fulfilling than they would like. They feel trapped at home. When Helen reads on the news that people in her community are choosing not to get vaccinated because it’s their “right” or “COVID isn’t as bad as the hype” or “the government can’t tell them what to do,” she is deeply enraged. She talks bitterly about how they are “selfish” or “uneducated” and that perhaps dying from COVID as a result of their actions “is what they deserve.”

Helen is feeling enraged at the people who aren’t getting vaccinated or wearing masks. Some would argue justifiably so—their actions are denying her and her husband safety and dramatically affecting their lives. However, by attributing a lack of empathy, lack of intelligence, or malicious intent to those people, Helen is adding a second narrative to counteract her feelings of powerlessness about the situation.

Thus, whether our clients are calling the unvaccinated “stupid” or they are protesting mandatory vaccines or mask mandates, purchasing medicines not advised by the medical community, or grasping on to conspiracy ideology in order to feel more empowered by having “insider” information, these actions, amongst so many others, are ways in which Helen and others in similar or related circumstances are reacting to an experience of powerlessness and anger.

***

Anger and powerlessness are understandable under the circumstances described above in the cases of Jonathan and Helen, but their reactions, like most of those my clients experience, end up being destructive to self and others. As a therapist, I have found it useful to help my clients understand their feelings and then hold the discomfort of their powerlessness while letting the anger move through them. It has also been very helpful for me to guide them in avoiding the creation of secondary narratives, through which they attempt to grasp feelings of empowerment through frantic and unhealthy action that only serve to feed their rage. Instead, I encourage them to remain as safe as possible in this COVID era, while living with the uncomfortable feelings that powerlessness often brings.

The Day My Life Turned Upside Down

Posted on by Psychotherapy.net Team

The call came at 5:45 in the morning from an unknown number in a familiar area code, an auspicious beginning to any day. An emergency room nurse was calling to inform me that my twenty-six-year-old son had been in an accident and had arrived at the hospital unconscious with a traumatic brain injury. He was nearly 2000 miles away and his prognosis was unclear.

I was due to see my first patient on Zoom in a little over an hour and had a full day scheduled. As panic set in, I literally started walking in circles and I knew that, “COVID be damned,” I was getting on a plane as soon as I could to be with him. I also knew that I could not take care of anyone else at that moment. I was channeling all of my energy to will him back to health.

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For someone who is a planner, I have a professional will as well as a personal will, disability insurance, and life insurance. I was thoroughly unprepared to have my life upended so suddenly. I have maintained a solo psychotherapy practice for more than thirty years, and I’ve always managed my own schedule. There have been days when I woke up ill or had a sick child which required last-minute cancellations, but typically my absences were thought-out and scheduled. This was different. I quickly realized I was incapable of determining what next steps needed to be taken at that moment.

Operating on instinct and adrenaline, I called a close friend who offered to contact everyone on my schedule for that day. This was a godsend, because I knew I was unable to speak to anyone at that moment with any semblance of professional decorum. She also canceled the next day’s appointments, which gave me through the weekend to figure out what I would need going forward.

Just as I longed to have someone reassure me that my son would make a full recovery, I found myself wishing I had been better prepared for such an emergency. No one wants to have a dress rehearsal for trauma, but feeling so out of my depth only added to my distress.

Ironically, because of COVID-19, I had been working remotely for over a year and a half, which meant I had all my patients’ contact information on hand. In the past it would have been in my office and inaccessible to me from afar. Having up-to-date patient contact information readily available made it possible for me to draft an email to all my patients. Before writing to my patients, I called a colleague and asked her to cover my practice for me. In the email, I informed my patients that due to a family emergency I was taking a leave of absence from my practice for the month of July. I included contact information for my colleague in case they had an emergency. I promised to be back in touch by the end of the month with an update regarding when I might be able to resume work. In the email I tried to walk the line between providing sufficient but limited information about my son’s accident. Since I didn’t trust my ability to communicate clearly, I asked my colleague to proofread my email and kept her in the loop of what information my patients had.

Traumatic events rip the Band-Aid off our belief that we are in control of our lives. Without this protective layer it can be hard to regulate emotions. At other times when there was stress in my personal life, work often offered a respite from these concerns. But this time was different. Living out of a hurriedly-packed suitcase in an unfamiliar city and spending long hours at the hospital each day was exhausting. Although my son’s prognosis improved, the timeline for traumatic brain injuries is not clear cut. In the early days of my son’s hospital stay, I was consumed with fear and anxiety for his well-being and future. Both my husband (who went on FMLA for the month of July) and I were riding the waves of our son’s recovery and setbacks, unsure of when we could return home and resume our life.

Having been immersed in a pandemic for over a year was a good lesson that plans need to be held delicately and that caveats are the rule, not the exception. As we spoke with the medical personnel about discharge plans for my son and the possibility of his returning home with us, I began to do a self-assessment about my capacity to work.

Therapists are not interchangeable, and the particulars of each case are privy only to those in the relationship. This puts additional pressure on clinicians to return to work. When I am on vacation, thoughts of various patients enter my mind. Often, I have found those periods to bring fresh insights into my work. But this was far from a vacation, and I had no bandwidth to think about my patients. This was one measure I used to assess whether or not I thought I was ready to work. The first time I found myself on a walk with thoughts of a patient entering my awareness, I took that as a sign of my own road to recovery.

Fortunately, my son improved more quickly than anyone predicted, and we were able to bring him home with us. Despite his favorable outcome, the remnants of this traumatic event left me emotionally raw.

As promised in my first email, I sent another email to all my patients at the end of July. I updated them about my son’s progress and my decision to return to work at the beginning of August. As a way to check in and allow each of them to ask questions without using their clinical hour, I decided that I would call each of them before scheduling a session. I wasn’t able to talk easily about my son’s condition, and I was afraid of getting overwhelmed with my own emotions during their clinical hour. I scheduled four phone calls a day with time in between each one. After a month, or more in some cases, since our last appointment, I didn’t think it was fair to use their time with me to update them on my situation.

As with any significant interruption in a therapy relationship, each patient handled the break differently. One patient said, “I know in the back of my mind that you’re a mother, but I never think about you that way. I was so worried for you because I know I couldn’t bear to lose one of my kids.” Other patients were afraid I might never come back to work and felt selfish for having this concern. A few patients decided not to resume sessions, reporting that the month away had given them an opportunity to decide that they were doing well. I wasn’t surprised by this reaction and tried to process it with each one to bring closure. Two patients gave birth during the month I was away, and both spoke about how differently they reacted to my situation because of their new role as a mother. All of my patients expressed concern for me and appreciation for our connection. I found this especially meaningful at a time when I was questioning so much about the vagaries of life.

Initially there were some bumps in the road as I returned to work. Some patients struggled to share their concerns without feeling self-conscious. They compared their situations to mine and felt foolish to be upset over seemingly trivial matters. This is a common concern in therapy and one I have encountered many times over the years. As I struggled with managing my own anxiety, I was afraid I wasn’t projecting my usual self-assured presence to my patients. A few colleagues of mine have had to navigate more difficult life events, such as sudden deaths and personal medical crises while continuing to work, so I reached out to some of them for support and guidance.

To take care of myself, I started back to work slowly, spacing out sessions when possible. Not surprisingly I was exhausted at the end of each day, yet I found sleep hard to come by. Three weeks after returning to work, I took a previously planned vacation. This further disruption to my practice was admittedly quite difficult for some of my patients, but it felt crucial for my own well-being. During my two weeks off, I noted all the ways a vacation felt so different from an emergency leave, and I returned to work in September more refreshed. This additional break had an unexpected outcome in that it allowed my patients to express a wider range of feelings about my absence. As one patient said, tongue in cheek, “You won’t be doing that again for a long time!” She was in the middle of a painful divorce, and the timing of my absences was especially hard for her. She could express her feelings after my vacation, but not when I returned from my leave.

Modeling self-care is different from talking about it. As therapists, we know “actions speak louder than words,” but often we communicate “do as I say, not as I do.” I thought back to all the times I’ve encouraged patients to take a leave from work or make other life changes to support their own mental health. I could sense how carefully some of my patients were watching to see if I was truly okay. For those who are invested in keeping me on a pedestal, the illusion of my perfect life was shattered, and this was an uncomfortable intrusion into the transference. For others, knowing that something bad had happened to me helped them trust that I could actually understand their pain. Still others expressed an increase in their fear that if I wasn’t safe from harm, then no one could protect them. Processing this variety of responses while tending to my own anxiety was challenging.

***

Throughout my career, there have been stories from my life that I occasionally share with patients as points of illustration or connection. One day I hope I will be able to draw from this recent traumatic experience in a similar way, but for now it is still too raw. As we near the sixth month mark from the accident, the timeframe given by the medical professionals for the fractures to fully heal, all indications are that my son will make a full recovery. I am truly grateful for this outcome, but tears are still close to the surface for me. It takes time to integrate such a life-changing experience, but with support from others I trust I, too, will heal.

Being a psychologist is one of my life’s greatest pleasures. It gives me a sense of purpose and allows me to engage fully with other people. Relying on myself for so many years in private practice comes naturally to me, but this recent experience was my wake-up call that I need to be better prepared to make sure my patients can be cared for in the event that I can’t do it by myself.

Then My Christianity Kicked In

Posted on by Psychotherapy.net Team

My father told me that his grandmother practiced Santeria by wearing amulets and skirts of various colors and surrounding herself with stones in order to honor the various deities. She also made herbal remedies. I remember him explaining to me that this practice was no different from other religious traditions, that it was not witchcraft, did not hurt others, and was deeply spiritual. He believed that it was looked down upon because of its origins in slavery and false association with witchcraft.

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However, I grew up mostly with my mother’s side of the family, in which everyone is (was) actively involved in the Christian faith. I, too, practiced Christianity for many years, although not as devoutly as they did. My family actively distanced itself from those who practiced Santeria. While they acknowledged it as a religion, they even more deeply believed that it was about hurting others, did not honor God in the way that Christians do, was equivalent to witchcraft, and sought to lead followers down a path of misery and suffering. My family also believed that according to Santeria, we bring spirits with us when we die, which for them was the equivalent of demonic possession.

Recently, while interning as a counseling trainee at a local Hospice facility, these two religious pathways intersected most dramatically for me. I had stopped by the room of one of our residents, a middle-aged Cuban woman who had recently suffered a stroke and whose life had been cut short by cerebral arteriosclerosis. She would soon be leaving behind two sisters and two daughters.

As I stood in the doorway to her room, about to knock, I noticed her stones, crystals, and spirit dolls, material staples of Santeria practice. While I know people who practice the religion, I have never had, nor taken, the opportunity to speak with them about it. While the religious adornments in her room were not what I would call “extreme,” I was immediately uncomfortable. I remember thinking, “Oh, wow, what do I do now? and “Why does she have this around,” and “I don’t want to touch these things.” In looking back at that moment, I worried that my lack of experience with and knowledge of the practices of Santeria might taint my interactions with this woman.

It was at that moment that my Christianity kicked in. All those negative messages I had heard over the years about Santeria swirled in my head as I stood there unable, or perhaps unwilling, to enter. I felt caught between the competing pulls of my rigid, conservative Christian religious upbringing and my desire to enter the patient’s space and in some way be helpful. It was like trying to simultaneously focus on two discordant melodies, and not being able to clearly hear either. I realized that I was there to help this woman, to be present and open to “her,” but felt guilty for somehow betraying the values of my family. My Christianity had never been put to this kind of test.

While I so wanted to help ease her burden of impending death, I also felt guilty for not being able in the moment to fully put aside the biases I had been exposed to regarding Santeria. I remember telling myself to stay open-minded, but was painfully aware of feeling that I wasn’t going to be able to help her at all. I took a deep breath and entered her room, trying as best I could to free myself from the gravitational pull of that doorway and my inherited beliefs. I really had no choice but to push forward, at least for the moment. I knew as I entered the room that I would have to revisit this painful moment of conflict if I was to become the therapist I hoped someday to be.

When I later spoke with the patient’s daughters and sisters, each of them kind and compassionate, I realized that they, too, were having difficulty, but not for the same reasons I was. They were struggling to come to terms with the impending loss of their loved one rather than with her religious practices. I worked hard to focus on their pain so that I could be there for them as they were attempting to be there for my patient.

During that first meeting with the patient and her family, I had difficulty freeing my gaze from the dolls and scent of Florida water perfume, said to bring peace, luck, and fortune. We did not discuss Santeria—that was my issue, although I probably could’ve asked how Santeria played a role in their lives and that of my patient. They shared that my patient was the one who had been responsible for bringing most of her family from Cuba and how she was this larger-than-life person. This small but deeply significant piece of family history helped me almost instantly to see my patient as someone larger than the small, frail woman who just happened to practice a faith so different from the one in which I had been raised.

Subsequent family meetings focused on their efforts to accept the impending physical loss of their loved one and how they were attempting to build a support system around one of my patient’s daughters who was in the grips of addiction. They, like every other family in Hospice, irrespective of religious practice, were trying to come together. When my patient finally passed, they were saddened but relieved that she was no longer in pain.

I have not historically viewed myself as a closed-minded person, but in retrospect see how my faith, my religion, came with blinders. I won’t soon forget that initial feeling of discomfort when I stood in that doorway, caught between two different worlds and self-focused. My biases were laid bare that day, and thankfully, I was able to hold them in check just long enough to be of use to that dying woman. I now realize that moments of growth and self-awareness are not always accompanied by good feelings. I am, however, willing to learn, and I am taking the opportunity to better understand Santeria, and what it means to take a giant step away from certain aspects of my family history without feeling diminished or disconnected. It helps that in this my second-to-last semester of graduate studies that I am enrolled in a diversity course and am trying to be a better version of myself, so that the next time I stand in an uncomfortable doorway, I will walk inside with a lighter step.

Confessions of a Student Counsellor

Posted on by Psychotherapy.net Team

Both Sides Now

At the time of this writing, I have one semester to go before completing my Master of Counselling degree, and I am sixty-five hours into the one hundred required hours of counselling contact hours of my student placement. I am still unsure as to who has received the lion’s share of therapy during these sixty-five hours, my clients or me?

This has not been my first exposure to the rudiments of counselling, however—I had some years of experience in addictions counselling and case management and no shortage of support work in various fields to ease me into the relative displacement of a professional counselling placement. At forty-seven years of age, I have undergone many transitions and life experiences.

Nevertheless, the Masters has been quite a proficient primer and prodder of the all-too-many things I didn’t (and still don’t) know about counselling practice, and of the myriad of things that I need to know in order to provide effective and ethical therapy for a range of concerns and to a broad demographic.

Having had experience in various counselling settings—and being quite familiar with both sides of the counsellor’s chair—together with the fact that I consider myself an avid collector of knowledge, particularly in this field, I still felt a strange cognitive dissonance of both excited preparedness and complete inadequacy to the task at hand at the commencement of my placement. But that was then. At sixty-five hours in, I am a worldly veteran!

The first thing that stood out to me about my placement experience was how pretty much every session turned into a countertransference case study from my ethics class, except that I was the subject. I knew about countertransference. I had studied it. Experienced it. Was consciously aware of it. Prepared, I thought. But I never really had that meta-cognition before that one develops, both while counselling and in the post-session self-flagellation…ahem, reflective practice.

Almost every session seemed like a mirroring of the personal life struggles I had faced, parallel processes of my current situations, relatables that were bone deep. The client I was sitting with was recounting the very relationship issues I had struggled with. Of course I was batting for him! My heart was filled with sympathy, my responses were, albeit textbook, empathetic, while my mind was firing off mostly Andrew-shaped responses ready for delivery. Often, I would catch myself before essentially counselling myself instead of my client. Sometimes I was too late and would realise, embarrassingly, later that day or week. More often than not, in supervision. Or because of past supervisions.

Or I could be sitting in front of the horrifying ghost of my mother-self. That is, this particularly triggering, discomforting, and disquieting quality that my mother possessed which I painfully one day realised I had inherited, now (mostly) exorcised out of me (thank you therapists circa 2000-2004, 2008-2009, 2012-2013 and 2020-2021; you know who you are). Noticing the life force draining from my being, I would sometimes sit across from the ghost-client in a sorrowful-seething state of frustration, compassion, bewilderment, intrigue, and hopelessness. I could swing between feeling annoyed and way out of my depths to such misguided compassion that I would feel the urge to take them home and care for them.

Going it Alone

Something I knew before but re-experienced in a fresh new light during my placement is that a significant part of learning to be a counsellor is essentially done alone. There is generally no direct supervision. There is no one in the room to monitor the minutiae of one’s work. There is no direct feedback loop. It is not as if your supervisor has a document to proofread. There is no material structure to assess for imperfections or to correct. No one is surveying clients at the end of sessions to establish trainee performance. No one is there to say, “Hmmm, maybe when you froze for a minute and a half with silence…” or “Perhaps Texas Hold ’em Poker isn’t the most appropriate game to play in a session with a six-year-old…” Of course, there are opportunities to be observed by colleagues and supervisors or to record sessions and review them. But this is limited in its scope and practicability. And daunting as hell! Or as daunting as having my own personal therapy sessions broadcast to the world, perhaps. Being utterly exposed. Vulnerable.

Sitting with clients who have just expressed something, there are a plethora of potential responses in any given moment of a therapy session. Sometimes they flow readily and easily. At other times they feel forced. And in some cases, when a response hasn’t felt right, an also potential plethora of self-reflective doubt and questioning can follow: “Did I say the right thing?”; “How am I going with this client? Doesn’t seem to be any progress being made”; “What is the correct intervention to use here?”; “They have been coming for three sessions now, why won’t they volunteer something… anything?!” Being left to one’s own devices (well, me to mine) can leave one unsure at times about particular interventions to use, ways of progressing through impasse, whether or not to refer, whether I am beyond my professional competence, and one’s capacity to be a counsellor, which can undermine self-trust and even self-worth.

And then at other times, when I am feeling in my flow, when I have recognised counselling greatness in myself—you know, when a client has expressed eternal gratitude or you witness a breakthrough or an insight emerges—then I can quite easily develop that very shiny, bulletproof sheen of self-satisfaction and self-congratulation, feeling like the king of the counselling castle! Either polarity can be both misguided and unhelpful to me, I have discovered, and, left alone with such musings, can be a potentially missed opportunity to see beyond my own perspectives and to develop my practice.

Thank goodness we are not completely alone during this, at times, trial by fire. Having practicing colleagues around is such a comforting and valuable scaffold of support. I am fortunate to be doing my placement in a medium-size clinic providing both psychology and counselling services, so there are usually at least a few others to talk to or debrief to if needed. I am aware, however, that others’ placements are more isolated and devoid of such support, and I have witnessed the emotional and psychological strain that this can take. I am very grateful to be developing in the kind of environment where I feel supported and not alone. Hmmmm, maybe there’s a market for a Tinder-like app for counsellors in isolation?

I think there is a limit, however, to how far collegial support can go. There are certainly limits to my own (and I am guessing other humans’) capacity to expose oneself in the workplace. Especially as an up-and-coming trainee counsellor, wanting to exude competence and confidence at every opportunity (I am willing to admit that could just be me, but I suspect not). Clinical supervision during my counselling placement has been a great support and I think the site of my most focussed learning during this Masters and certainly during my placement. I am fortunate to have both group and individual clinical supervision. They are both supportive, instructive and provide opportunities to develop and learn from others’ practice. I have found that it is in individual supervision, however, that I have the greatest opportunity to be vulnerable and to shed light on the more shadowy areas of my practice. It feels a bit safer than group supervision and I like its structure, containment, consistency, and predictability.

Maybe Not Completely

I am fortunate that I was paired with an external clinical supervisor by my university placement team whom I like and respect, but, most importantly, with whom I feel safe. Safe to say (almost) anything to. Safe to expose my insecurities and doubts to, to be able to tell them what I did and said in a session, for example, without any debilitating apprehension. They provide safety and security in calling me out when needed, ensuring I understand my limits and blind spots. Kind of like a parent’s love in providing firm and consistent boundaries to an overly exuberant child. They encourage me and validate me, sharing their own stumbles and falls. But the catch is, as I recognised a while ago, I must be willing to be vulnerable and uncomfortable and wrong, again and again, to gain the most from this. I must be willing to be a beginner again and again and again if I am to grow and develop as a person and as a therapist. But this is hard to do at times. For fear of judgement (self and other), feeling inadequate and for (the generally unfounded) fear of finding out that maybe I am not cut out for this profession. The most satisfying, albeit challenging, learning I have experienced during this placement, and the Masters too, has been exposing myself in supervision.

Like when I reluctantly discussed a client I had seen once whom I suspected to be beyond my scope of competence. Reluctant because I was personally and professionally very curious and they claimed they weren’t in a position to engage in costly treatment options and so I really wanted to keep working with them. And I suspected that if I spoke about them in supervision (and to my line manager) that they would advise referral. But I did. And it was right. And I referred. It was frustrating and challenging, but a great experience to have in the sandpit. And I incidentally had reflected to me my potential for a hero complex. Ouch! But yes, probably accurate. Or when I spoke about how I responded to an awkward situation with a child client and their mother, suspecting I didn’t handle it very well and wanting input. And then getting feedback that challenged as well as expanded me, reinforcing that I really do not know what I do not know as well as not knowing what I do know, too. These things can sting for a bit, but I am a better counsellor for it.

Just like when I have been in therapy myself, the more I am willing to be vulnerable and uncomfortable and reveal those shadowy parts of myself, so too in my counselling role (especially as a trainee), the more I allow this, the more space I make within myself to expand. I make the space for learning and growth and development and career and life satisfaction and ideally to be a more effective therapist and, of course, to do no harm.

***

I recall a brief conversation I had with a university lecturer this year, a seasoned counselling psychologist and academic. I was reflecting on the challenges of not knowing it all and bemoaning if I would ever feel competent as a counsellor. Their response was heartening to me, then and now. They related to this feeling, stating that they still occasionally felt this way. But they also knew that they are a damn good therapist and a valuable resource for their clients. Nice.

Countering Client Hostility with Radical Candor

Posted on by Psychotherapy.net Team

“No offense, but I don't need self-awareness,” said Michelle. “That's not what I'm paying you for.” After a brief pause for emphasis, she proceeded. “I am not telling you how to do your job, but I need tools!” she demanded forcefully with a pen and notepad in her hand.

Michelle was self-referred after receiving multiple messages from friends and family that she was “difficult to deal with” and that she did not know how to “empathize” with others.

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Caught off guard, I sat silently and nodded. At that moment I felt powerless and ineffective. I also noticed my abdomen brace, as if preparing for a fight. I thought I had been doing well by actively listening to my client and helping her to feel understood. She had a gift for verbosity, which made it almost impossible for me to get a word in. By the end of the first session, however, I felt an impulse to refer her out. I even recall mentioning to her that I would find a list of providers who conducted strict CBT, as it appeared she would benefit from the structure. However, something in me then uttered out, “Let’s try my way first and if, after a few sessions you aren’t happy, I can provide you with some referrals.” I don’t know if I was slightly intrigued by the challenge or that I knew it would be difficult for Michelle to receive treatment elsewhere.

While Michelle’s intensity continued session after session, I began noticing patterns. The session would begin with some pleasantries, move seamlessly into an onslaught of reprobation, and then conclude with a slight glimmer of hope. I had never experienced anything like this.

She would admonish me for the session by saying that “it’s only me talking”—despite not allowing me to speak—and demanding that “in one of these sessions, I am going to need you to do most of the talking.” Further, she compared being in counseling to being in a “hospital” (the first time I had heard this reference).

“Don’t enact your rage on her,” said my own therapist, after I vented extensively about my exasperating and confusing sessions with Michelle. In my therapy, I would go on ad nauseum about how I wanted her to drop out of treatment. I even mentioned how I had dreams of Michelle being much larger than me and picking me up and repeatedly slamming me down. My therapist cleverly pointed out that being with Michelle felt like a rollercoaster ride (I am terrified of roller coasters). My therapist also helped me to realize that despite my criticism and Michelle’s seeming intractable intensity and displeasure with me and our work, she kept returning.

I persisted and became more optimistic over time as I noticed Michelle becoming easier to deal with, which I disclosed to her. She dismissed my praise by stating that I was lying and that the positive reinforcement was incentivized by the fact that she was paying me. I reminded her of how she had been telling me that her family noticed positive changes as well.

One of the strategies that seemed to be effective with Michelle—in addition to the basic attending skills—was my authenticity and self-disclosure. For instance, I disclosed the fact that working with her felt like entering a boxing match, and how I experienced her attitude as an attempt to push me away—even my dream about the rollercoaster.

With regard to payment, Michelle had mentioned the transactional nature of our relationship numerous times. For instance, she once accused me of using her to pay my phone bills. I wanted to be gentle but honest. “You think this is really about the money?”—pausing while Michelle nodded affirmatively—“I lose $700 per month by working with you, not including if you skip a session.” I noticed Michelle smiling. After inquiring about how she experienced my disclosure, Michelle mentioned that this was “good to hear” and inquired further about why I continued to see her at a reduced rate. This led me to mention that based on the way she initially presented herself, it would have been very difficult for her to find another therapist (she also had complained about struggling to find one in the past) and that it would cost her a lot more money for treatment that might not have been as effective (i.e., brief CBT as opposed to more ongoing relationship focused work).

***

Michelle still has moments that make it painful for me to work with her, but I do consider our work to be successful. She is recently much more likely to notice her maladaptive behavior in the moment. She often praises me for her progress, but I do not think I deserve it. I was simply the first person in her life whom she couldn’t push away. I was also honest about how her behavior affected me without discarding her.

I believe that we can do good work with most—if not all—clients if we are willing to travel with them despite their efforts to avoid meaningful connection. I also know that honesty is the best policy when it comes to engaging people who are resistant. Sitting with the discomfort that hostile clients like Michelle can stimulate and being the one person that stands by their side has often resulted in positive change for these clients—and for me.

Where Do the Therapist’s Tears Come From

Posted on by Psychotherapy.net Team

I would like to think that as a psychotherapist, I know where the tears of my clients come from. Perhaps, in the moment, they are experiencing an emotional breakthrough, an encounter with an estranged part of themselves, which has come into consciousness. Or perhaps they are bravely reliving a past trauma, which will hopefully result this time in a different, less painful imprint on their soul. But at the same time, moments like these have also been important ones for me, as I witness this cathartic unfolding in the safe space that I have helped craft, in which the client can face and express some of their most difficult feelings. And in that shared moment, I encourage the client not to hold back, not to feel embarrassed, but to acknowledge their tears and allow their emotion to spring to the fullest. But could it also be that such special moments have also elicited powerful emotions in me? Is it my role to simply welcome them in the context of the healing relationship, or is there something more in it for me, more personal and sensitive in what I feel in these moments? Most of us have watched films where the therapist dives headlong into the emotional wave of their client’s story. In the film Good Will Hunting, we witness a heart-warming scene in which the misty-eyed, unconventional psychologist, Sean, played by Robin Williams, embraces young, delinquent but traumatised Will, played by Matt Damon, when the latter sobs after a profound emotional breakthrough. How often do we encounter something like this in “real” practice? Probably not that often. Indeed, the landmark TV series In Treatment takes an approach that arguably resembles much more the “real” practice of psychotherapy. The series takes us through the sessions of the protagonist-psychotherapist, Paul who practices from a psychodynamically-informed, relational therapeutic model. Even though Paul does indeed connect with his clients in a deep way, and even if many of their struggles trigger strong emotional reactions in him, he never lets them become too visible, nor does he allow himself to become tearful. Instead, following “standard” professional practice, he brings his reactions and feelings to his own personal therapist or to his supervisor, whose validation seems quite important to him. So, are the therapist’s tears “allowed” in front of clients or not? What does psychotherapy research actually say about this? Not much, actually! Even though there has been a good amount written on how to manage the client’s tears within the therapeutic encounter, the therapist’s tears—in the presence of their clients—have until recently been almost entirely ignored in the literature. Could this be because this is such a rare phenomenon that is not even worth investigating? Maybe, but then again, maybe not, as one of the few studies addressing this issue revealed that a large number of the surveyed psychologists and trainees reported having cried at some point with their clients, and almost a third of them had experienced this within the last four weeks. An interesting related finding was that crying in session did not actually correlate with the therapist’s personality, gender, or with other demographic factors, except for that older and more experienced practitioners seem to become tearful in therapy more often as compared to their younger colleagues. And these more senior therapists exhibited a lower frequency of crying in their daily lives, which discredits the assumption that their in-session tears more likely reflected a generalized increased emotionality, or even psychological instability. In any case, such feelings seem to be important for a great number of therapists, as approximately half of them bring this topic to their supervisors and possibly even more are concerned about but never discuss them, as they are among the “most-avoided” topics in supervision. So it seems that while many therapists have dealt with this issue of crying in session with their clients, very few actually talk about it, and even fewer researchers and authors write about it. Could this be because we still largely view this phenomenon as a weakness, as an embarrassment for a healing profession, and we would much rather not expose this weakness to others and to the public in general? But is it really a weakness? Does it happen just because we are unable to control our emotions, and does it really harm clients when they witness it? Would it make sense then to ask the clients themselves how they actually perceive it? As it turns out, a survey was performed on clients, indicating that the way they perceived their therapist’s tears depended on their overall perception of the therapist. For example, a client may already view their therapist as empathetic and sensitive, so would perceive emotional displays such as tears as being related to these qualities of caregiving. But if the clinician spontaneously bursts into tears in response to an otherwise neutral narrative, the client might understandably associate this reaction with something very personal to the therapist which may be largely irrelevant to them. In this latter scenario, this seemingly unrelated emotional display on the part of the therapist could compromise the client’s confidence in their clinician or might even activate feelings of guilt for causing them psychological distress. It seems fair to conclude that clients do not necessarily interpret their therapist’s tears as “this is too much for me to handle,” but may also interpret them as “I can feel how sad this is for you.” As a therapist, tears rarely come to my eyes in session. Usually I can hold them back, especially if the client is already too emotional. But I may occasionally allow myself to become misty-eyed if I feel they could use some non-verbal encouragement to visit a difficult area of their lives. However, the last time I experienced this, it actually reflected a mix of sadness, release, and contentment—sadness about the painful feelings my client was expressing, release about the arrival of their realization and insight, and contentment for the opportunities for their future that came with this insight. I had been working therapeutically for some time with a couple. Despite their challenges and their somewhat turbulent relationship history, they did love each other, wanted to live together, and discussed a shared future. However, something invisible was getting in the way that prevented this from happening. Towards the end of one particular session, one of the clients was talking about his persistent worries of being inadequate, should he and his partner decide to live together. I suggested that this worry might be getting in the way of committing to her and that perhaps he believed that no matter what and regardless of how much he tried, he would once again and eventually let her down, that she would never really accept him for who he is, and that he would ultimately be rejected. I wondered aloud if this fear was coming from a different place, perhaps earlier attachments which stopped him from giving himself into this relationship? This client became emotional and began sobbing as his girlfriend embraced him, saying, “I love you and accept you as you are, I don’t expect you to change anything, I know you are not perfect, but I have chosen you.” In that moment of his emotional release, I experienced a sense of vicarious catharsis as I re-experienced the familiar feeling of letting out a hidden, inner burden from a space deep inside of me, where it had resided for far too long. Once liberated, that painful feeling leaves room for an even deeper sense of trust in the other and openness to merging. As if sitting front row in an ancient Greek drama and experiencing by proxy the protagonist’s catharsis, the essence of drama, according to Aristotle. My eyes welled up with tears, and my clients, upon seeing my emotions laid bare, said, “we better go now, otherwise we will make Nicholas cry, too!” As they said that, I happily left them with each other and said goodnight, closed the lid of my laptop, and stared at the English rain outside of my window.

***

So, where do therapists’ tears come from? It seems as if they are coming from so many different places that trying to track and trace their roots could just end up in drying up their wellspring… they may not always be so welcomed or comfortable, by either the therapist or client, but they do carry something rich, deep, and ineffable that words possibly cannot express.

Thinking of You Too

Posted on by Psychotherapy.net Team

I don’t typically assign homework to patients, at least not in the traditional sense. But when patients ask for something to work on during the week, something that would help maintain the momentum they’ve gathered in resolving distress, I suggest they think about our work—to reflect on the themes we’re uncovering and how they apply to their current experiences. I emphasize that while growth starts in session, it is a process that continues after.

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The work of therapy is not limited to 50-minute sessions every week; it’s happening during all that time in between, too—for both patients and therapists. I think about my patients after sessions as well; it is only natural when we’re working persistently, week after week, to understand sources of distress and facilitate change. Some of my own insights about my relationships with patients occur when I’m off the clock. And in the same way I ask patients to make sense of their thoughts, it’s equally important that I do the same.

The Regulars

While picking up the living room the other night, it suddenly occurred to me: my patient earlier in the day had spent the entire session attempting to get my approval in the same indirect way he tried to engage with his mother in the past. Amaan* and I had been working together for almost two years, and a large theme in our work has been recognizing his mother’s limited capacity for offering emotional support and the impact this has had on his efforts in current relationships. Amaan has made great progress in integrating his experiences of his mother, coming to terms with what she may never be able to give him; I realized suddenly that he was trying to cast me in that now-vacant role. In session, he had listed the areas in which he felt he had grown, the insights he had fostered about himself, and the clarity with which he felt he could move forward. I actually agreed entirely with him, but there was something about the way he expected me to corroborate his own opinions, as though anything but clear agreement on my part would undermine all his progress.

I thought about why this did not occur to me during session; after all, this is someone I’ve come to know very well, and was part of a conversation related to the exact theme we’ve been identifying for quite some time. I’ve gathered that at times, my patients’ ways of relating directly complement my own—I enjoy validating their experiences and highlighting progress we’ve made together. Recognizing Amaan’s progress would also mean an opportunity in recognizing my own as his therapist, but I have to remind myself this is not about my own ego. With this discovery, I can return to future sessions with even more awareness of what Amaan is attempting to reconstruct in our relationship and identify his efforts in real time. More importantly, I can encourage him to take faith in his own progress as he recognizes it, not through me.

Realizing blind spots are not the only reasons I find myself thinking about patients, though. Sometimes I find myself thinking about them out of genuine care, concern, and curiosity for what they are going through. Did their husband take the news well? They were grappling with whether to call their mom—what did they decide? Did our session help provide any clarity? When I find myself wanting to know more, I think about what this says of the patient more than it says of me. Perhaps the patient’s general motivation is to keep others engaged by employing a “stay tuned” attitude—and it certainly works. Maybe it is unlike a patient to attract this much concern, which is even more telling of the gravity of their distress.

Other times, a patient stays with me in a gnawing way, long after the session is over. I wonder if they’re feeling it, too. This feeling lingers after sessions where it felt like a patient was not feeling something enough. These moments feel like a dramatic irony, in which I see the whole story but they’re not yet ready to. Depending on the patient, I may use these thoughts to motivate an intervention—point out distorted thinking or question their assumptions. But if it feels so strong, I may realize that this patient needs me to hold on to the feelings they cannot yet own until they are fully capable of doing so. And that guides our work—preparing them for a realization instead of directly handing them one.

The Absentees

What about the patients who regularly cancel or forget? The patients who are ambivalent about therapy, saying that they really want to be here, but their attendance say otherwise. How is it that the patients we see less often seem to take up the most space in our minds? I’ve gathered that they use their absence to communicate something to me—to shake things up, to make me feel more toward them, to get me more engaged, only for them to walk away. When patients cancel repeatedly, or even no-show, I’ve learned that rather than take feelings toward them at face value, it’s more beneficial to use these feelings as a cue to their ambivalence about treatment.

Melanie* is a newer patient of mine, unknown to therapy in the past. In session she would often say she wasn’t sure if therapy would be helpful and was confused as to why she was here in the first place. After her initial distress regarding her relationship with her father had subsided, she grappled with how to use the space, minimized other stressors, and looked to me for direction. Her anxiety about being in therapy but not knowing how to make use of the time likely explains her frequent cancellations without request to reschedule.

Initially, I offered to reschedule and was usually met with the impossibility of doing so. Over time, I began to feel resentful of the way in which she treated our relationship and disappointed in being more interested in her experience than she was. These feelings stayed with me, and I wondered for a while how to make sense of them. Why did I seem to care more than she did? I remembered how she had a “one foot in, one foot out” attitude at the start of most sessions but eventually warmed up after a few minutes. Her ambivalence made sense all of a sudden—she needed validation for the pain she felt so deeply before being able to commit to the space and herself.

The Graduates

And then there are the patients I’ve worked with in the past. I wonder so often how they are doing—if they ever married that guy we spent so many sessions talking about, if they ever found what they were looking for that we could not seem to find together, if they think about the relationship we shared at all. For some time in both our lives, we were constants for each other. For as much as I was a part of their lives, they were a part of mine. Therapeutic relationships coming to an end means coming to terms with possibly never hearing from our patients again. But I still let myself wonder how they’re doing. When I think of these patients, I am reminded of what seemed to be most helpful, what wasn’t, what they learned, and what I did. I think about how much I’ve grown and changed because of every relationship I have had with a patient and how to make meaning of this growth for myself and other patients.

From time to time, I have run into some previous patients. Pauline* stands out to me, since I ran into her at a time when I was going through some personal life transitions and was caught off guard in seeing her. But in the few minutes we spoke, she shared that she had made many steps forward in ways we hadn’t even spoken about but in ways she was very proud of. And I was so proud of her, too. I remember when our work ended, I wondered if I could have done more to foster more insight and self-compassion. She had not accomplished her goals in the ways she intended at the start and our work had to end abruptly. In running into her, I learned that even if our relationship ended, the work continued. She too was changed because of it, and it continued to impact her motivation to take steps toward herself.

***

Patients wonder if we think about them just as they are thinking about us. When I tell patients that I think of them or disclose that something they said has stayed with me since the last session, I can detect both surprise that they are remembered and relief for finally being seen. We want our patients to make meaning of therapy and take in the work. I think that when they realize we’ve internalized them, they’ll finally do the same.

A Revealing Moment

Posted on by Psychotherapy.net Team

Each week, my interns submit a summary of their clinical hours along with a “process note,” pretty standard training fare. These notes are supposed to document their internal ups and downs; the good, bad, and ugly of their week with clients whose challenges and pathologies are probably a bit above their current pay grade. Good learning opportunity, I often rationalize, especially since they have competent on-site supervisors who are there to teach, train, and support their burgeoning yet fragile clinical identities.

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If the academic/clinical interface were a bit tighter, I would have these folks work their way up from simple and acute disorders to the more severe and chronic pathologies as they evolved through their training. But such is not always possible. So, for most of my trainees, this entails some arduous hikes on those steep and unmarked learning curves that we more seasoned clinicians have experienced—and still may.

Sure, we process some of the more complex clinical challenges in class, and they are in resource-rich learning environments at their sites, but for the most part this is boots-on-the-ground OJT-101. Such was recently the case, when one of my interns wrote in his process note, “I find myself dealing with [a] therapeutic boundary [with a client who] was giving signals of perversion [related to] the dress code. I felt uncomfortable and reported [this] to my supervisor, and the client was confronted. I felt supported and protected.”

I was curious about what he actually meant by the word “perversion,” given the loaded and historically pejorative nature of the term. Upon follow-up, I discovered that in this intern’s culture, women are quickly and quite aggressively shamed and oftentimes punished by family and community if they act or dress in a way that is considered immoral and violates biblical principles.

The client was a 32-year-old female attendee in a day-treatment program who, in the intern’s words, had chosen to wear “a cut-off shirt without a bra and see-through sport leggings without panties.” In that moment of discomfort, my intern abruptly ended the session by telling the client that he had to attend an intake session. He then went to his supervisor for guidance. While I was very glad that the intern took this immediately to his supervisor who gave him the support and protection he needed at the time, I was dismayed that in that very uncomfortable moment, perhaps understandably, he simply told the client that he had an intake to perform and abruptly ended the session. He lied to her.

Apparently, this was not the first time this client had approached therapy with a male clinician in this manner; she was subsequently transferred to a seasoned female clinician after her brief visit with my intern.

In retrospect, my intern understood that this might not have been the best way to handle the situation, but he had clearly been taken off guard by this “attractive woman,” was intensely uncomfortable, and expressed concern that if he did not act immediately that his “imagination” might get ahead of him. While he momentarily considered the possible role of transference in this client’s wardrobe choice, he was even more relieved that his supervisor and the clinical director handled the situation “sensibly and professionally.”

This scenario brought me back to an incident during my own training when, during a practicum placement in a state psychiatric hospital, my supervisor decided it would be instructional to set up an intake for me with one of the “chronic” patients. Soon after being ushered into the seclusion room with me—a strange choice of setting—the patient sat down facing me with her bathrobe open and nothing underneath. All I remember about that tortuous moment in time was that I froze. As then, as if from thin air, my supervisor emerged from behind the one-way mirror and into the room. Upon my supervisor’s entry, the patient immediately sat erect, closed her bathrobe, and had the most delightful conversation with my supervisor, who later said to me, “I can write a book about any patient after meeting with them once.”

In retrospect, I believe, knowing what I later learned about this man, that it was an exercise designed to humor him and shame me. After my initial embarrassment and sense of ineptitude receded, the shame set in.

Getting back to my own intern, I was very aware of not wanting to shame him and wanting his own moment of torture to be a learning opportunity for him and the rest of the class. So I asked them all to consider what they might have said in that moment, while my intern listened in and then reflected upon their responses. These included, “I probably would have done something very similar,” “I would have told her about boundaries and that I was not comfortable continuing the session,” and “I would have ended the session and rescheduled after telling her that her attire was inappropriate for the setting.”

Each of their responses was appropriate given their level of experience, but in retrospect, I was a bit disappointed, perhaps unrealistically, that none of them had considered the possibility that this client’s choice of attire might actually not have been a choice, at least not a conscious one. So, I wondered out loud with them about the possibilities that she had been sexually assaulted or trafficked or both, and/or had come to rely on seduction to navigate relationships of power imbalance, particularly with men. It might have been erotic transference. Or perhaps, it might have been none of these, and she was simply proud of her body, and had chosen not to heed past messages around the inappropriateness of this behavior.

***

As I write this, I am an hour out from my supervision class in which I hope the incident will come up again; if it doesn’t, I will bring it back into focus. I’ll be most interested to know what about that client’s behavior triggered my intern to consider it a “perversion.” Hopefully, he will not feel the shame I did many years ago, and we will have a rich discussion.

What would you have done?
 

Successful Intervention with a Family Impacted by Treatment-Resistant BPD

Posted on by Psychotherapy.net Team

Borderline Personality Disorder (BPD) is one of the most difficult psychiatric disorders to treat, the main reason being that it affects the entire family. Thus, effective treatment requires working with as much of the family as possible in a coordinated effort. Multiple professionals are also often involved, which adds to the need for coordination of resources. Further adding to the complexity of intervening with families impacted by this disorder is the fact that there is usually significant resistance to the treatment by one or more parties.

Treating families impacted by BPD also requires specialized therapeutic skills. I have found that many techniques that are effective with other diagnostic groups are not only ineffective with BPD, but may actually make the disorder worse. This is why most of the families who present themselves to me have already been exposed to numerous therapists and treatment modalities by the time we meet, leaving them exhausted and disappointed. In many cases, large amounts of money and other resources have already been spent, also leaving them jaded and skeptical. These families are very often on the brink of their breaking point.

Am I expected to produce a Hail Mary, or am I just another soon-to-be-discarded and/or disappointing clinician in their minds? This is a very high-pressure situation for a clinician, and for this reason I suggest that colleagues only take on such situations if they have specialized skill in treating this disorder or other debilitating personality disorders. A full illustration of all of the specialized skills needed to work with these families is beyond the scope of this paper. For expediency, I will focus first on four tools that I have crafted and found to be highly useful in treating families impacted by this disorder. These tools are described below and will be illustrated in a case study that follows.

Useful Tools

Manage Expectations

This applies to the patient, the family, the other professionals, and yourself. Healing and growth are processes and not singular, disconnected events. All participants in the intervention should be told overtly that this process will take months, if not years, to reach an optimal outcome. I generally tell patients and their families, “Things will most likely get worse before they get better.” This prepares everyone for the inevitable resistance while creating a future milestone measured by increased cooperation.

Protect, Protect, Protect

You must protect the patient, the family, the process, and yourself. A key, and possibly the most disruptive, feature of BPD is the client’s lashing out at others when frustrated. Many families allow this behavior to provoke them into participating in disruptive behavior by shouting back or threatening. The therapist must provide some basic level of safety to the process and all who are involved in order to avoid disruption of the therapeutic work, often manifested by one or more parties’ walking out.

As a therapist in this situation, you are at very high risk for being triangulated into the family dysfunction, in which case this lashing out may be directed at you. Your chair should be the closest to the door, and you need to prepare to split up the group if you cannot deescalate conflicts with all present.

Modeling

You have to teach the family how to cope with disruptive behaviors such as lashing out, triangulation, codependency, and self-mutilation that are common with BPD and rare in other disorders. This is where the specialized skills come in. Each of these disruptive behaviors requires its own set of coping mechanisms. This is where conventional methods can backfire. For example, healthier families can share diverse opinions without the divisive effects of triangulation. In families with BPD, encouraging sharing of diverse opinions is likely to lead to further polarization and increased conflict, thereby worsening rather than improving the situation.

Starve, Do Not Feed, the Monster

The monster is the disorder, the BPD, not the sufferer. The family must bond together with the sufferer and the professional team to fight it. While traditional therapeutic methods encourage compromise and flexibility as solutions to conflict, these methods may feed the monster or make the disruptive and disturbing nature of the disorder worse in families with BPD. The emotional dysregulation caused by the BPD often escalates into rapid, impulsive acting out towards self and others. Introducing compromise, flexibility, or, worse, compliance, reinforces that lashing out will get at least some of what you want. This will increase the frequency and intensity of the lashing out. Conversely, withholding all possibility of acquiescence because of the lashing out starves the monster and sets the stage for the introduction of more socialized, and hence more successful, strategies. This is consistent with basic behavioral principles.

Case Study

The following is based on a real case, but with many details changed in order to protect identity.

Mary Zohn called me about her 19-year-old daughter, Rosa. She had been referred to me by her therapist because although her daughter was in treatment with a therapist, things were getting much worse at home and the family was in crisis. I agreed to meet with her and her husband Charlie for an intake.

The Zohns showed up at my office with two thick files that documented difficulties with Rosa since the beginning of high school. Since that time, Rosa had experienced steady deterioration despite multiple treatments with several different professionals. They explained that although she was intelligent, she had ongoing difficulty functioning in a school environment. She often missed classes and rarely completed assignments on time, if at all.

In her frustration with school, Rosa began engaging in other less productive and more self-damaging activities such as sexual promiscuity, substance abuse, and excessive computer video gaming. She began staying out late, and then overnight. Her room was dirty and her hygiene was regressing.

The Zohns began confronting her about her poor school performance and unhealthy habits. They tried to set limits. This was associated with screaming conflicts that ended up with her sometimes leaving for days at a time, and often included self-destructive behavior such as cutting and going days without food and water in protest. Her parents were becoming increasingly concerned about her health.

They were also becoming increasingly concerned about her influence on her younger sister. Rosa was the middle child of three girls. Her older sister, Wilma, did very well in school and had a good job. She was self-supporting and lived in her own apartment about an hour away from the family residence. The younger sister, Bertha, was in middle school and struggling with a learning disability and social issues at school. The Zohns were very concerned about how Rosa’s behavior would affect Bertha’s struggles.

Initial Interview

What precipitated their reaching out to me was that Rosa had been arrested with her boyfriend for possession and distribution of narcotics. Following are some excerpts from my initial interview with the Zohn’s:

Dr. Lobel: What is Rosa’s current legal status?

Mary: She is out on bail.

Dr. Lobel: What is she doing with her days?

Charlie: Supposedly she is in school.

Mary: She is enrolled in college but we think that she does not attend classes.

Charlie: She leaves every night pretending to go to school but she goes to see her boyfriend instead.

Dr. Lobel: How do you know that?

Charlie: Because she is getting incompletes in all of her classes and she doesn’t come home until 4 AM.

Dr. Lobel: How does she get to school?

Mary: She drives herself.

Dr. Lobel: She has a car?

Charlie: We got her a car so that she can go to school.

Dr. Lobel: But she is not going to school, right?

Mary: We don’t know for sure.

Charlie: Yes, we do. This is the 3rd semester I am paying for, and she hasn’t even earned two credits.

Dr. Lobel: So, you pay her tuition and buy her a car to go to school. She doesn’t go to school and you continue to pay her bills?

Mary: Are you suggesting that we should cut her off?

Charlie: I can’t do that to my daughter.

Dr. Lobel: You mean stop enabling her?

Charlie: What do you mean?

Dr. Lobel: Under the guise of paying for school you are enabling her to engage in unhealthy and illegal activities with her boyfriend.

Mary: We have discussed this before, but her therapist has recommended that we try not to stress her out; that we should give in to the small stuff so that she does not get dysregulated.

Dr. Lobel: How is that working for you?

Charlie: Not good.

The Zohns left the initial consultation a bit shaken by my recommendations. Up until this point, therapists had recommended walking on eggshells around their daughter by reasoning with her, trying to be flexible and forgiving, and overlooking Rosa’s outbursts and acting out.

Second Consultation

Three months later, the Zohns contacted me again. Rosa had been arrested. This time she had been driving while intoxicated and crashed. The car was totaled, and she was charged with driving under the influence (DUI). Fortunately, she was not significantly injured.

They came in for another consultation. They explained that they had come to realize that they were indeed enabling her, feeding her monster, and that they needed guidance. They didn’t know how to say no to her and follow through consistently. We agreed that we would meet with her together in order to help them to set up some healthier boundaries. Most notably, this included the plan that resources such as money and transportation would only be available for the pursuit of healthy activities.

I asked the Zohns whether they were on the same page regarding what was right for Rosa. They shared that they often argued about whether or not to be “strict” with her and how strict to be. I told them that they must be united in the setting and reinforcement of boundaries and that I would help them with this. They agreed. I suggested that I see Rosa individually before we again met as a family so that she would not feel ganged up on. They agreed, but she did not.

First Family Meeting

When the three arrived for our first session together, I asked Rosa to come in by herself for a few minutes, and she agreed. Here is an excerpt of our meeting.

Dr. Lobel: Do you know why your parents asked you to meet with me?

Rosa: They just want to control me. They irritate me constantly.

Dr. Lobel: How do they do this?

Rosa: They are constantly on my case. I don’t do anything right. They want me to be like Wilma. They have always favored her. I can’t be Wilma so I am a disappointment to them.

Dr. Lobel: In what way do they want you to be like Wilma?

Rosa: Smart, beautiful, and successful. That is not me.

Dr. Lobel: What do you think prevents you from being successful?

Rosa: Them. They nag me all the time and then I can’t concentrate on my studies.

Dr. Lobel: That’s why you don’t go to class?

Rosa: Yes. I get so upset I just want to get high. I would rather be with my boyfriend.

Dr. Lobel: What does your therapist suggest?

Rosa: She has tried to get them to back off, but they can’t stop themselves.

Dr. Lobel: What would you do if they were not bothering you?

Rosa: I would get a job.

Dr. Lobel: Have you ever had a job?

Rosa: Yes. Several.

Dr. Lobel: How did that go?

Rosa: I usually work for a while and then they start hassling me.

Dr. Lobel: At work?

Rosa: Yes.

Dr. Lobel: Out of the blue.

Rosa: They get all upset if I am late once or twice or if I call in sick.

Dr. Lobel: And then you get fired.

Rosa: Yes. But the reason I am late or sick is because of my parents!!

We brought the parents in. We all agreed that Rosa needed to take a leave from college while she resolved her legal issues and living situation and began to more directly address her mental health challenges. We then introduced the idea that Rosa’s access to resources, such as a car and money, would be contingent on her manifesting healthy behaviors. Her parents agreed to support healthy behaviors rather than unhealthy ones. Rosa began yelling at her parents and at me, stating that this was little more than additional control and would make things worse. She stormed out of the meeting. As she came in the car with her parents, we were confident that she would not be able to go far, so we finished the hour by offering suggestions as to how to respond to her agitation. We reviewed the “form before content” tool. This basically required that Rosa speak in civil tones, or the conversation would stop.

Dealing with Resistance from Rosa’s Therapist

The following Monday morning, I received a call from Rosa’s therapist, Ms. Hartman, who wanted to know what was going on in our meetings that was so upsetting to her patient. She expressed that Rosa was “triggered” by the meeting and it was making her sicker. I was expecting this call. Here is an excerpt of our conversation:

Dr. Lobel: What about our meeting did Rosa find triggering?

Ms. Hartman: She felt ganged up on.

Dr. Lobel: Which part made her feel ganged up on.

Ms. Hartman: You and her parents trying to control her.

Dr. Lobel: Did she give you any specifics?

Ms. Hartman: No. She just said that she was so triggered she had to leave.

Dr. Lobel: She appeared to get agitated as soon as I said that her parents would support healthy activities and not support unhealthy ones. Does this contradict what she told you?

Ms. Hartman: No.

Dr. Lobel: I imagine you must be working with Rosa on increasing her tolerance for frustration and difficult situations.

Ms. Hartman: Yes. I specialize in Dialectical Behavior Therapy (DBT). I think she also takes medication.

Dr. Lobel: We are trying to help Rosa take responsibility for her choices and behaviors and she is having difficulty tolerating it. Can you help her accept that she has to accept responsibility for herself while giving her the confidence that she can do so in a healthy way and grow from the experience?

Therapy Begins

Several meetings with the Zohns followed, in which we created a contract through which Rosa could benefit from all of the resources her parents had to offer if she used them for healthy pursuits. She got a job and prepared to resume her studies. She agreed to maintain sobriety. The sticking point was the parents not wanting her to be alone with her boyfriend, as they felt his influence corrupted her. We agreed that he could visit her at the family residence but that the Zohns refused to have their vehicle or their financial support to be used to spend time with him. She very reluctantly agreed.

I also inquired as to the status of her pharmacotherapy. She apparently had a psychiatrist who prescribed a combination of medications that included psychostimulants for attentional difficulties, a mood stabilizer, and an antidepressant. She refused to take the mood stabilizer and antidepressant but wanted to continue with the psychostimulants. The psychiatrist refused to treat her under these circumstances, so she was getting Vyvanse prescriptions from her pediatrician. I suggested that she consult with another psychiatrist, as I thought that the stimulant alone was adding to her emotional dysregulation. She saw a psychiatrist and agreed to work with her on a more therapeutic regimen.

Rosa seemed to stabilize for a few months and was moving forward on our plan, until, that is, when the testing began. Her parents noticed that she was not always at work when she said that she was at work. They suspected that she was seeing her boyfriend. They also found evidence in her bedroom that she was vaping marijuana again.

Mary and Charlie met with me to discuss their fear, apprehension, and guilt at holding to their boundaries. They feared confronting Rosa, which they knew they needed to do, and they feared for Rosa as well. They did confront Rosa, who denied everything. Then Rosa disappeared.

She went to work one day and did not return. The Zohns contacted her employer the next day, who confirmed that she had not shown up for work. They tried to contact her via cell phone, but she “ghosted” them (refused to answer). They were pretty sure that she was with her boyfriend, most likely using drugs and engaging in other unhealthy and risky behaviors.

I met with the parents a few times over the next few days. They were very frightened and questioned our plan. They contemplated texting her and allowing her to do whatever she wanted if she just returned home. I discouraged this and explained that this would be a major setback. I told them that she and her boyfriend did not have the resources to survive on their own and that she would have to return home eventually. She had nowhere else to go.

We began preparing for her return with the understanding that the Zohns’ home was not viable as a therapeutic environment for Rosa and that she was in need of inpatient treatment. I encouraged the Zohns to research options and prepare to have her admitted promptly when she returned.

It took about a month. Rosa missed one of her court appearances and was again arrested. She called from the police station. The Zohn were prepared and let her know her options. She had no choice but to agree.

She was admitted to an inpatient facility that specialized in BPD and substance abuse. She stayed for three months and then transitioned to a sober living residence near her parents. She stayed there for six months, during which time she got a job, resolved her legal issues and embraced sobriety with the help of a Twelve-Step Program and a good sponsor. She went from sober living to the university.

Conclusions

In this case, BPD had not only metastasized throughout the family, but also infected the professionals involved. Approaching Rosa’s treatment from an individual perspective was not successful, because her disorder caused her to manipulate her environment into a codependent mess that enabled her to stay sick and get sicker. The only way for her to recover was to assemble a team that included her entire family and all providers working together and consistently.

Intervening in a system impacted by BPD, as in this case, required specialized skills and the willingness to confront all aspects of the patient’s treatment, including enabling providers. This was often like stirring up a bee’s nest. Great care had to be taken to protect these providers by not making them feel negligent or naïve while at the same time engaging them in a consistent therapeutic process. It was critical to anticipate resistance, even by the professionals who attacked me for challenging them. I didn’t take it personally and haven’t, which has proven to be an effective tactic. I explained to them my process and expectations in non-accusatory terms and showed them their value in the coordinated healing process.

In looking back over the case, I knew I was going to be seen as a snake-oil salesman, met with skepticism and doubt. I had to effect a paradigm shift. I also expected things to get worse before they get better. And they did. I reminded myself that as a clinician. I had to stick with what I knew: with the treatment plan, with the best techniques at my disposal.

I also knew that if this approach failed, there would probably not be another chance. Rosa would lose her only lifeline, and the family would all suffer. I reached the point of no return. I was fully committed and I had to see this case through, no matter what. I have treated families like this countless times over the years, but each case is different and each path its own.

If you are going to venture into this challenging treatment domain, conviction is critical, and still there will be no guarantees.