Category: Therapeutic Issue

Ancestral Narrative Building: A Path to Healing Generational Trauma

Posted on by Psychotherapy.net Team

“I am so afraid to be like the men in my family when I am angry. I find myself holding in so much rage because I do not want to be like my dad or my grandfather. I also refuse to be part of the angry Black man stereotype.”
“What didn’t you like about their rage?” I ask my client to examine his narrative of his ancestors’ rage in order to understand his own.
“The way it was framed in my family is that it got them in trouble. It got them both killed.”

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We take time to process these situations about the men in my client’s lineage. Both his father and grandfather had been killed at the hands of the state, and my client began to believe at an early age that if he had less rage inside of him, he would live longer and safer.

I tell him I am not convinced that their rage was unwarranted, knowing that the United States has unjust systems that impact the lives of Black and Brown people daily. I believe that micro- and macro-aggressions pile up and that our reactions, or non-reactions, to them can be survival tactics or indications of insidious trauma. And we can still create new narratives around their deaths and “rage.” We have to understand the social and physical contexts they were born into and living in, to make sure we can make these claims about their rage, since it is coming up in therapy. Although I can guide him through it, my client needs some deep ancestral healing, and he has to do it himself. He has to be the one who is committed to researching, asking questions, and making meaning.
 

I start by creating a reading list for the client. I read the books, too. At first, he doesn’t quite see the point. I explain that we have to study the time and place in which both of these ancestors lived. We read Isabel Wilkerson’s The Warmth of Other Suns, Langston Hughes’ The Ways of White Folks, James Baldwin’s The Fire Next Time, and Zora Neale Hurston’s Their Eyes Were Watching God in order to get a sense of the time periods his family lived through. We research articles from the relevant time periods in the cities his family resided in and take a deep look at the cultural climate of the cities. We find research about the impacts of Jim Crow laws, the GI Bill, and redlining, policies that impacted his family directly and indirectly.

“I have only heard the stories and the warnings from my mom, aunts, uncles, and grandma. Stay inside! Stay calm! Don’t be too forward! Don’t speak up! We don’t want you to get killed out there! Reading about other people from the same time period gives me more information than what was passed down to me. Black people were unsafe even if they did stay calm and remained inside. My family was so fearful of more death that they played into the respectability politics—‘Be good and nothing will happen.’ But the truth is, things still happened.”

This kind of ancestral digging creates a new narrative that allows the client to build, expand, and contextualize his sense of self. Prior to our research, he had limited information from which to make sense of his childhood and the messages he received both implicitly and explicitly. The messages he received growing up are important and tell him a lot about his lineage, but he needs to do more digging to get a fuller story. Intentionally getting new information about people similar to him and his generational trauma allows him to make space for new framing of his paternal lineage.

“I learned about the political climate my grandfather was living in. I saw an article about a man killed for looking at a White woman the wrong way in the city we lived in. I realized that my grandfather might not have been angry, he might have been just living his life, and that there are not actually any stories about him being angry or reactive at all.”

Though he has limited people alive to discuss this with, we create a list of questions he has for his extended family. My client is able to make new meaning about his father by doing some interviewing of distant family members. He asks about the time periods, the rituals they had in their family related to his Black American culture, and anecdotes about his grandfather and father. He records their responses to his questions in order to keep a record of what he found for his future son. He reckons with the fact that after his grandfather was unjustly killed by the county police, his father became an advocate to make changes in his community. His father became an activist and fought for the rights of Black Americans in his city.

“My mom always made it sound like when we speak up we are likely to be hurt, because we are putting ourselves at risk, but that is because she had trauma from my dad’s dying during a protest. She always seems so strong, but my aunt told me she was different after my dad died. She didn’t want him to go that day, and he told her he had to make a better life for his kids. Understanding that my father was fighting for what is right has totally changed what I understand about my anger.”

***

The old adage of becoming your parents is more than just a saying. Clients and therapists alike carry forward and live ancestral history and messages that have the power to impact and influence triggers. We may find ourselves reacting similarly to our ancestors, or reacting completely opposite from the way they did, without a lot of knowledge about why they acted the way they did in the first place.

Ancestral trauma impacts us in ways we don’t realize, and we need to investigate our lineages, whether we have direct access or need to gain access through texts and articles, to make sense of who we are and who we want to become. And therapists, along with developing an anti-racist framework that appreciates the racial climate of the country in which the client resides, must guide the ancestral trauma towards ancestral resilience when the client is ready to do their deep exploration.

That Tipsy Session: The Power of Self-Disclosure

Posted on by Psychotherapy.net Team

“This is the first time in years that I am feeling proud of myself,” Chris announces with a timid smile. His eyes are unusually bright, his pale face beaming with a new energy.
He has not been drinking for a month, his longest stretch without alcohol in almost a decade. His words trigger the memory of a year-old incident that still sends waves of shame through my body.

A Sudden Loss

That day, Paris was just opening after its very strict first lockdown, and I had lunch with a friend. We sat at the newly-created terrace of a restaurant just behind the Palais Royal. My beautiful friend had already ordered drinks. “Just one glass,” I thought to myself. We sipped the crisp white wine, a well-deserved celebration under the shining sun of that spring as she recited her lockdown poems.

Two hours later, I was back to my office, covered with sweat and dreading the session to come. With a bitter taste in my mouth, I was appreciating the particular irony of the situation: getting tipsy just before the session with Chris, my alcoholic client. As his familiar face appeared on my screen, a fleeting thought popped into my mind about one advantage of online therapy—at least he could not smell the alcohol on my breath.

“I hate being stuck in this place,” he offered immediately, skipping the usual icebreaker about the weather with which my British clients often begin their sessions.

His company had switched to remote work, and Chris had fled London for his parents’ home in Spain. They had acquired the house a couple of years earlier. Their move to Spain had been hastily decided without consulting their son; seemingly out of the blue, they had swiftly sold their home in England, along with almost every belonging that had been part of Chris’s childhood.

“Why did they have to go?” Chris had wondered many times, struggling with this sudden loss. His parents’ decision had seemed senseless at the time, inexplicable. Chris’s previously unremarkable drinking then spiralled out of control. Freshly graduated from college, unemployed, and lonely, Chris had simultaneously lost his home and his family following the crazy self-exile of his parents. At that point, his life seemed to come to a halt; his drinking slowly but surely replaced everything that he was missing—friends, career, and any challenge that could have given him an opportunity to feel good about himself.

Locked-down in Spain, Chris complained: “It is so weird to be here, locked down in this dreadful villa… it feels surreal.” Every time he spoke about his parents, he looked confused, his grey eyes wandering, slipping away from my gaze. Chris was spending all of his time with his parents, something that had not happened since he had left home for college. Outside and all around the otherwise beautiful Spanish villa-turned-prison, there was a foreign town, blindingly bright under the scolding sun, a town in which he knew no one.

“In the evening they just sit in front of the television, staring at some random Spanish talk show… I feel like an idiot. I have no clue what it is about,” he grumbled, more puzzled than ever.

“Do your parents speak Spanish?”

“No, they don’t, apart from a few basic words. This freaks me out… I simply feel like I am playing a part in a bad movie,” he shared, his eyes filled with loss.

“Is this feeling something you have experienced being around your parents before?”

“I am not sure… I don’t have much recollection of my childhood… at least not about my feelings… my parents were working a lot. I was spending most of the time at school, or at my friends’ places.”

In our previous sessions we had tried to make some sense of his confusion, but something seemed to be missing, a piece of information without which we could not move forward. We stumbled, and Chris was drinking in his usual solitary and well-controlled manner.

“I think I am fine,” he reassured me (or himself) every time I inquired about the approximate amount of alcohol he had drunk during the week.

“Fine? What do you mean by ‘fine’?” I would stubbornly ask, reminding him that at the age of thirty-two he had no close friends, no experience of romantic relationships, and no exciting career, despite his reasonably successful studies.

After a year of weekly conversations, we were stuck in a dynamic that had left us both steaming with frustration. This is when that dreadful “tipsy session” happened.

That Tipsy Session

I was sitting in front of my screen, fighting the dizziness from my drink at the Palais Royal, when Chris delivered the piece of information we had been missing: “My father spilled everything out,” he announced without noticing my discomfort.

The previous evening, his mother had been down with a migraine, and his father had brought him to a nearby recently-reopened eatery. He had ordered a bottle of wine and emptied his glass immediately. Then he explained: back in the UK, Chris’s mother had had an affair with the local pub landlord. This was the only reason for their sudden decision to expatriate. This had been his ultimatum, and the only way they felt they could keep their relationship together.

As I was doing my very best to focus on Chris’s words, his face magnified by my screen, I was painfully aware of failing him. I knew that his father’s telling this difficult truth might open a window for Chris to share his own. But could he use it? After all, shame had been keeping him silent. The window of possibility was closing quickly, as Chris’s return to London was planned for a few days later.

“How do you feel about what your father has disclosed to you?”

“I didn’t know what to say… I couldn’t imagine anything like this was going on… they are too old for that!”

“This must have been difficult for your father to open up about…”

“So awkward… We sat there, drinking and trying to avoid each other’s eyes… He never told me anything this private before,” Chris admitted, fidgeting uneasily in his chair.

“So, you were not the only one withholding something important from your family?” My own allusion to his drinking resonated with an obvious irony.

“What do you mean?” he hissed, pretending that he had no idea about what I was speaking about.

“Maybe this was an opportunity for you to talk to your father openly about your struggles with alcohol?” I made another desperate push.

Chris shook his head with resolve. He had been keeping his drinking problem for himself for years, and the shame he had accumulated in the process was an obstacle he could not overcome. Not yet.

I sighed and let him go with a certain relief. Even if I made it through the session without a major blow, by the end of it I was exhausted and, for the first time, wished to be elsewhere, not in front of my screen with Chris.

For the full week following that session, Chris stayed on my mind. To tell or not to tell? I was not sure whether a self-disclosure would break the brittle trust we had both worked hard to establish. The next time Chris appeared on my screen, I plunged in first.

“Before we start, I have to share something with you,” I announced, and his face dropped in response, preparing for bad news. “During our last session… you may have noticed that I was not fully present,” I stumbled forward, and he nodded. “I thought you were distracted for some reason… but it was ok,” he added generously.

“No, it wasn’t ok,” I sighed and stumbled further. “Just before our session, at lunch, I had a glass of wine. It was a mistake, and I have to apologize.”

“So, you were drunk?” he giggled, and I could not figure out whether there was more confusion or relief in his voice.

“Well, a little tipsy, I guess,” I nodded, trying not to avoid his eyes.
We stayed silent for a minute before he asked, perplexed, “Why are you telling me this today? You didn’t have to…”

“No, I didn’t… but I value our relationship, and owe it to you to be honest… but I was too ashamed to tell you last time,” I shared, hoping that we could capitalize on this example of self-disclosure.

“I know what you mean…” he sighed and looked sideways.
From that point on, Chris finally started opening up. Instead of endlessly complaining about his mother’s misstep and other misfortunes, he now talked honestly about himself.

“I actually know exactly when this whole ridiculous affair started… I got really drunk one evening at the pub, and the landlord had to call my parents to fetch me. My mother came, and this is when they took it off…”

Chris’s discovery that his drinking was somehow at the root of what he saw as his family’s downfall added a new dimension to the shame he was constantly feeling about his unfulfilled life. It took us much longer, of course, to realize that his mother had other reasons to cheat on her husband which had nothing to do with her son but rather with her husband’s very quiet but steady drinking, which had been going on unnoticed for years.

“This was probably his one and only way to relax…” Chris had always seen his father returning from work and pouring himself a large glass of whisky, calling it his “medicine.”

***

Through our increasingly honest conversations, Chris was slowly learning the power of vulnerability. After several months he became strong enough to tell his parents about his own struggle with alcohol. Initially, his father met his honesty with defiance. Chris’s admission put him in an uncomfortable place where he had to face his own addiction. In the weeks that followed that confrontation, from a distance I witnessed their family stumbling through an uneasy change of dynamics. They talked more openly about the drinking issue that had run in the family for a few generations, and Chris eventually opened up about his therapy work. The change was slow, but with each passing week, he felt stronger about his decision to quit alcohol and soon started experimenting with sober days, then weeks… Today he has not had a drink in a month.

“I am really proud of you today, what a journey,” I say, and then I finally ask the burning question that has been on my mind since that dreadful session: “Did my telling you about that drink I had before our session play any role in your recovery?”

“I was first shocked that you would tell me… then I felt angry about it… but somehow this helped me feel less ashamed about my own drinking… I remember thinking that if you didn’t die from shame when you told me, then I wouldn’t die either if I told my parents,” he admitted.

Through his further conversations with his mother, we have now learned that her affair had been a desperate attempt to recover the intimacy she had lost with her husband. My turning up tipsy for the session was probably a similar kind of act. That incident, or rather what we were able to make out of it, strengthened our therapeutic bond. On a more immediate level, by self-disclosing, I demonstrated to Chris in the here-and-now of the session that shame does not kill you.

Thinking back, I am still bewildered by that shameful drink, which fortunately became a step on Chris’s path towards pride.

When Psychotherapist and Client Share Similar Crises

Posted on by Psychotherapy.net Team

It’s been almost nine months since I found out that my husband has been unfaithful, and my life and world have been turned upside down and inside out. It has been almost nine months of being in a seemingly unrelenting state of shock, disbelief, distraction, exhaustion, and overwhelm. From the start, sitting in my psychologist chair and doing my psychologist thing have felt fraudulent. How can I listen, really listen and comfort another, when I am in this raw and vulnerable place? I can’t say for sure, but I have been. In fact, my job has been the one consistent thing in my life that hasn’t really changed. It has been a welcomed distraction to focus on others rather than spending all of my waking hours being lost in my thoughts and the vast array of emotions that I feel on a daily basis.

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I am an empathic, highly sensitive person who also happens to be a psychologist who can become engrossed in the feelings and pain of others. This is likely why I was drawn to the field. Over time, however, I have learned how to create boundaries between myself and those for whom I care so that I don’t burn out. Yet as a caretaker, the potential for burnout remains ever-present.

Let’s take this one step further. In the midst of learning what the red flag signs were and are and understanding what my legal rights are as a divorcing parent, I recently began working with a woman who is slowly awakening to her sense of unhappiness in her marriage—a woman whose story is eerily familiar to my own. In one breath, it is difficult to reflect back on all of the accusations, fights, and sequences of events that she is facing, and that I have faced and continue to. In another, I can judiciously share some insights with her that I’ve gained in hopes of helping to foster her sense of self, her self-confidence, a trust in her instincts, and to acknowledge and respect her feelings of marital dissatisfaction.

Just as I was met with scare tactics and threats about my own marital relationship and its dissolution, she is too. Rather than becoming intimidated, my hope is to help her find her strength to do her own research and gain her own information to help reach her own conclusions.That is because if her story is anything like mine, she may be thrown off by inaccurate information that will disempower and wear her down.

These sessions have not been easy. On some days, they’re painful, as I listen to her story and feel the visceral reactions that I have and still experience and that she is having now. I experience flashbacks after the sessions, but my hope continues to be to try to change her story in an effort to process my own. On the flip side, I have found that being able to help another person in a similar position is cathartic and empowering for me. If I am able to give another woman a little bit of direction so that she is not blind-sided by the upcoming phases she may pass through, I can begin to find solace in my horrific experience.

Although I am still in the midst of the divorce and grieving process, there are a few things that are helping to keep me chugging along.

Self-Care

As a psychologist, I continually reflect on the need for self-care. However, it didn’t really click with me until I arrived in this very place. Self-care means different things for me right now:
It’s okay if I don’t cook dinner every night
It’s okay if my house is not as neat as it usually is
It’s okay to want to sleep more
It’s okay to want to be left alone
It’s okay to give myself a break and not beat myself over it
It’s okay if I didn’t accomplish as much as I intended because I’m fatigued
It’s okay to cry often

Self-care has also taken on the additional meaning of being forgiving and stopping when I think I should keep going on my to-do list. My sense of self-care has taken on the additional and much-welcomed elements of self-compassion and self-forgiveness for the upheaval that is now my and my children’s life. Self-care is the growing understanding and appreciation that this won’t be forever, but it is for now.
Self-care, at a more basic, moment-to-moment level is also:

Drinking enough water to stay hydrated on the days when I don’t wish to eat or drink
Getting enough sleep
Taking my vitamins
Exercising—walking, jogging, lifting weights, stretching, yoga
Taking a shower
Changing out of my pajamas even on the days when I’m not seeing patients in person or virtually, and accessorizing too
Dying my roots and getting a haircut
Scheduling a manicure and/or pedicure
Scheduling a massage and/or facial

Know When to Take a Break

I like to consider myself a diligent, persevering individual who can push beyond fatigue for the sake of learning something new or helping another person to find emotional relief. That high level of motivation and ability to delay gratification is what helped me to get through earlier challenges, including comprehensive exams, dissertation, licensing exam, post-doctoral training, and all of the other intensive training we psychologists have completed. The downside, if there is one, to my diligence is that I haven’t always acknowledged the importance of slowing down, pausing, putting on hold, rescheduling, or just stopping. My personal and professional experiences have centered around the axiom, “Keep on going until I reach the finish line.”

One thing I’ve learned is that I need—I mean really need—breaks on a daily basis. I need time to stare out my window or sit in the sun. I need to sometimes leave my desk and work on something monotonous like laundry because it’s a welcomed break from thinking so much. It’s okay to take that break even when there are phone calls, emails, texts, case notes, and invoices to prepare. That list will never be short, nor will it ever be “all done.” I’m embracing the unfinished nature of my work and realizing that it’s okay to walk away from my desk or office.

Grieving, Boundaries and Growth

Logically, I know that divorce is a loss, a huge loss. Now that I’m in it, I deeply understand that it is the true death of the life that I thought I was going to have, the life I thought I had, and the loss of the family unit that we created together. The sadness that I feel is quite unbearable on certain days and it drains my energy and results in physical pain (i.e., headaches, stomachaches, joint pain, muscle soreness). This experience gives me a new perspective on having a broken heart. Not only in divorce, but in loss by death and break-ups for people of all ages. Loss is loss.

And now, more than ever, in the shadow of this immense sense of loss and emotional exhaustion, it is an incredibly important time for me to set boundaries around when I start my work day and when I will end it. I am a bit of a workhorse, and I balance my practice with my three children and home life by keeping a hand in all three arenas—all day long. I can’t do this right now. I’m learning to understand that if I invest a few hours into a work project, then I won’t get to the items for my home. I need to let it go for another day or enlist the help of my children. And vice versa; if I invest a few hours into a project in my home, I will not be able to also accomplish work tasks.

This also means saying no to social plans or volunteer opportunities for my children’s school or activities. It means prioritizing what I need to get done and what I have energy for.

***

As a psychologist, I, like many of my professional colleagues, believe that I need to “pull it together,” because that’s what we do and because that’s the implicit expectation our clients have. We are “available” to others, and sometimes, that means our “stuff” has to take the side or perhaps even the back seat. However, what happens when personal issues and conflicts take over? It has and will continue to happen, because we are all humans, and psychologists are no different
 

Finding a New Normal in the Era of COVID

Posted on by Psychotherapy.net Team

As I scrolled through the cartoons on our website, an image flashed through my mind. A therapist sits pensively across from their patient, framed by a newspaper caption on the wall behind which proclaims, “The pandemic is receding!” The therapist says to the patient, “OK, let’s talk about your new normal,” to which the patient laments, “But Doc, I didn’t even have an old normal.”

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I am fully aware of the dangers and COVID-related challenges that linger, so am not proclaiming the pandemic’s recession, nor its end. However, I have directly experienced and am aware of the many ways in which the world is attempting to right and re-balance itself—from individuals to institutions to cities, states, and countries. People seem desperate to throw off the oppressive cloak of darkness and fear that the pandemic ushered in, as well as the emerging threats on all fronts, both medical and non. At the same time, people seem a bit less resistant to feeling their way down unfamiliar corridors, both public and private, even in the shadow of lingering uncertainties and elusive futures. We seem to be at an inflection point, or perhaps a liminality—a time of existential crisis on scales both small and large, not just for our patients and trainees, but also for ourselves as healers.

In a recent blog entitled Fellow Travelers During the Coronavirus Pandemic, Victor Yalom wrote, “There is nothing like a pandemic to put us on equal footing with our clients! To even pretend otherwise, to not acknowledge to our clients that we are living on the same planet, that we are going through this epic crisis along with them, seems to me entirely disingenuous.” He couched this statement in the context of his father, Irvin Yalom’s notion that we, along with our patients, are fellow travelers. And as fellow travelers, I think that we have a two-fold obligation to find our way to a new normal, whether or not we or our patients had a firm grasp on an old one.

I like the idea that we and our patients are fellow travelers; however, the roads we travel may be very different from theirs, especially so for those who struggle day-to-day around the basics and don’t enjoy the privileges familiar to many of us and our professional colleagues. I have no doubt that COVID has been merciless for many of us and our colleagues, requiring adaptation and forcing upon us losses at many levels. But, as Roberta Satow said in The Uneven Effects of the Pandemic, “there is a great divide in this country in terms of race and class that has been exacerbated by the coronavirus…[and] as therapists, we must keep sight of the unevenness of the effects of the pandemic, empathizing with those who are suffering and encouraging those who are thriving (even ourselves) to not feel guilty.” So, as we return to a previous normal or attempt to construct a new one both for ourselves and our patients, I think it important to take this opportunity to explore deeply exactly what that means.

One of the more common return-to-normal phenomena that clinicians face is how to re-balance their therapeutic relationships between face-to-face and virtual interactions. From the perspective of the clinician, Matthew Martin’s The I-Thou Relationship in the Age of Telehealth- Part II suggests that “teletherapy holds the potential for new horizons for therapeutic gain. However, client and therapist must both be willing to cultivate the process of being together in authentic relation for these gains to find fruition.” Here, Martin addresses the seeming inevitability of telehealth as a newly-ubiquitous mode of psychotherapy delivery, and how, perhaps, it can evolve into a meaningful bridge for connection with our clients despite the geographic separation. This directly challenges the fear (or concern) therapists have historically and more recently voiced about telehealth’s inability to create real connection with clients or, as Lori Gottleib described it, of “doing therapy with a condom on.”

From the other side of the couch, Martin, in The Quarantine Void: A Reminder of the Central Role of Being, asks us to consider how COVID has forced many of his clients to reconsider the balance between “being” and “doing.” He says, “How my clients and I choose to respond to this new normal has the power to restore the centrality of being, along with our shared humanity, or bring us back into the dizzying energy of a doing-centered world.” Will we, as citizens both of the world and shepherds of our patients’ well-being, consider that balance alongside our clients as the shroud of COVID slowly lifts?

And what of our patients who entered the pandemic already struggling for balance in their lives, such as those whose lifelong relationship with introversion in a society that values its opposite left them feeling alone, different, alienated? While they may have struggled less than extroverts during the pandemic, many may have and are still struggling for the new balance that accompanies re-entry. In Pandemic Lessons for Introverts (and their Therapists), F. Diane Barth reflected on her clinical work with Melissa and shared, “the gradual ending of the isolation resulting from the pandemic has brought on some concerns, including what Melissa and several other clients call ‘fear of re-entry,’ that is, fears about returning situations in which interpersonal interactions stir up discomfort and anxiety.” How will we help those Melissas out there whose pre-pandemic normals were elusive?

Then there are clients whose pathologies and challenges were more unsettling and disruptive, not only for themselves, as they struggled for balance and normality, but for their intimates, who were often at a loss in the turbulent wake of their loved one’s personal battle. In a thought-provoking essay by Dana Harron, Eating Disorders, Couples, and COVID-19, we met Jamie, who had long struggled with Anorexia, and her partner Lyndon, who had become increasingly aware of Jamie’s disordered eating because of the forced isolation. With the aid of couples therapy, Lyndon became better “able to notice, and to share with Jamie, how out of control and alone he felt [and, with therapeutic support] became much better able to sit with his vulnerability [which] made him able to sit with Jamie’s vulnerability, too, and ask her about her feelings and experiences when he noticed her having difficulty with food.” In this case, it took a village to help Jamie and Lyndon wrestle a new normal from COPVID’s grip.

***

For some of us and our patients who have been fortunate, or perhaps privileged, enough to sidestep COVID’s unswerving trajectory, we have experienced an unavoidable and involuntary inflection point. Whether this inflection point was or has become an opportunity for growth, self-awareness and change certainly depends upon the way it has landed in our and their lives. Whether for better or worse, new normals await…hopefully!

A Path Towards Self-Compassion and Healing

Posted on by Psychotherapy.net Team

Foundations of Relationship

To be in an intimate and interdependent relationship with another person is one of the most challenging endeavors in life, which is why conflict in relationships is one of the major reasons many come to me for therapy.

Clients often reach out to me because they are in pain and struggling with a significant relationship break-up. It is particularly difficult for my clients to be in a close relationship with others if they do not have a conscious relationship to their own self. Thus, an important task in therapy is to identify what it means for them to first be in an intimate relationship with themselves. This may include learning how to sit with their feelings of emptiness, being present with their bodily sensations and emotions, and examining their past. Therapy can be challenging, but it also offers clients the opportunity to heal wounds and to reclaim the forgotten and disconnected parts of themselves that may be unconsciously re-enacted in current relationships.

Many women come into my office suffering with low self-esteem, depression, and anxiety. They feel isolated, alone, and long for a sense of purpose in their lives. They long for connection and believe that closeness with another will help them feel complete, that being in love will alleviate their emotional pain. Close contact with others in reciprocal and enduring relationships is both a biological and psychological need, which increases their urgency to be in close partnerships with others.

Many of the relationship problems I work with are fueled by the belief that another person can fill their emptiness and replace the pain with feelings of love and passion. However, as my very wise mother once said, “we fall in love to the same degree that we are lonely,” fall being the operative word. In this context, if a client falls in love out of distress, to fill a void or erase the emptiness, there is a good chance it will lead to more distress. Family therapist John Fogarty asserts that our emptiness and pain are related to our relationship to our most distant parent. If that is accurate, then healing comes when we can help clients reclaim the hurt child of the past and repair their wounds there. If not, they are at risk of getting trapped in the past and replaying their early stories in adult relationships. To help ensure that dysfunctional patterns of the past do not get re-enacted, unlocking and facing the past becomes an important goal in therapy.

The Case of Alana

Alana was referred to me by a clinician from an inpatient substance abuse program who had diagnosed her with Post-Traumatic Stress Disorder (PTSD) and a severe Cannabis Use Disorder. Her clinician explained to me that since Alana entered the program and stopped using marijuana, she had become flooded with horrific memories of child abuse. The referring therapist was concerned that Alana would be at risk of relapse if her PTSD symptoms, which included flashbacks, were not addressed. I have found that it is not uncommon for people to turn to the use of substances to manage their PTSD symptoms of flashbacks and hypervigilance.

When Alana walked into my office for our very first session, her fragility was immediately apparent. She was small in stature, five-feet tall and thin. Her head was down, her shoulders drooped, and she did not make eye contact. She talked softly, almost inaudibly, and had long pauses between sentences. She was easily startled, and when she heard the door in the waiting room close, she jumped, and her body tightened. This was certainly a shaky start for this fragile and uncertain woman.

A year into treatment, Alana entered one particular session smiling and happy. She had had a lunch date with someone she had met through a friend. During lunch they discovered they had a number of commonalities: they both loved animals and had dogs, they loved to hike and travel, they were both teachers and enjoyed working with young children. At the end of lunch, they exchanged numbers and he “promised” he would be in touch. Alana was happy, and I was happy for her. She had worked hard in therapy and was gaining a stable foundation in her life without the use of substances. I interpreted her desire to reach out and make a connection with another person as a sign that she was moving forward in her recovery. Four days after this particular session, I received a call from Alana who asked for an “emergency session” because, in her words, “I am not doing well.” During the session, Alana was shaking and could not stop crying. She said she felt she was going down a dark abyss and was fearful she would never return. She had reached out to me because she was desperately trying not to “spiral out of control.” She was afraid she was going crazy. Contacting me for that emergency session was her attempt to anchor and ground herself. Alana explained the trigger that brought her into the emergency session was that Michael, the man with whom she had been on a lunch date, had “promised” he would be in touch with her but she had not heard from him. In the four days since they had lunch, Alana texted him and tried calling him a number of times, but he was not responding. She drove to his house to check if his car was there and if he was home. The lack of contact with Michael was bewildering, and Alana began to doubt if the positive feelings she experienced during lunch were “one way” and “all in my head.”

Alana’s levels of fear and anxiety were high. In general, I have found that when a client’s feelings are exaggerated and seemingly out of proportion to the current situation, it is a signal that their emotional response has roots in unresolved experiences from the past. When these clients are in a highly emotional, reactive, and anxious state, a rational response actually raises their level of apprehension and serves to exacerbate the client’s sense of disconnection from the therapist. With this in mind, I asked Alana if she was willing to slow down, breathe more deeply, and focus her awareness inward on her body. We had done similar exercises in the past, and Alana was not new to this type of therapeutic inquiry. However, familiarity does not always make this journey any less challenging. It takes courage to sit with and explore the bodily sensations and feelings that are experienced as overwhelming.

I was aware of Alana’s abuse history and her terror associated with feeling abandoned and alone. As a result, I used phrases like “You are not alone—we can take a look at this together.” I could see she found these words soothing and the words helped her to self-regulate. Her face relaxed, her breathing became easier, and her words and the quality of her voice softened. The following is a segment from the session (C represents client and T represents therapist):

T: Is it okay to take a few moments to breathe and go into your body?
C: Yes.
T: What part of your body wants to talk now?
C: My stomach and throat.
T: How do you know your stomach and your throat want to talk?
C: My stomach and throat feel tight.
T: Anything else?
C: My stomach feels tight, like it wants to throw up, and my throat feels like it is hot and on fire.
T: Your stomach feels tight like it wants to throw up, and your throat feels tight like it is hot on fire—anything else?
C: No.
T: Which do you want to take a look at first—your stomach or your throat?
C: Stomach.
T: Is it okay to stay with the sensations in your stomach?
C: Yes.
T: Your stomach is tight and wants to throw up. If you could give it a feeling, what would the feeling be?
C: I don’t know.
T: Breathe… What would tight and wanting to throw up be—mad, sad, glad, or scared? Breathe into the tightness in your stomach, just for a moment. Can you give the tightness in your stomach permission to relax? Then it can tighten up again.
C: It feels scary.
T: Can you stay with scary?
C: Yes—I am alone, and it’s dark.
T: Is it okay to give room for scared and alone in the dark?
C: [With eyes closed she nods yes]
T: Breathe… I am right here with you. What might happen if you let yourself feel scared and alone in the dark?
C: I would disappear and never come back.
T: What would happen if you disappeared and never came back? Breathe and stay with the tightness in the stomach.
C: I would never be able to find my way out of the darkness.
T: What would happen if you could not find your way out of the darkness?
C: I would disappear and be lost forever—I would not know how to find my way back.
T: Can we go into the nausea?
C: [Nods. After a few moments] The tightness and nausea help keep me in my body.
T: So the tightness and the nausea in your stomach protects you and keeps you connected to your body so you do not get lost in the darkness?
C: Yes.
T: Is it okay if we go to the sensations in your throat?
C: Yes—It is tight and hot like it’s on fire.
T: If tight and hot like it's on fire could talk, what would it say?
C: There are no words—just a sound.
T: What sound would it make?
C: A long, wailing cry.
T: Can we stay there?
C: Yes—the wailing cry is the sound of all the fear and pain in my stomach.

Alana started to sob. She was finally able to put words to her visceral experience which, until this moment, was out of her awareness. As the session continued, Alana was able to explore the childhood event that was fueling her current experience with Michael.

C: For as long as I can remember, my father would beat me and pushed away my attempts to get close to him.
T: When was the first time you can remember being pushed away from your father when trying to get close to him?
C: I can remember when I was three or four years old and my father was sitting in the living room chair watching television, sipping on what I know now was a glass of scotch. I was staring at him from across the room. I knew I needed to be quiet and almost invisible so as not to get him upset. While sitting on the floor, I slowly and quietly moved closer and closer in proximity to where he was sitting. I just wanted to be near him and hear him breathing. I wanted some kind of connection. When I finally got close to him, he stood up from the chair, and without a word he kicked me and I curled up in pain. I could hear the door slam behind him as he left our apartment.

Alana was able to stay with the bodily sensations that eventually led her to this memory. As the session continued, Alana made the link between her past and the pain and fear she felt when Michael did not contact her. Over time, Alana came to understand that her relentless and arduous pursuit to contact Michael served as a protective function—to avoid the pain associated with the memory of her father’s abuse. Michael’s lack of contact triggered the despair that she struggled with in dealing with her most distant parent—her detached, angry, cold, and physically abusive father. Alana had spoken about this emptiness and pain in previous sessions. She was keenly aware that her substance use that began at the age of 11 was a way to soothe the pain of rejection and abuse from her father. At these crossroads, when the present felt like the past, Alana was at risk of relapsing and resorting to past mechanisms to self-soothe. For Alana, this included drinking alcohol and using substances.

In later sessions, Alana named this trigger as “wanting connection and being kicked by my father.” Naming the trigger allowed Alana to achieve awareness and take control of her emotions and behaviors when she perceived a disengagement from others. The awareness allowed her the space and time she needed to self-regulate, re-evaluate, and think of more appropriate and rational responses to perceived rejection.

When Alana finally heard from Michael, he explained that he had not been in contact because his father had a heart attack and Michael was called home to be with family. Michael also explained to Alana that he did not think this was a good time for him to begin a relationship, because his free time would be spent with his parents during his father’s recovery. I also assumed that Michael was overwhelmed by Alana’s frantic attempts to get in touch with him. Alana’s desperation had its origins in her early life experiences. Michael became an object of Alana’s distress, which was manifested in the barrage of compulsive texts and phone messages. This objectification contributed to the rupture in their relationship—a rupture that occurred soon after meeting one another, when the lack of a strong relational history did not promote efforts towards a possible repair.

As with most of my clients who experience trauma-related distress, Alana expressed a desire for a secure, comforting, and safe relationship. Despite this desire, Alana’s connections with others could be depicted as highly dysregulated, frantic, and fraught with friction and misunderstanding. Many of the women I have worked with who have histories of trauma are more likely to undergo autonomic nervous system (ANS) responses of fight/flight and/or shutdown/collapse. These physiological states are mechanisms that assisted them in surviving overwhelming physical and/or emotional experiences. However, over a long period of time, after the threat passed, these states no longer served a protective function. Instead, fight created more animosity, flight kept them running in fear, and collapse didn’t allow them energy to live life fully. Eventually, these protective states interfered with their ability to think clearly and make thoughtful decisions. In Alana’s situation, the lack of response from Michael put her in a hyper-aroused state, causing her to be vigilant and unable to maintain calm, think about consequences, and come up with alternative solutions. From this hyper-aroused position, Alana misinterpreted Michael’s distance as rejection and responded with a high degree of emotional intensity and pursuit behaviors. Her attempts to restore the connection was her misguided approach of trying to soothe the feelings of terror associated with being kicked and rejected by her father. Alana believed (just as her three-year old self had) that her only relief from the pain and emptiness was through reconnecting with Michael.

My goal with Alana and clients with similar challenges is to bring the unconscious to conscious awareness by remembering and examining the early experiences and emotions that fuel their current reenactments. One method I have used in many cases is exploration of core beliefs, which creates a psychic prism from which all experiences and relationships are perceived. In therapy, I explore core beliefs with my clients, the feelings attached to each belief, the origins of the belief, and how the belief and feelings are exhibited in present-day behaviors and one’s worldview. Beliefs often include, but are not limited, to such thoughts as “I am defective,” “unlovable,” “a misfit,” “alone,” or “a failure.” The associated feelings are just as varied and include feelings of grief, sadness, loneliness, shame, anger, and fear. If an individual’s core beliefs and the source of those beliefs remain out of awareness, then the person is at risk of reenacting the past in the present, always with the hope of a different and more affirming outcome. The chronic, painful, and recurring patterns of our lives can be reframed as our younger and fragmented parts of self that are calling out for attention.

The child in all of us hopes to be seen and heard, yearning to be found and reclaimed. This can be framed as a call to bring us back to ourselves. It is in reclaiming our earlier selves that our emancipation and release from the past begins, and that we can start our journey toward rebuilding lives that resonate with our authentic intentions, desires, and values.

Clients with complex and relational traumas share stories of unthinkable acts of abuse that they experienced as children. For many clients, the therapeutic process challenges what they have learned in order to defend, protect, and keep themselves safe and, for some, to stay alive. The therapeutic journey requires the client to expose their vulnerability, fragility, and imperfections. For survivors of trauma, to be vulnerable is equivalent to being weak and at risk for being hurt. Thus, to allow themselves to be vulnerable takes great courage. Courage is the place where they confront fear, anger, sadness and/or shame. However, clients also bring hope—hope that somewhere, in all the confusion, desperation, and negative internal dialogue, life can be different, and that on the other side awaits a better way of being and living in the world. When the client doesn’t have hope, the therapist can hold it for them.

***

The women I interviewed for my book on survivor moms emphatically stated that their relationships to their therapists served as the model they used to develop healthy relationships. The therapist and the therapeutic process taught them how to effectively communicate. In therapy, they learned how to listen, ask questions, talk about feelings, solve problems, tolerate strong emotions, and stay composed when engaging in difficult conversations. Their therapists offered the means to increase feelings of self-worth, enhance self-care, and create a compassionate connection to themselves. This fostered inner confidence and the capacity to develop healthy and intimate relationships with others. Their therapists’ abiding presence offered them an opportunity to sit with, feel, and explore their deepest wounds in a safe and contained relationship. The therapeutic process also afforded the opportunity to become more deeply attuned to themselves and others and enabled an understanding of both the vulnerability and resilience of being human. The knowledge, tools, and wisdom that comes from one’s own healing could then be transferred to the ways they interacted and responded in their relationships with intimate partners, family, friends, and, as importantly, with children—the next generation.

Russell Ramsay on Attending to ADHD in Adulthood

Posted on by rezendevknowfully.com

Three Avenues to ADHD

Lawrence Rubin:  Hi, Russell. Can you tell us about the typical clinical presentation of someone who has either been diagnosed with or is a good candidate for the diagnosis of ADHD in adulthood?


Russell Ramsay: Well, there’s a couple of different avenues.

If there is a history of ADHD or suspected ADHD they may think, 'All right, I’d better see somebody about this for managing adult life.'
The first is exemplified by somebody who may have been diagnosed in childhood or adolescence and is seeking out continuity of care in adulthood. They may not have come to us right out of high school but are usually making a transition, when all of a sudden and with increased chronological age, there are increased demands for self-regulation and self-management. Waking up and getting to class in college, managing homework, getting to a job on time, things like that. Usually, these clients will say things like, “You know what? I struggled with the same things over several years as I am right now and I keep starting anew, but I’m not making progress.” If there is a history of ADHD or suspected ADHD, they may think, “All right, I’d better see somebody about this for managing adult life.”

This may sound much more pessimistic than I actually intend, but there’s no end of the school year in adult life. You keep going, unless you're a teacher, whereas for children and adolescents, not that it’s any easy go, but if they can hang on until summer, everything stops. And then they can start over in the fall with a fresh slate—which also keeps some people from getting diagnosed until they move into adulthood. Maybe they can hold it together until the end of the school year when they say something like, “I should probably get an assessment,” followed by, “All right, I got through. It was okay and I started off the new school year okay. So maybe it was just last year.” But that gets repeated, and it becomes a continuity of care issue, with some people saying, “Okay, I had treatment in high school, and now I need some help in college.”

For people who do not come to us until adulthood and weren’t diagnosed in childhood or adolescence, we call them late-identified, not late diagnosis. With a full and thorough evaluation, we can usually confirm that there was emergence of symptoms in childhood or adolescence, even if they weren’t diagnosed at that time. And so people will come to us saying, “I’ve tried to make changes. I’ve made adjustments.” We’ve actually had college students who quit a sports team saying, “I have more time, but I’m not getting any farther ahead.”

a client may present in adulthood with repetitive difficulties managing what previously seemed to be manageable affairs
Or a client may present in adulthood with repetitive difficulties managing what previously seemed to be manageable affairs. And it is not all or nothing. It’s not like, “I never go to class. I never hand in homework.” The frustrating thing is, it’s something within reach, or there’s some documented evidence that “I know I can do this. The admission committee let me in the school. I did well in this class or I did well through midterms, but then I lost it later on.” That consistent inconsistency.

And that sort of drives some of the self-mistrust that can develop within these individuals. So, the second avenue is people saying, “I’m not fulfilling my potential.” We could have a philosophical argument about whether there is such a thing as potential, and if we’re not reaching it, is it reachable? But usually what people mean is, “I’ve done it well, but I don’t sustain it.” There are often college-related difficulties, dropping classes due to falling behind. And it’s not necessarily due to trying to be a physics major, then just finding out you’re not wired for physics.

In managing workplace affairs, even if it’s not a performance improvement plan, people might say, as one of my colleagues so insightfully described, that they’re “working twice as hard for half as much.” Or they might say, “People think I’m so dedicated because I stay late, but that’s how long it takes.” Or they do a lot of extra work on the weekends, which we are all familiar with, but it’s not because they are trying to get ahead so much as they are saying, “No, this is not me going above and beyond. This is me trying to catch up before Monday comes.”

The third avenue, which has recently gotten more clinical and research attention, is people experiencing the effect of ADHD on relationships, be it committed romantic relationships, parenting, or just keeping up with friendships. We see this occurring a lot after college, where people lose touch with people because it takes more maintenance to keep up with friends, as does scheduling and coordination.

We really need to think about ADHD as a problem of self-regulation
From the diagnostic standpoint, ADHD, the name, is probably not going to change. It’s a brand. The A and the H of ADHD are really red herrings. A friend and colleague, Russell Barkley, who is probably a leading, if not the leading figure in ADHD and other matters, has a great line for it. He says, “Calling ADHD an attention problem is like calling Autism eye gaze disorder or saying, ‘Oh, their eye contact seems to be okay, so it’s not autism.’” Some people, whether diagnosed with Autism or ADHD, can perform well in some circumstances. We really need to think about ADHD as a problem of self-regulation. How efficiently do you do what you set out to do?

And without diving too deeply into that, these folks can function pretty well some of the time, but there are enough recurring areas of difficulty. These include difficulties following through, usually towards deferred goals that take sustained effort to reach. And this could be retirement funds, papers for school, organizing behavior across time towards these ends.
LR: So ADHD, whether first recognized as an adult disorder or a continuity of a child/adolescent disorder, is a life management disorder based in part on continuous and pervasive deficits in self-regulation and executive function.
RR:
we’re probably not treating the symptoms of ADHD, we’re treating the life problems associated with ADHD
Right. As psychologists, we understand that medication use is evidence-based and that it can be very helpful, like prescription eyeglasses. And whether we’re speaking of medication or eyeglasses, some people will say that’s all they need. This is just like cognitive therapy for depression. I’m sure this isn’t empirically accurate, but the rule of thirds applies. One-third of people do well with meds only, one-third with therapy only, one-third with combined. A lot of people can do fine with medications alone. But even with a positive medication response, many people will say, “Yeah, but I still procrastinate,” or “I still don’t look forward to reading Beowulf or working on my income taxes, so I still put it off, but I can really pay attention to the sports page or whatever I’m reading.” So we’re probably not treating the symptoms of ADHD, we’re treating the life problems associated with ADHD.

Psychiatric Comorbidities

LR: You say in your writing that psychiatric comorbidity is the rule rather than the exception. What type of psychiatric syndromes or symptoms have you noticed in your work with this population?

RR: Well, both from my noticing it, and also from what has been found in the literature, the top three in ascending order are anxiety, depression, and substance use or addiction problems. And with that, we can probably even bundle in dealing with technology as a distraction.

Now, comorbidities are always interesting because anything could be a comorbidity, really. It makes sense that among these top three, anxiety, which we often see even in subthreshold form, is number one. I think that in the DSM-IV, this particular subthreshold phenomenon was relegated to the “not otherwise specified” domain. Now, in the DSM-5, it’s “other specified” or “unspecified.” In adult-identified ADHD, this anxiety is related to that consistent inconsistency, that uncertainty which is often associated with underlying fear and risk.

uncertainty creates the apprehension, and creating uncertainty is exactly what ADHD does. “I know I can do it, but I don't know if I’m going to be able to make myself
Uncertainty creates the apprehension, and creating uncertainty is exactly what ADHD does. “I know I can do it, but I don't know if I’m going to be able to make myself. I did fine on the midterm exam, but am I going to be able to study and retain and test well enough on the final to get a decent grade or pass the course?” Domains of difficulty can be layered with that uncertainty.

In some ways, anxiety is adaptive because it makes somebody pay attention more and focus on it, like gasoline on fire. But it can also lead to avoidance. And then depression is a sense of loss, so that can lead to disappointment. And that can create a cycle of avoidance, and then comes the self-fulfilling prophecy of, “Oh, you see, it didn’t work out well.” Or, “I tried my therapy and it’s not working, so nothing works for me.” And then comes disengaging.
LR: Hopelessness?
RR: And there’s hopelessness. And then the substance use problem seems to be tied in with the need to self-medicate or self-soothe or, in other cases, it’s maybe related to early initiation due to poor impulse control.
LR: So when you see these comorbidities like anxiety, depression, or substance abuse, is it more helpful for a clinician to conceptualize those as sequelae, with ADHD as the foundational deficit? Or can depression or anxiety or substance abuse lead to symptoms that mimic ADHD? Seems to be a nuanced differential diagnostic issue.
RR: Right. Taking that last point first, absolutely! And even going back to the executive functioning model or that self-regulation model, which addresses the importance of organizing behavior across time towards a delayed goal. We all have executive functions. Going back to Walter Mischel’s marshmallow study, we saw kids who were sitting on their hands during the study so they could earn the second marshmallow—that’s self-regulation. At age eight, sitting on your hands is self-regulation. Just like if those kids had marshmallow issues later on in life, not bringing marshmallows into the house so they weren’t tempted to snack on them would be an example of how this self-regulatory skill followed them forward in life.

So, just like attention problems are ubiquitous in the psychiatric emotional disorders, they’re also a symptom of pretty much every one of the disorders. If you’re in the midst of a major depressive episode, your executive functioning will go down. In the midst of an anxiety disorder, executive functioning goes down. If you have a sleep disorder, executive functioning goes down. In tracking these generally episodic conditions, it becomes important to ask these clients if these executive functioning problems or ADHD predate their emergence?

asking people later on in life which came first, the symptoms of ADHD or the trauma, can be a very difficult discrimination for them to make
One of the tricky ones is when there’s an early childhood trauma. Asking people later on in life which came first, the symptoms of ADHD or the trauma, can be a very difficult discrimination for them to make. Problems with attention and dissociation can both look very ADHD-like. They can also coexist, or the persisting executive functioning problems can exist and endure outside of specific triggering situations or a year with a teacher who might have been abusive and not effective in working with that client when they were younger. Experiences that occurred outside of the triggering situation and outside of any other explanation would warrant further follow-up about the possibility of ADHD.

Then there’s a second conceptualization, where we are simply seeing true coincidental disorders. This would be a clinical scenario where the disorders don’t necessarily or typically overlap, like panic disorder and ADHD, or maybe obsessive-compulsive disorder and ADHD. Social anxiety is another one, because sometimes the ADHD difficulties are very public, like the uncertainty and fear accompanying being called on in class.
LR: When evaluating a client for anxiety, depression, or substance abuse, would a clinician be well advised to also consider some sort of ADHD questionnaire, just to get a sense of executive functioning capacity and the possibility of a more pervasive underlying ADHD?
RR:
there are some good screening scales in the public domain for assessing the components of ADHD
I can be very liberal with heaping more work on some hard-working therapists out there, but there are some good screening scales in the public domain for assessing the components of ADHD. It’s important to remember that screening scales are designed, both for psychological psychology and medical practice, to cast a little bit of a wider net, trying to reduce some false negatives and maybe tolerate some false positives. But in order to identify potential follow-up as a differential diagnosis, sure, they can be helpful.

ADHD as Executive Dysfunction

LR: Okay. Let me drop back a step, Russell, because you’ve used a couple of terms that a lot of therapists out there may be familiar with but haven’t really connected to other disorders. You say that ADHD is an executive dysfunction disorder and a deficit in self-regulation?
RR: Executive functions pretty much are self-regulation, and as an umbrella term within the neuropsychology literature, they generally cluster around one factor. How efficiently do you do what you set out to do? And a lot of this comes right from some of the research of Russ Barkley, Martha Denckla, Tom Brown. There are several executive functioning scales out there, and they generally cluster around goal-focused behavior, referring to goals that we want—we have skin in the game.

Executive functions include task initiation, time management, organization, problem solving, motivation, impulse control, and emotional regulation. We now know that difficulty with emotional regulation within the domain of executive functions is a core feature of ADHD, even if it’s not in the DSM. And it’s not necessarily a mood or anxiety disorder itself. It’s managing the same frustrations and stressors in day-to-day life that we all face, but they just tend to be more disruptive and distracting for individuals with ADHD. And they have a harder time rebounding from them.

I use the example of taking your car in for an oil change, finding out that you need a whole new transmission, and having to decide whether or not to get a new car. Yeah, that’s going to be a little bit distracting, but most people can say, “You know what? When I get home, I’ll talk it over with my partner, and we’ll decide.” While somebody with ADHD may be more prone to say, “I have to look up things now and figure this out now and skip class or lose half a day at work.”
LR: Along these lines of executive dysfunction, which is associated with the frontal lobe, what are the implications of calling ADHD a neurodevelopmental disorder?
RR: I think it draws on evidence, on one of the more consistent findings, that within that particular category, there is a high genetic loading for ADHD. Whether or not genetics are destiny, the unfolding of that predisposition has a lot to do with environmental influences.

there is a high heritability rate in ADHD, which is tied with several interdigitating brain networks, particularly the prefrontal cortex, where the executive functions are housed
We also know there is a high heritability rate in ADHD, which is tied with several interdigitating brain networks, particularly the prefrontal cortex, where the executive functions are housed. It’s not a matter of justifying it one way, as genetic or environmental. I think where we are going with this is that there is going to be a predisposition, and these disorders that emerge in childhood might require some form of lifetime management. This would be similar to the case of diabetes in the medical model, which requires ongoing insulin or paying attention to one’s diet.

We all do that to some degree in the event of more chronic or lifelong conditions, but with ADHD, there might be more specific domains, a little different for each person, that require ongoing, intentional management. Another term in the literature related to this discussion is that ADHD is a quantitative difference, not a qualitative difference, particularly with regard to executive functions. The difference with somebody who, for lack of a better phrase, has intact executive functions is that they have a relatively consistent baseline, while that baseline for someone with ADHD is more variable.

'Well, if you’ve seen one person with ADHD, you’ve seen one person with ADHD.'

It’s almost like the baseline for the ADHD client is a moving target, that consistent inconsistency. And there can be different domains of the executive functions, each of which has its own developmental timing and unfolding. In this sense, different people can have different rabbit holes that can pull them down. One of the lines in my field is, “Well, if you’ve seen one person with ADHD, you’ve seen one person with ADHD.”

Culture and Society

LR: Contemporary clinical practice revolves around an increasingly diverse client base. Does ADHD target any one culture, SES, or race more than it does others?
RR: From the available evidence, it seems like ADHD is equal opportunity. Wherever there are human brains, the risk factor for ADHD is probably around 1 to 3%. Now, what we will see is in terms of identifying ADHD and seeking help specifically for it, that can be where we will hear people of a certain age say, “I grew up in the ‘70s or ‘80s. We didn’t have ADHD back then.” Actually, we did, but it probably just wasn’t as recognized. Or somebody will come from a different country, culture, or family system where they say that mental health issues were not first on people’s minds in terms of looking at what could be helpful.

I think there was an international study conducted around 2001 with college students. They might have found that there were zero Italian women with ADHD, but that was probably more of a cultural difference at that time. They couldn’t determine the differences in prevalence were culturally bound or related to gender. So, I think it would be safe to say that wherever there’s a brain, or a population of people with brains, there’s probably roughly the same prevalence of ADHD. But then there is a difference in rates of help-seeking behavior.
LR: Before we shift into some questions about treatment, Maggie Jackson’s book, Distracted, came to mind. Is the prevalence of ADHD somehow related to the complex, increasingly technology-dependent, fast-moving pace of our society? Or has it always been there, just waiting to come out, as would a previously latent viral threat?
RR:
even though ADHD is not environmentally caused, it is environmentally bound
You know what? It has always been there, because we see early accounts in the literature going back to the early 1700s. Even William James talked about attention and what grabs it. Now that said, even though ADHD is not environmentally caused, it is environmentally bound.

People say, “What about the anxieties and uncertainties in hunter gatherer or farming societies,” like forgetting to close a fence or things like that. When you start looking, there are different manifestations of it. But I would say from a diagnostic standpoint, and in the past 18 months or so of COVID reactions and working from home, there may be more people who are struggling with executive functions now than in the past. And where we rely on environmental scaffolding, like something as simple as going to the office, we can otherwise spend all day not working. But there’s limitations on what we’re going to do. Actually, there’s a term for that. It’s called presenteeism.
LR: Presenteeism?
RR: You’re at work but are nonproductive. This kind of phenomenon might be part of a thorough developmental review of different levels of academic achievement. Whether somebody was valedictorian of their high school class or, on the other hand, struggled with low or mediocre grades, people might have said, “You’re not fulfilling your potential.” You might even hear the class valedictorian say, “Well, my parents had to sit with me every night, even through high school.” Or somebody might have had mediocre grades whose parents said, “You’re not fulfilling your potential,” and they responded with, “No, I can do it. I choose not to. And I can pull it together, and I know what I am doing. And I do enough to stay on my sports team.”

we’re probably going to see some research on how this access to technology affects brain functioning for kids compared with other people
Bringing this back to issues like managing technology and whatnot, you’re right. The advent of digital technology is a unique watershed event in human history, this jump—I mean, humans have always had tools, but nothing like this. And so, that is part of the assessment. And even developmentally, children now have access to smartphones and tablets early on. And I think we’re probably going to see some research on how this access to technology affects brain functioning for kids compared with other people. Going back to self-regulation, there can be a lot of distractions, so it becomes important to ask about screen time and how much they are actually getting done. On the positive side, technology can help us to be more efficient and get more done in less time.

And then, somebody might say, “Yeah, I binge watched the show, I did all this, but when I was at work, I also got all my work done. And I’m on top of things. I clean up the kitchen when I say I’m going to.” It comes down to looking at that executive function. Someone might be struggling, and it could be ADHD that pre-dated COVID. And it’s just that the pandemic kicked it over in terms of their holding it together. But even in that case, they might say things like, “You know what? It was hard enough before. I was staying at work late and all these things. And now that I’m at home and have to make sure my kids are doing classes and things like that, that was the proverbial straw that broke the camel’s back.”

Shifting Focus to Treatment

LR: Russell, I’d like to shift gears a bit and chat about treatment by asking, what is it about CBT that lends itself so well to the treatment of ADHD in adulthood?

RR:
the initial and immediate appeal of CBT was its structured orientation and focus on performance and implementation outside of the session
I think the initial and immediate appeal of CBT was its structured orientation and focus on performance and implementation outside of the session. And not that other good therapies don’t do this, but that initial appeal came from the behavioral side and then along the way, seeing the role that cognitions play. And then we found that the emotional part, anxiety or discomfort, for example, were related to that “ugh” feeling. It’s like, “Ugh, I don’t feel like doing the lawn right now.”

It became important to help these clients to put words on the emotion. The cognitive piece plays a role in follow-through and emotional management. So, I think it started with the structure and the focus on behavioral follow through, setting up the environment differently, and then it became more nuanced over the past couple decades, including expanding into focusing on strengths and making the most of those as well.
LR: In what way does CBT specifically address the cognitive and emotional components of ADHD, including cognitive schema?
RR:
From the behavioral side, CBT’s value comes in helping these clients with engagement versus avoidance, because avoidance is probably the number one problem with adult ADHD
From the behavioral side, CBT’s value comes in helping these clients with engagement versus avoidance, because avoidance is probably the number one problem with adult ADHD. It’s not from a lack of caring, but instead they might say things like, “These things are difficult. It’s easy not to do them.” Their challenges can come from feeling overwhelmed or mismanaging time. There are a lot of ways that we don’t budget ourselves and end up spreading ourselves out.

From the emotional side, there is no single theme, but I think the main emotional task is avoidance and managing discomfort. The “ugh” feeling. Addressing the discomfort is very similar to progressive exposure for anxiety. We ask them, “How can you handle the discomfort by changing your relationship with it?” And we remind them that the discomfort doesn’t have to stop them and that they can then follow through with a plan for engagement and, by engaging, have the discomfort diminish. This is the proverbial, “Once I get started, it’s not as bad.” And then, hopefully, they can access their skills.

It’s not that they can simply think themselves into it. So much of it is about things we want to do and achieve, even if it’s stuff like homework that we just want to get out of the way so we don’t have to think about it anymore. But it can also be things that we want to do, like following through on an exercise plan or being able to play a sport.

it is important to remind them that even if ADHD is not their fault, it is their responsibility
If ADHD gets in the way of these goals, it may lead to disappointments and frustrations, and those then get turned back on the self in the form of negative self-talk and low self-esteem. One of the early popular books on adult ADHD was called You Mean I’m Not Stupid, Lazy, or Crazy? I think that’s very often the attribution that people have. While it is important to help these people with this negative attribution, it is important to remind them that even if ADHD is not their fault, it is their responsibility.

So we look towards coping strategies for ADHD that include reframing the mindset. That involves an understanding of ADHD, why things were difficult, and why some of the setbacks happened, and trying to set up systems and expectations moving ahead so that people feel more efficacious. I use that term decidedly because within cognitive therapy, different disorders have different themes. In depression, the cognitive theme centers around loss—loss of esteem, loss of opportunity. With anxiety, it’s dealing with uncertainty and the threat or risk that comes from that.

I landed on the recently-deceased Albert Bandura’s notion of self efficacy, which initially seemed too general. But in going through some of his writings, I came across the concept of “self-regulatory efficacy,” which is about one’s ability to stick through with all the dirty work that you have to do for those outcomes. I’ve got to sit down, I’ve got to study. I’ve got to write the paper. I’ve got to do something I don’t feel like, and that sort of gets to that emotional “ugh” feeling. It was virtually a rewording of the executive functions, without ever using that word.

And my sense of Bandura’s writings was that this capacity is assumed to be intact for most people. If somebody’s depressed and they have problems with efficacy, it’s more at the depression level. But I saw that as more of a fundamental feature for folks with ADHD. They know at some level that “I know I can do it, but I’m not sure I can get myself to do it when I have to do it.” And I think that’s what goes into the thoughts of procrastination: “I’ll do it later, and hopefully, at that time, then I’ll be ready to do it.” Interestingly, some of my colleagues have developed an ADHD cognition scale that actually includes distorted positive thoughts which lead to avoidance.
LR: Distorted positive thoughts?!
RR: They are permission-giving beliefs. A non-ADHD example is, “You know what? I’m going to have a second scoop of ice cream, and I’ll work out twice as hard tomorrow.” And if they do it, that’s fine. But these distorted permission-giving beliefs are things like, “I know this usually sucks me in, but I’ll just do it for a minute. Being impulsive is a big part of who I am. I work best waiting until the last minute.” Or these self-justifications for not now, later. And I think it is coming from that point of, “All right, I’m not feeling up to this now, but maybe I will be later.” But later then becomes now. What did George Carlin say, “‘Now’ is the only word in the English dictionary that changes definition every time it’s used?” But there’s always that “I’ll do it a little later, a little later, a little later” that then comes back to bite them.

Intention to Action

LR: Is this why you say that one of the core elements of CBT treatment with ADHD adults is converting attention into action?
RR:
we CBT psychologists are pretty good at helping people understand how they don’t do things
People say, “I know what I need to do, but I just don’t do it.” And there’s no trade secret about the strategies. I mean, it’s useful having different reframes or different ways to approach it, but we generally know what we need to do. And so, people say, “I know exactly what I need to do. If I could do all these things, I wouldn’t need you, psychologist. So what good is talking with you going to do about it?” And my answer to that is that we CBT psychologists are pretty good at helping people understand how they don’t do things.

Almost like a reverse engineering of the executive function. If we’re talking about procrastination, I’ll tell my clients, “You know what? You really need to start earlier.” Please, sue me for malpractice. But if we look at situations, and this is cognitive behavioral therapy in general, “Let’s reverse engineer it to understand how you procrastinated, because it could be a planning issue.”

If they say, “All right, I knew I had to do it, but I never made an appointment or told myself, ‘I really should do this Saturday at 10:00,’” in this instance, it could be organization. If they say, “I had the plan, but I lost it or didn’t check it,” it could be that they had the plan but didn’t feel up to it at the time and thought themselves out of executing it. The “ugh” feeling. Or they may say, “I just didn’t feel right, it was too uncomfortable or overwhelming,” or “I saw something else that needed to be done. Tell you what, let me clean up the kitchen, then I’ll be in the mood to work on taxes.” In actuality, they probably weren’t. If they were, that’s great.

I’m a big believer in the idea that there are multiple ways to do things well, which is what I mean by helping these clients to convert intention into action
I’m a big believer in the idea that there are multiple ways to do things well, which is what I mean by helping these clients to convert intention into action, by following our grandmothers’ rule of breaking it down into manageable tasks. But it is also sitting with somebody and being able to work through it. Like, how do I do that with this task to get to the point that they can say, “I can get started with that. This is manageable. It’s some sort of bounded task. I can see the end point and then I can work from there, reach the next end point, and then do it again and again.”
LR: Is this self-regulatory efficacy or lack of self-regulatory efficacy what you might consider a core schema underlying ADHD? And how do you address such an embedded belief system that is so potentially debilitating?
RR:

Core ADHD Schema

Right—that is my clinically informed hypothesis. And with that theme, within cognitive behavioral therapy, there’s the automatic thought, so we might ask the client, “What thought went through your mind at 10:00 on Saturday that led you to go mow the lawn rather than work on homework, or whatever it may be?” That’s like Freud’s notion of the preconscious, which is that there is a flow of thoughts or self-talk that we have going through our head. And if we pay attention to it—and that was one of Aaron Beck’s revolutionary ideas—then people can catch themselves thinking in this way and change it. You know, sort of promoting efficacy.

As the field of cognitive therapy for depression went forward and we saw that some people did really well, while others who didn’t had these core beliefs, it became clear that these nonconscious beliefs were probably being encoded emotionally. We could help people to become more aware of this process and catch themselves. This might sound something like, “You know what? If I feel okay, if it feels good, I can do it. Or if it’s interesting, I can do it.” This is the conditional rule. Or another version of that rule might be, “But if it doesn’t feel good, it must be bad, or I don’t do this.”

What we’re really doing is putting words on emotions. At the level of automatic thought, it becomes more about semantics. If we say the person has self-distrust thoughts, then it is a more localized process, as opposed to the embedded schema or global belief system around the notion of self-mistrust, which is more pervasive. They are related to each other.

in two studies of schema in adult ADHD, failure was the number one schema endorsed in both
In the case of ADHD, some people may say, “Hey, I know I’m good. I know I can do it, but it’s just, I really struggle in this specific domain at work.” Here, it’s relatively circumscribed, while for others, it extends beyond the workplace and is more pervasive. These people might believe, “I’m a failure. I’m no good.” Actually, in two studies of schema in adult ADHD, failure was the number one schema endorsed in both.

This makes sense, tying in with the efficacy. All the have-tos and many of the want-tos in adult life feel like, “I haven’t achieved as I ‘should.’” But when dealing with schema, we’re recognizing them—“All right, let’s put words on the old belief or the old frame.” And very often, it could be a failure belief of, “I haven’t done, and I can’t do, what I need to do, and nothing is ever going to work out.” That may be so, but it’s only one view.

Is there evidence to the contrary? And even if you say, “Well, no, I dropped out of school, did whatever”—all right, well, what do you want to do now? With getting treatments, medications, whatever it is for ADHD, what would you like to re-approach? And is there a different view you can have that’s like, “Okay, this has been difficult for me before, but I can at least give it a try and maybe put forth a better effort now that I have these supports and see what happens.” There may not be any guarantees, but it’s worth the try.

The Power of Framing

RR: There is support for this thinking from research on the power of framing. Just having a counterpoint of, “Is there something else I’m working towards or a different way of looking at this?” Even if we don’t buy it yet. It can feel like being an actor learning lines when the other ones had a head start. But at least now you doubled your options. There’s the, if you will, the failure outcome of this. But let’s come with at least, at the very least, the possibility view and consider how to manifest that. And then, nothing convinces like experience. Emotional, cognitive, behavioral—and each of them can change the other two.
LR: I can imagine, then, that a clinician can also draw on some of the techniques of Solution Focused Brief Therapy and Narrative Therapy to help a person draw out success experiences that they’ve had as a foundation for building future successes. How did you get yourself to class? How did you get that work done?
RR:
that’s the insidious thing about ADHD. It can overgeneralize and contaminate everything
Robert Brooks and Sam Goldstein talk about islands of competence. Sometimes, that’s the insidious thing about ADHD. It can overgeneralize and contaminate everything. It might be helpful to ask somebody who is really good at getting to the gym or really good at a sport, “How do you practice all the time?” or “How do you get yourself at the gym?” Or you might point out to them, “There’s got to be plenty of days you don’t feel like doing it. Is there any way you can translate that into getting started on whatever chore it is or homework? Just as an analogy, just have that mode that you go to.” And they may respond with, “All right, here’s something I can try, and this can be like the first 10 minutes on the treadmill. Where it’s like, okay, it’s not my workout yet, but I need to break a sweat. So, I can give myself 10 minutes to break a sweat on homework or something like that.” I think the restorying that happens with narrative therapy is relevant here.

As an aside, I did my doctoral dissertation on personal narratives, so that’s near and dear to my heart. The thing about editing a story in the here-and-now is equivalent to saying, “Okay, this is sort of like there’s been a plot change, with the diagnosis of ADHD. What do I want to do with my character now?” It can be very useful to build on positives and things that might have gotten short shrift, either projects or wishes, or passions abandoned prematurely at the first sign of trouble, before the knowledge of ADHD was there. Or maybe it’s about things that somebody previously said “I can’t do.” And I might offer something like, “You know what? I can’t guarantee anything. That might be true, but is that something you’re willing to give a chance or give a try? And what does that look like, and how can you do it differently now?”
LR: As we wind down, Russ, I wonder if some of the symptomatology—the behavioral, emotional, and cognitive patterns that you described in folks with ADHD—also complicate treatment by leading to treatment resistance or avoidance or not following through outside of session?
RR:
therapeutic alliance plays a big part, because the therapist who is familiar with ADHD can validate the difficulties and setbacks, but also the successes
I think this is why we try to set up early success experiences, which also comes from the change literature and specifically the stages of change model. It’s sort of like building up momentum or getting a running start. If somebody has some big issues, like a performance improvement plan at work or getting ready for a final exam, there may be smaller examples from their day-to-day lives, like unloading a dishwasher or submitting their room application for next semester, that also have to be done. In these instances, my line for that is, “We procrastinate on the small stuff the same way we do the big stuff.” So it’s not like we have to go through every single thing, like, “Okay, here’s how you procrastinate on income taxes. Let’s talk about how you procrastinate on your local taxes.” No, we can take some of those elements and then adapt them, they can generalize to other things. And that’s similar to what we were talking about before, the solution focused, “All right, what can you use here over there for help?” So we try to have some success experiences. I think this is where the therapeutic alliance plays a big part, because the therapist who is familiar with ADHD can validate the difficulties and setbacks, but also the successes.

And it’s important that the clinician focus on normalizing by saying, for instance, “You know what? As we move ahead, there will be areas of difficulty. But that’s the name of the game.” So two things are at play which go back to the cognitions. People with ADHD tend to compare themselves unfavorably to others, thinking that everybody else has it so much easier. It becomes therapeutically important to validate that taxes and homework, especially writing assignments, can be very challenging.
LR: For everybody.
RR: Actually, writing assignments among college students, ADHD or not, are the number one procrastination target. People procrastinate on writing assignments because writing is hard. And even that reframe of, “Okay, this is hard for everybody” can be empowering, because we know that misery loves company, and we can point out that it’s a matter of degree. ADHD makes it harder, but can we get in there and then, you know, tolerate the discomfort that may be associated with that?

most people just want a clearer, more consistent sense of cause and effect. 'If I put in the effort and the time, then I’ll be able…'
And there can be this overgeneralization. “If I can’t do this, then there are other things I can’t do.” We want to ask, ”Let’s find out what you can do. And can you do this better? And it still may be difficult.” Most often, people say, “If I can just get the assignment done, if I get a B, I’ll take it.” And it gets back to that notion of efficacy, in that most people just want a clearer, more consistent sense of cause and effect. “If I put in the effort and the time, then I’ll be able…” to submit the homework, finish my classes by the end of the semester, whatever it is. It may not be “I have to be the CEO of some Fortune 500 company.”

But it’s just attending to the more immediate cause-effect relationships, like, “Okay, I did the work and I got the outcome, and now it’s gone. I did it. Now I don’t have to worry about it anymore.” And that’s just a nice starting foundation for people finding out that they can do the things that they want to do, and then maybe even start to expand beyond that more.

We can almost look at this process through a medical lens. There’s “rehabilitation,” and that is getting back to a baseline, such as rehabilitating a knee. Then there is “habilitation,” which is making the most of it with whatever resources we have. Here, someone might say, “I don’t have dyslexia or anything, but I’m just a slow reader. I have to read things a couple times.” Whatever it may be. It’s like, okay, how are you going to work with that?

So there are ways that you can play to their strengths and things like that. And my own cutesy line is “abilitation.” Like, after you take care of managing the problems with ADHD, are there some things, maybe some newfound directions that you can go in?

It’s like, “Hey, maybe I can try this.” It could be going back to school. It could be trying a new endeavor. It could be somebody saying, “No, I don’t want to go back to school and read textbooks. But if I read a biography of my favorite athlete, maybe I can get back to pleasure reading.” Whatever, however people define it. And that’s how newfound avenues get unlocked.
LR: I think that’s a good note to stop on. I want to thank you so much, Russell, for sharing your wisdom and your experience with our readers who may be struggling to succeed with their adult ADHD clients.
RR: Sure thing. You’re welcome.

Unlocked: Online Therapy Stories

Posted on by Psychotherapy.net Team

Laila

Riyadh, Saudi Arabia

Laila is very good at hiding. This is the first time we meet, and as her unveiled face appears on my screen, I can barely distinguish her features hidden by the thick darkness of the room.

From her initial email, I know that Laila is in her late 30s, unmarried and, as a result of these circumstances, is living in her parents’ house in a very conservative Middle Eastern country. She warns me straightaway that it has been a difficult and risky decision for her to engage in therapy, especially online and with a Western therapist. It is also her only option if she wants to keep it away from her family and confidential.

Privacy is an issue. Her parents’ house is vast and has many rooms, but her nine siblings come and go as they wish, following the rhythms of their prayers, meals and social obligations. Some of them are married, and their young children are constantly running around the house, untamed and loud.

Connecting with Laila for our first session, I automatically become an accomplice in her rule-breaking behaviour. Starting as partners-in-crime results in an immediate intimacy and a strange sense of kinship that usually takes time to create in therapy.

“Where are you now? Is this your room?”

“Yes, it is my room, and fortunately the door is locked.”

I overhear children’s voices and some music resonating from the bowels of the house. By contrast, her room is very quiet, and from the little I can see of it, rather spartan.

“I told them I was having a migraine and had to lie down.”

“Do you have migraines often?” She smiles sadly: “Yes, I do.”

As we would realise later, this was the only excuse she had found as a child to isolate herself and get some personal space. Nevertheless, Laila’s migraines’ ‘purpose’ does not make them any less real or painful. They can last for days, and self-isolating in a dark room has become a habit that her family accepts as another bothersome part of her character, alongside the irritating stubbornness that she displays on certain occasions. The recently installed lock on her door, which has caused many heated conversations with her father, is also the welcome consequence of her ‘condition’.

“I am not sure therapy can help me. Something terrible is about to happen …”

Before she can finish, we are interrupted by a strong knock on the door. Shaken by its invasive forcefulness and Laila’s abrupt backing away, I do not have time to fully realise what is happening, and she is gone. My screen suddenly goes blank.

For several days, I can’t stop thinking about this aborted session, worrying for Laila and wondering whether she will ever make it back to my virtual therapy room. In the meantime, Paris empties as a result of the lockdown. Bewildered Parisians watch its deserted streets from their windows or balconies. Their screens become the only way of maintaining a connection with others. The fleeting conversation with Laila is nearly forgotten when an email from her arrives. This time she is resolved to start working with me, as soon as I am free. We arranged to reconnect the following evening.

As Laila joins the video call, her face instantly fills my screen in an unexpected close-up. She is wearing a dark purple hijab neatly framing the beautifully defined features of her face. A fierce energy emanates from her. No distance or screen dampens that down.

Laila tells me that she has been postponing therapy for years, unsure of how to proceed. It started with her parents insisting that she consult a local psychiatrist, perplexed as they were by her moodiness and unwillingness to engage in any discussions about marriage plans. Laila hated it. One of her older brothers, chosen to drive her to the appointment (as she was obviously not allowed to drive), would wait for her in the corridor. She could feel his presence behind the door and his annoyance at what was just another time-consuming task for him.

***

The psychiatrist did not unveil anything (nor did Laila unveil her face in his presence). He did not seem very interested in her concerns and promptly prescribed antidepressants and a break from work. It convinced Laila not to come back to this or any other local doctor. Taking a pill would not make her problems go away. The risk of being forced to leave her job scared her.

She works as a nurse in the maternity ward of a large hospital and, strangely enough, her work has become her most cherished space in finding some privacy. There, she is valued for her skills, away from her father’s constant scrutiny.

“How do you feel about talking with me, a Western woman living thousands of miles away?”

“I do not know if I can trust you. But I have no choice.”

I tell her that confidentiality is the very basis of therapy, but I don’t know if my words are enough to reassure her.

So here we are – two women sitting in front of their computers in two opposite parts of the world – talking with each other through a screen, in a language that is neither one’s mother tongue. Having grown up in an autocratic state, I know too well that a foreign language can turn into a space of freedom, a boundary and a safety blanket, unavailable in one’s mother tongue.

Laila has to talk in a hushed voice. Her family members are constantly passing by her room, and sometimes I clearly distinguish their voices resonating in the tiled corridors of her parents’ vast house, approaching and vanishing again.

Do they speak English? Yes, a bit, but not as well as her. Laila has been passionate about learning English since her teens. She has always felt that this language offered her a space for free thinking and privacy, which she considers unattainable to her in Arabic. Her father has always scolded her for spending too much time reading in English or watching American films, but since she has had to study English for her nursing degree and, later on, to work at the international hospital, he has grudgingly conceded her this ‘frivolousness’.

Since her late teens, Laila has been avidly using social media, where she now has the majority of her meaningful social connections, her ‘online friends,’ as she calls these virtual bonds. In this parallel world, women are able to befriend men; friends can exchange unveiled pictures of each other, discuss intimate topics and even share their religious doubts.

“Last time we spoke, you said that something terrible was about to happen. What did you mean?”

Laila shoots a quick look towards the door as if to check that nobody is there to intrude her space, but the house is silent.

“My parents received another marriage proposal for me … they know that this is maybe the last chance to get rid of me.”

“Do you know this man?”

“No, but his mother is coming tomorrow to look at me.”

Laila lowers her head and slips away from the camera, so that only a part of her forehead, covered by the hijab, stays visible.

The marriage hunt started when she was eighteen, and her parents’ attempts to find her a suitable husband have become ever more determined and desperate. First Laila could highlight the flaws in the aspiring grooms that would make good deal-breakers: lack of a respectable career, a physical defect or, even more convincing for her parents, lack of religious fervour. As time went by, the suitors grew older, their flaws became more obvious, but her parents’ desire to finally settle their insubordinate daughter also became more urgent.

This time, it is an older cousin who is already married and is now considering taking a second wife.
“I am getting too old to be a first wife … but not old enough to be left in peace.” Laila’s voice cracks and she is close to tears.

That evening I find it hard to join in the conversation over the now-traditional online aperitif with friends. The mundane topics around COVID symptoms, current government strategy and facemasks feel far removed from what I am still struggling with: the prospect of a forced marriage on Laila.

This is one of those times when I almost physically stumble on the limits of what I am able to offer to a client; therapy can be an empowering force, but certain brute realities of existence can have a stronger adverse effect. I desperately want Laila to be free, and the intensity of my yearning is only a distant pale echo of what she is probably feeling, trying to get to sleep in her lonely room. The laughter of my friends and the jazz in the background are making Laila’s isolation even more blatant in my mind.

I grew up as an only child and, at bedtime, my desolate condition would usually feel cruel. I would lie in bed for hours, fantasising about potential siblings, little doll-like brothers and sisters to dress and feed. Laila, on the contrary, has many siblings but this did not make her any less lonely; none of them understood her stubborn rebellion against the family rules or arranged marriage. I imagine her sitting on her lonely bed, scrolling through on her laptop her online friends’ intimate messages. Would she be able to act on what we had plotted, maybe foolishly, together?

That night I dream that I am lost in a strange place – maybe an abandoned hotel or a school – unable to get out of its intricate staircases, endless corridors, and vast empty rooms. I am pacing through the rooms as a lonely ghost, unable to find an exit or someone to ask for directions. Rescued by the morning alarm, I have to lie down for a few seconds, trying to distinguish the harrowing dream from the nightmarish reality of another lockdown day.

During the day I find myself checking emails between sessions, hoping to hear from Laila, but she keeps silent. Or is she kept silent? In my current monotonous reality, Laila’s story starts to resemble a television drama with weekly episodes on my computer screen. I do not need Netflix, as my clients’ real-life stories are filling the void left by the lockdown which has robbed me of many of my daily joys. Laila’s distress washes me away in a powerful emotional wave that I am unable or unwilling to control; I find myself washed out on the shore of my balcony, covered with the debris of my own frustration, hurt and with a deep feeling of loss. I stand there contemplating the grey field of Parisian rooftops with hundreds of red chimneys erected in a frozen dance; birds are swirling in the still air, oblivious to the lockdown. For the first time I regret not smoking, as a cigarette would probably have been a good kick right now. My tea has become cold and tasteless. I go to the kitchen and pour myself a large glass of crisp white Burgundy.

By the time I go to bed – later with every passing day – Laila’s email is waiting for me in my inbox: “I barricaded myself in the room as planned. Did not come out when the man’s mother came. I don’t know what happened there. Have to go now, as my father wants to talk. Will write later.”

My heart starts racing; I know I should not be checking my emails at this time, but the lockdown seems to have altered many rules. I know that I have to do something. I go to the bathroom and wash my face with cold water. I look in the mirror and dislike what I see – an ageing woman with unkempt hair and puffy eyes. Since hairdressers shut down, my usually dark curls are showing more and more grey. I open the drawer, fetch the scissors and start cutting, methodically, until the sink is filled with hair. As I cut, I think about my husband telling me that he really prefers women with long hair; all the things I could not say no to come over me like a big wave. My own anger takes me by surprise; how can I have all this inside, after all these years of therapy, trying to heal? Then I realise that this is not just about me, but also about Laila. I am outraged and rebelling on her behalf.

***

Next time we meet online, the connection takes a while to settle, like the surface of a lake disturbed by the stone thrown by a child, and her bright face appears. She looks at me in bewilderment and I start thinking that something has gone wrong. But before I can utter a word, Laila takes her hijab off in a resolute gesture. This is the first time I see her head uncovered – she looks like a little girl, and her hair is even shorter than mine, she is almost bald. We stare at each other in amazement and the mirroring effect of our screen encounter becomes even more striking. She is the first to talk.

“I cut my hair. You did too?”

“Yes, I did.”

“If my father finds out, he will be really mad.”

“Do you want him to see it?”

She keeps silent for a moment, playing with her hijab, which is lying on her lap like a little dead animal.

“In a way I do, even if I am scared he may kill me.”

“Kill you?”

“I mean … I don’t know. I never did anything like this before.”

She looks directly into the camera; in her wide-open eyes I see a mixture of excitement and defiance.

Now it is my turn to feel scared.

“But does he really need to know?”

“No, maybe not yet.”

With her naked head she looks so young and vulnerable that I want to protect her, to make sure she is safe. But I have to remind myself that she came to me in search of empowerment. Trusting me, she took a risk, and it is now my turn to trust her. I feel like the parent of a toddler who is climbing a jungle gym for the first time, realising that the child could fall and hurt themselves, but also has to learn this new skill in order to eventually master it.

“My father called me yesterday after he learnt I did not show up in the guest room. He was very upset.”

“Is this over now or will she return?”

“Anyway, not before the lockdown is over.”

“Oh, good. This gives us a few weeks to figure something out.”

“Yes. I do not want to marry, ever.”

She stares at me with her intense dark eyes and I desperately look for words to reassure her, but I stumble as I am not certain that we can fight against her father’s will, the omnipotent power over his daughter given to him by his country’s tradition and law.

“Can you talk about it with your mother?”

“I tried. She keeps repeating that I have to marry and have children, otherwise I will never be happy. She does not know any other way.”

“What about your older sisters?”

“They all wanted to get married. Now they think I should too.”

“What about your online friends?”

“Yes, they understand. We talked about the ways out. They advise me to get ill or to lose a lot of weight. Just to gain some time.”

Laila shows me her room. It looks like a prison cell, although the bare necessities for a reasonably comfortable life are there. The only objects Laila cherishes are a few books on a shelf and a television. But even those tend to attract the unwanted attention from her family – why doesn’t she watch television in the common room? Why does she need all these American books?

The electric light is always on, even though the bright Middle East sun shines outside nearly all year around.

“We are strong on privacy here,” Laila explains.

The shutters are closed all the time, to prevent neighbours getting a glimpse of the women of the house. As a result, Laila has no access to the outside world. Before the lockdown, almost her only outings consisted in commuting to her workplace in her brother’s car, with tinted windows for the same reasons of privacy, making everything outside look bleak and slightly unreal. Laila recognises that often she feels like a ghost, as the familiar world turns into an uncanny copy of what reality is supposed to be. The days go by in a sort of depleted way, a succession of small familiar tasks, starting with making coffee for her father, ending with the evening prayer. Only then, as she finally locks her door behind her, taking off her hijab, does Laila feel that she is still alive.

After our session I gasp for fresh air. The balcony is not enough; I also feel a terrible itch to be moving. I put my running shoes on and venture outside after signing the compulsory ‘attestation de déplacement dérogatoire’ (‘self-declaration form for travel’). I feel rebellious again and, as I start running, I take my mask off my face and shove it into my pocket. The prospect of a police patrol stopping me only heightens my resolve.

The riverbanks are closed, but I ignore the warning sign as I sprint down to calm and vast Seine. As I follow the river, very close to the edge, I can smell its slightly rotten water, finally free of pollution. The water carries a sense of calm power, vague possibility and quiet hope. But Laila lives in a desert. I have not run properly for weeks and the air soon starts hurting my lungs. I ignore the pain and keep pushing towards the Eiffel Tower, looking ghostly and slightly out of place in the middle of the empty city.

***

The next time I connect for the session with Laila, it is with a palpable sense of dread in my stomach. I realise that Laila is late, which is unusual. I open Telegram, our prearranged back-up option, only to find a message from her asking to chat here instead. Of course, we can. This is not the time for worrying about strict boundaries.

“My father found out that I’d cut my hair and confiscated my computer. He thinks that it is all because of the American films.”

“How did he find out?”

“I think my mother told him. She tells him everything.”

“How are you doing?”

“It does not make such a difference to me. It is just that my door is locked on the other side.”

Using a chat room adds the option of staying hidden. Laila seems comfortable with this new set up; I am less used to sudden restrictions. She is so accustomed to things being taken away from her that it does not seem to throw her out of balance.

“For how long will you be punished?”

“I don’t know. It depends on his mood.”

“Has it happened before?”

“Yes. When I was a teenager I spent a lot of time in here, but I actually liked it. It gave me some peace … this is when I studied English.”

The language that she learnt whilst imprisoned has eventually become her space of freedom. Ironically, we use English for a therapy session, both being in breach of her country’s expectations. As we are chatting with our respective doors locked, it feels like two teenagers secretly communicating behind their parents’ backs.

“As a teen, did you have friends to talk with?”

“No. Not really. I did not have social media back then.”

Laila is sounding distant. Is she typing something to her friends simultaneously?

“Can I ask you about something?”

I am glad that she asks, whatever the question may be.

“Do you think about me sometimes?”

If she only knew how much I have, she would probably feel uncomfortable.

“I do. I worry for you. And sometimes I wonder how much I am really helping you.”

“You don’t know how much you have been helping me.”

I am regretting that this conversation is taking place by chat, but again, we have to settle for what we have. I would prefer to see her eyes, even if the screen turns eye contact into a weird imagination game. Doing with less, turning things around: these are lockdown lessons that Laila has had to master well before many of us.

***

It is the sixth week of lockdown and I am lying in bed at midnight, unable to calm down the frenetic flow of my thoughts. All the little things that my life ‘before’ was made of are spinning in my mind – a coffee with a friend in the nearby café, a chat with the friendly waiter at the bistro where I stop by for lunch, a stroll to an art museum, a quick drive to the seaside for a lunch of oysters, outside under the pale Normandy sun – all things made impossible by the need to keep away from others. In the end, life’s pleasures are a lot about being with or at least near others.

As I am quietly mourning all things lost, my phone buzzes, announcing a Telegram call. Before picking up, I notice that the screen displays an international number with a prefix I cannot place.

“It’s Laila.”

Her now familiar voice is filled with a mixture of dread and excitement; I suddenly feel completely awake, with a jolt of adrenalin rushing into my blood.

“Where are you, are you ok?”

“I am in Bangkok … at the airport. I ran away.”
“Are you alone? Does your family know where you are?”

“I don’t know. I am so scared … if they find me, they will kill me.”

Her voice is that of a little girl; the kind of voice my daughter would have when waking up from a horrible nightmare in the middle of the night.

“How can I help you?”

“You cannot. It is too dangerous. My online friends are helping.”

She keeps silent for a moment; I am waiting for her to reassure me that everything is ok, that she will be fine somehow. My heart is pounding heavily in my chest.

“Laila …? Are you there?”

“I have to go now! I just wanted to say goodbye and … thank you.”

Before I am able to respond, she is gone, her voice abruptly replaced by the long beep of a dead line. As I put down the phone, I suddenly understand all that I have been missing. Everything clicks into place. Laila had been preparing her escape all along. I feel betrayed, like an object that fulfilled its purpose and can now be discarded. After a few moments the hurt gives way to anxiety: what will happen to Laila now? I pick up my phone again and start scrolling the international news. No mention of a Saudi girl on the run. Not yet.

The next time the phone comes alive in my hands, it is past midnight. Laila sounds different, she talks with a new urgency that makes me sit up in bed, alert.

“Why didn’t you tell me about your plan?”

“I couldn’t. It was too dangerous.”

I can now hear some muffled male voices and a noise as if somebody is banging on a door.

“Where are you now? What is happening there?”

“I am in a hotel room, still at the airport. Look at the news.”

Laila disconnects or maybe the call drops out.

I return to the live news page still open on my phone screen: this time Laila is there. I recognise her frail silhouette in the slightly blurred images. A short video shows her walking through a dark corridor flanked by several men in uniform – Thai police most probably. They escort her somewhere. With her black t-shirt, a red backpack and an uncovered head, Laila could easily pass for a normal teenager were it not for the policemen with watchful looks surrounding her in a tight circle. She looks vulnerable but proud.

This time I call her back; she responds in a second.

“What is your plan?”

“To ask for asylum. I am not leaving this room until I see somebody from the United Nations.”

As we talk, I can hear the banging on the door and the voices getting closer again; something smashes loudly on the floor.

“They are trying to get me to unlock the door.”

“Are you sure they cannot break in and harm you?”

“I don’t know. I barricaded it with all the furniture that I had in here.” Her voice is trembling; I can sense her terror almost physically.

“Do you want us to stay on the phone? Is this helpful?”

She keeps silent for a second; I can hear her heavy breathing.

“Yes, please.”

I grab my dressing gown and, headphones in my ears, I go to the kitchen and make some coffee. I have to keep my hands busy to keep the anxiety at bay. The futile routine of making coffee contrasts with the mayhem in a Bangkok hotel room on the other end of the line; it is surreal. But Laila’s voice confirms that this is not just a bad dream of mine.

As we sit and talk, her online friends are rushing to attract as much attention as possible to her case. After just a few hours, social media is buzzing with her story, but it is still not enough to reach a high-ranking UN official. She keeps silent for a long moment and I can hear her tapping on her phone, fast and furious. I just stay there, listening to the noises from yet one more room where she has had to lock herself in. I hope this is the last time she has to do that.

Then Laila starts talking. She tells me all about how she has planned for this since the very first day of the lockdown. Her family was scheduled to have a holiday in Turkey and when it was cancelled, she managed to keep the travel authorisation signed by her father. The household was shaken by the lockdown, and the usually steady routine was disrupted as all family members had more time on their hands. With Ramadan starting a few days before, Laila knew that this was the right time for her to attempt the escape. The impending marriage, which now seemed inescapable, had left her with no other option than to act before the end of the quarantine.

“You have helped me to feel stronger, I have had hope again.”

***

That night, those who know Laila are not sleeping. After a few hours of social media frenzy, she finally receives a message from a French journalist.

“He wants me to record a video and post it on social media. To attract more attention.”

I see his point. The only images of Laila that are circulating online are blurred and vague; her scream for help has no face yet. But I also know what showing her uncovered face to the whole world would mean for her. Her family would never get over the shame; they would be unforgiving.

“Are you prepared to do this?”

She stays silent for a long moment. I listen to her accelerated breathing; she is hyperventilating.

“Laila, let’s try to breathe more slowly, breathe with me.”

For a few minutes we are inhaling and exhaling together, finding a shared rhythm.

“I am so scared,” she whispers.

“I know you are. I am scared for you too.”

“They will kill me.”

“Let’s make sure they cannot. Do you remember the first time you showed me your face?”

“Yes …”

“You did it then, even though it was risky.”

“I did.”

A few seconds pass and I finally hear her voice, trembling but clear. Laila tells the world about who she is and why she has barricaded herself in this room. She asks for asylum. As soon as she is done, the video of her talking to the camera appears in my Twitter feed. Then we both observe how her video makes a storm; it is also taken by this storm and propelled further and further around the virtual world. To watch this happening is fascinating. There is no way back for Laila after this, we both know it.

I suddenly feel exhausted; outside the sun is coming out from behind the sleepy buildings. Paris is waking up, oblivious to what has been happening to Laila that night. I make myself another coffee and take it to the balcony. As I watch the sunrise, Laila is crying, at the other end of the world.

I use my phone again, this time to photograph the sky and the rooftops, bathing in the pink light of pale morning sunshine. As she receives my picture, both of us already know that she will make it.

“I have to go and unlock the door … There is somebody from the United Nations here. Thank you for staying with me.”

“Yes, the world is waiting for you outside.”

We hang up, and back on my computer screen I watch her march out of the room under the glare of the waiting cameras, towards a future in which she will probably still have to hide for a while. As I contemplate my city slowly returning from a deep and troubled sleep, I hope that the days of locked rooms are over for Laila.

***

Unlocked: Online Therapy Stories was published by Confer Books on 20th January 2022 and can be found online at Amazon UK, Amazon US, and Karnac Bookshop.
 

Psychocardiology: Psychotherapists Helping Cardiac Patients

Posted on by Psychotherapy.net Team

According to the Centers for Disease Control, one person in the U.S. dies every 36 seconds from cardiovascular disease (CVD). And heart disease is the leading cause of death for men and women of most racial and ethnic groups.

Obviously, this is a huge challenge for cardiologists. But cardiologists aren’t the only ones working to slow the encroachment of these deadly diseases. The psychotherapy community is also getting involved through a field known as psychocardiology. Researchers in this area are interested in understanding how psychological factors, such as depression, anxiety, stress disorders and substance abuse, contribute to CVD and vice versa.
 

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For example, a study in the European Heart Journal by Sripal Bangalore and colleagues found that individuals with a history of CVD are more likely to experience symptoms of depression than those without such a history. Conversely, the risk of developing CVD increases by as much as 65% in individuals with depression. And in those who are already being treated for heart diseases, psychological problems can cause further complications. All of this suggests a deep, bi-directional connection between the heart and the brain.

Let’s consider what therapists need to know to put this information into practice.

What we Know About the Brain-Heart Connection

We’re only just beginning to understand the deep connection between the heart and the brain. We know, for instance, that psychological stress can put extra strain on our hearts. When our bodies are in “flight-or-flight” mode, our blood pressure increases and our brains release adrenaline, along with other chemicals that can cause our hearts to spasm.

Although these physiological changes can help us survive immediate threats to our lives, when we spend most of our time in “flight-or-flight” mode, as is the case with most of our patients, the odds of developing heart disease greatly increase. In fact, one large scale study by Salim Yusuf and his team which involved 25,000 participants in 52 countries, found that psychological factors accounted for about 30% of heart attacks and strokes.

One explanation for the increase here is that stress hormones can cause damage to our hearts when constantly released into our bloodstreams over long periods of time. Additionally, mental stress increases inflammation of the brain and the heart, which can also lead to further complications.

The Need for New Interventions

Stress Management
Armed with the information above, many psychocardiologists are focused on stress management. The hope here is that cardiac patients who learn how to better manage stress through behavioral change will not only improve their symptoms of depression, but will also see improvements in their heart symptoms.

Such findings suggest that stress management training administered by therapists and psychologists would be beneficial for every cardiac rehabilitation patient. And when compared to the cost of other interventions, like angioplasty or bypass surgery, stress management is quite cost efficient.

Improved Quality of Life
Other psychocardiologists look for ways to improve quality of life. Yes, many heart patients end up with depression after surgery or other medical treatment for cardiovascular disease. And yes, depressed people often don't exercise, eat well, or take their medications. But there may also be physiological connections between CVD and depression.

Because we know that cognitive behavioral therapy combined with talk therapy can effectively reduce depression and anxiety, there is reason to believe these interventions can also reduce levels of stress hormones, decrease elevated heart rates, and calm hyper-active responses to physical stressors.

Challenges Remain
Unfortunately, while acceptance of psychocardiology is growing among the medical community, there are still challenges. For one thing, it’s difficult to get insurance companies to pay for any cardiac rehabilitation, let alone adding a psychological component. And with hospital stays getting shorter in the U.S., there’s little hope for inpatient rehabilitation and outpatient rehabilitation tends to focus on physical therapy, since insurance refuses to pay for other services.

However, none of the above has to get in the way of therapists’ treating their own patients, inquiring about heart disease symptoms, and making them aware of the heart-brain connection. Additionally, we all need to look for ways to treat the whole patient and to partner with cardiologists or other clinicians to ensure that our patients receive the best care possible.

Case Application

Jeffrey, a 48-year-old male with symptoms of depression, was referred to my office by his cardiologist for an evaluation. Jeffrey presented with both anxiety and depressive symptoms. His symptoms of depression had been present for nine months. Jeffrey was an avid cyclist who had recently suffered a myocardial infarction (MI) that required a cardiac catheterization, medication management and a cardiac rehabilitation program. Even though Jeffrey recovered from the MI, it left him with damage to his heart muscle, and he was advised by his cardiologist to continue to exercise but that he must also “slow it down.” This meant that Jeffrey could no longer ride with his buddies, something he used to look forward to all week long, since they rode at a level that would cause too much strain on his heart.

Even though Jeffrey was given clearance by his cardiologist to ride again, over the past nine months he had been struggling to get started. Jeffrey was becoming increasingly anxious that riding would put too much strain on his heart and possibly cause another cardiac event to occur. He worried about what would happen to his wife and two children if he had another MI and did not survive. He would ruminate over the possibility of never being able to keep up with his cycling buddies, a group that he had been riding with for over ten years.

The worry was starting to negatively impact Jeffrey. He now had low energy during the day, no motivation to exercise or join his family and friends in weekend activities, difficulty concentrating at work, poor sleep, weight gain, and feeling “down” on most days.
After taking Jeffrey’s medical and psychological history, I explained the mind-body connection, the concept of psychocardiology, and the comorbidity between psychiatric disorders and heart diseases. I also explained the bi-directional relationship between the heart and mind and how his heart problems were negatively impacting his mental health state, and that by working with him to help his mood, he would feel better physically.

To alleviate some of his anxiety and to highlight his body–mind connection, I incorporated breathing exercises and other relaxation techniques, such as guided imagery and body scanning to reduce stress and muscle tension. Body scanning is like meditation; it enabled Jeffrey to get in touch with his physical symptoms and their meaning. Jeffrey started to realize that cycling was a coping mechanism that he used to alleviate his anxiety and that now he needed to discover new methods. He identified his all-or-nothing thinking, e.g., “If I cannot ride my bicycle a certain way, I would consider myself a failure.” In sessions we addressed how this rigid thinking made it difficult to recover when something unexpected occurs.

CBT exercises helped Jeffrey explain the link between cognitions (beliefs that he would never be able to keep up with his riding buddies) and emotions (fear, failure) and safety (he may have another MI and not survive this time). Cognitive restructuring helped to identify old and new stressors, understand what response they trigger, and find alternative responses. During sessions, Jeffrey identified and processed the negative feelings that surfaced during his forced time away from riding. To increase self-confidence and reduce anxiety, measurable, realistic, performance-based goals were developed and monitored in each session.

***

Jeffrey’s unexpected cardiac event resulted in an immediate imbalance and disruption to his life. The inability for him to continue cycling was devastating and hindered his recovery process and negatively impacted his mental health. Jeffrey’s deeper understanding of the role psychological well-being played in his physical functioning resulted in greater motivation to work on his mental and physical health. The collaboration between two specialties, cardiology and mental health, enabled Jeffrey to have his psychological and physical needs managed simultaneously.
 

Exploring Our Client’s Multiverse

Posted on by Psychotherapy.net Team

Whether you ascribe to Jung’s theory of archetypal selves or follow Richard Schwartz’s Internal Family System’s (IFS) theory of parts, clinicians likely agree that the human consciousness contains multitudes. Consciousness—collective or otherwise—is multifaceted. IFS or the clinical practice of inviting a client’s different parts to engage in both internal and external change can offer something to even those clients who report a life free of both pathos and pain.

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For clients who make meaning of their lives through stories, we prefer to call this work Internal Fandom Systems (IFans). We have used the power of fanfiction to make IFS more inviting to our pop culture-fan clients, and still appreciate the canon that Schwartz created. We made this change to help our story-loving clients become curious about the wide cast of characters who inhabit their inner world. Inviting clients to notice and then engage with these different parts of themselves can be the beginning of a mythic adventure. But how do we get clients to notice the different parts that exist within them?

First, we engage the client in a brief psycho-education dialogue explaining the theory behind parts. For clients who are particularly interested in psychodynamic theory, we take a heaping spoonful out of the collective unconscious and explain the ways that the work of other great thinkers both paved the road for and are consistent with IFS. Once the logic of parts starts to become clear, we invite the client to get curious about the parts of themselves that are currently present. This differs from our standard Therapeutic Fanfiction approach in two important ways:

We are using fandom characters to help the client get to know an aspect of their own personality rather than using fandom characters and archetypes to help a client build competency and/or skills to meet an external challenge, and

Rather than learning to access the power of a fandom character in the greater collective unconscious, we are helping clients to get to know the characters of their personal unconscious. In IFans, the client learns about their own multi-verse rather than channeling a character or learning a skill from fandom.

As the client describes different thoughts, feelings, and sensations, we begin to get curious with them about the identity of a particular part. Clients often come up with fandom characters on their own, but when they struggle to describe the part, we might ask them if there is a character or fandom object that matches with the part they are currently noticing. If a client continues to struggle, we might offer a fandom character or archetype that comes to mind for us.

In a recent session with a client, I (Larisa) offered, “It sounds like this part is really worried about you but communicates in almost a condescending tone. It’s making me think of Tony Stark from the Marvel Cinematic Universe.” While the client agreed that Tony is someone who shows he cares through quips and snarks, they reported that this didn’t feel quite like their part. In this case, the client ended up choosing a different fandom character. But sharing the character that came to my own mind helped the client continue to sit with what felt most authentic to them, ultimately leading to the character who resonated most with this part—Sam Wilson, once the Falcon and now Captain America. In Therapeutic Fanfiction, the next step would have been for me to ask the client to share the skills, values, or attributes of Sam Wilson that appealed most to them. Then, we would get specific about which aspect of Sam might be able to help them face their current external challenge. But in this scenario, my goal was to help the client practice listening to their parts. Their Sam Wilson part turned out to be a protector, who was working to keep the client’s adult consciousness or Self away from the part we would eventually come to know as the Winter Solider, i.e., the shadow side of their Bucky Barnes part.

Just as in IFS proper, when using the Therapeutic Fanfiction lens of Internal Fandom Systems, clinicians help ensure that both client and therapist are getting curious about different parts, avoiding the blending of Self and other parts that can sometimes occur. As Sam observes to Bucky, “You have to stop letting other people tell you who you are.” Of course, Sam is correct. It isn’t our job as therapists to tell our clients who they are. It is our job to help them learn how to listen to their parts, to support them in learning who they are at present, and then to get curious about who they’d like to become.

Therapeutic Reflections of a Former Gang Member

Posted on by Psychotherapy.net Team

A Special Niche

“What population do you work with?” is a question that often induces mild anxiety in me. It seems like a convenient excuse for therapists to exclude groups that they don’t enjoy working with. As an example, I have heard several clinicians state that they refuse to treat people with personality disorders. While we have a right to choose (no one wants to be miserable at work), I think this attitude alienates those who may need our help most.

“Blasphemy!,” you might cry out, “We can’t be everything to everyone.” I understand. However, I got into this profession to help people. I try my best to accept people unless I believe I am unable to help from an ethical standpoint. There is something to be said about advanced training for more complex disorders. Even so, I believe that the therapeutic alliance is what matters most.

To tackle my resistance to the above question, I took a deeper look at my work over the past few years and came to realize that there is no specific population I focus on. Between private practice and a local outpatient clinic, I see clients ranging in age from five to 82 who have disorders across the mental health spectrum. If I were forced into choosing a specialty, however, it would be gang-affiliated children. I have been working with self-reported gang members since 2017, and even co-founded a clinical think tank to address their mental health needs.

Despite running the think tank and conducting individual psychotherapy with this population, I don’t consider it a niche. Instead, I view it as working with children who struggle with a wide variety of mental health challenges—especially trauma. However, admittedly, there is a part of me that may be failing to fully “claim” this population because of its associated stigma. Therapists often mention “I don’t work with those people,” or “that’s not my cup of tea,” when I share my work in this area. I also sometimes get reactions from them that appear to fetishize violence. It causes me to feel alone and ashamed.

While working with gang members may not sound appealing, it has been very meaningful for me. I credit my work with these clients as the reason for most of my clinical competency. Working with children is not easy in its own right, but working with children who are marginalized due to their gang status poses an even greater challenge. Another layer of complexity is that I, too, identify as a former gang member.

I Was a Gang Member

There is a common assumption that I might have more in common with these clients than other therapists. Sometimes this is the case, but often it is not. In fact, very few of my clients are aware of my former status. Though I am a big proponent of self-disclosure when it is useful, I rarely feel the need to disclose. The main reason is that most of what they bring to sessions are age-appropriate stressors just like other children’s: video games, struggles with parents, relationship issues. Their gang membership often comes up more as a cultural identity than an area of focus. Perhaps there could also be a small part of me that does not consider myself a “real” gang-member. After all, you can’t Google what I was a part of, and it neither made the news nor even extended very far beyond my local neighborhood.

Nevertheless, my past affiliation as a member (and leader) helps me to understand some of the nuanced challenges that these children face. I have experienced them myself. There are systemic barriers that are next to impossible to overcome, such as racism, oppression, and self-hate. My clients also share complicated feelings that they grapple with, such as feeling unwanted, constant fear, and pressure. Further, there is often confusion about who they really are.

At school I was viewed as a “nice” and “honest” child who showed respect to adults and completed assignments on time. I also had a side of me that could be aggressive and intimidating when I wanted to be. Was I the aggressive kid that some of my friends knew me as? Was I the nice child that aimed to please all of his teachers? This schism resulted in frustration about who I was and how I presented myself to different groups of people. My clients struggle with the same plight.

As I reflect on my personal experience in working with gang-affiliated clients, I often feel conflicted. I am cognizant of the ugly side of being in a gang. I am also aware of some of its benefits. This may sound distorted, but there are some strong emotional needs that are met from being gang-affiliated. For instance, I have not been able to replicate the sense of nurturance that I felt from knowing that there were multiple people willing to stand up for me at any given moment. My clients experience something similar.

I also learned leadership skills that I would later use to lead multiple organizations in the future. For example, there are ways to utilize your tone of voice to get almost any message across. I also learned the power of “the look”—a way of looking at people that makes them feel like they are the only person that matters in that moment. I would be negligent if I did not highlight some of these positive attributes. One of my clients recently told me that he watches for how people “squinch their eyes” to get a sense of who they are as a person. It took me back to my past as well.

The conflict continues. Do I act as a salesman who cleverly convinces these children to desist from gangs? The media and law enforcement would certainly suggest it. I know this is inappropriate. Gangs have been around forever, and they aren’t going anywhere; they also aren’t only present in urban neighborhoods. I know that my clients would stop trusting me if I tried to dissuade them. A break in trust could result in their losing a connection with the one person who “gets” them.

Instead, I utilize my unique skill set to help promote prosocial behaviors. For instance, I can convey that I am on their side. While I personally have not been able to replicate the sense of nurturance I felt while gang-involved, I try to help these particular clients realize that they can receive nurturance and loyalty outside of their gang. I offer a sense that I am willing to take on some of their emotional burden as we collaborate to figure things out together. I can read body language to get a sense of how I am affecting them. I can utilize self-disclosure in a manner that brings me closer to them.

The big question is, does it work?

I can only use my own experience and those of the clinicians in our think tank (it is next to impossible to find therapists that positively affirm that they work with these children). If we are using the metric of “getting kids out of gangs,” then no. However, when considering helping these children to open up, look at their lives more critically, and feel accepted in a society that is intolerant of them, then yes.

Some of the things I have heard recently from my clients are: “You’re one of two people that I feel like I can talk to,” “Talking to you eases my pain,” and even “I love you.” This is significant, considering that most of my gang-affiliated clients are impacted by stereotypical masculinity.

The Case of Jay

Jay is a thirteen-year old African American boy who struggles with symptoms associated with ADHD and Oppositional Defiant Disorder. Up until this point, he has been living with his mother and two siblings. However, due to his “attitude” and problematic interactions with his older sister, he was recently sent to live with his godmother, who lives nearby. He is engaged in school but has been declining academically. Some of his interests include playing basketball and internet gaming. While Jay has a difficult time opening up to people and is very easily agitated, he comes across as bored, disengaged, and angry.

I began working with Jay in 2018. During the first session, he sat slumped in his chair and sucked his teeth for most of the time (I later learned that Jay had a long list of therapists he didn’t like). Jay was described in the notes I received as “non-communicative” and “guarded.”

At the time of that first meeting, I was freshly out of graduate school and desperate to do a good job. “How are you?” I asked. Jay gave me a look of exasperation and continued staring off into space. Uncomfortable with silence, I proceeded to introduce myself and explained that I had been assigned to work with him (dumb move, but it helped to ease some of my anxiety). Jay didn’t budge.

This went on for the majority of the first session and the next. Anything I asked was either dismissed with one-word responses or ignored entirely. Somewhat desperate, I decided to do something unorthodox towards the end of the second session. I noticed he had been wearing some trendy sneakers that matched the rest of his outfit.

If I was going to get anywhere with this client, I had to relate with him. The only issue was that I had an unwritten, self-imposed, rule that I didn’t want to sound like some kind of camp counselor (I had some insecurities about being called a “counselor,” as it can easily be confused with a non-clinical role). I was there to be a clinician. I told myself, “Forget it!” (replace “forget” with an expletive) and went with my gut.

“I see you like to get fresh,” I noted while nodding my head and pointing at his sneakers. Something interesting happened.

“You like my drip?” (slang for nice outfit), Jay replied with a slight smile, and gave me a handshake. It was progress. I felt like a fool. Why hadn’t I tried this earlier?

Fast forward a bit. Although subsequent sessions remained generally anti-climactic, Jay did begin arriving to them a little earlier. Nothing dramatic occurred, and to an outsider, it may have appeared like wasted time. Jay insisted on telling me about the latest games he had been playing and eventually started challenging me to play him as well.

Once I felt like a strong rapport had been developed, I casually asked Jay why he thought he was in counseling. He revealed that he had been in counseling for several years before and that his family did not “like” him. He mentioned his perception of how he was disciplined more harshly than his other siblings.

Now we were getting somewhere. As time went on, the sessions oscillated between video games and minor disclosures about how upset he was with his family. “I don’t care” was one of Jay’s favorite responses.

One day I asked him to draw a picture of his family. It was not a specific intervention. I just knew, by this point, that it was one of the activities that younger kids enjoyed doing. The drawing looked like a few beetles, with his mother being slightly larger than the rest. He took the picture home with him without saying anything further.

During the following session, Jay revealed how drawing the picture helped him to realize how much he did care about his family. I was annoyed. Really? After all the sophisticated interventions I learned in graduate school, this is what stuck? I was happy with the small progress but was distressed by how random the occurrence seemed to be. Was this something that could be replicated with other clients? I soon learned that this was not necessarily the case; every client was different. Jay helped me to learn that.

A big milestone for us occurred when Jay asked if he could visit with me twice weekly at the clinic. This was not possible due to insurance restrictions, but it suggested that I had been doing something right. He became much more talkative about his life and what mattered to him.

It was not a miracle. Over time, Jay continued working well with me, but he also developed habits such as daily marijuana usage and decreased engagement in school. His mother also complained about his being “influenced” by the wrong crowd. He was no longer fighting with his older sister, but he also was not actively speaking to her either.

I could relate with his feelings of being excluded by most peers but included by other teens in his neighborhood. I told him this. Jay continued working with me as he realized I was not much different from him. I “got” him.

No Fairy-Tale Ending

This case does not have a fairy-tale ending. Due to scheduling conflicts, Jay was no longer able to work with me. Admittedly, he mentioned also becoming tired with counseling, as he had been working with therapists since he was ten. I respected it.

Jay mentioned that though he no longer wanted to continue therapy, he refused to work with anyone else (his mother was insistent upon his staying). One of the things he mentioned during our last few sessions was “you helped me control my anger,” and “now I know how to ignore people” in lieu of lashing out.

As I reflect on my work with Jay, I realized that most of what I learned in graduate school did not help me connect with him. He appreciated me for being real, being on his side (when the world—including other therapists—seemed to be against him) and disclosing parts of my life when it was relevant (i.e., the fact that I often felt unwanted in many social settings as a teen).

Further, and most importantly, I approached him as a child (now teenager) before a gang member.

I am still apprehensive when asked what population I work with. However, it is getting easier, as I remind myself of the gifts that these clients have brought to me as a clinician. My work with gang-affiliated clients has made me a much stronger clinician. I know what it is like to connect with “treatment-resistant” people. That has made me much better at connecting with clients overall.