Unlocked: Online Therapy Stories

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

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

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

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.

Fellow Therapists: Do You Work With Sex Offenders?

I have had a career-long commitment, or understanding, primarily with myself, but also with insurance companies, that I choose to not work with child-abusers. It is not that I can’t see redemptive possibilities. It is just that I know I have a strong bias and am not willing to forge a pathway to empathy for those who molest children. It is a boundary I set when deciding whom and who not to treat. My thoughts about this dilemma came to the forefront very recently.

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Yesterday, a man who had been on my therapy waiting list finally arrived at my office. On his intake he noted a recent breakup with his girlfriend of several months. He stated he experienced depression and needed help to “get over the relationship.” It was only in session that the rest of his concerns emerged. At the beginning of their relationship, he told her that he had been married and had several children, but lost custody of them in the divorce. At that time, he was in deep financial trouble, having lost his then recently-purchased home, cars, and his wife to her drug addiction. Nevertheless, the Department of Children and Families (DCF) had determined that neither he nor his ex-wife were capable of raising their children, who were subsequently placed into foster care.

The divorce and subsequent foster placement of the children occurred several years prior to my meeting with him. Several of the children had since reached the age of majority. For a seemingly inexplicable reason, the foster parent who later became the adoptive parent of several of the children took it upon herself to contact my client’s girlfriend (I have no idea how she learned about her) in order to warn her that my client had been accused by his then young daughter of inappropriately touching her. True? Not true?

My client vehemently denied that this ever happened and maintains that position to date. According to him, there had been no legal proceedings, and instead, four hours of reported verbal assault by the local police. He was then purportedly presented with paperwork which he signed without reading. Why? As it turned out, he could not read. He only recently discovered that the paperwork was an affirmation of his guilt, precipitating removal of his contact privileges with his children. The most important sentence, that he could not read and was not read to him, was that he was (and possibly still is) forbidden to be around all children under a certain age. He was later told by his ex-wife that he had been placed on the state Registry of Sex Offenders. Boundary alert! But there was something about this man that compelled me to search a bit deeper.

It was easy for me to confirm that he had never been placed on that Registry through a simple request form and a phone call to the state. But what about the other accusations? I suggested he engage an attorney to find out whatever he could from the DCF offices in his state. As stated, he and his wife had been deemed unfit and the children were placed in foster care, from which they were eventually adopted. He has not seen these children since.

If he was and still is a concerned parent, I wondered why would he not have fought this and tried for all these years to see his children? He did admit that one of his older children had recently contacted him and said that the child abuse was a fiction delivered to DCF by his mother, no doubt out of anger and rooted in her addiction. This child, now an adult, refuses to make a legal statement.

As it turns out, DCF initially denied him access to any of the historical paperwork, reportedly stating that it was too late that they could not find electronic versions of it. As the children were no longer “his,” no documents could or would be turned over to him. Nevertheless, his newly-retained attorney persisted and indicated that there was indeed a document my client is not aware of indicating only that in saying goodbye to his children he was “observed hugging his daughter tightly.” This seemed appropriate to me, as he was saying goodbye to her for an indeterminable length of time. As per the attorney’s suggestion, I have not disclosed the existence of the document to my client. There may be more information forthcoming, and while I trust my intuition and am fairly accurate in “reading” my clients, I would be profoundly sad to learn that these accusations of child abuse against this man are true. It will be up to his attorney to share any “new” findings of legal significance. For now, my client is very relieved to know that he is not listed on his state’s offender registry.

Given that he has recently lost another relationship, I believe that my job at this point is to help this man try and understand why that relationship ended and to move forward if possible. His only response in this context thus far is that he just feels more broken. In light of my long-term and deeply-held conviction to not treat child abusers, I question whether I am comfortable treating him. Or, I wonder, am I too far in right now to bow out should more information come forth indicating that the charges of child abuse were indeed valid? As a parent, I intellectually appreciate how the trauma and drama of those events converged in a legal mess for this naïve, then-illiterate man who struggles to date, but am disturbed by his seeming inability or lack of initiative to have fought for custody and have found a way to hold on to his children.

***
 

As a therapist, I have asked myself new questions about how to set professional boundaries as to who I do and do not choose to treat. Do I believe everyone deserves a second chance? No—not when it comes to abusing a child. But this is not a matter of another shot at life. This is partly a story of a man who carries with him the stigma of assuming he was listed as a sex offender in the state for all these years. That was simply not true. A victim of a vicious ex-wife, a potentially inept police team, the inability to read, and the lack of good legal counsel at the time, conspired to trap this man, holding him hostage for wrongs not committed. Had he been found to be an abuser, DCF would have reported him to the state and he would have been on their list. That was never the case. And what about when these boundary lines become blurred? How do I (re)define my role in order to help a client like this one to establish new goals in the center of a complicated and lingering legal morass that may never be resolved? I have decided, at least for now, to continue to meet with him. But what if information does indeed emerge that implicates him? Do I search for redemption or reestablish my professional boundaries? I do not have that answer, at least at this moment in time.
 

Costumed Authenticity: Building Trust in LGBTQ+ Telehealth

He was the kind of client who liked to sneak in jokes to relieve his own anxiety. A deflector. The kind of client who is openly gay, but emotionally closed. In telehealth sessions he rarely looked at the camera, or even the screen. His thoughts were off in the distance. He had a lot to say, but it was going unsaid. Or, more accurately, he had a lot to share, but it wasn’t being verbalized.

Social camouflage can be a powerful survival mechanism. While it can lead to compartmentalizing social identities, it’s important to value a client’s need for safety. In fact, if there’s anything I’ve learned from my LGBTQ+ clients, it’s how multifaceted identities open up progressively through tiers of trust. Codeswitching is common, as is reserving whole aspects of personal identity for those who actually appreciate it. This can make it hard to trust anyone, especially a mental health professional.

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Even amongst the LGBTQ+ community there is no guarantee of acceptance, requiring camouflage just as much within the rainbow as outside of it. Pansexuals and omnisexuals may tell people they’re bi because it’s more commonly understood and socially accepted, just as bisexuals may tell people they’re gay. Genderqueer, genderfluid, and agender people may generalize themselves as queer or nonbinary rather than get into the specifics of their actual identity. Likewise, there are many nuanced facets to being a transgender person, but there’s no chance of talking about that with someone who’s unfamiliar with even the most basic Trans 101 terms. Yes, a client may talk about their sexuality or gender identity with a therapist, but at what level is the conversation? Tier one? Tier two? Tier ten?

In the back of my mind, I found myself relating to his bemused smile and his coy silence. But how could I, as his counselor, create enough safety in a telehealth session for him to share more of his unspoken authenticity? Or, at the very least, another side of himself?

I’ll be the first to say that telehealth has more than a few problems, yet having a small window into the client’s home is a game changer. I’ve had some clients proudly take me on a video tour of their house, and others who actively hid their home environment. Getting to see someone’s sanctum of comfort, or playground of self-expression, is an honor that should not be taken lightly. Yet when a client doesn’t know how to talk about themselves, a little curiosity about their external environment can go a long way.

In the background of his bedroom was a sewing mannequin. When I asked if he sewed, he laughed and said he was better with a hot glue gun. Then, when I asked what he’d been working on, there was a second of hesitation. A second of hope, mottled with the fear of rejection. The natural prelude to authenticity.

No, he wasn’t a Drag Queen. He was a Drag Cosplayer, who spent a small fortune every year transforming himself into sci-fi and fantasy characters to attend massive conventions. And he walked a fine line, in heels no less. He didn’t fit in with Drag Ball Culture, and he was sure most Queens would call him a nerd. On the flip side, not every conventioneer appreciates a cross-dressing cosplayer. Here was courage and shame in the same costume. Here was cognitive dissonance. He kept all his social media accounts private but had hundreds of people take pictures with him at every event. He was an anonymous celebrity.

This disclosure segued into a conversation about his favorite anime characters and, most importantly, why they were his favorite. People are drawn to certain fandoms for key archetypal reasons, because they resonate with a specific character, or universe, or story arc. Fortunately, I happened to grow up in the height of America’s anime revival, so I recognized not only his characters, but also his attention to detail. After that, I was updated on the status of his latest costume for the next two months. It turned out he had a soft spot for manic female antiheroes who are vibrant, loud, and completely over the top.

It takes time to build rapport. As therapists, we are outsiders, approaching each tier of privacy like a gate. It’s not enough to say friend or foe. For this client, I had to not only know the password to be let in, but I also had to speak the language. It’s because of this that I encourage therapists to take an active interest in their client’s media. Dive into their music scene, or favorite book series, or television show, or movie fandom, or video game community, because there you will learn a hidden language.

So I asked him if, in our next telehealth session, he would be willing to show up in character, and he laughed, and cringed, and said he’d have to think about it.

My next session was with Haruko Haruhara, from the spastic anime masterpiece FLCL.

My next session was with my client’s shadow, imagination, and feminine inspiration, and this time, they looked right into the camera.

Psychodermatology: Understanding the Mental Health Component of Skin Conditions

There is a relatively new subspecialty within dermatology that is of interest to therapists. Psychodermatology, the study of the connection between the “mind” and the skin—or an understanding of the psychosocial context of skin diseases—is giving many patients a new lease on life. While we’ve always known that there is a connection between mental health and certain skin conditions, we’re now finding that this connection runs much deeper than scientists first believed. For example:

  • Among patients with disfiguring, chronic skin conditions, the prevalence of psychiatric disorders is 30% to 40%.¹
  • Significant stress and anxiety have been reported in 44% of patients before the initial flare of psoriasis, and recurrent flares have been attributed to stress in up to 80% of individuals.²
  • The prevalence of psychiatric disorders among patients with skin conditions is greater than in patients with brain disorders, cancer, and heart issues combined.³
So, what can psychotherapists do to recognize patients who could benefit from seeing a psychodermatologist or drawing connections between their skin conditions and their mental health? Continue reading for tips to guide your recognition and treatment of psychodermatologic conditions. How to Identify and Treat the Symptoms Symptoms to look for in patients include any skin condition, including severe acne, eczema, pruritus (itching), psoriasis, vitiligo, and others, that may arise at the same time as particular mental health challenges. If you notice a skin condition, ask your patient to tell you about it. Find out what makes it worse or better and when they notice flare-ups. You have to become a bit of a detective at first until you can teach your patient how to start connecting dots for themselves. Certain patterns may be obvious, while others will require further investigation. But once you discover a connection between the brain and skin, you can dig deeper to better understand the nature of the connection. The goals of psychodermatology are:
  • To investigate the emotional impacts of a patient’s skin condition,
  • To help the patient work through these emotional impacts,
  • To reduce the threats posed by these emotional impacts,
  • To help the patient develop coping mechanisms for if and when a recurrence occurs
With patient-centered approaches to explore the patient’s feelings, concerns, and experience regarding the impact of their condition and with cognitive behavioral therapy, you can begin to reveal a clearer picture of what stimuli and stressors contribute to the physical manifestations of a patient’s emotional condition. For example, suppose you have a patient who you’re treating for depression and social anxiety. During one therapy session, you notice eczema on the back of your patient’s hands. You enquire—just as you would when assessing any physical behavior. Your patient discloses that ever since they started a new job, their eczema has gotten worse. Armed with this new information, you can have your patient jot down when flare-ups occur and bring their notes to sessions with you. Together, you can collaborate to spot patterns, which can help you create a timeline. From here, it’s time to focus on healing from the inside out. Working with Other Health Professionals While many conditions can be eliminated through psychotherapy alone, patients experiencing any of the above symptoms often benefit from an interdisciplinary approach. Many dermatologists understand that while they can treat the physical manifestations of a patient’s mental health condition, patients often also need mental health professionals, like psychologists, psychiatrists, or psychiatric mental health nurse practitioners, to target the source of the skin condition. One good strategy may be for therapists to seek out partnerships with dermatologists in the know.? Also, if you see patients who suffer from compulsions or skin conditions, such as skin picking or hair pulling, which you know have a psychological component, referring them to a psychodermatologist can be especially productive. While any dermatologist can prescribe drugs to treat the physical skin condition, working with someone who understands the deeper connection can be the ticket to deeper healing for particular patients. Ultimately, psychodermatology is all about improving quality of life by healing the skin condition and enhancing the patient’s emotional state. When we give our clients the tools they need to find true healing from the inside out, we show them that the journey to healthy skin and mental stability is a path they can walk. Case Application Glenda, a 21-year-old-woman, was referred to my office by her dermatologist because of anxiety that heightened when asked questions about her visibly red, scaly and raw-appearing rash on her hands and forearms. She insisted that she must be allergic to the soap she had been using and possibly the prescription cream that her primary care physician (PCP) had prescribed. Glenda had been examined by her PCP for her rash three times over the past few months and diagnosed with contact dermatitis, allergic dermatitis, and possibly eczema. Her PCP also prescribed a steroid cream and instructed to wash her hands with hypoallergenic soap and apply Aquaphor healing ointment daily. Glenda’s dermatologist took a thorough medical history and asked her about having repetitive thoughts that may be causing her distress. Glenda started to talk about the stress she has been experiencing over the past year due to COVID. She talked about staying up late at night worrying about getting infected with COVID and spreading it to others. She began to wash her hands multiple times a day. She shared that she had always frequently washed her hands, but now felt compelled to carry out a hand washing ritual—hand washing, turning the cold water on and off four times, then washing her hands, scrubbing until she counted to 30, turning the cold water on and off four more times, then applying hand sanitizer and rubbing it into her skin for 30 seconds. Lately she had been washing her hands every half hour and had been applying extra hand sanitizer to make sure her hands were clean, since washing her hands made her feel less anxious about getting COVID. She believed that carrying out this ritual had the additional benefit of protecting her family. At that point, the dermatologist explained that her skin rash and anxiety were interconnected, prescribed a hand ointment that promoted healing, and referred her to my outpatient mental health practice for an evaluation. After taking her medical and psychological history, I asked Glenda “What is your story?” to provide her with an opportunity to construct her personal narrative and share her experiences and beliefs about her current psychosocial circumstances. She opened up about her repetitive hand washing behaviors and worries about COVID that “hijacked” her brain. As a first-line intervention, cognitive behavior therapy for OCD directed at her behavior (compulsions) and cognitions (obsessions) made good sense. Sessions with Glenda included cognitive restructuring, psychoeducation, imagery exposure, self-monitoring, relaxation training, coping skills development, and self-care to alleviate her OCD-related distress. Relapse prevention was used to reduce the occurrence of initial lapses and to prevent any lapses that might escalate into a full-blown relapse. For homework, journaling was used to help Glenda identify harmful patterns of thoughts, emotions and actions and to develop techniques to help her better cope with uncomfortable feelings.

***

The collaboration between two specialties, dermatology and mental health, enabled this patient to have her psychological and physical needs treated holistically and simultaneously.  References: 1.  Goldin, D. (2020). Concepts in Psychodermatology: An overview for primary care providers. The Journal for Nurse Practitioners, 17(1), 93-97. 2.  Jafferany M. (2007).Psychodermatology: A guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry, 9(3), 203-13. 3.  Ghosh S, Behere R.V., Sharma P, & Sreejayan K. (2013). Psychiatric evaluation in dermatology: An overview. Indian J Dermatol., Jan;58(1), 39-43. 4.  Azambuja R. D. (2017). The need of dermatologists, psychiatrists and psychologists joint care in psychodermatology. Anais brasileiros de dermatologia, 92(1), 63–71.

Jude Austin on Wisdom for Counseling Students and Educators

Into the Wilderness

Lawrence Rubin: Why did you entitle your latest book “Surviving and Thriving in Your Counseling Program?” It sounds like you’re sending them out into the wilderness with a backpack and a knife and saying, “Good luck. Let me know how you’re doing in three years.”
Jude Austin: When my brother Julius, who is also my writing partner, and I were thinking about the title for this book, that’s the image we had in our minds. You get equipped in graduate school with these different tools, skills, and attitudes and then go off and get your Ph.D., and you think you’re prepared.

But when you’re sitting in that first session unsupervised, you just feel this sense of, “I need an adult and a Swiss Army knife of some type.” So, that’s kind of what we wanted this book to be—a Swiss Army knife for counseling students and counselor educators who were reading it and feeling out of touch with their students like, “Hey, this is what they’re going through!" So yeah, we wanted it to come across as if this was your guide to surviving but also thriving in your counseling program.
LR: Sort of a field guide to counselor educators and counseling students and an army knife with different utilities. Can graduate counseling programs ever adequately prepare students for what’s to come?
JA:  
when you’re sitting in that first session unsupervised, you just feel this sense of, “I need an adult
That’s the million-dollar question. It depends on the type of program—and there are different types. You have programs that train clinicians, and then you have programs that train people who become clinicians. The counseling program that I teach in at the University of Mary Hardin Baylor focuses on the person of the therapist.

When beginning therapists (interns) are out there in the clinical wilderness, and all their practiced techniques fail, we want them to fall back on themselves as the tool. If a counseling program focuses on developing the person, their attitudes, awareness, and then helps them to develop some skills along the way, then I think that person has something solid to fall back on.
LR: What happens when you have a counselor educator who understands the importance of building self, self-esteem, and relational, not just technical, skills, paired with a student who thinks that they’re the finished product? Or perhaps an older student whose cup is already too full or a younger one who hasn’t yet been put in a position where they’ve been tested either interpersonally or emotionally?
JA: I struggle with that sometimes. We get students who come in with already-filled cups because they’ve had a successful career or currently have many competing obligations including family. They may feel like, “I know this. All I really need is for you to give me that paper at the end of this, and I’ll be fine.

I see that as an invitation to build a relationship with that student so that we can model the relationship we want them to have with clients
I see that as an invitation to build a relationship with that student so that we can model the relationship we want them to have with clients. I don’t see that confidence or arrogance as a threat, and I don’t want to humble them. I feel like that’s what a lot of counselor educators tend to do anyway; something like “We’ve got to do something that will break them down.”
LR: Drop them to their knees.
JA: Yeah, drop them to their knees! I feel like a better approach—or at least one that’s helpful for me, is to help that student understand what they do know and what they don’t know. It’s not about bringing them down to where they can sit humbly with a client. It’s about saying, “Okay, what do you have that works for you? And what do you have that doesn’t work? And how can we work around that and use it to build a better counselor?”

Getting What They Need

LR: Have you encountered such students or those who are clearly trying to work through their own issues either early on in training or while they are actually providing therapy?
JA: That’s OK, because it gives us an opportunity to help the student learn boundaries, because counseling is like that. I mean we get the clients we need, and so this isn’t going to be the first time they’re going through these kinds of issues and those issues come up. So, our job, or my job as the counselor educator, is to help that student understand that boundary.

That counseling student is actually in a good position to use the issues that they have experienced or are currently experiencing to build a better relationship with a client. And when the student is at that boundary and it is hindering the therapeutic relationship, the teaching moment is right there in front of them, as is the teaching tool for their supervisor. What you don’t want to do is set the stage where a student feels like, “I’ve got to get my shit together, or I can’t do this.” That’s just not sustainable.
LR: I like the idea that we help students understand that sometimes they get the clients they need. Try as I might to selectively place interns in facilities where they’re not going to be thrown to the lions, they invariably end up not only with clients they need but also with those who are very complex and well-beyond their skill and experience levels.
JA:
what you don’t want to do is set the stage where a student feels like, “I’ve got to get my shit together, or I can’t do this”
As far as I do it in supervision, it’s really just helping them navigate those multiple and often complex relationships. I try to do my best to encourage students to chew on things before they swallow it. We start them in practicum at our free, university-based community clinic before sending them on to internship at an outside site.

During internship, we tell them something like, “Hey, you’re going to be hearing some stuff and be asked to do some things at the site that may run counter to what we said or what we’ve trained you to do. And so, you’re out there in the world.” And so, they begin to learn, “How do I integrate some of the things I learned in school with what I’ll learn here and not allow it to negatively impact my development as a counselor?” I think the key is helping students recognize and take ownership over their own development, so they can’t be manipulated or pushed or pulled when a supervisor asks them to do something different from what they have been taught or experienced while in school.
I’ve seen many a student who goes off into a site with a supervisor who is overwhelmed or unprepared or not trained to be a supervisor because they are first and foremost a clinician. And so, students lose confidence and get set back. We as clinical educators have to help them take ownership over and protect their own personal and professional development.
LR: And we have to protect students from supervisors who might be overwhelmed, overwhelming, and/or incompetent.
JA:
we as clinical educators have to help them take ownership over and protect their own personal and professional development
Up to a point, I don’t want to rob them of the learning experience of being next to somebody who may be incompetent, unavailable, unhealthy, or who may be just not be a good role model. I want them to learn that. It’s kind of like when my son is climbing up stairs for the first time, I don’t want to be next to him and holding his hand. I want him to struggle and wait for him to ask for help.

Similarly, it’s about teaching that student when they need to come and tell me that something is beyond their capabilities, especially when they’re in internship. Because when they’re in internship, we need to make sure that they know how to strike that balance between knowing when it is necessary to ask for help and when it is not. Otherwise, they won’t build strong roots.
LR: They have to have their own immune system.
JA: Yeah, exactly.
LR: So, being a clinical educator/supervisor requires that we also strike a balance; between protecting and…
JA: …letting them struggle.
LR: Just like the APA Code of Ethics says…promoting autonomy while also making sure that they’re not a danger to themselves or others.
JA: I’ve had many supervision sessions where we’re just like, “This sucks.” You also have to build a relationship with their site supervisor. Sort of like co-parenting.

Rising or Falling

LR: If you were called on by the ACA to write a formula for predicting failure of a graduate counseling student, what would go into that equation?
JA: I had two thoughts but will share my second one first, which is about counselor educators. I’m a big believer that oftentimes our limitations as counselor educators can then become our student’s limitations. And so, if a student is failing—or failing to thrive—for some reason, then I merely have to look inward and be congruent and be healthy about the responsibility I take in that student’s failure and think, “Wow, is this a support issue? Maybe I didn’t prepare them enough. Maybe we didn’t have a big enough informed consent around what this would mean for them,” right?
LR: So, the second part of your answer, which comes first, is that if a student is on a track to fail or is failing to thrive, then it is the counselor educator’s job to look within to ask, as a parent might, “How have I failed to support this student’s thriving?”
JA:
our limitations as counselor educators can then become our student’s limitations
Yes. What are my limitations here?
LR: What’s the other part of your answer?
JA: I think sometimes they can’t be helped. And sometimes students come in not expecting how challenging the program is, not giving the challenge of this enough respect. If I were to create a formula for predicting a counseling student’s failure, I would probably say it has something to do with lack of awareness or acknowledgement of how challenging this program is, plus maybe a lack of support. They know it’s going to be hard, because it’s graduate school. But I don’t think they know how hard graduate counseling is, graduate psychology is. It asks a bunch of questions of you that, if you aren’t prepared to answer, it can have a domino effect in your relationships and your mental health and your ability to process things.
LR: Conversely, what do you think are some of the characteristics of the counseling graduate student who will thrive not only in graduate school but in their career, in their personhood, in their lives?
JA: The #1 characteristic for me is humility.
LR: Yeah, amen.
JA: And not just humility in the sense of self-deprecation. I mean this humbleness around the idea that maybe their reality isn’t the correct reality, and their willingness to allow their client’s reality to be correct for that client. It’s about cultural humility, to be able to come in and say, “Oh, man. There are some things that I don’t know. There are some things that I don’t perceive about the world like everyone else does, but I’m willing to learn.”

it’s not like people who are wounded or hurting can’t do this work. It’s just they have to work on the stuff that they need to work on
I think that’s the humility that I’m talking about, to be able to say, “Okay. Here’s my stuff. I’m going to work on my stuff.” And I think that’s the clear thing. It’s not like people who are wounded or hurting can’t do this work. It’s just they have to work on the stuff that they need to work on. And when students are aware of that and they’re doing that parallel kind of process, then it’s a beautiful thing. I feel like that’s when students can be successful.

So humility, for me, is the thing that we’re trying to foster in counseling students. And to be honest with you, a lot of the students that we accept are already good at this. We just give them skills and tools in the hopes that when they get to internship, they’ll remember who they were when they first started the program. And then when they remember that person, they can be that person with some skills and attitudes and knowledge. And so, if you can go through that process humbly, I feel like you can stay grounded and remember who you are. That’s kind of my perspective.
LR: So, it’s the counselor educator’s job to teach counseling students to hold onto who they are and maybe shave off or trim those parts of themselves that are going to get in the way, so they can become more psychologically lean but hopefully learn to become the person who is a counselor, not a counselor who is not sure who they are as a person.
JA: Yeah. Now, that sounds easier said than done. And I think that also means that as counselor educators, we have to do that too. We have to model that for students. We have to let them into our experience and our journey of becoming, step-by-step, more and more ourselves in supervision, in class. Let them into that process and show appreciation. One of the things that I say after each class is, “Thank you for letting me be myself.” And I invite students to do the same. When I mess up, when I forget my keys and I have to walk back to my car or when it’s just like it’s not a good lecture, owning that and showing them that this is what we want you to do in session.

Healer, Heal Thyself

LR: In the context of this piece of the conversation, what are your thoughts about counseling as a mandatory part of counseling training?
JA: You know, it’s strongly suggested in our program, strongly suggested. I feel like we build a culture of support in the sense that we have alumni who are now working in the field who kind of understand a little bit of what students are going through. And so we try our best to refer them out to clinicians in the area that can help. But mandatory? If I could make it mandatory, I think I would be at least a couple sessions. Just so you can see how it feels.

But making it mandatory? I feel it could be detrimental for students who aren’t ready to process their stuff. I mean if they’re not ready, it doesn’t mean that they can’t be good counselors, but here’s the thing. If you’re not working on your stuff, if you don’t go to counseling, you may become a really good technician but not a clinician. You can go and do skills, you can go and do theories, you can go in and do techniques and activities. But can you really connect with somebody? Can you have a therapeutic presence that allows that client to feel pulled toward you and can you evoke your client’s awareness? I don’t know if you can do that without working.

one of the things that I say after each class is, “Thank you for letting me be myself.” And I invite students to do the same
Yeah, it’s a dilemma. In a lot of ways, it’s safer to do rather than be, right? How can you cultivate a therapeutic environment where you feel safe enough to be? Most counseling students are going to graduate and feel like, “I know some stuff now.” But I think what makes our program special is that we really focus on training students to be, but not every student is ready for that, and that, too, is a dilemma. I notice it sometimes in clients with whom I am trying to connect on a deeper level, and they don’t want it.

They want… “Give me the coping skills. I don’t want to talk about…” And so, you have to meet that client where they are. And it’s the same thing with students and the same thing with the field, like allowing students to hear, “Hey. This is where the field is. This is what we’re trying to get you to do. We’re trying to find a balance between doing and being.”
LR: So if a student is not ready for internship for emotional, psychological reasons, what do they do instead? How do you work with a student who just is not ready for internship by all your standards but is insistent or demanding or even litigious about it?
JA: We go through this a lot. We have a couple of different options. This is not like a plug for our program, because I think most programs have this. By the time they get to internship, we want them to have a really good idea about how we feel about their potential to succeed or fail. We don’t want it to be a surprise. And so, by the time they get to internship, we’ve had that conversation where it’s like, “Hey. There’s a lot of things that you… There’s a lot of hang-ups. There’s a lot of things that could limit your success there. If you want to do it, we can’t stop you, but it may behoove you to take some time and then come back and start internship.” And if students are like, “No. I’m good. I want to do internship,” then we help them find an internship and a supervisor that could support that student’s limitations.

So, sometimes we’ll have students who are veterans, and maybe they experienced a TBI and they struggle with death work. And they acknowledge it, they know it. And so, we work with them to say, “Okay. What kind of work can you do? Where can you serve your community?" And so we try to guide them into the place where they could be most successful. But sometimes, rarely perhaps, I have students who are not ready to integrate it, and we just have to kind of let them survive… or not, you know? And when they don’t, we’re there to support them.

The Right to Fail

LR: I had a supervisor once, a very wise older woman who loved the metaphor of a safari guide. Her idea was that “As we walk through the terrain, I’ll point out the quicksand. I’ll point out the thickets and the brambles. If you choose to go into the quicksand, I’ll be waiting on the edge if I can help you.”
JA: Absolutely. And students have a right to fail. They very much have a right. And I think that’s the thing that we try to get students to understand. It’s like they’re not paying for this degree, they’re paying for an opportunity to get a degree. And if they destroy that opportunity because they go into an internship site when they’re not prepared to do so, there’s nothing that we can do about it. Those internship sites can hire you and fire you. If you get fired, there’s consequences. We’re very open about that.
LR: Do you ever experience transference/countertransference relationships with your students?
JA: I think I can answer this question in a way that’s most favorable for me [smiling]. I just genuinely care about the students and their success. When we accept a student into our program, when I’m working with a student, I see the impact they can have in their community, the ripple effect that they can have. And all I want for them is to be successful.

watching them struggle is the hardest part
And so it’s triggering because it’s like watching someone doing something that is going to hurt them but allowing them to get hurt so they learn the lesson. I think that’s the hardest part about being a counselor educator. I think that’s the countertransference, especially because I’m a relatively new dad of a two-year-old and a four-month-old. It’s like that same process of watching them go through it and identifying with that struggle.

So you just have this sense of ownership over that person’s development. And then when they get to internship, you’re letting it go and that ownership transitions to someone else—their site supervisor. And so, watching them struggle is the hardest part. And we go through that every year, because there isn’t an internship cohort that doesn’t have one or two students who is realizing at that moment like, “Oh, crap,” as they fall behind. It’s brutal because they have to watch their cohort members move forward.
LR: You clearly have a heart for your students and want them to succeed, but I want to push you on this one. What about those counseling students that you don’t like? You know, the ones that burrow under your skin or those that you simply don’t care about or like?
JA: I just try to put obstacles in their way, which means that I have to have that conversation that I don’t want to have but I know I need to have with that student earlier than other students. Like with that student that is burrowing under your skin, I very much experience a parallel process where I’m saying, “If this person is affecting me this way, they’re probably going to affect clients this way as well.”

that’s what I mean by obstacles, like slowing down their process so that they can gain awareness of how they affect other people
And so, before they even get to apply techniques, which is the second semester where they first learn how to do mock sessions, we need to have a conversation. We need to have that talk like, “Hey, you know that thing that you do in class? That’s annoying, man.” And what I try to do is say, “Whenever you…” Like if a student has a loud laugh, that’s saying like, “Pay attention to me,” right? What I try to get them to do is, “When you laugh, pay attention to everyone else’s reaction. Pay attention. Feel how you affect other people.” That’s what I mean by obstacles, like slowing down their process so that they can gain awareness of how they affect other people. Because if they’re affecting me, they’re going to affect other people.
LR: So, what you’re trying to do is not simply model empathy or pray to God that they sort it out through osmosis or some other way. Sometimes, you have to really just actively teach them what it means to be empathetic because in therapy, the audience is watching. The audience is listening
JA: Worst-case scenario, you’re doing it live in class and the student does something and you have to say, “Hey, pay attention to how everyone is feeling around you. Would anybody like to share how this person is affecting you right now?" And then sometimes I may say something like, “This is how I’m experiencing you right now. You don’t have to respond to it. This is just how I’m experiencing it. Do you want to be experienced in that way? Is that what you’re trying to get me to experience you?" And I think that’s kind of the learning that we need them to get.
LR: So, counselor educators need to manage their triggers so they can be most present for their counseling students, just as we ask counseling students to have those qualities with their clients.
JA: Exactly.

Straddling Two Worlds

LR: How do you balance on that tightrope separating the supervisory and therapeutic aspects of your role as a counselor educator?
JA: I straddle that line as carefully as possible, because that’s probably one of the most unexpected challenges my doctoral program prepared me for. And they can’t really prepare you for that. So, the way that I keep a boundary around it is that when I’m with a student, I’m always thinking about learning opportunities. I’m always thinking about teachable moments. And so, there’s times when I go there with a student, especially when we’re processing deep stuff. But there is a stopping point when it gets to, “Okay. We’ve got to stop because I feel like this is what you need to process in therapy. This is what’s affecting the client, that you need to process that in therapy.”

I’m always thinking about teachable moments
But when I can cultivate a relationship with the student or supervisee that is safe, then sometimes in supervision I may feel like being open about, “Okay. We need to work through this so that you can better work with clients,” then, “Here’s where we’re going to work, and here’s where we’re going to stop.” Does that make sense? It’s almost like an instinctual knowing of when I’m going too far, when we’re getting too deep. And I can feel that with students. I may see them becoming uncomfortable. So, I want it to be a wisdom-based engine, and I don’t want that engine to spoil over into fear, because then they’ll push away.
LR: In this context, many counselor educators are also practicing clinicians, and I wonder if that is beneficial or detrimental.
JA: I have a small private practice here in Temple, and I don’t know how I would be able to do this job without seeing a client or two a week. And it’s mainly because sometimes when I haven’t worked with clients and I’m in front of the class with the alphabet behind my name, I feel like I am The Guy. And then I go into a session, and I’m humbled and reminded, “Oh, yeah. I don’t know what the hell I’m doing,” or, “This session got away from me.”

I feel like it becomes hard to manage whenever my practice hinders my health, when I’m scheduling, managing things when it’s overwhelming, when I’m burnt out, and my students become a secondary priority. That’s when I know, okay, something’s going on. But, yeah, I work with individuals, couples, families. And I usually have about four or five clients that I’m seeing in a semester.

Lifespan Issues

LR: How, as a parent to young children and also in a sense a parent to young, evolving clinicians, do you teach them about the uncertainty and our limited ability to influence others?
JA: I think you put them in situations intentionally where it’s grey and uncertain and watch them go through it. What we try to do is have a healthy balance between safety and ambiguity. We want clinical trainees to feel safe enough to be able to feel okay floating in the wilderness somewhere. We know where they’re at. They may not know where they’re at, but we want them to feel safe to be lost a little bit.

we want clinical trainees to feel safe enough to be able to feel okay floating in the wilderness somewhere
And so, I think that’s how you train them. It’s like you intentionally scaffold and build into your program situations, places, activities where students can get a healthy dose of “I’m just going to go with it, and I’m okay because I know I have a healthy attachment to my faculty.” It’s the same thing as a new parent. It’s like I know my relationship is strong when my son can play independently and then come back and check in and then play independently and then come back and check in.

It’s like he knows that he can wander and it’s safe to come back. Same thing with students, right? We want them to go off and explore a theory, a technique or try this out or bring this into session or bring this into practice and then come back and say, “I don’t know what I did.” You know what I mean? So yeah, building that in intentionally.
LR: You’re in a unique position, Jude, because you’re learning what it means to be a parent while you are shepherding counseling students into their professional identities. It makes me wonder—what are some of the challenges that clinical educators have who are later on in their life, who are no longer dealing with raising young children but perhaps launching teenagers, or have children who are getting married, or are dealing with their own mortality? How do counselor educators separate or merge the challenges in their own personal lives with what it is their students need in theirs?
JA: I feel like the challenges that the more-experienced clinician or the counselor educator may have are the same issues that the students may have who come in as they begin a second career. It’s arrogance, you know? It’s that idea that you know everything. You don’t see yourself as a student anymore. And I think that is the downfall of a good counselor educator, is when they feel like they know all there is to know.

I think the way that they can combat that is integrating the experiences that they have but not relying solely on those experiences. I think that’s the difference—if you’re integrating them, you say, “Gosh. I remember what it was like when my kid was two or when my kid was four. I remember when my kid was 13.” That’s the emotional age of some of these students. What did I do when my kid was 13, and what did I want to do that I didn’t do that I wish I could’ve done and I can do now with this student? I feel like those are the ways that you can kind of integrate those experiences into raising students.
LR: So, it goes back to sort of a thread that’s woven its way through this interview, which is that we as counselor educators/clinicians have to continue to evolve, to look inside. We have to impose that challenge on our counseling students. We can expect no less from our counseling students than we can for ourselves.
JA:
we as counselor educators/clinicians have to continue to evolve, to look inside
And we’ve got to have the courage to let them into our journey with that. You know, we’ve got to have the courage to say, “This is life. I’m tired. I’m exhausted.” We don’t have to put on that front. Because then students will do that, and then the clients will do that, and there’d be that butterfly effect where nobody’s really being themselves.
LR: Do clinical educators get the students they need?
JA: It’s that butterfly effect, right? It’s like this parallel process where my relationship to my supervisee will impact my supervisee’s relationship to their client, which will then impact that client’s relationship to their environment. And so, a lot of the times when I’m in supervision and we’re having that come-to-Jesus moment like, “Why do you have this client,” I also have to ask myself, “Why do I need this supervisee to have that client?”

And then I may start thinking, “What do I need to do in my life in order to be able to better support this student so that they can better support this client?” That becomes the question, right? But then the beauty of supervision is that you can outwardly process that with a student so that they can learn how to do that for themselves with a client. You can say, “Gosh, man. When you’re working with this client, this is what it brings up for me. This is my hang-up, and this is where I struggle to support you. Where in your life do you feel like this client is kind of poking?" This processing and processing is a beautiful thing when it’s done right. In a lot of ways, it can feel like inception. Sometimes you’re in supervision like trying to spin a top asking, “Are we in reality, or is this a dream?”

True Cultural Awareness

LR: This next question could probably stand as its own interview, but I can’t help but ask. What are the challenges that counselor educators face in really effectively teaching these students what cultural awareness means?
JA: The first thing that comes to my mind is that we’ve got to be mindful of our fragility as counselor educators and be willing to address things that make us uncomfortable talking about, things that make us squeamish. I feel like we’ve got to be aware of that. We’ve got to be aware of our political stances and how that influences our work and how it influences our teaching. We’ve got to be aware of our perspective, our biases, our thoughts, our perceptions of individuals who don’t look like us, don’t like the same people we like, don’t pray like we pray.

we’ve got to be mindful of our fragility as counselor educators
I think the key to fostering culturally humble students and clinicians is for us as counselor educators to be humble, to be mindful of our fragility, and be courageous enough to have those conversations in class. Each diversity class that I teach feels like Thanksgiving, because a lot of people’s families are uncomfortable around that Thanksgiving table. That’s what diversity class feels like.

I feel like what we have to do is to foster this atmosphere of openness around these discussions and safety in the classrooms. What we don’t want is for students to feel the tension or the discomfort, and that hinders their ability to go there. We need them to go there. And so, we have to be aware. We have to be humble. We have to be courageous. I think those three qualities can really help develop culturally-competent students.
LR: We recently released a three-video series, Counseling African American Men, featuring Darrick Tovar-Murray from DePaul University. In the conversations between Darrick and Victor Yalom, Psychotherapy.net’s founder, the idea came up that counselors need to learn to be comfortable with discomfort, which sounds like exactly what you’re talking about.
JA: Yeah. Yeah. Yeah. We’ve got it steeped in our program. We’ve got it steeped in security and safety with a little bit of ambiguity and discomfort. It has to be equal measures. We have to steep the students in there for two years and two semesters, you know?
LR: I’ve heard of the notion of “White Fragility.” What did you mean by fragility?
JA: You know, like those developmental stages. Like whether or not you’re in the early stages of identity development. Then you’re experiencing a lot of anger, right? Because that’s fragility too, right? We talk about this in diversity class. Sometimes, as a man of color, as an African American male, I have anger toward White men, White people, especially when I feel unsafe.

sometimes we can give off the impression as counselor educators that if you are a White counselor, then you can’t do culturally sensitive work
And so, when clients come in, sometimes that anger leeches into the therapeutic relationship. And I think that’s what I mean by fragility. It’s not that you can’t be angry. It’s that you have to be mindful of “How is this going to impact my therapeutic relationship, my work, my relationship with my peers, my relationship with my supervisor? What do I need to do to work through that?
LR: When I started at the university 32 years ago, the student body was White, and I have learned to be more aware of the privilege that comes with whiteness. And I have been put in very uncomfortable situations with my students. So, this idea of a counselor educator being comfortable with discomfort and modeling it is very important.
JA: Absolutely! And a lot of that has to do with just acknowledging when “This is uncomfortable.” Like, look around the room. What have we done as a program, as an organization? What have you done individually as a student to perpetuate this sameness? Let’s have that discussion. Because I think sometimes we can give off the impression as counselor educators that if you are a White counselor, then you can’t do culturally sensitive work.

I feel like that impression is dangerous, especially for White students. There’s so much opportunity for corrective emotional experiences for clients. If we train White counselor educators well, they can go out into their communities into the field and build strong relationships and repair relationships with clients. I mean, speaking for myself as a supervisor, it meant a lot to me to work with a supervisor, like when I was a student, who was White but who came into the relationship humble, aware, willing to acknowledge things. It was kind of like, oh, okay. Okay, we can do this. And it was even more impactful sometimes when that happened.
LR: Yeah. Do you think there’s an implicit expectation that, because you are a Black man, that you have a deeper sensitivity to cultural oppression and unfairness?
JA: Yeah. Yeah. Yeah. Yeah. That’s the work we don’t get paid for. That’s fine with me, you know? That’s the stuff that they don’t add to the tenure packet. They don’t have a box for that on your year-end evaluation. It’s how many times you’re stopped in the hall and, “Hey. I’m trying to do this diversity thing.” It’s like, I’m going to Google it just as you, just as much as you.

sometimes it’s just hard. It’s like, “Man, I don’t have the bandwidth to do this when I also have to do other things”
You know, it’s that extra work that you do to support a community, the calls you get, the students that you’re supporting, the organizations you’re connected with. Sometimes you do have a deeper understanding of these diversity issues, because you have to. But sometimes it’s just hard. It’s like, “Man, I don’t have the bandwidth to do this when I also have to do other things.”

I feel like what I love the most about my faculty is that we all take equal responsibility in having those conversations. So, it doesn’t just feel like it relies on one person. But I’m blessed. My program is diverse. We have two White men, and the rest of the faculty are people of color, women of color.
We very much match our student population demographics. But, yeah, that’s the stuff you don’t get paid for. And that expectation gets you voluntold to be on committees. And I’m just like, “Gosh, man. I’m struggling too, you know?”
LR: I think we’ll stop there Jude. I want to thank you so much for sharing your wisdom and experiences from the trenches of graduate school.
JA: I hope this was meaningful for students or for whoever’s reading it.

Overcoming the Pernicious Chronicle

Therapy stagnates when patients doggedly chronicle the events that have occurred since their last session or when they use all their therapy time to recite their grievances, bewail the injustice of their situation, and air their resentments. The therapy, in short, fails to fulfill a treatment plan. The misuse of these sessions can lead to “interminable” outcomes, where patients continue to catalog their problems but do not modify or alter how they deal with them. The therapist can be caught up in this paradigm, resigned to listening and sympathizing without making any meaningful headway in helping these patients recover.

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Worse yet, the therapist may become comfortable with this covert contract: “If you tell me your troubles and adventures, I’ll listen and make occasional wise remarks, I’ll even offer you some advice, but little will change in your life due to our therapy. You’ll be comforted, and I’ll be compensated.” This arrangement can go on for years, even decades, and only end if the patient can no longer pay, by the death of either party, or by the therapist’s retirement. A colleague of mine used to refer to these patients as “psychiatric annuities.” To him, they were an income stream providing steady payments that would support his earnings “forever.” The patient will never reach the therapy’s goals (if indeed there ever were therapy goals!) and instead become so dependent on the therapist that their lives will be diminished instead of enhanced by their treatment.

Some therapists feel comfortable with this long-term arrangement. Sessions with these patients are predictable and require little or no effort. They might even grow fond of this long-suffering patient and wouldn’t want to trade for a new case with all its uncertainties and hard work. And they’re getting paid for little or no work. If asked, these therapists might argue that they are providing “Supportive Therapy.” This rationalization adds insult to injury: The patient is incapable of change? Are they so damaged they need a weekly boost from a therapist to tell them how to live their life? Does the therapist need a therapy-dependent patient, hanging onto every word, to boost his or her own self-esteem? What is being supported? The status quo?

A real regard for the patient’s benefit, not to mention simple professional ethics, requires that all of us resist the siren’s call of these cases and, instead, interrupt the chronicle, reinstate active treatment, and forego the insidious pleasure of these unworkable, so-called supportive arrangements.

A Matter of Death and Life

Excerpted from A Matter of Death and Life by Irvin D. Yalom and Marilyn Yalom, published by Stanford University Press, ©2021 by Irvin D. Yalom and Marilyn Yalom. All Rights Reserved.

Numbness, 50 Days After

Numbness persists. My children visit. We take walks in the neighborhood, cook together, play chess, and watch movies on TV. Yet I remain numb. I feel uninvolved in the chess games with my sons. Winning or losing has lost significance.

Yesterday evening there was a neighborhood poker game, and my son Reid and I both played. It was the first time I’ve ever played together with one of my sons in a game of adults. I’ve always loved poker but at this game, at this time, I could not shuck the numbness. Sounds like depression, I know, but still I took pleasure in seeing Reid’s happiness about winning thirty dollars. As I walked back to my home, I imagined how good it would have felt to arrive home, be greeted by Marilyn, and tell her about our son’s winning night at poker.

The following night I try an experiment and place the portrait of Marilyn in plain view in the room while my son, his wife, and I watch a movie on TV. But, after a few minutes, I feel so much tightness in my chest that I again put Marilyn’s portrait out of sight. The numbness persists as the film proceeds. After about a half hour, I realize that Marilyn and I had seen this movie several months before. I lose interest in seeing it again but remembering that Marilyn had enjoyed it a great deal, I honor the bizarre notion that I owe it to her to watch the entire film.

“I notice that the numbness recedes the first few hours of the day when I am immersed in writing this book and also when I work as a therapist”. Today, a woman in her late twenties enters my office for a consultation. She presents her dilemma. “I’m in love with two men, my husband and another man I’ve been involved with for the last year. I don’t know which is the real love. When I’m with one of them, I feel that he’s my real love. And then the next day or so I feel the same way about the other man. It’s as though I want someone to tell me which one is the real love.”

She discusses her dilemma at length. Midway through the session, she notes the time and mentions that she had seen my wife’s obituary. She thanks me for being willing to see her at this difficult time. “I worry” she says, “about burdening you with my issues when you’re suffering such a huge loss.”

“Thank you for those words,” I reply, “but some time has gone by, and I find that it helps me if I’m engaged in helping others. And also, there are times when issues arising from my grief enable me to help others.”

“How does that work?” she asks. “Are you thinking of something that may be helpful to me?”

“I’m not clear about that. Let me just ramble for a minute. Let’s see . . . I know that getting involved in your life in this session temporarily diverts me from my own. I’m thinking, too, of your comment that you don’t know your real self and that you cannot know which of these two men the real you really wants. I keep thinking about your use of real. I feel this may be tangential, but I’ll just trust my instincts and tell you what our discussion stirs up in me.

“For a very long time I’ve felt that an event often felt ‘real’ only after I shared it with my wife. But now, weeks after my wife’s death, I have this very strange experience of something happening and my feeling I must tell my wife about this. It’s as though things don’t become ‘real’ until my wife knows about them. And, of course, that is entirely irrational because my wife no longer exists. I don’t know how to put this in a way that will be helpful but here it is: I, and only I, have to take full responsibility for determining reality. Tell me, does this have any meaning for you?”

She seems deep in thought and then looks up and says, “That does speak to me. You’re right if you’re implying that I cannot trust my sense of reality and that I want others—perhaps one of my two men, perhaps you—to identify reality. My husband is weak and always defers to my observations, to my sense of reality. And the other man is stronger, very successful in business, very sure of himself, and I feel safer and more protected and trust his sense of reality. Yet I also know that he’s a long-term addict who is now in AA and has now been sober for only a few weeks. I think the truth is that I mustn’t trust either of them to define reality for me. Your words make me realize that it’s my job to define reality—my job and my responsibility.”

Toward the end of our hour together, I suggest that she is not ready to make a decision and should tackle this in depth in continued therapy. I give her the names of two excellent therapists and ask that she email me a few weeks from now to let me know how she is doing. She is deeply touched by my sharing so much with her and says that this hour has been so meaningful that she didn’t want to leave.